Answer: Haemorrhoidal disease

Haemorrhoids are a normal part of the anatomy of the anorectum. They are vascular cushions that serve to protect the anal sphincter, aid closure of the anal canal during increased abdominal pressure, and provide sensory information that helps differentiate among stool, liquid and gas. Because of their high vascularity and sensitive location, they are also a frequent cause of pathology. Contributing factors include pregnancy, chronic constipation, diarrhoea or prolonged straining, weight lifting, and weakening of supporting tissue as a result of aging or genetics.
Haemorrhoids are classified according to their position relative to the dentate line. External haemorrhoids lie below the dentate line, are covered by squamous epithelium and innervated by cutaneous nerves. If symptomatic, the only definitive therapy is surgical excision.
Internal haemorrhoids arise above the dentate line, are covered by columnar cells and have a visceral nerve supply. They are further categorized — and treated — according to their degree of prolapse:
-Grade I haemorrhoids bleed but do not prolapse; on colonoscopy, they are seen as small bulges into the lumen.
-Grade II haemorrhoids prolapse outside the anal canal but reduce spontaneously.
-Grade III haemorrhoids protrude outside the anal canal and usually require manual reduction.
-Grade IV haemorrhoids are irreducible and constantly prolapsed. Acutely thrombosed haemorrhoids and those involving rectal mucosal prolapse are also grade IV.

Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of haemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Anal fissures are tears of the sensitive mucosal lining of the anus. Anal fissures often cause pain during and after a bowel movement, sometimes followed by throbbing pain for several hours. They are also often associated with itching and blood on toilet tissue, in the bowl, or on the surface of the stool. Anal fissures are caused by
trauma to the anal canal usually during bowel movements. Anal fissures are also sometimes caused by inflammatory bowel disease or infection.

Flow in any vessel = Effective perfusion pressure divided by resistance, where effective perfusion pressure is the mean intraluminal pressure at the arterial end minus the mean pressure at the venous end. Thus, in the given problem, resistance = (60 − 20)/200 = 0.2 mmHg/ml per min.

Vitamin K is a fat soluble vitamin requiring fat metabolism to function properly to allow for its absorption. People with obstructive jaundice develop vitamin k deficiency as fat digestion is impaired. Vit K causes carboxylation of glutamate residue and hence regulates blood coagulation including: prothrombin (factor II), factors VII, IX, X, protein C, protein S and protein Z.

The T-wave is formed due to ventricular repolarisation. Normally, it is seen as a positive wave. It can be normally inverted (negative) in V1 (occasionally in V2-3 in African-Americans/Afro-Caribbeans). Hyperacute T-waves are the earliest ECG change of acute myocardial infarction. ECG findings of hyperkalaemia include high, tent-shaped T-waves, a small P-wave and a wide QRS complex. Hypokalaemia results in flattened (notched) T-waves, U-waves, ST-segment depression and prolonged QT interval.

It is known that the small saphenous vein has nine to twelve valves along its course. This vein begins as a direct continuation of the lateral marginal vein posterior to the lateral malleolus. It is superficially situated but closer to its termination, perforates the deep fascia in the lower part of the popliteal fossa to end in the popliteal vein.

Treatment of Crohn’s disease is based on the disease site, pattern, activity, and severity. The general goals of treatment for Crohn’s disease are as follows:
To achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medication.
To permit the patient to function as normally as possible.
Therapy for mild Crohn’s disease is typically administered in a sequential “step-up” approach, in which less aggressive and less toxic treatments are initiated first, followed by more potent medications or procedures if the initial therapy fails.
Patients are treated with preparations of 5-aminosalicylic acid (5-ASA), antibiotics, and nutritional therapy. However, the use of 5-ASA for the treatment of Crohn’s disease is controversial; only a small subset of patients may benefit from this agent. Although 5-ASA is effective for reducing disease activity in active Crohn’s disease, it typically has a lower efficacy for Crohn’s disease than for ulcerative colitis, and its efficacy for maintenance of remission remains unproven.

If no response occurs or if the disease is more severe than initially thought, corticosteroids and inhibitors of DNA synthesis (i.e., immunomodulators) with 6-mercaptopurine (6-MP)/azathioprine or methotrexate are administered. Finally, biologic agents (infliximab, adalimumab, certolizumab pegol, and natalizumab) and surgical therapies can be useful.

For the treatment of moderate to severe Crohn’s disease, current recommendations include the “top-down” approach, which differs from the conventional step-up approach in that more potent agents are administered initially. Top-down therapies include biologic agents and steroids as needed versus combination therapy with both biologic drugs and immunomodulatory agents.

Azathioprine or 6-MP is effective for maintenance of remission in Crohn’s disease; each is effective for avoiding surgery and for preventing postoperative and endoscopic relapse. Both agents can be used in combination with infliximab.

If medical therapy for active Crohn’s disease fails, surgical resection of the inflamed bowel, with the restoration of continuity, is indicated.

Recommended indications for surgical intervention include the following:
Failed medical therapy
Persistent symptoms despite high-dose corticosteroid therapy
Treatment-related complications, including intra-abdominal abscesses
Medically intractable fistulae
Fibrotic strictures with obstructive symptoms
Toxic megacolon
Intractable haemorrhage
Perforation
Cancer

For Rectal Crohn’s: Proctectomy is appropriate, and in published series, it is required in 10 to 20% of cases. Unfortunately, proctectomy can be complicated by poor wound healing and perineal sinus formation in up to 25 to 50% of patients. A gracillis flap can be helpful.

A cervical rib in humans is an extra rib which arises from the C7 vertebra. Its presence is a congenital abnormality located above the normal first rib, and it consists of an anomalous fibrous band that often originates from C7 and may arc towards but rarely reaches the sternum. It is estimated to occur in 0.2% to 0.5% of the population. People may have a cervical rib on the right, left, or both sides.

Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they vary widely in size and shape, and in rare cases, they may cause problems such as contributing to thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery.

Compression of the brachial plexus may be identified by weakness of the muscles near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson’s sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.

Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision of the cervical rib.

Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.

The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours.

Fat embolism is a life-threatening form of embolism in which the embolus consists of fatty material or bone marrow particles that are introduced into the systemic venous system. It may be caused by long-bone fractures, orthopaedic procedures, sickle cell crisis, parenteral lipid infusion, burns and acute pancreatitis. Patients with fat embolism usually present with symptoms that include skin, brain, and lung dysfunction.

The proximal part of the duodenum is supplied by the gastroduodenal artery. This artery is found descending behind the first part of the duodenum after branching from the hepatic artery. If gastric content was to be expelled in the posterior portion of the first part of the duodenum, then this artery would be most likely to be damaged. The common hepatic artery and the left gastric artery are branches of the coeliac trunk that are found superior to the duodenum. The proper hepatic artery is a branch of the common hepatic artery also found superior to the duodenum. The superior mesenteric artery is found behind the pancreas as a branch of the aorta that is at the bottom of the L1 level. The right gastric artery arises above the pylorus from the proper hepatic artery and supplies the lesser curvature of the stomach. The intestinal arteries supply the ileum and the jejunum.

Antithrombin III is a glycoprotein that inactivates multiple enzymes involved in the coagulation system. It inactivates factor X, factor IX, factor II, factor VII, factor XI and factor XII. Its activity is greatly increased by the action of heparin.

Extradural haematoma (EDH) is defined as an acute bleed between the dura mater and the inner surface of the skull. This then causes increased intracranial pressure, which puts vital brain structures at risk. The question asks for the least likely cause, and extradural hematoma would be acute in onset.

The diagnosis for this case is acute haemolytic transfusion reaction, due to ABO incompatibility. Haemolysis of the transfused cells can cause loin pain, shock, and hemoglobinemia, which may subsequently lead to disseminated intravascular coagulation. A direct Coombs test should confirm haemolysis. Other tests include unconjugated bilirubin, haptoglobin, serum and urine free haemoglobin.

Delayed haemolytic reactions, however, are normally associated with antibodies to the Rh system and occur 5–10 days after transfusion.

Acute transfusion reactions present during or within 24 hours of a blood transfusion. The most frequent clinical features are fever, chills, pruritus, or urticaria, which typically resolve, promptly, without specific treatment or complications. Other signs occurring in temporal relationship with a blood transfusion such as severe dyspnoea, pyrexia, or loss of consciousness may be the first indication of a more severe, potentially fatal reaction. Transfusion reactions may be immune-mediated or non-immune-mediated.

The sympathetic nervous system regulates vascular tone, dilation of pupils, arrector pili muscles, sweat production and visceral reflexes. Neurones that supply the voluntary muscles originate from the ventral horn of the spinal cord. If these nerves were thus damaged, these functions would be impaired. The sympathetic nervous system is not responsible for voluntary muscle activity.

An increase in the rate of renal blood flow (RBF) greatly increases the glomerular filtration rate (GFR). The more plasma available (from increased RBF), the more filtrate is formed. Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman’s capsule per unit time. Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles.

The oesophageal hiatus is located in the muscular part of the diaphragm a T10 and is above, in front and a little to the left of the aortic hiatus. It transmits the oesophagus, the vagus nerves and some small oesophageal arteries.

The passage of extremely loose and watery stools is characteristic of Vibrio cholera infection. Most of the other gastroenteric infections do not produce such watery motions.

Vibrio cholerae is a Gram-negative, comma-shaped bacterium. It’s natural habitat is brackish or saltwater. Some strains of V. cholerae cause the disease cholera.

Transmission occurs through the ingestion of contaminated water or food. Sudden large outbreaks are usually caused by a contaminated water supply. Outbreaks and endemic and sporadic cases are often attributed to raw or undercooked seafood.

Symptoms of the disease include sudden onset of effortless vomiting and profuse watery diarrhoea. Correction of fluid and electrolyte losses are the mainstay of treatment. Most cases resolve shortly afterwards, and therefore, antibiotics are not generally indicated.

Streptokinase is an enzyme that is produced by group A beta haemolytic streptococcus and is an effective and cost efficient method for the dissolution of a clot used in cases of MI and pulmonary embolism. It works by directly converting plasminogen to plasmin which breaks down the blood components in the clot and fibrin, dissolving the clot. Streptokinase is a bacterial product and thus the body will develop immunity against it.

Thirst is the basic need or instinct to drink. It arises from a lack of fluids and/or an increase in the concentration of certain osmolites such as salt. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, the brain signals thirst. Excessive thirst, known as polydipsia, along with excessive urination, known as polyuria, may be an indication of diabetes. Angiotensin II is a hormone that is a powerful dipsogen (i.e. it stimulates thirst) that acts via the subfornical organ. It increases secretion of ADH in the posterior pituitary and secretion of ACTH in the anterior pituitary.

Jaundice can occur due to any of the possible causes and treatment depends upon diagnosing the correct condition. Mild hyperbilirubinemia with normal levels of aminotransferase and alkaline phosphatase is often unconjugated (e.g., due to haemolysis or Gilbert’s syndrome rather than hepatobiliary disease). Moderate or severe hyperbilirubinemia along with increased urinary bilirubin (bilirubinuria), high alkaline phosphatase or aminotransferase levels suggest hepatobiliary disease. Hyperbilirubinemia produced by any hepatobiliary disease is largely conjugated. In this case, other blood tests include hepatitis serology for suspected hepatitis, prothrombin time (PT) or international normalised ratio (INR), albumin and globulin levels, and antimitochondrial antibody levels (suspected primary biliary cirrhosis). Low albumin and high globulin levels suggest chronic rather than acute liver disease. In cases where there is only a an elevation of alkaline phosphatase, γ-glutamyl transpeptidase (GGT) levels should be checked – the levels of which will be found high in hepatobiliary disease, but not in bone disorder which can also lead to elevated alkaline phosphatase levels. In diseases of hepatobiliary origin, aminotransferase elevations > 500 units suggest a hepatocellular cause, whereas disproportionate increases of alkaline phosphatase (e.g., alkaline phosphatase > 3 times normal and aminotransferase < 200 units) suggest cholestasis. Because hepatobiliary disease alone rarely causes bilirubin levels > 30 mg/dl, higher levels are suggestive of a combination of severe hepatobiliary disease and haemolysis or renal dysfunction. Imaging is best for diagnosing infiltrative and cholestatic causes of jaundice. Liver biopsy is rarely needed, but can be of use in intrahepatic cholestasis and in some types of hepatitis.

Hypoventilation (or respiratory depression) causes an increase in carbon dioxide (hypercapnia) and respiratory acidosis. It can result due to drugs such as alcohol, benzodiazepines, barbiturates, opiates, mechanical conditions or holding ones breath. Strong opioids such as heroin and fentanyl are commonly implicated and can lead to respiratory arrest. In recreational drug overdose, acute respiratory acidosis occurs with an increase in p(CO2) over 45 mm Hg and acidaemia (pH < 7.35)

The percentages of body water contained in various fluid compartments add up to total body water (TBW). This water makes up a significant fraction of the human body, both by weight and by volume. The total body water (TBW) content of humans is approximately 60% of body weight. Two-thirds is located in the intracellular and one-third in the extracellular compartment. So, in a 75-kg individual, TBW = 60 × 75/100 = 45 l. Intracellular content = 2/3 × 45 = 30 l and extracellular content = 1/3 × 45 = 15 l.

The perineum has it’s deep boundaries in front of the pubic arch and the arcuate ligament of the pubis, behind the tip of the coccyx and on either side of the inferior rami of the pubis and ischium and the sacrotuberous ligament. It also corresponds to the outlet of the pelvis. A line drawn transversely across, in front of the ischial tuberosities divides the space into two portions, the posterior contains the termination of the anal canal and the anterior, contains the external urogenital organs.

Breast implants are mainly: saline-filled and silicone gel-filled. Complications include haematoma, fluid collections, infection at the surgical site, pain, wrinkling, asymmetric appearance, wound dehiscence and thinning of the breast tissue.

Answer: Spina bifida occulta

Spina Bifida Occulta is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, Spina Bifida Occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.

Eighty percent of those with a spinal cord problem will have skin over the defect with:
a hairy patch
a fatty lump
a haemangioma—a red or purple spot made up of blood vessels
a dark spot or a birthmark—these are red and don’t include blue-black marks, called “Mongolian spots”
a skin tract (tunnel) or sinus—this can look like a deep dimple, especially if it’s too high (higher than the top of the buttocks crease), or if its bottom can’t be seen
a hypopigmented spot—an area with less skin colour.

Myelocele is herniation of spinal cord tissue through a defect in a region of the vertebral column. The protrusion of the tissue is flush with the level of the skin surface. In myelocele, the spinal cord is exposed so that nerve tissue lies exposed on the surface of the back without even a covering of skin or of the meninges, the membranous tissue surrounding the brain and spinal cord.

Etoposide phosphate is an inhibitor of the enzyme topoisomerase II. It is used as a form of chemotherapy for malignancies such as lung cancer, testicular cancer, lymphoma, non-lymphocytic leukaemia and glioblastoma multiforme. Side effects are very common and can include low blood cell counts, vomiting, loss of appetite, diarrhoea, hair loss, and fever.

Hypospadias is the condition where the urethra opens along the underside or ventral aspect of penile shaft. First-degree hypospadias is seen in 50-75% cases, where the urethra open on the glans penis. Second-degree hypospadias is seen in 20% cases where the urethra opens on the shaft, and third-degree in 30% cases with the urethra opening on the perineum. The severe cases are usually associated with undescended testis (cryptorchidism) or chordee, where the penis is tethered downwards and not completely separated from the perineum.
It is a common male genital birth defect but varying incidences are noted in different countries. There is no obvious inheritance pattern noted. No exact cause has been determined, however several hypotheses include poor response to androgen, or interference by environmental factors.

The adrenal gland comprises an outer cortex and an inner medulla, which represent two developmentally and functionally independent endocrine glands.
The adrenal medulla secretes adrenaline (70%) and noradrenaline (30%)
The adrenal cortex consists of three layers (remembered by the mnemonic GFR):
G = zona glomerulosa – secretes aldosterone
F = zona fasciculata – secretes cortisol and sex steroids
R = zona reticularis – secretes cortisol and sex steroids.
Aldosterone facilitates the reabsorption of sodium and water and the excretion of potassium and hydrogen ions from the distal convoluted tubule and collecting ducts. Conn’s syndrome is characterized by increased aldosterone secretion from the adrenal glands.

Azlocillin, like piperacillin, is an acylampicillin antibiotic with an extended spectrum of activity and greater in vitro potency than the carboxypenicillins. Azlocillin is similar to mezlocillin and piperacillin. It demonstrates antibacterial activity against a broad spectrum of bacteria, including Pseudomonas aeruginosa.

The cells in the anterior horn can be arranged in the following three main groups: medial, lateral and central. The medial group of nuclei in the anterior horn of the spinal cord are located along the entire length of the spinal cord and are responsible for the innervation of the axial muscles of the body ( muscles of the head and neck region). Thus this disease will most likely affect the functioning of the muscles of the head and neck.