python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: print(f"Total pages: {len(pdf.pages)}") # First read all pages to understand structure for i, page in enumerate(pdf.pages): text = page.extract_text() if text: print(f"\n=== PAGE {i+1} ===") print(text[:3000]) if i >= 5: print("\n... [truncated for preview] ...") break EOF

python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: total = len(pdf.pages) # Extract pages 14 onwards (Paper 2 content + assessment sections) # First find Paper 2 table of contents area (pages 14-30 approx) full_text = "" for i in range(13, 30): # pages 14-30 page = pdf.pages[i] text = page.extract_text() if text: full_text += f"\n=== PAGE {i+1} ===\n" + text print(full_text) EOF

python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: total = len(pdf.pages) # Get question paper pattern pages (around pages 240-258) full_text = "" for i in range(239, total): page = pdf.pages[i] text = page.extract_text() if text: full_text += f"\n=== PAGE {i+1} ===\n" + text print(full_text) EOF

python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: # Paper 2 learning objectives start around page 120 (index says page 120) # Let's find the start for i in range(118, 135): page = pdf.pages[i] text = page.extract_text() if text and ("Paper 2" in text or "Bhagna" in text or "Topic 27" in text or "27" in text): print(f"\n=== PAGE {i+1} ===") print(text[:2000]) EOF

python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: # Get more Paper 2 learning objectives - topics 36-54 # These are around pages 160-230 of PDF full_text = "" for i in range(155, 235): page = pdf.pages[i] text = page.extract_text() if text and ("MK" in text or "DK" in text): # Only include lines with MK markers to identify must-know topics lines = text.split('\n') mk_lines = [l for l in lines if 'MK' in l or 'Topic' in l or 'CO' in l] if mk_lines: full_text += f"\n=== PAGE {i+1} ===\n" + '\n'.join(mk_lines[:20]) print(full_text[:8000]) EOF

python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/9cef927e-6c75-41e3-bdc2-c04c1fef4813/3.-NCISM_IIIBAMS_AyUG-ST.pdf" with pdfplumber.open(pdf_path) as pdf: # Get topics 42-54 MK content (pages 175-230) full_text = "" for i in range(173, 232): page = pdf.pages[i] text = page.extract_text() if text and ("MK" in text or "Topic" in text): lines = text.split('\n') relevant = [l for l in lines if 'MK' in l or 'Topic' in l or 'DK' in l] if relevant: full_text += f"\n=== PAGE {i+1} (Topic info) ===\n" + '\n'.join(relevant[:15]) print(full_text[:8000]) EOF

mkdir -p /tmp/workspace/shalya-paper2 && ls /tmp/workspace/shalya-paper2/

cat << 'PYEOF' > /tmp/workspace/shalya-paper2/generate_answers.py from docx import Document from docx.shared import Pt, Inches, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement doc = Document() # ── Page margins from docx.shared import Cm section = doc.sections[0] section.top_margin = Cm(2) section.bottom_margin = Cm(2) section.left_margin = Cm(2.5) section.right_margin = Cm(2.5) # ── Default style style = doc.styles['Normal'] style.font.name = 'Times New Roman' style.font.size = Pt(11) def heading1(doc, text): p = doc.add_heading(text, level=1) p.runs[0].font.color.rgb = RGBColor(0x1A, 0x1A, 0x8C) p.runs[0].font.size = Pt(14) return p def heading2(doc, text): p = doc.add_heading(text, level=2) p.runs[0].font.color.rgb = RGBColor(0xB0, 0x30, 0x00) p.runs[0].font.size = Pt(12) return p def heading3(doc, text): p = doc.add_heading(text, level=3) p.runs[0].font.color.rgb = RGBColor(0x00, 0x60, 0x00) p.runs[0].font.size = Pt(11) return p def bold_para(doc, text): p = doc.add_paragraph() run = p.add_run(text) run.bold = True run.font.size = Pt(11) return p def normal_para(doc, text): p = doc.add_paragraph(text) p.paragraph_format.space_after = Pt(4) return p def bullet(doc, text, bold_part=None): p = doc.add_paragraph(style='List Bullet') if bold_part: run1 = p.add_run(bold_part) run1.bold = True p.add_run(text) else: p.add_run(text) return p def add_table(doc, headers, rows): table = doc.add_table(rows=1+len(rows), cols=len(headers)) table.style = 'Table Grid' # header row hdr = table.rows[0].cells for i, h in enumerate(headers): hdr[i].text = h for para in hdr[i].paragraphs: for run in para.runs: run.bold = True run.font.size = Pt(10) for r_idx, row_data in enumerate(rows): row = table.rows[r_idx+1].cells for c_idx, val in enumerate(row_data): row[c_idx].text = val for para in row[c_idx].paragraphs: for run in para.runs: run.font.size = Pt(10) return table def marks_box(doc, marks_text): p = doc.add_paragraph() run = p.add_run(f' [{marks_text}] ') run.bold = True run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) # can't easily do background in python-docx simply; use bold bracketed text p.alignment = WD_ALIGN_PARAGRAPH.RIGHT # ════════════════════════════════════════════ # TITLE PAGE # ════════════════════════════════════════════ title = doc.add_paragraph() title.alignment = WD_ALIGN_PARAGRAPH.CENTER run = title.add_run('MODEL ANSWER SHEET') run.bold = True run.font.size = Pt(18) run.font.color.rgb = RGBColor(0x1A, 0x1A, 0x8C) doc.add_paragraph() sub = doc.add_paragraph() sub.alignment = WD_ALIGN_PARAGRAPH.CENTER run2 = sub.add_run('III Professional BAMS Examination\nSHALYA TANTRA — PAPER II\nShalya Tantra Chikitsa Siddhanta\nSubject Code: AYUG-ST') run2.font.size = Pt(12) run2.bold = True doc.add_paragraph() info = doc.add_paragraph() info.alignment = WD_ALIGN_PARAGRAPH.CENTER info.add_run('Total Marks: 100 | Time: 3 Hours\nSAQ: 8 × 5 = 40 Marks | LAQ: 4 × 10 = 40 Marks | MCQ: 20 × 1 = 20 Marks') doc.add_page_break() # ════════════════════════════════════════════ # SECTION B — SAQs # ════════════════════════════════════════════ heading1(doc, 'SECTION B — SHORT ANSWER QUESTIONS (SAQ)') normal_para(doc, 'Each question carries 5 marks. Attempt ALL 8 questions.') doc.add_paragraph() # ─── SAQ 1 ─── heading2(doc, 'SAQ 1: Bhagandara (Fistula-in-Ano) — Nidana, Prakara, Chikitsa with Kshara Sutra [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Bhagandara is defined as a fistulous tract connecting the anorectal canal with the perianal skin. The word "Bhagandara" means a condition causing distress (darana) in the perineal region (bhaga). It is one of the Ashta Mahagada (eight dreadful diseases) described by Sushruta.') bold_para(doc, '1. NIDANA (Etiopathogenesis)') bullet(doc, 'Intake of Vidahi (irritant), Ruksha (dry), and Guru (heavy) Ahara', '') bullet(doc, 'Excessive sitting on hard surfaces, horse-riding, cycling', '') bullet(doc, 'Untreated or recurrent Guda Vidradhi (anorectal abscess)', '') bullet(doc, 'Trauma to perineal region', '') bullet(doc, 'Modern: Crohn\'s disease, tuberculosis, trauma, post-surgical', '') normal_para(doc, 'Samprapti: Vitiated Vata, Pitta, and Kapha cause Shotha (inflammation) → Pakva (suppuration) → Drana (drainage) → formation of Nadi Vrana (sinus/fistulous tract).') bold_para(doc, '2. PRAKARA (Classification)') normal_para(doc, 'Sushruta classified Bhagandara into 5 types:') rows = [ ['1','Shataponaka','Vataja — multiple opening, star-shaped'], ['2','Ushtragreeva','Pittaja — camel-neck shaped, yellowish discharge'], ['3','Parisravi','Kaphaja — discharging sinus, itching'], ['4','Shambukavarta','Tridoshaja — spiral/snail-shaped, most severe'], ['5','Unmargi','Agantuja (traumatic) — irregular course'], ] add_table(doc, ['No.','Ayurvedic Type','Features'], rows) doc.add_paragraph() normal_para(doc, 'Parks Classification (Modern):') bullet(doc, 'Intersphincteric (most common — 70%)', '') bullet(doc, 'Transsphincteric', '') bullet(doc, 'Suprasphincteric', '') bullet(doc, 'Extrasphincteric (most complex)', '') bold_para(doc, '3. LAKSHANA (Clinical Features)') bullet(doc, 'Persistent purulent/blood-stained discharge from perianal opening', '') bullet(doc, 'Intermittent swelling and pain (due to blockage of tract)', '') bullet(doc, 'Palpable indurated cord-like tract', '') bullet(doc, 'Internal opening identifiable on proctoscopy', '') bullet(doc, 'Goodsall\'s Rule: Posterior external openings → curved tract → posterior midline; Anterior → straight tract', '') bold_para(doc, '4. CHIKITSA (Management)') normal_para(doc, 'A. Ayurvedic — Kshara Sutra Therapy (Gold Standard):') bullet(doc, 'A medicated thread prepared with Apamarga Kshara (alkaline), Haridra powder, and Snuhi latex', '') bullet(doc, 'Inserted through the entire fistulous tract under LA/SA', '') bullet(doc, 'Changed every 7 days; cuts through tissue by chemical action + mechanical pressure', '') bullet(doc, 'Advantages: No incontinence, no recurrence (5%), OPD procedure, minimal blood loss', '') bullet(doc, 'Sutras of Sushruta: "Ksharasutram hi shastranam param" — Kshara Sutra is superior to all surgical instruments', '') normal_para(doc, 'B. Modern Surgical Options:') bullet(doc, 'Fistulotomy (lay-open technique) — for low fistulas', '') bullet(doc, 'Fistulectomy — excision of entire tract', '') bullet(doc, 'Seton placement — for high/complex fistulas', '') bullet(doc, 'LIFT procedure (Ligation of Intersphincteric Fistula Tract)', '') bullet(doc, 'Advancement flap repair — for suprasphincteric fistulas', '') doc.add_paragraph() # ─── SAQ 2 ─── heading2(doc, 'SAQ 2: Acute Pancreatitis (Agnyashaya Shotha) — Etiopathogenesis, Clinical Features, Management [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Acute Pancreatitis is an acute inflammatory condition of the pancreas characterized by autodigestion of the gland by its own activated enzymes, causing varying degrees of pancreatic edema, fat necrosis, and hemorrhage.') bold_para(doc, '1. ETIOPATHOGENESIS') normal_para(doc, 'Common Causes (GET SMASHED Mnemonic):') bullet(doc, 'G — Gallstones (most common in India, 40–60%)', '') bullet(doc, 'E — Ethanol/Alcohol (second most common, 30%)', '') bullet(doc, 'T — Trauma', '') bullet(doc, 'S — Steroids, Scorpion sting', '') bullet(doc, 'M — Mumps, Malignancy', '') bullet(doc, 'A — Autoimmune, Anatomical (pancreas divisum)', '') bullet(doc, 'S — ERCP (post-procedural)', '') bullet(doc, 'H — Hyperlipidaemia, Hypercalcaemia', '') bullet(doc, 'E — Emboli', '') bullet(doc, 'D — Drugs (azathioprine, thiazides, tetracycline)', '') normal_para(doc, 'Pathophysiology: Acinar cell injury → premature activation of trypsinogen → trypsin activation → cascade activation of lipase, elastase, phospholipase A2 → pancreatic autodigestion, fat necrosis, hemorrhage, systemic SIRS.') bold_para(doc, '2. CLINICAL FEATURES') bullet(doc, 'Severe epigastric pain radiating to back (band-like), sudden onset', '') bullet(doc, 'Nausea, vomiting (does not relieve pain)', '') bullet(doc, 'Fever, tachycardia, hypotension (in severe cases)', '') bullet(doc, 'Tenderness and guarding in epigastrium', '') bullet(doc, 'Grey Turner\'s sign — flank ecchymosis (retroperitoneal hemorrhage)', '') bullet(doc, 'Cullen\'s sign — periumbilical ecchymosis', '') bullet(doc, 'Tetany (hypocalcaemia due to fat saponification)', '') bold_para(doc, '3. INVESTIGATIONS') bullet(doc, 'Serum amylase >3× normal (rises in 2–12 hrs, falls in 3–5 days)', '') bullet(doc, 'Serum lipase — more specific, rises later and stays elevated longer', '') bullet(doc, 'Serum calcium — reduced (bad prognosis)', '') bullet(doc, 'Blood glucose, WBC, LFT, serum triglycerides', '') bullet(doc, 'Ultrasound abdomen — gallstones, edematous pancreas', '') bullet(doc, 'CECT abdomen (gold standard for severity assessment — Balthazar grading)', '') bold_para(doc, '4. SEVERITY ASSESSMENT — Ranson\'s Criteria') normal_para(doc, 'On Admission: Age >55, WBC >16,000, Blood glucose >200, LDH >350, AST >250') normal_para(doc, 'Within 48 hrs: Fall in Hct >10%, Rise in BUN >5, Serum Ca <8, PaO2 <60, Base deficit >4, Fluid sequestration >6L') normal_para(doc, 'Score ≥3 = Severe pancreatitis. Score ≥6 = high mortality.') bold_para(doc, '5. MANAGEMENT') bullet(doc, 'Nil by mouth (bowel rest), NG tube aspiration if vomiting', '') bullet(doc, 'IV fluids — aggressive fluid resuscitation (Hartmann\'s solution preferred)', '') bullet(doc, 'Analgesia — pethidine (not morphine — causes sphincter of Oddi spasm)', '') bullet(doc, 'Antibiotics — if infected necrosis suspected (imipenem/meropenem)', '') bullet(doc, 'Nutritional support — enteral (nasojejunal tube) preferred over TPN', '') bullet(doc, 'ERCP + sphincterotomy — if gallstone pancreatitis with CBD obstruction', '') bullet(doc, 'Surgery — for infected necrosis (necrosectomy), abscess, pseudocyst', '') bold_para(doc, 'COMPLICATIONS') bullet(doc, 'Local: Pseudocyst (most common), abscess, necrosis, fistula, hemorrhage', '') bullet(doc, 'Systemic: ARDS, AKI, DIC, shock, hypocalcaemia, hyperglycaemia', '') doc.add_paragraph() # ─── SAQ 3 ─── heading2(doc, 'SAQ 3: Intestinal Obstruction (Baddhagudodar) — Clinical Features, Diagnosis, Management [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Intestinal obstruction is the interruption of the normal forward flow of intestinal contents. "Baddhagudodar" (baddha = obstructed, guda = intestine, udara = abdomen) is described in Sushruta Samhita as one of the types of Udara Roga.') bold_para(doc, '1. CAUSES / CLASSIFICATION') rows2 = [ ['Mechanical','Intraluminal','Gallstone ileus, bezoar, foreign body, meconium'], ['Mechanical','Intramural','Carcinoma colon, Crohn\'s, intussusception, stricture'], ['Mechanical','Extramural','Adhesions (most common), hernias, volvulus, compression'], ['Functional (Ileus)','—','Post-op, peritonitis, hypokalemia, mesenteric ischemia'], ] add_table(doc, ['Type','Subtype','Examples'], rows2) bold_para(doc, '2. CLINICAL FEATURES') normal_para(doc, 'The classic tetrad of intestinal obstruction:') bullet(doc, 'Colicky abdominal pain (intermittent, central)', '') bullet(doc, 'Vomiting (early in small bowel, late in large bowel; feculent in low obstruction)', '') bullet(doc, 'Absolute constipation (no flatus or feces — late sign)', '') bullet(doc, 'Abdominal distension (more in large bowel obstruction)', '') normal_para(doc, 'Signs: Visible peristalsis, high-pitched tinkling bowel sounds, tenderness, tympanic abdomen. In strangulation: fever, constant pain, peritoneal signs, shock.') bold_para(doc, '3. INVESTIGATIONS') bullet(doc, 'X-ray abdomen erect + supine: Multiple air-fluid levels, dilated bowel loops, "step-ladder" pattern', '') bullet(doc, 'CT abdomen: Gold standard — identifies site, cause, strangulation', '') bullet(doc, 'Barium enema: For large bowel obstruction (contrast study)', '') bullet(doc, 'Blood: CBC, electrolytes, urea, creatinine, ABG (metabolic alkalosis in high obstruction)', '') bold_para(doc, '4. MANAGEMENT') normal_para(doc, 'Non-surgical (initial resuscitation — "DRIP AND SUCK"):') bullet(doc, 'Drip — IV fluids (correct dehydration and electrolytes)', '') bullet(doc, 'Suck — NG tube aspiration (decompression)', '') bullet(doc, 'Catheter — monitor urine output', '') bullet(doc, 'Analgesia + antibiotics', '') normal_para(doc, 'Surgical Management:') bullet(doc, 'Adhesiolysis — for adhesive obstruction', '') bullet(doc, 'Resection and anastomosis — for gangrenous bowel, tumor', '') bullet(doc, 'Hartmann\'s procedure — for perforated left colon', '') bullet(doc, 'Decompressive stoma — caecostomy/colostomy if primary repair not possible', '') bold_para(doc, 'AYURVEDIC CONCEPT') normal_para(doc, 'Baddhagudodar: Vata gets obstructed in Gudashaya (large intestine) → causes Adhmana (distension), Shoola (pain), Vibandha (constipation). Chikitsa: Snehana, Swedana, Tikshna Shodhana, Basti (enema) — Niruha Basti is described as primary treatment.') doc.add_paragraph() # ─── SAQ 4 ─── heading2(doc, 'SAQ 4: Head Injury (Shirobhighata) — Classification, Clinical Features, GCS [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Shirobhighata (Shiro = head, abhighata = injury) refers to craniocerebral injuries. It encompasses scalp injuries, skull fractures, and brain injuries including concussion, contusion, laceration, and intracranial hemorrhages.') bold_para(doc, '1. CLASSIFICATION') normal_para(doc, 'A. Based on pathology:') bullet(doc, 'Primary injury — at moment of impact (concussion, contusion, laceration, DAI)', '') bullet(doc, 'Secondary injury — subsequent (hypoxia, hypotension, raised ICP, infection)', '') normal_para(doc, 'B. Types of Intracranial Hemorrhage:') rows3 = [ ['Extradural (EDH)','Middle meningeal artery rupture','Biconvex/lenticular hyperdense on CT, "lucid interval"'], ['Subdural (SDH)','Bridging vein rupture','Crescent-shaped hyperdense on CT, seen in elderly/alcoholics'], ['Subarachnoid (SAH)','Berry aneurysm rupture','"Thunderclap" headache, blood in cisterns on CT'], ['Intracerebral','Direct trauma, hypertension','Within brain parenchyma'], ] add_table(doc, ['Type','Common Cause','Key Feature'], rows3) bold_para(doc, '2. CLINICAL FEATURES') bullet(doc, 'Loss of consciousness, confusion, amnesia', '') bullet(doc, 'Headache, vomiting (raised ICP)', '') bullet(doc, 'Pupillary changes — blown pupil (herniation)', '') bullet(doc, 'Focal neurological deficits', '') bullet(doc, 'Battle\'s sign (mastoid ecchymosis), Raccoon eyes (periorbital ecchymosis) — base of skull fracture', '') bullet(doc, 'CSF rhinorrhoea/otorrhoea — base of skull fracture', '') bold_para(doc, '3. GLASGOW COMA SCALE (GCS)') rows4 = [ ['Eye Opening','4','Spontaneous'], ['','3','To voice'], ['','2','To pain'], ['','1','None'], ['Verbal Response','5','Oriented'], ['','4','Confused'], ['','3','Inappropriate words'], ['','2','Incomprehensible sounds'], ['','1','None'], ['Motor Response','6','Obeys commands'], ['','5','Localises pain'], ['','4','Withdraws'], ['','3','Abnormal flexion (decorticate)'], ['','2','Extension (decerebrate)'], ['','1','None'], ] add_table(doc, ['Parameter','Score','Response'], rows4) normal_para(doc, 'Maximum = 15 (Normal). Minimum = 3 (Deep coma).') normal_para(doc, 'Mild TBI: GCS 13–15 | Moderate TBI: GCS 9–12 | Severe TBI: GCS ≤8') bold_para(doc, '4. MANAGEMENT') bullet(doc, 'ABC resuscitation — airway, breathing, circulation', '') bullet(doc, 'CT head (no contrast) — investigation of choice', '') bullet(doc, 'Raised ICP: 30° head elevation, hyperventilation (target PaCO2 35mmHg), mannitol 20% IV, dexamethasone', '') bullet(doc, 'Surgery: Craniotomy + evacuation for EDH, large SDH, depressed skull fracture', '') bullet(doc, 'Monitoring: ICP monitoring, neurological observation charting', '') bold_para(doc, 'AYURVEDIC CONCEPT') normal_para(doc, 'Shirobhighata: Described in Sushruta Samhita as Sadya Pranahara Marma injury. Classified into Sadyovrana (immediate) and Kalaja (delayed). Management: Shiro Abhyanga, Nasya, Shirolepa with cooling herbs (Chandana, Yashtimadhuka), Shamanoushadhi for neurological symptoms.') doc.add_paragraph() # ─── SAQ 5 ─── heading2(doc, 'SAQ 5: Hydrocele (Mutravriddhi) — Types, Clinical Features, Management [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Hydrocele is an abnormal collection of serous fluid between the two layers of the tunica vaginalis. In Ayurveda, it is called "Mutravriddhi" — one of the seven types of Vriddhi Roga described by Sushruta in Nidana Sthana.') bold_para(doc, '1. TYPES OF HYDROCELE') rows5 = [ ['Vaginal','Most common in adults','Fluid in tunica vaginalis, not extending to cord'], ['Congenital','Infants/children','Patent processus vaginalis — communicates with peritoneum'], ['Encysted of cord','Any age','Fluid trapped in cord — non-communicating'], ['Infantile','Children','Extends to internal ring but no peritoneal communication'], ['Secondary (Symptomatic)','Any age','Due to torsion, orchitis, TB, trauma, filariasis, tumor'], ] add_table(doc, ['Type','Age Group','Feature'], rows5) bold_para(doc, '2. CLINICAL FEATURES') bullet(doc, 'Painless scrotal swelling — gradual onset', '') bullet(doc, 'Transilluminates brilliantly (pathognomonic)', '') bullet(doc, 'Cannot get above the swelling (scrotal origin)', '') bullet(doc, 'Smooth, fluctuant, non-tender (unless secondary)', '') bullet(doc, 'Testis palpated posteriorly and separately', '') bullet(doc, 'Congenital: swelling reduces on lying down (communicating)', '') bold_para(doc, '3. INVESTIGATIONS') bullet(doc, 'Ultrasound scrotum — confirms diagnosis, rules out testicular tumor (secondary hydrocele)', '') bullet(doc, 'Tumor markers (AFP, beta-hCG) — if secondary hydrocele suspected', '') bold_para(doc, '4. MANAGEMENT') normal_para(doc, 'A. Conservative: Small, asymptomatic hydroceles — observation only') normal_para(doc, 'B. Aspiration: Temporary; risk of recurrence and infection — not preferred') normal_para(doc, 'C. Surgical (definitive):') bullet(doc, 'Jaboulay\'s operation (eversion of sac) — for large vaginal hydrocele (most common)', '') bullet(doc, 'Lord\'s plication — for thin-walled hydrocele', '') bullet(doc, 'Herniotomy + ligation of processus — for congenital hydrocele in children', '') bold_para(doc, 'AYURVEDIC CHIKITSA') normal_para(doc, 'Mutravriddhi: Caused by vitiation of Vata and Kapha in Mushka (scrotum). Sushruta advocates Agnikarma (cauterization), Kshara Karma, and Shastra Karma (surgical drainage). Pathya: Light diet, avoidance of cold and heavy food. Shamana: Punarnavadi Kwatha, Varunadi Ghana.') doc.add_paragraph() # ─── SAQ 6 ─── heading2(doc, 'SAQ 6: Cholecystitis (Pittashaya Shotha) — Etiopathogenesis, Features, Management [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Cholecystitis is inflammation of the gallbladder. Acute cholecystitis usually results from cystic duct obstruction by a gallstone (calculous cholecystitis — 90%). Acalculous cholecystitis (10%) occurs in critically ill patients.') bold_para(doc, '1. ETIOPATHOGENESIS') bullet(doc, 'Cystic duct obstruction by gallstone → bile stasis → bacterial superinfection (E. coli, Klebsiella, Enterococcus)', '') bullet(doc, 'Chemical irritation from concentrated bile salts → mucosal inflammation → wall edema, empyema', '') bullet(doc, 'Acalculous: ICU patients, prolonged fasting, TPN, major surgery, trauma, burns', '') bold_para(doc, '2. CLINICAL FEATURES') normal_para(doc, 'Biliary colic: Sudden severe right hypochondrial pain → radiates to right shoulder/back → constant (unlike gallstone colic)') bullet(doc, 'Nausea, vomiting, fever (bacterial infection)', '') bullet(doc, 'Murphy\'s sign: Arrest of inspiration on deep palpation of right hypochondrium (94% sensitive)', '') bullet(doc, 'Boas\' sign: Hyperaesthesia below right scapula', '') bullet(doc, 'Palpable tender globular mass in RHC (empyema)', '') bullet(doc, 'Jaundice if CBD involved (Mirizzi syndrome)', '') bold_para(doc, '3. INVESTIGATIONS') bullet(doc, 'USG abdomen: Thickened gallbladder wall (>3.5mm), pericholecystic fluid, gallstones, positive sonographic Murphy\'s sign', '') bullet(doc, 'Blood: Leukocytosis, elevated CRP', '') bullet(doc, 'LFT: Mildly elevated bilirubin/ALP', '') bullet(doc, 'HIDA scan: If USS inconclusive (non-filling of GB = obstruction)', '') bullet(doc, 'MRCP/ERCP: If CBD stones suspected', '') bold_para(doc, '4. MANAGEMENT') normal_para(doc, 'Conservative (initial):') bullet(doc, 'IV fluids, bowel rest, NG tube if vomiting', '') bullet(doc, 'IV antibiotics: Co-amoxiclav/cephalosporin + metronidazole', '') bullet(doc, 'Analgesia: Diclofenac/pethidine (avoid morphine)', '') normal_para(doc, 'Definitive — Laparoscopic Cholecystectomy:') bullet(doc, 'Early (within 72 hrs of onset) — preferred; lower conversion rate, shorter hospital stay', '') bullet(doc, 'Delayed (6 weeks later) — if patient unfit for surgery', '') bullet(doc, 'Open cholecystectomy — if laparoscopic not possible', '') normal_para(doc, 'Complications: Empyema, gangrene, perforation, Mirizzi syndrome, cholecystoenteric fistula, gallstone ileus.') bold_para(doc, 'AYURVEDIC CONCEPT') normal_para(doc, '"Pittashaya Shotha" — Pitta Dosha vitiation causes inflammation of the Pittashaya (gallbladder). Treatment: Vamana, Virechana, Pittahara Aushadhi (Kutaki, Bhumi Amla, Punarnava). Arogyavardhini Vati is commonly used.') doc.add_paragraph() # ─── SAQ 7 ─── heading2(doc, 'SAQ 7: Udara Roga — Nidana, Prakara, Samprapti, Lakshana, Chikitsa (Ayurvedic) [5 Marks]') bold_para(doc, 'INTRODUCTION') normal_para(doc, 'Udara Roga is a group of diseases characterized by abnormal enlargement of the abdomen. Sushruta has described 8 types of Udara Roga in Nidana Sthana. It is caused by vitiation of all three Doshas with predominance of Vata and Kapha.') bold_para(doc, '1. NIDANA (Causes)') bullet(doc, 'Intake of Guru (heavy), Vidahi (irritant), Abhishyandi (channel-blocking) Ahara', '') bullet(doc, 'Excessive intake of Alcohol, Amla (sour) and Lavana (salt)', '') bullet(doc, 'Suppression of natural urges (Vegavarodha)', '') bullet(doc, 'Agni Dushti (impairment of digestive fire) → Ama formation', '') bullet(doc, 'Diseases of liver, spleen, intestines, kidney', '') bold_para(doc, '2. PRAKARA (8 Types by Sushruta)') rows6 = [ ['1','Vatodara','Gaseous distension, predominant Vata'], ['2','Pittodara','Inflammatory ascites, jaundice, fever'], ['3','Kaphodara','Cold, heavy, whitish fluid accumulation'], ['4','Sannipatodara','All three doshas, most severe'], ['5','Pleehodara','Splenomegaly-related ascites (Pleeha)'], ['6','Yakritodara','Hepatomegaly / liver disease'], ['7','Baddhagudodara','Intestinal obstruction'], ['8','Chidrodara','Perforation / hollow viscus injury'], ] add_table(doc, ['No.','Type','Description'], rows6) bold_para(doc, '3. SAMPRAPTI (Pathogenesis)') normal_para(doc, 'Nidana Sevana → Agni Dushti → Sama Dosha accumulation in Kostha → Dhamani Pratichaya (engorgement of vessels) → Udara Vridhi (abdominal distension) → fluid accumulation or obstruction depending on Dosha predominance.') bold_para(doc, '4. LAKSHANA (Clinical Features)') bullet(doc, 'Udara Shotha (abdominal distension)', '') bullet(doc, 'Adhmana (tympanites — gaseous distension)', '') bullet(doc, 'Agnimandya (loss of appetite, poor digestion)', '') bullet(doc, 'Vibandha (constipation) or Atisara (diarrhoea)', '') bullet(doc, 'Pindikodveshtana (muscle cramps)', '') bullet(doc, 'Shotha (edema) of face and limbs (in Jalodara/ascites)', '') bullet(doc, 'Trishna (thirst), Jwara (fever), Shwasa (breathlessness)', '') bold_para(doc, '5. CHIKITSA (Treatment)') normal_para(doc, 'Shodhana (Purification):') bullet(doc, 'Tikshna Vamana (therapeutic emesis) — for Kaphodara', '') bullet(doc, 'Tikshna Virechana (purgation) — for Pittodara', '') bullet(doc, 'Asthapana Basti (decoction enema) — for Vatodara', '') bullet(doc, 'Raktamokshana — if vascular engorgement', '') normal_para(doc, 'Shamana (Palliative) Drugs:') bullet(doc, 'Punarnavashtaka Kwatha, Rohitakarishta, Arogyavardhini Vati', '') bullet(doc, 'Shilajatu, Gomutra Haritaki for liver diseases', '') bullet(doc, 'Trikatu, Chitrakadi Vati for Agnidipana', '') normal_para(doc, 'Pathya (Diet): Light, easily digestible food; Yava (barley), Takra (buttermilk); avoid salt, heavy, and cold food.') doc.add_paragraph() # ─── SAQ 8 ─── heading2(doc, 'SAQ 8: Osteomyelitis (Asthi Vidradhi) — Etiopathogenesis, Clinical Features, Management [5 Marks]') bold_para(doc, 'DEFINITION') normal_para(doc, 'Osteomyelitis is infection of bone and bone marrow. In Ayurveda, it is described as "Asthi Vidradhi" — inflammation and suppuration of bone tissue caused by vitiation of Vata and Pitta Doshas involving Asthi and Majja Dhatu.') bold_para(doc, '1. CLASSIFICATION') rows7 = [ ['Haematogenous (most common)','Children','Long bones — distal femur, proximal tibia, proximal humerus'], ['Direct inoculation','Any age','Post-surgery, trauma, compound fracture'], ['Contiguous spread','Adults','From adjacent soft tissue infection'], ['Chronic osteomyelitis','Adults','Sequestrum and involucrum formation'], ] add_table(doc, ['Type','Age','Common Site'], rows7) bold_para(doc, '2. CAUSATIVE ORGANISMS') bullet(doc, 'Staphylococcus aureus — most common (80%)', '') bullet(doc, 'Streptococcus (neonates)', '') bullet(doc, 'Salmonella — in sickle cell disease', '') bullet(doc, 'Mycobacterium tuberculosis — in Asthi Kshaya', '') bullet(doc, 'Gram-negatives — in IV drug users, diabetics', '') bold_para(doc, '3. CLINICAL FEATURES') normal_para(doc, 'Acute Osteomyelitis:') bullet(doc, 'Sudden onset fever (high grade), malaise, toxemia', '') bullet(doc, 'Localized bone pain, tenderness, swelling, warmth', '') bullet(doc, 'Restricted movement of adjacent joint', '') bullet(doc, 'Pus formation → discharging sinus (if untreated)', '') normal_para(doc, 'Chronic Osteomyelitis:') bullet(doc, 'Persistent discharging sinus', '') bullet(doc, 'Sequestrum (necrotic bone) + Involucrum (new bone around sequestrum)', '') bullet(doc, 'Cloaca (opening through cortex) for pus drainage', '') bold_para(doc, '4. INVESTIGATIONS') bullet(doc, 'X-ray: Normal in first 10 days; later periosteal reaction, bone destruction', '') bullet(doc, 'MRI: Early diagnosis — detects bone marrow edema (investigation of choice for early diagnosis)', '') bullet(doc, 'Bone scan (Tc99m): Increased uptake', '') bullet(doc, 'CBC: Leukocytosis, raised ESR/CRP', '') bullet(doc, 'Blood culture + sensitivity (before antibiotics)', '') bullet(doc, 'Bone biopsy: Definitive — histopathology + culture', '') bold_para(doc, '5. MANAGEMENT') normal_para(doc, 'Medical:') bullet(doc, 'IV antibiotics (as per culture sensitivity) for 4–6 weeks — flucloxacillin/clindamycin for S. aureus', '') bullet(doc, 'Immobilization of limb (splint/traction)', '') bullet(doc, 'Analgesics, antipyretics, nutritional support', '') normal_para(doc, 'Surgical (if no response to antibiotics in 24–48 hrs):') bullet(doc, 'Drilling + drainage (sequestrectomy for chronic OM)', '') bullet(doc, 'Removal of sequestrum + curettage of cavity', '') bullet(doc, 'Saucerization (excision of cavity roof) + cancellous bone graft', '') bullet(doc, 'Papineau technique — open cancellous bone grafting for large defects', '') bold_para(doc, 'AYURVEDIC CONCEPT') normal_para(doc, 'Asthi Vidradhi: Pitta-Vata vitiation in Asthi and Majja Dhatu. Lakshana: Ativedana (severe pain), Shotha (swelling), Suptata (numbness), Paka (suppuration). Chikitsa: Tikta Ghrita (internal), Shashtika Shali Pinda Sweda (external), Kshira Basti, Ashwagandha Churna, Guduchi, Punarnavadi Kwatha.') doc.add_paragraph() # ════════════════════════════════════════════ # SECTION C — LAQs # ════════════════════════════════════════════ doc.add_page_break() heading1(doc, 'SECTION C — LONG ANSWER QUESTIONS (LAQ)') normal_para(doc, 'Each question carries 10 marks. Attempt ALL 4 questions.') doc.add_paragraph() # ─── LAQ 1 ─── heading2(doc, 'LAQ 1: Renal Calculus (Vrikka Ashmari / Nephrolithiasis) [10 Marks]') normal_para(doc, 'Describe etiopathogenesis, classification, clinical features, investigations, complications, and management. Add a note on ESWL and PCNL.') bold_para(doc, '1. DEFINITION AND AYURVEDIC CONCEPT [1 mark]') normal_para(doc, 'Renal calculus (kidney stone) is a crystalline solid that forms in the kidney from minerals and salts present in urine. In Ayurveda, it is described as "Vrikka Ashmari" — stones (Ashmari) in the kidney (Vrikka), caused by vitiation of all three Doshas with Kapha predominance. Sushruta describes four types of Ashmari: Vataja, Pittaja, Kaphaja, and Shukraja (semen calculus).') bold_para(doc, '2. ETIOPATHOGENESIS [2 marks]') normal_para(doc, 'A. Pathophysiology — CRYSTAL FORMATION involves:') bullet(doc, 'Supersaturation of urine with stone-forming salts', '') bullet(doc, 'Decreased inhibitors (citrate, magnesium, glycosaminoglycans)', '') bullet(doc, 'Nucleation → crystal aggregation → crystal growth → stone formation', '') normal_para(doc, 'B. Risk Factors:') bullet(doc, 'Low fluid intake (most common modifiable risk factor)', '') bullet(doc, 'Metabolic: Hypercalciuria (most common), hyperoxaluria, hyperuricosuria, hypocitraturia', '') bullet(doc, 'Dietary: High animal protein, high sodium, high oxalate (spinach, nuts)', '') bullet(doc, 'Anatomic: UPJ obstruction, horseshoe kidney, medullary sponge kidney', '') bullet(doc, 'Infections: Urease-producing organisms (Proteus, Klebsiella) → struvite stones', '') bullet(doc, 'Medications: Indinavir, topiramate, acetazolamide, excess vitamin D/C', '') bullet(doc, 'Systemic: Hyperparathyroidism, IBD, gout, RTA', '') bold_para(doc, '3. CLASSIFICATION OF RENAL CALCULI [2 marks]') rows8 = [ ['Calcium oxalate','Most common (75–80%)','Radiopaque, spiky, mulberry-shaped, hard'], ['Calcium phosphate','10–15%','Radiopaque, often mixed with oxalate'], ['Struvite (MgNH4PO4)','10–15%','Radiopaque, staghorn, infection-related'], ['Uric acid','5–10%','Radiolucent, associated with gout'], ['Cystine','1–3%','Faintly opaque, hexagonal crystals, hereditary'], ['Xanthine','Rare','Radiolucent'], ] add_table(doc, ['Type','Frequency','Features'], rows8) bold_para(doc, '4. CLINICAL FEATURES [1 mark]') bullet(doc, 'Renal colic: Sudden severe colicky loin-to-groin pain (classical presentation) — patient unable to lie still', '') bullet(doc, 'Haematuria (microscopic or macroscopic) — in 80% of cases', '') bullet(doc, 'Nausea, vomiting', '') bullet(doc, 'Dysuria, frequency, urgency (if stone in lower ureter/vesico-ureteric junction)', '') bullet(doc, 'Fever + rigors if associated infection (urological emergency)', '') bullet(doc, 'Signs: Renal angle tenderness (CVA tenderness), loin pain on palpation', '') bullet(doc, 'Silent stones: Staghorn calculus may be asymptomatic, presenting with recurrent UTI or renal failure', '') bold_para(doc, '5. INVESTIGATIONS [1 mark]') bullet(doc, 'NCCT KUB (Non-contrast CT KUB) — gold standard; detects all stones (including radiolucent), identifies size, location, obstruction', '') bullet(doc, 'USG KUB — first line; shows hydronephrosis, large stones; misses ureteric stones', '') bullet(doc, 'Plain X-ray KUB — 60–70% stones visible; misses uric acid/cystine stones', '') bullet(doc, 'IVU/IVP — historical; shows anatomy and function', '') bullet(doc, 'Urine analysis: Haematuria, pyuria, crystals, culture & sensitivity', '') bullet(doc, 'Serum: Calcium, uric acid, creatinine, urea, electrolytes', '') bullet(doc, 'Stone analysis — chemical composition after passage/surgery', '') bullet(doc, 'Metabolic workup — 24-hr urine: calcium, oxalate, citrate, uric acid (for recurrent stone formers)', '') bold_para(doc, '6. COMPLICATIONS [1 mark]') bullet(doc, 'Hydronephrosis (ureteric obstruction)', '') bullet(doc, 'Pyonephrosis — infected hydronephrosis (emergency)', '') bullet(doc, 'Pyelonephritis, urosepsis', '') bullet(doc, 'Chronic kidney disease (CKD) — bilateral or solitary kidney stones', '') bullet(doc, 'Perinephric abscess', '') bullet(doc, 'Anuria (bilateral stones or stone in solitary kidney)', '') bold_para(doc, '7. MANAGEMENT [2 marks]') normal_para(doc, 'A. Conservative Management:') bullet(doc, 'Stones <5 mm: High probability of spontaneous passage (~80%)', '') bullet(doc, 'Hydration: 2.5–3 litres/day urine output target', '') bullet(doc, 'Medical Expulsion Therapy (MET): Alpha-blockers (tamsulosin) increase ureteric stone passage rate', '') bullet(doc, 'Analgesia: NSAIDs (diclofenac preferred) — reduce ureteric spasm and renal pelvis pressure', '') normal_para(doc, 'B. ESWL (Extracorporeal Shock Wave Lithotripsy):') bullet(doc, 'Indications: Stones 5–20 mm in renal pelvis or upper ureter', '') bullet(doc, 'Principle: Focused shock waves fragmentize stone → fragments passed per urethra', '') bullet(doc, 'Contraindications: Pregnancy, bleeding disorders, distal obstruction, AAA, pacemaker', '') bullet(doc, 'Limitations: Hard stones (cystine, calcium oxalate monohydrate) — poor fragmentation', '') normal_para(doc, 'C. PCNL (Percutaneous Nephrolithotomy):') bullet(doc, 'Indications: Large stones >2 cm, staghorn calculus, failed ESWL, lower pole stones >1 cm', '') bullet(doc, 'Technique: Percutaneous access under fluoroscopic guidance through posterior calyx → nephroscope → ultrasonic/pneumatic lithotripsy → stone removal', '') bullet(doc, 'Advantages: Minimally invasive, high stone-free rate for large stones (>95%)', '') bullet(doc, 'Complications: Haemorrhage, adjacent organ injury, residual stones, infection', '') normal_para(doc, 'D. Ureteroscopy (URS) + Laser:') bullet(doc, 'Indications: Ureteric stones 5–15 mm, failed ESWL', '') bullet(doc, 'Holmium laser lithotripsy — gold standard for ureteric stones', '') normal_para(doc, 'E. Open Surgery (rare now):') bullet(doc, 'Nephrolithotomy, pyelolithotomy — for complex staghorn stones', '') bold_para(doc, 'AYURVEDIC MANAGEMENT') normal_para(doc, 'Vrikka Ashmari Chikitsa:') bullet(doc, 'Pashanabheda (Bergenia ligulata) — chief drug; lithotriptic action', '') bullet(doc, 'Varunadi Kwatha — promotes stone passage, diuretic', '') bullet(doc, 'Gokshuradi Guggulu — anti-inflammatory, relieves obstruction', '') bullet(doc, 'Cystone (Himalaya) — classical Ayurvedic formulation for urinary calculi', '') bullet(doc, 'Pathya: Barley water (Yava jala), coconut water, plenty of fluids', '') doc.add_paragraph() # ─── LAQ 2 ─── heading2(doc, 'LAQ 2: Peptic Ulcer (Parinama Shoola / Annadrava Shoola) [10 Marks]') normal_para(doc, 'Describe etiopathogenesis, classification, clinical features, diagnosis, complications, management including Ayurvedic concept.') bold_para(doc, '1. DEFINITION AND AYURVEDIC CONCEPT [1 mark]') normal_para(doc, 'Peptic ulcer disease (PUD) is a mucosal break in the stomach or duodenum ≥5 mm in size with depth to submucosa. It results from an imbalance between aggressive factors (acid, pepsin, H. pylori) and defensive factors (mucus, bicarbonate, prostaglandins).') normal_para(doc, 'Ayurvedic Correlation: "Parinama Shoola" — pain appearing after digestion of food (2–3 hrs after meals), corresponding to gastric ulcer. "Annadrava Shoola" — pain related to food intake, corresponding to peptic/duodenal ulcer. Caused by Pitta Prakopa in Aamashaya.') bold_para(doc, '2. ETIOPATHOGENESIS [2 marks]') normal_para(doc, 'A. Aggressive Factors:') bullet(doc, 'H. pylori infection — present in 90% of duodenal ulcers, 70% of gastric ulcers (most important cause)', '') bullet(doc, 'NSAIDs/Aspirin — inhibit COX-1 → reduce prostaglandin synthesis → decrease mucus and bicarbonate secretion', '') bullet(doc, 'Excess acid secretion — basal acid output elevated in duodenal ulcers', '') bullet(doc, 'Zollinger-Ellison Syndrome — gastrinoma causing massive hypersecretion', '') bullet(doc, 'Smoking, alcohol, stress, steroids', '') normal_para(doc, 'B. Defensive Factor Failure:') bullet(doc, 'Decreased mucus secretion, impaired bicarbonate secretion', '') bullet(doc, 'Reduced mucosal blood flow', '') bullet(doc, 'Delayed gastric emptying (in gastric ulcer)', '') bold_para(doc, '3. CLASSIFICATION [1 mark]') normal_para(doc, "Johnson's Classification of Gastric Ulcers:") rows9 = [ ['Type I','Lesser curvature at incisura','Normoacidic — most common (60%)'], ['Type II','Gastric + duodenal ulcer','Hyperacidic'], ['Type III','Prepyloric','Hyperacidic'], ['Type IV','High on lesser curvature near OGJ','Normoacidic/hypoacidic'], ['Type V','Anywhere (NSAID-induced)','Any acid level'], ] add_table(doc, ['Type','Site','Acid Secretion'], rows9) normal_para(doc, 'Duodenal Ulcer: 90% on anterior wall of first part of duodenum (D1)') bold_para(doc, '4. CLINICAL FEATURES [1 mark]') normal_para(doc, 'Duodenal Ulcer (DU):') bullet(doc, 'Burning/gnawing epigastric pain — 2–4 hours after meals (hunger pain)', '') bullet(doc, 'Pain RELIEVED by food, antacids', '') bullet(doc, 'Night pain (typical), periodicity (weeks of pain then remission)', '') bullet(doc, 'Nausea, waterbrash, heartburn', '') normal_para(doc, 'Gastric Ulcer (GU):') bullet(doc, 'Pain PRECIPITATED by food (30–60 min after meals)', '') bullet(doc, 'Weight loss (patients afraid to eat)', '') bullet(doc, 'Vomiting is more common', '') bullet(doc, 'Anorexia, anaemia', '') bold_para(doc, '5. INVESTIGATIONS [1 mark]') bullet(doc, 'Upper GI endoscopy (OGD) — gold standard; allows biopsy, H. pylori testing, CLO test', '') bullet(doc, 'H. pylori testing: CLO test (rapid urease), histology, urea breath test (UBT), stool antigen test', '') bullet(doc, 'Biopsy of gastric ulcer edges (rule out malignancy)', '') bullet(doc, 'Serum gastrin — if Zollinger-Ellison suspected (>1000 pg/mL diagnostic)', '') bullet(doc, 'Barium meal: Niche sign (ulcer crater), Hampton\'s line — now rarely used', '') bullet(doc, 'CBC, LFT, coagulation profile', '') bold_para(doc, '6. COMPLICATIONS AND MANAGEMENT [2 marks]') rows10 = [ ['Haemorrhage (most common)','Haematemesis, melaena','Endoscopic haemostasis (adrenaline injection, heater probe); PPIs IV; surgery if failed'], ['Perforation (2nd most common)','Sudden severe abdominal pain, board-like rigidity, pneumoperitoneum','Emergency surgery — Graham\'s omental patch closure; laparoscopic preferred'], ['Pyloric stenosis / Obstruction','Projectile vomiting, succussion splash, metabolic alkalosis','IV correction, NG suction, surgery — Heineke-Mikulicz pyloroplasty'], ['Malignant change','Weight loss, anorexia','Gastrectomy (Billroth I/II)'], ['Penetration','DU penetrates into pancreas — causes pain radiating to back','Medical management; surgery if refractory'], ] add_table(doc, ['Complication','Features','Management'], rows10) bold_para(doc, '7. MEDICAL MANAGEMENT [1 mark]') normal_para(doc, 'First Line (Triple Therapy for H. pylori eradication — 14 days):') bullet(doc, 'PPI (omeprazole 20 mg BD) + Clarithromycin 500 mg BD + Amoxicillin 1 g BD', '') bullet(doc, 'Success rate 70–90%. Confirm eradication with UBT at 4 weeks post-therapy', '') normal_para(doc, 'Maintenance:') bullet(doc, 'PPIs (omeprazole, pantoprazole) — heal ulcer in 4–8 weeks', '') bullet(doc, 'H2 blockers (ranitidine) — second line', '') bullet(doc, 'Sucralfate, misoprostol — mucosal protection', '') bullet(doc, 'Avoid NSAIDs, smoking, alcohol, spicy food', '') bold_para(doc, '8. AYURVEDIC MANAGEMENT [1 mark]') bullet(doc, 'Pitta Shamana: Avipattikar Churna, Yashtimadhuka (DGL — demulcent, anti-ulcer), Shatavari churna', '') bullet(doc, 'Sheetala dravyas: Chandanasava, Ushirasava, Pravala Pishti', '') bullet(doc, 'Triphala — mild laxative, wound healing', '') bullet(doc, 'Pathya: Milk, ghee, rice, bland diet; avoid Amla, Lavana, Katu, Ushna, and spicy foods', '') bullet(doc, 'Virechana — for Pitta shodhana in severe cases', '') doc.add_paragraph() # ─── LAQ 3 ─── heading2(doc, 'LAQ 3: Haemorrhoids / Arsha — Classification, Ayurvedic & Modern Management [10 Marks]') normal_para(doc, 'Describe etiopathogenesis, classification, clinical features, diagnosis, complications, and management including Saptavidha Arsha Chikitsa.') bold_para(doc, '1. DEFINITION AND AYURVEDIC CONCEPT [1 mark]') normal_para(doc, 'Haemorrhoids (piles) are abnormal dilated, displaced vascular cushions in the anal canal and lower rectum. They occur due to downward displacement of the anal cushions (normally present at 3, 7, and 11 o\'clock positions in lithotomy position).') normal_para(doc, 'Arsha: "Arsha" in Sanskrit means "enemy." Sushruta defines it as: "Mamsankurantare Jataha Sphikparshnigudabhagaha Arshah Vartmavadeva Dhirate" — flesh-like growths that obstruct the anal canal, like a gate-keeper, causing distress. It is one of the Ashta Mahagada.') bold_para(doc, '2. ETIOPATHOGENESIS [1 mark]') normal_para(doc, 'A. Ayurvedic Nidana:') bullet(doc, 'Intake of Guru, Abhishyandi, Vidahi Ahara (heavy, channel-blocking, irritant food)', '') bullet(doc, 'Excessive intake of dry, cold, and stale food', '') bullet(doc, 'Sedentary lifestyle, sitting on hard surfaces for long periods', '') bullet(doc, 'Constipation, chronic straining at stool', '') bullet(doc, 'Genetic predisposition (Kulaja Arsha)', '') normal_para(doc, 'B. Modern Pathophysiology:') bullet(doc, 'Increased intra-abdominal pressure → weakening of supporting connective tissue → downward displacement of anal cushions', '') bullet(doc, 'Straining, constipation, pregnancy, obesity, portal hypertension, pelvic tumors', '') bold_para(doc, '3. CLASSIFICATION [2 marks]') normal_para(doc, 'A. Ayurvedic Classification (Sushruta — 6 types):') rows11 = [ ['Vataja Arsha','Dry, rough, thin, black/grey, painful, severe constipation'], ['Pittaja Arsha','Soft, red/yellow, burning sensation, bleeding, loose stools'], ['Kaphaja Arsha','Large, pale/white, hard, itching, mucus discharge'], ['Sannipataja','All three Doshas — most severe, all above symptoms'], ['Raktaja','Bleeding piles — Rakta Dosha vitiation'], ['Sahaja (Congenital)','Present from birth — Janmaja Arsha'], ] add_table(doc, ['Type','Features'], rows11) normal_para(doc, 'B. Modern Classification (Degree):') rows12 = [ ['1st Degree','Bleed but do not prolapse outside anal canal'], ['2nd Degree','Prolapse on straining but reduce spontaneously'], ['3rd Degree','Prolapse on straining, require manual reduction'], ['4th Degree','Permanently prolapsed, cannot be reduced (may be strangulated)'], ] add_table(doc, ['Degree','Description'], rows12) normal_para(doc, 'C. By Location: Internal (above dentate line — insensate), External (below dentate line — painful), Mixed/Interno-external') bold_para(doc, '4. CLINICAL FEATURES [1 mark]') bullet(doc, 'Painless bright red rectal bleeding (most common — per rectum, on paper, on stool surface)', '') bullet(doc, 'Prolapse of piles (Gudabhramsha) — Grade 2,3,4', '') bullet(doc, 'Mucus discharge → pruritis ani (Guda Kandu)', '') bullet(doc, 'Anaemia in chronic bleeding', '') bullet(doc, 'Pain — only in external or thrombosed/strangulated piles', '') bullet(doc, 'Proctoscopy: Vascular cushions at 3, 7, 11 o\'clock positions above dentate line', '') bold_para(doc, '5. INVESTIGATIONS [1 mark]') bullet(doc, 'Digital rectal examination (DRE) — mandatory to rule out carcinoma', '') bullet(doc, 'Proctoscopy — visualize internal haemorrhoids, grade them', '') bullet(doc, 'Sigmoidoscopy/Colonoscopy — rule out colorectal carcinoma (especially in patients >50 yrs)', '') bullet(doc, 'CBC — for anaemia assessment', '') bold_para(doc, '6. MANAGEMENT [3 marks]') normal_para(doc, 'A. SAPTAVIDHA ARSHA CHIKITSA (Sushruta\'s Seven Treatment Methods):') rows13 = [ ['1','Bheshaja Karma','Oral and local medications — conservative management'], ['2','Kshara Karma','Chemical cauterization using Apamarga Kshara — for 1st and 2nd degree'], ['3','Agnikarma','Thermal cauterization using Shalaka (metallic probe) — for smaller piles'], ['4','Shastra Karma','Surgical excision (haemorrhoidectomy) — for large piles'], ['5','Anushashtra Karma','Leeching (Raktamokshana) — for engorged, congested piles'], ['6','Kshara Sutra','For associated fistula — Kshara Sutra ligation'], ['7','Pathya (Diet)','Fiber-rich diet, fluids, lifestyle modification'], ] add_table(doc, ['No.','Method','Description'], rows13) normal_para(doc, 'B. Modern Outpatient Procedures (Grade 1 and 2):') bullet(doc, 'Injection Sclerotherapy: 5% phenol in almond oil injected submucosally — shrinks piles', '') bullet(doc, 'Rubber Band Ligation (Barron\'s band): Most effective for Grade 1–3; rubber band strangulates pedicle → necrosis → sloughing (Gold standard OPD procedure)', '') bullet(doc, 'Infrared Coagulation (IRC): For Grade 1–2', '') bullet(doc, 'Cryotherapy: Now rarely used', '') normal_para(doc, 'C. Surgical Treatment (Grade 3 and 4):') bullet(doc, 'Milligan-Morgan Haemorrhoidectomy (open): Three primary haemorrhoids excised; most common; gold standard for Grade 3–4', '') bullet(doc, 'Ferguson\'s Haemorrhoidectomy (closed): Wounds closed — fewer complications', '') bullet(doc, 'Stapled Haemorrhoidopexy (PPH — Procedure for Prolapsing Haemorrhoids): Circular stapler resects redundant mucosa and repositions cushions; less pain, quicker recovery', '') bullet(doc, 'HAL-RAR (Haemorrhoidal Artery Ligation with Recto-Anal Repair): Doppler-guided ligation of feeding arteries', '') normal_para(doc, 'D. Conservative Management:') bullet(doc, 'High-fibre diet, increased fluid intake', '') bullet(doc, 'Stool softeners (lactulose, ispaghula)', '') bullet(doc, 'Sitz bath (warm water soaks 10–15 min, 3×/day) for symptomatic relief', '') bullet(doc, 'Topical ointments: Lignocaine, hydrocortisone for pain and itch', '') bold_para(doc, '7. COMPLICATIONS') bullet(doc, 'Strangulation and thrombosis — emergency: immediate haemorrhoidectomy', '') bullet(doc, 'Prolapse with irreducibility', '') bullet(doc, 'Anaemia from chronic blood loss', '') bullet(doc, 'Infection, sepsis, Fournier\'s gangrene (rare)', '') doc.add_paragraph() # ─── LAQ 4 ─── heading2(doc, 'LAQ 4: Inguinal Hernia (Antravriddhi) — Anatomy, Classification, Management [10 Marks]') normal_para(doc, 'Describe surgical anatomy of inguinal canal, classification, clinical features, complications, and management.') bold_para(doc, '1. DEFINITION AND AYURVEDIC CONCEPT [1 mark]') normal_para(doc, 'Hernia is defined as the protrusion of a viscus or part of a viscus through an abnormal opening in the walls of the cavity that normally contains it. Inguinal hernia is the most common type of hernia (75% of all hernias), more common in males (25:1 ratio).') normal_para(doc, 'Ayurvedic Concept — Antravriddhi: "Antram" (intestine) + "vriddhi" (enlargement). Sushruta classifies it under Vriddhi Roga. Caused by Vata vitiation → intestine descends through groin weakness. Described in Nidana Sthana of Sushruta Samhita.') bold_para(doc, '2. SURGICAL ANATOMY OF INGUINAL CANAL [2 marks]') normal_para(doc, 'The inguinal canal is an oblique intermuscular passage in the lower anterior abdominal wall, 4 cm long, running from deep inguinal ring to superficial inguinal ring.') normal_para(doc, 'Boundaries:') rows14 = [ ['Anterior wall','External oblique aponeurosis (entire length) + internal oblique (lateral 1/3)'], ['Posterior wall','Transversalis fascia (entire) + conjoint tendon (medial 1/3) — Hesselbach\'s triangle'], ['Roof','Arching fibres of internal oblique and transversus abdominis'], ['Floor','Inguinal ligament (poupart\'s ligament) + lacunar ligament (medially)'], ] add_table(doc, ['Wall','Structure'], rows14) normal_para(doc, 'Rings: Deep ring (in transversalis fascia, 1.25 cm above midpoint of inguinal ligament) → Superficial ring (in external oblique aponeurosis, above pubic tubercle)') normal_para(doc, 'Contents in Male: Spermatic cord (vas deferens, testicular artery, pampiniform venous plexus, genital branch of genitofemoral nerve, cremasteric artery, lymphatics)') normal_para(doc, 'Contents in Female: Round ligament of uterus') normal_para(doc, "Hesselbach's Triangle: Lateral border — inferior epigastric vessels; Medial border — lateral border of rectus abdominis; Base — inguinal ligament. Direct hernias pass through this triangle.") bold_para(doc, '3. CLASSIFICATION [1 mark]') rows15 = [ ['Indirect Inguinal','Most common (66%)','Lateral to inferior epigastric vessels; congenital (patent processus vaginalis); may descend into scrotum; any age; M>F'], ['Direct Inguinal','30%','Medial to inferior epigastric vessels through Hesselbach\'s triangle; acquired (muscle weakness); usually adult males; rarely descends into scrotum'], ['Femoral Hernia','4–5%','Below and lateral to pubic tubercle through femoral canal; M>F (adults, obese); high risk of strangulation'], ] add_table(doc, ['Type','Frequency','Features'], rows15) bold_para(doc, '4. CLINICAL FEATURES [1 mark]') bullet(doc, 'Lump in groin — appears on standing/straining/coughing, reduces on lying down', '') bullet(doc, 'Dragging/aching discomfort in groin', '') bullet(doc, 'Impulse on coughing felt at superficial ring', '') bullet(doc, 'Indirect: Sausage-shaped swelling, can get above swelling negative (enters scrotum)', '') bullet(doc, 'Direct: Hemispherical swelling, does not enter scrotum, can be reduced easily', '') bullet(doc, 'Examination: Deep ring occlusion test — indirect hernia controlled by finger at deep ring; direct not controlled', '') bold_para(doc, '5. COMPLICATIONS [1 mark]') rows16 = [ ['Irreducibility','Contents cannot be reduced back; risk of obstruction'], ['Obstruction','Lumen of bowel in hernial sac obstructed — intestinal obstruction features'], ['Strangulation (most serious)','Blood supply to hernial contents cut off → ischemia → gangrene; Femoral hernia has highest risk; Emergency surgery required'], ['Richter\'s hernia','Partial obstruction — anti-mesenteric border of bowel herniated; no complete obstruction initially but risk of gangrene'], ['Sliding hernia (Hernia en glissade)','Part of sac wall is viscus (sigmoid colon/caecum/bladder)'], ['Infection','Post-surgical complication'], ] add_table(doc, ['Complication','Description'], rows16) bold_para(doc, '6. INVESTIGATIONS [0.5 mark]') bullet(doc, 'USG groin — differentiates hernia from lymph node, lipoma, femoral aneurysm', '') bullet(doc, 'CT scan — for complex, recurrent, or occult hernias', '') bullet(doc, 'Herniography — rarely used (contrast injected into peritoneum)', '') bold_para(doc, '7. MANAGEMENT [2.5 marks]') normal_para(doc, 'A. Conservative: Truss (spring-loaded pad) — ONLY for very unfit patients who refuse surgery; does NOT cure hernia; risks masking strangulation.') normal_para(doc, 'B. Surgical Options:') bullet(doc, '', 'Herniotomy:') normal_para(doc, ' Sac dissected, reduced, and ligated at neck; no repair of posterior wall; done in children (where muscle is normal); also in emergency strangulated hernia.') bullet(doc, '', 'Herniorrhaphy:') normal_para(doc, ' Herniotomy + repair of posterior wall using adjacent structures:') normal_para(doc, ' - Bassini\'s repair: Conjoint tendon sutured to inguinal ligament (historical)') normal_para(doc, ' - Modified Bassini / Shouldice repair: Multi-layer fascial repair; gold standard for open repair') bullet(doc, '', 'Hernioplasty (tension-free mesh repair — current gold standard):') normal_para(doc, ' - Lichtenstein repair (open anterior mesh): Polypropylene mesh placed to reinforce posterior wall; gold standard open technique; recurrence rate <1%') normal_para(doc, ' - TAPP (Trans-Abdominal Pre-Peritoneal): Laparoscopic — mesh placed pre-peritoneally') normal_para(doc, ' - TEP (Totally Extra-Peritoneal): Laparoscopic — purely extra-peritoneal dissection; preferred for bilateral hernias, recurrent hernias, females') normal_para(doc, ' Advantages of Laparoscopic repair: Less post-op pain, quicker return to work, better for bilateral and recurrent hernias') normal_para(doc, 'C. Emergency Surgery (Strangulated Hernia):') bullet(doc, 'Herniotomy + assess bowel viability', '') bullet(doc, 'Viable bowel → reduce; Non-viable bowel → resection and anastomosis', '') bullet(doc, 'Mesh NOT used in contaminated/infected field', '') bullet(doc, 'Prophylactic antibiotics, IV fluids resuscitation', '') bold_para(doc, '8. AYURVEDIC MANAGEMENT') normal_para(doc, 'Antravriddhi Chikitsa per Sushruta:') bullet(doc, 'Vatahara Chikitsa: Sneha, Sweda, Basti (Matra, Niruha), Anuvasan Basti', '') bullet(doc, 'Shastra Karma: Surgical reduction described; Sushruta advocates Traction and restoration of viscus', '') bullet(doc, 'Varunadi Kwatha, Dashamula Kwatha, Ashwagandha — strengthen abdominal muscles', '') bullet(doc, 'Pathya: Avoid heavy lifting, straining; light diet, treat constipation', '') bullet(doc, 'Pandu (truss-like support) for non-surgical management', '') doc.add_paragraph() # ════════════════════════════════════════════ # CLOSING NOTE # ════════════════════════════════════════════ doc.add_page_break() heading1(doc, 'MARKS ALLOCATION GUIDE') normal_para(doc, 'LAQ (10 marks) Breakdown:') add_table(doc, ['Component','Marks'], [['Definition + Ayurvedic concept','1'], ['Etiopathogenesis / Nidana','2'], ['Classification + Clinical features','2'], ['Investigations + Diagnosis','1'], ['Complications + Management','3'], ['Ayurvedic Chikitsa / Special notes','1']]) doc.add_paragraph() normal_para(doc, 'SAQ (5 marks) Breakdown:') add_table(doc, ['Component','Marks'], [['Definition / Introduction','1'], ['Classification / Types','1'], ['Clinical features / Symptoms','1'], ['Management / Chikitsa','1'], ['Ayurvedic reference / Special notes','1']]) doc.add_paragraph() bold_para(doc, 'Important Examination Tips:') bullet(doc, 'Always begin with an Ayurvedic definition and Dosha correlation before modern content', '') bullet(doc, 'Draw diagrams wherever possible (anatomy, flow charts, tables)', '') bullet(doc, 'Use Sushruta Samhita chapter references for authenticity', '') bullet(doc, 'Include Samprapti (pathogenesis) and Chikitsa Siddhanta for Ayurvedic topics', '') bullet(doc, 'End LAQs with Pathya-Apathya (diet and lifestyle) and Prognosis', '') # ── Save out_path = '/tmp/workspace/shalya-paper2/BAMS_Paper2_Model_Answers.docx' doc.save(out_path) print(f'Saved: {out_path}') PYEOF python3 /tmp/workspace/shalya-paper2/generate_answers.py

ls -lh /tmp/workspace/shalya-paper2/BAMS_Paper2_Model_Answers.docx