TICKET № 1. 1. Asepsis: concept, sources, and routes of infection penetration into a wound. Prevention methods. 2. Hemotransfusion shock: pathogenesis, clinical features, emergency care. 3. Classification of purulent diseases of the hand. Characteristics of the spread of pus on the hand. 4. Basic principles of conservative therapy for vascular pathology of the lower extremities, list the groups of medications. TICKET № 2. 1. Parenteral and enteral nutrition, classification, and indications. 2. Definition, goals, and stages of surgery (operation). Concept of surgical approach and basic techniques. 3. Types of rejection and methods of immunosuppression in organ and tissue transplantation. 4. Chronic arterial insufficiency of the lower extremities: causes, clinical features, diagnosis, and treatment. TICKET № 3. 1. Determination of blood grouping according to the ABO system using standard serums. Evaluation of results. 2. Local and general signs of inflammation. Principles of treating purulent wounds in the first phase of wound healing(process). 3. Chronic venous insufficiency: causes, clinical features, and diagnosis. Main types of lower extremity vein surgeries (operations). 4. Opisthorchiasis: clinical features, diagnosis, and treatment. TICKET № 4. 1. Types of sterilization. 2. Local and general signs of inflammation. Principles of treating purulent wounds in the second stage of the inflammatory process. 3. Osteomyelitis: classification, clinical features, diagnosis, and treatment. 4. Pulmonary embolism: causes, clinical features, diagnosis, and treatment. TICKET № 5. 1. Hand treating for surgeons before surgery (operation): rules and types. 2. Shock, classification. First aid for traumatic shock. 3. Pleural empyema, classification, clinical presentation, diagnosis, and treatment. 4. Aneurysm, clinical presentation of aortic dissection, diagnosis, and treatment. TICKET № 6. 1. Antiseptics, classification. 2. Drowning, clinical features, first aid. 3. Peritonitis, classification, clinical features, diagnosis, treatment. 4. Lymphostasis, clinical features, treatment. TICKET № 7. 1. Bleeding, classification. 2. Signs of biological death. 3. Prevention of postoperative thromboembolic complications. 4. Echinococcosis: clinical presentation, diagnosis, and treatment. TICKET № 8. 1. Indications for blood transfusion. 2. Collapse, causes, first aid. 3. Classification of specific surgical infections. Tetanus. 4. Alveococcosis: clinical features, diagnosis, treatment. TICKET № 9. 1. Blood transfusion complications. 2. Coma, clinical features, diagnosis, treatment. 3. Fast-track therapy. 4. Classification of congenital diseases. TICKET № 10. 1. Classification of blood components. 2. Mechanical and physical antisepsis. 3. Clinical groups of oncology patients. 4. Diagnosis of congenital diseases. TICKET №11. 1. Contraindications to blood donation. 2. Chemical and biological antisepsis. 3. Types of surgical procedures for malignant diseases. 4. Treatment of congenital diseases. TICKET №12. 1. Methods of blood component transfusion. 2. Wound classification. 3. Criteria for brain death. 4. Congenital esophageal stenosis: clinical features, diagnosis, and treatment. TICKET №13. 1. Contraindications to blood transfusion. 2. Wound healing, phases of wound healing. 3. Phlegmons of the hand: classification, diagnosis, treatment. 4. Congenital diaphragmatic hernia: clinical presentation, diagnosis, treatment. TICKET №14. 1. Algorithm before performing red blood cell transfusion. 2. Types of wound healing (proсess). 3. Рurulent arthritis: classification, clinical features, diagnosis, and treatment. 4. Congenital pyloric atresia: clinical features, diagnosis, and treatment. TICKET №15. 1. Individual selection before blood transfusion. 2. Frostbite, stages, and basic treatment principles. 3. Treatment methods for cancer patients. 4. Basic principles of plastic surgery. TICKET №16. 1. Rules for the use of medical masks. 2. Transfusion shock, diagnosis, and treatment. 3. Classification of purulent infections. 4. Congenital biliary atresia: clinical presentation, diagnosis, and treatment. TICKET №17. 1. Classification of blood products. 2. Basic principles of treating purulent infections. 3. Acute arterial obstruction: cause, clinical features, diagnosis, and treatment. 4. Congenital annular pancreas: clinical features, diagnosis, and treatment. TICKET №18. 1. Classification of blood substitutes and their use. 2. Terminal conditions. Signs of clinical death, first aid. 3. Classification of purulent diseases of the skin and subcutaneous tissue: clinical presentation, diagnosis, and treatment principles. 4. Congenital intestinal atresia: clinical presentation, diagnosis, and treatment. TICKET №19. 1. Indications for blood component transfusion, indications for use. 2. Ensuring surgical safety. 3. Classification of superficial forms of panaritiums (felon), clinical features, diagnosis, treatment principles, and pain management. 4. Congenital Hirschsprung's disease: clinical features, diagnosis, and treatment. TICKET №20. 1. Blood type and Rh factor determination, and procedure. 2. Hospital-acquired infections, prevention. 3. Classification of deep forms of panaritiums (felon), clinical presentation, diagnosis, treatment principles, and pain management. 4. Define the terms reconstructive, restorative, plastic surgery, and transplantation. TICKET №21. 1. Blood compatibility tests. 2. Electrical injury, clinical presentation, first aid. 3. Classification of hand phlegmons, clinical presentation, diagnosis, treatment principles, and pain management. 4. Transplantation, classification. TICKET №22. 1. Physician's actions before transfusing blood components. 2. Burn disease, periods, and treatment. 3. Patient assessment scales. 4. Brain death criteria. TICKET №23. 1. Local anesthesia, classification. Highest single dose of novocaine. Contraindications to local anesthesia. 2. Define each symbol: TNM in the International Classification of Malignant Diseases. 3. Acute venous insufficiency, clinical presentation, diagnosis, treatment. 4. Organ and tissue donor service, tasks. TICKET №24. 1. Classification of anesthesia. Conduction anesthesia, examples. 2. Principles of rational antibiotic therapy for purulent infections. 3. Differences between benign and malignant tumors. 4. Contraindications to organ harvesting. TICKET № 25 1. General anesthesia. Stages of anesthesia. 2. Initial patient examination. 3. Laparostomy: types and indications. 4. Tissue compatibility in organ transplantation, principles of organ selection, waiting list. Rejection, immunosuppression methods. TICKET №26. 1. Bleeding classification, clinical presentation, diagnosis, and treatment principles. 2. Hypothermia, stages, first aid. 3. Sepsis, etiology, pathogenesis, clinical presentation, diagnosis, and treatment principles. 4. Artificial organs, examples. TICKET №27. 1. Forest's endoscopic classification of ulcer bleeding. 2. Stages of patient examination. 3. Diagnostic methods in angiology. 4. Requirements for organ retrieval during transplantation. TICKET №28. 1. Hemorrhagic shock: stages, diagnosis, Algover index, treatment principles. 2. Methods for closing skin defects in burns. 3. Classification of malignant diseases by stage based on the international TNM classification. 4. Types of organ preservation during transplantation. TICKET №29. 1. Criteria for assessing the quality of medical care for blood loss. 2. Treatment options for deep burns. 3. Carcinogens, types, and effects. 4. Skin grafting, types. TICKET №30. 1. Sterile zones in the operating room. 2. Basic principles of burn treatment. 3. Precancerous conditions: optional and obligatory conditions, examples. 4. Legal and ethical issues of organ donation. TICKET №31. 1. Types of operating room cleaning. Medical waste classes. 2. Burns, classification by depth. 3. List the methods of body detoxification (hemosorption, hemodialysis, plasmapheresis) and their indications. 4. MARS - artificial liver, indications.

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SURGICAL EXAM TICKETS - ANSWERS

TICKET № 1

1. Asepsis: concept, sources, and routes of infection - prevention methods. Asepsis is a set of measures to prevent microorganisms from entering a wound. Sources: exogenous (environment, staff, instruments, air) and endogenous (patient's own flora - skin, gut, foci of infection). Routes: airborne, contact, implantation, hematogenous/lymphogenous. Prevention: sterilization of instruments, surgical hand scrub, sterile draping, antiseptics, preoperative skin prep, laminar airflow in OR.

2. Hemotransfusion shock: pathogenesis, clinical features, emergency care. Caused by ABO incompatibility - donor red cells are hemolyzed by recipient antibodies, releasing free hemoglobin, activating complement, DIC, and renal tubular obstruction. Clinically: agitation, chest/lumbar pain, fever, hypotension, hemoglobinuria (red/brown urine), jaundice, oliguria/anuria. Emergency care: stop transfusion immediately, maintain IV access with saline, furosemide, dopamine for BP support, sodium bicarbonate to alkalinize urine, treat DIC, possibly hemodialysis.

3. Classification of purulent diseases of the hand - spread of pus. Classified as: panaritium (felon - finger infections: cutaneous, subcutaneous, tendinous, bone, articular, pandactylitis) and hand phlegmons (subcutaneous, subfascial, midpalmar space, thenar space, subaponeurotic, commissural, U-shaped phlegmon). Pus spreads along tendon sheaths (fingers II-IV drain to midpalmar space; thumb and little finger sheaths communicate - causing U-shaped/horseshoe phlegmon), fascial spaces, and neurovascular bundles.

4. Conservative therapy for vascular pathology of lower extremities - medication groups.

Antiplatelet agents (aspirin, clopidogrel)
Anticoagulants (heparin, warfarin, NOACs)
Vasodilators / vasoactive drugs (pentoxifylline, cilostazol, naftidrofuryl)
Venotonics (for venous pathology: diosmin, troxerutin)
Statins (lipid lowering + pleiotropic vascular effects)
Thrombolytics (in acute occlusion: alteplase, streptokinase)
Prostaglandins (iloprost - for critical ischemia)

TICKET № 2

1. Parenteral and enteral nutrition - classification and indications. Enteral nutrition: delivery via oral, nasogastric, nasojejunal tube, or stoma (gastrostomy, jejunostomy). Used when GI tract is functional but patient cannot eat adequately (trauma, stroke, oropharyngeal cancer, ICU). Parenteral nutrition: intravenous delivery of amino acids, lipid emulsions, glucose, electrolytes, vitamins. Peripheral (short-term, low-osmolarity) or central (via CVC, long-term, high-calorie needs). Indicated when gut is not usable (ileus, bowel fistula, short bowel syndrome, severe pancreatitis).

2. Definition, goals, and stages of surgery. Surgical approach and basic techniques. Surgery is a planned sequence of manual and instrumental actions on tissues to treat disease. Goals: cure, palliation, or diagnosis. Stages: preoperative preparation → anesthesia → surgical approach (access) → main step (intervention) → wound closure → postoperative care. Surgical approach is the incision/route to reach the target organ (must be adequate, gentle, and anatomically safe). Basic techniques: incision, dissection, hemostasis, ligation, suturing, anastomosis.

3. Types of rejection and immunosuppression in transplantation. Hyperacute rejection: minutes-hours, antibody-mediated, irreversible. Acute rejection: days-weeks, T-cell mediated, reversible with treatment. Chronic rejection: months-years, gradual fibrosis, poorly reversible. Immunosuppression: induction (anti-thymocyte globulin, IL-2 receptor blockers), maintenance (calcineurin inhibitors - cyclosporine/tacrolimus, antimetabolites - mycophenolate, corticosteroids, mTOR inhibitors - sirolimus), treatment of acute rejection (high-dose steroids, anti-CD3 antibody).

4. Chronic arterial insufficiency of lower extremities. Caused by atherosclerosis (most common), thromboangiitis obliterans (Buerger's), diabetes. Classified by Fontaine stages: I - asymptomatic, II - intermittent claudication (IIa >200m, IIb <200m), III - rest pain, IV - trophic ulcers/gangrene. Diagnosis: ABI (ankle-brachial index <0.9), duplex ultrasound, CT/MR angiography. Treatment: risk factor modification, antiplatelet therapy, exercise, vasodilators; surgical: bypass grafting, endarterectomy, balloon angioplasty/stenting, amputation if necessary.

TICKET № 3

1. Blood grouping by ABO using standard serums - evaluation. Standard serums of groups O(I), A(II), B(III) are applied in a row with the test blood. A positive reaction (agglutination) indicates the corresponding antigen is present. Results: no agglutination in any = group O(I); agglutination in O and B serums only = group A(II); agglutination in O and A serums = group B(III); agglutination in all three = group AB(IV). Must be confirmed by reverse grouping with standard red cells. Temperature must be 15-25°C; results read at 5 min.

2. Local and general signs of inflammation. Treating purulent wounds in phase 1. Local signs (Celsus-Galen): rubor, calor, tumor, dolor, functio laesa. General signs: fever, leukocytosis with left shift, elevated CRP/ESR, malaise, tachycardia. Phase 1 (inflammatory/exudative): goal is to remove pus, necrosis, and reduce bacteria. Treatment: surgical debridement and drainage (wide incision), hypertonic (10% NaCl) dressings, antiseptic irrigations (chlorhexidine, povidone-iodine), proteolytic enzymes (trypsin), systemic antibiotics, analgesics.

3. Chronic venous insufficiency - causes, features, diagnosis, operations. Caused by deep vein thrombosis (post-thrombotic syndrome), primary varicose veins, or valvular incompetence. Features: heaviness, edema (worse in evening), skin changes (hyperpigmentation, lipodermatosclerosis), venous ulcers (medial malleolus). Diagnosis: duplex ultrasound (gold standard), phlebography if needed. Operations: stripping (Babcock), crossectomy (high ligation of great saphenous vein), miniphlebectomy, endovenous laser/radiofrequency ablation, perforator ligation (SEPS).

4. Opisthorchiasis - clinical features, diagnosis, treatment. Caused by Opisthorchis felineus (from eating raw freshwater fish). Affects bile ducts and pancreatic ducts. Acute phase: fever, urticaria, eosinophilia, hepatomegaly, right upper quadrant pain. Chronic phase: cholangitis, cholecystitis, biliary strictures, pancreatitis, increased risk of cholangiocarcinoma. Diagnosis: stool exam (eggs), serology (ELISA), ultrasound/CT (dilated bile ducts), ERCP. Treatment: praziquantel (single course), choleretics, antispasmodics; surgery for complications.

TICKET № 4

1. Types of sterilization.

Steam (autoclave): 121°C/1 atm for 30 min or 134°C/2 atm for 20 min - standard for instruments, linen
Dry heat (oven): 160°C/60 min or 180°C/30 min - for glassware, oils, powders
Chemical (EO gas, formaldehyde, glutaraldehyde): for heat-sensitive items (endoscopes, plastics)
Radiation (gamma): for disposable factory-sterilized items
Plasma (hydrogen peroxide): low-temperature, for delicate instruments
Filtration: for liquids and gases

2. Local and general signs of inflammation. Treating purulent wounds in phase 2. (Local/general signs same as Ticket 3-2). Phase 2 (proliferation/regeneration): granulation tissue forms; goal is to protect granulations and stimulate healing. Treatment: gentle cleansing, ointment-based dressings (methyluracil, Vishnevsky balsam, hydrocolloids), secondary suture closure when granulations are healthy, skin grafting for large defects, physical therapy (UVR, laser).

3. Osteomyelitis - classification, clinical features, diagnosis, treatment. Classification: hematogenous (acute/chronic) vs. traumatic/postoperative; Cierny-Mader staging (1-4). Acute hematogenous: children, long bones; fever, bone pain, soft tissue swelling, leukocytosis, elevated ESR/CRP; X-ray changes appear at 10-14 days (periosteal reaction); MRI/bone scan earlier. Chronic: sequestra (necrotic bone), involucrum, fistulae. Treatment: IV antibiotics (4-6 weeks), surgical drainage of subperiosteal abscess, sequestrectomy, debridement, bone grafting/Ilizarov fixation in chronic forms.

4. Pulmonary embolism - causes, clinical features, diagnosis, treatment. Caused by DVT (most common), rarely air, fat, amniotic fluid. Risk: immobility, surgery, cancer, thrombophilia. Features: sudden dyspnea, pleuritic chest pain, hemoptysis, tachycardia, hypoxia; massive PE causes hypotension, syncope, cardiac arrest. Diagnosis: D-dimer (screening), CT pulmonary angiography (gold standard), echocardiogram (right heart strain), V/Q scan. Treatment: anticoagulation (LMWH → warfarin or NOAC), thrombolysis for massive PE, surgical embolectomy, IVC filter if anticoagulation contraindicated.

TICKET № 5

1. Surgical hand scrub - rules and types. The goal is to remove transient flora and reduce resident flora. Rules: nails short, no jewelry, wash hands and forearms to elbows for 2-6 min. Types: (1) Classic soap + brush scrub followed by 70% alcohol or chlorhexidine; (2) Alcohol-based handrub (WHO standard - 1.5 min rubbing with 3-5 mL of product, no brush needed, most widely used); (3) Spasokukotsky-Kochergin method (historical, ammonia solution); (4) Chlorhexidine 0.5% in 70% alcohol. Sterile gloves are worn after any method.

2. Shock - classification. First aid for traumatic shock. Classification: hypovolemic (hemorrhagic, dehydration), distributive (septic, anaphylactic, neurogenic), cardiogenic, obstructive (PE, tamponade). Traumatic shock is primarily hypovolemic + pain component. Grades (I-IV) by blood loss and hemodynamics. First aid: stop bleeding (tourniquet/pressure), ensure airway, IV access with 2 large-bore lines, rapid crystalloid infusion (saline/Ringer's), analgesia (morphine if no hypotension), immobilize fractures, oxygen, urgent transport; transfuse blood products for grade III-IV.

3. Pleural empyema - classification, clinical features, diagnosis, treatment. Classification: by duration (acute <3 months, chronic), by cause (parapneumonic, postoperative, traumatic, tuberculous), by extent (free/encapsulated), by bacteriology. Features: fever, chest pain, dyspnea, toxemia; dullness to percussion, absent breath sounds. Diagnosis: chest X-ray (opacity), ultrasound (loculated vs free), CT, pleural fluid analysis (exudate, pH <7.2, glucose low, LDH high, bacteria). Treatment: antibiotics + drainage (tube thoracostomy), fibrinolytics for loculated empyema, VATS debridement, open decortication for chronic/organized empyema.

4. Aortic dissection - clinical presentation, diagnosis, treatment. Classified by Stanford (A: ascending aorta involved; B: only descending) or DeBakey (I, II, III). Presents with sudden, severe tearing/ripping chest pain radiating to the back; pulse differentials between arms, aortic regurgitation murmur, stroke/limb ischemia. Diagnosis: CT angiography (gold standard), TEE, MRI. Treatment: Type A - emergency surgery (replace ascending aorta). Type B - medical (beta-blockers + nitroprusside to reduce HR and BP), endovascular stent-grafting for complicated Type B; aneurysm is a localized dilation >50% of normal diameter.

TICKET № 6

1. Antiseptics - classification.

Mechanical: debridement, wound irrigation, drainage
Physical: hypertonic dressings, UV light, laser, ultrasound
Chemical: halogens (iodine, chlorhexidine), oxidizers (H₂O₂, KMnO₄), alcohols (70% ethanol), aldehydes (formaldehyde), detergents (benzalkonium chloride), dyes (brilliant green), heavy metals (silver sulfadiazine), nitrofurans (furacilin)
Biological: antibiotics, bacteriophages, proteolytic enzymes, immunoglobulins

2. Drowning - clinical features, first aid. Types: true (water aspiration), asphyxial (laryngospasm), syncopal (cardiac arrest from cold/shock). Features: cyanosis, coughing/foaming, hypoxia, confusion, cardiac arrhythmia, pulmonary edema (secondary drowning). First aid: remove from water safely, check responsiveness, start CPR if no pulse/breathing (30:2 ratio), clear airway of water/foam, recovery position if breathing, call EMS, oxygen, warmth (hypothermia common), hospitalize even if "recovered" (secondary drowning risk within 24h).

3. Peritonitis - classification, clinical features, diagnosis, treatment. Classification: primary (spontaneous, e.g., SBP), secondary (bowel perforation, appendicitis - most common), tertiary (persistent, hospital-acquired). By spread: local (1 region) vs diffuse (2 regions) vs generalized. Features: abdominal pain, guarding/rigidity, rebound tenderness, absent bowel sounds, fever, tachycardia, nausea; late signs of septic shock. Diagnosis: clinical + WBC, abdominal X-ray (free air), CT. Treatment: emergency surgery (source control - closure, resection), peritoneal lavage, drains; IV antibiotics (broad-spectrum), fluid resuscitation, ICU support.

4. Lymphostasis - clinical features, treatment. Also called lymphedema. Primary (congenital, Milroy disease) or secondary (infection, tumor, surgery, radiation - most common). Features: painless, non-pitting edema (initially pitting) of limb, skin thickening, fibrosis, "orange peel" skin, recurrent erysipelas, elephantiasis in late stages. Treatment: conservative (compression stockings/bandaging, manual lymphatic drainage, skin care, antibiotics for infections), surgical (lymphovenous anastomosis, liposuction, Charles procedure - radical excision for severe cases).

TICKET № 7

1. Bleeding - classification. By vessel: arterial (bright red, pulsatile), venous (dark red, continuous flow), capillary, parenchymal (mixed). By direction: external, internal (into cavity - hemothorax, hemoperitoneum), interstitial (into tissue). By timing: primary (at injury), secondary early (within 3 days, clot dislodgement), secondary late (>3 days, vessel erosion by infection/arrosion). By volume: classes I-IV (mild <15%, moderate 15-30%, severe 30-40%, massive >40% BV).

2. Signs of biological death. Early signs (first 1-4 hours): livor mortis (hypostatic spots, purplish discoloration dependent areas), algor mortis (body cooling ~1°C/hour), desiccation of corneas. Late signs: rigor mortis (begins 2-4h, maximal 6-12h, resolves by 48-72h), putrefaction (green discoloration abdomen, begins 24-48h), Larcher spots (triangular desiccation sclera). Absolute intraoperative signs: absence of cardiac activity on ECG >30 min, fixed dilated pupils, no respiration.

3. Prevention of postoperative thromboembolic complications. Non-pharmacological: early mobilization, compression stockings (Class II), intermittent pneumatic compression devices, adequate hydration. Pharmacological: LMWH (enoxaparin 40 mg/day or 20 mg/day low risk) starting 12h pre-op or 6-12h post-op; UFH for renal impairment; NOACs (rivaroxaban, apixaban) for orthopedic surgery. Duration: 10-14 days (general surgery), 35 days (hip/knee arthroplasty). Risk stratification by Caprini or Rogers score guides intensity.

4. Echinococcosis - clinical presentation, diagnosis, treatment. Caused by Echinococcus granulosus (cystic) or E. multilocularis (alveolar). Liver (most common) and lung involvement. Symptoms: slow-growing cyst, RUQ mass/pressure, hepatomegaly, biliary obstruction; cyst rupture causes anaphylaxis and dissemination. Diagnosis: ultrasound/CT (cyst with daughter cysts, "sand" appearance), serology (ELISA, indirect hemagglutination), X-ray (calcified cyst). Treatment: surgery (pericystectomy, or PAIR - puncture-aspiration-injection-reaspiration + albendazole pre/postoperatively); medical alone (albendazole) for inoperable cases.

TICKET № 8

1. Indications for blood transfusion.

Acute hemorrhagic anemia: Hb <70 g/L (in stable patients) or <100 g/L with ongoing bleeding/cardiovascular compromise
Symptomatic anemia unresponsive to treatment
Surgical blood loss >20-25% blood volume
Pre-operative preparation: Hb <80 g/L before major surgery
Coagulopathy with active bleeding (FFP, platelets)
Exchange transfusion (hemolytic disease of newborn, severe malaria) Transfusion is NOT indicated solely by Hb number - clinical signs must be considered.

2. Collapse - causes, first aid. Collapse is acute vascular insufficiency with BP drop without loss of consciousness (distinguishes from syncope). Causes: massive hemorrhage, acute myocardial infarction, severe infection/toxemia, adrenal insufficiency, vasovagal (orthostatic). Features: pallor, cold sweats, weak rapid pulse, hypotension, nausea, confusion. First aid: lay patient flat (legs elevated), ensure airway, IV access, crystalloid infusion (saline), vasopressors (norepinephrine) if BP unresponsive, treat underlying cause, oxygen, ECG monitoring.

3. Specific surgical infections - Tetanus. Specific surgical infections: tetanus, gas gangrene (Clostridium perfringens), anthrax, erysipelas, diphtheria of wounds. Tetanus caused by Clostridium tetani neurotoxin (tetanospasmin) - blocks glycine/GABA at spinal cord, causing spastic paralysis. Incubation 3-21 days; early: trismus (lockjaw), risus sardonicus, dysphagia; generalized: opisthotonus, tonic spasms triggered by stimuli, autonomic instability. Treatment: wound debridement, tetanus antitoxin (TIG 3000-6000 IU), metronidazole/penicillin, diazepam/muscle relaxants, mechanical ventilation. Prevention: toxoid vaccination (DTP schedule); active-passive immunization post-injury.

4. Alveococcosis - clinical features, diagnosis, treatment. Caused by Echinococcus multilocularis larvae (fox tapeworm). Behaves like a malignant tumor - infiltrative growth, no fibrous capsule. Mainly liver; metastasizes to brain, lungs. Symptoms: hepatomegaly, jaundice, portal hypertension, biliary cirrhosis; late presentation common. Diagnosis: CT/MRI (irregular, densely calcified, infiltrative mass), serology (Em2/Em18 ELISA), PET scan. Treatment: radical resection when possible (R0), but often unresectable due to infiltration; albendazole long-term (years, sometimes lifelong) to halt progression; liver transplantation in select cases.

TICKET № 9

1. Blood transfusion complications.

Immunological: hemolytic reaction (ABO/Rh incompatibility), febrile non-hemolytic reaction (most common), allergic/anaphylactic, TRALI (transfusion-related acute lung injury), TA-GvHD
Infectious: HIV, hepatitis B/C, CMV, syphilis, malaria, prions
Metabolic: hyperkalemia, hypocalcemia (citrate toxicity), hypothermia, metabolic acidosis
Circulatory: TACO (transfusion-associated circulatory overload), air embolism
Massive transfusion complications: coagulopathy (dilutional), hypothermia, acidosis triad

2. Coma - clinical features, diagnosis, treatment. Coma is a state of unarousable unresponsiveness. Causes: metabolic (hypoglycemia, hepatic, uremic, DKA), structural (stroke, TBI, tumor, infection). Glasgow Coma Scale <8 = coma. Features: no eye opening, no verbal/motor response, absent protective reflexes. Diagnosis: blood glucose (first!), ABG, electrolytes, toxicology screen, CT head, LP if meningitis suspected. Treatment: ABCDE, correct hypoglycemia (50% dextrose), naloxone (opioids), thiamine (alcoholism), intubation if GCS <8, treat underlying cause, ICP monitoring if TBI.

3. Fast-track (Enhanced Recovery After Surgery - ERAS) therapy. ERAS is a multimodal perioperative care protocol to reduce surgical stress and speed recovery. Key elements: preoperative (carbohydrate loading, no prolonged fasting, prehabilitation), intraoperative (minimal invasive approach, goal-directed fluid therapy, normothermia, short-acting anesthetics), postoperative (early oral intake and mobilization, multimodal analgesia avoiding opioids, removal of drains/catheters early). Benefits: reduced hospital stay, complications, and costs.

4. Classification of congenital diseases.

By etiology: genetic (chromosomal - Down syndrome; monogenic - PKU; multifactorial - cleft palate), environmental (teratogen-induced), combined
By system: cardiovascular, GI, CNS, urogenital, musculoskeletal, etc.
By severity: lethal, severe (requiring urgent correction), moderate, minor
By timing: embryopathies (1st trimester - major malformations), fetopathies (2nd-3rd trimester - functional/growth disorders)
Isolated vs. multiple malformations (syndromes)

TICKET № 10

1. Classification of blood components.

Red cell components: packed RBCs, leukoreduced RBCs, washed RBCs, irradiated RBCs, frozen RBCs
Platelet components: random donor platelets, apheresis (single-donor) platelets
Plasma components: fresh frozen plasma (FFP), cryoprecipitate (fibrinogen, FVIII, vWF), single-donor plasma
Granulocyte concentrates (rare, specific indications)
Each component addresses a specific deficiency; whole blood rarely used now.

2. Mechanical and physical antisepsis. Mechanical antisepsis: removal of microorganisms by physical means - primary surgical debridement (excision of necrotic tissue), wound irrigation, drainage (passive/active), dressing changes, pus evacuation. Physical antisepsis: drying effect (hypertonic solutions), UV irradiation (germicidal wavelength 253.7 nm), laser therapy, ultrasonic cavitation, heat, X-ray therapy (rarely), sorption dressings (activated charcoal, silica).

3. Clinical groups of oncology patients.

Group I: patients with precancerous conditions (Ia) or under examination with suspected cancer (Ib)
Group II: patients with malignant tumors potentially curable by radical treatment
Group IIa: patients subject to radical treatment (surgery, radiation, chemotherapy)
Group III: patients in practical recovery (after radical treatment, observation)
Group IV: patients with advanced cancer not amenable to radical treatment; palliative/symptomatic care only

4. Diagnosis of congenital diseases. Prenatal: ultrasound (structural anomalies from 18-20 weeks), maternal serum screening (AFP, hCG, estriol - Down/NTD screening), amniocentesis (chromosomal analysis, biochemistry), chorionic villus sampling (CVS - 10-12 weeks), cordocentesis, NIPT (cell-free fetal DNA). Postnatal: neonatal screening (PKU, hypothyroidism, cystic fibrosis), clinical examination, imaging (X-ray, US, CT, MRI), chromosomal karyotyping, enzyme assays, molecular genetic tests.

TICKET № 11

1. Contraindications to blood donation. Absolute: HIV/AIDS, hepatitis B/C, syphilis, active tuberculosis, malignancy, serious cardiac/renal/hepatic disease, blood disorders, history of Creutzfeldt-Jakob disease. Relative (temporary deferral): recent infection/fever (4 weeks), recent surgery, pregnancy/lactation (6 months postpartum), recent vaccination (2-4 weeks), travel to endemic areas (malaria), recent tattoo/piercing (4-6 months), low Hb (<120 g/L women, <130 g/L men).

2. Chemical and biological antisepsis. Chemical: halogens (iodine 5% tincture, povidone-iodine, chlorhexidine), oxidizers (H₂O₂ 3%, KMnO₄), alcohols (70% ethanol, isopropanol), aldehydes (glutaraldehyde), surfactants, heavy metal salts (silver nitrate), nitrofurans (furacilin 1:5000), dyes (brilliant green, methylene blue). Biological: antibiotics (systemic and local), bacteriophages, proteolytic enzymes (trypsin, chymotrypsin - break down necrosis), immune sera, immunoglobulins, interferons, probiotics.

3. Types of surgical procedures for malignant diseases.

Radical: complete removal of tumor with regional lymph nodes (R0 resection) - curative intent
Extended radical: resection of adjacent organs involved by tumor
Palliative: reduces tumor bulk to improve quality of life or enable other therapy (debulking)
Symptomatic: relieves complications (colostomy for obstructing colon cancer, biliary bypass)
Cytoreductive + HIPEC (peritoneal malignancies)
Diagnostic/staging: biopsy, exploratory laparotomy, sentinel node biopsy

4. Treatment of congenital diseases. Conservative: medications (enzyme replacement, hormone therapy, dietary restriction in metabolic diseases), physiotherapy, orthoses. Surgical: timing depends on severity (emergency - intestinal atresia; elective - cleft palate 6-12 months); correction of structural defects (heart, GI, urogenital). Genetic: gene therapy (in development), bone marrow transplant (SCID, thalassemia). Prenatal interventions: fetal surgery (spina bifida, hydronephrosis). Multidisciplinary team approach required.

TICKET № 12

1. Methods of blood component transfusion.

Intravenous (most common): peripheral or central venous catheter
Intra-arterial: for severe peripheral spasm/arterial thrombosis (rarely)
Intraosseous: in emergencies when IV access impossible (children, field)
Intraperitoneal/intracardiac: historical, not used now
Autologous transfusion: preoperative donation, intraoperative cell salvage (Cell Saver), acute normovolemic hemodilution
Exchange transfusion: hemolytic disease of newborn, toxicology

2. Wound classification. By mechanism: incised (clean edges), lacerated (irregular), contused, stab, gunshot, bite, avulsion, scalp. By depth: superficial (skin/subcutaneous), deep (fasciae/muscles), penetrating (into body cavity). By contamination: clean (surgical, aseptic), clean-contaminated, contaminated, dirty/infected. By timing: fresh (<6h), stale (6-24h), old (>24h). Surgical wounds: Class I (clean), II (clean-contaminated), III (contaminated), IV (dirty/infected).

3. Criteria for brain death. Preconditions: known irreversible cause, normothermia, no drug intoxication/metabolic disturbance. Clinical criteria: coma (GCS 3, no response to pain), absent brainstem reflexes (pupillary, corneal, oculocephalic, oculovestibular, gag, cough), apnea (no breathing at pCO₂ >60 mmHg). Confirmatory tests (if needed): EEG (isoelectric), cerebral angiography (no intracranial blood flow), TCD, somatosensory evoked potentials. Two physicians certify; required waiting period varies by jurisdiction.

4. Congenital esophageal stenosis - clinical features, diagnosis, treatment. Rare congenital narrowing due to fibromuscular thickening, cartilaginous rings (tracheobronchial remnants), or membranous web. Presents in neonates/infants when solids introduced: dysphagia, regurgitation, choking, failure to thrive, recurrent aspiration pneumonia. Diagnosis: barium swallow (smooth, fusiform narrowing), esophagoscopy (confirms + biopsies). Treatment: endoscopic balloon dilation (first-line, multiple sessions); surgical resection with anastomosis for long-segment or refractory stenosis; cartilaginous type often requires surgery.

TICKET № 13

1. Contraindications to blood transfusion. Absolute: decompensated heart failure with pulmonary edema, severe hypertension, thromboembolism, acute glomerulonephritis, hepatic failure. Relative (weigh risk/benefit): compensated heart failure, hepatic/renal disease, allergic conditions, bronchial asthma, polyvalent allergy. In life-threatening hemorrhage with no alternative, there are no absolute contraindications. Always use leukoreduced/washed products in sensitized patients.

2. Wound healing - phases. Phase 1 - Inflammatory (days 1-4): hemostasis, neutrophil infiltration, debridement of necrotic tissue, exudation. Phase 2 - Proliferation (days 4-21): fibroblast migration, collagen synthesis, granulation tissue formation, angiogenesis, wound contraction (myofibroblasts). Phase 3 - Remodeling (3 weeks to 2 years): collagen cross-linking and reorganization (Type III → Type I), scar maturation, tensile strength increases (max ~80% of normal). Overlapping phases, disrupted by infection, ischemia, diabetes, malnutrition.

3. Phlegmons of the hand - classification, diagnosis, treatment. Phlegmon = diffuse purulent inflammation of cellular spaces. Hand phlegmons: subcutaneous (dorsal/palmar), subfascial, midpalmar space (most common deep), thenar space, hypothenar space, subaponeurotic, commissural ("collar-button"), web space, U-shaped (horseshoe - spreads from thumb to little finger via communicating tendon sheaths). Diagnosis: throbbing pain, tense edema, finger held in flexion (tendon sheath involvement), fever. Treatment: urgent surgical drainage via adequate incisions (counter-incisions), antibiotic therapy (antistaphylococcal), hand elevation, splinting.

4. Congenital diaphragmatic hernia - clinical presentation, diagnosis, treatment. Herniation of abdominal organs into thorax (90% left-sided, Bochdalek type) through diaphragmatic defect. Pulmonary hypoplasia is the main cause of mortality. Presents at birth: respiratory distress, cyanosis, scaphoid abdomen, absent breath sounds on affected side, bowel sounds in chest, mediastinal shift. Diagnosis: prenatal US (polyhydramnios, stomach in chest), chest X-ray (bowel loops in thorax, mediastinal shift). Treatment: stabilize first (avoid bag-mask ventilation), intubate, NG tube, delayed surgical repair (primary closure or patch) after physiologic stabilization; ECMO for severe cases.

TICKET № 14

1. Algorithm before performing red blood cell transfusion.

Verify indication and written consent
Check blood group and Rh of patient (re-check from patient sample)
Inspect blood bag (label, expiry, integrity, color/clots)
Confirm ABO/Rh of unit matches patient
Bedside ABO compatibility check (patient serum + donor cells)
Biological test: infuse 10-15 mL slowly, observe 3 min × 3 times
Transfuse at correct rate; observe patient continuously
Document in medical record (lot number, volume, time, reaction)

2. Types of wound healing. Primary intention (per primam): clean wound edges approximated surgically, minimal granulation, thin scar. Requires: no infection, good blood supply, adequate tissue apposition. Secondary intention (per secundam): wound left open, heals by granulation, contraction, re-epithelialization; larger scar; used for infected or contaminated wounds. Tertiary intention (delayed primary closure): wound debrided and left open, closed surgically at 3-5 days once infection controlled; combines advantages of both.

3. Purulent arthritis - classification, clinical features, diagnosis, treatment. Classification: by cause (hematogenous, post-traumatic, iatrogenic), by stage (serous → seropurulent → purulent → putrid), by joint involved. Features: severe joint pain, swelling, redness, warmth, restricted motion, fever, leukocytosis; joint held in position of comfort. Diagnosis: joint aspiration (turbid fluid, WBC >50,000/μL, bacteria on Gram stain/culture), X-ray (joint space widening/narrowing), ultrasound, MRI. Treatment: joint drainage (aspiration ± irrigation, arthroscopic washout, open arthrotomy for severe cases), IV antibiotics (antistaphylococcal), immobilization, analgesics.

4. Congenital pyloric atresia. Very rare; pylorus is completely obstructed by membrane, solid cord, or gap defect. Presents in neonates: bilious-free (non-bilious!) vomiting from birth, visible gastric peristalsis, upper abdominal distension, dehydration. May be associated with epidermolysis bullosa (EB-PA syndrome). Diagnosis: abdominal X-ray (single "bubble" - gastric distension, no distal gas), upper GI contrast (obstruction at pylorus), ultrasound. Treatment: surgical correction after resuscitation - pyloroplasty or gastroduodenostomy; excellent prognosis if isolated.

TICKET № 15

1. Individual selection (compatibility testing) before blood transfusion. Steps: (1) ABO/Rh grouping of patient and donor unit. (2) Antibody screen (indirect Coombs) for irregular antibodies in patient's serum. (3) Crossmatch: major crossmatch (patient serum + donor RBCs) - most important; minor crossmatch (donor serum + patient RBCs) - rarely done. Methods: immediate spin (saline), incubation at 37°C, Coombs phase (detects IgG antibodies). Electronic crossmatch acceptable if antibody screen negative and ≥2 previous negative screens.

2. Frostbite - stages and treatment. Degrees: I (erythema, edema, no blisters), II (clear fluid blisters, superficial necrosis), III (hemorrhagic blisters, full-thickness skin necrosis), IV (deep necrosis of all tissues including bone). Treatment: remove from cold, remove wet clothing; rapid rewarming in 38-42°C water bath (not dry heat); analgesia (ibuprofen, opioids); antibiotics prophylactically for grade III-IV; aspiration of clear blisters, leave hemorrhagic blisters intact; antiplatelet therapy (aspirin, iloprost); surgical debridement/amputation delayed until demarcation clear (weeks); hyperbaric oxygen adjunct.

3. Treatment methods for cancer patients. Surgical (radical, palliative, symptomatic), radiation therapy (external beam, brachytherapy, stereotactic), chemotherapy (cytotoxic - alkylating, antimetabolites, taxanes, anthracyclines), targeted therapy (tyrosine kinase inhibitors, monoclonal antibodies - trastuzumab, imatinib), immunotherapy (checkpoint inhibitors - PD-1/PD-L1, CTLA-4; CAR-T cells; cancer vaccines), hormone therapy (breast, prostate cancer), photodynamic therapy, radiofrequency/cryoablation. Multimodal combinations are standard.

4. Basic principles of plastic surgery. Goals: restoration of form and function. Principles: (1) Tissues must have adequate blood supply; (2) Minimal tension on closure; (3) Precise tissue handling and atraumatic technique; (4) Use similar tissue to replace like (skin, mucosa, muscle). Techniques: primary closure, skin grafts (split-thickness, full-thickness), local flaps (rotation, transposition, advancement), pedicled flaps (TRAM, latissimus dorsi), free flaps (microsurgical anastomosis - e.g., DIEP flap), tissue expanders, implants.

TICKET № 16

1. Rules for use of medical masks. Masks must cover nose and mouth completely with no gaps. Change every 2 hours (sooner if moist); do not touch the front surface; remove by ear loops only; discard (never reuse disposable masks). Surgical masks: protect against droplets; FFP2/N95 respirators: protect against aerosols/airborne pathogens. Hand hygiene before and after removal. Mask alone insufficient - must be combined with hand hygiene, gloves, eye protection for high-risk procedures.

2. Transfusion shock - diagnosis and treatment. (= Hemotransfusion shock from Ticket 1-2). Diagnosis: occurs during/immediately after transfusion; agitation → chest/lumbar pain → hypotension (BP drop >20 mmHg), tachycardia, fever, hemoglobinuria (red-brown urine), oliguria. Lab: free hemoglobin in plasma/urine, positive direct Coombs, rising bilirubin, coagulation abnormalities. Treatment: stop transfusion immediately, keep IV line open with saline, IV furosemide, sodium bicarbonate IV, dopamine/norepinephrine for BP, corticosteroids, antihistamines, monitor urine output (>100 mL/h), hemodialysis if anuria develops, treat DIC.

3. Classification of purulent infections. By location: skin and subcutaneous (furuncle, carbuncle, abscess, phlegmon, erysipelas, hidradenitis), tendon sheaths/joints/bones (tenosynovitis, arthritis, osteomyelitis), cavities (empyema, peritonitis, pericarditis), organs (mastitis, parotitis, liver abscess). By causative agent: staphylococcal, streptococcal, gram-negative, anaerobic (putrid), mixed. By extent: local vs. generalized (sepsis). By clinical course: acute vs. chronic.

4. Congenital biliary atresia - clinical presentation, diagnosis, treatment. Progressive fibro-obliterative cholangiopathy affecting extrahepatic bile ducts, cause unknown (possibly immune-mediated postnatal). Presents in neonates at 2-8 weeks: prolonged jaundice (conjugated hyperbilirubinemia), acholic (pale clay) stools, dark urine, hepatomegaly; progresses to biliary cirrhosis and liver failure. Diagnosis: ultrasound (absent/small gallbladder), hepatobiliary scintigraphy (no excretion into bowel), liver biopsy (bile duct proliferation, fibrosis), intraoperative cholangiography (gold standard). Treatment: Kasai portoenterojejunostomy (before 60 days of life = better outcome); liver transplantation for failed Kasai or advanced liver disease.

TICKET № 17

1. Classification of blood products.

Whole blood (rarely used)
Cellular components: packed RBCs, leukoreduced RBCs, washed RBCs, platelets (pooled or apheresis), granulocytes
Plasma products: FFP, cryoprecipitate, albumin (5%, 20%, 25%)
Coagulation factor concentrates: Factor VIII, Factor IX, prothrombin complex concentrate (PCC), fibrinogen concentrate, recombinant FVIIa
Immunoglobulins: IVIG, specific immunoglobulins (anti-D, anti-tetanus)
Plasma-derived vs. recombinant products

2. Basic principles of treating purulent infections.

Surgical: timely incision and drainage, excision of necrotic tissue, adequate drainage
Antimicrobial: empirical then culture-guided antibiotics (antistaphylococcal coverage + broad-spectrum for polymicrobial)
Local wound care: antiseptic dressings, phase-appropriate wound management
Detoxification: IV fluids, in severe cases - extracorporeal methods
Immunostimulation: immunoglobulins, specific sera, vitamins
Supportive: analgesia, nutritional support, treat comorbidities

3. Acute arterial obstruction - cause, clinical features, diagnosis, treatment. Causes: embolism (cardiac - AF, MI, valvular disease; 80% of cases) vs. thrombosis (on atherosclerotic plaque). Presents with "6 Ps": Pain (sudden, severe), Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (cold). Time-critical: muscle necrosis begins at 4-6h. Diagnosis: clinical + Doppler ultrasound, CT angiography. Treatment: immediate anticoagulation (heparin bolus), surgical embolectomy (Fogarty catheter - up to 6h), thrombolysis (catheter-directed - beyond 6h or small vessels), bypass if thrombotic, fasciotomy for compartment syndrome, amputation if unsalvageable.

4. Congenital annular pancreas - clinical features, diagnosis, treatment. Ring of pancreatic tissue encircles and obstructs the second part of duodenum. Associated with Down syndrome (20-30%), other anomalies. Neonatal presentation: bilious vomiting, duodenal obstruction signs (double bubble on X-ray). Adult presentation: upper abdominal pain, nausea, peptic ulcer (30%), pancreatitis. Diagnosis: X-ray (double bubble), upper GI series, CT, MRCP/ERCP (pancreatic duct encircling duodenum). Treatment: surgical bypass (duodenoduodenostomy or duodenojejunostomy) - never attempt to divide the annular tissue; excellent prognosis.

TICKET № 18

1. Classification of blood substitutes and their use.

Volume expanders (colloids): albumin, dextrans (dextran-40 improves microcirculation), hydroxyethyl starch (HES), gelatins - for hypovolemia
Crystalloids: saline, Ringer's, PlasmaLyte - fluid resuscitation
Oxygen carriers: perfluorocarbon emulsions (Perftoran), hemoglobin-based oxygen carriers (HBOC) - experimental
Plasma substitutes: FFP, albumin - for coagulopathy/oncotic pressure
Detoxification solutions: hemodez (povidone), reopolyglucin - improve microcirculation, bind toxins
Parenteral nutrition solutions: amino acid mixtures, lipid emulsions, glucose

2. Terminal conditions - signs of clinical death, first aid. Terminal states: predagony (impaired consciousness, agonal breathing, fading pulse) → agony → clinical death → biological death. Clinical death: cessation of circulation and respiration, reversible for 4-6 min (longer in hypothermia). Signs: absence of pulse (carotid), absence of breathing, unconsciousness, dilated pupils (1-2 min). First aid (CPR): place on firm surface; chest compressions 30:2 (rate 100-120/min, depth 5-6 cm); AED as soon as available; epinephrine 1mg IV every 3-5 min; do not stop >10 min without ROSC (unless hypothermia).

3. Classification of purulent skin/subcutaneous diseases - presentation, diagnosis, treatment.

Furuncle: single hair follicle/sebaceous gland infection (S. aureus); painful red nodule → pustule → necrotic core. Tx: incision when fluctuant, antibiotics if systemic signs.
Carbuncle: multiple follicles, wider necrosis; severe systemic signs; requires surgical debridement + antibiotics.
Abscess: walled-off pus collection; fluctuance, fever; Tx: incision and drainage.
Phlegmon: diffuse spreading cellulitis without clear border; Tx: surgical incisions + drainage + antibiotics.
Erysipelas: β-hemolytic Streptococcus, sharp-bordered skin inflammation; Tx: penicillin.
Hidradenitis: sweat gland infection (axillae, groin); recurrent; Tx: drainage, excision.

4. Congenital intestinal atresia - clinical presentation, diagnosis, treatment. Duodenal (50%), jejunal/ileal (40%), colonic (10%). Pathology: mesenteric defect, apple-peel deformity, multiple atresias. Presents in neonates: bilious (if below Vater's ampulla) or non-bilious vomiting, abdominal distension (distal), failure to pass meconium, scaphoid abdomen (proximal). Diagnosis: prenatal US (polyhydramnios), plain X-ray (air-fluid levels, "double bubble" for duodenal, multiple loops for ileal), contrast enema (microcolon in ileal atresia). Treatment: surgical correction after stabilization - anastomosis (primary or tapering), stoma if contaminated; TPN postoperatively.

TICKET № 19

1. Indications for blood component transfusion.

RBCs: Hb <70 g/L (stable) or <100 g/L (cardiac/respiratory disease, active bleeding); acute hemorrhage >30% blood volume
Platelets: <10×10⁹/L (prophylactic), <50×10⁹/L (active bleeding/surgery), <100×10⁹/L (neurosurgery/ophthalmology)
FFP: coagulopathy with active bleeding, PT/INR >1.5 before invasive procedures, DIC, TTP (with plasmapheresis), warfarin reversal when PCC unavailable
Cryoprecipitate: fibrinogen <1.5 g/L, hemophilia A, vWD when specific factor unavailable
Granulocytes: prolonged neutropenia (<0.5×10⁹/L) with life-threatening infection not responding to antibiotics

2. Ensuring surgical safety. WHO Surgical Safety Checklist (3 pauses): (1) Sign In (before anesthesia): patient identity, consent, site marking, anesthesia check, pulse oximeter. (2) Time Out (before incision): team introduction, confirm patient/procedure/site, antibiotics given, critical steps discussed, equipment available. (3) Sign Out (before leaving OR): procedure confirmed, specimen labeled, instrument/sponge count correct, key recovery concerns. Reduces surgical mortality and complications by ~50%.

3. Superficial panaritiums (felons) - classification, features, diagnosis, treatment, anesthesia. Superficial types: (1) Cutaneous - pus under epidermis, "run-around" (periungual); (2) Subcutaneous - most common, painful pulp abscess; (3) Periungual (paronychia) - nail fold infection; (4) Subungual - under nail plate. Features: throbbing pain, redness, swelling at fingertip. Diagnosis: clinical; probe test to determine depth. Treatment: incision and drainage (fishmouth/hockey-stick incision for subcutaneous); removal of nail for subungual. Anesthesia: ring block (metacarpal nerve block) with 1% lidocaine without epinephrine at base of finger.

4. Congenital Hirschsprung's disease - clinical features, diagnosis, treatment. Absence of ganglion cells (Meissner's and Auerbach's plexuses) in rectum ± sigmoid, causing functional obstruction. The aganglionic segment fails to relax. Clinical: neonates - failure to pass meconium in 48h, bilious vomiting, abdominal distension; older children - chronic constipation, abdominal distension, failure to thrive. Enterocolitis = life-threatening complication. Diagnosis: rectal biopsy (absent ganglion cells - gold standard), barium enema (transition zone, no evacuation at 24h), anorectal manometry (absent rectoanal inhibitory reflex). Treatment: Swenson, Duhamel, or Soave pull-through operation (resect aganglionic segment + anastomosis); initially defunctioning colostomy in sick neonates.

TICKET № 20

1. Blood type and Rh factor determination. ABO: standard sera method (2 drops each of anti-A, anti-B, anti-AB serum on white tile + drop of test blood; read agglutination at 5 min); or monoclonal antibodies (same principle). Rh factor: 1 drop of anti-D serum + 1 drop of blood on heated plate (37°C) or slide at room temp; agglutination = Rh+. Cross-check with standard Rh+ and Rh- cells. Must be performed in 2 independent blood samples from the patient; confirmed in the lab.

2. Hospital-acquired (nosocomial) infections - prevention. Definition: infection acquired ≥48h after hospital admission not present at entry. Causative agents: multidrug-resistant organisms (MRSA, VRE, ESBL-producing gram-negatives, C. difficile, Candida). Transmission: contact (hands), droplet, airborne, instrument-borne. Prevention: standard precautions (hand hygiene is #1), contact/airborne precautions for resistant organisms, aseptic technique for procedures, SSI bundle (prophylactic antibiotics, skin prep, normothermia), proper catheter/line care (CLABSI bundles), environmental cleaning, surveillance and antibiotic stewardship.

3. Deep panaritiums (felons) - classification, presentation, diagnosis, treatment, anesthesia. Types: (1) Tendinous (tenosynovitis): infection of flexor tendon sheath - Kanavel's 4 signs (finger held in flexion, fusiform swelling, tenderness along sheath, pain on passive extension - most important!); (2) Bony: necrosis of phalanx, X-ray changes; (3) Articular: joint swollen, boggy; (4) Pandactylitis: all structures involved. Treatment: urgent incision and drainage of tendon sheath (Brunner incisions), continuous irrigation; IV antibiotics (antistaphylococcal); bony/articular - debridement ± amputation. Anesthesia: wrist block or general for deep forms.

4. Definitions: reconstructive, restorative, plastic surgery, transplantation.

Reconstructive surgery: correction of anatomical defects caused by disease, trauma, or congenital anomalies (e.g., mastectomy reconstruction, mandible reconstruction)
Restorative surgery: restoration of normal function lost due to injury or disease (e.g., nerve repair, tendon repair)
Plastic surgery: operations that alter the shape and appearance of body structures; includes cosmetic (aesthetic) and reconstructive
Transplantation: transfer of cells, tissues, or organs from a donor to a recipient to replace lost/failed function; types: autotransplantation, allotransplantation, xenotransplantation

TICKET № 21

1. Blood compatibility tests. (1) ABO compatibility: patient serum + donor RBCs on slide - look for agglutination. (2) Rh compatibility: same + anti-globulin serum at 37°C. (3) Indirect Coombs test (antibody screen): detects alloantibodies in patient serum. (4) Full crossmatch: major (patient serum + donor cells at room temp, 37°C, Coombs phase) + minor (donor serum + patient cells). Electronic crossmatch: computer verification if ≥2 historical negative screens. Biological compatibility test (bedside): infuse 10 mL slowly × 3, observe for reaction.

2. Electrical injury - clinical presentation, first aid. Severity depends on voltage, current type (AC > DC), path through body, resistance, duration. Local: entry/exit burns (deep, charred), "crocodile skin" burns along current path, deep muscle necrosis (higher voltage). Systemic: cardiac arrhythmias (VF - leading cause of death), respiratory arrest, CNS - seizures/unconsciousness, myoglobinuria (rhabdomyolysis) → renal failure, tetanic muscle contractions (may prevent release from source). First aid: disconnect power source safely, CPR if cardiac arrest, do not touch victim until safe, treat burns, IV fluids (prevent renal failure from myoglobin), ECG monitoring, hospitalize all significant exposures.

3. Hand phlegmons - classification, diagnosis, treatment, anesthesia. (See Ticket 13-3 for full classification). Specific spaces: midpalmar (most common deep space - dorsal edema despite palmar infection), thenar (thumb/index involvement), hypothenar, subaponeurotic (between aponeurosis and metacarpals), subfascial dorsal, commissural (between fingers). Diagnosis: severe throbbing pain, fingers in forced flexion, massive edema (dorsal often more obvious than palmar), fever/sepsis. Treatment: urgent drainage through adequate incisions (palmar - transverse; dorsal - longitudinal; counter-incisions), tendon sheath irrigation, IV antibiotics. Anesthesia: brachial plexus block (axillary, infraclavicular) or general anesthesia.

4. Transplantation - classification. By donor-recipient relationship:

Autotransplantation: same individual (e.g., skin graft, saphenous vein bypass)
Isotransplantation (syngeneic): identical twins - no rejection
Allotransplantation: same species, different individual - most common clinical transplants
Xenotransplantation: across species (pig → human - experimental)

By organ/tissue: solid organs (kidney, liver, heart, lung, pancreas), composite tissue (hand, face), cells (bone marrow/stem cells, islet cells), tissues (cornea, heart valves, bone) By technique: orthotopic (native organ removed, e.g., heart) vs. heterotopic (native retained, e.g., kidney placed in iliac fossa)

TICKET № 22

1. Physician's actions before transfusing blood components.

Check patient identity (name, DOB, medical record number) against blood unit label
Verify ABO/Rh of patient and unit match
Inspect unit: expiry date, integrity, color (RBCs should be red, not brown/black), no clots/turbidity
Review patient's transfusion history and antibody screen
Obtain informed consent
Confirm pre-transfusion labs (Hb, platelets, coagulation as appropriate)
Perform bedside biological test
Set correct infusion rate (RBCs: 1-4h; platelets: 20-30 min; FFP: 30 min)
Document all details; monitor patient throughout

2. Burn disease - periods and treatment. Burn disease occurs with burns >10-15% BSA (adults), >5-10% (children). Periods:

Burn shock (first 1-3 days): massive fluid shifts, hypovolemia; Tx: Parkland formula resuscitation (4 mL × weight(kg) × %BSA; half in first 8h, half in next 16h)
Acute burn toxemia (3-10 days): absorption of burn toxins, fever, organ dysfunction
Septicotoxemia (2 weeks - months): wound infection, sepsis, multiple organ failure
Convalescence: wound healing, rehabilitation. Treatment principles: analgesia, fluid resuscitation, wound care (silver sulfadiazine, mafenide), early excision and grafting, nutritional support, physiotherapy.

3. Patient assessment scales.

Glasgow Coma Scale (GCS): eye (1-4) + verbal (1-5) + motor (1-6) = 3-15; <8 = intubate
APACHE II/III: ICU severity scoring
SOFA/qSOFA: organ dysfunction in sepsis; qSOFA ≥2 (RR≥22, altered mentation, SBP≤100) = suspected sepsis
Braden scale: pressure ulcer risk
Wells score: DVT/PE probability
Caprini score: VTE risk in surgical patients
NRS-2002 / MUST: nutritional risk screening
ASA physical status: anesthesia risk (I-VI)
Visual Analogue Scale (VAS): pain assessment

4. Brain death criteria. (Same as Ticket 12-3 - see above)

TICKET № 23

1. Local anesthesia - classification, max dose of novocaine, contraindications. Classification: (1) Surface/topical (lidocaine spray, cocaine on mucosa); (2) Infiltration (injection into tissues - A. Vishnevsky "creeping infiltrate"); (3) Conduction/regional: nerve block, plexus block, epidural, spinal; (4) IV regional (Bier block). Max single dose of novocaine (procaine): 0.25% - 500 mL (1.25 g); 0.5% - 150 mL (0.75 g); 1% - 75 mL (0.75 g); 2% - 25 mL (0.5 g). With epinephrine - dose can be increased by 1/3. Contraindications: allergy to local anesthetics (ester class), coagulopathy (for spinal/epidural), infection at injection site, severe hypovolemia (spinal), increased ICP (spinal), patient refusal.

2. TNM classification.

T (Tumor): size/extent of primary tumor: Tx (not assessed), T0 (no evidence), Tis (in situ), T1-T4 (increasing size/invasion)
N (Nodes): regional lymph node involvement: Nx (not assessed), N0 (no nodes), N1-N3 (increasing number/extent)
M (Metastasis): distant metastasis: Mx (not assessed), M0 (no distant metastasis), M1 (distant metastasis present) Stage groupings (I-IV) are derived from TNM combinations; guide treatment decisions and prognosis.

3. Acute venous insufficiency - clinical presentation, diagnosis, treatment. Caused by DVT, superficial thrombophlebitis, or iatrogenic venous injury. DVT features: calf/thigh pain, edema, warmth, redness, Homans' sign (pain on dorsiflexion - not sensitive). Phlegmasia alba dolens (iliac vein thrombosis): pale, painful, swollen leg. Phlegmasia cerulea dolens (massive outflow obstruction): blue, painful, severe edema → venous gangrene. Diagnosis: duplex ultrasound (gold standard), D-dimer. Treatment: anticoagulation (LMWH, NOACs), leg elevation, compression; catheter-directed thrombolysis or thrombectomy for massive/phlegmasia; IVC filter if anticoagulation contraindicated.

4. Organ and tissue donor service - tasks. Tasks: (1) Identification and referral of potential brain-dead donors; (2) Donor evaluation (medical suitability, infectious disease screening, tissue typing); (3) Coordination with transplant centers and organ procurement organizations; (4) Family communication and consent; (5) Organ preservation and procurement surgery; (6) Allocation according to national transplant registry (matching, waiting list, urgency); (7) Quality assurance and outcome tracking; (8) Education and awareness programs to increase donation rates.

TICKET № 24

1. Classification of anesthesia. Conduction anesthesia - examples. Classification by method: local (topical, infiltration, conduction), regional (spinal, epidural, nerve blocks), general (inhalational, IV, combined). By route: inhalational (isoflurane, sevoflurane, desflurane), IV (propofol, ketamine, thiopental), combined (most common). Conduction (nerve block) anesthesia - local anesthetic deposited near specific nerves: brachial plexus (axillary, supraclavicular, interscalene blocks), femoral nerve block, sciatic nerve block, intercostal nerve block, paravertebral block, pudendal block, dental nerve block. Epidural and spinal are central neuraxial conduction anesthesia.

2. Principles of rational antibiotic therapy for purulent infections.

Identify pathogen + sensitivity (culture before starting if possible)
Choose antibiotic based on likely/confirmed pathogen (antistaphylococcal for skin/soft tissue; broad-spectrum for polymicrobial)
Correct dose, route (IV for severe), duration (not too short, not too long)
De-escalate when culture results available
Monitor for efficacy and toxicity
Combine if needed (synergy, prevent resistance - e.g., beta-lactam + aminoglycoside for pseudomonal)
Adequate surgical source control first - antibiotics alone insufficient for abscess/empyema
Avoid prophylactic antibiotics >24h for surgical prophylaxis

3. Differences between benign and malignant tumors.

Feature	Benign	Malignant
Growth	Slow, expansive	Fast, invasive
Capsule	Usually present	Absent
Borders	Clear	Irregular, infiltrative
Metastasis	No	Yes (hallmark)
Recurrence	Rare after excision	Common
Cell atypia	Minimal	Marked
Necrosis	Rare	Common
Effect	Local compression	Systemic (cachexia, paraneoplasia)

4. Contraindications to organ harvesting. Absolute: HIV infection (except HIV+ to HIV+ transplant in some countries), active malignancy (except primary CNS tumors and some skin cancers), prion diseases (CJD), uncontrolled sepsis with multi-organ failure, unknown cause of death. Relative: prolonged warm ischemia, hepatitis B/C with active replication (can be used for specific recipients), older donor age, severe organ dysfunction, prolonged hypotension. Social history (IV drug use, high-risk behavior) - requires additional infectious screening.

TICKET № 25

1. General anesthesia - stages. Guedel's ether stages (classically described, still referenced):

Stage I (Analgesia): conscious, responds, pain reduced
Stage II (Excitement/Delirium): unconscious but excited, irregular breathing, breath-holding, vomiting risk - dangerous!
Stage III (Surgical anesthesia): divided into 4 planes - regular breathing, loss of reflexes, progressive muscle relaxation; planes 2-3 are surgical planes
Stage IV (Medullary/Overdose): respiratory and circulatory center depression → death With modern agents: induction → maintenance → emergence; stages less distinct. Induction: propofol/thiopental; maintenance: inhalational agent + opioid + muscle relaxant; monitored by: BIS, end-tidal anesthetic agent, clinical signs.

2. Initial patient examination. History: chief complaint, present illness, past medical/surgical history, medications, allergies, family/social history, review of systems. Physical exam: general appearance, vital signs (HR, BP, RR, T, SpO₂), then systematic: head/neck, chest (inspection, palpation, percussion, auscultation), abdomen, extremities, neurological. Documentation in medical record. For surgical patients: assess surgical risk (ASA score), determine if additional investigations needed before intervention.

3. Laparostomy - types and indications. Laparostomy = intentional temporary open abdomen (abdominal cavity left open with temporary covering). Types: (1) with Bogota bag (sterile saline bag sewn to fascia); (2) VAC (vacuum-assisted closure - negative pressure dressing); (3) Wittmann patch (Velcro-like fascial closure for planned re-operations); (4) mesh/zipper closure. Indications: damage control surgery (severe trauma with uncontrolled hemorrhage + coagulopathy), generalized peritonitis with severe contamination, abdominal compartment syndrome (ACS), planned second-look surgery for ischemic bowel, fascial dehiscence.

4. Tissue compatibility in transplantation - organ selection, rejection, immunosuppression. (Combined with Ticket 2-3 content). HLA matching (HLA-A, -B, -DR most important); ABO compatibility required; PRA (panel reactive antibody) - measures sensitization. Waiting list criteria: urgency (e.g., Status 1A for heart), time on list, compatibility match, geographic proximity for cold ischemia time. Crossmatch: donor lymphocytes + recipient serum → agglutination = positive crossmatch (contraindication). Rejection types: hyperacute (complement-mediated, pre-formed antibodies), acute (T-cell, days-weeks), chronic (fibrosis, months-years). Immunosuppression: see Ticket 2-3.

TICKET № 26

1. Bleeding classification, clinical presentation, diagnosis, treatment. (See Ticket 7-1 for classification). Clinical: arterial - bright red, pulsatile; venous - dark, steady flow; capillary - oozing; internal - hidden, diagnosed by signs of hypovolemia + imaging. Hemorrhagic shock classes: I (<750mL, HR<100), II (750-1500mL, HR 100-120, narrow pulse pressure), III (1500-2000mL, HR>120, hypotension, altered mentation), IV (>2000mL, life-threatening). Diagnosis: vital signs + FAST ultrasound + CT. Treatment: ABCDE, direct pressure/tourniquet, IV access × 2, crystalloid + blood products (1:1:1 ratio for massive hemorrhage - RBC:FFP:platelets), surgical source control, tranexamic acid within 3h of injury.

2. Hypothermia - stages, first aid. Stages: mild (32-35°C): shivering, confusion, ataxia; moderate (28-32°C): shivering stops, severe confusion, bradycardia, atrial arrhythmias; severe (<28°C): unconscious, fixed dilated pupils, VF/asystole - "no one is dead until warm and dead." First aid: prevent further heat loss, remove wet clothing, horizontal position, handle gently (avoid VF trigger), rewarm (passive - insulate; active external - warm blankets, warm IV fluids; active core - warmed humidified O₂, peritoneal lavage, ECMO for severe cases), continuous cardiac monitoring, CPR if arrested (continue until >35°C).

3. Sepsis - etiology, pathogenesis, clinical presentation, diagnosis, treatment. Sepsis-3 definition: life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score increase ≥2). Sources: lung, abdomen, urinary tract, soft tissue, vascular access. Pathogens: gram-negatives (E. coli, Klebsiella, Pseudomonas), gram-positives (Staph, Strep). Pathogenesis: PAMP → TLR activation → cytokine storm (IL-1, IL-6, TNF) → endothelial dysfunction, coagulopathy, vasoplegia, organ failure. Features: fever/hypothermia, tachycardia, hypotension, altered mentation, oliguria, hyperlactatemia. Diagnosis: Sepsis-3 criteria, lactate, cultures × 2 before antibiotics, procalcitonin. Treatment (Surviving Sepsis bundle): blood cultures → broad-spectrum antibiotics within 1h, IV fluids 30 mL/kg crystalloid, vasopressors (norepinephrine) for MAP <65, surgical source control, hydrocortisone if refractory shock, glucose control, VTE prophylaxis.

4. Artificial organs - examples.

Heart: total artificial heart (SynCardia, Abiomed), ventricular assist devices (LVAD - HeartMate, HeartWare)
Kidney: renal replacement therapy (hemodialysis, CVVHDF - not implantable yet); wearable artificial kidney (in development)
Liver: MARS (Molecular Adsorbent Recirculating System), PROMETHEUS - extracorporeal support
Lung: ECMO (extracorporeal membrane oxygenation - veno-venous for respiratory, veno-arterial for cardiac)
Pancreas: artificial pancreas (closed-loop insulin pump system)
Ear: cochlear implant
Joint replacements: hip, knee, shoulder (bionic prosthetics)

TICKET № 27

1. Forrest's endoscopic classification of ulcer bleeding.

Class	Description	Rebleeding risk
Ia	Active spurting	~90%
Ib	Active oozing	~50%
IIa	Non-bleeding visible vessel	~40-50%
IIb	Adherent clot	~25-30%
IIc	Flat pigmented spot	~5-10%
III	Clean base	<2%
Forrest Ia/Ib/IIa require endoscopic hemostasis (injection, thermal, clips); IIb usually treated; IIc/III managed medically (high-dose PPI).

2. Stages of patient examination.

Chief complaint collection
Medical history (present illness - onset, character, duration; past history; family history; social history; allergies; medications)
Physical examination (general → systemic by body system)
Additional investigations: laboratory (CBC, biochemistry, coagulation, urinalysis), instrumental (ECG, X-ray, ultrasound, CT, endoscopy, biopsy)
Formulation of clinical diagnosis (preliminary → confirmed)
Treatment planning
Monitoring and reassessment

3. Diagnostic methods in angiology. Non-invasive: pulse examination, skin temperature, ABI (ankle-brachial index - normal ≥0.9), duplex ultrasound (B-mode + Doppler - gold standard non-invasive), transcutaneous oximetry, photoplethysmography, segmental limb pressures, CT angiography (CTA), MR angiography (MRA). Invasive: digital subtraction angiography (DSA - gold standard for intervention planning), intra-arterial pressure measurement, intravascular ultrasound (IVUS). Functional: treadmill test (walking distance before claudication), reactive hyperemia test.

4. Requirements for organ retrieval during transplantation.

Legal: brain death certified by ≥2 physicians (not from transplant team), informed consent from family or documented donor consent
Medical: donor hemodynamic stability, absence of absolute contraindications (HIV, active malignancy, prion disease)
Logistics: multi-organ procurement team, organ preservation solutions (UW, Custodiol, Celsior) ready, transplant centers notified
Technique: aortic cannulation and cold flush with preservation solution, en bloc removal; minimize warm ischemia time
Documentation: organ viability assessment, tissue biopsies
Cold ischemia limits: kidney 24-36h, liver 12-24h, heart/lung 4-6h, pancreas 12-18h

TICKET № 28

1. Hemorrhagic shock - stages, diagnosis, Algover index, treatment. Stages (ATLS classification): I (<15% BV, <750 mL): normal vitals, slight tachycardia; II (15-30%, 750-1500 mL): HR 100-120, narrow pulse pressure, anxiety; III (30-40%, 1500-2000 mL): HR >120, hypotension, confusion; IV (>40%, >2000 mL): HR >140, BP severely low, lethargy, imminent death. Algover (Shock) Index = HR/systolic BP: normal <1.0; SI 1.0-1.5 = moderate (20-40% loss); >1.5 = severe (>40%). Treatment: stop bleeding, 2 large-bore IVs, crystalloid + blood products (1:1:1), permissive hypotension (MAP 50-65 in penetrating trauma), tranexamic acid within 3h, surgical/radiological hemorrhage control.

2. Methods for closing skin defects in burns.

Split-thickness skin graft (STSG): most common; donor site heals spontaneously; meshed graft (1.5:1 to 3:1) expands coverage
Full-thickness graft (FTSG): better cosmesis, for face/hands
Sheet graft: unmeshed for cosmetically important areas
Cultured epidermal autograft (CEA): grown from biopsy; useful for massive burns (limited donor sites)
Temporary biological cover: allograft (cadaveric skin), xenograft (pig skin), amnion, synthetic substitutes (Integra, Biobrane) - temporary until autograft available
Local flaps: for small specialized defects

3. TNM staging of malignant diseases. Stage groupings combine T, N, M:

Stage 0: Tis, N0, M0 (carcinoma in situ)
Stage I: T1-2, N0, M0 (localized, small)
Stage II: T3-4, N0, M0 or T1-2, N1, M0 (locally advanced, ± limited nodes)
Stage III: any T, N2-3, M0 (extensive node involvement)
Stage IV: any T, any N, M1 (distant metastasis) (Specific cutoffs vary by tumor type.) Stage determines resectability, treatment choice, and prognosis.

4. Types of organ preservation during transplantation.

Cold static storage: flush with cold preservation solution (4°C), place in iced solution; simplest, most used. Solutions: UW (University of Wisconsin) for liver/kidney, Custodiol (HTK), Celsior.
Machine perfusion: hypothermic machine perfusion (HMP) for kidneys - reduces DGF; normothermic machine perfusion (NMP - 37°C) - assesses and reconditions organs (DCD livers); becoming standard for marginal organs.
Cold ischemia time limits must not be exceeded.
Ex-vivo normothermic perfusion (EVNP): allows organ viability assessment and targeted treatment before transplantation.

TICKET № 29

1. Criteria for assessing quality of medical care for blood loss. Quality indicators: (1) Time to recognition of hemorrhage (shock index, serial vitals); (2) Time to IV access and first fluid bolus; (3) Use of massive transfusion protocol (MTP) activation; (4) Tranexamic acid given within 3h; (5) Blood product ratio used (target 1:1:1 RBC:FFP:platelets); (6) Time to surgical/angiographic hemorrhage control; (7) Achieving hemostatic endpoints (temperature >35°C, pH >7.35, Ca²⁺ >1.1 mmol/L, fibrinogen >1.5 g/L); (8) 24h and 30-day mortality; (9) Avoidance of transfusion when not indicated (Hb trigger adherence).

2. Treatment options for deep burns. Deep partial thickness and full thickness burns: (1) Early tangential excision (within 48-72h): shave down to viable tissue, reduces sepsis risk; (2) Fascial excision: down to fascia for very deep burns; (3) Biological temporary cover: allograft, xenograft, synthetic (Integra) while awaiting autograft donor site healing; (4) Autologous split-thickness skin grafting: definitive closure; (5) Cultured skin for massive burns; (6) Full-thickness grafts for hands, face; (7) Flap reconstruction for exposed bone/tendons; (8) Escharotomy: for circumferential deep burns causing compartment syndrome (chest/extremities).

3. Carcinogens - types and effects. Types: (1) Chemical: polycyclic aromatic hydrocarbons (tobacco smoke), nitrosamines, aflatoxin B1, asbestos, benzene, vinyl chloride, aromatic amines (bladder cancer); (2) Physical: ionizing radiation (X-ray, gamma, radon - DNA double-strand breaks), UV radiation (skin cancer - mainly UV-B → pyrimidine dimers); (3) Biological: oncogenic viruses (HPV → cervical/oropharyngeal cancer; HBV/HCV → hepatocellular carcinoma; EBV → lymphoma/nasopharyngeal; H. pylori → gastric cancer). Mechanisms: direct DNA mutation, epigenetic changes, chronic inflammation, immunosuppression.

4. Skin grafting - types. (1) Split-thickness graft (STSG): includes epidermis + partial dermis; donor site heals; used for large areas, burn wounds. (2) Full-thickness graft (FTSG): epidermis + full dermis; better cosmetic result, less contraction; for face, hands, eyelids; donor site requires primary closure. (3) Composite graft: skin + cartilage or fat; for ear/nose defects. (4) Pedicled flap: retains blood supply through pedicle (rotation, transposition, advancement, island flap). (5) Free flap: completely detached, vessels anastomosed microsurgically (DIEP, ALT, latissimus dorsi). (6) Cultured epithelial autograft (CEA): laboratory-grown sheets.

TICKET № 30

1. Sterile zones in the operating room.

Zone 1 (Sterile/Restricted zone): surgical field, instrument tables draped sterile, scrub team (hands, arms, front of gown from waist up, sterile gloves); only sterile items contact this zone
Zone 2 (Clean zone): circulating nurse, anesthetist area; staff wear scrubs and masks; non-sterile
Zone 3 (Semi-clean zone): OR corridor, changing areas
Zone 4 (Unclean zone): general hospital corridor Sterile field rules: only sterile items on sterile table, draped items sterile only on top surface, gown considered sterile only from chest to table level and cuff to elbow.

2. Basic principles of burn treatment.

First aid: cool with running water 15-20 min (not ice); cover with clean dressing
Calculate %BSA: Rule of Nines (adults) or Lund-Browder chart (children)
Fluid resuscitation: Parkland formula (4 mL × kg × %BSA; first 8h/next 16h)
Analgesia and sedation
Wound care: clean, debride, silver sulfadiazine, non-adherent dressings; early excision and grafting for deep burns
Nutritional support: high-protein, high-calorie; early enteral feeding
Prevent/treat infection: wound surveillance, antibiotics only for documented infection
Physiotherapy and rehabilitation: prevent contractures, restore function

3. Precancerous conditions: obligatory and optional.

Optional (facultative) precancers: background diseases that occasionally transform; low risk; examples: chronic atrophic gastritis, gastric ulcer, cervical ectopia, actinic keratosis, colon polyps (hyperplastic), chronic inflammatory bowel disease
Obligatory precancers: almost always progress to cancer if untreated; high risk; examples: familial adenomatous polyposis (FAP), Barrett's esophagus with high-grade dysplasia, carcinoma in situ (any site), erythroplasia of Queyrat, leukoplakia with dysplasia, Paget's disease of nipple, hereditary nonpolyposis colorectal cancer (HNPCC) lesions

4. Legal and ethical issues of organ donation. Key principles: (1) Informed consent - opt-in (most countries) vs. opt-out/presumed consent (Spain, France, Austria - higher donation rates); (2) Dead donor rule - organs only from dead donors (brain dead or DCD); (3) Prohibition of organ trade and commercialization (WHO principle); (4) Equity in allocation - based on medical urgency and compatibility, not wealth; (5) Family rights: family should be informed/consulted even in opt-out systems; (6) Confidentiality: donor/recipient anonymity; (7) Conflict of interest: treating physicians must not be part of transplant team; (8) Special issues: pediatric donors, DCD (donation after circulatory death), living donors (kidney, liver lobe) - require independent ethics committee approval.

TICKET № 31

1. Types of OR cleaning. Medical waste classes. OR cleaning types: (1) Preliminary (morning before operations); (2) Current (between operations - wipe surfaces, remove used materials); (3) Post-operation (after each case - full surface disinfection); (4) Final (end of workday - thorough cleaning of all surfaces, UV irradiation); (5) General (weekly - deep clean including walls, ceiling, air ducts). Medical waste classes (European classification): A - non-hazardous (comparable to household); B - potentially hazardous (sharps, biological waste); C - hazardous (cytotoxic, chemical); D - radioactive; E - highly contagious (Class III-IV pathogens).

2. Burns - classification by depth.

Grade I (superficial): epidermis only; erythema, pain, no blisters; heals 3-5 days
Grade II (partial thickness):
- IIa (superficial partial): epidermis + superficial dermis; blisters, moist, pink, very painful; heals 10-14 days spontaneously
- IIb (deep partial): deep dermis; pale/mottled, less painful (nerve destruction), blisters; heals >21 days, scarring; may need grafting
Grade III (full thickness): epidermis + entire dermis; white/brown/charred, leathery, painless (nerves destroyed); requires grafting
Grade IV: deep structures (fat, muscle, bone, tendons); requires flap/amputation

3. Body detoxification methods - hemosorption, hemodialysis, plasmapheresis.

Hemodialysis: blood circulates through semi-permeable membrane; removes small/medium solutes (urea, creatinine, K⁺, drugs), excess water by ultrafiltration; indications: acute/chronic renal failure, severe electrolyte/acid-base disturbance, dialyzable drug overdose
Hemosorption (hemoperfusion): blood passed through activated charcoal or resin column; removes larger hydrophobic toxins, drugs (barbiturates, cardiac glycosides), bilirubin; indications: exogenous poisoning, hepatic failure
Plasmapheresis: plasma separated from blood cells and removed (replaced with albumin, FFP); removes large-molecule toxins, antibodies, immune complexes; indications: TTP, Guillain-Barré, myasthenia gravis, Goodpasture's, hyperviscosity, severe autoimmune disease, drug-protein-bound toxins

4. MARS (Molecular Adsorbent Recirculating System) - artificial liver, indications. MARS is an extracorporeal liver support system that removes albumin-bound toxins (bilirubin, bile acids, aromatic amino acids, fatty acids, cytokines) and water-soluble toxins via a circuit with albumin dialysate, activated charcoal, and anion exchanger columns. It mimics detoxification functions of the liver but does not replace synthetic function. Indications: acute liver failure (ALF) as bridge to transplantation, acute-on-chronic liver failure (ACLF), hepatic encephalopathy grades III-IV, drug-induced liver injury, primary graft non-function after liver transplantation, cholestatic pruritus refractory to medical therapy. Used until liver recovers or transplant occurs.

---All 31 tickets are now answered. Here is a summary of what was covered:

All 31 Tickets Completed. Key topics covered across the answers:

Asepsis/Antiseptics (T1, T6, T10, T11): concepts, classification of antiseptics (mechanical, physical, chemical, biological), sterilization types
Blood Transfusion (T1, T2, T8, T9, T12-T17, T20-T22): indications, contraindications, compatibility testing, components, complications, hemotransfusion shock
Wound healing & Infections (T3, T4, T7, T13, T14, T16, T18, T19): phases, types of healing, purulent diseases of skin/hand, osteomyelitis, sepsis, peritonitis
Vascular (T1-T2, T3, T4, T5, T23, T26-T27): arterial/venous insufficiency, DVT, PE, aneurysm/dissection, diagnostic methods, angioplasty
Oncology (T10, T11, T15, T23, T28, T29, T30): TNM, clinical groups, tumor differences, carcinogens, precancerous conditions, treatment methods
Transplantation (T2, T21, T23-T25, T27-T28, T30): rejection types, immunosuppression, donor service, preservation, legal/ethical issues
Congenital diseases (T9-T14, T17-T19): classification, esophageal stenosis, diaphragmatic hernia, pyloric atresia, biliary atresia, annular pancreas, intestinal atresia, Hirschsprung's
Burns (T22, T28-T31): classification, burn disease periods, fluid resuscitation, treatment, grafting
Anesthesia (T5, T23-T25): hand scrub, local anesthesia types, conduction, general anesthesia stages
Emergency/Critical Care (T5, T6, T7, T8, T18, T26): shock, CPR, coma, drowning, hypothermia, collapse
Plastic/Reconstructive surgery (T15, T20, T21, T29): principles, skin grafting types
Parasitic infections (T3, T7, T8): opisthorchiasis, echinococcosis, alveococcosis
Extracorporeal detox (T31): hemodialysis, hemosorption, plasmapheresis, MARS

Rewrite the answer little more short, and don't write see ticket xx , write full answer again where it need to to written.

SURGICAL EXAM TICKETS — ANSWERS

TICKET № 1

1. Asepsis Asepsis is a system of measures preventing microorganisms from entering a wound. Sources: exogenous (air, staff, instruments, environment) and endogenous (patient's own skin, gut, chronic infection foci). Routes: airborne, contact, implantation, hematogenous. Prevention: sterilization of instruments, surgical hand scrub, sterile draping, antiseptic skin prep, laminar airflow in OR.

2. Hemotransfusion shock Caused by ABO incompatibility — donor RBCs hemolyzed by recipient antibodies → free hemoglobin release, DIC, renal tubular obstruction. Signs: agitation, chest/lumbar pain, fever, hypotension, hemoglobinuria (red-brown urine), jaundice, oliguria. Emergency care: stop transfusion immediately, keep IV line open with saline, furosemide, sodium bicarbonate IV, dopamine for BP support, treat DIC, hemodialysis if anuria develops.

3. Purulent diseases of the hand Classified as: panaritium (cutaneous, subcutaneous, periungual, subungual, tendinous, bony, articular, pandactylitis) and hand phlegmons (midpalmar, thenar, hypothenar, subaponeurotic, commissural, U-shaped). Pus spreads along tendon sheaths — thumb and little finger sheaths communicate, causing U-shaped (horseshoe) phlegmon. Dorsal edema often more visible despite palmar source.

4. Conservative therapy for lower extremity vascular pathology Drug groups: antiplatelet agents (aspirin, clopidogrel), anticoagulants (heparin, warfarin, NOACs), vasoactive drugs/vasodilators (pentoxifylline, cilostazol), venotonics (diosmin, troxerutin — for venous pathology), statins, prostaglandins (iloprost — critical ischemia), thrombolytics (alteplase — acute occlusion).

TICKET № 2

1. Parenteral and enteral nutrition Enteral nutrition: delivery via oral route, nasogastric/nasojejunal tube, or stoma (gastrostomy, jejunostomy). Used when GI tract functional but patient cannot eat (stroke, trauma, ICU). Parenteral nutrition: IV delivery of amino acids, lipids, glucose, electrolytes, vitamins — peripheral (short-term) or central via CVC (long-term, high-calorie). Indicated when gut is non-functional: ileus, bowel fistula, short bowel syndrome, severe pancreatitis.

2. Definition, goals, and stages of surgery Surgery is a planned sequence of manual and instrumental actions on tissues to treat disease. Goals: curative, palliative, or diagnostic. Stages: preoperative preparation → anesthesia → surgical approach → main operative step → wound closure → postoperative care. Surgical approach is the incision/route to reach the target organ (must be adequate, safe, and anatomically sound). Basic techniques: incision, dissection, hemostasis, ligation, suturing, anastomosis.

3. Rejection types and immunosuppression in transplantation Hyperacute: within minutes-hours, antibody-mediated (preformed antibodies), irreversible. Acute: days to weeks, T-cell mediated, reversible with treatment. Chronic: months to years, gradual fibrosis, poorly reversible. Immunosuppression: induction (anti-thymocyte globulin, IL-2 receptor blockers), maintenance (calcineurin inhibitors — tacrolimus/cyclosporine; mycophenolate; corticosteroids; mTOR inhibitors — sirolimus), acute rejection treatment (high-dose steroids, anti-CD3 antibody).

4. Chronic arterial insufficiency of lower extremities Causes: atherosclerosis (most common), Buerger's disease, diabetes. Fontaine stages: I — asymptomatic; IIa — claudication >200 m; IIb — claudication <200 m; III — rest pain; IV — trophic ulcers/gangrene. Diagnosis: ABI (<0.9 abnormal), duplex ultrasound, CT/MR angiography. Treatment: risk factor control, antiplatelet therapy, exercise; surgical: bypass grafting, endarterectomy, angioplasty/stenting, amputation for irreversible ischemia.

TICKET № 3

1. ABO blood grouping using standard serums Three standard serums (O, A, B groups) are placed in a row and mixed with test blood on a white plate. Read agglutination at 5 min at 15–25°C. Results: no agglutination = Group O(I); agglutination with O and B serums = Group A(II); agglutination with O and A serums = Group B(III); agglutination with all three = Group AB(IV). Confirmed by reverse grouping with standard red cells.

2. Signs of inflammation + treating purulent wounds phase 1 Local signs (Celsus-Galen): rubor, calor, tumor, dolor, functio laesa. General: fever, leukocytosis with left shift, elevated ESR/CRP, malaise, tachycardia. Phase 1 (inflammatory/exudative): goal is pus removal and bacterial reduction. Treatment: surgical incision and drainage, hypertonic (10% NaCl) dressings, antiseptic irrigation (chlorhexidine, povidone-iodine), proteolytic enzymes (trypsin), systemic antibiotics, analgesics.

3. Chronic venous insufficiency Causes: post-thrombotic syndrome (DVT), primary varicose veins, valvular incompetence. Features: heaviness, edema (worse in evenings), skin hyperpigmentation, lipodermatosclerosis, venous ulcers (medial malleolus). Diagnosis: duplex ultrasound (gold standard), phlebography. Operations: stripping (Babcock), crossectomy (high ligation of GSV), miniphlebectomy, endovenous laser/radiofrequency ablation, subfascial endoscopic perforator surgery (SEPS).

4. Opisthorchiasis Caused by Opisthorchis felineus from eating raw freshwater fish; affects bile and pancreatic ducts. Acute: fever, urticaria, eosinophilia, hepatomegaly, RUQ pain. Chronic: cholangitis, cholecystitis, pancreatitis, risk of cholangiocarcinoma. Diagnosis: stool microscopy (eggs), serology (ELISA), ultrasound/CT (dilated bile ducts), ERCP. Treatment: praziquantel, choleretics, antispasmodics; surgery for complications (strictures, stones).

TICKET № 4

1. Types of sterilization

Steam (autoclave): 121°C/30 min or 134°C/20 min — instruments, linen
Dry heat oven: 160°C/60 min or 180°C/30 min — glassware, oils, powders
Chemical (ethylene oxide, glutaraldehyde): heat-sensitive items (endoscopes, plastics)
Radiation (gamma): factory-sterilized disposables
Plasma (hydrogen peroxide): low-temperature, delicate instruments
Filtration: sterile liquids and gases

2. Signs of inflammation + treating purulent wounds phase 2 Local signs: rubor, calor, tumor, dolor, functio laesa. General: fever, leukocytosis, elevated CRP/ESR, tachycardia. Phase 2 (proliferative/regenerative): granulation tissue forms; goal is to protect granulations and stimulate healing. Treatment: gentle cleansing, ointment dressings (methyluracil, Vishnevsky balsam, hydrocolloids), secondary suture closure when granulations are healthy, skin grafting for large defects, physiotherapy (UVR, laser).

3. Osteomyelitis Classification: hematogenous (acute/chronic) vs. traumatic/postoperative; Cierny-Mader stages 1–4. Acute hematogenous: mainly children, long bones; high fever, bone pain, soft tissue swelling; X-ray changes appear at 10–14 days (periosteal reaction); MRI detects earlier. Chronic: sequestra, involucrum, fistulae. Treatment: IV antibiotics 4–6 weeks, surgical drainage of abscess, sequestrectomy, debridement; bone grafting/Ilizarov fixation for chronic forms.

4. Pulmonary embolism Causes: DVT (most common), immobility, surgery, cancer, thrombophilia. Features: sudden dyspnea, pleuritic chest pain, hemoptysis, tachycardia, hypoxia; massive PE causes hypotension, syncope, cardiac arrest. Diagnosis: D-dimer (screening), CT pulmonary angiography (gold standard), echo (right heart strain). Treatment: anticoagulation (LMWH → warfarin or NOAC), systemic thrombolysis for massive PE, surgical embolectomy, IVC filter if anticoagulation contraindicated.

TICKET № 5

1. Surgical hand scrub Goal: remove transient flora and reduce resident flora. Nails short, no jewelry; wash hands and forearms to elbows. Types: (1) Classic brush scrub + 70% alcohol/chlorhexidine; (2) Alcohol-based handrub — WHO standard, 1.5 min rubbing, 3–5 mL product, most widely used; (3) 0.5% chlorhexidine in 70% alcohol; (4) Spasokukotsky-Kochergin (historical, ammonia). Sterile gloves worn after any method.

2. Shock classification. First aid for traumatic shock Types: hypovolemic (hemorrhagic, dehydration), distributive (septic, anaphylactic, neurogenic), cardiogenic, obstructive (PE, tamponade). Traumatic shock = hypovolemic + pain component. First aid: stop bleeding (tourniquet/pressure), ensure airway, 2 large-bore IV lines, rapid crystalloid infusion, analgesia (morphine if no hypotension), immobilize fractures, oxygen, urgent transport; blood products for grade III–IV shock.

3. Pleural empyema Classification: acute (<3 months) vs. chronic; parapneumonic, postoperative, traumatic, tuberculous; free vs. encapsulated. Features: fever, chest pain, dyspnea, toxemia; dullness to percussion, absent breath sounds. Diagnosis: chest X-ray, ultrasound, CT, pleural fluid analysis (exudate, pH <7.2, bacteria). Treatment: antibiotics + tube thoracostomy, fibrinolytics for loculated empyema, VATS debridement, open decortication for chronic/organized empyema.

4. Aortic dissection Stanford: Type A (ascending aorta involved — surgical emergency), Type B (descending only — medical first). Aneurysm = localized aortic dilation >50% of normal diameter. Presents with sudden tearing chest/back pain, pulse differentials, aortic regurgitation, stroke/limb ischemia. Diagnosis: CT angiography (gold standard), TEE, MRI. Treatment: Type A — emergency surgical replacement of ascending aorta; Type B — IV beta-blockers + nitroprusside; endovascular stent-graft for complicated Type B.

TICKET № 6

1. Antiseptics classification

Mechanical: debridement, wound irrigation, drainage
Physical: hypertonic dressings, UV light, laser, ultrasonic cavitation
Chemical: halogens (iodine, chlorhexidine), oxidizers (H₂O₂, KMnO₄), alcohols, aldehydes (formaldehyde), detergents (benzalkonium chloride), dyes (brilliant green), heavy metals (silver sulfadiazine), nitrofurans (furacilin)
Biological: antibiotics, bacteriophages, proteolytic enzymes, immunoglobulins

2. Drowning Types: true (water aspiration), asphyxial (laryngospasm without aspiration), syncopal (cardiac arrest from cold/shock). Features: cyanosis, foaming from mouth, hypoxia, confusion, pulmonary edema, arrhythmia. First aid: remove safely from water, check responsiveness, CPR if no pulse/breathing (30:2), clear airway, recovery position if breathing, call EMS, oxygen, warmth (hypothermia common), hospitalize even if "recovered" — secondary drowning risk within 24h.

3. Peritonitis Classification: primary (spontaneous bacterial peritonitis), secondary (bowel perforation, appendicitis — most common), tertiary (persistent, hospital-acquired). By spread: local, diffuse, generalized. Features: abdominal pain, guarding/rigidity, rebound tenderness, absent bowel sounds, fever, tachycardia; septic shock in late stages. Diagnosis: clinical exam, WBC, abdominal X-ray (free air), CT. Treatment: emergency surgery (source control, peritoneal lavage, drains), broad-spectrum IV antibiotics, fluid resuscitation, ICU support.

4. Lymphostasis (Lymphedema) Primary (congenital, Milroy disease) or secondary (infection, tumor, surgery, radiation). Features: painless non-pitting edema of limb, skin thickening and fibrosis, "orange peel" appearance, recurrent erysipelas, elephantiasis in advanced stages. Treatment: conservative — compression stockings/bandaging, manual lymphatic drainage, skin care, antibiotics for infections; surgical — lymphovenous anastomosis, liposuction, Charles procedure (radical excision) for severe cases.

TICKET № 7

1. Bleeding classification By vessel: arterial (bright red, pulsatile), venous (dark red, continuous), capillary (oozing), parenchymal (mixed). By direction: external, internal (into cavity — hemothorax, hemoperitoneum), interstitial (into tissue). By timing: primary (at injury), secondary early (<3 days, clot dislodgement), secondary late (>3 days, arrosion by infection). By volume: Class I (<15%), II (15–30%), III (30–40%), IV (>40% blood volume).

2. Signs of biological death Early (1–4 h): livor mortis (dependent purplish discoloration), algor mortis (body cools ~1°C/h), corneal desiccation. Late: rigor mortis (begins 2–4 h, maximum 6–12 h, resolves by 48–72 h), putrefaction (green abdominal discoloration begins 24–48 h), Larcher spots (triangular scleral desiccation). Absolute sign: absence of cardiac activity on ECG for >30 min, fixed dilated pupils, no respiration.

3. Prevention of postoperative thromboembolic complications Non-pharmacological: early mobilization, compression stockings, intermittent pneumatic compression, adequate hydration. Pharmacological: LMWH (enoxaparin 40 mg/day) starting 12 h pre-op or 6–12 h post-op; UFH for renal impairment; NOACs (rivaroxaban, apixaban) for orthopedic surgery. Duration: 10–14 days (general surgery), 35 days (hip/knee arthroplasty). Risk stratified by Caprini or Rogers score.

4. Echinococcosis Caused by Echinococcus granulosus (cystic form). Liver most common, then lung. Slow-growing cyst; RUQ mass, hepatomegaly, biliary obstruction; rupture causes anaphylaxis and dissemination. Diagnosis: ultrasound/CT (cyst with daughter cysts, calcification), serology (ELISA, indirect hemagglutination). Treatment: surgery (pericystectomy) or PAIR (puncture-aspiration-injection-reaspiration) + albendazole pre/postoperatively; albendazole alone for inoperable cases.

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1. Indications for blood transfusion

Acute hemorrhagic anemia: Hb <70 g/L (stable) or <100 g/L with ongoing bleeding/cardiovascular disease
Surgical blood loss >20–25% blood volume
Pre-operative: Hb <80 g/L before major surgery
Coagulopathy with active bleeding (FFP, platelets)
Exchange transfusion (hemolytic disease of newborn) Transfusion should be based on clinical signs, not Hb value alone.

2. Collapse Acute vascular insufficiency with sudden BP drop without loss of consciousness. Causes: massive hemorrhage, MI, severe infection/toxemia, adrenal insufficiency, vasovagal. Features: pallor, cold sweats, weak rapid pulse, hypotension, nausea, confusion. First aid: lay flat with legs elevated, IV access, crystalloid infusion, vasopressors (norepinephrine) if BP unresponsive, treat underlying cause, oxygen, ECG monitoring.

3. Specific surgical infections — Tetanus Specific infections include: tetanus, gas gangrene (C. perfringens), anthrax, erysipelas. Tetanus: caused by C. tetani neurotoxin (tetanospasmin) blocking glycine/GABA → spastic paralysis. Incubation 3–21 days. Signs: trismus (lockjaw), risus sardonicus, opisthotonus, tonic spasms triggered by stimuli, autonomic instability. Treatment: wound debridement, TIG 3000–6000 IU, metronidazole/penicillin, diazepam/muscle relaxants, mechanical ventilation. Prevention: DTP vaccination; active-passive immunization post-injury.

4. Alveococcosis Caused by Echinococcus multilocularis (fox tapeworm). Behaves like a malignant tumor — infiltrative growth, no capsule. Mainly liver; metastasizes to brain and lungs. Symptoms: hepatomegaly, jaundice, portal hypertension, biliary cirrhosis; late presentation common. Diagnosis: CT/MRI (irregular, densely calcified infiltrative mass), serology (Em2/Em18 ELISA), PET. Treatment: radical resection when possible; albendazole long-term (often lifelong) for inoperable cases; liver transplantation in select patients.

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1. Blood transfusion complications

Immunological: hemolytic reaction (ABO/Rh incompatibility), febrile non-hemolytic reaction (most common), allergic/anaphylactic, TRALI, transfusion-associated GvHD
Infectious: HIV, hepatitis B/C, CMV, syphilis, malaria
Metabolic: hyperkalemia, hypocalcemia (citrate toxicity), hypothermia, acidosis
Circulatory: TACO (volume overload), air embolism
Massive transfusion: dilutional coagulopathy, hypothermia, acidosis triad

2. Coma Unarousable unresponsiveness; GCS <8. Causes: metabolic (hypoglycemia, hepatic, uremic, DKA), structural (stroke, TBI, tumor, meningitis). Features: no eye opening, no verbal/motor response, absent protective reflexes. Diagnosis: blood glucose first, ABG, electrolytes, toxicology screen, CT head, LP if infection suspected. Treatment: ABCDE, correct hypoglycemia (50% dextrose), naloxone (opioids), thiamine (alcoholism), intubate if GCS <8, treat underlying cause.

3. Fast-track (ERAS) therapy Multimodal perioperative protocol to reduce surgical stress and speed recovery. Preoperative: carbohydrate loading, no prolonged fasting, prehabilitation. Intraoperative: minimally invasive approach, goal-directed fluid therapy, normothermia, short-acting anesthetics. Postoperative: early oral feeding and mobilization, multimodal non-opioid analgesia, early removal of drains/catheters. Benefits: shorter hospital stay, fewer complications, lower costs.

4. Classification of congenital diseases By etiology: genetic (chromosomal — Down syndrome; monogenic — PKU; multifactorial — cleft palate), environmental (teratogens), combined. By timing: embryopathies (1st trimester — major structural defects), fetopathies (2nd–3rd trimester — functional/growth disorders). By severity: lethal, severe (urgent correction needed), moderate, minor. By number: isolated vs. multiple malformations (syndromes).

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1. Classification of blood components

Red cell components: packed RBCs, leukoreduced RBCs, washed RBCs, irradiated RBCs, frozen RBCs
Platelet components: random donor platelets, apheresis (single-donor) platelets
Plasma components: fresh frozen plasma (FFP), cryoprecipitate (fibrinogen, FVIII, vWF), single-donor plasma
Granulocyte concentrates (rare indications) Whole blood is rarely used; component therapy is standard.

2. Mechanical and physical antisepsis Mechanical: removal of microorganisms by physical means — primary surgical debridement, wound irrigation, drainage (passive/active), dressing changes, pus evacuation. Physical: drying effect of hypertonic solutions, UV irradiation (germicidal wavelength 253.7 nm), laser therapy, ultrasonic cavitation, sorption dressings (activated charcoal, silica gel).

3. Clinical groups of oncology patients

Group Ia: patients with precancerous conditions
Group Ib: under examination with suspected cancer
Group II: malignant tumor potentially curable by radical treatment
Group IIa: subject to radical treatment
Group III: practical recovery after radical treatment (remission/observation)
Group IV: advanced cancer not amenable to radical treatment; palliative/symptomatic care only

4. Diagnosis of congenital diseases Prenatal: ultrasound (structural anomalies from 18–20 weeks), maternal serum screening (AFP, hCG, estriol), amniocentesis (chromosomal analysis), CVS (10–12 weeks), NIPT (cell-free fetal DNA). Postnatal: neonatal screening (PKU, hypothyroidism, cystic fibrosis), clinical examination, imaging (X-ray, US, CT, MRI), karyotyping, enzyme assays, molecular genetic testing.

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1. Contraindications to blood donation Absolute: HIV/AIDS, hepatitis B/C, syphilis, active TB, malignancy, serious cardiac/renal/hepatic disease, blood disorders, CJD history. Temporary deferral: recent infection/fever (4 weeks), recent surgery, pregnancy/lactation (6 months), recent vaccination (2–4 weeks), travel to malaria-endemic areas, recent tattoo/piercing (4–6 months), low Hb (<120 g/L women, <130 g/L men).

2. Chemical and biological antisepsis Chemical: halogens (iodine 5%, povidone-iodine, chlorhexidine), oxidizers (H₂O₂ 3%, KMnO₄), alcohols (70% ethanol, isopropanol), aldehydes (glutaraldehyde), detergents (benzalkonium chloride), heavy metals (silver nitrate), nitrofurans (furacilin 1:5000), dyes (brilliant green, methylene blue). Biological: antibiotics, bacteriophages, proteolytic enzymes (trypsin, chymotrypsin — break down necrosis), immune sera, immunoglobulins, interferons.

3. Types of surgical procedures for malignant diseases

Radical: complete tumor removal with regional lymph nodes (R0 resection) — curative intent
Extended radical: resection of adjacent involved organs
Palliative: tumor bulk reduction to improve quality of life or enable other therapy
Symptomatic: relieves complications (colostomy for obstructing cancer, biliary bypass)
Cytoreductive + HIPEC (peritoneal malignancies)
Diagnostic/staging: biopsy, exploratory laparotomy, sentinel node biopsy

4. Treatment of congenital diseases Conservative: medications (enzyme replacement, hormone therapy, dietary restriction), physiotherapy, orthoses. Surgical: timing by severity (emergency — intestinal atresia; elective — cleft palate at 6–12 months). Genetic: gene therapy (developing), bone marrow transplant for SCID/thalassemia. Prenatal interventions: fetal surgery for spina bifida, hydronephrosis. Multidisciplinary team approach required.

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1. Methods of blood component transfusion

Intravenous: peripheral or central venous catheter (standard)
Intraosseous: emergency when IV impossible (children, field conditions)
Intra-arterial: historical, rarely used for severe peripheral spasm
Autologous: preoperative donation, intraoperative cell salvage (Cell Saver), acute normovolemic hemodilution
Exchange transfusion: hemolytic disease of newborn, severe toxicology

2. Wound classification By mechanism: incised, lacerated, contused, stab, gunshot, bite, avulsion. By depth: superficial, deep, penetrating (into body cavity). By contamination: clean (surgical), clean-contaminated, contaminated, dirty/infected. By timing: fresh (<6 h), stale (6–24 h), old (>24 h). Surgical wound classes: I (clean), II (clean-contaminated), III (contaminated), IV (dirty/infected).

3. Criteria for brain death Preconditions: known irreversible cause, normothermia, no drug intoxication or metabolic disturbance. Clinical: deep coma (GCS 3), absent brainstem reflexes (pupillary, corneal, oculocephalic, oculovestibular, gag, cough reflex), apnea test (no breathing at pCO₂ >60 mmHg). Confirmatory tests: EEG (isoelectric), cerebral angiography (no intracranial blood flow), TCD. Two independent physicians certify; observation period varies by jurisdiction.

4. Congenital esophageal stenosis Rare narrowing due to fibromuscular thickening, cartilaginous (tracheobronchial) remnants, or membranous web. Presents when solids are introduced: dysphagia, regurgitation, choking, failure to thrive, recurrent aspiration pneumonia. Diagnosis: barium swallow (smooth fusiform narrowing), esophagoscopy with biopsy. Treatment: endoscopic balloon dilation (first-line, multiple sessions); surgical resection with anastomosis for long-segment or refractory stenosis; cartilaginous type usually requires surgery.

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1. Contraindications to blood transfusion Absolute: decompensated heart failure with pulmonary edema, severe hypertension, thromboembolism, acute glomerulonephritis, hepatic failure. Relative: compensated heart failure, hepatic/renal disease, allergic conditions, bronchial asthma, polyvalent allergy. In life-threatening hemorrhage with no alternative, there are no absolute contraindications — use leukoreduced/washed products in sensitized patients.

2. Wound healing phases Phase 1 — Inflammatory (days 1–4): hemostasis, neutrophil infiltration, debridement of necrotic tissue, exudation. Phase 2 — Proliferation (days 4–21): fibroblast migration, collagen synthesis, granulation tissue formation, angiogenesis, wound contraction by myofibroblasts. Phase 3 — Remodeling (3 weeks to 2 years): collagen reorganization (Type III → Type I), scar maturation, tensile strength increases to ~80% of normal. Disrupted by infection, ischemia, diabetes, malnutrition.

3. Phlegmons of the hand Diffuse purulent inflammation of cellular spaces. Types: subcutaneous (dorsal/palmar), subfascial, midpalmar space, thenar space, hypothenar, subaponeurotic, commissural ("collar-button"), U-shaped (horseshoe — communicating thumb/little finger tendon sheaths). Diagnosis: throbbing pain, tense edema, finger held in flexion, fever. Treatment: urgent surgical drainage via adequate incisions (counter-incisions where needed), antistaphylococcal antibiotics, hand elevation, splinting.

4. Congenital diaphragmatic hernia Herniation of abdominal organs into thorax (90% left-sided, Bochdalek type). Pulmonary hypoplasia is the main cause of mortality. Neonatal presentation: respiratory distress, cyanosis, scaphoid abdomen, bowel sounds in chest, mediastinal shift. Diagnosis: prenatal ultrasound (stomach in thorax), chest X-ray (bowel loops in chest, mediastinal shift). Treatment: stabilize first, intubate, NG tube decompression; delayed surgical repair (primary closure or patch) after physiological stabilization; ECMO for severe pulmonary hypertension.

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1. Algorithm before red blood cell transfusion

Verify indication and obtain written consent
Check patient identity (name, DOB, medical record) against blood unit label
Inspect blood bag (expiry, integrity, color — no brown/black discoloration or clots)
Confirm ABO/Rh of unit matches patient's group
Perform bedside ABO compatibility test (patient serum + donor cells)
Biological test: infuse 10–15 mL slowly, observe 3 min × 3 cycles
Transfuse at correct rate (RBCs: 1–4 h); monitor patient continuously
Document lot number, volume, time, and any reactions in medical record

2. Types of wound healing Primary intention (per primam): clean wound edges surgically approximated, minimal granulation, thin scar — requires no infection, good blood supply, adequate apposition. Secondary intention (per secundam): wound left open, heals by granulation, contraction, and re-epithelialization — larger scar; for infected or contaminated wounds. Tertiary intention (delayed primary closure): wound debrided and left open 3–5 days, then surgically closed once infection controlled — combines benefits of both methods.

3. Purulent arthritis Classification: by cause (hematogenous, post-traumatic, iatrogenic), by stage (serous → seropurulent → purulent → putrid), by joint. Features: severe joint pain, swelling, redness, warmth, restricted movement, fever, joint held in position of comfort. Diagnosis: joint aspiration (turbid fluid, WBC >50,000/μL, bacteria on culture), ultrasound/X-ray, MRI. Treatment: joint drainage (aspiration with irrigation, arthroscopic washout, or open arthrotomy for severe cases), IV antistaphylococcal antibiotics, immobilization.

4. Congenital pyloric atresia Very rare complete pyloric obstruction (membranous, solid cord, or gap defect). Neonatal presentation: non-bilious vomiting from birth, visible gastric peristalsis, upper abdominal distension, dehydration. Associated with epidermolysis bullosa (EB-PA syndrome). Diagnosis: abdominal X-ray (single "bubble" — gastric dilation, no distal gas), upper GI contrast (obstruction at pylorus), ultrasound. Treatment: surgical correction after resuscitation — pyloroplasty or gastroduodenostomy; excellent prognosis if isolated.

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1. Individual selection (compatibility testing) before transfusion Steps: (1) ABO/Rh grouping of patient and donor unit. (2) Antibody screen (indirect Coombs) for irregular antibodies in patient's serum. (3) Crossmatch: major crossmatch (patient serum + donor RBCs) — most important; tests at room temperature, 37°C, and Coombs phase. Electronic crossmatch acceptable if ≥2 previous negative antibody screens. All results documented before blood issued.

2. Frostbite — stages and treatment Degrees: I — erythema/edema, no blisters; II — clear fluid blisters, superficial necrosis; III — hemorrhagic blisters, full-thickness skin necrosis; IV — necrosis of all tissues including bone. Treatment: remove from cold, remove wet clothing; rapid rewarming in 38–42°C water bath; analgesia (ibuprofen, opioids); antiplatelet therapy (aspirin, iloprost); aspirate clear blisters, leave hemorrhagic ones intact; antibiotics for grade III–IV; surgical amputation delayed until clear demarcation (weeks).

3. Treatment methods for cancer patients Surgical (radical, palliative, symptomatic), radiation therapy (external beam, brachytherapy, stereotactic), chemotherapy (alkylating agents, antimetabolites, taxanes, anthracyclines), targeted therapy (TKIs, monoclonal antibodies — trastuzumab, imatinib), immunotherapy (checkpoint inhibitors PD-1/PD-L1, CTLA-4; CAR-T cells), hormone therapy (breast, prostate), radiofrequency/cryoablation. Multimodal combination is standard.

4. Basic principles of plastic surgery Goal: restoration of form and function. Principles: adequate blood supply to tissues, minimal tension on closure, atraumatic technique, replace like tissue with like. Methods: primary closure, split-thickness skin graft (STSG), full-thickness graft (FTSG), local flaps (rotation, transposition, advancement), pedicled flaps (TRAM, latissimus dorsi), free flaps (microsurgical anastomosis — DIEP, ALT), tissue expanders, implants.

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1. Rules for use of medical masks Must cover nose and mouth completely with no gaps. Change every 2 hours or sooner if moist; do not touch front surface; remove by ear loops only; never reuse disposable masks. Surgical masks protect against droplets; FFP2/N95 respirators protect against aerosols. Hand hygiene before and after mask removal. Must be combined with hand hygiene, gloves, and eye protection for high-risk procedures.

2. Transfusion shock — diagnosis and treatment Occurs during or immediately after transfusion due to ABO incompatibility. Diagnosis: agitation → chest/lumbar pain → hypotension (BP drop >20 mmHg), tachycardia, fever, hemoglobinuria (red-brown urine), oliguria. Lab: free hemoglobin in plasma/urine, positive direct Coombs, rising bilirubin, DIC markers. Treatment: stop transfusion immediately, keep IV line open with saline, furosemide IV, sodium bicarbonate IV, dopamine/norepinephrine for BP, corticosteroids, maintain urine output >100 mL/h, hemodialysis if anuria, treat DIC with FFP/platelets.

3. Classification of purulent infections By location: skin/subcutaneous (furuncle, carbuncle, abscess, phlegmon, erysipelas, hidradenitis), tendon sheaths/joints/bones (tenosynovitis, arthritis, osteomyelitis), body cavities (empyema, peritonitis), organs (mastitis, liver abscess). By pathogen: staphylococcal, streptococcal, gram-negative, anaerobic (putrid), mixed. By extent: local vs. generalized (sepsis). By course: acute vs. chronic.

4. Congenital biliary atresia Progressive fibro-obliterative cholangiopathy of extrahepatic bile ducts. Presents at 2–8 weeks: prolonged conjugated jaundice, acholic (pale clay) stools, dark urine, hepatomegaly; progresses to biliary cirrhosis and liver failure. Diagnosis: ultrasound (absent/small gallbladder), hepatobiliary scintigraphy (no excretion into bowel), liver biopsy (bile duct proliferation, fibrosis), intraoperative cholangiography (gold standard). Treatment: Kasai portoenterojejunostomy (best results before 60 days of age); liver transplantation for failed Kasai or advanced liver disease.

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1. Classification of blood products

Whole blood (rarely used)
Cellular: packed RBCs, leukoreduced RBCs, washed RBCs, platelets, granulocytes
Plasma: FFP, cryoprecipitate, albumin (5%, 20%, 25%)
Coagulation factor concentrates: Factor VIII, Factor IX, prothrombin complex concentrate (PCC), fibrinogen concentrate, recombinant FVIIa
Immunoglobulins: IVIG, specific immunoglobulins (anti-D, anti-tetanus)

2. Basic principles of treating purulent infections

Surgical: timely incision and drainage, excision of necrotic tissue, adequate drainage
Antimicrobial: empirical → culture-guided antibiotics (antistaphylococcal + broad-spectrum for polymicrobial)
Local wound care: phase-appropriate antiseptic dressings
Detoxification: IV fluids; extracorporeal methods in severe cases
Immunostimulation: immunoglobulins, vitamins, specific sera
Supportive: analgesia, nutritional support, treatment of comorbidities

3. Acute arterial obstruction Causes: embolism (cardiac source — AF, MI, valvular disease — 80%) vs. thrombosis (on atherosclerotic plaque). Signs — "6 Ps": Pain (sudden, severe), Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (cold). Muscle necrosis begins at 4–6 h. Diagnosis: Doppler ultrasound, CT angiography. Treatment: immediate heparin bolus, surgical embolectomy (Fogarty catheter, up to 6 h), catheter-directed thrombolysis (>6 h or distal vessels), bypass for thrombotic origin, fasciotomy for compartment syndrome.

4. Congenital annular pancreas Ring of pancreatic tissue encircles and obstructs the second part of the duodenum. Associated with Down syndrome (20–30%). Neonates: bilious vomiting, duodenal obstruction (double bubble on X-ray). Adults: upper abdominal pain, peptic ulcer (30%), pancreatitis. Diagnosis: X-ray (double bubble), upper GI series, CT, MRCP. Treatment: surgical bypass — duodenoduodenostomy or duodenojejunostomy; never attempt to divide the annular tissue; excellent prognosis.

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1. Classification of blood substitutes

Volume expanders (colloids): albumin, dextrans (dextran-40), hydroxyethyl starch (HES), gelatins — for hypovolemia
Crystalloids: saline, Ringer's, PlasmaLyte — fluid resuscitation
Oxygen carriers: perfluorocarbon emulsions (Perftoran), hemoglobin-based carriers (HBOC) — experimental
Detoxification solutions: hemodez (povidone), reopolyglucin — improve microcirculation, bind toxins
Parenteral nutrition solutions: amino acid mixtures, lipid emulsions, glucose

2. Terminal conditions — clinical death, first aid Terminal states: predagony → agony → clinical death → biological death. Clinical death: cessation of circulation and respiration, reversible for 4–6 min (longer in hypothermia). Signs: absent carotid pulse, absent breathing, unconsciousness, dilated pupils (after 1–2 min). CPR: firm surface, compressions 30:2 (rate 100–120/min, depth 5–6 cm), AED as soon as available, epinephrine 1 mg IV every 3–5 min; continue until ROSC or 30+ min without response (except hypothermia).

3. Purulent skin/subcutaneous diseases

Furuncle: single hair follicle/sebaceous gland (S. aureus); painful nodule → pustule → necrotic core. Tx: drainage when fluctuant, antibiotics if systemic signs
Carbuncle: multiple follicles, wide necrosis, severe systemic signs; surgical debridement + IV antibiotics
Abscess: walled-off pus collection; fluctuance, fever. Tx: incision and drainage
Phlegmon: diffuse spreading, no clear border. Tx: multiple incisions + drainage + antibiotics
Erysipelas: β-hemolytic Streptococcus, sharp-bordered skin inflammation. Tx: penicillin
Hidradenitis: sweat gland (axillae/groin), recurrent. Tx: drainage, excision

4. Congenital intestinal atresia Duodenal (50%), jejunal/ileal (40%), colonic (10%). Neonatal signs: bilious (below Vater's) or non-bilious vomiting, abdominal distension (distal type), failure to pass meconium. Diagnosis: prenatal ultrasound (polyhydramnios), plain X-ray (double bubble for duodenal; multiple air-fluid levels for ileal), contrast enema (microcolon). Treatment: surgical anastomosis (primary or tapering) after stabilization; stoma if contaminated; TPN postoperatively.

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1. Indications for blood component transfusion

RBCs: Hb <70 g/L (stable) or <100 g/L (cardiac disease/active bleeding); acute hemorrhage >30% blood volume
Platelets: <10×10⁹/L (prophylactic), <50×10⁹/L (active bleeding/surgery), <100×10⁹/L (neurosurgery)
FFP: coagulopathy with active bleeding, INR >1.5 before invasive procedure, DIC, warfarin reversal
Cryoprecipitate: fibrinogen <1.5 g/L, hemophilia A, vWD
Granulocytes: neutropenia <0.5×10⁹/L with life-threatening infection not responding to antibiotics

2. Ensuring surgical safety WHO Surgical Safety Checklist — 3 pauses: (1) Sign In (before anesthesia): patient identity, consent, site marking, anesthesia/equipment check. (2) Time Out (before incision): confirm patient/procedure/site, antibiotics given, team introductions, critical steps reviewed. (3) Sign Out (before leaving OR): procedure confirmed, specimens labeled, instrument/sponge count correct, key recovery concerns communicated. Reduces surgical mortality and complications by ~50%.

3. Superficial panaritiums Types: (1) Cutaneous — pus under epidermis; (2) Subcutaneous — most common, painful pulp abscess; (3) Periungual (paronychia) — nail fold infection; (4) Subungual — under nail plate. Features: throbbing pain, redness, swelling at fingertip. Treatment: incision and drainage (fishmouth or hockey-stick incision); nail removal for subungual type. Anesthesia: ring block (metacarpal nerve block) with 1% lidocaine without epinephrine at base of finger.

4. Congenital Hirschsprung's disease Absence of ganglion cells (Meissner's and Auerbach's plexuses) in rectum ± sigmoid → functional obstruction. Neonates: failure to pass meconium within 48 h, bilious vomiting, abdominal distension. Older children: chronic constipation, distension, failure to thrive. Enterocolitis is a life-threatening complication. Diagnosis: rectal biopsy (absent ganglion cells — gold standard), barium enema (transition zone, no evacuation at 24 h), anorectal manometry (absent rectoanal inhibitory reflex). Treatment: Swenson/Duhamel/Soave pull-through operation; initial colostomy in sick neonates.

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1. Blood type and Rh factor determination ABO: apply 2 drops each of anti-A, anti-B, anti-AB monoclonal serums on white tile + 1 drop of test blood; read agglutination at 5 min at 15–25°C. Rh factor: anti-D serum + test blood on heated slide (37°C); agglutination = Rh+. Confirmed with standard Rh+ and Rh- cells. Must be performed in 2 independent blood samples from the patient; confirmed in the laboratory.

2. Hospital-acquired (nosocomial) infections — prevention Definition: infection acquired ≥48 h after admission, not present on entry. Pathogens: MRSA, VRE, ESBL gram-negatives, C. difficile, Candida. Transmission: contact (hands — most common), droplet, airborne. Prevention: hand hygiene (#1 measure), standard/contact/airborne precautions, aseptic technique, surgical site infection bundles (prophylactic antibiotics, skin prep, normothermia), catheter/line care bundles, environmental disinfection, antibiotic stewardship.

3. Deep panaritiums Types: (1) Tendinous (tenosynovitis) — Kanavel's 4 signs: finger held in flexion, fusiform swelling, tenderness along sheath, pain on passive extension (most important); (2) Bony — phalanx necrosis, X-ray changes; (3) Articular — joint swollen and boggy; (4) Pandactylitis — all structures involved. Treatment: urgent drainage of tendon sheath (Brunner incisions + continuous irrigation), IV antistaphylococcal antibiotics; debridement ± amputation for bony/articular types. Anesthesia: wrist block or general anesthesia.

4. Definitions: reconstructive, restorative, plastic surgery, transplantation

Reconstructive surgery: correction of anatomical defects caused by disease, trauma, or congenital anomalies (e.g., post-mastectomy breast reconstruction)
Restorative surgery: restoration of normal function lost due to injury or disease (e.g., nerve repair, tendon repair)
Plastic surgery: operations altering shape/appearance of body structures; includes cosmetic (aesthetic) and reconstructive components
Transplantation: transfer of cells, tissues, or organs from donor to recipient to replace lost/failed function (autologous, allogeneic, xenogeneic)

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1. Blood compatibility tests (1) ABO compatibility: patient serum + donor RBCs on slide — agglutination = incompatible. (2) Rh compatibility: same with anti-globulin serum at 37°C. (3) Indirect Coombs (antibody screen): detects irregular alloantibodies in patient serum. (4) Full crossmatch: major (patient serum + donor cells at room temp, 37°C, Coombs phase) + minor (donor serum + patient cells). (5) Electronic crossmatch: computer verification if ≥2 historical negative screens. (6) Bedside biological test: infuse 10 mL slowly × 3, observe for reaction.

2. Electrical injury Severity depends on voltage, current type (AC > DC), path through body, duration. Local: entry/exit burns (deep, charred), deep muscle necrosis along current path. Systemic: ventricular fibrillation (leading cause of death), respiratory arrest, CNS seizures/unconsciousness, rhabdomyolysis → myoglobinuria → renal failure. First aid: disconnect power safely, CPR if cardiac arrest, do not touch victim until safe; IV fluids (prevent myoglobin-induced renal failure), ECG monitoring, burn treatment, hospitalize all significant exposures.

3. Hand phlegmons Diffuse purulent inflammation of hand fascial spaces. Types: midpalmar (most common deep space), thenar (thumb/index), hypothenar, subaponeurotic, subfascial dorsal, commissural (collar-button between fingers), U-shaped/horseshoe (communicating sheaths thumb–little finger). Diagnosis: severe throbbing pain, fingers in forced flexion, massive edema (dorsal often more prominent), fever/sepsis. Treatment: urgent drainage through adequate incisions, tendon sheath irrigation, IV antistaphylococcal antibiotics. Anesthesia: brachial plexus block (axillary/infraclavicular) or general anesthesia.

4. Transplantation classification By donor-recipient relationship:

Autotransplantation: same individual (e.g., skin graft, saphenous vein bypass)
Isotransplantation (syngeneic): identical twins — no rejection
Allotransplantation: same species, different individual — most common clinical transplants
Xenotransplantation: across species (pig → human — experimental)

By organ/tissue: solid organs (kidney, liver, heart, lung, pancreas), composite tissue (hand, face), cells (bone marrow, islet cells), tissues (cornea, heart valves, bone). By technique: orthotopic (native organ removed, e.g., heart) vs. heterotopic (native retained, e.g., kidney placed in iliac fossa).

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1. Physician's actions before transfusing blood components

Verify indication and obtain informed consent
Confirm patient identity against blood unit label (name, DOB, medical record)
Inspect unit: expiry date, integrity, color (RBCs must not be brown/black), no clots
Confirm ABO/Rh of unit matches patient
Review transfusion history and antibody screen
Perform bedside compatibility and biological tests
Set correct infusion rate (RBCs: 1–4 h; platelets: 20–30 min; FFP: 30 min)
Monitor patient throughout; document lot number, volume, time, and any reactions

2. Burn disease — periods and treatment Occurs with burns >10–15% BSA. Periods: (1) Burn shock (first 1–3 days): massive fluid shifts, hypovolemia — Parkland formula: 4 mL × kg × %BSA; half in first 8 h, half in next 16 h. (2) Acute burn toxemia (3–10 days): toxin absorption, fever, organ dysfunction. (3) Septicotoxemia (2 weeks to months): wound infection, sepsis, multi-organ failure. (4) Convalescence: wound healing, rehabilitation. Treatment: analgesia, fluid resuscitation, wound care (silver sulfadiazine), early excision and grafting, nutritional support, physiotherapy.

3. Patient assessment scales

GCS (Glasgow Coma Scale): eye (1–4) + verbal (1–5) + motor (1–6) = 3–15; <8 = intubate
APACHE II/III: ICU severity scoring
SOFA/qSOFA: organ dysfunction in sepsis; qSOFA ≥2 (RR ≥22, altered mentation, SBP ≤100) = suspected sepsis
Braden scale: pressure ulcer risk
Wells score: DVT/PE pre-test probability
Caprini score: VTE risk in surgical patients
NRS-2002 / MUST: nutritional risk screening
ASA physical status: anesthetic risk (I–VI)
VAS: pain intensity (0–10)

4. Criteria for brain death Preconditions: known irreversible cause, normothermia, no drug intoxication or metabolic disturbance. Clinical criteria: coma (GCS 3, no response to pain), absent brainstem reflexes (pupillary, corneal, oculocephalic, oculovestibular, gag, cough), apnea (no breathing when pCO₂ >60 mmHg). Confirmatory tests (when needed): isoelectric EEG, cerebral angiography/TCD (no intracranial flow), somatosensory evoked potentials. Two independent physicians certify; required waiting period varies by jurisdiction.

TICKET № 23

1. Local anesthesia — classification, max novocaine dose, contraindications Types: (1) Topical/surface (lidocaine spray, cocaine on mucosa); (2) Infiltration (injection into tissues, Vishnevsky "creeping infiltrate"); (3) Conduction/regional (nerve block, plexus block, epidural, spinal); (4) IV regional (Bier block). Max single dose of novocaine (procaine): 0.25% — up to 500 mL; 0.5% — up to 150 mL; 1% — up to 75 mL; 2% — up to 25 mL. Dose increases by 1/3 with epinephrine. Contraindications: allergy to ester-class anesthetics, coagulopathy (spinal/epidural), infection at injection site, severe hypovolemia (spinal), patient refusal.

2. TNM classification

T (Tumor): Tx — not assessed; T0 — no evidence; Tis — in situ; T1–T4 — increasing size/local invasion
N (Nodes): Nx — not assessed; N0 — no regional nodes; N1–N3 — increasing nodal involvement
M (Metastasis): M0 — no distant metastasis; M1 — distant metastasis present Stage groupings (0, I, II, III, IV) derived from T+N+M combinations; determine treatment choice and prognosis.

3. Acute venous insufficiency Caused by DVT, superficial thrombophlebitis, or iatrogenic venous injury. DVT: calf/thigh pain, edema, warmth, redness. Phlegmasia alba dolens (iliac thrombosis): pale, painful, swollen leg. Phlegmasia cerulea dolens (massive outflow obstruction): blue, severely edematous leg → venous gangrene. Diagnosis: duplex ultrasound (gold standard), D-dimer. Treatment: anticoagulation (LMWH, NOACs), leg elevation, compression; catheter-directed thrombolysis or thrombectomy for massive/phlegmasia cases; IVC filter if anticoagulation contraindicated.

4. Organ and tissue donor service — tasks Tasks: (1) Identification and referral of potential brain-dead donors; (2) Medical suitability evaluation (infectious disease screening, tissue typing); (3) Family communication and consent; (4) Coordination with transplant centers and procurement organizations; (5) Organ preservation and procurement surgery; (6) Allocation by national registry (matching, waiting list, urgency, cold ischemia time); (7) Quality assurance and outcome tracking; (8) Public education and donation awareness programs.

TICKET № 24

1. Classification of anesthesia — conduction anesthesia By method: local (topical, infiltration, conduction), regional (spinal, epidural, nerve blocks), general (inhalational, IV, combined). By route: inhalational (isoflurane, sevoflurane, desflurane), IV (propofol, ketamine, thiopental), combined (most common). Conduction anesthesia — local anesthetic deposited near specific nerves: brachial plexus (axillary, supraclavicular, interscalene blocks), femoral nerve block, sciatic nerve block, intercostal block, paravertebral block, pudendal block, dental nerve blocks. Spinal and epidural = central neuraxial conduction blocks.

2. Principles of rational antibiotic therapy for purulent infections

Culture before starting antibiotics when possible
Empirical coverage for likely pathogens (antistaphylococcal for skin/soft tissue; broad-spectrum for polymicrobial)
Correct dose, route (IV for severe infections), and duration
De-escalate based on culture/sensitivity results
Combine agents for synergy or resistance prevention where indicated
Surgical source control is mandatory — antibiotics alone insufficient for abscess/empyema
Limit surgical prophylaxis to ≤24 h

3. Differences between benign and malignant tumors

Feature	Benign	Malignant
Growth	Slow, expansive	Fast, invasive
Capsule	Usually present	Absent
Borders	Clear	Irregular, infiltrative
Metastasis	No	Yes
Recurrence	Rare	Common
Cell atypia	Minimal	Marked
Necrosis	Rare	Common
Systemic effect	Local compression	Cachexia, paraneoplasia

4. Contraindications to organ harvesting Absolute: HIV infection (except HIV+ → HIV+ in some countries), active malignancy (except primary CNS tumors/some skin cancers), prion diseases (CJD), uncontrolled sepsis with multi-organ failure. Relative: prolonged warm ischemia, hepatitis B/C with active replication (usable for specific recipients), advanced donor age, severe organ dysfunction, prolonged hypotension before death. High-risk social history (IV drug use) requires additional infectious disease screening.

TICKET № 25

1. General anesthesia — stages Guedel's stages (described for ether; referenced clinically): Stage I (Analgesia) — conscious, responsive, pain reduced. Stage II (Excitement/Delirium) — unconscious but agitated, irregular breathing, vomiting risk — dangerous, pass through quickly. Stage III (Surgical anesthesia) — 4 planes: regular breathing, progressive reflex loss and muscle relaxation; planes 2–3 = optimal surgical level. Stage IV (Overdose) — respiratory and circulatory center depression → death. With modern agents: induction (propofol/thiopental) → maintenance (inhalational agent + opioid + muscle relaxant, monitored by BIS, end-tidal agent) → emergence.

2. Initial patient examination History: chief complaint, history of present illness, past medical/surgical history, medications, allergies, family and social history, review of systems. Physical examination: general appearance, vital signs (HR, BP, RR, temperature, SpO₂), then systematic — head/neck, chest (inspection, palpation, percussion, auscultation), abdomen, extremities, neurological assessment. Document findings in medical record. For surgical patients: assess ASA risk and determine if additional investigations are needed.

3. Laparostomy — types and indications Laparostomy = intentional temporary open abdomen. Types: (1) Bogota bag (sterile saline bag sewn to fascia); (2) VAC (vacuum-assisted closure — negative pressure dressing); (3) Wittmann patch (Velcro-type fascial closure for planned re-operations); (4) Mesh/zipper closure. Indications: damage control surgery (severe trauma with uncontrolled hemorrhage + coagulopathy), generalized peritonitis with severe contamination, abdominal compartment syndrome (ACS), planned second-look for ischemic bowel, fascial dehiscence.

4. Tissue compatibility in transplantation — organ selection, rejection, immunosuppression HLA matching (HLA-A, -B, -DR most important); ABO compatibility required; PRA (panel reactive antibody) measures sensitization. Crossmatch: donor lymphocytes + recipient serum — agglutination = positive crossmatch (contraindication to transplant). Waiting list criteria: medical urgency, time on list, HLA compatibility, geographic proximity. Rejection types: hyperacute (preformed antibodies, minutes-hours, irreversible), acute (T-cell mediated, days-weeks, reversible with treatment), chronic (fibrosis, months-years, poorly reversible). Immunosuppression: induction (ATG, IL-2 blockers), maintenance (tacrolimus + mycophenolate + corticosteroids), rejection treatment (high-dose steroids, anti-CD3).

TICKET № 26

1. Bleeding — classification, clinical presentation, diagnosis, treatment By vessel: arterial (bright red, pulsatile), venous (dark red, continuous), capillary/parenchymal. By direction: external, internal (hemothorax, hemoperitoneum), interstitial. Hemorrhagic shock classes: I (<750 mL, HR <100), II (750–1500 mL, HR 100–120, narrow pulse pressure), III (1500–2000 mL, HR >120, hypotension, confusion), IV (>2000 mL, life-threatening). Diagnosis: vitals + FAST ultrasound + CT. Treatment: ABCDE, direct pressure/tourniquet, 2 large-bore IVs, crystalloids + blood products (1:1:1 ratio for massive hemorrhage), tranexamic acid within 3 h, surgical source control.

2. Hypothermia — stages, first aid Mild (32–35°C): shivering, confusion, ataxia. Moderate (28–32°C): shivering stops, severe confusion, bradycardia, atrial arrhythmias. Severe (<28°C): unconscious, fixed dilated pupils, VF/asystole — "no one is dead until warm and dead." First aid: prevent further heat loss, remove wet clothing, handle gently (avoid triggering VF), horizontal position. Rewarming: passive (insulation), active external (warm blankets, warm IV fluids), active core (warmed humidified O₂, peritoneal lavage, ECMO for severe cases); continuous cardiac monitoring; CPR if arrested until rewarmed to >35°C.

3. Sepsis Sepsis-3: life-threatening organ dysfunction (SOFA increase ≥2) caused by dysregulated host response to infection. Sources: lung, abdomen, urinary tract, soft tissue, vascular access. Pathogens: gram-negatives (E. coli, Klebsiella, Pseudomonas), gram-positives (Staph, Strep). Pathogenesis: PAMPs → TLR activation → cytokine storm → endothelial dysfunction, coagulopathy, vasoplegia, organ failure. qSOFA ≥2 (RR ≥22, altered mentation, SBP ≤100) = suspected sepsis. Treatment (Surviving Sepsis bundle): blood cultures → broad-spectrum antibiotics within 1 h, 30 mL/kg IV crystalloids, norepinephrine for MAP <65, surgical source control, glucose control, VTE prophylaxis.

4. Artificial organs — examples

Heart: total artificial heart (SynCardia), ventricular assist devices (LVAD — HeartMate, HeartWare)
Kidney: hemodialysis/CVVHDF machines (extracorporeal); wearable artificial kidney in development
Liver: MARS, Prometheus systems (extracorporeal support)
Lung: ECMO (veno-venous for respiratory failure, veno-arterial for cardiac failure)
Pancreas: closed-loop artificial pancreas (insulin pump + continuous glucose monitor)
Ear: cochlear implant
Joints: hip, knee, shoulder endoprostheses

TICKET № 27

1. Forrest's endoscopic classification of ulcer bleeding

Class	Description	Rebleeding risk
Ia	Active arterial spurting	~90%
Ib	Active oozing	~50%
IIa	Non-bleeding visible vessel	~40–50%
IIb	Adherent clot	~25–30%
IIc	Flat pigmented spot	~5–10%
III	Clean base	<2%

Forrest Ia/Ib/IIa require endoscopic hemostasis (injection + thermal/clips); IIb usually treated; IIc/III managed medically (high-dose PPI).

2. Stages of patient examination

Chief complaint
Medical history (present illness — onset, character, duration; past history; family/social history; medications; allergies)
Physical examination (general → systemic by body system)
Laboratory investigations (CBC, biochemistry, coagulation, urinalysis)
Instrumental investigations (ECG, X-ray, ultrasound, CT, endoscopy, biopsy)
Clinical diagnosis formulation (preliminary → confirmed)
Treatment planning and ongoing monitoring/reassessment

3. Diagnostic methods in angiology Non-invasive: pulse examination, skin temperature, ABI (ankle-brachial index — normal ≥0.9), duplex ultrasound (gold standard non-invasive), transcutaneous oximetry, CT angiography (CTA), MR angiography (MRA), photoplethysmography, segmental limb pressures. Functional: treadmill test (claudication distance), reactive hyperemia. Invasive: digital subtraction angiography (DSA — gold standard for intervention planning), intra-arterial pressure measurement, IVUS.

4. Requirements for organ retrieval during transplantation Legal: brain death certified by ≥2 independent physicians (not from transplant team); informed family consent or documented donor card. Medical: donor hemodynamic stability, absence of absolute contraindications. Technical: multi-organ procurement team, preservation solutions ready (UW, Custodiol, Celsior), transplant centers notified. Procedure: aortic cannulation + cold flush, en bloc removal, minimize warm ischemia time. Cold ischemia limits: kidney 24–36 h, liver 12–24 h, heart/lung 4–6 h, pancreas 12–18 h. Organ viability assessed; tissue biopsies taken; full documentation required.

TICKET № 28

1. Hemorrhagic shock — stages, Algover index, treatment Stages (ATLS): I (<15% BV, <750 mL) — normal vitals; II (15–30%, 750–1500 mL) — HR 100–120, narrow pulse pressure, anxiety; III (30–40%, 1500–2000 mL) — HR >120, hypotension, confusion; IV (>40%, >2000 mL) — HR >140, severely low BP, lethargy, imminent death. Algover Shock Index = HR/systolic BP: normal <1.0; 1.0–1.5 = moderate (20–40% loss); >1.5 = severe (>40%). Treatment: stop bleeding, 2 large-bore IVs, crystalloids + 1:1:1 blood products, permissive hypotension (MAP 50–65 in penetrating trauma), tranexamic acid within 3 h, surgical/radiological hemorrhage control.

2. Methods for closing skin defects in burns

Split-thickness skin graft (STSG): most common; donor site heals spontaneously; meshing (1.5:1 to 3:1) expands coverage
Full-thickness graft (FTSG): better cosmesis; for face/hands; donor site requires primary closure
Cultured epidermal autograft (CEA): grown from small biopsy; for massive burns with limited donor sites
Temporary biological cover: cadaveric allograft, porcine xenograft, amnion, synthetic substitutes (Integra, Biobrane) — bridge until autograft available
Local flaps: for small specialized defects (exposed bone/tendons)

3. TNM staging Stage 0: Tis, N0, M0 (carcinoma in situ). Stage I: T1–2, N0, M0 (localized). Stage II: T3–4, N0, M0 or T1–2, N1, M0 (locally advanced). Stage III: any T, N2–3, M0 (extensive node involvement). Stage IV: any T, any N, M1 (distant metastasis). Specific cutoffs vary by tumor type; stage determines resectability, treatment choice, and prognosis.

4. Types of organ preservation during transplantation

Cold static storage: flush with cold solution at 4°C, store in ice; simplest, most used. Solutions: UW (University of Wisconsin) for liver/kidney, Custodiol (HTK), Celsior.
Hypothermic machine perfusion (HMP): reduces delayed graft function in kidneys; increasingly used.
Normothermic machine perfusion (NMP, 37°C): assesses and reconditions marginal/DCD organs; allows viability testing before transplant.
Ex-vivo normothermic perfusion (EVNP): targeted organ treatment and assessment before implantation.

TICKET № 29

1. Criteria for assessing quality of care for blood loss Key indicators: (1) Time to hemorrhage recognition; (2) Time to IV access and first fluid bolus; (3) Activation of massive transfusion protocol (MTP); (4) Tranexamic acid given within 3 h; (5) Blood product ratio achieved (1:1:1 RBC:FFP:platelets); (6) Time to surgical/angiographic hemorrhage control; (7) Hemostatic endpoints achieved (temperature >35°C, pH >7.35, Ca²⁺ >1.1 mmol/L, fibrinogen >1.5 g/L); (8) 24-hour and 30-day mortality; (9) Avoidance of unnecessary transfusion (adherence to Hb triggers).

2. Treatment options for deep burns

Early tangential excision (within 48–72 h): shave to viable tissue, reduces sepsis risk
Fascial excision: down to fascia for very deep burns
Biological temporary cover: allograft, xenograft, Integra, Biobrane — while awaiting autograft
Autologous STSG: definitive closure of excised areas
Cultured skin for massive burns with limited donor sites
Full-thickness grafts for hands/face
Escharotomy: for circumferential deep burns causing compartment syndrome (chest/extremities)
Flap reconstruction: for exposed bone/tendon defects

3. Carcinogens — types and effects Chemical: polycyclic aromatic hydrocarbons (tobacco), nitrosamines, aflatoxin B1, asbestos, benzene, vinyl chloride, aromatic amines → cause DNA mutations and adducts. Physical: ionizing radiation (X-ray, gamma, radon → DNA double-strand breaks), UV-B radiation → pyrimidine dimers → skin cancer. Biological: oncogenic viruses (HPV → cervical/oropharyngeal cancer; HBV/HCV → hepatocellular carcinoma; EBV → lymphoma; H. pylori → gastric cancer). Mechanisms: direct DNA mutation, epigenetic changes, chronic inflammation, immunosuppression.

4. Skin grafting — types (1) Split-thickness (STSG): epidermis + partial dermis; donor site heals; for large/burn wounds. (2) Full-thickness (FTSG): epidermis + full dermis; better cosmesis, less contraction; for face, hands, eyelids. (3) Composite graft: skin + cartilage or fat; for ear/nose. (4) Pedicled flap: retains blood supply through pedicle — rotation, transposition, advancement, island flap. (5) Free flap: completely detached, vessels anastomosed microsurgically (DIEP, ALT, latissimus dorsi). (6) Cultured epithelial autograft (CEA): laboratory-grown epithelial sheets for massive burns.

TICKET № 30

1. Sterile zones in the operating room

Zone 1 (Sterile): surgical field, instrument tables, scrub team (sterile gloves, gown sterile from chest to waist-level and cuff to elbow); only sterile items contact this zone
Zone 2 (Clean): circulating nurse area, anesthetist station; scrubs and mask; non-sterile
Zone 3 (Semi-clean): OR corridor, changing rooms
Zone 4 (Unclean): general hospital corridors Sterile field rules: items are sterile only on top surface, gown is sterile only front chest-to-table and sleeve to elbow; any contamination requires replacement.

2. Basic principles of burn treatment

First aid: cool with running water 15–20 min (not ice); cover with clean dressing
Calculate %BSA: Rule of Nines (adults) or Lund-Browder chart (children)
Fluid resuscitation: Parkland formula (4 mL × kg × %BSA; half in first 8 h/half in next 16 h)
Analgesia and sedation
Wound care: debridement, silver sulfadiazine, non-adherent dressings; early excision + grafting for deep burns
Nutritional support: high-protein, high-calorie; early enteral feeding
Infection control: surveillance cultures, antibiotics only for documented infection
Physiotherapy: prevent contractures, restore function

3. Precancerous conditions — obligatory and optional Optional (facultative): occasionally transform, low risk — examples: chronic atrophic gastritis, gastric ulcer, cervical ectopia, actinic keratosis, hyperplastic colon polyps, chronic inflammatory bowel disease. Obligatory: almost always progress to cancer if untreated, high risk — examples: familial adenomatous polyposis (FAP), Barrett's esophagus with high-grade dysplasia, carcinoma in situ (any site), erythroplasia of Queyrat, leukoplakia with dysplasia, Paget's disease of nipple.

4. Legal and ethical issues of organ donation (1) Informed consent: opt-in (most countries) vs. opt-out/presumed consent (Spain, France — higher rates). (2) Dead donor rule: organs only from dead donors (brain dead or DCD — donation after circulatory death). (3) No organ commercialization (WHO principle). (4) Equitable allocation: based on medical urgency and compatibility, not wealth. (5) Family rights: family informed/consulted even in opt-out systems. (6) Confidentiality: donor/recipient anonymity. (7) No conflict of interest: treating physicians must not be on transplant team. (8) Living donors (kidney, liver lobe) require independent ethics committee approval.

TICKET № 31

1. Types of OR cleaning — Medical waste classes OR cleaning: (1) Preliminary (morning, before first operation); (2) Current (between cases — surfaces wiped, used materials removed); (3) Post-operation (after each case — full surface disinfection); (4) Final (end of workday — thorough cleaning of all surfaces + UV irradiation); (5) General (weekly — deep clean including walls, ceiling, ventilation ducts). Medical waste classes: A — non-hazardous (household equivalent); B — potentially hazardous (sharps, biological waste); C — hazardous (cytotoxic, chemical waste); D — radioactive; E — highly contagious (Class III–IV pathogens).

2. Burns — classification by depth

Grade I: epidermis only; erythema, pain, no blisters; heals 3–5 days
Grade IIa (superficial partial thickness): epidermis + superficial dermis; blisters, moist, pink, very painful; heals 10–14 days spontaneously
Grade IIb (deep partial thickness): deep dermis; pale/mottled, less painful (nerve destruction), blisters; heals >21 days with scarring; often requires grafting
Grade III (full thickness): entire dermis destroyed; white/brown/charred, leathery, painless; requires grafting
Grade IV: deep structures (fat, muscle, bone, tendons); requires flap reconstruction or amputation

3. Body detoxification methods

Hemodialysis: blood through semi-permeable membrane; removes small/medium solutes (urea, creatinine, K⁺, drugs) and excess water. Indications: acute/chronic renal failure, severe electrolyte/acid-base disturbance, dialyzable drug overdose.
Hemosorption (hemoperfusion): blood passed through activated charcoal or resin; removes large hydrophobic toxins (barbiturates, cardiac glycosides, bilirubin). Indications: exogenous poisoning, hepatic failure.
Plasmapheresis: plasma separated and removed (replaced with albumin or FFP); removes large-molecule toxins, antibodies, immune complexes. Indications: TTP, Guillain-Barré, myasthenia gravis, Goodpasture's, hyperviscosity, severe autoimmune disease.

4. MARS (artificial liver) — indications MARS (Molecular Adsorbent Recirculating System) is an extracorporeal liver support system removing albumin-bound toxins (bilirubin, bile acids, aromatic amino acids, fatty acids, cytokines) and water-soluble toxins via albumin dialysate + activated charcoal + anion exchanger columns. It mimics detoxification but does not replace synthetic liver function. Indications: acute liver failure (bridge to transplantation), acute-on-chronic liver failure (ACLF), grade III–IV hepatic encephalopathy, drug-induced liver injury, primary graft non-function post-transplant, refractory cholestatic pruritus.

All 31 tickets completed — 124 questions answered.

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