Surgery
Surgical items in the NMCLE test the decision to operate and the preparation that makes operation safe, rather than fine operative detail. Expect acute abdomen, trauma, burns, hernia, breast lumps, testicular pain, and wound and fluid management.
Core rules
- Trauma: follow ABCDE. Tension pneumothorax is a clinical diagnosis - needle decompression before any X-ray. Unstable pelvic fracture needs a binder and blood, not repeated imaging.
- Peritonitis: rigidity, absent bowel sounds or free gas means laparotomy, not observation.
- Appendicitis: migrating pain to the right iliac fossa, Alvarado score, ultrasound when equivocal, then appendectomy.
- Burns: Parkland formula 4 mL/kg/%TBSA of Ringer lactate over 24 hours, half in the first 8 hours from the time of burn; target urine output 0.5–1 mL/kg/h.
- Scrotal pain: testicular torsion is an emergency - explore within 6 hours rather than wait for Doppler.
- Breast lump: triple assessment - clinical, imaging, and cytology or core biopsy.
Worked example
A 60 kg man has 30% TBSA flame burns. Parkland: 4 × 60 × 30 = 7,200 mL in 24 hours. Half (3,600 mL) goes in the first 8 hours counted from the burn time, the remainder over 16 hours. Titrate to urine output rather than infusing blindly, and add analgesia, tetanus cover and burn wound care.
Traps
- Starting colloid instead of crystalloid in the first 24 hours of a burn.
- Sending a tender scrotum for imaging and losing the torsion window.
- Missing a ruptured ectopic pregnancy in a woman with right iliac fossa pain.
- Forgetting that a strangulated hernia needs emergency repair, not a truss.