Surgery
Family physicians see undifferentiated abdominal pain, hernias, wounds and burns, and must decide who can be managed at the unit and who needs a surgical referral. The Board tests systematic assessment, scoring tools and safe initial management rather than operative technique.
Core rules
- Surgical sieve for any symptom: congenital, inflammatory/infective, neoplastic, obstructive, vascular, traumatic, metabolic, iatrogenic, functional.
- Acute abdomen: vomiting before pain suggests gastroenteritis; pain before vomiting suggests a surgical cause. Examine for guarding and rebound; check urine dipstick, pregnancy test, CBC and imaging as indicated.
- Appendicitis: Alvarado (MANTRELS) score - migration to right iliac fossa, anorexia, nausea/vomiting, right iliac fossa tenderness, rebound tenderness, elevated temperature, leucocytosis, shift to the left. A score of 7 or more means surgical referral.
- Hernia: reducible hernias are elective referrals; irreducible, tender or with obstruction and systemic upset means strangulation and an emergency. Never attempt forceful manual reduction.
- Burns: Wallace rule of nines (each arm 9%, each leg 18%, front trunk 18%, back 18%, head 9%, perineum 1%). Parkland formula: 4 mL × body weight in kg × percentage TBSA over 24 hours, half in the first eight hours from the time of the burn. Refer extensive, facial, hand, circumferential, electrical or chemical burns.
- Wounds: irrigate with saline, remove foreign bodies, assess neurovascular status distally, close within 6 to 8 hours (up to 24 hours on the face), and check tetanus status.
- Postoperative fever by timing: atelectasis (days 1-2), urinary infection (3-5), wound infection (5-7), deep vein thrombosis (7-10), drugs and lines at any time.
Worked example
A 24-year-old woman has periumbilical pain that migrated to the right iliac fossa eight hours ago, anorexia, temperature 37.9 °C and guarding. Reasoning: Alvarado score is at least 7, so refer surgically; give analgesia and intravenous fluids, keep nil by mouth and exclude pregnancy with a urine or serum test before imaging.
Traps that cost marks
- Withholding analgesia in suspected appendicitis; it does not mask the diagnosis.
- Missing ectopic pregnancy in any woman of childbearing age with abdominal pain.