Master Surgery & Allied
for PMDC NLE Step 1

Core Concepts

Shock: Inadequate tissue perfusion. Types: Hypovolemic (hemorrhagic - most common surgical), Cardiogenic, Obstructive, Distributive (septic, anaphylactic, neurogenic). Initial management: Airway, Breathing, Circulation (ABCs), intravenous fluids (crystalloids for hypovolemic), address underlying cause.
Fluid Management: Isotonic crystalloids (e.g., Ringer's Lactate, Normal Saline) for resuscitation and maintenance. Hypotonic solutions for free water deficits. Dextrose solutions for calorie/maintenance. Monitor electrolytes (Na, K), acid-base balance.
Wound Healing: Stages: Inflammation, Proliferation (granulation, contraction, epithelialization), Remodeling. Intentions: Primary (clean, approximated edges), Secondary (left open to heal by granulation/contraction), Tertiary (delayed primary closure).
Surgical Site Infection (SSI): Risk factors include patient factors (diabetes, obesity, malnutrition, immunosuppression) and surgical factors (poor technique, prolonged surgery, foreign bodies). Prophylaxis: Pre-op antibiotics (within 60 mins of incision), sterile technique, skin prep.
Pre-operative Assessment: Aim to optimize patient condition. Assess cardiac (ECG, stress test), pulmonary (PFTs), renal, hepatic function. ASA physical status classification (I-V). Medication review (e.g., anticoagulants).
Post-operative Complications: Early: Bleeding, infection, DVT/PE, atelectasis, ileus, anastomotic leak. Late: Hernia, adhesions. Post-op fever "5 W's": Wind (atelectasis), Water (UTI), Wound (SSI), Walk (DVT), Wonder drugs.
Trauma (ATLS): Primary Survey (ABCDE - Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure/Environment), Resuscitation, Secondary Survey (Head-to-toe exam, AMPLE history - Allergies, Medications, Past illness/Pregnancy, Last meal, Events), Definitive care.

Clinical Presentation

• Acute Appendicitis: Periumbilical pain migrating to RLQ (McBurney's point), anorexia, nausea, vomiting, low-grade fever, guarding, rebound tenderness. Rovsing's, Psoas, Obturator signs may be present.
• Acute Cholecystitis: Severe RUQ pain, radiating to right shoulder/back, often post-prandial (fatty meals), nausea, vomiting, fever, leukocytosis. Positive Murphy's sign (inspiratory arrest on palpation of RUQ).
• Small Bowel Obstruction (SBO): Crampy abdominal pain, abdominal distention, nausea, vomiting (bilious to feculent), obstipation (no flatus/stool). High-pitched tinkling bowel sounds early, then absent.
• Diverticulitis: LLQ pain, fever, chills, nausea, vomiting, change in bowel habits, localized tenderness.
• Peritonitis: Generalized, severe abdominal pain, rigid "board-like" abdomen, guarding, rebound tenderness, absent bowel sounds, fever, tachycardia, hypotension.
• Deep Vein Thrombosis (DVT): Unilateral leg swelling, pain, warmth, erythema, tenderness along venous distribution. May be asymptomatic.
• Acute Limb Ischemia: The "6 P's": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (cold limb).
• Thyrotoxicosis/Graves' Disease (surgical relevance): Weight loss, palpitations, tremor, heat intolerance, anxiety, exophthalmos (Graves').
• Benign Prostatic Hyperplasia (BPH): Lower urinary tract symptoms (LUTS): frequency, urgency, nocturia, weak stream, hesitancy, incomplete emptying.

Diagnosis (Gold Standard)

Appendicitis: CT Abdomen/Pelvis (adults), Ultrasound (children/pregnant women) for initial evaluation.
Acute Cholecystitis: Ultrasound (initial imaging), HIDA scan (cholescintigraphy) if ultrasound is equivocal or for suspected acalculous cholecystitis.
SBO: Abdominal X-ray (dilated bowel loops, air-fluid levels), CT Abdomen (identifies transition point, cause, strangulation signs).
Diverticulitis: CT Abdomen/Pelvis with IV/oral contrast.
Peritonitis: Clinical diagnosis; confirmed by imaging (free air on erect CXR/CT) or diagnostic laparoscopy/laparotomy.
DVT: Duplex Ultrasound of the affected limb.
Thyroid Nodule: Fine Needle Aspiration (FNA) with cytology for malignancy risk assessment.
Abdominal Aortic Aneurysm (AAA): Ultrasound for screening, CT Angiogram for detailed evaluation and surgical planning.

Management (First Line)

Shock (General): Resuscitation with IV fluids (crystalloids), oxygen, monitor vital signs. Address underlying cause immediately. Vasopressors (e.g., norepinephrine) for septic shock, blood products for hemorrhagic shock.
Appendicitis: NPO, IV fluids, broad-spectrum antibiotics, urgent laparoscopic appendectomy.
Acute Cholecystitis: NPO, IV fluids, analgesia, broad-spectrum antibiotics. Laparoscopic cholecystectomy (ideally within 72 hours for acute, otherwise delayed if severe inflammation).
SBO: NPO, Nasogastric (NG) tube decompression, IV fluids, serial abdominal exams. Surgical intervention for complete obstruction, strangulation, or failure of conservative management.
Diverticulitis (Uncomplicated): NPO, IV fluids, oral or IV antibiotics. Surgical resection for complicated disease (perforation, abscess, fistula, obstruction) or recurrent episodes.
Peritonitis: Aggressive resuscitation (fluids, electrolytes), broad-spectrum IV antibiotics, urgent surgical exploration (laparotomy) to identify and correct the source of contamination.
DVT: Anticoagulation (e.g., LMWH, DOACs). Consider IVC filter if anticoagulation is contraindicated or fails.
Trauma: Follow ATLS protocol. Stabilize, resuscitate, identify life-threatening injuries, and perform definitive surgical repair or damage control surgery.
Pre-op Prophylaxis: VTE prophylaxis (e.g., LMWH, sequential compression devices), SSI prophylaxis (e.g., cefazolin IV pre-incision).

Exam Red Flags