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BPT/BOT General Surgery - Complete Answers

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Q1. Define Shock. Classify Shock According to Etiology. Discuss Management of Hypovolemic Shock. (15 marks)

Definition of Shock

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Classification of Shock (by Etiology)

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Hypovolemic Shock - In Detail

ATLS Classification (Hemorrhagic Shock)

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Management of Hypovolemic Shock

A. Immediate (Primary Survey - ABCDE)

• Airway: Secure airway; give high-flow O2
• Breathing: Assess and support ventilation
• Circulation: Two large-bore IV cannulas (antecubital fossa), apply direct pressure to bleeding wounds
• Disability: Check GCS, pupil reaction
• Exposure: Undress patient, identify all injuries

B. Fluid Resuscitation

• Class I: No treatment needed; oral fluids
• Class II: Crystalloid (Normal Saline or Ringer's Lactate) - 1-2 litres IV bolus
• Class III: Crystalloids + Blood transfusion
• Class IV: Immediate blood transfusion + emergency surgical intervention; O-negative blood if type-and-cross not available

C. Monitoring Parameters

• Pulse rate, BP, pulse pressure
• Urine output (target: >0.5 mL/kg/hr in adults, >1 mL/kg/hr in children)
• Central venous pressure (CVP)
• Capillary refill time (<2 sec = normal)
• Serum lactate (indicator of tissue perfusion)

D. Specific Measures

• Control of bleeding source (surgical hemostasis, angioembolization)
• Vasopressors (norepinephrine) only after adequate volume replacement
• Treat underlying cause (e.g., fracture stabilization)
• Tranexamic acid (antifibrinolytic) in hemorrhagic shock - given within 3 hours of injury
• Keep patient warm (prevent hypothermia triad: hypothermia + coagulopathy + acidosis)

E. Physiotherapy Relevance

• Post-stabilization: chest physiotherapy to prevent atelectasis and pneumonia
• Early mobilization to prevent DVT
• Respiratory exercises

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Q2. Short Notes

(a) Complications of Blood Transfusion

Complications from a Single Transfusion

Complications from Massive Transfusion (>10 units in 24 hrs)

• Coagulopathy - dilutional; manage with FFP, platelets, cryoprecipitate in 1:1:1 ratio
• Hypocalcaemia - citrate in stored blood chelates calcium; give IV calcium gluconate
• Hyperkalaemia - stored RBCs leak potassium
• Hypothermia - use blood warmers
• Iron overload - in repeated transfusions (e.g., thalassaemia); each unit contains ~250 mg elemental iron

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(b) Flail Chest

Definition

Mechanism

• High-energy trauma (RTA, crush injury)
• The paradoxical movement itself is NOT the primary cause of respiratory failure
• Underlying pulmonary contusion is the main cause of hypoxia

Clinical Features

• Paradoxical chest wall movement (visible)
• Severe pain on breathing
• Respiratory distress, tachypnoea
• Hypoxia, cyanosis
• Subcutaneous emphysema may be present

Investigations

• CXR: multiple rib fractures
• CT chest: better assessment of rib fractures and pulmonary contusion
• ABG: hypoxia, hypercapnia

Management

1. Oxygen therapy - high-flow O2
2. Analgesia - this is the cornerstone of treatment
   • Thoracic epidural anaesthesia (TEA) - gold standard for pain management in flail chest (EAST guidelines)
   • Intercostal nerve blocks, IV morphine/NSAIDs
3. Positive pressure ventilation - for respiratory failure (internal pneumatic stabilization)
4. Operative Rib Fixation (ORIF) - surgical stabilization of ribs; indicated in severe cases
5. Treat underlying pulmonary contusion

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(c) Electrical Burn

Definition

Types

• Flash burns: From arc; surface burns only
• Flame burns: Clothing ignites
• True electrical burns: Current passes through body - entry and exit wounds

Pathophysiology

• Electrical current generates heat as it passes through tissues
• Resistance: Bone > Fat > Skin > Muscle > Blood vessels > Nerves (least resistance)
• Tissues with least resistance carry more current and sustain deeper injury
• Hidden deep tissue destruction - extent is always greater than visible surface injury ("iceberg phenomenon")

Clinical Features

• Entry wound: Small, charred, well-defined
• Exit wound: Larger, explosive appearance
• Muscle necrosis - rhabdomyolysis
• Myoglobinuria (dark urine) - leads to acute tubular necrosis
• Cardiac arrhythmias (ventricular fibrillation, asystole)
• Respiratory arrest
• Neuropathy, spinal cord injury
• Cataract (delayed complication)

Management

1. Safety first - switch off the current source
2. CPR if in cardiac arrest
3. Cardiac monitoring (ECG) for 24-48 hours

• Parkland formula (modified) - based on actual burn area
• Increase fluid volume due to hidden muscle damage
• Target urine output: 1-1.5 mL/kg/hr (higher than thermal burns to flush myoglobin)
• Urinary alkalinization with sodium bicarbonate to prevent myoglobin precipitation in renal tubules

• Wound care - debridement of necrotic tissue
• Escharotomy/fasciotomy for compartment syndrome
• Tetanus prophylaxis
• Nutritional support
• Amputation may be required for severe extremity burns
• Refer to burn unit (ABA criteria)

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(d) Difference Between Split Skin and Full Thickness Graft

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(e) Regional Anaesthesia

Definition

Advantages over General Anaesthesia

• Patient remains conscious/cooperative
• Reduced systemic drug effects
• Better postoperative analgesia
• Suitable for high-risk patients
• Reduced blood loss
• Early recovery, suitable for day surgery

Types of Regional Anaesthesia

• Spinal (Subarachnoid block): LA injected into CSF in subarachnoid space (L3-L4 or L4-L5); rapid onset, dense block; used for lower limb, perineal, lower abdominal surgery
• Epidural block: LA injected into epidural space; can be continuous via catheter; slower onset; used in labour, thoracic/abdominal surgery, postop analgesia
• Caudal block: Through sacral hiatus into epidural space; used in paediatric perineal/rectal surgery

• Brachial plexus block: Interscalene (shoulder), supraclavicular (arm), infraclavicular, axillary (hand/forearm)
• Femoral nerve block: Knee/thigh surgery
• Sciatic nerve block: Lower leg/foot surgery
• Intercostal nerve block: Rib fractures, thoracic pain
• Digital nerve block: Finger surgery

• LA (lignocaine) injected IV into exsanguinated, tourniquet-isolated limb
• Used for short upper limb procedures

• LA infiltrated directly at surgical site

Drugs Used

• Lidocaine (Lignocaine) - short acting
• Bupivacaine - long acting (preferred for blocks)
• Ropivacaine - less cardiotoxic than bupivacaine

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Q3. Classify Wounds. Discuss Factors Affecting Wound Healing and Management of Chronic Ulcers. (15 marks)

Classification of Wounds

By Mechanism/Cause

1. Incised wounds: Clean cut by sharp instrument (scalpel, knife) - cleanest, heals best
2. Lacerated wounds: Irregular tear by blunt force - ragged edges
3. Contused (Bruised) wounds: Crush injury - devitalized tissue
4. Puncture/Penetrating wounds: Deep narrow track (nail, bullet)
5. Abrasion: Superficial scraping of skin
6. Avulsion: Tissue torn away
7. Gunshot wounds: Entry/exit wounds, tissue destruction along tract
8. Burns: Thermal, chemical, electrical, radiation

By Contamination (Surgical Wound Classification)

By Duration

• Acute wounds: Heal in predictable stages (< 4-6 weeks)
• Chronic wounds: Fail to heal in orderly fashion (>6 weeks); e.g., venous ulcers, diabetic foot, pressure sores

By Tissue Loss

• Superficial (skin only), partial thickness (skin + subcutaneous), full thickness (to muscle/bone)

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Types of Wound Healing

• Primary intention: Wound edges approximated; minimal scar (surgical incisions)
• Secondary intention: Wound left open; heals from base up by granulation tissue; larger scar
• Tertiary intention (Delayed Primary Closure): Contaminated wound cleaned, left open 4-5 days, then closed

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Factors Affecting Wound Healing

Local Factors

Systemic Factors

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Management of Chronic Ulcers

General Management Principles

• Venous ulcer: Compression therapy (four-layer bandage), limb elevation
• Arterial ulcer: Vascular surgery (angioplasty/bypass) - DO NOT compress
• Diabetic ulcer: Strict glycaemic control, offloading footwear
• Pressure sore: Pressure relief, pressure-relieving mattress, regular repositioning

• T - Tissue debridement (surgical, enzymatic, maggot therapy)
• I - Infection/Inflammation control (wound swab + targeted antibiotics)
• M - Moisture balance (appropriate wound dressings)
• E - Epithelial (edge) advancement

• Moist wound healing principle - maintains optimal wound environment
• Hydrocolloids, hydrogels, alginates, foam dressings based on exudate level

• High-protein diet, Vitamin C supplementation, Zinc supplementation

• Skin grafting (split skin graft most common)
• Flap cover for deep defects
• Vacuum Assisted Closure (VAC/NPWT) - negative pressure wound therapy

• Exercise to improve venous return (calf pump)
• Compression bandaging application
• Positioning and pressure relief
• Patient education

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Q4. What is Hernia? Precipitating Factors and Advanced Management of Inguinal Hernia. (15 marks)

Definition of Hernia

Parts of a Hernia

• Sac: Peritoneal covering (neck, body, fundus)
• Contents: Bowel (most common), omentum, bladder, ovary
• Coverings: Layers of abdominal wall

Types of Hernia

• Reducible: Contents return to cavity spontaneously or on manipulation
• Irreducible (Incarcerated): Contents cannot be returned
• Obstructed: Lumen of bowel is blocked but no vascular compromise
• Strangulated: Blood supply to contents is compromised - SURGICAL EMERGENCY
• Sliding: Part of the wall of the sac is formed by the herniated viscus

Common Types by Site

• Inguinal (most common - 75%), Femoral, Umbilical, Incisional, Epigastric

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Precipitating Factors for Hernia

Factors Increasing Intra-abdominal Pressure (Predisposing)

Factors Causing Weakness of Abdominal Wall

• Congenital: Patent processus vaginalis (indirect inguinal hernia)
• Age: Muscle atrophy, loss of collagen in elderly
• Malnutrition: Poor collagen synthesis
• Previous surgery: Scar tissue weakness (incisional hernia)
• Connective tissue disorders: Marfan's syndrome, Ehlers-Danlos

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Inguinal Hernia - Types

• Enters internal inguinal ring → travels through inguinal canal → may exit external ring into scrotum
• Follows the path of the processus vaginalis
• More common in young males

• Pushes through the posterior wall of the inguinal canal through Hesselbach's triangle
• Medial to inferior epigastric vessels
• More common in older men due to muscle weakness

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Advanced Management of Inguinal Hernia

Conservative Management

• Truss (hernia belt): Only in unfit patients; not curative
• Risk factor modification: Treat cough, constipation, BPH

Surgical Management - Gold Standard

1. Herniotomy (in children): Simple ligation and excision of the hernial sac through internal ring; no repair needed as muscle wall is intact
2. Herniorrhaphy: Herniotomy + repair of the posterior wall of inguinal canal
   • Bassini's repair: Classic; approximates conjoint tendon to inguinal ligament
   • Shouldice repair: Multilayer repair of transversalis fascia; low recurrence (1-2%)
3. Hernioplasty: Herniotomy + mesh placement (tension-free repair)
   • Lichtenstein repair: Most common open mesh repair; onlay mesh; recurrence <1%

1. TAPP (Trans-Abdominal Pre-Peritoneal): Mesh placed in pre-peritoneal space via laparoscope entering peritoneal cavity
2. TEP (Totally Extra-Peritoneal): Mesh placed in pre-peritoneal space WITHOUT entering peritoneal cavity; preferred as no peritoneal breach
3. IPOM (Intraperitoneal Onlay Mesh): Mesh placed inside the peritoneum; special composite mesh needed to prevent adhesions

• Less postoperative pain
• Earlier return to activity
• Better for bilateral hernias (both repaired through same incision)
• Better for recurrent hernias

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Q5. Types of Urinary Incontinence and Management. (15 marks)

Definition

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Types of Urinary Incontinence

1. Stress Urinary Incontinence (SUI)

• Involuntary leakage of urine on effort, exertion, sneezing, or coughing
• Due to urethral sphincter weakness / hypermobility of bladder neck
• Most common in women (post-partum, post-menopausal)
• No detrusor contraction

2. Urge Urinary Incontinence

• Involuntary leakage accompanied or immediately preceded by a sudden, compelling desire to void (urgency)
• Due to detrusor overactivity (involuntary detrusor contractions)
• Associated with overactive bladder (OAB) syndrome

3. Mixed Urinary Incontinence

• Combination of both stress and urge incontinence
• Most common type in older women

4. Overflow Incontinence

• Bladder is overdistended, unable to empty; urine constantly dribbles
• Causes: BPH (men), atonic bladder (DM neuropathy), spinal cord injury
• Characterized by a large residual urine volume

5. Functional Incontinence

• Normal bladder control but person cannot reach toilet in time
• Due to physical (immobility - arthritis, stroke) or cognitive (dementia) disability

6. Neurogenic Incontinence

• Due to neurological disease (MS, Parkinson's, spinal cord injury, stroke)
• Detrusor-sphincter dyssynergia

7. Total/Continuous Incontinence

• Constant leakage regardless of position or activity
• Due to fistula (vesicovaginal, urethrovaginal), ectopic ureter, sphincter destruction

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Management of Urinary Incontinence

A. Conservative (First-line)

• Most important physiotherapy intervention
• Strengthens levator ani and external urethral sphincter
• Effective for stress incontinence
• 3 sets of 8-12 contractions daily for minimum 3 months
• Physiotherapy's primary role in management

• For urge incontinence
• Gradually increase voiding intervals (start 30 min, gradually increase to 3-4 hrs)
• Teaches suppression of urgency

• Weight reduction (reduces intra-abdominal pressure)
• Fluid management (avoid excessive fluids, caffeine, alcohol)
• Treat constipation
• Smoking cessation (reduces cough)

• Neuromuscular stimulation of pelvic floor
• Biofeedback helps patients correctly identify and contract pelvic floor muscles

B. Pharmacological

C. Surgical

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Q6. Short Notes

(a) Presbyopia

Definition

Cause

• The crystalline lens loses its elasticity with advancing age
• The ciliary muscle contracts but cannot produce adequate change in lens curvature
• Typically becomes symptomatic after age 40-45 years

Symptoms

• Difficulty reading small print (holds book at arm's length)
• Headache and eye strain after near work
• Need for brighter light to read
• Squinting to see near objects

Investigation

• Near vision chart (Jaeger card) - reduced near vision
• Slit lamp examination

Management

1. Reading glasses (convex/plus lenses) - simplest and most common
2. Bifocal glasses: Upper half for distance, lower for near
3. Progressive/multifocal lenses: Gradual change in power (no visible line)
4. Contact lenses: Monovision, multifocal contacts
5. Surgical options:
   • LASIK monovision: One eye corrected for near
   • Conductive Keratoplasty (CK): Radiofrequency to reshape cornea
   • Refractive lens exchange (RLE): Replace lens with multifocal IOL
   • KAMRA corneal inlay

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(b) Glasgow Coma Scale (GCS)

Definition

Scoring

• Maximum: 15 (fully conscious)
• Minimum: 3 (deeply unconscious)

Interpretation

Uses

• Assessment of head injury severity
• Monitoring level of consciousness over time
• Prognostication after brain injury
• Guiding airway management (GCS ≤8 = intubate)
• Triggers CT scan (GCS <15 after head injury)

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(c) Conjunctivitis

Definition

Classification and Features

Clinical Features (general)

• Red eye (conjunctival injection)
• Discharge (varies by type)
• Gritty/sandy sensation (foreign body feeling)
• Eyelid swelling
• No pain, no vision loss (if pain or vision loss → consider more serious diagnosis)

Management

• Topical antibiotic eye drops: Chloramphenicol, ciprofloxacin, tobramycin (4-6 times/day for 5-7 days)
• Lid hygiene (warm compresses, clean discharge)

• Supportive: cold compresses, lubricant drops
• Antiviral (Acyclovir) only for HSV conjunctivitis
• No antibiotics needed (unless secondary bacterial infection)

• Remove allergen
• Topical antihistamines (Olopatadine)
• Topical mast cell stabilisers (Sodium cromoglicate)
• Cold compresses
• Systemic antihistamines for severe cases

• IV/IM Ceftriaxone (systemic)
• Topical penicillin/chloramphenicol
• Eye irrigation with saline

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(d) Common ENT Infections

1. Otitis Media (Middle Ear Infection)

• Acute Otitis Media (AOM): Usually follows URTI; bacterial (Strep pneumoniae, H. influenzae, Moraxella catarrhalis); features: otalgia (ear pain), fever, conductive hearing loss, bulging red tympanic membrane; Rx: Amoxicillin 5-7 days; myringotomy if no response
• Chronic Suppurative Otitis Media (CSOM): Persistent mucosal (safe - tubotympanic) or dangerous (unsafe - atticoantral with cholesteatoma); ear discharge, hearing loss
• Otitis Media with Effusion (Glue ear): Fluid in middle ear without infection; conductive hearing loss; treat with grommets

2. Otitis Externa (Swimmer's Ear)

• Infection of external ear canal
• Pseudomonas aeruginosa, Staph aureus
• Pain on moving pinna/tragus, discharge
• Rx: Topical antibiotic + steroid ear drops (Sofradex), keep ear dry

3. Tonsillitis

• Bacterial (Group A beta-haemolytic Streptococcus - most common), viral
• Features: Sore throat, fever, enlarged red tonsils with exudate, cervical lymphadenopathy
• Rx: Penicillin V (10 days) or Amoxicillin; never Amoxicillin in EBV infection (causes rash)
• Quinsy (Peritonsillar abscess): Complication; trismus, drooling, hot potato voice; drain + antibiotics
• Tonsillectomy: Indications - recurrent tonsillitis (≥5/year for 2 years), obstructive sleep apnoea, peritonsillar abscess

4. Sinusitis

• Inflammation of paranasal sinuses (maxillary most common)
• Follows URTI, dental infection
• Features: Facial pain/pressure, nasal congestion, mucopurulent nasal discharge, post-nasal drip, headache worse on bending forward
• Acute: Viral (symptomatic treatment); bacterial (amoxicillin/clavulanate if >10 days or worsening)
• Chronic (>12 weeks): FESS (Functional Endoscopic Sinus Surgery)

5. Pharyngitis / URTI

• Usually viral (rhinovirus, adenovirus)
• Symptomatic treatment (analgesics, fluids, saline gargle)

6. Epiglottitis

• H. influenzae type b (now rare with vaccination)
• Life-threatening airway emergency
• Features: drooling, dysphagia, muffled voice, stridor, tripod position
• Management: DO NOT examine with tongue depressor; secure airway in theatre, IV cefotaxime

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(e) Reactionary Haemorrhage

Definition

Types of Post-Operative Haemorrhage

Causes of Reactionary Haemorrhage

• Ligature slippage from a tied vessel
• Incomplete haemostasis during operation
• Rise in blood pressure as patient recovers from anaesthesia/shock
• Reversal of vasospasm (vessels had been in spasm during shock)

Clinical Features

• Fresh blood in drain (bright red)
• Swelling/haematoma at surgical site
• Falling blood pressure + rising pulse (shock signs)
• Patient becomes restless, pale, sweaty
• Reduced urine output

Management

1. Monitor vitals closely
2. IV access - large bore cannula
3. Blood sample for FBC, coagulation, crossmatch
4. IV crystalloid/colloid resuscitation
5. Blood transfusion if required

• Return to theatre for surgical re-exploration and haemostasis (ligation of bleeding vessel/removal of clot)
• Pressure dressing as temporary measure

• Meticulous surgical haemostasis
• Check all ligatures before wound closure
• Proper blood pressure control pre-operatively

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Quick Exam Tips

1. Always attempt 5 questions - any 5 from the paper
2. Q1 (Shock) and Q3 (Wounds) are high-yield and frequently repeated
3. For each question draw a table or flowchart where possible - examiners love visual organization
4. The ATLS classification table for hypovolemic shock is almost always asked
5. GCS table should be memorized perfectly (3-15 scoring, each component)
6. For inguinal hernia, know Hesselbach's triangle, Lichtenstein's repair, and TAPP/TEP difference
7. Kegel exercises and PFMT are the physiotherapy answer for urinary incontinence - always emphasize your role
8. For short notes: use the format Definition → Causes → Features → Management