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Provide answers in the form of flowcharts and tabular column by referring S Das surgery mbbs textbook or any other rguhs mbbs standard textbook
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Finding Sources
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Below are comprehensive answers to all questions from your RGUHS Surgery papers (2024-2026), presented in flowchart + tabular format as requested, based on Bailey & Love's Surgery, Robbins Pathology, Schwartz's Principles of Surgery, and S Das Surgery principles.
RGUHS MBBS PHASE III SURGERY - COMPLETE ANSWERS
(Flowchart + Tabular Format)
LONG ESSAY 1: BREAST CARCINOMA (50-yr-old postmenopausal female, painless hard lump, axillary node)
A. DIAGNOSIS
Most likely: CARCINOMA OF THE BREAST (Invasive Ductal Carcinoma, most common type ~80%)
B. ETIOLOGY - Risk Factors Table
(Bailey & Love, Table 58.3)
| Category | Risk Factor | Relative Risk (RR) |
|---|---|---|
| Non-modifiable | Age >50 years (postmenopausal) | High |
| Family history (mother affected) | RR 2-3 (1st degree relative) | |
| BRCA1/BRCA2 mutation | RR 5-7 | |
| Early menarche / Late menopause | Moderate | |
| Nulliparity / Late first pregnancy >35y | Moderate | |
| Previous breast cancer | RR 4 | |
| Atypical ductal hyperplasia on biopsy | RR 4-5 | |
| Modifiable | Obesity (BMI >30, postmenopausal) | RR 1.29 |
| HRT use >10 years | RR 1.2 | |
| Alcohol >4 drinks/day | RR 1.46 | |
| Tobacco smoking | RR 1.14 | |
| Radiation exposure | RR 6 |
C. INVESTIGATIONS & MANAGEMENT - FLOWCHART
CLINICAL PRESENTATION
Painless hard lump + Axillary node + Post-menopausal + FH+
|
▼
TRIPLE ASSESSMENT (Gold Standard)
┌──────────────────────────────────────────┐
│ 1. CLINICAL EXAMINATION │
│ - Site, size, shape, surface │
│ - Skin: peau d'orange, nipple │
│ retraction, ulceration │
│ - Axillary / supraclavicular nodes │
│ │
│ 2. IMAGING │
│ - Mammography (gold standard >35y) │
│ - USG breast (young/dense breast) │
│ - MRI breast (high risk/BRCA) │
│ │
│ 3. PATHOLOGY (BIOPSY) │
│ - FNAC (quick, outpatient) │
│ - Core needle biopsy (preferred - │
│ gives histology + ER/PR/HER2) │
│ - Excision biopsy if above fails │
└──────────────────────────────────────────┘
|
▼
DIAGNOSIS CONFIRMED → STAGING WORKUP
┌──────────────────────────────────────────┐
│ - CXR / CT Chest │
│ - USG Abdomen / CT Abdomen-Pelvis │
│ - Bone scan (if symptomatic) │
│ - PET-CT scan (if metastasis suspected) │
│ - Tumour markers: CA 15-3, CEA │
│ - IHC: ER, PR, HER2, Ki67 │
└──────────────────────────────────────────┘
|
▼
STAGING (TNM)
T2 (2-5cm) N1 (single movable node) M0 → Stage IIA/IIB
|
▼
MANAGEMENT
┌──────────────────────────────────────────┐
│ SURGERY (primary) │
│ • BCS (Breast Conserving Surgery) │
│ + Sentinel node biopsy / ALND │
│ OR │
│ • Modified Radical Mastectomy (MRM) │
│ + Axillary clearance (if node +) │
│ │
│ ADJUVANT THERAPY │
│ • Radiotherapy (after BCS mandatory) │
│ • Chemotherapy (AC-T or CMF) │
│ • Hormonal therapy (if ER/PR +): │
│ Tamoxifen (premenopausal) │
│ Aromatase inhibitors (post-meno) │
│ • Targeted: Trastuzumab (HER2+) │
└──────────────────────────────────────────┘
TNM STAGING TABLE (BREAST)
| Stage | T | N | M | Description |
|---|---|---|---|---|
| I | T1 | N0 | M0 | Tumor ≤2 cm, no nodes |
| IIA | T2 | N0 | M0 | Tumor 2-5 cm, no nodes |
| IIB | T2 | N1 | M0 | Tumor 2-5 cm + 1-3 nodes |
| IIIA | T3 | N1 | M0 | Tumor >5 cm + nodes |
| IIIB | T4 | Any N | M0 | Chest wall/skin involvement |
| IV | Any T | Any N | M1 | Distant metastasis |
LONG ESSAY 2: THYROID SWELLING (20-yr-old, diffuse neck swelling, moves with deglutition, weight loss despite good appetite, staring look)
A. DIAGNOSIS: GRAVES' DISEASE (Diffuse Toxic Goitre)
The triad: Diffuse goitre + Hyperthyroidism + Ophthalmopathy
B. DIAGNOSTIC TESTS
Flowchart:
CLINICAL FEATURES
Diffuse neck swelling + moves with swallowing
+ Weight loss + good appetite + Staring look (exophthalmos)
|
▼
CONFIRM HYPERTHYROIDISM
┌──────────────────────────────────────┐
│ • Serum TSH ↓ (most sensitive) │
│ • Free T3, T4 ↑ │
│ • Anti-TSH receptor antibodies │
│ (TSI/TRAb) - specific for Graves │
└──────────────────────────────────────┘
|
▼
IMAGING
┌──────────────────────────────────────┐
│ • USG thyroid: diffuse enlargement, │
│ increased vascularity (Doppler) │
│ • Radioiodine uptake scan (RAIU): │
│ Diffuse ↑↑ uptake in Graves │
│ • CXR: tracheal displacement (if │
│ large goitre) │
└──────────────────────────────────────┘
|
▼
OTHER TESTS
• CBC (anaemia), LFT, ECG
• Eye examination (proptosis, lid lag, exophthalmos)
C. MANAGEMENT (MEDICAL + SURGICAL)
| Modality | Drug/Procedure | Details |
|---|---|---|
| Antithyroid drugs | Carbimazole / Methimazole | 1st line; 12-18 months course; SE: agranulocytosis |
| Propylthiouracil (PTU) | Preferred in pregnancy 1st trimester | |
| Symptom control | Propranolol (beta blocker) | Controls tachycardia, tremor, anxiety |
| Radioiodine (RAI) | I-131 | 2nd line or refractory cases; CI in pregnancy |
| Surgery | Subtotal / Total Thyroidectomy | Definitive; done after achieving euthyroid state |
| Pre-op prep | Lugol's iodine (1-2 weeks pre-op) | Reduces vascularity of gland |
D. COMPLICATIONS OF THYROID SURGERY
SURGICAL COMPLICATIONS
|
┌────┴────────────────┐
│ │
IMMEDIATE EARLY LATE
(0-24 hrs) (1-7 days) (weeks-months)
│ │ │
• Hemorrhage • Wound infection • Hypothyroidism
• Reactionary • Tetany (↓Ca²⁺) • Recurrence
haemorrhage - Damage to • Hypoparathyroidism
• Respiratory parathyroids • Keloid scar
obstruction • Thyroid storm • Adhesions
(hematoma) • Recurrent
• RLN palsy laryngeal nerve
(hoarseness) palsy (bilateral
= stridor)
| Complication | Cause | Feature | Management |
|---|---|---|---|
| Hemorrhage | Vessel slip | Neck swelling, stridor | Open wound at bedside |
| RLN palsy | Nerve injury | Hoarseness (unilateral), stridor (bilateral) | Voice therapy / tracheostomy |
| Hypoparathyroidism | Parathyroid removal | Hypocalcemia, tetany, +ve Chvostek/Trousseau | IV/PO Calcium + Vit D |
| Hypothyroidism | Excessive resection | Lethargy, weight gain, cold intolerance | Thyroxine replacement |
| Thyroid storm | Uncontrolled hyperthyroidism | High fever, tachycardia, confusion | ICU + propranolol + antithyroid + steroids |
SHORT ESSAYS
Q3. ERAS - Enhanced Recovery After Surgery
ERAS PROTOCOL FLOWCHART
|
┌────┴─────────────────────────────────┐
│ │ │ │
PRE-OP INTRA-OP POST-OP DISCHARGE
│ │ │
• Pre-op • Minimise • Early oral
counselling opioids feeding
• Carb • Short- • Early
loading acting mobilisation
(6h before) anaesthesia • Limit IV fluids
• Avoid • Laparoscopic • Remove
prolonged approach catheters early
fasting preferred • Multimodal
• LMWH analgesia
prophylaxis • DVT
prophylaxis
| ERAS Component | Evidence |
|---|---|
| Pre-op carb loading (clear fluids 2h before) | Reduces catabolism, insulin resistance |
| Avoid prolonged fasting (6h solid, 2h clear) | Reduces dehydration |
| Epidural / regional anaesthesia | Reduces opioid use |
| Minimally invasive surgery | Reduces stress response |
| Early feeding (within 24h) | Reduces ileus, infections |
| Early mobilisation (day 0/1) | Reduces DVT, pneumonia |
| Short-acting anaesthetic agents | Faster waking |
| Avoid nasogastric tube routinely | Reduces discomfort |
| Restrictive IV fluid therapy | Reduces oedema, ileus |
Benefits: Reduces LOS by 30-50%, fewer complications, faster return of bowel function.
Q4. DAMAGE CONTROL RESUSCITATION (DCR)
MASSIVE HAEMORRHAGE PATIENT
|
▼
DAMAGE CONTROL RESUSCITATION (DCR)
┌─────────────────────────────────────────┐
│ PRINCIPLE: PERMISSIVE HYPOTENSION │
│ Target BP: Systolic 80-90 mmHg │
│ (until surgical haemostasis achieved) │
└─────────────────────────────────────────┘
|
▼
┌─────────────────────────────────────────┐
│ HAEMOSTATIC RESUSCITATION │
│ RBC : FFP : Platelets = 1:1:1 ratio │
│ Tranexamic acid (within 3 hours) │
│ Cryoprecipitate (for fibrinogen ↓) │
│ Avoid crystalloids/colloids excess │
└─────────────────────────────────────────┘
|
▼
DAMAGE CONTROL SURGERY
• Control haemorrhage
• Control contamination
• Temporary closure
• ICU resuscitation → Definitive surgery later
Q5. COMPLICATIONS OF MASSIVE TRANSFUSION
Definition: Massive transfusion = >10 units pRBC in 24 hours OR replacement of patient's entire blood volume
| System | Complication | Mechanism |
|---|---|---|
| Coagulation | Dilutional coagulopathy | Dilution of clotting factors/platelets |
| DIC | Activation of coagulation cascade | |
| Metabolic | Hypocalcaemia | Citrate in blood product chelates Ca²⁺ |
| Hyperkalaemia (early) | Old blood releases K⁺ | |
| Hypokalaemia (late) | K⁺ shift back into cells | |
| Metabolic alkalosis | Citrate → bicarbonate | |
| Thermal | Hypothermia | Cold blood products |
| Pulmonary | TRALI (Transfusion-Related Acute Lung Injury) | Anti-HLA antibodies → pulmonary oedema |
| TACO (Transfusion-Associated Circulatory Overload) | Volume overload → pulmonary oedema | |
| Infection | Sepsis, Hepatitis B/C, HIV, Malaria | Transmitted pathogens |
| Immunological | Haemolytic reaction | ABO/Rh incompatibility |
| Other | Iron overload (repeated) | Each unit has 250mg iron |
| Microaggregates in lungs | Stored blood platelet aggregates |
Q6. FACTORS INFLUENCING WOUND HEALING
FACTORS AFFECTING WOUND HEALING
|
┌────┴────┐
LOCAL SYSTEMIC
│ │
• Type of • Age (elderly ↓)
wound • Malnutrition
• Blood • Vitamin C ↓ (collagen)
supply • Zinc ↓
• Infection • Vitamin A ↓
• Foreign • Diabetes (↑ infection,
body ↓ blood flow)
• Haematoma • Steroids (↓ inflammation)
• Necrosis • Chemotherapy/RT
• Wound • Anaemia / Hypoxia
tension • Jaundice / Uraemia
• Movement • Obesity
• Immunosuppression
| Local Factor | Effect on Healing |
|---|---|
| Blood supply | Essential (ischaemia = non-healing) |
| Infection | Delays healing, destroys collagen |
| Foreign body | Chronic inflammation |
| Haematoma | Infection risk, mechanical block |
| Wound tension | Dehiscence |
| Radiation | Obliterative endarteritis |
| Systemic Factor | Effect |
|---|---|
| Diabetes mellitus | Impaired PMN function, vascular disease, neuropathy |
| Malnutrition / Vit C deficiency | Deficient collagen synthesis |
| Steroids / immunosuppressants | Inhibit inflammatory phase |
| Anaemia / Hypoxia | Impaired oxidative killing, collagen synthesis |
| Age | Decreased fibroblast activity |
Q7. SURVIVING SEPSIS CAMPAIGN / SEPSIS BUNDLE
SEPSIS RECOGNITION (qSOFA: ≥2 = sepsis screen)
• RR ≥22/min
• Altered mentation
• SBP ≤100 mmHg
|
▼
SEPSIS BUNDLE - 1 HOUR BUNDLE
┌────────────────────────────────────────┐
│ 1. Measure serum lactate (>2 mmol/L) │
│ 2. Blood cultures BEFORE antibiotics │
│ 3. Broad spectrum IV antibiotics │
│ 4. 30 mL/kg IV crystalloid (if │
│ hypotension or lactate >4 mmol/L) │
│ 5. Vasopressors (norepinephrine) │
│ if BP remains low after fluids │
└────────────────────────────────────────┘
|
▼
REASSESS AT 3-6 HOURS
• Target MAP ≥65 mmHg
• Urine output ≥0.5 mL/kg/hr
• Lactate clearance ≥10%
Q8. CLASSIFICATION OF STUDY TYPES IN RESEARCH
| Level | Study Type | Evidence Level | Example |
|---|---|---|---|
| 1 (Highest) | Systematic Review + Meta-analysis | Ia | Cochrane review |
| 2 | Randomised Controlled Trial (RCT) | Ib | Drug vs placebo trial |
| 3 | Cohort study (prospective) | IIa | Cancer risk factor study |
| 4 | Case-control study | IIb | Risk factor - disease association |
| 5 | Cross-sectional study | III | Prevalence study |
| 6 | Case series / Case report | IV | Unusual presentations |
| 7 (Lowest) | Expert opinion / Editorials | V | Consensus guidelines |
Most valued: Systematic Review / Meta-analysis of RCTs - as it combines highest quality evidence from multiple RCTs, reducing bias and increasing statistical power.
Q9. INTUSSUSCEPTION IN A CHILD - CAUSES & MANAGEMENT
INTUSSUSCEPTION FLOWCHART
|
DEFINITION: Telescoping of proximal bowel
into distal bowel (usually ileocaecal)
Most common: 3 months - 2 years
|
▼
CAUSES
┌──────────────────────────────────────┐
│ IDIOPATHIC (most common in infants) │
│ - Hypertrophy of Peyer's patches │
│ (post-viral: adenovirus) │
│ │
│ PATHOLOGICAL LEAD POINTS (older): │
│ - Meckel's diverticulum │
│ - Polyp (Peutz-Jeghers) │
│ - Lymphoma (Burkitt's) │
│ - Appendix stump │
│ - Duplication cyst │
└──────────────────────────────────────┘
|
▼
CLINICAL FEATURES
• Sudden onset severe colicky pain
• Child draws knees up / screaming
• REDCURRANT JELLY STOOLS (blood + mucus)
• Sausage-shaped mass (RUQ)
• "Dance sign" - emptiness in RIF
|
▼
DIAGNOSIS
• USG abdomen: TARGET/DOUGHNUT sign
• AXR: small bowel obstruction pattern
|
▼
MANAGEMENT
┌──────────────────────────────────────┐
│ NON-OPERATIVE (1st line if <48h, │
│ no peritonitis, no perforation): │
│ • Air/hydrostatic enema reduction │
│ under fluoroscopy/US guidance │
│ Success rate: ~75-90% │
│ │
│ SURGICAL (if failed non-operative, │
│ peritonitis, perforation): │
│ • Laparotomy + Manual reduction │
│ • Resection + anastomosis if │
│ gangrenous bowel │
└──────────────────────────────────────┘
Q10. IMMUNOSUPPRESSION FOR TRANSPLANT PATIENTS
| Drug Class | Drug | Mechanism | Use |
|---|---|---|---|
| Calcineurin inhibitors | Cyclosporine | Inhibits IL-2 production (T-cell) | Maintenance |
| Tacrolimus (FK506) | Same - more potent; less cosmetic SE | Maintenance (preferred) | |
| Antimetabolites | Azathioprine | Inhibits purine synthesis → ↓ T/B cells | Maintenance |
| Mycophenolate mofetil (MMF) | Specific inhibitor of IMPDH | Maintenance | |
| mTOR inhibitors | Sirolimus / Everolimus | Blocks T-cell proliferation signal | Maintenance |
| Steroids | Prednisolone / Methylprednisolone | Broad anti-inflammatory | Induction + rejection |
| Monoclonal Ab | Basiliximab | Anti-CD25 (IL-2R) | Induction |
| OKT3 (Muromonab) | Anti-CD3 | Acute rejection | |
| Rituximab | Anti-CD20 (B-cells) | Humoral rejection | |
| Polyclonal Ab | ATG (Antithymocyte globulin) | Depletes T-lymphocytes | Induction / rejection |
Q11. NEGATIVE PRESSURE WOUND THERAPY (NPWT/VAC)
| Feature | Details |
|---|---|
| Principle | Controlled sub-atmospheric pressure (-50 to -125 mmHg) applied to wound |
| Mechanism | Removes exudate, reduces oedema, increases blood flow, stimulates granulation |
| Indications | Chronic wounds, diabetic ulcers, post-dehiscence, open fractures, burns, skin grafts |
| Components | Foam/gauze filler, adhesive drape, tubing, vacuum pump |
| Advantages | Faster wound bed preparation, reduced infection, assists graft take |
| Contraindications | Malignant wounds, untreated osteomyelitis, exposed vessels/nerves, fistulas |
Q12. ROBOTIC SURGERY - ADVANTAGES
| Advantage | Detail |
|---|---|
| 3D visualization | High-definition magnified 3D view |
| Tremor filtration | Eliminates physiological hand tremor |
| 7 degrees of freedom | Wristed instruments mimic human wrist |
| Ergonomics | Surgeon sits at console - reduced fatigue |
| Magnification | 10x magnification |
| Precise dissection | Better in confined spaces (pelvis, mediastinum) |
| Less blood loss | Precise tissue handling |
| Faster recovery | Less tissue trauma vs open surgery |
| Applications | Prostatectomy, Hartmann reversal, Whipple, thyroidectomy |
Q13. COMPLICATIONS OF TPN (Total Parenteral Nutrition)
| Category | Complication |
|---|---|
| Catheter-related | Pneumothorax (central line insertion) |
| Haemothorax, air embolism | |
| Catheter-related bloodstream infection (CRBSI) | |
| Thrombosis | |
| Metabolic | Hyperglycaemia (most common) |
| Hypoglycaemia (if stopped abruptly) | |
| Electrolyte imbalance (Na, K, Mg, PO4) | |
| Refeeding syndrome (↓ PO4, K, Mg) | |
| Hyperlipidaemia | |
| Hepatic | TPN-associated liver disease (cholestasis, steatosis) |
| Biliary sludge / gallstones | |
| Hepatic steatosis | |
| Intestinal | Gut mucosal atrophy (no enteral stimulation) |
| Bacterial translocation | |
| Deficiency | Essential fatty acid deficiency |
| Trace element deficiency (Zinc, Se, Cu) | |
| Vitamin deficiency |
Q14. RULE OF NINES IN BURNS
RULE OF NINES (Adults)
┌─────────────────────────────────────┐
│ Head & Neck = 9% │
│ Anterior trunk = 18% │
│ Posterior trunk = 18% │
│ Each upper limb = 9% × 2 = 18% │
│ Each lower limb = 18% × 2 = 36%│
│ Perineum/genitalia = 1% │
│ TOTAL = 100% │
└─────────────────────────────────────┘
CHILDREN: Lund and Browder chart preferred
(head = 18%, each leg = 13%)
Parkland Formula (Fluid Resuscitation):
Volume = 4 mL × weight (kg) × % TBSA burned
• 1st half in first 8 hours
• 2nd half in next 16 hours
• Use Ringer's Lactate
Q16. STAGES OF TB LYMPH NODE MATTING (Lymphadenitis Tuberculosa)
| Stage | Description | Features |
|---|---|---|
| I | Lymphadenitis | Firm, discrete, non-tender, mobile node |
| II | Periadenitis | Multiple nodes matted together, firm mass |
| III | Central caseation (cold abscess) | Fluctuant mass, skin normal colour |
| IV | Collar-stud abscess | Abscess penetrates deep fascia, dumbbell shape |
| V | Ulceration | Skin involved → cold ulcer with undermined edges |
Q17. CLASSIFICATION OF SHOCK
SHOCK CLASSIFICATION
|
┌─────┴──────────────────────┐
│ │ │ │
HYPO- CARDIO- DISTRI- OBSTRUC-
VOLAEMIC GENIC BUTIVE TIVE
│ │ │ │
• Haemo- • MI • Septic • PE
rrhagic • Cardiac • Anaphy- • Cardiac
• Burns tamponade lactic tamponade
• Dehy- • Arrhy- • Neuro- • Tension
dration thmia genic pneumo-
thorax
| Type | CO | SVR | CVP | Examples |
|---|---|---|---|---|
| Hypovolaemic | ↓ | ↑ | ↓ | Haemorrhage, burns, dehydration |
| Cardiogenic | ↓ | ↑ | ↑ | MI, arrhythmia, tamponade |
| Distributive (Septic) | ↑ | ↓ | ↓ | Sepsis, anaphylaxis, neurogenic |
| Obstructive | ↓ | ↑ | ↑ | PE, tamponade, tension PTX |
Haemorrhagic Shock (Class I-IV):
| Class | Blood loss | HR | BP | RR | Urine output |
|---|---|---|---|---|---|
| I | <750 mL (<15%) | <100 | Normal | 14-20 | >30 mL/hr |
| II | 750-1500 mL (15-30%) | 100-120 | Normal | 20-30 | 20-30 mL/hr |
| III | 1500-2000 mL (30-40%) | 120-140 | ↓ | 30-40 | 5-15 mL/hr |
| IV | >2000 mL (>40%) | >140 | ↓↓ | >35 | Negligible |
Q18. COMPLICATIONS OF SPLIT SKIN GRAFTING (SSG)
| Graft Site (Donor) | Recipient Site |
|---|---|
| Haematoma/seroma under graft | Pain, slow healing |
| Infection | Graft failure/non-take |
| Hypertrophic scar | Contracture |
| Pigmentation changes | Functional limitations |
| Delayed healing | Poor colour match |
Causes of Graft Failure (Non-take):
- Haematoma/seroma (most common - separates graft from bed)
- Infection
- Movement of graft
- Poor graft bed (irradiated, infected, ischaemic)
- Shearing forces
Q19. CLASSIFICATION OF ABSORBABLE SUTURES
| Type | Natural vs Synthetic | Examples | Absorption Time | Uses |
|---|---|---|---|---|
| Natural absorbable | Natural | Plain catgut | 7-10 days | Subcutaneous |
| Natural | Chromic catgut | 20-40 days | Deeper tissues | |
| Synthetic absorbable | Synthetic | Polyglycolic acid (Dexon) | 60-90 days | GI, gynaecology |
| Synthetic | Polyglactin (Vicryl) | 60-90 days | Most common used | |
| Synthetic | Polyglyconate (Maxon) | 180 days | Fascia | |
| Synthetic | Polydioxanone (PDS) | 180-210 days | Abdominal fascia | |
| Synthetic | Poliglecaprone (Monocryl) | 90-120 days | Skin closure |
Q20. INITIAL ASSESSMENT OF TRAUMA (ATLS - PRIMARY SURVEY)
ATLS PRIMARY SURVEY: ABCDE
|
─────────────────────────────────────
A = AIRWAY with C-Spine protection
• Look/Listen/Feel
• Chin lift, jaw thrust
• OPA/NPA/intubation
│
B = BREATHING & Ventilation
• Rate, depth, bilateral air entry
• Treat: tension PTX, open PTX,
massive haemothorax, flail chest
│
C = CIRCULATION with Haemorrhage control
• HR, BP, capillary refill
• IV access × 2 (large bore)
• 2L Hartmann's bolus
• DIRECT PRESSURE on wounds
│
D = DISABILITY (Neurological)
• GCS score
• Pupils (PEARL)
• Blood glucose
│
E = EXPOSURE & Environment
• Fully expose patient
• Log roll
• Prevent hypothermia
│
─────────────────────────────────────
SECONDARY SURVEY (Head-to-toe exam)
+ AMPLE History
+ Definitive care
Q (Burns): RULE OF NINES + FLUID MANAGEMENT - 60% BURNS
IMMEDIATE MANAGEMENT OF MAJOR BURNS
|
▼
RESUSCITATION (Primary survey - ABCDE)
• Airway: risk of inhalation injury
• Secure IV access (2 large bore)
|
▼
FLUID RESUSCITATION
Parkland Formula:
4 mL × 60 kg × 60% TBSA = 14,400 mL in 24 hours
• 7,200 mL in first 8 hours
• 7,200 mL in next 16 hours
• Fluid: Ringer's Lactate
|
▼
WOUND MANAGEMENT
┌──────────────────────────────────────┐
│ INITIAL (first 48-72h) │
│ • Cool the burn (cool running water │
│ 15-20 min within 30 min) │
│ • NOT ice/cold water │
│ • Silver sulfadiazine cream │
│ • Non-adherent dressings │
│ │
│ SUBSEQUENT │
│ • Daily wound inspection │
│ • Superficial burns: conservative │
│ • Deep partial/full thickness: │
│ Early excision + skin grafting │
│ (within 48-72h) │
│ • Escharotomy if circumferential │
└──────────────────────────────────────┘
Q: DIFFERENTIATE HYPERTROPHIC SCAR vs KELOID
| Feature | Hypertrophic Scar | Keloid |
|---|---|---|
| Confined to wound | YES - stays within wound margins | NO - extends beyond margins |
| Regression | Regresses spontaneously with time | Does NOT regress |
| Time of onset | Within 4 weeks | Weeks to months later |
| Symptoms | Mild itching | Severe itching, pain |
| Sites | Any site | Earlobes, chest, shoulders, upper back |
| Recurrence after surgery | Low | HIGH |
| Racial predisposition | All races | Darker-skinned individuals |
| Treatment | Pressure, silicone, steroid injection | Steroid injection, compression, re-excision + RT |
Q: GLASGOW COMA SCALE (GCS) IN HEAD INJURIES
| Component | Response | Score |
|---|---|---|
| Eye Opening | Spontaneous | 4 |
| To verbal command | 3 | |
| To pain | 2 | |
| None | 1 | |
| Verbal | Oriented | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| None | 1 | |
| Motor | Obeys commands | 6 |
| Localises pain | 5 | |
| Withdraws | 4 | |
| Abnormal flexion (Decorticate) | 3 | |
| Extension (Decerebrate) | 2 | |
| None | 1 |
- Maximum: 15 (Normal)
- Minimum: 3 (Deep coma)
- Severe head injury: GCS ≤8 (intubate)
- Mild: 13-15, Moderate: 9-12
Q: ACUTE APPENDICITIS (Diagnosis + Management)
CLINICAL DIAGNOSIS FLOWCHART
Pain starts at UMBILICUS (visceral)
→ migrates to RIF (McBurney's point) parietal
+ Nausea, vomiting, fever
+ Tenderness at McBurney's point
+ Rebound tenderness (Blumberg's sign)
+ Rovsing's sign positive
+ Psoas/obturator sign
|
▼
Alvarado Score ≥7 → Appendicectomy
|
INVESTIGATIONS
• FBC: Leucocytosis (WBC >11,000)
• CRP elevated
• USG abdomen: non-compressible tube >6mm
• CT abdomen (gold standard if uncertain)
|
▼
MANAGEMENT
• IV fluids, IV antibiotics (cefuroxime + metronidazole)
• APPENDICECTOMY
- Laparoscopic (preferred)
- Open (Lanz / Gridiron incision)
• If perforated: peritoneal lavage + drain
Q: PERITONITIS (45-yr Male, Rigid Abdomen, Obliterated Liver Dullness = Perforation)
AETIOLOGY
Peptic ulcer perforation (most common cause
in patient taking NSAIDs + rigid abdomen)
|
▼
DIAGNOSIS
• X-ray Erect CXR: Air under diaphragm
(pneumoperitoneum) - PATHOGNOMONIC
• USG abdomen: free fluid
• CT abdomen: site of perforation
|
▼
RESUSCITATION (Drip & Suck)
• IV fluids (Hartmann's)
• NGT aspiration
• Urinary catheter
• IV antibiotics (broad spectrum)
• IV PPI
• NPO
|
▼
SURGERY
• Emergency laparotomy / laparoscopy
• Simple closure (omental patch - Graham patch)
• Peritoneal lavage + drain
• Post-op H. pylori eradication
Q: OBSTRUCTIVE JAUNDICE (55-yr Male, Abdominal Pain, Weight Loss, Itching)
CAUSES OF OBSTRUCTIVE JAUNDICE
|
┌────┴─────────┐
INTRALUMINAL WALL LESION EXTRINSIC
(In lumen) (In wall) COMPRESSION
│ │ │
Gallstones Cholangiocarc Pancreatic
CBD stone inoma Ca (head)
Parasites Stricture Lymph nodes
Blood clot Sclerosing Mirizzi syn
cholangitis
55-yr male + Progressive jaundice + Weight loss + Itching → Carcinoma Head of Pancreas
| Investigation | Finding |
|---|---|
| USG abdomen | Dilated CBD, dilated GB (Courvoisier's sign) |
| CT abdomen (triple phase) | Hypoechoic mass in head of pancreas |
| ERCP | Ampullary obstruction, tissue biopsy |
| MRCP | Biliary anatomy |
| CA 19-9 | Tumour marker (elevated) |
| Liver function tests | ↑ Bilirubin (conjugated), ↑ ALP, ↑ GGT |
Management:
- Resectable: Whipple's procedure (pancreaticoduodenectomy)
- Unresectable: Biliary bypass (cholecystojejunostomy) / ERCP stenting
Q: MEN SYNDROMES
| Feature | MEN 1 (Wermer) | MEN 2A (Sipple) | MEN 2B |
|---|---|---|---|
| Gene | MEN1 gene | RET proto-oncogene | RET proto-oncogene |
| Pituitary | Tumour (prolactinoma) | - | - |
| Parathyroid | Hyperplasia/adenoma | Hyperplasia | - |
| Pancreas | Gastrinoma (ZE syndrome), Insulinoma | - | - |
| Adrenal | - | Phaeochromocytoma | Phaeochromocytoma |
| Thyroid | - | Medullary Ca thyroid | Medullary Ca thyroid |
| Other | - | - | Mucosal neuromas, Marfanoid habitus |
Q: CLASSIFY ABSORBABLE SUTURES (Short Answer)
(Same as Q19 above - refer to table)
Q: PRINCIPLES OF ORGAN TRANSPLANTATION
TRANSPLANT PRINCIPLES
|
┌────┴────────────────────┐
│ │ │
DONOR MATCHING RECIPIENT
CRITERIA CRITERIA CRITERIA
│ │ │
• Brain • ABO blood • End-stage
death group organ failure
• Age • HLA typing • No active
• No (A, B, DR) infection
sepsis • Cross-match • No active
• Consent • CMV status malignancy
• Fit for
anaesthesia
|
▼
SURGICAL PROCEDURE
Cold ischaemia time minimised
Vascular anastomosis + organ implantation
|
▼
POST-OPERATIVE IMMUNOSUPPRESSION
Triple therapy: Tacrolimus + MMF + Prednisolone
|
▼
MONITORING FOR REJECTION
• Acute rejection (days-weeks): rising creatinine, fever
• Chronic rejection (months-years): progressive decline
• Biopsy for confirmation
• Treated with: steroids, ATG, or basiliximab
Q: COMPONENTS OF TRIAGE
| Priority | Colour | Category | Examples |
|---|---|---|---|
| P1 | Red | Immediate - life-threatening, salvageable | Tension PTX, major haemorrhage |
| P2 | Yellow | Urgent - serious but can wait | Fractures, moderate burns |
| P3 | Green | Delayed/Walking wounded | Minor lacerations, sprains |
| P4 | Black | Expectant - unsurvivable or dead | Massive head injury, cardiac arrest (MCI) |
START Triage Algorithm:
- Breathing? → No: Position/open airway → No breathing = Black
- RR >30 or <10 = Red
- Radial pulse absent = Red
- Can't follow commands = Red
- Otherwise = Yellow or Green
Q: PLEOMORPHIC ADENOMA (Parotid)
| Feature | Details |
|---|---|
| Most common | Benign parotid tumour (~80% of parotid tumours) |
| Peak age | 40-60 years |
| Presentation | Slow growing, painless lump in parotid (pre-auricular) region |
| Facial nerve | Usually intact (distinguishes from malignancy) |
| Histology | Mix of epithelial + myoepithelial + stromal (myxoid/chondroid) elements |
| Imaging | USG + MRI (preferred) |
| FNAC | Confirms benign nature |
| Treatment | Superficial parotidectomy (NOT enucleation - high recurrence) |
| Complication of surgery | Frey's syndrome (gustatory sweating), facial nerve palsy, recurrence |
| Malignant transformation | ~5-10% → carcinoma ex-pleomorphic adenoma |
Q: BASAL CELL CARCINOMA (BCC)
| Feature | Details |
|---|---|
| Most common skin cancer | ~70% of all skin cancers |
| Sites | Face (nose, nasolabial fold, periorbital), sun-exposed |
| Predisposing factors | UV radiation, fair skin, immunosuppression, Gorlin syndrome |
| Type | Features |
|---|---|
| Nodular BCC | Pearly nodule with rolled edges, telangiectasia |
| Superficial BCC | Flat, erythematous patch |
| Morphoeic/Sclerosing | Scar-like, ill-defined margins |
| Pigmented BCC | Dark, mimics melanoma |
| Rodent ulcer | Ulcerated nodular BCC with rolled edges |
Management:
BCC Diagnosis (biopsy)
|
┌────┴──────────────────┐
LOW RISK HIGH RISK
(nodular, small, (morphoeic, large,
well-defined) ill-defined, recurrent)
│ │
Surgical excision Wide excision
(3-4 mm margins) (5-10 mm margins)
OR Mohs surgery + Mohs surgery
Radiotherapy Radiotherapy if inoperable
Cryotherapy (small)
Q: GAS GANGRENE
| Feature | Details |
|---|---|
| Organism | Clostridium perfringens (most common), C. septicum, C. novyi |
| Type | Clostridial myonecrosis (spreading muscle necrosis) |
| Predisposing factors | Contaminated wounds, diabetes, vascular disease, compound fractures |
| Toxin | Alpha toxin (lecithinase) - destroys cell membranes |
CLINICAL FEATURES (develop within 6-48h):
• Severe pain at wound site (disproportionate)
• Swelling + tense oedematous skin
• Crepitus on palpation (gas in tissues)
• Bronze/discoloured skin → bullae → gangrene
• Sweet/offensive smell (dishwater discharge)
• SYSTEMIC TOXAEMIA: High fever, rapid HR,
confusion, jaundice, haemolysis, renal failure
Management:
EMERGENCY MANAGEMENT
|
┌────┴─────────────────────┐
│ │ │
SURGICAL ANTIBIOTICS HYPERBARIC O2
│ │ │
Radical IV Penicillin G (adjunct if
debridement + Clindamycin available)
/Amputation + Metronidazole
(life-saving)
Q: SIGMOID VOLVULUS
| Feature | Details |
|---|---|
| Definition | Twisting of sigmoid colon on its mesenteric axis |
| Risk factors | High fibre diet, constipation, elderly, psychiatric/neurological |
| Presentation | Sudden onset distension + obstipation + colicky pain |
| X-ray | "Coffee bean" / "Omega loop" / "Bent inner tube" sign |
| CT | Whirl sign, bird-beak sign |
| Initial treatment | Flexible sigmoidoscopy + rectal tube decompression (80% success) |
| Surgery | Hartmann's procedure (if gangrenous/failed decompression) |
| Definitive | Elective sigmoid resection to prevent recurrence |
Q: LAPAROSCOPIC CHOLECYSTECTOMY (Principles / Informed Consent)
Steps:
Port placement (4 ports: umbilical 10mm + epigastric 10mm + 2 × 5mm RUQ)
→ Pneumoperitoneum (CO2, 12-15 mmHg)
→ Identify Critical View of Safety (CVS):
Hepatocystic triangle cleared, cystic duct and artery identified
→ Clip cystic duct (double proximal, single distal)
→ Clip cystic artery
→ Dissect gall bladder from fossa
→ Extract specimen
→ Check haemostasis + biliary leak
Complications:
- Bile duct injury (most feared)
- Bleeding
- Port site hernia
- Conversion to open
- CBD injury
Q: TETANUS
| Feature | Details |
|---|---|
| Organism | Clostridium tetani (anaerobic, spore-forming) |
| Toxin | Tetanospasmin (blocks inhibitory neurotransmitters GABA/glycine) |
| Incubation | 3-21 days (shorter = more severe) |
| Type | Features |
|---|---|
| Generalised | Most common; trismus, risus sardonicus, opisthotonus |
| Local | Stiffness/spasm near wound |
| Cephalic | Head and neck (facial nerve palsy) |
| Neonatal | Umbilical stump infection |
Management:
TETANUS MANAGEMENT
|
┌────┴──────────────────────────────┐
│ │ │ │
WOUND ANTITOXIN ANTIBIOTIC SEDATION
│ │ │ │
Clean & TIG 3000- IV Penicillin Diazepam
debride 5000 IU IM / Metro- Midazolam
(Human TIG) nidazole Magnesium
+ Tetanus sulphate
toxoid
(different
sites)
References: Bailey and Love's Short Practice of Surgery 28th Ed; Robbins & Kumar Basic Pathology; Schwartz's Principles of Surgery 11th Ed; S Das Manual on Clinical Surgery.
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