Master Adult Health (Surgery)
for AMC Cat 1

Core Concepts

Surgical assessment relies on a systematic approach: accurate history, thorough physical exam, and targeted investigations. Perioperative care encompasses risk stratification (e.g., ASA classification, cardiac risk indices), optimizing patient health, preventing complications (e.g., DVT/PE prophylaxis, surgical site infection), and managing post-operative issues (pain, nausea, fluid balance). Trauma management follows ATLS principles: primary survey (ABCDE - Airway, Breathing, Circulation, Disability, Exposure), resuscitation, and secondary survey. Common surgical emergencies include acute abdomen (inflammatory, obstructive, vascular, perforative causes), obstructed/strangulated hernias, and vascular catastrophes.

Clinical Presentation

• Appendicitis: Periumbilical pain migrating to RLQ, anorexia, nausea/vomiting, low-grade fever. Tenderness at McBurney's point, guarding, rebound tenderness.
• Acute Cholecystitis: RUQ pain (constant, may radiate to right shoulder/scapula), fever, nausea/vomiting. Murphy's sign (inspiratory arrest on palpation of RUQ).
• Small Bowel Obstruction (SBO): Colicky abdominal pain, abdominal distension, vomiting (bilious to feculent), absolute constipation (late sign). Hyperactive "tinkling" bowel sounds early, then diminished/absent.
• Large Bowel Obstruction (LBO): Less colicky pain, more distension, delayed vomiting, absolute constipation.
• Perforated Viscus (e.g., peptic ulcer): Sudden onset, severe, generalized abdominal pain ("knife-like"), rigid/board-like abdomen, rebound tenderness, guarding. Signs of shock may develop.
• Incarcerated/Strangulated Hernia: Tender, painful, irreducible lump at hernia site. Strangulation adds systemic signs: fever, tachycardia, erythema over lump, signs of peritonitis/sepsis.
• Abdominal Aortic Aneurysm (AAA) Rupture: Sudden, severe abdominal/back pain, pulsatile abdominal mass (if palpable), hypotension, syncope.

Diagnosis (Gold Standard)

• Appendicitis: Clinical suspicion supported by CT abdomen/pelvis (especially in adults). Ultrasound in children/pregnant patients.
• Acute Cholecystitis: Clinical features with ultrasound abdomen (gallstones, thickened gallbladder wall, pericholecystic fluid, sonographic Murphy's sign). HIDA scan (Cholescintigraphy) if diagnosis is equivocal.
• Bowel Obstruction: Abdominal X-rays (dilated loops, air-fluid levels, absence of colonic gas in SBO) for initial assessment. CT abdomen/pelvis (identifies transition point, cause, and signs of ischemia/perforation) is gold standard.
• Perforated Viscus: Clinical suspicion with erect chest X-ray (free air under diaphragm). CT abdomen is more sensitive.
• Incarcerated/Strangulated Hernia: Clinical diagnosis based on exam. Ultrasound can differentiate from other masses.
• AAA: Ultrasound for screening/diagnosis. CT angiography for detailed assessment and surgical planning.
• Deep Vein Thrombosis (DVT): Duplex ultrasound.
• Pulmonary Embolism (PE): CT Pulmonary Angiogram (CTPA).

Management (First Line)

• Acute Abdomen (General Principles): NPO, IV fluids, analgesia, antiemetics, broad-spectrum antibiotics (if infection suspected), monitor vital signs, Foley catheter.
• Appendicitis: Laparoscopic appendectomy. Non-operative management with antibiotics for selected cases (phlegmon/abscess).
• Acute Cholecystitis: NPO, IV fluids, analgesia, antibiotics. Early laparoscopic cholecystectomy (within 72 hours) or delayed after inflammation settles. Percutaneous cholecystostomy for high-risk patients.
• Bowel Obstruction: Nasogastric tube for decompression, IV fluids, electrolyte correction. Conservative management for partial or adhesive SBO (trial of NPO, NG decompression). Urgent laparotomy if signs of strangulation, ischemia, peritonitis, or complete LBO.
• Perforated Viscus: Urgent resuscitation (IV fluids, broad antibiotics) followed by urgent laparotomy for repair/source control and peritoneal lavage.
• Incarcerated/Strangulated Hernia: Urgent surgical repair (herniorrhaphy/hernioplasty) with resection of any non-viable bowel.
• AAA Rupture: Immediate resuscitation (permissive hypotension, IV fluids/blood products) and urgent open or endovascular repair (EVAR).
• Trauma: ATLS protocol (ABCDE, primary survey, resuscitation, secondary survey, definitive care).