PMDC National Licensing Examination Surgery and Allied Syllabus

What distinguishes neurogenic shock from other shock states on examination?

Neurogenic shock (from spinal cord injury, loss of sympathetic tone) causes hypotension WITH bradycardia and warm, dry skin - unlike hypovolemic shock which causes tachycardia with cool, clammy skin.

What is the initial fluid resuscitation in adult trauma per ATLS, and the transfusion strategy in massive hemorrhage?

Give 1 L of warmed balanced crystalloid (isotonic), reassess, then move to blood products early. Massive transfusion uses a balanced ratio (~1:1:1 packed red cells : plasma : platelets) with permissive hypotension and damage-control principles.

Define the lethal triad (trauma triad of death).

Hypothermia, coagulopathy, and metabolic acidosis - a self-perpetuating cycle in severely injured/hemorrhaging patients that worsens bleeding and mortality.

What does an elevated ASA physical status classification (ASA I-V) represent?

ASA I: normal healthy. II: mild systemic disease. III: severe systemic disease (not incapacitating). IV: severe disease that is a constant threat to life. V: moribund, not expected to survive without operation. (E added for emergency.)

How long before elective surgery should patients fast for solids and clear fluids?

Solids/non-clear fluids: 6 hours. Clear fluids: 2 hours (the '6-2 rule' to reduce aspiration risk).

List common perioperative management of medications: which to stop and which to continue.

Stop/adjust: warfarin (bridge if high-risk), DOACs, antiplatelets (case-by-case), metformin (peri-op, contrast risk), oral hypoglycemics. Continue: most beta-blockers, statins; manage insulin per protocol. Hold ACE inhibitors/ARBs morning of surgery if hypotension risk.

What is the typical timeline-based differential for post-operative fever (the 5 W's)?

Wind (atelectasis/pneumonia, day 1-2), Water (UTI, day 3-5), Walking (DVT/PE, day 5+), Wound (infection, day 5-7), Wonder drugs/abscess (drug fever or anastomotic leak/collection, day 7+).

What is the most common cause of fever in the first 48 hours postoperatively?

Atelectasis (and the inflammatory/cytokine response to surgery itself); managed with early mobilization, deep breathing, and incentive spirometry.

Define the classic order of pain migration in acute appendicitis and the underlying mechanism.

Pain begins as vague periumbilical (visceral, T10 referred) pain due to luminal distension, then migrates and localizes to the right iliac fossa/McBurney's point (somatic) once the inflamed appendix irritates the parietal peritoneum.

Name four eponymous signs of appendicitis and what each tests.

Rovsing's sign (RLQ pain on LLQ palpation), Psoas sign (pain on right hip extension - retrocecal appendix), Obturator sign (pain on internal rotation of flexed right hip - pelvic appendix), Blumberg's sign (rebound tenderness).

Where is McBurney's point located?

One-third of the distance along a line from the right anterior superior iliac spine (ASIS) to the umbilicus - the surface marking of the appendix base.

What scoring system aids appendicitis diagnosis and what are its components?

Alvarado (MANTRELS) score: Migration of pain, Anorexia, Nausea/vomiting, Tenderness RLQ (2), Rebound, Elevated temperature, Leukocytosis (2), Shift of WBC to left. Score >=7 suggests high probability.

Define peritonitis and distinguish localized from generalized signs.

Peritonitis is inflammation of the peritoneal cavity. Localized: focal guarding/rebound over the affected area. Generalized: board-like rigidity, diffuse rebound, absent bowel sounds, a rigid still patient - indicates diffuse contamination (e.g., perforated viscus).

Define a hernia and name its three constituent parts.

A hernia is the protrusion of a viscus or part of a viscus through an abnormal opening in the wall of its containing cavity. Parts: the sac (peritoneum), the contents, and the coverings.

Distinguish an indirect from a direct inguinal hernia anatomically.

Indirect: passes through the deep inguinal ring, LATERAL to the inferior epigastric vessels, traverses the canal (congenital, can reach scrotum). Direct: pushes through the posterior wall (Hesselbach's triangle), MEDIAL to the inferior epigastric vessels (acquired).

What are the boundaries of Hesselbach's triangle?

Medial: lateral border of rectus abdominis. Lateral/superolateral: inferior epigastric vessels. Inferior: inguinal ligament. (Direct inguinal hernias protrude here.)

Define reducible, incarcerated, obstructed, and strangulated hernia.

Reducible: contents return to the abdomen. Incarcerated: irreducible but not compromised. Obstructed: contained bowel is obstructed. Strangulated: blood supply is compromised (ischemia) - a surgical emergency with pain, tenderness, irreducibility, and signs of bowel ischemia.

Which groin hernia lies below and lateral to the pubic tubercle, and why is it dangerous?

Femoral hernia - it passes through the femoral canal, lying below and lateral to the pubic tubercle (inguinal hernias lie above and medial). It is more common in women and has a high risk of strangulation due to the narrow, rigid femoral ring.

What is Richter's hernia?

A hernia in which only part of the circumference (antimesenteric border) of the bowel wall becomes incarcerated/strangulated. It can strangulate and become gangrenous WITHOUT causing intestinal obstruction, making it dangerously deceptive.

State the components of Charcot's triad and Reynolds' pentad in biliary disease.

Charcot's triad (ascending cholangitis): fever/rigors, jaundice, right upper quadrant pain. Reynolds' pentad adds hypotension (shock) and altered mental status - indicating suppurative cholangitis.

What is Murphy's sign and what does it indicate?

Arrest of inspiration due to pain when the examiner palpates the right upper quadrant under the costal margin during deep inspiration - a positive sign indicates acute cholecystitis.

Differentiate biliary colic, acute cholecystitis, and choledocholithiasis/cholangitis.

Biliary colic: transient RUQ pain after meals from gallstone obstructing the cystic duct, no fever/inflammation. Acute cholecystitis: persistent pain + fever + inflammation (positive Murphy's). Choledocholithiasis: stone in common bile duct causing jaundice; cholangitis adds infection (Charcot's triad).

State Courvoisier's law.

In the presence of painless jaundice, a palpable (enlarged) non-tender gallbladder is unlikely to be due to gallstones and suggests a malignant obstruction of the common bile duct (e.g., pancreatic head cancer), because chronic stone disease causes a fibrosed, non-distensible gallbladder.

What are the 'F' risk factors for gallstones?

Female, Fat (obesity), Forty (age), Fertile (multiparity), and Fair - classic risk factors for cholesterol gallstones.

Differentiate the clinical presentation of small bowel vs large bowel obstruction.

Small bowel obstruction: early/profuse vomiting, central colicky pain, less distension, dehydration prominent; X-ray shows central valvulae conniventes. Large bowel obstruction: marked distension, later vomiting (feculent), constipation early; X-ray shows peripheral haustra not crossing the lumen.

What are the four cardinal features of intestinal obstruction?

Colicky abdominal pain, vomiting, abdominal distension, and absolute constipation (no passage of flatus or feces). Bowel sounds are high-pitched/tinkling early and absent later.

List the most common causes of small bowel obstruction vs large bowel obstruction.

Small bowel: adhesions (most common), hernias, and tumors. Large bowel: colorectal carcinoma (most common), volvulus, and diverticular stricture.

Distinguish mechanical obstruction from paralytic ileus on examination.

Mechanical obstruction: colicky pain, hyperactive/tinkling bowel sounds (early). Paralytic ileus: painless distension with ABSENT bowel sounds and no peristalsis (often post-operative, electrolyte disturbance, or peritonitis).

What is the order of the ABCDE primary survey in ATLS?

A - Airway with cervical spine protection; B - Breathing and ventilation; C - Circulation with hemorrhage control; D - Disability (neurological status, GCS, pupils); E - Exposure/Environment (undress and prevent hypothermia).

What is the purpose of the secondary survey in ATLS and when is it performed?

A head-to-toe examination with full history (AMPLE: Allergies, Medications, Past history, Last meal, Events) to identify all injuries. It is performed only after the primary survey is complete, life-threats are addressed, and resuscitation has begun and the patient is responding.

Name the immediately life-threatening chest injuries identified in the primary survey (Breathing).

ATOM-FC: Airway obstruction, Tension pneumothorax, Open pneumothorax (sucking chest wound), Massive hemothorax, Flail chest, Cardiac tamponade. These must be detected and treated during ABC.

Describe tension pneumothorax findings and immediate management.

Respiratory distress, tracheal deviation away from the affected side, absent breath sounds and hyperresonance on the affected side, distended neck veins, hypotension. Immediate needle decompression (2nd intercostal space midclavicular line or 5th ICS anterior axillary line) followed by chest tube.

How is the Glasgow Coma Scale scored and what range defines severe head injury?

GCS scores Eye opening (1-4), Verbal response (1-5), and Motor response (1-6), total 3-15. Severe head injury = GCS 3-8; moderate = 9-12; mild = 13-15. GCS <=8 generally mandates definitive airway (intubation).

Differentiate an extradural (epidural) from a subdural hematoma.

Extradural: arterial (middle meningeal artery), often after temporal fracture, biconvex/lens-shaped on CT, classic lucid interval then deterioration, doesn't cross suture lines. Subdural: venous (bridging veins), crescent-shaped, crosses suture lines, common in elderly/alcoholics, more gradual onset.

What is the FAST scan and which four areas does it assess?

Focused Assessment with Sonography in Trauma - bedside ultrasound to detect free fluid (blood). Views: pericardial (subxiphoid), right upper quadrant (hepatorenal/Morrison's pouch), left upper quadrant (splenorenal), and pelvis (pouch of Douglas).

In blunt abdominal trauma, which two solid organs are most commonly injured?

The spleen (most common) and the liver. Splenic injury presents with LUQ pain and may cause referred left shoulder pain (Kehr's sign).

What is the Rule of Nines for estimating burn surface area in an adult?

Head & neck 9%, each upper limb 9%, each lower limb 18%, anterior trunk 18%, posterior trunk 18%, perineum/genitalia 1%. (The patient's palm ~1% TBSA for patchy burns.)

State the Parkland formula for burn fluid resuscitation.

4 mL x body weight (kg) x %TBSA burned of Ringer's lactate over 24 hours; give HALF in the first 8 hours (from time of burn) and the remaining half over the next 16 hours. Titrate to urine output (0.5-1 mL/kg/hr).

Classify burns by depth and their clinical features.

Superficial (1st degree): epidermis only, red, painful, no blisters (e.g., sunburn). Partial thickness (2nd): blisters, moist, painful, blanches. Full thickness (3rd): leathery, white/charred, painless, non-blanching. 4th degree extends to muscle/bone.

When is escharotomy indicated in burns?

In circumferential full-thickness burns of a limb (causing compartment syndrome/distal ischemia) or of the chest (restricting ventilation). Escharotomy incises the eschar to relieve the constriction.

What features suggest inhalational airway injury in a burn patient, mandating early intubation?

Facial/neck burns, singed nasal/facial hair, soot in mouth/sputum (carbonaceous sputum), hoarseness/stridor, history of fire in an enclosed space. Early intubation is done before airway edema makes it impossible.

State the Salter-Harris classification of pediatric physeal (growth plate) fractures.

Type I: through physis only. Type II: through physis + Metaphysis (most common). Type III: through physis + epiphysis (into joint). Type IV: through metaphysis, physis, and epiphysis. Type V: crush injury to physis (worst prognosis). Mnemonic SALTR.

Describe the components of a complete fracture description.

Site (which bone/region), pattern (transverse, oblique, spiral, comminuted, segmental), displacement, angulation, rotation, shortening, whether open or closed, intra/extra-articular, and associated neurovascular injury.

What are the cardinal principles of fracture management ('the 4 R's')?

Resuscitation (if needed), Reduction (restore alignment - closed or open), Restriction/Immobilization (cast, splint, or fixation), and Rehabilitation (restore function). Plus 'hold' and 'rehabilitate' in the reduce-hold-rehabilitate framework.

What is compartment syndrome and its earliest reliable clinical sign?

A surgical emergency where increased pressure within a fascial compartment compromises perfusion. Earliest/most reliable sign is PAIN out of proportion to injury, worsened by passive stretch of the muscles. (The other 'P's - pallor, pulselessness, paresthesia, paralysis - are late.) Treat with urgent fasciotomy.

What is the difference between a dislocation and a subluxation, and which joint dislocates most commonly?

Dislocation: complete loss of articular contact between the two bones of a joint. Subluxation: partial loss of contact. The shoulder (glenohumeral joint) is the most commonly dislocated major joint, usually anteriorly.

Which nerve is at risk in an anterior shoulder dislocation and how is it tested?

The axillary nerve - tested by sensation over the 'regimental badge' area (lateral upper arm/deltoid) and deltoid motor function. It should be assessed before and after reduction.

Compare osteomyelitis spread and the most common causative organism.

Acute osteomyelitis is most commonly caused by Staphylococcus aureus, spreading hematogenously (commonly to metaphyses of long bones in children) or by direct/contiguous spread from open fractures/surgery. Sickle cell patients have increased risk of Salmonella osteomyelitis.