Master Adult Health (Surgery)
for AMC Cat 1
Access 50+ high-yield questions tailored for the 2026 syllabus. Includes AI-powered explanations and performance tracking.
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).
Exam Red Flags
- Signs of Shock: Hypotension, tachycardia, altered mental status, oliguria -> indicates severe hemorrhage, sepsis, or organ dysfunction.
- Peritonism: Board-like rigidity, severe diffuse guarding, rebound tenderness -> suggests peritonitis from perforation, severe inflammation, or ischemia.
- Pulsatile Abdominal Mass with Acute Pain/Hypotension: Highly suspicious for ruptured AAA.
- Acute Scrotal Pain with Swelling/Tenderness: Consider testicular torsion (surgical emergency).
- Tender, Irreducible Hernia with Systemic Signs (fever, tachycardia) or Skin Changes: Indicates strangulation and requires urgent surgery.
- Sudden Onset Severe Limb Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Perishingly Cold: Acute limb ischemia (surgical emergency).
- Progressive Neurological Deficit Post-Trauma: Signifies expanding intracranial lesion or spinal cord injury.
- Absent Bowel Sounds with Severe Abdominal Pain/Distension: Late sign of obstruction, peritonitis, or paralytic ileus.
Sample Practice Questions
An 80-year-old male with a history of hypertension, type 2 diabetes, and smoking presents with left calf pain that occurs after walking approximately 100 meters and is relieved by rest. He reports that recently he has started experiencing pain in his left foot at night, which is only relieved by hanging his leg off the side of the bed. On examination, his left foot is cool to touch, pale, and he has absent pedal pulses. There are also some trophic changes to the nails. What is the most appropriate initial diagnostic step to assess the severity of his condition?
A 72-year-old male with a history of hypertension, type 2 diabetes, and hyperlipidemia presents with severe, constant pain in his left foot that has worsened over the past 24 hours. The pain is present even at rest and is not relieved by analgesics. He describes a 6-month history of intermittent claudication in his left calf after walking about 100 meters. On examination, his left foot is cool to touch, pale, and dependent rubor is noted. Pedal pulses (dorsalis pedis and posterior tibial) are absent. Capillary refill in the toes is delayed (>5 seconds). There is no sensory deficit or motor weakness. What is the most appropriate initial investigation to assess the severity and location of the arterial occlusion?
A 28-year-old male presents to the emergency department with a 12-hour history of right lower quadrant pain. The pain initially started periumbilically and migrated to the right lower quadrant. He reports nausea, one episode of vomiting, and a fever of 38.2°C. On examination, he has localized tenderness and rebound tenderness in the right iliac fossa. His white blood cell count is 14 x 10^9/L. What is the most appropriate initial management for this patient?
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