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SURGERY QUESTION SET 1 - FULL ANSWERS

Reference: Bailey and Love's Short Practice of Surgery, 28th Edition (B&L); S. Das Manual of Clinical Surgery, 13th Edition (S. Das); Schwartz's Principles of Surgery, 11th Edition

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SET CODE G

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Q1. Define ulcer and classify according to edge of the ulcer. (2+4)

• Base - the floor of the ulcer, composed of granulation tissue, slough or necrotic material
• Edge - the margin between the floor and the surrounding normal tissue
• Surrounding area - the tissue around the ulcer (may be indurated, pigmented, oedematous)

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Q2. Tell the name of common operations that can be done under general anaesthesia. (6)

• Completely unconscious
• Pain-free
• With a relaxed operating field
• Or where other forms of anaesthesia are inadequate or contraindicated

• Appendicectomy
• Cholecystectomy (laparoscopic or open)
• Bowel resection (colectomy, hemicolectomy)
• Exploratory laparotomy
• Gastrectomy
• Hernia repair (inguinal, femoral, incisional)
• Splenectomy

• Lobectomy / pneumonectomy
• Oesophagectomy
• Thoracotomy

• Aortic aneurysm repair
• Carotid endarterectomy
• Bypass procedures

• Hip/knee replacement
• Internal fixation of fractures (long bones, pelvis)
• Spinal surgery

• Thyroidectomy, parathyroidectomy
• Tonsillectomy, adenoidectomy
• Mastoidectomy

• Nephrectomy, cystectomy
• Prostatectomy (open radical)
• Pyeloplasty

• All major surgery in children

• Trauma surgery
• Damage control laparotomy
• Any emergency where rapid sequence induction (RSI) is needed

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Q3. A 26-year-old lady of 60 kg came to the burn unit with complaints of 30% flame burn 2 hours back. How will you resuscitate the patient by fluid? (6)

• 30% TBSA burn in a 60 kg female - this is a major burn requiring IV fluid resuscitation
• Resuscitation should start from the time of burn injury - any delay must be calculated and caught up

Volume (mL) = TBSA% burn × weight (kg) × 4

Volume = 30 × 60 × 4 = 7,200 mL in the first 24 hours

• First 8 hours (from time of burn, not time of admission): give half = 3,600 mL
• Next 16 hours: give remaining half = 3,600 mL

• If the patient arrives 2 hours after the burn, the first 3,600 mL must be given in the remaining 6 hours (i.e., 600 mL/hour)
• In addition to resuscitation fluid, this patient also needs maintenance fluid (approximately 30-35 mL/kg/24 hr = ~1,800-2,100 mL/day)
• Target urine output: 0.5-1.0 mL/kg/hour = 30-60 mL/hour - this is the best clinical monitor of adequacy of resuscitation
• Insert urinary catheter for strict hourly monitoring
• Insert two large-bore IV cannulae (14-16G), preferably through non-burned skin
• Blood investigations: FBC, U&E, blood glucose, group & cross-match, ABG

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Q4. Which burn patient needs hospitalization and what are the complications of burn? (6)

• Burns > 15% TBSA in adults
• Burns > 10% TBSA in children or the elderly
• Full-thickness burns of any size
• Burns of special areas: face, hands, feet, genitalia, perineum, major joints
• Inhalation injury (suspected or confirmed)
• Circumferential burns (of limbs or chest) - risk of compartment syndrome
• Chemical burns (require prolonged irrigation and monitoring)
• Electrical burns (risk of deep internal injury, cardiac arrhythmias, rhabdomyolysis)
• Burns associated with other major trauma
• Burns in patients with significant pre-existing medical conditions (diabetes, immunosuppression, cardiac disease)
• Burns at extremes of age
• Suspected non-accidental injury (child protection)
• Social circumstances where care at home is not possible

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• Hypovolaemic shock - massive fluid shifts from intravascular to interstitial space
• Airway obstruction and inhalation injury - oedema of upper airway, CO poisoning, HCN poisoning
• Carbon monoxide (CO) poisoning - from enclosed space fires; binds haemoglobin with 240x affinity; treat with 100% O₂
• Wound infection / sepsis - most common cause of death in burns
• Hypothermia - large surface area exposed; treat with warming blankets
• Acute renal failure - from hypovolaemia, myoglobinuria (especially in electrical burns)

• Wound sepsis and bacteraemia - Pseudomonas, Staphylococcus, Streptococcus
• Pneumonia - from inhalation injury or aspiration
• Curling's ulcer - acute stress ulcer of the stomach/duodenum; prevented with PPIs
• Anaemia - from haemolysis and failure of erythropoiesis
• Marjolin's ulcer - squamous cell carcinoma developing in a chronic burn scar (late complication)

• Hypertrophic scarring and keloid formation
• Contractures - especially at flexion creases; can cause severe functional disability
• Psychological complications - PTSD, depression, social isolation
• Marjolin's ulcer (malignant change in old burn scar)

Q5. Causes of Intestinal Obstruction. (6)

• Gallstone ileus
• Bezoar (food bolus, hair ball)
• Meconium (in neonates)
• Parasites (roundworms - Ascaris lumbricoides)

• Carcinoma of the colon (most common cause of large bowel obstruction)
• Crohn's disease (stricture)
• Diverticular stricture
• Intussusception (telescoping of bowel)
• Radiation stricture
• Congenital atresia (in neonates)

• Adhesions - most common overall cause; post-operative fibrous bands
• Hernias (inguinal, femoral, incisional, internal) - strangulated hernia is a common cause
• Volvulus (sigmoid or caecal) - twisting of the bowel on its mesentery
• External compression by tumour or abscess

• Post-operative (most common cause of paralytic ileus)
• Peritonitis
• Retroperitoneal haematoma
• Hypokalaemia, hyponatraemia
• Drugs (opioids, anticholinergics)
• Spinal cord injury

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SET CODE H

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Q1. Define ulcer and classify according to edge of the ulcer. (2+4)

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Q2. Define abscess and classify it. What is the importance of the pyogenic membrane? (2+4)

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• Subcutaneous abscess (most common, e.g., boil/furuncle)
• Anorectal abscess (perianal, ischiorectal, intersphincteric, supralevator)
• Breast abscess
• Parotid abscess

• Intraperitoneal abscess:
  • Subphrenic abscess (under diaphragm)
  • Pelvic abscess
  • Interloop (intermesenteric) abscess
  • Appendix abscess
• Retroperitoneal (psoas) abscess
• Liver abscess (amoebic, pyogenic)
• Lung abscess
• Brain abscess
• Epidural abscess
• Bone abscess (Brodie's abscess - chronic)

• Acute abscess - hot, tender, red, painful
• Chronic abscess - "cold abscess" (e.g., tuberculous - no warmth, no redness); contains caseous material and may calcify
• Metastatic abscess - formed by bacteraemia seeding a distant site

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• Granulation tissue (macrophages, fibroblasts, new blood vessels)
• It forms as a biological reaction to contain the infection and wall off the pus

1. Barrier function - it limits the spread of infection to surrounding healthy tissues, preventing generalised sepsis
2. Indicator of chronicity - a well-formed pyogenic membrane indicates a mature abscess; a thin or absent one indicates an early/acute process
3. Prevents systemic absorption - the fibrinous wall limits absorption of bacterial toxins into the bloodstream
4. Surgical significance - after incision and drainage (I&D) of an abscess, the walls of the pyogenic membrane should be curetted to remove the infected lining and allow the cavity to heal from within by secondary intention. If the wall is left intact, the abscess tends to recur
5. Resistance to antibiotics - the membrane's poor vascularity means antibiotics penetrate poorly, which is why drainage is the definitive treatment, not antibiotics alone
6. It eventually leads to fibrous scar formation once infection is controlled

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Q3. Define and classify anaesthesia with examples. (2+4)

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• Complete loss of consciousness, sensation, and reflexes
• Achieves the anaesthetic triad: amnesia + analgesia + muscle relaxation
• Examples of GA agents:
  • IV induction: Propofol, Thiopentone, Ketamine, Etomidate
  • Inhalational maintenance: Sevoflurane, Isoflurane, Desflurane, Nitrous oxide
• Used for: major abdominal surgery, thoracic surgery, head and neck surgery, all surgery in children

• Spinal anaesthesia (subarachnoid block): Local anaesthetic injected into the subarachnoid space (CSF). Produces immediate, dense block. Used for: hernia repair, appendicectomy, caesarean section, TURP, lower limb surgery. Agent: Hyperbaric bupivacaine 0.5%
• Epidural anaesthesia: Local anaesthetic injected into the epidural space (outside the dura). Slower onset, catheter allows top-ups. Used for: labour analgesia, post-operative pain, major abdominal/thoracic surgery

• Brachial plexus block (axillary, interscalene) - upper limb surgery
• Femoral nerve block, sciatic nerve block - lower limb surgery
• Intercostal nerve block - chest wall analgesia
• Digital nerve block - finger surgery

• Infiltration anaesthesia: injection around the wound; e.g., Lidocaine for skin suturing
• Topical anaesthesia: applied directly to surface; e.g., EMLA cream, lidocaine spray
• Field block: multiple injections around an area to create a zone of anaesthesia; e.g., inguinal hernia repair

• IV sedative/analgesic drugs given to relax the patient, reduce anxiety and pain, but without full loss of consciousness
• Patient maintains own airway and can respond to commands
• Used for: endoscopy, minor procedures, dental procedures
• Agents: Midazolam, Fentanyl, Propofol (subanaesthetic doses)

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Q4. What do you mean by rule of nines? (6)

• Determines whether IV fluid resuscitation is required: >15% TBSA in adults, >10% in children/elderly
• Used to calculate fluid requirements using the Parkland formula
• Guides decision on hospital admission vs. outpatient management
• Helps triage in mass casualty burn incidents

• Not suitable for children under 10 years - in children, the head is proportionally larger (up to 18% in infants) and the legs are smaller. The Lund and Browder chart is used instead
• Tends to overestimate burn size
• Less accurate in obese patients - the torso is proportionally larger and the limbs smaller
• A modification (5% arms, 20% legs, 50% torso) has been suggested for obese patients but is not widely adopted

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Q5. Causes of painful and painless haematuria. (6)

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1. Ureteric colic (renal/ureteric calculus) - most common cause; loin-to-groin colicky pain; haematuria is due to stone trauma to the urothelium
2. Acute cystitis (UTI) - dysuria, frequency, suprapubic pain; terminal haematuria
3. Acute pyelonephritis - loin pain, fever, dysuria; haematuria is common
4. Acute prostatitis - perineal pain, dysuria, tender prostate on DRE
5. Trauma - to kidney, ureter, bladder or urethra; post-traumatic haematuria with pain
6. Haemorrhagic cystitis - due to cyclophosphamide, radiation; painful dysuria + haematuria
7. Bladder/renal tuberculosis - chronic dysuria, frequency, "sterile" pyuria

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1. Bladder carcinoma - most important cause to exclude; painless macroscopic haematuria in an elderly patient; total haematuria (throughout the stream)
2. Renal cell carcinoma (hypernephroma) - classical triad: loin pain + haematuria + palpable mass (but haematuria can be painless)
3. Transitional cell carcinoma (renal pelvis, ureter)
4. Benign prostatic hyperplasia (BPH) - from congested prostatic veins; terminal haematuria
5. Carcinoma of the prostate - painless in early disease
6. Glomerulonephritis (IgA nephropathy, post-streptococcal) - microscopic haematuria, no pain
7. Polycystic kidney disease - may bleed into cysts; haematuria
8. Schistosomiasis (Bilharziasis) - terminal haematuria; most common cause worldwide in endemic areas
9. Coagulopathy / anticoagulant therapy - warfarin, heparin, rivaroxaban
10. Exercise-induced haematuria - in athletes after vigorous exercise; self-limiting

Rule: Painless macroscopic haematuria = bladder carcinoma until proven otherwise

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SET CODE D

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Q1. Define mismatched blood transfusion and its complications. (2+4)

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• Occurs immediately, within minutes of starting the transfusion
• Caused by ABO incompatibility; complement-mediated intravascular haemolysis
• Features: fever, rigors, loin/back/chest pain, hypotension, tachycardia, haemoglobinuria (port-wine urine), haemoglobinaemia, restlessness; in unconscious/anaesthetised patients: unexplained bleeding and hypotension
• Complications:
  • Acute kidney injury (AKI) - haemoglobin precipitates in renal tubules causing tubular necrosis
  • Disseminated intravascular coagulation (DIC) - activation of clotting cascade
  • Cardiovascular collapse / shock
  • Death - if not recognised and stopped immediately

• Occurs 5-10 days after transfusion
• Due to an anamnestic (secondary) antibody response to minor blood group antigens (Kidd, Duffy, Kell systems) in previously sensitised patients
• Features: unexplained anaemia, jaundice, positive direct antiglobulin test (DAT/Coombs' test)
• Usually mild and self-limiting

• Due to antibodies against donor white cell (HLA) antigens, or cytokine release from stored leucocytes
• Features: fever (>1°C rise), chills, rigors; no haemolysis
• Management: stop transfusion, give paracetamol; restart cautiously; use leukodepleted blood in future

• Free haemoglobin in plasma turns urine dark red/port-wine coloured

• From haemoglobin cast deposition in renal tubules (acute tubular necrosis)

1. Stop the transfusion immediately
2. Maintain IV access; give IV fluids (0.9% saline)
3. Send: patient and donor blood samples for repeat cross-match, direct Coombs' test, FBC, U&E, clotting, urine for haemoglobin
4. Monitor urine output (catheterise); force diuresis if needed (IV fluids ± frusemide)
5. Treat DIC with FFP, cryoprecipitate, platelets
6. Involve haematologist

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Q2. What do you mean by herniotomy, herniorrhaphy and hernioplasty?

• Examples: Bassini's repair, Shouldice repair (layered tissue repair - gold standard tissue repair)
• Disadvantage: creates tension at the suture line, leading to higher recurrence rates (~10%)

• Examples: Lichtenstein tension-free mesh repair (gold standard in adults - recurrence rate < 1%), Plug and patch repair, Laparoscopic repair (TAPP - transabdominal preperitoneal; TEP - totally extraperitoneal)
• Advantage: no tension at repair, very low recurrence rate
• Disadvantage: risk of mesh infection, chronic groin pain, mesh erosion

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Q3. How to assess a burn patient? (6)

• A - Airway (with cervical spine control):
  • Is the airway patent? Look for singed nasal hairs, eyebrows, facial burns
  • Hoarse voice, stridor, carbonaceous (sooty) sputum - signs of airway burn/inhalation injury
  • If inhalation injury suspected: early intubation before oedema develops
  • Give high-flow 100% oxygen immediately
• B - Breathing and Ventilation:
  • Respiratory rate, oxygen saturation
  • Look for circumferential chest burns causing restriction of chest expansion
  • Check for signs of CO poisoning (confusion, cherry-red skin)
  • Escharotomy may be needed for circumferential chest burns
• C - Circulation:
  • Pulse rate and blood pressure
  • Check for circumferential limb burns causing compartment syndrome - capillary refill, pulses
  • Two large-bore IV cannulae; send blood for FBC, U&E, clotting, glucose, group & cross-match, ABG, carboxyhaemoglobin
  • Insert urinary catheter for hourly urine output monitoring
• D - Disability (Neurological status):
  • GCS (Glasgow Coma Scale)
  • Pupils
  • Blood glucose
• E - Exposure with Environmental control:
  • Completely expose the patient to assess all burns
  • Maintain warm environment to prevent hypothermia (burns patients lose heat rapidly through the wound)
  • Remove all clothing and jewellery
• F - Fluid Resuscitation:
  • Calculate % TBSA burned using Rule of Nines or Lund and Browder chart
  • Begin Parkland formula fluid resuscitation if >15% TBSA (adult) or >10% (child)

• Rule of Nines (adults): each arm 9%, head 9%, anterior torso 18%, posterior torso 18%, each leg 18%, genitalia 1%
• Patient's palm = ~1% TBSA (for scattered small burns)
• Lund and Browder chart: used at burns unit for accurate assessment, especially in children

• Superficial (epidermal): erythema only (like sunburn); very painful; no blisters; heals in 5-7 days; NOT included in TBSA calculation for fluid resuscitation
• Superficial partial-thickness (superficial dermal): blisters; moist, pink dermis; VERY painful; blanches with pressure; heals in 10-14 days without scarring
• Deep partial-thickness (deep dermal): dry dermis; fixed capillary staining that does NOT blanch; reduced sensation (cannot distinguish sharp vs blunt); takes >3 weeks; usually needs grafting
• Full-thickness: leathery, white, brown or charred; painless (nerve endings destroyed); no blisters; requires skin grafting

• History of burn in enclosed space
• Facial burns, singeing of nasal hairs/eyebrows
• Hoarse voice, stridor, carbonaceous sputum
• Raised carboxyhaemoglobin (COHb) on ABG

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Q4. Lumps in different quadrants. (6)

• Enlarged liver (hepatomegaly): hepatocellular carcinoma, metastatic liver disease, cirrhosis, amoebic/pyogenic abscess, Riedel's lobe
• Enlarged gallbladder: mucocele, empyema, carcinoma of gallbladder, Courvoisier's gallbladder (carcinoma head of pancreas)
• Right kidney: hydronephrosis, renal cell carcinoma, polycystic kidney

• Stomach: carcinoma of stomach, dilated stomach in GOO
• Pancreas: carcinoma of the pancreas, pancreatic pseudocyst, pancreatitis mass
• Aortic aneurysm (expansile, pulsatile)
• Retroperitoneal lymph nodes

• Splenomegaly: portal hypertension, haematological malignancies (lymphoma, leukaemia), malaria, kala-azar, myelofibrosis
• Left kidney: hydronephrosis, renal cell carcinoma, polycystic kidney
• Carcinoma of splenic flexure of colon

• Appendix mass / appendicular abscess
• Carcinoma of the caecum
• Ileocaecal tuberculosis (most common cause of RIF mass in South Asia)
• Crohn's disease mass
• Ovarian cyst / ovarian tumour (right)
• Ectopic pregnancy
• Iliac lymph nodes
• Undescended testis

• Carcinoma of the sigmoid colon
• Diverticular disease (phlegmon/abscess)
• Ovarian cyst / tumour (left)
• Constipation (loaded sigmoid - faecal mass - indentable)
• Iliac lymph nodes
• Ectopic kidney

• Small bowel tumour
• Mesenteric cyst
• Retroperitoneal sarcoma
• Umbilical hernia
• Aortic aneurysm

• Distended urinary bladder (retention)
• Uterus: fibroid, gravid uterus, carcinoma
• Ovarian cyst

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Q5. Formation of appendicular lump. (6)

1. Obstruction: Acute appendicitis begins with obstruction of the lumen of the appendix (by a faecolith, lymphoid hyperplasia, or foreign body), leading to raised intraluminal pressure, mucosal ischaemia and bacterial proliferation.
2. Perforation/Threatened Perforation: As the inflammation progresses over 48-72 hours, the appendix becomes gangrenous and either perforates or is at risk of perforation. This usually occurs at the point of maximum ischaemia - the anti-mesenteric border near the tip.
3. Walling-off: The body's natural defence mechanism then mobilises:
   • The greater omentum (the "policeman of the abdomen") migrates to the site of infection
   • Adjacent loops of small bowel and peritoneum adhere to the area
   • Together they form a protective barrier (phlegmon) around the inflamed/perforated appendix, preventing generalised peritonitis
4. Result: A tender, firm, ill-defined mass in the right iliac fossa is felt on clinical examination, usually 2-5 days after the onset of symptoms. The patient may have had a typical attack of acute appendicitis that seemed to "settle," only for a mass to be noticed later.

• Patient is typically seen 3-5 days after onset of symptoms
• RIF pain (initially colicky, then constant)
• Low-grade fever
• Tender, ill-defined, firm mass in RIF
• Overlying muscle guarding

1. Resolution - lump resolves with conservative treatment (antibiotics + IV fluids) - most common
2. Appendicular abscess formation - pus collects within the mass; requires drainage
3. Perforation / generalised peritonitis - if not managed; patient deteriorates

• Conservative (Ochsner-Sherren regimen):
  • IV antibiotics (metronidazole + third-generation cephalosporin)
  • IV fluids, bed rest, nil by mouth (initially)
  • Monitor 4-hourly: temperature, pulse, pain, lump size
  • If improving: continue; plan interval (elective) appendicectomy after 6-8 weeks
• Surgery (if deteriorating):
  • Rising fever, increasing lump size, generalised peritonitis - drain abscess ± appendicectomy

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SET CODE B

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Q1. Tell the indication of blood transfusion in surgical practice. (6)

• To replace circulating volume and maintain oxygen delivery to vital organs
• In haemorrhagic shock: if Hb < 8 g/dL with active bleeding, or if haemodynamically unstable
• Trauma, gastrointestinal haemorrhage (haematemesis, melaena, PR bleeding), ruptured viscus

• To ensure adequate oxygen delivery during major surgery
• Indicated if Hb < 8 g/dL in a patient who is symptomatic or undergoing major surgery
• Reduces operative risk of cardiac/cerebral ischaemia intraoperatively

• Anaemia of chronic disease, aplastic anaemia, haematological malignancy
• Indicated when Hb is symptomatic (breathlessness, angina, fatigue)

• Hb < 6 g/dL: Probably benefits from transfusion
• Hb 6-8 g/dL: Unlikely to benefit unless bleeding or surgery is imminent
• Hb > 8 g/dL: No indication in the absence of other risk factors

• Fresh Frozen Plasma (FFP): Coagulopathy, DIC, massive transfusion, liver failure
• Platelets: Thrombocytopaenia with bleeding (platelet count < 50 × 10⁹/L pre-op; < 100 × 10⁹/L if in CNS)
• Cryoprecipitate: Low fibrinogen (< 1.5 g/L), haemophilia A, von Willebrand disease

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Q2. Complications of massive blood transfusion. (6)

• Dilution of clotting factors and platelets by stored packed red cells (which contain no viable clotting factors)
• Leads to dilutional coagulopathy and uncontrolled bleeding
• Management: balanced resuscitation (RBC : FFP : platelets in 1:1:1 ratio), tranexamic acid (antifibrinolytic), cryoprecipitate for low fibrinogen

• Sodium citrate (preservative in blood bags) chelates ionised calcium (Ca²⁺)
• Results in reduced cardiac contractility, arrhythmias, tetany, hypotension
• Management: IV calcium gluconate or calcium chloride

• Lysis of red cells during storage releases potassium (K⁺) into the surrounding plasma
• Can cause cardiac arrhythmias, especially in patients with pre-existing renal failure
• Management: treat with calcium gluconate (membrane stabilisation), insulin + dextrose, salbutamol

• May develop paradoxically as red cells re-equilibrate and take up K⁺ from plasma after rewarming
• Can cause cardiac arrhythmias

• Large volumes of cold blood (stored at 4°C) lower core body temperature
• Hypothermia impairs clotting factor function (worsening coagulopathy), causes cardiac arrhythmias, and reduces drug metabolism
• Management: use blood warmers, warming blankets, warm IV fluids

• Especially from FFP
• Donor anti-leukocyte antibodies react with recipient neutrophils in pulmonary vasculature causing non-cardiogenic pulmonary oedema
• Features: acute breathlessness, bilateral infiltrates on CXR, hypoxaemia, within 6 hours of transfusion
• Treatment: supportive, oxygen, mechanical ventilation if necessary

• Stored blood is acidic (citric acid + lactic acid from anaerobic metabolism of stored RBCs)
• May worsen metabolic acidosis in trauma patients
• Usually self-correcting once haemostasis achieved and liver metabolises citrate

• Each unit of RBCs contains approximately 250 mg elemental iron
• Relevant for patients with chronic transfusion requirements (thalassaemia, sickle cell)

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Q3. Describe the steps of Kocher's incision. (6)

• Open cholecystectomy
• Common bile duct exploration
• Hepatic surgery (right hepatectomy)
• Whipple's procedure (pancreaticoduodenectomy)
• A bilateral version (Rooftop / Mercedes-Benz incision) is used for liver transplantation and total gastrectomy

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• Begin at the midline, 2-3 cm (two finger breadths) below the xiphisternum
• Extend obliquely downward and to the right, parallel to and 2.5 cm below the right costal margin
• Extend laterally to the lateral border of the rectus abdominis (standard) or further to the anterior axillary line if wider access needed

• Divide the superficial fascia (Camper's and Scarpa's fascia) in the line of the incision; control bleeding with diathermy

• Incise the anterior layer of the rectus sheath along the line of the skin incision

• The rectus abdominis muscle is divided transversely using electrocautery
• Alternatively, it may be split longitudinally along its fibres (less common)
• The right rectus muscle is divided and retracted; bleeding from the superior epigastric vessels is controlled

• These three flat muscle layers are divided in the lateral part of the incision along the line of the incision using diathermy

• The posterior rectus sheath (present above the arcuate line) and the transversalis fascia are divided

• The peritoneum is lifted between two haemostats, a nick is made and the incision extended along the line of the incision, entering the peritoneal cavity
• Care is taken to avoid injury to the underlying bowel

• Peritoneum: continuous absorbable suture (Vicryl)
• Posterior rectus sheath and muscle: continuous absorbable (PDS or Vicryl 0 or 1)
• Anterior rectus sheath: mass closure with loop PDS or Vicryl
• Skin: subcuticular Monocryl or clips

• Excellent access to right upper quadrant
• Follows Langer's lines - gives a cosmetically acceptable scar

• Denervation of the rectus muscle medial to the incision (nerve supply runs from lateral to medial)
• More bleeding than midline
• Longer closure time

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Q4. Name 2 intravenous and 2 inhalational anaesthetic agents. (6)

• Most widely used induction agent (has replaced thiopentone)
• Milky white emulsion
• Features: smooth induction, better haemodynamic stability, blunts autonomic reflexes, can be used as a continuous infusion for TIVA (Total Intravenous Anaesthesia) or sedation
• Rapid onset (30-60 seconds) and rapid recovery
• Side effects: pain on injection, hypotension, apnoea, propofol infusion syndrome (rare)
• Uses: induction and maintenance of GA, procedural sedation, ICU sedation

• Unique agent: produces dissociative anaesthesia - patient appears awake (eyes open, nystagmus) but is analgesic and amnesic
• Features: preserves blood pressure and respiratory reflexes; provides excellent analgesia
• Ideal for: field anaesthesia, burns patients (dressing changes), haemodynamically unstable patients, children
• Side effects: emergence delirium (vivid dreams, hallucinations on recovery - prevented by benzodiazepine); increases ICP (contraindicated in head injury); increases secretions
• Also used: Thiopentone (barbiturate - rapid induction, reduces ICP, used in neurosurgery but causes myocardial depression); Etomidate (best haemodynamic stability, used in cardiac patients)

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• Halogenated volatile agent; non-pungent (pleasant smell)
• The agent of choice for inhalational induction in children, needle-phobic adults, and patients in whom a difficult airway is anticipated (because it doesn't irritate the airway)
• Rapid onset and rapid recovery
• Minimal cardiovascular depression
• May cause nephrotoxicity at very low fresh gas flows (compound A formation) - clinical significance debated

• Halogenated volatile agent
• Most commonly used volatile agent for maintenance of general anaesthesia
• Slightly pungent smell (not suitable for inhalational induction)
• Good muscle relaxation
• Causes coronary vasodilation - may cause "coronary steal" in ischaemic heart disease
• Also used: Desflurane (very rapid recovery - good for day surgery), Nitrous oxide (N₂O - weak anaesthetic, used as adjunct analgesic, "laughing gas")

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Q5. Complications of anaesthesia. (6)

• Failed intubation - cannot secure airway; risk of hypoxia, death (Difficult Airway Society guidelines)
• Airway obstruction - tongue, laryngospasm (most common cause post-extubation in children), foreign body
• Pulmonary aspiration (Mendelson's syndrome) - aspiration of gastric contents causing chemical pneumonitis; prevented by RSI and cricoid pressure
• Oesophageal intubation - unrecognised: fatal hypoxia

• Hypotension - due to anaesthetic agents, hypovolaemia, epidural/spinal sympathetic block
• Arrhythmias - sinus tachycardia, bradycardia, ventricular arrhythmias (especially with halothane)
• Cardiac arrest - rare; from anaphylaxis, hypoxia, tension pneumothorax

• Anaphylaxis - to muscle relaxants (most common), latex, antibiotics, IV agents
• Malignant hyperthermia - rare, life-threatening; hypermetabolic crisis triggered by volatile agents (sevoflurane) or succinylcholine in genetically susceptible patients; treat with dantrolene
• Awareness under anaesthesia - patient is conscious but paralysed; causes PTSD; prevented by adequate depth of anaesthesia monitoring (BIS)

• Postoperative nausea and vomiting (PONV) - most common complaint (30-80%); treat with ondansetron, metoclopramide, dexamethasone
• Postoperative pain - inadequate analgesia
• Urinary retention - especially with spinal/epidural anaesthesia; anticholinergic drugs
• Respiratory depression - from opioids, residual muscle relaxant, airway oedema
• Aspiration pneumonia / pneumonitis
• Post-dural puncture headache - after spinal anaesthesia; postural headache; treat with blood patch
• Backache - after spinal/epidural

• Hypotension, bradycardia
• High/total spinal (respiratory arrest)
• Post-dural puncture headache
• Urinary retention
• Nerve damage (rare)
• Meningitis (very rare)

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SET CODE E

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Q1. Classify burn according to skin depth. How to resuscitate fluid loss of a burn patient? (2+4)

• Epidermis alone is involved; dermis is intact
• Appearance: Erythema (red), dry, no blisters; resembles sunburn
• Sensation: Very painful (all nerve endings intact)
• Blanching: Blanches with pressure (capillaries intact)
• Healing: Spontaneous healing within 5-7 days without scarring
• Included in TBSA?: NO - not counted in fluid resuscitation calculation
• Example: Mild sunburn, brief flash burn

• Epidermis + superficial (papillary) dermis involved
• Appearance: Blisters, moist pink/red dermis; weeping wound
• Sensation: Extremely painful (nerve endings exposed)
• Blanching: Blanches with pressure (dermal capillaries intact)
• Healing: Heals in 10-14 days with proper wound care; minimal or no scarring
• Example: Scalds in children, most domestic burns

• Epidermis + deep (reticular) dermis involved; skin appendages (hair follicles, sweat glands) partially destroyed
• Appearance: Exposed dermis; dry; fixed capillary staining that does NOT blanch; may appear white/red mottled
• Sensation: Reduced (cannot distinguish sharp from blunt with a pin); less painful than superficial
• Healing: Takes >3 weeks without surgery; invariably heals with hypertrophic scarring; usually requires skin grafting
• Example: Deep scalds, contact burns

• All layers of skin (epidermis, dermis, and skin appendages) destroyed; may involve subcutaneous tissue, muscle, bone
• Appearance: Leathery, white, brown, or charred (eschar); dry
• Sensation: Painless - all nerve endings destroyed; insensate to pin prick
• Blanching: Does NOT blanch
• Healing: Cannot heal spontaneously (no viable dermis or skin appendages); requires skin grafting
• Example: Flame burns, electrical burns, chemical burns

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• Adults: burns > 15% TBSA
• Children/elderly: burns > 10% TBSA

Volume (mL) = 4 × weight (kg) × % TBSA burned

• Fluid: Hartmann's solution (Ringer's lactate) - first-choice crystalloid; most closely replicates plasma osmolality

• First 8 hours (from time of burn, not arrival): give half the calculated volume
• Next 16 hours: give the remaining half

4 × 60 × 30 = 7,200 mL in 24 hours

• First 8 hours (from burn): 3,600 mL
• Next 16 hours: 3,600 mL

• Urine output = best clinical indicator; target 0.5-1.0 mL/kg/hour (30-60 mL/hr for adults)
• Pulse and blood pressure
• If urine output falls below target: increase fluid rate
• If above target: reduce rate (risk of fluid overload, pulmonary oedema)

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Q2. Definition of sterilization and disinfection. Methods of sterilization. (2+4)

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• Moist heat in the form of pressurised steam; steam penetrates all materials and transfers heat to kill all organisms including spores
• Standard cycles:
  • 134°C at 207 kPa (30 psi) for 3 minutes (porous load - for wrapped instruments)
  • 121°C at 103 kPa (15 psi) for 15 minutes (fluid cycle)
• Used for: surgical instruments, drapes, gowns, swabs, glassware, most surgical materials
• The method of choice for heat-stable items

• Uses conduction of dry heat through an oven
• Requires higher temperatures and longer times than moist heat (steam conducts heat poorly compared to water)
• Cycles: 160°C for 60 minutes; or 180°C for 30 minutes
• Used for: oils, powders, glass syringes, sharp instruments (won't blunt), metallic instruments that can be damaged by moisture

• High-energy ionising radiation from a Cobalt-60 source
• Destroys DNA of all microorganisms including spores
• Used industrially for disposable items: packaged surgical gloves, sutures, syringes, catheters, implants
• Cannot be used for live tissues or food for hospital patients
• Advantage: penetrates packaging; does not leave residue

• Short-wavelength UV light damages DNA and RNA of microorganisms
• Used for sterilisation of air in operating theatres, laminar flow systems, pharmacy preparation areas
• Cannot penetrate solid objects; does not sterilise surfaces effectively
• Limited penetration

• Used for heat-sensitive liquids and gases (intravenous solutions, biological products, ophthalmic solutions)
• Millipore membrane filters (0.22 micron pore size) remove bacteria and fungi but NOT viruses

• Alkylating agent; penetrates packaging and kills all organisms including spores
• Used for heat-sensitive equipment: flexible endoscopes, plastics, electronic equipment, catheters, cardiac valves, powered surgical instruments
• Disadvantage: slow process (2-6 hours), toxic and carcinogenic; long aeration period required before safe use (12-24 hours); flammable; expensive

• Used for heat-sensitive instruments
• Less widely used due to carcinogenic risk

• High-level disinfection in 20-30 minutes; full sterilization in 10 hours
• Used for: flexible endoscopes, cystoscopes, laparoscopes (heat-sensitive items)
• Disadvantage: skin/mucosa sensitiser; must be thoroughly rinsed before use; cannot use on open wounds
• Being superseded by hydrogen peroxide plasma (Sterrad) and peracetic acid systems

• Modern low-temperature sterilisation system
• Gaseous hydrogen peroxide activated by radiofrequency energy into plasma
• Non-toxic, no residue, fast cycle (45-75 minutes)
• Increasingly replacing EO and glutaraldehyde for heat-sensitive devices

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Q3. Name some inguino-scrotal swellings. (6)

1. Indirect inguinal hernia (inguino-scrotal hernia) - most common cause of inguino-scrotal swelling; reducible, impulse on coughing, can get above the swelling is possible only partially
2. Undescended testis in the inguinal canal (cryptorchidism)
3. Encysted hydrocele of the cord (in males)

• Primary (idiopathic)
• Secondary (to epididymo-orchitis, torsion, tumour)

1. Epididymal cyst - smooth, fluctuant, transilluminates, separate from testis; can get above; filled with clear or milky fluid
2. Varicocele - dilated veins of the pampiniform plexus; "bag of worms" feel; more common on the left (left testicular vein drains into left renal vein at right angle); impulse on Valsalva; secondary varicocele suggests renal tumour
3. Epididymo-orchitis - painful, tender, swollen epididymis and testis; usually secondary to UTI, STI (gonorrhoea, chlamydia), TB
4. Testicular torsion - sudden severe testicular pain; high-riding testis; absent cremasteric reflex; surgical emergency
5. Testicular tumour (teratoma, seminoma) - firm, heavy, painless testicular mass; does not transilluminate; most common solid testicular tumour in young males
6. Haematocele - blood in the tunica vaginalis; following trauma; does not transilluminate
7. Sebaceous cyst of scrotum - multiple, small, non-transilluminant, attached to skin
8. Filariasis - chylous hydrocele; caused by Wuchereria bancrofti; opaque, does not transilluminate

1. Can you get above the swelling? (If NO → inguinal hernia descending into the scrotum)
2. Is it separate from the testis? (If YES → epididymal cyst, hydrocele)
3. Does it transilluminate? (If YES → hydrocele, epididymal cyst)
4. Is it tender? (YES → torsion, epididymo-orchitis; NO → tumour, hydrocele)

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Q4. Causes of intestinal obstruction. (6)

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Q5. Define shock and classify with example. (3+3)

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• Absolute reduction in circulating blood volume
• Most common type of shock encountered in surgical practice
• Examples:
  • Haemorrhagic (trauma, GI bleeding, ruptured AAA, ectopic pregnancy)
  • Non-haemorrhagic (severe burns, extensive vomiting/diarrhoea, intestinal obstruction - third space losses, pancreatitis)
• Features: tachycardia, hypotension, cold clammy pale skin, decreased urine output

• Primary failure of the heart to pump blood adequately; not a volume problem but a pump failure
• Examples:
  • Acute myocardial infarction (most common cause)
  • Severe cardiac arrhythmias
  • Acute valvular failure (mitral regurgitation, aortic stenosis)
  • Blunt myocardial contusion (trauma)
  • End-stage cardiomyopathy
• Features: raised JVP, pulmonary oedema, cold skin, poor cardiac output despite adequate filling

• Mechanical obstruction prevents adequate filling or emptying of the heart; results in reduced cardiac output
• Examples:
  • Cardiac tamponade (blood in pericardium - Beck's triad: raised JVP + hypotension + muffled heart sounds)
  • Tension pneumothorax (trachea deviated away, absent breath sounds, raised JVP)
  • Massive pulmonary embolism
  • Severe aortic stenosis
  • Air embolism

• Maldistribution of blood flow - adequate (or raised) cardiac output but peripheries are vasodilated; tissues underperfused despite normal or high flow
• Features: warm peripheries (initially), bounding pulse, low SVR, high cardiac output
• Examples:
  • Septic shock (most common cause of distributive shock; e.g., gram-negative bacteraemia, peritonitis, pneumonia)
  • Anaphylactic shock (IgE-mediated; to drugs, insect stings, foods; histamine release causes profound vasodilation)
  • Neurogenic shock (high spinal cord injury → loss of sympathetic tone; bradycardia + hypotension)

• Caused by hormonal deficiency affecting vascular tone or cardiac function
• Examples:
  • Addisonian crisis (adrenal insufficiency - insufficient cortisol and aldosterone)
  • Hypothyroidism (myxoedema crisis - reduced cardiac output)
  • Thyrotoxic crisis (high output failure)

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SET CODE A

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Q1. Name some fluids used in surgery ward. (6)

1. 0.9% Normal Saline (isotonic saline)
   • Na⁺: 154 mmol/L; Cl⁻: 154 mmol/L; pH: 4.5-7.0
   • Isotonic with plasma; used for volume replacement, correcting hyponatraemia, flushing IV lines
   • Caution: large volumes cause hyperchloraemic metabolic acidosis (high Cl⁻ content)
2. Hartmann's Solution (Ringer's Lactate)
   • Na⁺: 131; K⁺: 5; Cl⁻: 111; HCO₃⁻ (as lactate): 29; Ca²⁺: 2 mmol/L
   • Most physiologically balanced crystalloid; most closely matches plasma composition
   • First-choice fluid for: IV resuscitation, burn resuscitation (Parkland formula), intraoperative fluid
   • Lactate is metabolised by the liver to bicarbonate (alkalinising effect)
3. 5% Dextrose (Glucose)
   • Glucose 50 g/L in water; provides free water once glucose metabolised
   • Distributes throughout total body water (2/3 intracellular, 1/3 extracellular)
   • Used for: maintenance fluid, hypoglycaemia, vehicle for drug infusions
   • NOT suitable for resuscitation (distributes too widely; no lasting intravascular effect)
4. Dextrose-Saline (0.18% NaCl + 4% Dextrose)
   • Hypotonic; used for maintenance fluids in adults and children
   • Not for resuscitation
5. Hypertonic Saline (3%, 7.5%)
   • Used in specific settings: traumatic brain injury (reduces cerebral oedema), refractory hyponatraemia, burns resuscitation in some centres

1. Gelofusine (4% succinylated gelatin)
   • Plasma expander; volume expands for approximately 3-4 hours
   • Used for: resuscitation in trauma, sepsis, perioperative volume expansion
   • Risk: coagulopathy, renal failure (less than starch)
2. Volplex (4% succinylated gelatin) - similar to Gelofusine
3. Hydroxyethyl Starch (HES - Voluven 6%)
   • Plasma expander; longer duration than gelatins
   • Associated with acute kidney injury and increased mortality in septic patients - now banned/restricted in many countries

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Q2. Describe the names of five incisions commonly used in abdominal surgery. (6)

• Most commonly used incision in emergency and elective abdominal surgery
• Runs vertically in the midline, through the linea alba (avascular plane)
• Upper midline: from xiphisternum to umbilicus - for stomach, duodenum, liver, biliary tree, spleen
• Lower midline: from umbilicus to pubic symphysis - for pelvic surgery, bladder, uterus, appendix
• Full midline: entire length from xiphisternum to pubis - for major trauma, exploratory laparotomy
• Advantages: rapid access, minimal bleeding, easy extension, avoids all major nerves and vessels
• Disadvantage: incisional hernia (especially if wound infection occurs); poor cosmesis

• Runs 2.5 cm lateral to the midline, through the anterior and posterior rectus sheaths, with medial retraction of the rectus muscle
• Provides excellent wound strength (layered closure, muscle acts as additional support)
• Largely superseded by the midline in modern surgery

• Oblique incision, 2.5 cm below and parallel to the right costal margin
• Divides external oblique, internal oblique, transversus abdominis, rectus abdominis
• Used for: open cholecystectomy, CBD exploration, hepatic surgery, Whipple's procedure
• Bilateral Kocher's = Rooftop (Mercedes-Benz) incision - liver transplantation, total gastrectomy

• Transverse curved incision, 5 cm above the pubic symphysis; skin and fat cut transversely, but the anterior rectus sheath is cut transversely, the rectus muscles are separated vertically, and the peritoneum opened vertically
• Gives excellent cosmesis (scar hidden by pubic hair)
• Used for: caesarean section, hysterectomy, pelvic lymph node dissection, cystectomy, open prostatectomy

• Oblique incision over McBurney's point (1/3 of the way from the ASIS to the umbilicus)
• Muscle-splitting (the three flat muscle layers are split in the direction of their fibres - not cut)
• Used for: open appendicectomy
• Advantage: minimal muscle damage; strong closure; low hernia rate
• Disadvantage: limited access; if appendix is in atypical position, may need extending

• Lanz incision - transverse skin crease incision at McBurney's point; better cosmesis than Grid-iron
• Thoraco-abdominal incision - combined chest + abdomen; for oesophagectomy, hepatic tumours
• Transverse incision - for neonatal/paediatric surgery; for specific procedures (colostomy)
• J-shaped / Hockey stick - for right hepatectomy

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Q3. What do you mean by Pre-Anaesthetic Check-up (PACU)? (6)

1. Assess the patient's fitness for surgery and anaesthesia
2. Identify and optimise risk factors that could lead to perioperative complications
3. Plan the appropriate anaesthetic technique
4. Obtain informed consent for the anaesthetic
5. Reduce perioperative morbidity and mortality

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• Nature and urgency of the proposed surgery
• Previous anaesthetics and any complications (difficult intubation, malignant hyperthermia, PONV)
• Current medications (anticoagulants, antihypertensives, steroids, aspirin - may need bridging or stopping)
• Allergies (drugs, latex, plasters)
• Medical comorbidities: cardiovascular (IHD, hypertension, heart failure), respiratory (asthma, COPD, OSA), renal, hepatic, endocrine (diabetes, thyroid), neurological
• Social history: smoking (lung function), alcohol, illicit drug use
• Family history of anaesthetic problems (malignant hyperthermia is autosomal dominant)
• Fasting status: last oral intake of solids and fluids (AAGBI guidelines: 6 hours for solid food, 2 hours for clear fluids)

• Airway assessment (MOST IMPORTANT for anaesthetist):
  • Mallampati score (Grade I-IV based on pharyngeal visibility)
  • Mouth opening (< 3 cm = difficult)
  • Neck movements (limited in ankylosing spondylitis, rheumatoid arthritis, cervical spondylosis)
  • Thyromental distance (< 6 cm = difficult intubation)
  • Micrognathia, macroglossia
  • Presence of teeth (loose teeth, dentures)
• Cardiovascular examination: pulse, BP (both arms), JVP, heart sounds, peripheral oedema
• Respiratory examination: auscultation, peak flow (if asthma/COPD)
• Body weight (for drug dosing, fluid calculation)
• IV access sites

• FBC (haemoglobin, platelet count)
• U&E (renal function, electrolytes)
• Coagulation screen (INR, APTT)
• Blood glucose (diabetics)
• ECG (males > 40 years, females > 50 years, or those with cardiac history)
• Chest X-ray (if respiratory disease, cardiac failure, or recent respiratory illness)
• Lung function tests / spirometry (COPD, asthma)
• Echocardiogram (if valvular disease or poor LV function)
• Group and save / cross-match (if significant blood loss anticipated)

• ASA I: Healthy, no disease
• ASA II: Mild systemic disease (e.g., well-controlled hypertension, mild asthma)
• ASA III: Severe systemic disease (e.g., poorly controlled diabetes, angina)
• ASA IV: Life-threatening systemic disease (e.g., recent MI, end-stage renal failure)
• ASA V: Moribund patient (not expected to survive > 24 hours)
• ASA VI: Brain-dead (organ donation)
• E: Emergency (suffix added for emergency cases)

• Informed consent for the specific anaesthetic technique (GA vs. regional vs. spinal)
• Explanation of risks: PONV, sore throat, dental damage, awareness, blood transfusion

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Q4. Definition and classify with examples of shock. (6)

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Q5. Clinical features of shock. (6)

• Tachycardia (pulse rate > 100 bpm) - earliest and most sensitive sign; compensatory response to low stroke volume via baroreceptor-catecholamine axis
  • Exception: Neurogenic shock (bradycardia due to loss of sympathetic tone)
  • Exception: Beta-blocker therapy may mask tachycardia
• Hypotension (systolic BP < 90 mmHg) - a late sign; indicates decompensated shock (>30% blood volume lost)
• Narrow pulse pressure (difference between systolic and diastolic)
• Collapsed peripheral veins, prolonged capillary refill time (> 2 seconds)

• Pallor - peripheral vasoconstriction (sympathetic response)
• Cold, clammy skin - sweating (catecholamines) + vasoconstriction
• Mottling / cyanosis - in severe/late shock
• Exception: Septic and neurogenic shock (distributive) - initially warm, flushed, vasodilated peripheries due to loss of vascular tone

• Tachypnoea (respiratory rate > 20/min) - to compensate for metabolic acidosis (by blowing off CO₂)
• Respiratory rate is one of the earliest signs to change in shock

• Oliguria (urine output < 0.5 mL/kg/hour; or < 30 mL/hour in adults)
• The kidney is extremely sensitive to underperfusion - urine output is the best clinical monitor of organ perfusion
• If untreated: anuria → acute tubular necrosis → renal failure

• Anxiety, restlessness - early sign; due to cerebral hypoperfusion
• Confusion, agitation - moderate shock
• Drowsiness, unconsciousness - severe/late shock; indicates profound cerebral ischaemia

• Metabolic acidosis (lactic acidosis) - cells switch to anaerobic metabolism, accumulating lactic acid; base deficit < -6 on ABG is significant
• Raised serum lactate (> 2 mmol/L = shock; > 4 mmol/L = severe shock/poor prognosis)

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