confidence is the key

How to answer:
State → % TBSA (Total Body Surface Area) + depth + associated injuries.

Model Answer:

• Extent: Use Rule of Nines – Head 9 %, Each upper limb 9 %, Each lower limb 18 %, Front trunk 18 %, Back 18 %, Perineum 1 %.
• Depth: Superficial / Partial thickness / Full thickness.
• Severity classification:
  • Minor < 10 % TBSA (adult)
  • Moderate 10–20 %
  • Major > 20 % or any airway / face / circumferential / electrical burns.

🔹Tip: Mention Lund–Browder chart for children.

Model Answer:
💧 Parkland Formula:
→ 4 mL × % TBSA × Body weight (kg)

• Give ½ in first 8 h, remaining ½ in next 16 h.
• Use Ringer Lactate solution.

Example: 60 kg adult with 40 % burns → 4 × 60 × 40 = 9600 mL.
• 4800 mL in 1st 8 h • 4800 mL in next 16 h.

Monitor: Urine output ≥ 0.5 mL/kg/hr.

🔹Tip: Resuscitation starts from time of burn, not hospital arrival.

Model Answer:

1. Stop the burn → remove source / smouldering clothes.
2. Cool area with running water (15–20 min, not ice).
3. Cover with clean cloth / sterile sheet.
4. Do not apply ointment / toothpaste.
5. Give analgesic + tetanus prophylaxis.

🔹Tip: Avoid prolonged cooling → may induce hypothermia.

Model Answer:
🔸 A → Airway: Secure airway & check for inhalation injury.
🔸 B → Breathing: 100 % oxygen / intubate if soot in airway.
🔸 C → Circulation: 2 wide-bore IV lines + fluids (Parkland).
🔸 D → Disability: Pain control – IV opioids preferred.
🔸 E → Exposure: Estimate TBSA, prevent hypothermia.

• Wound care, antibiotics, nutrition, monitor urine output.

🔹Tip: Always check for carbon-monoxide poisoning → treat with 100 % oxygen.

🔹Tip: Marjolin ulcer = squamous cell carcinoma in old burn scar.

Model Answer:

• Crystalloids: Normal saline, Ringer lactate, 5 % dextrose.
• Colloids: Albumin, Dextran, Hetastarch.
• Blood products: PRBCs, FFP, platelets.

Choice:

• Maintenance → Crystalloids.
• Resuscitation → Ringer lactate / normal saline.
• Hypoalbuminemia → Colloids.

🔹Tip: Avoid 0.45 % saline in resuscitation → risk of hyponatremia.

• Definition: Hernia is the protrusion of a viscus or part of it through a normal or abnormal opening in the wall that contains it.
• Common sites:
  • Inguinal region (Indirect / Direct)
  • Femoral
  • Umbilical
  • Incisional
  • Epigastric

Direct hernia

Mnemonic (DIRect is Direct ) Old man are straight forward person

Age – Old Age So Acquired Hernia Except Ogilvie Hernia

DM HTP (every website start from   www.htp…so lets start..) ^{every line is Q}

• Direct hernia
• medial to the inferior epigastric vessel ^Q
• Protrudes through the Hesselbach’s triangle (a weak area in the abdominal wall).
• Transversalis fascia weakness ^Q
• Protrusion through Posterior wall of the inguinal canal

** wide neck of sac – less chance of obstruction ^{Q upsc cms}

^{** some} important Point about Hesselbach’s triangle

Signature mnemonic by DR Varun Agarwal

inguinal triangle (Hesselbach’s triangle) ^{** cms **}

is a region in the anterior abdominal wall.

Boundaries Mnemonic (every one knows  MLA LIE .. leader jhoot bolte hai ) ^{** cms **}

MLA :    Medial – Lateral border of Rectus Abdominis muscle

LIE :  Lateral – inferior Epigastric vessel

II  Inferior- inguinal ligament   ( I match with I )

Model Answer:

• Definition: When the blood supply of herniated contents is compromised, leading to ischemia and gangrene.
• Symptoms: Severe pain, tenderness, vomiting, irreducible lump, absent cough impulse.
• Management:
  • Resuscitate (fluids, antibiotics, NG tube)
  • Emergency surgery (hernia reduction + resection of gangrenous bowel + hernioplasty).

🔹Tip:
Painful irreducible hernia with vomiting = Strangulation until proved otherwise.

Model Answer:

• Definition: Type of hernia where only part of the bowel wall (antimesenteric border) is trapped in the defect.
• Feature: May not cause obstruction but can cause gangrene and perforation.
• Sites: Femoral > Inguinal.
• Management: Emergency surgical repair.

🔹Tip:
Richter’s = “Partial loop trapped, full trouble.”

Model Answer:

• Definition: Hernia in which part of the wall of the sac is formed by a viscus (commonly colon or bladder).
• Sites: Left side → sigmoid colon; Right side → cecum or bladder.
• Surgery: Handle carefully to avoid bowel injury during sac dissection.

🔹Tip:
Always open sac from the opposite side in a sliding hernia.

• Definition: Collection of serous fluid within the tunica vaginalis surrounding the testis.
• Types:
  • Congenital: Patent processus vaginalis (communicates with peritoneum).
  • Acquired: Secondary to trauma, infection, or idiopathic.
• Clinical features:
  • Painless scrotal swelling, translucent on transillumination, testis not separately palpable.
• Treatment:
  • Plication (Lord’s), eversion (Jaboulay’s), or excision of sac.

🔹Tip:
Always examine testis separately — inability to feel → think hydrocele; if testis separate → epididymal cyst.

🔹Tip:
“Glows = Hydrocele; Gurgles = Hernia.”

State normal non-palpability → list conditions → highlight Courvoisier’s sign.

Model Answer:

• Normally, gallbladder is not palpable.
• It becomes palpable when distended due to obstruction of the cystic duct or CBD below the cystic duct junction.

Common causes:

• Carcinoma head of pancreas
• Carcinoma ampulla of Vater
• CBD obstruction (benign stricture, stone below cystic duct)
• Mucocele / empyema of gallbladder

Not palpable:

• Stone in cystic duct or chronic cholecystitis → fibrosed gallbladder.

🔹Tip:
Courvoisier’s Law: “In a jaundiced patient, palpable gallbladder → cause is not stone (malignant obstruction likely).”

🔹Tip:
Always ask: “Is stool pale, urine dark?” → points toward obstructive jaundice.

🔹Tip:
Dark urine + clay stool + itching = Obstructive Jaundice
Normal urine + dark stool = Hemolytic Jaundice

List anatomical/systemic causes + stress importance of ABC assessment.

Model Answer:

• Inflammatory: Appendicitis, cholecystitis, diverticulitis, pancreatitis
• Perforative: Peptic-ulcer perforation, typhoid perforation
• Obstructive: Intestinal obstruction (adhesions, hernia, volvulus)
• Vascular: Mesenteric ischemia, ruptured aneurysm
• Gynaecologic/Urinary: Ectopic pregnancy, renal colic, UTI

🔹Tip:
Always begin management with → ABCs + IV fluids + analgesia + urgent surgical review.

• Small bowel: Adhesions (60 %), hernia, intussusception, volvulus, strictures, gallstone ileus.
• Large bowel: Carcinoma colon, volvulus (sigmoid / cecal), diverticular stricture, fecal impaction.

🔹Tip:
Adhesion = most common overall; carcinoma = commonest large-bowel cause.

• Definition: Telescoping of one bowel segment into another (usually ileocolic).
• Triad: Colicky pain + “red currant jelly” stool + palpable sausage-shaped mass.
• Management:
  1. Initial resuscitation (IV fluids, NG tube, antibiotics).
  2. Non-operative reduction — hydrostatic or air enema (under fluoroscopy/USG).
  3. If failed / perforation → surgical reduction or resection.

🔹Tip:
Classic in children 6 mo – 2 yrs after viral infection or Meckel diverticulum

Conservative management of appendicular mass.

• Nil per oral + IV fluids.
• IV antibiotics (ceftriaxone + metronidazole).
• Analgesics + bed rest + observation.
• If fever or toxicity ↑ → abscess formation → USG guided drainage.
• Interval appendicectomy after 6–8 weeks.

🔹Tip:
Used only when appendicular mass present (not generalised peritonitis).

• Perforation of hollow viscus: Peptic ulcer (commonest).
• Post-operative / post-laparoscopy.
• Trauma to stomach or intestine.
• Infection with gas-forming organisms.

🔹Tip:
On erect X-ray chest → air beneath right hemidiaphragm = diagnostic sign of perforation.

Causes:

• Peptic ulcer (50 %) • Gastritis / duodenitis • Esophageal varices • Mallory–Weiss tear • Malignancy

Management:

1. Resuscitation: IV access × 2, fluids, cross-match blood.
2. Investigations: CBC, LFT, coagulation profile, endoscopy.
3. Specific:
   • PPI infusion (omeprazole / pantoprazole).
   • Endoscopic banding or sclerotherapy (varices).
   • Octreotide or terlipressin in portal HTN.
4. Surgery / TIPS if recurrent bleeding.

🔹Tip:
First resuscitate then investigate — “Don’t scope a shock patient.”

• Sudden severe abdominal pain with board-like rigidity.
• Obliteration of liver dullness (air under diaphragm).
• Tachycardia, fever, toxemia.
• X-ray chest erect → free air under diaphragm.

Management: Fluid resuscitation + NG tube + IV antibiotics + emergency exploratory laparotomy.

🔹Tip:
Commonest cause = duodenal ulcer perforation.

1. Stabilize: Airway + IV fluids + blood transfusion.
2. Medical: Octreotide / Terlipressin to reduce portal pressure.
3. Endoscopic: Variceal band ligation (preferred) / sclerotherapy.
4. Balloon tamponade (Sengstaken–Blakemore tube) if uncontrolled.
5. TIPS / surgery for recurrent bleed.
6. Prophylaxis: Non-selective beta-blocker (Propranolol).

🔹Tip:
Variceal bleed = medical emergency → start vasoactive drugs immediately.

Acute pancreatitis — inflammation of pancreas due to alcohol / gallstones.

• Pain: Severe epigastric → radiates to back, relieved by leaning forward.
• Diagnosis: ↑ Serum amylase / lipase × 3 normal, CT Balthazar score.
• Management: NPO, IV fluids, analgesics, antibiotics (if infected necrosis), treat cause (cholecystectomy later).

🔹Tip:
Mnemonic → “PANCREAS” – Pain, Amylase, NPO, Crystalloids, Relieve pain, Evaluate cause, Antibiotic selective, Surgery if necrosis.

Define clearly → state acute vs chronic → list common causes of non-healing.

Model Answer:

• Ulcer = break in continuity of epithelium with loss of surface tissue and discharge.
• Causes of non-healing ulcer:
  • Persistent infection (e.g. tuberculosis, osteomyelitis)
  • Poor blood supply (peripheral arterial disease, diabetes)
  • Malignancy (Marjolin ulcer)
  • Repeated trauma / pressure
  • Inadequate nutrition / immunosuppression

🔹Tip:
Always biopsy a chronic ulcer > 3 weeks duration to rule out malignancy.

• Area of venous stasis → high hydrostatic pressure → tissue hypoxia.
• Common cause: Chronic venous insufficiency after DVT or varicose veins.
• Skin here is thin and poorly vascularised → predisposed to ulceration.

🔹Tip:
Venous ulcer = medial malleolus | Arterial ulcer = lateral malleolus / toes.

🔹Tip:
Non-healing ulcer with everted edges = suspect SCC → biopsy.

Causes:

• Inflammatory: Appendicular mass / abscess / Crohn’s disease
• Neoplastic: Cecal carcinoma / Ileocecal tuberculosis
• Gynaecologic: Ovarian cyst / tubo-ovarian mass
• Others: Iliac lymphadenopathy, psoas abscess

Investigations:

• CBC, ESR, LFT, urine routine
• USG abdomen ± CT abdomen
• Colonoscopy if suspicious of malignancy

🔹Tip:
Always exclude appendicular mass first in acute presentation.

• Liver: Hepatomegaly, abscess, cyst, tumour
• Gall bladder: Empyema, carcinoma, mucocele
• Kidney: Right renal mass / hydronephrosis
• Colon: Hepatic flexure growth
• Chest: Pleural effusion / lung abscess downward palpable

🔹Tip:
Move the lump with respiration → liver origin likely.

• Gastrointestinal: Peptic ulcer, gastritis, GERD, pancreatitis, perforation
• Cardiac: MI or angina (esp. in elderly)
• Biliary: Gallstones, cholecystitis
• Aortic: Aneurysm dissection

🔹Tip:
Epigastric pain + radiation to back → think pancreatitis.
Epigastric pain + radiation to left arm → think MI.

Define each term briefly — cause + key feature + example.

Model Answer:

• Inflammation: Local protective response to injury or infection characterized by redness, heat, swelling, pain, and loss of function.
• Cellulitis: Diffuse, non-suppurative infection of connective tissue planes caused by Streptococcus pyogenes.
• Abscess: Localized collection of pus within tissue, usually due to Staphylococcus aureus infection.
• Cold Abscess: Chronic abscess without classical signs of acute inflammation, commonly due to tuberculosis.

🔹Tip:
Cellulitis → diffuse; Abscess → localized; Cold abscess → tubercular origin

🔹Tip:
Think “circumscribed = abscess, diffuse = cellulitis”.

• Gangrene: Death of tissue with putrefaction caused by loss of blood supply.

🔹Tip:
Gas gangrene → emergency → give high-dose IV penicillin + debridement + hyperbaric oxygen.

• Definition: Inadequate tissue perfusion causing cellular hypoxia.
• Types: Hypovolemic, cardiogenic, distributive (septic, anaphylactic), neurogenic.
• Management (ABCDE):
  • A: Airway with cervical spine protection.
  • B: Breathing — oxygen 10–15 L/min.
  • C: Circulation — 2 large-bore IV lines, fluids (crystalloids), monitor BP.
  • D: Disability — GCS assessment.
  • E: Exposure — look for bleeding, injuries.
  • Treat cause (fluids, vasopressors, blood transfusion).

🔹Tip:
Use 3:1 rule → 3 mL crystalloid for every 1 mL blood loss.

• Definition: Sorting of patients based on urgency of treatment.
• Categories:
  • Red: Immediate (life-threatening but treatable).
  • Yellow: Delayed (serious but stable).
  • Green: Minor (walking wounded).
  • Black: Dead or moribund.

🔹Tip:
Objective → maximize survival using limited resources.

Primary Survey (ABCDE):

• A: Airway with cervical spine protection
• B: Breathing & ventilation
• C: Circulation & control of hemorrhage
• D: Disability (neurological status)
• E: Exposure (remove clothing, prevent hypothermia)

Secondary Survey:

• Head-to-toe examination after stabilization
• Detailed history, focused investigations

🔹Tip:
Always reassess after each intervention.

• Purpose: To assess level of consciousness.
• Components:
  • Eye opening (E) — 4
  • Verbal response (V) — 5
  • Motor response (M) — 6
  • Total = 15 (best) to 3 (worst)

Interpretation:

• 13–15 → Mild head injury
• 9–12 → Moderate
• ≤8 → Severe

🔹Tip:
GCS ≤ 8 → Intubate immediately.