Surgery and allied is the second-largest domain in NRE Step I: about 24% of the paper, roughly 48 of 200 items, covering general surgery plus orthopaedics, urology, anaesthesia and neurosurgery basics. Stems are emergency-heavy: trauma and the ATLS primary survey, burns, shock, the acute abdomen, hepatobiliary and colorectal conditions. With medicine it makes up half the exam. The syllabus also includes surgical ethics, consent and informed decision-making, which candidates from exam-focused curricula tend to skip.
Weight and expected item count
PM&DC's blueprint lists Surgery and Allied at 48 of the 140 clinical items. Together with medicine's 52 that is 100 items, so the clinical core decides your result. The syllabus describes surgery as covering metabolic response to injury, wound healing, surgical infection, anaesthesia, trauma, burns, vascular surgery, systemic surgery and orthopaedics. Allocate about 50 minutes of paper time to this domain.
What is tested
| Block | Topics |
|---|---|
| Principles | Metabolic response to injury and wound healing; surgical infection, antibiotic prophylaxis and surgical site infection; pre-operative assessment, anaesthesia and post-operative care; fluid, electrolyte and nutritional management |
| Trauma and critical care | ATLS primary survey, head and chest injury; burns assessment and resuscitation; shock and haemorrhage control |
| Vascular and endocrine surgery | Arterial disease, aneurysm and peripheral vascular disease; venous disorders and DVT; thyroid and parathyroid surgery; breast disease and breast cancer |
| Upper GI and hepatobiliary | Oesophagus and stomach: GERD, achalasia, gastric carcinoma; gallstones, cholangitis, liver abscess; pancreas and spleen |
| Lower GI and abdominal wall | Acute abdomen: appendicitis, perforation, obstruction; colorectal cancer, diverticulitis, haemorrhoids, fistula; hernias |
| Urology | Stones, BPH, prostate and renal tumours |
| Paediatric surgery | Pyloric stenosis, intussusception, Hirschsprung disease |
| Orthopaedics and neurosurgery | Fractures, bone and joint infection, orthopaedic emergencies, bone tumours, paediatric orthopaedics; head injury and raised ICP |
| Cardiothoracic and ethics | Cardiothoracic basics; surgical ethics, consent and informed decision-making |
Local guideline points
- Trauma: ATLS-style ABCDE approach is the framework for stems on road traffic accidents, falls and violence, which are common in Pakistani emergency departments. Know the order: airway with cervical spine protection, breathing, circulation with haemorrhage control, disability, exposure.
- Typhoid perforation: ileal perforation is a recognised complication of enteric fever and can feature in acute abdomen stems with a fever history. See local guidelines for the XDR typhoid context.
- Hydatid disease and liver abscess: amoebic and pyogenic liver abscess, and hydatid cyst, are standard in South Asian surgery curricula and in the hepatobiliary block.
- Hepatitis B and C and surgery: blood-borne virus precautions, needle-stick management and infection control are part of surgical ethics and safety.
- Consent and ethics: informed consent and confidentiality follow the PM&DC Code of Ethics; stems may describe a patient who refuses treatment or a relative who wants information withheld.
- Burns: know a fluid resuscitation formula and the rule of nines for adults. Confirm the formula you use against a current reference.
Three typical traps
- Investigating before resuscitating. A stem about an unstable trauma patient or a perforated viscus tests whether you resuscitate first. The correct answer is often airway, intravenous access, fluids or surgery, not the CT scan.
- Mixing up obstruction, perforation and ischaemia. Abdominal pain with distension, vomiting and absolute constipation is a different problem from pain out of proportion to examination or free gas under the diaphragm. Match the single most informative sign to the diagnosis before reading the options.
- Using a procedure name when the question asks about timing. Many items ask when to operate, whether to observe, or which patients need urgent versus elective surgery. Hernias, gallstones and aneurysms all have timing rules. Learn indication and urgency together.
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How to revise it
| Block | Do this | Time |
|---|---|---|
| Emergencies | Learn the ATLS sequence, shock classes, chest injuries (tension pneumothorax, haemothorax, flail chest), head injury and burns. Then 40 questions. | 4 days |
| Acute abdomen | One table: appendicitis, perforation, obstruction, pancreatitis, cholecystitis, mesenteric ischaemia; sign, test, first step. | 3 days |
| Hepatobiliary and colorectal | Gallstone spectrum, cholangitis, liver abscess, colorectal cancer, haemorrhoids, fistula. | 4 days |
| Vascular, breast, thyroid | Limb ischaemia, aneurysm, DVT; breast lumps and staging; thyroid nodule work-up. | 3 days |
| Urology and orthopaedics | Stone management, BPH, haematuria work-up; fracture complications, compartment syndrome, bone and joint infection. | 4 days |
| Peri-operative and ethics | Pre-operative risk, fluids, antibiotic prophylaxis, post-operative complications, consent. | 2 days |
For every topic, practise stating the answer in one sentence: "This patient needs X because Y." That is the reasoning the paper rewards. Use the study plan to place these blocks in your weeks.
Core facts to state without notes
- Primary survey: airway with cervical spine protection, breathing, circulation with haemorrhage control, disability, exposure. A tension pneumothorax is a clinical diagnosis and is decompressed before any imaging.
- Haemorrhagic shock: ATLS classes I to IV run from under 15% blood loss to over 40%. Tachycardia and a narrowed pulse pressure come before hypotension, especially in young patients.
- Burns: the rule of nines estimates adult surface area. The Parkland formula (4 mL per kg per percentage burn, half in the first 8 hours) is the usual teaching; confirm the version in your reference.
- Biliary disease: Charcot's triad is fever, jaundice and right upper quadrant pain; Reynolds' pentad adds hypotension and confusion and signals suppurative cholangitis.
- Hernias: a femoral hernia lies below and lateral to the pubic tubercle and strangulates more often than an inguinal one; a strangulated hernia is an emergency.
- Breast and thyroid: breast lumps are assessed by triple assessment (clinical, imaging, biopsy); a thyroid nodule starts with thyroid function tests and fine-needle aspiration.
- Aneurysm: a symptomatic or ruptured abdominal aortic aneurysm is an emergency; elective repair is considered when the diameter reaches about 5.5 cm.
Self-check list
| Can you say, in one sentence each... | Mark |
|---|---|
| What you do first for an unstable trauma patient with a tension pneumothorax | red, amber or green |
| How you tell obstruction from perforation from ischaemia on history and examination | red, amber or green |
| Which gallstone presentations need urgent intervention | red, amber or green |
| The red flags that separate a benign from a malignant breast lump | red, amber or green |
| Which fractures cause compartment syndrome or neurovascular injury | red, amber or green |
| How you obtain valid consent from a patient who refuses a recommended operation | red, amber or green |
Links to other domains
Surgery draws on applied anatomy (hernias, nerve injuries, neck and abdominal anatomy), physiology (shock, fluids, acid-base) and pharmacology (anaesthetics, analgesics, antibiotic prophylaxis). The Step II OSCE has seven surgery stations, so what you learn here is used again; see the Step II guide.
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Frequently asked questions
How many surgery questions are there in NRE Step I?
PM&DC's blueprint gives 48 of the 140 clinical items to Surgery and Allied, about 24% of the 200-question paper. It includes orthopaedics, urology, anaesthesia and neurosurgery basics.
Which surgical topics matter most?
Trauma and the ATLS primary survey, burns, shock, the acute abdomen, hepatobiliary and colorectal disease, hernias, vascular disease, and orthopaedic emergencies. This ranking uses blueprint weight and syllabus wording, not recalled questions.
Is surgical ethics tested?
Yes. The syllabus lists surgical ethics, consent and informed decision-making within surgery and allied.
Are orthopaedics and urology part of this domain?
Yes. PM&DC groups orthopaedics, urology and anaesthesia under Surgery and Allied, not as separate domains.
How should I revise surgery for the NRE?
Learn emergency algorithms first, build a table for the acute abdomen, then work through hepatobiliary, colorectal, vascular, urology and orthopaedics with questions after each block.
Does Step II test surgery as well?
Yes. Seven of the 20 Step II OSCE stations are surgery and allied.