Surgery — Common Surgical Presentations, NMC MBBS licence examination syllabus (Nepal Medical Council).
Common surgical presentations: lumps, hernias and gallstones
The bread and butter of a surgical clinic — and mostly solved by examination.
Most surgical practice is not emergency laparotomy. It is a patient with a lump, a hernia or intermittent right upper quadrant pain, and the diagnosis is usually settled at the bedside by knowing which features matter. That makes these presentations unusually good value: a small number of physical signs and one or two organising frameworks answer most of them.
It also means the examinable content is precise. Where exactly does the lump sit relative to the pubic tubercle? Does it move on swallowing? Is the hernia tender and irreducible, or merely irreducible? Each of those questions changes the answer completely.
🩺 Where this lives: The most consequential mistake in this chapter is reducing a strangulated hernia. A tender, tense, irreducible hernia contains bowel whose blood supply is compromised, and pushing it back into the abdomen does not solve the problem — it hides dying bowel inside the peritoneal cavity, where perforation follows out of sight. The instinct to relieve an obvious mechanical problem is exactly the wrong one here. Tender and irreducible means theatre, not manipulation.
💡 A note on scope. Bowel obstruction is covered in the Acute Abdomen chapter — including the colicky-to-constant transition and the small versus large bowel distinction — and is referenced rather than repeated here. The acute abdomen, trauma, and wounds and surgical infection are separate chapters, as are thyroid nodules. This chapter gives no doses, and no breast cancer staging or screening ages, which follow current national guidance.
Hernia
The vocabulary is the clinical decision. Reducible means elective repair. Irreducible means the risk has risen but the blood supply is intact. Obstructed means the lumen is blocked. Strangulated means the blood supply is cut off and the bowel is dying — and the signs that announce it are tenderness, tension, irreducibility and loss of the cough impulse, usually with systemic upset. That last state is a surgical emergency, and the one thing you must not do is push it back.
The groin lump
WHY THE PUBIC TUBERCLE MATTERS
Find the pubic tubercle first — then decide where the lump
lies in relation to it.
INGUINAL hernia: ABOVE and MEDIAL to the tubercle
FEMORAL hernia: BELOW and LATERAL to the tubercle
This is not merely a naming exercise. FEMORAL HERNIAS ARE
FAR MORE LIKELY TO STRANGULATE, because the femoral canal
is narrow and bounded by rigid structures — so the contents
are gripped tightly. They are commoner in women, and they
are repaired promptly rather than watched.
Inguinal hernias are commoner overall and commoner in men.
A large one may be watched if it is small, asymptomatic and
easily reducible; the threshold for repair is lower when it
is symptomatic or difficult to reduce.
NOT EVERY GROIN LUMP IS A HERNIA. Also consider:
LYMPH NODES — often multiple; look for a source
SAPHENA VARIX — a soft, compressible swelling with a
cough impulse that disappears on lying down
FEMORAL ANEURYSM — pulsatile and expansile
UNDESCENDED or ectopic TESTIS — always check that both
testes are in the scrotum in a boy with a groin lump
A cough impulse is present in a reducible hernia and in a
saphena varix, so it does not by itself make the
diagnosis.
Gallstone disease
💡 Exam angle: the spectrum of gallstone disease is examined by asking you to distinguish four conditions that share a location. Biliary colic is pain without fever that settles. Cholecystitis adds fever and local inflammation with a positive Murphy's sign. Obstructive jaundice means the stone has moved into the common bile duct — jaundice with pale stools and dark urine. And ascending cholangitis adds infection to that obstruction, giving Charcot's triad: fever with rigors, jaundice and right upper quadrant pain. The last is a life-threatening emergency requiring antibiotics and biliary drainage.
CHOLANGITIS IS A SOURCE CONTROL PROBLEM
Infected bile behind an obstruction is a closed, infected
space — exactly the situation described in the surgical
infection chapter. Antibiotics alone cannot sterilise it,
because the infected bile cannot drain.
RESUSCITATE — these patients can become septic quickly
ANTIBIOTICS per local guidance
DRAIN the biliary tree — endoscopically or otherwise
A patient with cholangitis who is not improving on
antibiotics needs DRAINAGE, not a different antibiotic.
This is the same reasoning as the abscess: if there is pus
under pressure, it has to come out.
A NOTE ON JAUNDICE: painless jaundice with weight loss in
an older patient raises the possibility of malignant
obstruction rather than a stone, and needs investigation
rather than reassurance.
The breast lump
Triple assessment — clinical examination, imaging, and tissue sampling — is the framework, and the essential point is that all three are done, and a normal result in one does not exclude cancer. Discordance between them is itself a reason to go further rather than to reassure. A discrete new lump in an older woman is cancer until proven otherwise, and the red flags worth knowing are a hard fixed lump, skin tethering or dimpling, nipple retraction, bloody discharge and palpable nodes.
The neck lump
💡 Exam angle: two bedside questions do most of the work. Is it midline or lateral? and what does it move with? A midline lump moving on swallowing is thyroid; one moving on tongue protrusion is a thyroglossal cyst. Lateral lumps are most often lymph nodes. In Nepal and comparable settings, tuberculosis is a leading cause of persistent cervical lymphadenopathy — which links directly back to the tuberculosis chapter, and means a persistent neck node is investigated rather than watched.
Clinical reasoning: four presentations
🔍 Case 1 — a lump that will not go back
PresentationA man attends with a groin swelling that was reducible for years but is now tender, tense and will not reduce. There is no cough impulse. He is vomiting and looks unwell. The junior doctor attempts firm manual reduction.
ErrorReducing a hernia that shows every sign of strangulation.
ReasoningTenderness, tension, irreducibility and absent cough impulse with systemic upset indicate strangulation — the blood supply is compromised and the bowel is dying. Reducing it places necrotic bowel inside the abdomen where perforation goes unseen.
AnswerStop. Resuscitate, analgesia, nil by mouth, and urgent surgical referral for operative repair.
🔍 Case 2 — rigors with jaundice
PresentationA 60-year-old has right upper quadrant pain, jaundice and a fever with shaking rigors. She becomes confused and hypotensive. She is started on antibiotics and admitted for observation.
DiagnosisAscending cholangitis — Charcot's triad, now with confusion and hypotension.
ReasoningInfected bile behind an obstruction is a closed infected space. Antibiotics cannot sterilise undrained infected bile, and she is already showing signs of severe sepsis.
AnswerResuscitate, antibiotics per guidance, and arrange urgent biliary drainage. Source control is the treatment; observation is not.
🔍 Case 3 — a normal mammogram
PresentationA 57-year-old has a new hard lump with slight skin dimpling. Mammography is reported as normal, and she is reassured and discharged without biopsy.
TrapAllowing one normal component of triple assessment to overrule the others.
ReasoningClinical findings are suspicious — a hard lump with skin tethering in an older woman. Imaging can be normal in the presence of cancer, and discordance between the components of triple assessment is a reason to proceed, not to stop.
AnswerComplete the triple assessment with tissue sampling. A normal result in one modality does not exclude malignancy.
🔍 Case 4 — a neck lump that moves
PresentationA young woman has a smooth midline neck lump. It rises when she swallows, and also moves upwards when she protrudes her tongue.
The discriminating signMovement on tongue protrusion.
ReasoningThyroid lumps move on swallowing because the gland is attached to the larynx. Movement on tongue protrusion indicates attachment along the thyroglossal tract — a thyroglossal cyst.
AnswerAssess accordingly, including confirming the presence of normal thyroid tissue before any excision, since the cyst may rarely contain the only functioning thyroid tissue.
Commonly confused
Confusion
The distinction
Why it matters
Irreducible vs strangulated
Tenderness, tension and lost cough impulse
One is urgent; the other is an emergency.
Reducing vs operating
Never force a tender irreducible hernia
It hides dying bowel inside the abdomen.
Inguinal vs femoral
Above and medial versus below and lateral
Femoral hernias strangulate far more often.
Hernia vs other groin lumps
Nodes, saphena varix, aneurysm, ectopic testis
A cough impulse is not diagnostic alone.
Biliary colic vs cholecystitis
Fever and local inflammation
Different management and urgency.
Cholecystitis vs cholangitis
Jaundice with rigors — Charcot's triad
Cholangitis needs urgent drainage.
Antibiotics vs drainage in cholangitis
Infected bile cannot be sterilised undrained
The same logic as an abscess.
One normal test vs triple assessment
All three components are required
Discordance means proceed, not reassure.
Thyroid vs thyroglossal cyst
Swallowing versus tongue protrusion
A single bedside sign settles it.
Rapid revision
MUST-KNOW FACTS
1. REDUCIBLE hernia — contents return; elective repair.
2. IRREDUCIBLE — will not reduce, blood supply intact.
3. OBSTRUCTED — bowel lumen blocked.
4. STRANGULATED — blood supply cut off; the bowel is dying.
5. Strangulation: TENDER, TENSE, IRREDUCIBLE, NO cough impulse.
6. NEVER force a tender irreducible hernia back.
7. Reducing dead bowel converts a hernia into hidden peritonitis.
8. INGUINAL hernia: ABOVE and MEDIAL to the pubic tubercle.
9. FEMORAL hernia: BELOW and LATERAL to the pubic tubercle.
10. FEMORAL hernias strangulate more often — the canal is narrow and rigid.
11. Femoral hernias are commoner in women and repaired promptly.
12. Other groin lumps: nodes, saphena varix, femoral aneurysm, ectopic testis.
13. Always check both testes are in the scrotum in a boy with a groin lump.
14. BILIARY COLIC: RUQ pain after fatty food, NO fever, settles.
15. ACUTE CHOLECYSTITIS: adds fever and local inflammation; Murphy's sign.
16. OBSTRUCTIVE JAUNDICE: stone in the common bile duct; pale stools, dark urine.
17. ASCENDING CHOLANGITIS: CHARCOT'S TRIAD — fever with rigors, jaundice, RUQ pain.
18. Cholangitis with confusion and hypotension is severe and life-threatening.
19. Cholangitis needs antibiotics AND BILIARY DRAINAGE — source control.
20. Not improving on antibiotics? Drain it — do not change the drug.
21. Painless jaundice with weight loss suggests malignant obstruction.
22. BREAST LUMP: TRIPLE ASSESSMENT — clinical, imaging, tissue.
23. All three are required; one normal result does not exclude cancer.
24. Discordance between components means proceed further.
25. Breast red flags: hard fixed lump, skin tethering, nipple retraction, bloody discharge, nodes.
26. A discrete new lump in an older woman is cancer until proven otherwise.
27. NECK LUMP: ask midline or lateral, and what it moves with.
28. Moves on SWALLOWING → thyroid.
29. Moves on TONGUE PROTRUSION → thyroglossal cyst.
30. Lateral neck lumps are most often LYMPH NODES.
31. TUBERCULOSIS is a leading cause of persistent cervical lymphadenopathy.
32. Bowel obstruction is covered in the Acute Abdomen chapter.
💡 Exam angle: this chapter rewards precise physical signs over general knowledge. Position relative to the pubic tubercle, presence or absence of a cough impulse, tenderness in a hernia, what a neck lump moves with, and whether fever and jaundice accompany biliary pain — each is a single observation that determines the answer.
Syllabus points
Hernia terminology and what each implies
The signs of strangulation
Why a tender hernia is never reduced
Inguinal versus femoral and the pubic tubercle
Why femoral hernias strangulate
Other causes of a groin lump
Biliary colic and acute cholecystitis
Obstructive jaundice from a duct stone
Cholangitis and Charcot's triad
Why cholangitis needs drainage
Triple assessment of a breast lump
Breast red flags
The neck lump: site and movement
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