WOUND:

First inflammatory cell to reach wound site are- Neutrophils(PMNs)

Cell pivotal to wound healing is- Macrophage (Monocyte)
Maximum immediate strength in wound is between 16-30 days
The strength of wound keeps of increasing for 2-3 years
Wound never gains 100% strength
Max. possible strength of wound is 96% usual maximum strength is 80%
Maximum gain in strength in wounds is seen in first 90 days
The first priority in wound management is restoration of skin cover
Most common complication of wound healing is infection
Most important criteria for viability of a tissue is blood supply

BREAST:

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Teitz disease - costochondritis, MC involves 2nd costal cartilage

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Mondors disease superficial thrombophlebitis of veins over chest wall and upper
abdominal wall.

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Fibrocystic disease of breast is common in young females and is usually B/L.
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Fibro adenoma
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MC benign tumor of breast. (MC breast tumor in females less than 30 yrs of age)
Highly mobile (aka breast mouse)
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Firm in consistency
IOC- USG GUIDED FNAC
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Rx excision
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Breast cyst
Well defined lump
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IOC USG GUIDED FNAC

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Rx USG guided aspiration

Nipple discharge
Bloody M.C.C. - Duct Papilloma
Greenish / grumous M.C.C. - Duct Ectasia
Milky M.C.C. - Galactorrhea
Serous M.C.C. - Fibro cystic disease of breast

DUCT ECTASIA
IOC- Mammography
Rx HADFIELDs OPERATION

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DUCT PAPILLOMA
IOC- MAMMOGRAPHY
Rx- MICRODOCHETOMY

BACTERIAL (INFECTIVE) MASTITS (ABSCESS)

Staph Aureus
During lactation
IOC- USG
Rx Modified HILTONS method

Cystosarcoma phylloides
Huge lump
Irregular and variable consistency

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IOC FNAC

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Rx- Benign wide local excision
Malignant simple mastectomy

Breast Cancer
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Genetic BRCA 1, BRCA 2, P53
IOC Mammography
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Ductal carcinoma in situ

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MC non invasive breast cancer

MC comedo cell pattern
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IOC- incisional biopsy

Rx- simple mastectomy
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MC site for distant metastasis from Breast Ca: Vertebrae (Via Bateson plexus)
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THYROID:
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Rafetoff syndrome: end organ resistance to T4

Father of thyroid surgery: THEODOR KOCHER.
The external laryngeal nerve runs close to superior thyroid artery and recurrent
laryngeal nerve runs close to inferior thyroid artery.
Wolf-chaikoff effect: iodine induced hypothyroidism
Jod-basedows effect: iodine induced hyperthyroidism.
Thyroglossal cyst: NC site - Sub hyoid. (It can happen anywhere from the base of the
tongue to the isthmus of thyroid). It is a congenital tubule-dermoid. Treatment of
choice is Sistrunks procedure (complete removal of duct).
Thyroglossal fistula is always acquired (never congenital). It is a complication of cyst
infection of incomplete removal of duct. TOC Sistrunks procedure.

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 Acute suppurated thyroiditis is rarely seen in children & caused by streptococcus &
anaerobes.
Hashimotos thyroiditis or Struma Lymphomatos: M.C. inflammatory disorder of
thyroid and leading cause of hypothyroidism. Auto antibodies are producing against
Tg, TPO, TSH-R. It is an autoimmune thyroiditis and aka lymphocytic thyroiditis.
Graves disease (Diffuse toxic goiter): MC cause of hyperthyroidism caused by
stimulatory auto-antibodies to TSH R.
Toxic adenoma (Plummers disease): Single hyper functioning nodule typically
occurs in young patients.
Thyroid storm ( Thyrotoxic crisis) : It is an emergency. Occurs post-operatively in
not properly prepared patients. Manifests itself as hyperthermia, tachycardia, irritability
& profuse sweating
Riedel's thyroiditis is an uncommon chronic Thyroiditis in which the thyroid gland

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is replaced by fibrous tissue. The fibrotic process invades adjacent structures of the

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neck and extends beyond the thyroid capsule.It is supposed to be auto immune in
nature.

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MC postoperative complication after thyroidectomy: Hemorrhage
MC benign tumor of thyroid gland: follicular adenoma.
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Pre-disposing factor for long standing goiter: follicular carcinoma of thyroid.
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Sub- Acute thyroiditis / granulomatous thyroiditis / De Quervains thyroiditis is
associated with viral infection & can occur as a consequence of viral infection. only
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painful condition of thyroid

Pembertonss sign is most commonly associated with Retrosternal goiter.
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FNAC cannot differentiate between benign follicular adenoma and follicular

carcinoma.
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hi

ESOPHAGUS
Manometery finding in different esophageal motility disorders.
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Achalasia:

Incomplete lower esophageal sphincter (LES) relaxation (<75% relaxation)

Aperistalsis in the esophageal body
Elevated LES pressure 26 mmHg

Diffuse esophageal spasm (DES)

Simultaneous (nonperistaltic contractions) (>20% of wet swallows)
Repetitive and multipeaked contractions
Intermittent normal peristalsis

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 CREST syndrome
Normal peristalisis in the proximal esophagus and decreased or absent peristalisis in
distal 2/3.
The LES tone is decreased.
IOC of Achalasia cardia - Manometery
IOC of GERD 24 hours pH monitoring
IOC of esophageal dysphagia Endoscopy
IOC hiatus hernia Barium meal
Most common surgery done for Hiatus hernia/ GERD is Nissins fundoplication
EUS is the most sensetive tool for T and N staging of esophageal carcinoma
Sx for Middle 1/3 Esophageal carcinoma is Ivor Lewis

STOMACH:

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Absorptions-

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Stomach Alcohol
Duodenum Iron, Calcium

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Jejunum Water, Fats, Sugars, Folic Acid, Biotin
Ileum Bile & bile salts, VitB12
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Colon Short chain Fatty acids
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Peptic ulcer disease:

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MC site of gastric ulcer is lesser curvature (TYPE I ulcers). They are not associated
with hyperacidity.
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MCC of peptic ulcer disease is H. Pylori

H. Pylori is associated with Type B gastritis, peptic ulcer, Metastatic polyp, gastric
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carcinoma and MALToma.

H. Pylori has a protective role in GERD and its eradication increases the incidence of
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GERD
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MC site of duodenal ulcers is first part of duodenum (TYPE II ulcers). They are
associated with hyperacidity
Type I and Type IV peptic ulcers are not associated with hyperacidity
The surgery of choice for duodenal ulcers is Vagotomy with pyloroplasty

Operations for peptic ulcers:

Mc recommended surgery for DU with intractable pain - parietal cell vagotomy
Mc surgery for DU with perforation Omental patch (Grahams patch)
Mc surgery for DU with obstruction Vagotomy + gastrojejunostomy
C/c of vagotomy delayed gastric emptying

GASTRIC TUMORS:

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 Pre-pyloric/ Antrum region along greater curvature is the m/c site for gastric
carcinoma
The most common site of gastric carcinoma associated with Pernicious anemia is
fundus.
Gastric ulcers have a .5-3% risk of malignancy
Duodenal ulcers have very low malignant potential
The most common symptoms of gastric carcinoma are
o Weight loss
o Anorexia
o Early satiety
IOC - Endoscopy with biopsy
M.C. Surgery done for gastric carcinoma is subtotal gastrectomy with Billroth II
reconstruction.

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MC gastric lymphoma is B cell type.

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GISTs arise from interstitial cells of Cajal (ICC)
TOC of GIST is resection

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Imatinib/ Sunitnib can be used in metastatic or unresectable GIST
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SMALL AND LARGE INTESTINE
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TOC for Duodenal Atresia, Annular pancreas: Duodenoduodenostomy
Double bubble sign is associated with duodenal atresia
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TOC for superior mesenteric artery syndrome: Duodenojejunostomy

Proctoscopy : 10-12cm
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Rigid Sigmoidoscopy : 25cm

Flexible sigmoidoscopy: 60cm
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Colonoscopy: 160cm
MC site for distant metastasis from Colorectal Ca: Liver
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o IOC for bowel obstruction is X-Ray abdomen

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o MCC of small bowel obstruction is Iatrogenic adhesion

o MCC of acute mesenteric ischemia is Embolism
o MCC of colonic obstruction is Neoplasm
o Surgery done for Midgut volvulus/ intestinal malrotation is Ladds procedure
o Birds-beak or bird-of-prey sign is seen in sigmoid volvulus
o MC presentation of Meckels diverticulum in young is bleeding. In adults it is
intestinal obstruction.
o MC type of Hirschsprungs disease is short segment (Recto-sigmoid).
o MC malignant tumor of large intestine is adenocarcinoma

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 CROHNS DISEASE ULCERATIVE COLITIS
Cobble stone mucosa Ulcers in mucosa and submucosa
Striking sign of kantor C- continuous retrograde involvement
S- Skip lesions O- originate in rectum
I- ileum(mc site) L- lead pipe rigidity
S- saccharomyces cervisae I- increased chances of cancer
T- trans mural involvement T- toxic mega colon
E- extra chances of fistula and stricture I- increased growth of mucosa
R- rectum spared S- severe symptoms

SCORING:

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Appendicitis- Alvarado scoring
Acute pancreatitis- RANSONs Scoring

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Prostate cancer- Gleasons grading system
Ductal carcinoma in situ Van nuys index

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GALL BLADDER:
CHOLELITHIASIS-
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PIGMENTED STONES: MCC - hemolytic anemia

5-fs predisposing fatty, forty, female, fertile and flatulence. (M.C. Clinical
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presentation)
IOC- USG abdomen
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Rx laparoscopic cholecystectomy.
Acute cholecystitis
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M.C.C. Cholelithiasis
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IOC USG
Gold standard - HIDA scan
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Rx- Cholecystectomy
If patient present in less than 72 hours of precipitation of symptoms
immediate cholecystectomy.
If patient present in more than 72 hours of precipitation of symptoms initially
conservative (Antibiotics. Analgesics, fluids) followed by cholecystectomy after
a few weeks (4-6weeks).
Chronic cholecystitis
M.C.C. Chronic Cholelithiasis
IOC USG
Rx- laparoscopic cholecystectomy. If porcelain GB or suspicion of malignancy
then open cholecystectomy should be done.

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Empyema GB /pyocele
C/f- tender lump + fever
IOC USG
Rx- cholecystectomy +/- antibiotics
Acalculus cholecystitis
Cause- E. Coli, typhoid infection, trauma, septicemia ,DM
IOC USG
Rx- USG guided drainage + antibiotics

PANCREAS:
Acute pancreatitis-
MCC gall stones.
Ingle finger sign (Muslim prayer sign Pain decreases on bending forwards on

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pancreatitis).

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Cullens sign and Grey Turner sign may be seen.
Atlanta classification is used for acute pancreatitis

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Chronic pancreatitis-
MCC Alcohol.
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Sausage pancreas: is due to biliary & pancreatic duct strictures seen on CT in auto
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immune pancreatitis
TOC for annular pancreas Duodenojejunostomy
Mc site of ectopic pancreatic tissue stomach
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HERNIA:
MC type of hernia Inguinal
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Inguinal canal boundries:

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Anteriorly - External oblique aponeurosis, anterolaterally - Internal oblique

muscle laterally,
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Posteriorly - Transversalis fascia and transversus abdominis muscle

Superiorly - Internal oblique muscle
Inferiorly - Inguinal (Pouparts) ligament
NYHUS CLASSIFICATION OF HERNIA
Type 1 is an indirect hernia with a normal internal ring;
Type 2 is an indirect hernia with an enlarged internal ring;
Type 3: posterior wall defect
Type 3a is a direct inguinal hernia;
Type 3b is an indirect hernia causing posterior wall weakness; [medially
encroaching on or destroying the transversalis fascia of Hesselbach's triangle
(e.g., massive scrotal, sliding, or pantaloon hernia)]
Type 3c is a femoral hernia;

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 Type 4 represents all recurrent hernias.
A Direct
B Indirect
C Femoral
D - Combined

1) Hernia most likely to be strangulated femoral

2) Pantaloons hernia is m/c overlooked hernia in surgery
3) Spigelian hernia: at the level of arcuate line (reducible mass below umbilicus)
4) Lumbar hernia: Mostly occur through inferior lumbar triangle of Petite
5) Littres hernia: Content of the hernia sac is Meckels diverticulum
6) Richters hernia: Content of the hernia sac is a portion of the circumference of
the intestine

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7) Maydls hernia: Strangulated loop of W lying within the abdomen

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8) Sliding hernia: Slipping of posterior parietal peritoneum on retroperitoneal
structures.

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Sac has no posterior wall.
LEFT SIDE Sigmoid colon & Mesentery
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RIGHT Side Cecum, bladder.
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UROLOGY:
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Pyelonephritis-
Most common cause - E coli
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Clinical manifestation:
o Fever.
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o Flank pain.
o Vomiting and 90% have diabetes.
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Pyonephrosis
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Most common cause is renal stone

Clinical manifestation:
o Anemia
o Fever
o Swollen lion (Intermittent hydronephrosis (Dielts crises) is also associated
with swelling in the lion.)
Renal casts
RBC cast -seen in acute glomerulonephritis.
WBC cast- intestinal nephritis, pyelonephritis.
Brood granular casts -chronic renal failure.
Hyaline cast normal in urine.
Renal stones

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 Most common cause of ureteric obstruction is Stone
Most common type of kidney stone (85%) is calcium oxalate.
Radio Lucent - Uric acid stone &Xanthine. (LUX)
Infectious stones are more common in females.
Calcium oxalate, cysteine, uric acid (CCU)- Acidic urine
Calcium phosphate, Struvite (triple phosphate CaMgNh4PO4)-Alkaline urine
(esp. with urea splitting infection).They are the most silent renal stone.
Most sensitive investigation for renal calculi - NCCT
Rx: Stone <2cm = ESWL, Stone>2cm = PCNL.
Soft tissue calcification found in the deep renal medulla - Randalls plaques
Renal Tumors:
MC type of RCC mainly sporadic is clear cell carcinoma.
RCC/VHL syndrome - MC sites of distant metastasis are lungs>bone>liver>brain.

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MC primary renal tumor of childhood is Wilms tumor.

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Transitional cell carcinoma accounts for 90% of upper urinary tract cancers.
ADPKD associated with cyst in all sites except brain>lungs.

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Central stellate scars on CT scan Oncocytoma
Most imp prognostic factor for Wilmss tumor Grade
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Grading of RCC FUHRMANN GRADING SYSTEM
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ROBSONS STAGING pathological staging for RCC
Mc RCC seen in patients on long term dialysis therapy micro papillary variant
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Retro peritoneal hemorrhage in angiomyolipoma - WUNDERLICHS

SYNDROME
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Urinary Bladder/ Urethra:

MC type of bladder rupture Extra peritoneal
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MC type of bladder rupture associated with pelvic fracture Extra peritoneal

Urethral injury leading to floating prostrate membranous
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MCC of acquired urethral strictures Instrumentation

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MCC of gross total painless hematuria in an elderly male Ca urinary bladder

MC site for distant metastasis from Bladder Ca: Lung

TESTIS and SCROTUM:

They reach the iliac fossa during the 3rd month.
Lie at the site of the deep inguinal ring up to 7th month.
They pass through the inguinal canal during the 7th month.
Present at the superficial inguinal ring by 8th month.
Testes enter the scrotum in the 9th month.

Important tumor CLASSIFICATION:

1) Reiss Ellsworth classification , Esson prognostic index- Retinoblastoma

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2) Bloom Richardson classification: CA breast
3) Sullivan modification of Macfalen system: adrenocortical carcinoma
4) Gleason Ca prostrate
5) Duke staging: colorectal ca
6) Robson staging: RCC
7) Jackson: CA penis

NEUROSURGERY:
1) EDH: MC due to tear of middle meningeal artery, appear biconvex on CT, lucid
interval is present.
2) SDH: MC due to rupture of bridging veins, appear cresentic or concavo-convex on
CT.
3) MCC of SAH is Trauma

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4) MCC of spontaneous SAH is rupture of aneurysm

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5) Mc site of Medulloblastoma : Vermis
6) Most radiosensitive brain tumor is Medulloblastoma

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7) MC posterior fossa tumor in adults is Hemangioblastoma
8) MC spinal tumor : metastatic
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9) MC primary spinal tumor : nerve sheath tumor
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10) MC intra medullary tumor: astrocytoma
11) MC site of primary spinal tumor : intra dural extra medullary
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12) The term dumbbell lesion is used to describe Neurofibroma

13) MC site of dumbbell tumor is retro-peritoneum
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14) MC electrolyte abnormality associated with head injuries Hyponatremia

15) MC acquired cause of seizures is NCC
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16) MC traumatic intracranial bleed in children is SDH

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17) MC spots related intracranial bleed is SDH

18) MC traumatic brain injury is concussion
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19) MCC of intracranial hemorrhage is Hypertensive bleed

TRAUMA:
1) MC rib fractures during CPR 4-6th ribs
2) Flail chest Free moving segment due to fracture of 3 or more contiguous ribs at
2/>2 places
3) MC organ injured in blunt trauma abdomen spleen
4) MC organ damaged in penetrating trauma of abdomen SI
5) MCC of immediate death in poly trauma Asphyxia, Neurogenic shock
6) MCC of early death in polytrauma (During golden time 2-6 hours post trauma)
Thoracic injuries
7) MCC of death in polytrauma Head injuries

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8) Terrible triad of trauma hypothermia , acidosis , Coagulopathy
9) MC electrolyte abnormality in major trauma/ surgery Hypernatremia with
hypokalemia
10) Best method for calculation of TBSA in burns patients Lund & Browder charts
11) Best fluid for burns RL
12) Immediate cause of death in burns patients Neurogenic shock, Asphyxia
13) Early (DURING RESSUCITATION/ FIRST 24 HOURS) cause death in burns patients
hypovolemic shock
14) Late cause (MCC) of death in burns patient septicemia
15) Fluid of choice in Trauma is RL
16) Fluid of choice in head injury is NS
17) Dextran should not be used in hemorrhagic shock
MC organ to fail first in progression to MODS is LUNG (ARDS/ Respiratory failure)

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18)
19) MC initial investigation done in poly trauma patient eFAST (Focused assessment

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with sonography in trauma)
20) Simple triage and rapid treatment (START) is a triage method used by first

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responders to quickly classify victims during a mass casualty incident (MCI) based
on the severity of their injury.
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21) Red Tags- (immediate) are used to label those who cannot survive without
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immediate treatment but who have a chance of survival.
22) Yellow Tags- (observation) for those who require observation (and possible later re-
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triage). Their condition is stable for the moment and, they are not in immediate
danger of death. These victims will still need hospital care and would be treated
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immediately under normal circumstances.

23) Green Tags- (wait) are reserved for the "walking wounded" who will need medical
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care at some point, after more critical injuries have been treated.
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24) White tags - (dismiss) are given to those with minor injuries for whom a doctor's
care is not required.
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25) Black Tags- (expectant) are used for the deceased and for those whose injuries are so
extensive that they will not be able to survive given the care that is available.

RESPIRATORY:

1) The management of choice for pneumothorax Intercostal drainage under water

seal in 5th ICS in mid axillary line
2) Emergency management of tension pneumothorax Needle decompression in the
2nd ICS in mid clavicular line
3) MC site for tube thoracostomy in pleural effusion 7th ICS in the mid axillary line
4) MC bronchogenic tumor to show central cavitations Squamous cell carcinoma

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5) MC brochogenic carcinoma Adenocarcinoma
6) MCC of Pancost syndrome Adenocarcinoma
7) MC site of metastasis in SCLC is CNS
8) MC common site of metastasis of NSCLC is Adrenal
9) MC treatment of SCLC is CT
10) Grade I NSCLC is management by surgical resection only (provided the patient is fit
for surgery)
11) Bronchogenic malignancy presenting with pleural effusion is graded as T4
12) TOC for malignant pleural effusion is pleurodesis.
13) MCC of solitary pulmonary nodule is infectious granuloma
14) Most common mediastinal tumor is Neurofibroma (seen in the posterior
mediastinum only)
Most common Anterior mediastinal tumors are thymic tumors

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15)
16) Most common middle mediastinal mass are cysts

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s.
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at
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hi
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