Surgery Made Simple For NLE NRE Step 1

1. Burn Tissue Injury

1. Types

• 1st degree → Epidermis only (red, painful, no blister)
• 2nd degree → Epidermis + dermis → blister formation
• 3rd degree → Epidermis + dermis + hypodermis (subcutaneous tissue) → painless, scar formation

2. Common Infection

• Pseudomonas aeruginosa

3. Fluid Resuscitation

Parkland Formula Fluid (ml)=4[Weight (kg)×%BSA(burned)]

• Half in the first 8 hours
• The remaining half in the next 16 hours

🔹 Example:
Weight = 70 kg, Burn area = 5% BSA

4×70×5=1400 ml

Here are other materials for NLE NRE step 1

2. Shock

Mnemonic for shock types → SHOCk

• S: Septic
• H: Hypovolemic
• O: Obstructive
• C: Cardiogenic

1. Hypovolemic Shock

• Cause: ↓ blood/fluid volume
  • Dehydration
  • Diarrhea
  • Burns
  • Hemorrhage
• First sign → Tachycardia
• Peripheral signs → Cold, clammy extremities
• Treatment:
  • IV fluids (crystalloids)
  • Blood transfusion (if hemorrhage)

2. Obstructive Shock

• Cause: Mechanical obstruction to filling/emptying of the heart
  • Cardiac tamponade
  • Tension pneumothorax
  • Massive pulmonary embolism
• Mechanism → Heart can’t relax/fill properly
• Treatment → Relieve obstruction (pericardiocentesis, chest tube, thrombolysis)

3. Cardiogenic Shock

• Cause: Pump failure (heart cannot contract effectively)
  • Myocardial infarction (MC cause)
  • Cardiomyopathy
  • Severe valvular disease
• Signs → Cold periphery, hypotension, pulmonary edema
• Treatment → Inotropes (dobutamine), revascularization

4. Distributive Shock

Mechanism: Severe vasodilation → maldistribution of blood → warm periphery

(a) Anaphylactic Shock

• Type I Hypersensitivity (IgE mediated → histamine release → vasodilation, edema, bronchospasm)
• Treatment: Adrenaline IM (1:1000, 0.3–0.5 mg), airway support, antihistamines, steroids

(b) Septic Shock

• Cause: Infection (often gram-negative bacteria → endotoxin release)
• Signs:
  • Vasodilation + warm periphery
  • Hypotension
  • High-grade fever
• Treatment:
  • Norepinephrine (α1 agonist) = DOC
  • Broad-spectrum antibiotics
  • IV fluids

(c) Neurogenic Shock

• Cause: Spinal cord injury (above T6) → ↓ sympathetic tone, ↑ parasympathetic tone → vasodilation + bradycardia
• Signs: Warm, dry skin + hypotension + bradycardia
• Treatment: Treat underlying cause, vasopressors, atropine if severe bradycardia

Cold periphery → Hypovolemic, Cardiogenic, Obstructive

Warm periphery → Septic, Anaphylactic, Neurogenic

Type	Cause	Mechanism	Clinical Signs	Treatment
Hypovolemic	Hemorrhage, dehydration, diarrhea, burns	↓ Intravascular volume → ↓ preload → ↓ CO	Early tachycardia, hypotension, cold clammy skin	IV crystalloids, blood transfusion
Obstructive	Cardiac tamponade, tension pneumothorax, massive PE	Physical obstruction → impaired filling/output	Hypotension, JVP ↑ (tamponade), muffled HS, pulsus paradoxus	Relieve obstruction (pericardiocentesis, chest tube, thrombolysis)
Cardiogenic	MI, cardiomyopathy, valvular disease, arrhythmias	Pump failure → ↓ CO despite normal volume	Hypotension, cold clammy periphery, pulmonary edema	Inotropes (dobutamine), revascularization, diuretics
Distributive – Anaphylactic	Drugs, food, insect bite (IgE-mediated)	Histamine release → vasodilation + ↑ permeability	Warm skin, flushing, edema, bronchospasm	Adrenaline IM, airway, antihistamines, steroids
Distributive – Septic	Gram -ve bacteria (endotoxin), sepsis	Cytokines → vasodilation + capillary leak	Warm periphery, hypotension, fever, tachycardia	Norepinephrine, IV fluids, broad-spectrum antibiotics
Distributive – Neurogenic	Spinal cord injury (T6↑), anesthesia	Loss of sympathetic tone → vasodilation + bradycardia	Warm, dry skin, hypotension, bradycardia	Vasopressors, atropine, treat cause

3. Abnormal Scars

Type	Definition	Key Features
Hypertrophic scar	Excess collagen (Type I & III) within original wound boundary	Raised, red scar, but does not extend beyond wound
Keloid	Excess collagen (mostly Type III) extends beyond wound margin	Irregular, hard, itchy, common in ear lobes, chest, shoulders, darker skin

Key Difference:

• Keloid = Beyond the boundary
• Hypertrophic = Within boundary

3. Wound Healing & Scar Formation

Type	Definition (as per your info)
Primary intention	Original wound margins are approximated and closed with stitches.
Secondary intention	Wound left open → granulation tissue forms → later replaced with scar.
Delayed (Tertiary) intention	Wound healing delayed due to recurrent infection.

4. Indirect vs Direct Inguinal Hernia

Feature	Indirect Hernia	Direct Hernia
Pathway	Herniated organ enters through deep inguinal ring → exits via superficial inguinal ring	Hernia pierces fascia directly
Structure involved	Passes through transversalis fascia	Weakness of fascia (direct bulge)
Age group	Young age	Older age
Bulge test	No bulge (+Ve test)	Bulge present (+Ve test)
Relation to Inferior Epigastric Artery	Lateral to inferior epigastric artery	Medial to inferior epigastric artery

5. Scrotal Complaints

Condition	Key Feature	Prehn’s Sign	Transillumination	Special Note / Exam Finding	Treatment
Testicular torsion	Sudden pain, tender, high-riding testis	Negative (pain not relieved)	–	Surgical emergency	Urgent surgery
Epididymitis	Gradual pain, fever, tender epididymis	Positive (pain relieved)	–	Often post-infective	Antibiotics
Varicocele	Left-sided, venous retention, “bag of worms”	–ve	–	More prominent on standing/Valsalva	Surgery if symptomatic/infertility
Hydrocele	Scrotal swelling, smooth, fluctuant	–ve	Positive (transmits light)	Examiner can get above swelling	Surgery if persistent
Inguinoscrotal hernia	Scrotal swelling, expansile cough impulse	–ve	Negative	Cannot get above swelling	Surgery

Key clinical points:

• Cannot get above swelling → Hernia.
• Prehn’s sign + → Epididymitis (infection).
• Prehn’s sign – → Torsion (emergency).
• Transillumination + → Hydrocele.
• Bag of worms → Varicocele.

6. Neck Lump

Type / Duration	Key Features	Location / Notes	Treatment
< 3 weeks	Inflammatory lymph node	Usually tender, red, swollen	Treat underlying infection (lymphadenitis)
> 3 weeks	Alarming sign → investigate further	Could be cyst or tumor	Depends on underlying cause
Dermoid cyst	Congenital cyst	Midline, usually upper/middle neck	Surgical excision
Sebaceous cyst	Acquired, contains keratin/sebum	Dermal	Drainage or excision
Lipoma	Painless lump, fatty tissue	Anywhere on neck	Observation or excision if large
Painful lumps	Dermoid disease, influenced by hormones (↑F, ↓estrogen)	–	Surgical if symptomatic
Hashimoto / Thyroiditis	Neck mass	Thyroid region	Manage thyroid condition
Thyroglossal cyst	Midline neck mass, moves with swallowing or tongue protrusion	Midline	Surgical excision (Sistrunk procedure)
Ectopic thyroid	Sublingual mass	Under tongue	Depends on thyroid function, may require surgery

7. Thyroid Malignancy

Type	Age / Risk Factors	Origin	Spread / Metastasis	Key Findings / Markers	Prognosis
Papillary Ca	Any age; ↑ risk with childhood radiation	Follicular cells	Lymphatic route	Psammoma bodies, Orphan Annie nuclei	Good
Follicular Ca	40–60 yrs	Follicular cells	Hematogenous	–	Early detection → good; late detection → poor
Medullary Ca	–	Parafollicular (C cells)	–	Calcitonin tumor marker; Tetany; associated with MEN 2A, MEN 2B	–
Anaplastic Ca	>60 yrs	Poorly differentiated	–	Rare, aggressive	Poor prognosis

8. Thyroid Nodule & Scan

Feature	Details
Hot Nodule	↑ Radioactive iodine uptake
Cold Nodule	↓ Radioactive iodine uptake; 20% malignant → FNAC / biopsy required

9. Post-Thyroid Surgery Complications

Complication	Cause / Details
Hematoma	Can compress the airway → open the stitch immediately
Hoarseness of voice	Recurrent laryngeal nerve (RLN) damage
Bleeding control	Ligate the middle thyroid vein
Hypocalcemia	Parathyroid gland removed → ↓ calcium

10. Breast Cancer

Feature	Details / Notes
Gender	F > M
Common Location	Upper outer quadrant
Risk Factors	Advanced age, Family history (BRCA1, BRCA2), Estrogen exposure (nulliparity), Alcohol intake, HER2 mutation
Alarming Signs	Breast asymmetry, Skin dimpling, Nipple discharge, Palpable lump
Treatment / Targeted Therapy	Doc: Trastuzumab (HER2 positive)
Other Notes	Fat necrosis: history of trauma → necrosis; Mastitis: lump + fever, chills, rigor

11. Benign Breast Conditions

Condition	Age Group	Features / Notes	Investigation	Treatment
Fibroadenoma	15–35 yrs	Soft, painless, mobile lump	USG <30 yrs	Lumpectomy if needed
Phyllodes tumor	50–60 yrs	Breast lump, size increasing, leaf-like lobulation	Mammography >30 yrs	Surgical excision
Gynecomastia (male)	Any adult male	Enlargement of breast tissue	–	Evaluate underlying cause: cirrhosis, Klinefelter (47XXY), testicular tumor, Tx. (spironolactone, cimetidine)