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NEET PG HIGH-YIELD MASTERCLASS

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1. SURGERY (30-32 Questions)

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TRAUMA

• Airway with C-spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability (neurological)
• Exposure

• Damage control resuscitation = permissive hypotension + massive transfusion protocol (1:1:1 ratio - PRBCs : FFP : Platelets)
• FAST exam: fluid in Morrison's pouch, perisplenic, pericardial, pelvic
• Tension pneumothorax: needle decompression at 2nd ICS midclavicular line BEFORE chest X-ray
• Flail chest = paradoxical breathing, requires positive pressure ventilation
• Splenic injury: Grade I-II can be observed; Grade III-V needs intervention
• Zone I neck injury (below cricoid): always explore surgically
• FAST-negative + hemodynamically unstable = laparotomy

• Rule of Nines: Head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%
• Parkland formula: 4 mL x body weight (kg) x %BSA burned (Ringer's lactate - half in first 8 hrs, half in next 16 hrs)
• Full thickness (3rd degree): dry, leathery, painless, requires grafting
• Curling's ulcer = stress ulcer after burns (gastric)

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HERNIA

• Medial: lateral border of rectus abdominis
• Lateral: inferior epigastric vessels
• Inferior: inguinal ligament

1. Reducible - can be pushed back
2. Irreducible (incarcerated) - cannot be reduced, no vascular compromise yet
3. Obstructed - bowel contents cannot pass
4. Strangulated - blood supply cut off = EMERGENCY (most feared)

• Lichtenstein (tension-free mesh repair) = gold standard for adults
• Laparoscopic (TEP/TAPP) = bilateral hernias, recurrent hernias
• Bassini / Shouldice = tissue repair (no mesh)

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GENITOURINARY SYSTEM

• Grade I: contusion/subcapsular hematoma - observe
• Grade II: laceration <1 cm - observe
• Grade III: laceration >1 cm - observe
• Grade IV: collecting system involved - may need intervention
• Grade V: shattered kidney or renal pedicle - surgery

• Zone involved: Transitional zone
• Prostate cancer: Peripheral zone
• PSA >4 ng/mL = suspicious
• Medical treatment: Alpha-1 blockers (tamsulosin) + 5-alpha reductase inhibitors (finasteride)
• Surgical: TURP (gold standard); open prostatectomy if >80g

• Most common histology: Transitional cell carcinoma (TCC/urothelial)
• Painless hematuria = most common presentation
• Risk factors: Smoking (most common), aniline dyes, cyclophosphamide, schistosomiasis (squamous cell)
• Diagnosis: Cystoscopy + biopsy

• Painless testicular swelling in young males
• Most common type: Seminoma (most common) vs. Non-seminoma (NSGCT - teratoma, embryonal, yolk sac, choriocarcinoma)
• Seminoma = radiosensitive
• AFP elevated in yolk sac tumor, NOT in pure seminoma
• hCG elevated in choriocarcinoma

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ARTERIES & VEINS

• Young male smokers
• Affects small/medium vessels
• Presents with claudication, rest pain, digital gangrene
• Treatment: Absolute smoking cessation

• Long saphenous vein most common
• Trendelenburg test: identifies saphenofemoral incompetence
• Complications: DVT, bleeding, lipodermatosclerosis, venous ulcer (gaiter area = medial lower 1/3 leg)
• Treatment: EVLA (endovenous laser ablation), sclerotherapy, surgery (Trendelenburg operation + stripping)

• Stasis + Endothelial damage + Hypercoagulability
• Homan's sign: calf pain on dorsiflexion (unreliable)
• Investigation: Doppler USS (first line), D-dimer, venography
• Treatment: LMWH/DOAC; thrombolysis for massive PE

• AAA >3 cm = aneurysm; >5.5 cm = repair
• Risk: smoking, hypertension, male, family history
• Rupture triad: sudden severe back/abdominal pain + hypotension + pulsatile abdominal mass
• Endovascular repair (EVAR) preferred in unfit patients; open repair in fit patients

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HEPATOBILIARY SURGERY

• Types: Cholesterol (80%, radiolucent), Pigment (black = hemolysis; brown = infection)
• Murphy's sign: pain on inspiration with pressure at gallbladder fossa
• Mirizzi syndrome: common hepatic duct compressed by stone in Hartmann's pouch
• Courvoisier's law: Palpable gallbladder + jaundice = NOT gallstones (likely malignancy)
• Treatment: Laparoscopic cholecystectomy; ERCP for CBD stones

• Most common type: Adenocarcinoma
• Porcelain gallbladder = risk factor
• Most common site: fundus
• Spread: direct to liver (most common)

• HCC: Associated with cirrhosis, HBV, HCV; AFP raised; arterial enhancement + washout on CT
• Hepatic hemangioma: Most common benign tumor; "fill-in" on delayed CT
• FNH: Central scar on imaging; no malignant potential

• Most common cause worldwide: Gallstones; in India: alcohol
• Ranson criteria (at admission): Age >55, WBC >16,000, glucose >200, LDH >350, AST >250
• At 48 hrs: Hematocrit fall >10%, BUN rise >5, Ca <8 mg/dL, PaO2 <60, base deficit >4, fluid sequestration >6L
• Modified Glasgow (BISAP) also used
• Pseudocyst: collection of pancreatic juice - treat if symptomatic (>6 weeks)
• Necrotizing pancreatitis: most feared complication; infected necrosis = surgery/drainage

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GIT SURGERY

• McBurney's point: 1/3rd from ASIS on line to umbilicus
• Rovsing's sign: RIF pain on pressing LIF
• Psoas sign: pain on extending right thigh (retrocecal appendix)
• Obturator sign: pain on internal rotation of flexed right thigh (pelvic appendix)
• Alvarado score: >7 = appendicitis likely
• Treatment: Laparoscopic appendicectomy

• Right-sided colon: bleeding + anemia + weight loss (no obstruction early)
• Left-sided colon: obstruction + change in bowel habits + "apple-core" on barium enema
• Staging (Duke's/TNM): T staging determines surgical approach
• Screening: Colonoscopy at 50 years (average risk)
• FAP: APC gene mutation, >100 polyps, 100% malignancy risk, prophylactic colectomy
• HNPCC (Lynch syndrome): MLH1, MSH2 mutation; right-sided colon Ca; most common hereditary CRC

• Duodenal ulcer (DU): H. pylori >90%; pain relieved by food (night pain); more common
• Gastric ulcer (GU): NSAIDs, H. pylori; pain worsened by food
• Complications: Bleeding (most common), perforation, obstruction
• Perforation: Air under diaphragm on X-ray; emergency laparotomy
• Triple therapy: PPI + Amoxicillin + Clarithromycin

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BARIATRIC SURGERY (Recent Favorite)

• BMI ≥40 kg/m²
• BMI ≥35 kg/m² with obesity-related comorbidities (T2DM, HTN, OSA, etc.)
• BMI ≥30 kg/m² with uncontrolled T2DM (metabolic surgery)

• Dumping syndrome (early/late)
• Nutritional deficiencies: Iron, B12, Folate, Vitamin D, Calcium
• Wernicke's encephalopathy (B1 deficiency)

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TRANSPLANT SURGERY (Recent Favorite)

• Induction: Basiliximab (anti-IL-2R) or Anti-thymocyte globulin
• Maintenance triple therapy: Tacrolimus + Mycophenolate mofetil + Prednisolone
• Cyclosporine: Nephrotoxicity, gingival hyperplasia, hirsutism
• Tacrolimus: More potent; neurotoxicity + nephrotoxicity; does NOT cause gingival hyperplasia

• Fixed dilated pupils
• Absent brainstem reflexes (corneal, gag, oculocephalic)
• Apnea test positive
• Two consultants, minimum 6 hours apart

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2. MICROBIOLOGY (20-22 Questions)

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MYCOLOGY (4-5 Questions)

• Yeast: unicellular (Candida, Cryptococcus)
• Mold: multicellular filamentous (Aspergillus, Mucor, Rhizopus)
• Dimorphic: yeast in body (37°C), mold in environment (25°C) - "Body heat makes them yeast"

• Coccidioides immitis
• Histoplasma capsulatum
• Blastomyces dermatitidis
• Sporothrix schenckii
• Malassezia furfur (partially)
• Paracoccidioides brasiliensis
• Penicillium marneffei

• Neutropenia → Aspergillus, Candida, Mucor
• HIV/AIDS → Cryptococcus, PCP, Candida
• Corticosteroids → Aspergillus, Mucor, Cryptococcus
• IV catheters → Candida
• DKA → Mucormycosis (Rhizopus)

• Amphotericin B: Gold standard for serious infections; binds ergosterol; nephrotoxicity
• Azoles (Fluconazole, Itraconazole, Voriconazole): Inhibit ergosterol synthesis (CYP450)
• Voriconazole: Drug of choice for invasive Aspergillus
• Caspofungin (Echinocandin): Inhibits beta-1,3 glucan synthesis; for Candida and Aspergillus
• Flucytosine: Used with Ampho-B for Cryptococcal meningitis
• Griseofulvin: Dermatophytes only; disrupts microtubule assembly

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PARASITOLOGY (4-5 Questions)

• Uncomplicated falciparum: Artemisinin Combination Therapy (ACT) - Artemether+Lumefantrine
• P. vivax/ovale: Chloroquine + Primaquine (to kill hypnozoites; check G6PD first)
• Severe malaria: IV Artesunate (drug of choice); IV Quinine if artesunate unavailable

• Entamoeba histolytica
• Cyst = infective form (4 nuclei); Trophozoite = pathogenic (has RBCs inside = pathognomonic)
• Flask-shaped ulcers in colon
• Amebic liver abscess: RUQ pain + fever + tender hepatomegaly; chocolate-brown "anchovy sauce" pus
• Diagnosis: Serology (best for liver abscess), microscopy for intestinal
• Treatment: Metronidazole + Lumefantrine (diloxanide furoate for cyst passers)

• Kala-azar (visceral): L. donovani; vector = Phlebotomus sandfly; fever, splenomegaly, pancytopenia
• LD bodies (amastigotes) in macrophages
• rK39 test: quick diagnostic
• Treatment: Liposomal Amphotericin B (first line in India now); Miltefosine (oral)
• PKDL (Post Kala-azar Dermal Leishmaniasis): after treatment, skin manifestations

• W. bancrofti: lymphedema, elephantiasis; microfilariae in blood at night (nocturnal periodicity)
• Treatment: DEC (Diethylcarbamazine) + Albendazole (MDA program in India)
• Microfilariae seen in thick blood film at midnight

• Definitive host: Cat; Oocysts in cat feces
• TORCH infection: causes congenital toxoplasmosis
• Triad: Chorioretinitis + Hydrocephalus + Intracranial calcifications
• Ring-enhancing lesions in HIV patients (CD4 <100)
• Treatment: Pyrimethamine + Sulfadiazine + Folinic acid

• Echinococcus granulosus
• Most common site: Liver (65%) > Lung (25%)
• Daughter cysts inside; hydatid sand (scolices + brood capsules)
• Casoni test (intradermal), IHA serology
• Treatment: PAIR (Puncture-Aspiration-Injection-Reaspiration) or surgery; ALBENDAZOLE pre-op
• Never aspirate without coverage (anaphylaxis risk)

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VIROLOGY (2-3 Questions)

• HBsAg: Active infection (appears first)
• Anti-HBs: Recovery/immunity after vaccination
• HBeAg: High infectivity, active replication
• Anti-HBc IgM: Acute infection marker
• Anti-HBc IgG: Past infection or current chronic
• Window period: HBsAg disappears, Anti-HBs not yet detectable - ONLY Anti-HBc IgM positive

• Retrovirus (ssRNA); infects CD4+ T cells, macrophages, dendritic cells
• CD4 <200 = AIDS-defining
• Diagnosis: ELISA (screening) → Western blot (confirmatory)
• Window period for ELISA: 3-4 weeks
• Treatment: cART (Tenofovir + Lamivudine + Efavirenz = first line in India)
• Opportunistic infections by CD4 count:
  • <500: Oral thrush, HSV
  • <200: PCP, Toxoplasma, Cryptosporidium
  • <100: Cryptococcus, CMV, MAC, Microsporidiosis

• Antigenic drift: minor changes in H/N antigens - causes epidemics
• Antigenic shift: major reassortment - causes pandemics
• H1N1 (Swine flu): treatment with Oseltamivir (Tamiflu)
• M2 inhibitors (Amantadine): only for Influenza A

• Rhabdovirus; transmitted by animal bite
• Negri bodies: eosinophilic inclusions in Purkinje cells (cerebellum) and hippocampus
• Incubation: 1-3 months
• Post-exposure: wound washing + HRIG (rabies immunoglobulin at bite site) + 4 doses vaccine
• Pre-exposure: 3 doses on days 0, 7, 21/28

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IMMUNOLOGY (2-3 Questions)

• Classical pathway: activated by IgG/IgM antibody-antigen complexes
• Alternative pathway: activated by bacterial cell walls (LPS)
• Lectin pathway: MBL binds mannose on pathogens
• C3b: opsonization
• C5a: chemotaxis + anaphylatoxin (most potent)
• C5b-C9: Membrane Attack Complex (MAC) - kills bacteria
• C1q deficiency → increased SLE risk
• C3 deficiency → recurrent pyogenic infections
• C5-C9 deficiency → recurrent Neisseria infections

• IL-1, IL-6, TNF-α: Pro-inflammatory, fever, acute phase response
• IL-2: T-cell proliferation
• IL-4, IL-5: IgE class switching; eosinophil activation (allergy/parasites)
• IL-10: Anti-inflammatory (produced by Treg)
• IL-12: Activates NK cells, promotes Th1 differentiation
• IFN-γ: Activates macrophages; Th1 response; anti-viral
• TGF-β: Anti-inflammatory; promotes Treg; fibrosis

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3. BIOCHEMISTRY (10-15 Questions)

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CARBOHYDRATE METABOLISM

• Location: Cytoplasm; occurs in ALL cells
• Net gain: 2 ATP + 2 NADH per glucose
• Rate-limiting enzyme: Phosphofructokinase-1 (PFK-1)
  • Activated by: AMP, ADP, Fructose-2,6-bisphosphate, Pi
  • Inhibited by: ATP, citrate, H+
• Other key enzymes: Hexokinase (inhibited by glucose-6-P), Pyruvate kinase

• Location: Mitochondrial matrix
• Starts with: Acetyl-CoA + Oxaloacetate → Citrate
• Rate-limiting enzyme: Isocitrate dehydrogenase
• Produces per turn: 3 NADH + 1 FADH2 + 1 GTP
• Substrate-level phosphorylation: Succinyl-CoA → Succinate

• Aerobic: Pyruvate → Acetyl-CoA (Pyruvate dehydrogenase complex; requires B1-thiamine)
• Anaerobic: Pyruvate → Lactate (LDH)
• Gluconeogenesis: Pyruvate → OAA → Glucose

• Occurs in: Liver (main), kidney cortex
• Precursors: Lactate, Alanine, Glycerol, Odd-chain fatty acids
• Key enzymes (bypass glycolysis): Pyruvate carboxylase, PEPCK, Fructose-1,6-bisphosphatase, Glucose-6-phosphatase
• Fructose-1,6-bisphosphatase deficiency → cannot do gluconeogenesis → hypoglycemia after fasting

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LIPID METABOLISM

• Location: Cytoplasm (liver, adipose)
• Key enzyme: Acetyl-CoA carboxylase (rate-limiting; activated by citrate, insulin; inhibited by fatty acyl-CoA, glucagon)
• Biotin required
• NADPH required (from HMP shunt)

• Location: Mitochondrial matrix
• Each cycle: 1 Acetyl-CoA + 1 FADH2 + 1 NADH
• Carnitine shuttle: transports long-chain fatty acids into mitochondria
• Carnitine deficiency → cannot oxidize long-chain FA → myopathy + hypoglycemia

• Location: Liver mitochondria (but liver CANNOT USE ketones!)
• Rate-limiting enzyme: HMG-CoA synthase
• Occurs when: fasting, DKA, starvation
• Ketone bodies: Acetoacetate, Beta-hydroxybutyrate (predominant in DKA), Acetone

• Rate-limiting enzyme: HMG-CoA reductase (inhibited by statins)
• Activated by: insulin, thyroxine
• Inhibited by: glucagon, statins, cholesterol

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UREA CYCLE

• Location: Liver (both mitochondria and cytosol)
• Purpose: Detoxify ammonia → urea
• Enzymes in order:
  1. Carbamoyl phosphate synthetase I (CPS-I) - mitochondria, rate-limiting; requires N-acetylglutamate as cofactor
  2. OTC (Ornithine transcarbamylase) - mitochondria; most common urea cycle defect; X-linked
  3. Argininosuccinate synthetase - cytosol
  4. Argininosuccinate lyase (ASL) - cytosol
  5. Arginase - cytosol; produces urea + ornithine

• All defects except OTC: Autosomal recessive; OTC = X-linked
• OTC deficiency = most common urea cycle defect
• Present at 1-4 days of life: refusal to feed, lethargy → coma
• Key lab: High ammonia + High glutamine; Elevated OROTIC ACID (in OTC deficiency)
• CPS-1 deficiency: High ammonia, NORMAL orotic acid (differentiates from OTC)
• Treatment: Low protein diet, sodium benzoate/phenylbutyrate (to excrete nitrogen), arginine supplementation, liver transplant (definitive)

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ELECTRON TRANSPORT CHAIN (ETC)

• Complex I: NADH dehydrogenase (NADH → ubiquinone; pumps 4H+)
• Complex II: Succinate dehydrogenase (FADH2 → ubiquinone; NO H+ pumping)
• Complex III: Cytochrome bc1 complex (ubiquinol → cyt c; pumps 4H+)
• Complex IV: Cytochrome c oxidase (cyt c → O2; pumps 4H+)
• Complex V: ATP synthase (uses H+ gradient to make ATP)

• 1 NADH = ~2.5 ATP; 1 FADH2 = ~1.5 ATP
• Total from glucose: ~30-32 ATP

• 2,4-Dinitrophenol (DNP) - used illegally for weight loss
• Thermogenin (UCP-1): In brown adipose tissue (BAT); for non-shivering thermogenesis in newborns

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VITAMINS

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PROTEIN METABOLISM

• Essential (not synthesized): PVT TIM HALL (Phe, Val, Thr, Trp, Ile, Met, His, Arg*, Lys, Leu)
• Glucogenic: can be converted to glucose
• Ketogenic only: Leucine, Lysine
• Both: Phe, Tyr, Trp, Ile

• Phenylalanine hydroxylase deficiency
• Phenylalanine accumulates → Phenylacetate, Phenyllactate, Phenylpyruvate in urine
• Features: Musty odor, intellectual disability, fair skin/hair (reduced melanin), eczema
• Treatment: Low phenylalanine diet; avoid aspartame

• Cystathionine beta-synthase deficiency (most common) or B12/Folate deficiency
• Features: Marfanoid habitus, lens dislocation (DOWNWARD, unlike Marfan - upward), intellectual disability, thromboembolism
• Treatment: B6 (if responsive), low methionine diet

• Homogentisate oxidase deficiency
• Ochronosis: dark pigmentation of cartilage/sclerae
• Dark urine on standing
• Ochronotic arthropathy

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4. OBSTETRICS & GYNECOLOGY (25-30 Questions)

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PLACENTA PREVIA

• Placenta previa = covers internal os
• Low-lying placenta = edge within 20 mm but not covering os
• Normal = placental edge >20 mm from internal os

• Painless, bright red vaginal bleeding (hallmark) - usually at 28-32 weeks
• Soft, non-tender uterus
• Abnormal fetal lie (20% have malpresentation)
• No warning sign - bleeding can be sudden and severe

• Stable + preterm: Conservative - hospitalize, steroids for lung maturity, blood transfusion if needed
• Major hemorrhage / term: Cesarean section (method of delivery)
• Placenta accreta must be excluded (risk with prior CS + placenta previa)

• Accreta: Placenta attaches to myometrium (no decidua basalis)
• Increta: Invades into myometrium
• Percreta: Penetrates through myometrium (may invade bladder)
• Risk: #1 cause of peripartum hysterectomy

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HYDATIDIFORM MOLE

• Vaginal bleeding (most common)
• Uterus large for dates
• Hyperemesis gravidarum
• Pre-eclampsia <20 weeks (pathognomonic of mole)
• Hyperthyroidism (hCG cross-reacts with TSH receptors)

• Suction evacuation (method of choice)
• Oxytocin after suction starts
• Follow-up with serial hCG levels (should return to normal in 8 weeks for partial, 12 weeks for complete)
• Contraception for at least 6 months (OCP preferred - does not affect hCG levels)

• Includes: Invasive mole, Choriocarcinoma, PSTT, ETT
• Diagnosed by: Rising/plateauing hCG after mole evacuation
• Choriocarcinoma: Highly vascular; hematogenous spread to lung ("cannonball" metastases); extremely chemosensitive
• Treatment: Methotrexate (low risk); EMA-CO regimen (high risk)

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PREECLAMPSIA & ECLAMPSIA

• Proteinuria ≥300 mg/24 hrs
• Thrombocytopenia <100,000
• Renal insufficiency (Creatinine >1.1)
• Impaired liver function (LFTs doubled)
• Pulmonary edema
• New-onset headache or visual disturbances

• BP ≥160/110 mmHg
• Platelets <100,000
• Creatinine >1.1
• LFTs >2x normal
• Severe headache, visual changes
• Pulmonary edema

• H = Hemolysis (microangiopathic)
• EL = Elevated Liver enzymes
• LP = Low Platelets
• Can occur WITHOUT hypertension/proteinuria
• LDH >600, AST/ALT elevated, platelets <100,000
• Management: Delivery (definitive)

• Treatment of acute convulsions: MgSO4 (Pritchard regimen: 4g IV loading + 1g/hr maintenance)
• Anti-seizure: MgSO4 (not diazepam)
• Antihypertensive: Hydralazine (IV), Labetalol (IV), Nifedipine (oral) for acute BP control
• Antidote for MgSO4 toxicity: Calcium gluconate (10 mL of 10% IV)
• Monitor: patellar reflexes (first lost in toxicity), respiratory rate, urine output

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DIABETES IN PREGNANCY (GDM)

• 24-28 weeks with 75g OGTT (WHO criteria)
• Diagnosis: Fasting ≥92 mg/dL, 1-hr ≥180 mg/dL, 2-hr ≥153 mg/dL

• Macrosomia (most common) → Shoulder dystocia
• Congenital malformations (most important in pre-gestational DM, especially cardiac and neural tube)
• Neonatal hypoglycemia (baby is hyperinsulinemic - maternal hyperglycemia → fetal hyperinsulinemia → after birth, glucose supply cut → hypoglycemia)
• Respiratory distress syndrome (insulin inhibits surfactant synthesis)
• Polycythemia, hypocalcemia, hyperbilirubinemia

• Diet control first; if not adequate → Insulin (safest in pregnancy)
• Metformin and Glibenclamide used in some centers
• Target: Fasting <95, 1-hr postprandial <140, 2-hr postprandial <120

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ANEMIA IN PREGNANCY

• Hypochromic microcytic anemia
• Serum ferritin = most sensitive marker (decreases first)
• Treatment: Ferrous sulfate 200 mg TDS; IV iron if severe or non-compliance

• Most common cause: Folate deficiency (folate requirement doubles in pregnancy)
• B12 deficiency: Also causes megaloblastic + subacute combined degeneration
• Folate supplementation: 400 mcg/day pre-conception + first trimester; 5 mg/day if high-risk

• Increased risk of crisis, infections, maternal mortality
• Hydroxyurea contraindicated in pregnancy
• Folic acid + vaccinations + prophylactic transfusions in severe disease

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CONTRACEPTION

• Combined OCP: Estrogen + Progesterone; inhibits ovulation (most effective mechanism)
• Progesterone-only pill (Mini-pill): Thickens cervical mucus; suitable for breastfeeding
• Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera): 3-monthly injection; causes amenorrhea
• Emergency contraception: Levonorgestrel 1.5 mg within 72 hours; Cu-IUD within 5 days

• Copper IUD: Non-hormonal; spermicidal; lasts 10 years; DOC for emergency contraception
• Levonorgestrel IUD (Mirena): Hormonal; reduces menorrhagia; lasts 5 years

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UTEROVAGINAL PROLAPSE

• 1st degree: Cervix within vagina
• 2nd degree: Cervix at introitus
• 3rd degree (Procidentia): Entire uterus outside vagina

• Cardinal (Mackenrodt's) ligaments: Most important for cervical support
• Uterosacral ligaments
• Pubocervical fascia (anterior wall/cystocele)
• Rectovaginal fascia (posterior wall/rectocele)

• Conservative: Pelvic floor exercises (Kegel), ring pessary (for unfit patients)
• Surgical: Vaginal hysterectomy + repair (gold standard for most); Manchester operation (amputation of cervix + repair; fertility preserving)

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5. PSM - PREVENTIVE & SOCIAL MEDICINE (20+ Questions)

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NATIONAL HEALTH PROGRAMS

• Birth: BCG + OPV0 + Hepatitis B (birth dose)
• 6 weeks: OPV1 + DPT1 + HepB2 + IPV1 + PCV1 + Rotavirus1
• 10 weeks: OPV2 + DPT2 + PCV2 + Rotavirus2
• 14 weeks: OPV3 + DPT3 + IPV2 + PCV3 + Rotavirus3
• 9 months: Measles/MR1 + Vitamin A (1st dose)
• 16-24 months: DPT booster1 + OPV booster + MR2 + Vitamin A (2nd dose)

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NUTRITION

• Night blindness (first symptom)
• Bitot's spots: Triangular, foamy, silver-gray spots on conjunctiva
• Xerophthalmia → Keratomalacia (corneal melting = irreversible blindness)
• Prophylaxis: 200,000 IU at 9 months, 16-24 months, then 6 monthly till 5 years

• Goiter (most common sign), cretinism (most serious effect)
• Iodized salt: ≥15 ppm at consumer level
• Universal Salt Iodization (USI) policy in India

• Anemia (most common nutritional deficiency worldwide)
• NNMB surveys in India: Most common deficiency
• Weekly Iron and Folic Acid Supplementation (WIFS): School-age children and adolescents

• Excess fluoride (>1.5 ppm): Dental fluorosis → Skeletal fluorosis
• Deficiency (<0.5 ppm): Dental caries

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EPIDEMIOLOGY

• Incidence rate = New cases / Population at risk / Time
• Prevalence = All existing cases / Total population
• Attack rate = Cases / Those exposed (used in outbreak investigation)
• CFR = Deaths / Cases × 100

• Relative Risk (RR): Used in cohort studies; RR >1 = increased risk
• Odds Ratio (OR): Used in case-control; approximates RR when disease is rare
• Attributable risk (AR) = Risk in exposed - Risk in unexposed

• Sensitivity used when: disease is serious and must not be missed (e.g., HIV ELISA for screening)
• Specificity used when: false positives are costly/dangerous (e.g., confirmatory test)
• High sensitivity → low false negatives → used for screening
• High specificity → low false positives → used for confirmation (Western blot)
• Wilson's criteria for screening: Disease must be common, important, detectable at preclinical stage, effective treatment available, acceptable test

• Selection bias: Berkson's bias (hospital studies), Neyman (late-look) bias
• Information bias: Observer bias, recall bias, Hawthorne effect
• Confounding: third variable distorts association; controlled by randomization, matching, restriction

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BIOMEDICAL WASTE MANAGEMENT

• Common Bio-Medical Waste Treatment Facility (CBWTF) = facility authorized to treat BMW
• Healthcare facilities must have BMW management plan
• Bar-coded bags required
• Segregation at source = most important step
• Needle-stick injury rate = important occupational hazard; post-exposure prophylaxis (PEP) within 72 hours for HIV

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DISASTER MANAGEMENT

• Natural: Earthquake, floods, cyclone, drought, tsunami
• Man-made: Industrial accidents, nuclear, biological, chemical (CBRN)

1. Mitigation → 2. Preparedness → 3. Response → 4. Recovery

• Triage systems: START (Simple Triage And Rapid Treatment) - used in mass casualty
  • Red (Immediate): Life-threatening but salvageable
  • Yellow (Delayed): Serious but stable
  • Green (Minor): "Walking wounded"
  • Black (Expectant): Dead or unsurvivable injury

• National Disaster Management Act 2005
• National Disaster Management Authority (NDMA) - Chairman = Prime Minister
• State level: SDMA; District level: DDMA
• National Policy on Disaster Management 2009

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QUICK REVISION TABLE - HIGH-YIELD MNEMONICS

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STUDY STRATEGY RECAP

1. Surgery (30-32 Qs): Start with Trauma and GIT. Integrate with radiology (CT abdomen, X-rays of obstruction, perforation). Do maximum MCQs. Recent exams = Bariatric + Transplant.
2. Microbiology (20-22 Qs): Prioritize Mycology (dimorphic fungi, Candida, Aspergillus, Mucor) and Parasitology (malaria, Entamoeba, Plasmodium). Immunology = Hypersensitivity + immunodeficiency.
3. Biochemistry (10-15 Qs): Master Carbohydrate metabolism (glycolysis, TCA, GSD), Urea cycle (especially OTC deficiency), ETC inhibitors, and Vitamins table.
4. OBG (25-30 Qs): Obstetrics > Gynecology. Focus on Placenta Previa, Mole, Preeclampsia/HELLP, GDM. Know HELLP criteria cold.
5. PSM (20+ Qs): National programs (UIP schedule, RNTCP/NTP, RBSK), Epidemiology (study designs, sensitivity/specificity), BMW rules (color coding), and Nutrition (Kwashiorkor vs Marasmus).

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What You Got - Summary

1. Surgery (30-32 Qs)

• Trauma: ATLS, shock classification table, burns (Parkland formula, Rule of 9s)
• Hernia: Types with boundaries, Hesselbach's triangle, complications, surgical repairs
• GU System: Renal trauma grading, BPH vs prostate cancer zones, bladder + testicular cancer
• Arteries & Veins: Buerger's, DVT (Virchow's triad), varicose veins, AAA
• Hepatobiliary: Gallstones, Courvoisier's law, HCC markers, pancreatitis (Ranson criteria)
• GIT: Appendicitis signs, colorectal cancer (FAP/HNPCC genes), peptic ulcer
• Bariatric: BMI criteria, procedure types + mechanisms
• Transplant: Rejection types (timing + mechanism), immunosuppression drugs, brain death criteria

2. Microbiology (20-22 Qs)

• Mycology: Dimorphic fungi rule, Candida/Aspergillus/Mucor/Crypto identification, antifungals
• Parasitology: Malaria (complete species comparison table), Amoebiasis, Leishmaniasis, Filariasis, Tapeworms, Toxoplasma
• Virology: Hepatitis serology window period, HIV CD4 thresholds, Herpes viruses, Rabies
• Immunology: Hypersensitivity types I-IV, complement cascade, immunoglobulins, cytokines, primary immunodeficiencies

3. Biochemistry (10-15 Qs)

• Carbohydrate Metabolism: Glycolysis, TCA, gluconeogenesis, Glycogen Storage Diseases table
• Lipid Metabolism: FA synthesis, beta-oxidation, ketogenesis, cholesterol, lipoproteins
• Urea Cycle: All 5 enzymes in order, OTC deficiency (X-linked + orotic acid marker)
• ETC: All 5 complexes, inhibitors per complex, uncouplers
• Vitamins: Both fat-soluble and water-soluble - complete table with deficiency diseases

4. OBG (25-30 Qs)

• Placenta Previa (modern classification, management)
• Hydatidiform Mole (complete vs partial - complete comparison table)
• Preeclampsia/Eclampsia/HELLP (pathogenesis, MgSO4 protocol)
• GDM (OGTT criteria, fetal complications)
• Anemia in Pregnancy (iron, folate, B12)
• Contraception + Uterovaginal Prolapse

5. PSM (20+ Qs)

• National Health Programs + UIP schedule
• Nutrition (Kwashiorkor vs Marasmus, Vitamin A, Iodine)
• Epidemiology (study designs, sensitivity/specificity, bias types)
• Biomedical Waste (color-coded categories)
• Disaster Management (triage, NDMA)