Preoperative Assessment and ASA Grading

🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

ASA I–VI grades preoperative fitness; ASA III+ warrants deferral or optimisation before elective surgery.
Acute abdomen is localised by quadrant: RUQ → cholecystitis, RLQ → appendicitis, LLQ → diverticulitis; first imaging is erect CXR for perforation, then US or CT.
Parkland formula: 4 mL × kg × %TBSA of Ringer’s lactate over 24 h, half in the first 8 h counted from the time of burn, half over the next 16 h.
Local anaesthetic ceilings: lignocaine 3 mg/kg (7 mg/kg with adrenaline), bupivacaine 2 mg/kg — bupivacaine is cardiotoxic.
Abscess = incision, drainage, break loculi, loose pack, never suture closed.

🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

Preoperative Assessment and ASA Grading

Every GP surgical referral begins with fitness stratification. The ASA Physical Status scale (I = healthy, II = mild systemic disease, III = severe, IV = constant threat to life, V = moribund, VI = brain-dead organ donor) predicts anaesthetic risk. ASA III patients need cardiorespiratory optimisation and frequently shared decision-making before booking the list.

The Acute Abdomen

A systematic four-step approach is testable:

History — onset (sudden = perforation/ischaemia), migration (periumbilical → RLQ in appendicitis), associated symptoms.
Examination — inspect, palpate for guarding/rebound, percuss, do digital rectal exam when indicated.
Labs — CBC, CRP, lipase, LFTs, urinalysis, β-hCG in any woman of reproductive age.
Imaging — erect CXR (free air), abdominal US (biliary/ovarian), contrast CT (obstruction, perforation).

Differential by Quadrant

Quadrant	Top Surgical Causes	First-line Imaging
RUQ	Acute cholecystitis, perforated peptic ulcer	US abdomen
RLQ	Acute appendicitis, ovarian torsion, ectopic	US / CT
LUQ	Splenic rupture, perforated ulcer	CXR + CT
LLQ	Diverticulitis, ovarian pathology	CT abdomen

Burns: Estimation and Resuscitation

Use the Rule of Nines for adults (head 9 %, each arm 9 %, each leg 18 %, anterior trunk 18 %, posterior trunk 18 %, perineum 1 %). Children require Lund-Browder modification because the head is proportionally larger. The Parkland formula drives the first 24 hours: 4 × weight (kg) × %TBSA, half within the first 8 h from the time of burn, the rest over 16 h. Endpoint: urine output 0.5 mL/kg/h in adults, 1 mL/kg/h in children.

Exam trap: students commonly start the clock at hospital arrival; the Parkland clock begins at burn injury.

Wound Healing Phases

Phase	Timing	Key Process
Haemostasis	Immediate	Platelet plug, fibrin clot
Inflammation	0–3 days	Neutrophils, macrophages
Proliferation	3–21 days	Granulation, angiogenesis, re-epithelialisation
Remodelling	21 d–2 yr	Collagen cross-linking, scar maturation

🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for students on a longer study timeline.

Edge Cases and Atypical Presentations

Elderly and diabetic patients with acute abdomen frequently show blunted peritoneal signs — a “silent abdomen” does not exclude perforation or mesenteric ischaemia. Maintain a low threshold for CT with contrast and early surgical consultation. In any woman of reproductive age, exclude ectopic pregnancy (β-hCG + transvaginal US) and ovarian torsion (sudden pain + adnexal mass on US with absent Doppler flow) before anchoring on a GI diagnosis.

Suturing and Local Anaesthesia

Choose suture by tissue: monofilament (nylon, polypropylene) for skin (lower infection risk), braided (polyglactin/Vicryl) for subcutaneous or mucosal layers. Remove skin sutures at 7–10 days on the face, 10–14 on the trunk. Never exceed lignocaine 3 mg/kg plain or 7 mg/kg with adrenaline; bupivacaine is limited to 2 mg/kg and is cardiotoxic — treat toxicity with Intralipid 20 % emulsion.

Abscess and Hernia Principles

An abscess mandates incision over the point of maximal fluctuance, drainage, disruption of loculi, and loose packing — primary closure traps pus and guarantees recurrence. For hernias, document reducibility, cough impulse, and content; irreducible, obstructed, or strangulated hernias are surgical emergencies.

Postoperative Complication Recognition

Suspect anastomotic leak on POD 3–7 with fever, tachycardia, and new abdominal pain; CT with rectal contrast is diagnostic. DVT/PE peaks day 3–7 — apply mechanical prophylaxis immediately and pharmacological prophylaxis when bleeding risk allows. Atelectasis is the commonest cause of postoperative fever on day 1; incentive spirometry and early mobilisation prevent it.

Practice Prompts

A 28-year-old man presents 2 h after sustaining 40 % TBSA flame burns. Using Parkland, calculate his 24 h fluid requirement and the volume to be infused by hour 8.
A 62-year-old diabetic woman has 36 h of vague lower abdominal pain and a normal WBC. Outline your next steps and justify the imaging choice.

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Preoperative Assessment and ASA Grading