Proctalgia fugax (PF) is a benign painful rectal condition that is defined as intermittent, recurring, and self-limiting pain in the anorectal region in the absence of organic pathology. The pain of proctalgia fugax is sharp or gripping and severe. Similar to other urogenital focal pain syndromes, such as vulvodynia and proctodynia, the causes remain obscure. Stress and sitting for prolonged periods often increase the frequency and intensity of attacks of proctalgia fugax. Patients often feel an urge to defecate with the onset of the paroxysms of pain . Depression often accompanies the pain of proctalgia fugax but is not thought to be the primary cause. The symptoms of proctalgia fugax can be so severe as to limit the patient’s ability to perform activities of daily living. Reassurance has proven to help in many cases as the condition has been linked to stress.

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.

A cholesteatoma consists of squamous epithelium that is trapped within the skull base and that can erode and destroy important structures within the temporal bone. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal. The majority (98%) of people with cholesteatoma have ear discharge or conductive hearing loss or both in the affected ear.

Other more common conditions (e.g. otitis externa) may also present with these symptoms, but cholesteatoma is much more serious and should not be overlooked. If a patient presents to a doctor with ear discharge and hearing loss, the doctor should consider cholesteatoma until the disease is definitely excluded.

Other less common symptoms (all less than 15%) of cholesteatoma may include pain, balance disruption, tinnitus, earache, headaches and bleeding from the ear. There can also be facial nerve weakness. Balance symptoms in the presence of a cholesteatoma raise the possibility that the cholesteatoma is eroding the balance organs in the inner ear.

Achalasia is a failure of the lower oesophageal sphincter (LES) to relax that is caused by the degeneration of inhibitory neurons within the oesophageal wall. It is classified as either primary (idiopathic) or secondary (in the context of another disease). In patients with achalasia, the chief complaint is dysphagia to both solids and liquids, although regurgitation, retrosternal pain, and weight loss may also occur. Upper endoscopy, barium esophagram, and oesophageal manometry play complementary roles in the diagnosis of achalasia. While upper endoscopy and/or barium esophagram are often obtained initially, manometry usually confirms the diagnosis, and upper endoscopy is indicated to rule out a malignant underlying cause. In good surgical candidates, achalasia is usually treated with pneumatic dilation or myotomy. In most other cases, an injection of botulinum toxin is attempted. If these measures fail to provide relief, medical therapy (e.g., nifedipine) is indicated.

Answer: Rickets

Rickets is a disease of growing bone that is unique to children and adolescents. It is caused by a failure of osteoid to calcify in a growing person.
The signs and symptoms of rickets can include:

pain – the bones affected by rickets can be sore and painful, so the child may be reluctant to walk or may tire easily; the child’s walk may look different (waddling)
skeletal deformities – thickening of the ankles, wrists and knees, bowed legs, soft skull bones and, rarely, bending of the spine
dental problems – including weak tooth enamel, delay in teeth coming through and increased risk of cavities
poor growth and development – if the skeleton doesn’t grow and develop properly, the child will be shorter than average
fragile bones – in severe cases, the bones become weaker and more prone to fractures.

Marfan syndrome (MFS) is a genetic disorder of the connective tissue. The degree to which people are affected varies. People with Marfan tend to be tall and thin, with long arms, legs, fingers and toes. They also typically have flexible joints and scoliosis. The most serious complications involve the heart and aorta, with an increased risk of mitral valve prolapse and aortic aneurysm. Other commonly affected areas include the lungs, eyes, bones and the covering of the spinal cord.

Ehlers-Danlos syndrome is a group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls. People who have Ehlers-Danlos syndrome usually have overly flexible joints and stretchy, fragile skin. This can become a problem if you have a wound that requires stitches, because the skin often isn’t strong enough to hold them.
A more severe form of the disorder, called Ehlers-Danlos syndrome, vascular type, can cause the walls of your blood vessels, intestines or uterus to rupture.

Osteoporosis is a disease in which bone weakening increases the risk of a broken bone. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the vertebrae in the spine, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone.

Osteoporosis may be due to lower-than-normal maximum bone mass and greater-than-normal bone loss. Bone loss increases after menopause due to lower levels of oestrogen. Osteoporosis may also occur due to a number of diseases or treatments, including alcoholism, anorexia, hyperthyroidism, kidney disease, and surgical removal of the ovaries.

The patient has a Weber type A fracture, based on the Danis-Weber classification system for lateral malleolar fractures. It is a stable ankle injury and can, therefore, be managed conservatively. Whilst this patient could also be treated in a below-knee plaster, most clinicians, nowadays, treat this injury in an ankle boot. Patients are also advised to mobilise with the ankle boot as pain allows and can wean themselves off as the symptoms improve.

The Danis-Weber classification system is based on the level of the fibula fracture in relation to the syndesmosis (the connection between the distal ends of the tibia and fibula). The more proximal, the greater the risk of syndesmotic injury and, therefore, fracture instability.

1. Weber type A: fracture below the level of the syndesmosis
2. Weber type B: fracture at the level of the syndesmosis/level of the tibial plafond
3. Weber type C: fracture above the level of the syndesmosis. This includes Maisonneuve fracture (proximal fibula fracture) which can be associated with ankle instability.

Ankle fractures are common. They affect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women have a higher rate post-menopausal (fragility-type fractures). Patients present, following a traumatic event, with a painful, swollen ankle, and reluctance/inability to bear weight.

Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious, then plain radiographs are appropriate. Antero-posterior, lateral, and mortise views are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space, and lateral talar shift all indicate a syndesmotic injury.

When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Unimalleolar Weber type A fractures, by definition, are stable and therefore, can be mobilised fully in an ankle boot.

Anal fissure is a tear in the anoderm distal to the dentate line. It is the most common cause of severe anal pain. It is equally one of the most common reasons for bleeding per anus in infants and young children. The pain of an anal ulcer is intolerable and always disproportionate to the severity of the physical lesion. It may be so severe that patients may avoid defecation for days together until it becomes inevitable. This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle. The fissures can be classified into 1] Acute or superficial and 2] Chronic fissure in ano.

Initial therapy for an anal fissure is medical, and more than 80% of acute anal fissures resolve without further therapy.
The goals of treatment are to relieve the constipation and to break the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for the patient to pass.

First-line medical therapy consists of therapy with stool-bulking agents, such as fibre supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Mineral oil may be added to facilitate passage of stool without as much stretching or abrasion of the anal mucosa, but it is not recommended for indefinite use. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm.
Recurrence rates are in the range of 30-70% if the high-fibre diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fibre diet.

Second-line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter.
Some physicians use NTG ointment as initial therapy in conjunction with fibre and stool softeners, and others prefer to add it to the medical regimen if fibre and stool softeners alone fail to heal the fissure. NTG ointment is thought to relax the internal sphincter and to help relieve some of the pain associated with sphincter spasm; it also is thought to increase blood flow to the anal mucosa.
Unfortunately, many people cannot tolerate the adverse effects of NTG, and as a result, its use is often limited. The main adverse effects are headache and dizziness; therefore, patients should be instructed to use NTG ointment for the first time in the presence of others or directly before bedtime.
Analogous to the use of NTG intra-anal ointment, nifedipine ointment is also available for use in clinical trials. It is thought to have similar efficacy to NTG ointment but with fewer adverse effects.

Botulinum toxin has been used to treat acute and chronic anal fissures. It is injected directly into the internal anal sphincter, in effect performing a chemical sphincterotomy. The effect lasts about 3 months, until nerve endings regenerate. This 3-month period may allow acute fissures (and sometimes chronic fissures) to heal and symptoms to resolve. If botulinum toxin injection provides initial relief of symptoms but there is a recurrence after 3 months, the patient may benefit from surgical sphincterotomy.

Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after 3-4 weeks of medical therapy and for chronic anal fissures.
Sphincter dilatation
Lateral internal sphincterotomy

Quadrantanopia refers to an anopia affecting a quarter of the field of vision. While quadrantanopia can be caused by lesions in the temporal and parietal lobes, it is most commonly associated with lesions in the occipital lobe.
A lesion affecting one side of the temporal lobe may cause damage to the inferior optic radiations (known as the temporal pathway or Meyer’s loop) which can lead to superior quadrantanopia on the contralateral side of both eyes (colloquially referred to as pie in the sky).

Therefore, a left temporal lobe infarct will affect the right superior quadrantanopia.

Answer: Fasciotomy

Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. A delay in performing the procedure can lead to neurovascular complications or lead to the need for amputation of a limb. Complications can also involve the formation of scar tissue after the operation. A thickening of the surgical scars can result in the loss of mobility of the joint involved. This can be addressed through occupational or physical therapy.

Lesions bearing normal dermal appendages and regular borders are likely to be benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done.

Melanocytic naevi are pigmented moles. Some moles are present at birth or appear within the first two years of life. These are known as congenital melanocytic naevi. Most develop during childhood and early adult life and are, consequently, called acquired melanocytic naevi. The number of moles increase up to the age of 30–40. Thereafter, the number of naevi tend to decrease. New moles appearing in adulthood need to be monitored and checked if growing or changing. Moles can be found anywhere on the skin, including on the hands and feet, genitals, eyes, and scalp.

There are three main types of acquired melanocytic naevi:
1. Junctional melanocytic naevi: flat and usually circular.
2. Compound melanocytic naevi: raised brown bumps most of which are hairy, some have a slightly warty surface.
3. Intradermal melanocytic naevi: raised and often hairy bumps, similar to compound naevi but more pale coloured (often skin-coloured).

Answer: Mittelschmerz

Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
Pelvic inflammatory disease can be ruled out if the patient is not sexually active.

Ileal resection may lead to bile acid malabsorption and an altered biliary lipid composition. A “bile acid deficiency” in the enterohepatic circulation with a relative excess of cholesterol and cholesterol supersaturated bile might ensue, causing cholesterol gallstone formation.

In patients with Crohn’s disease involving the small
intestine, the prevalence of gall-bladder stones is higher
than that in the general population. One hypothesis
for this increased risk is that bile acid malabsorption,
secondary to impaired active bile acid transport as a
consequence of ileal disease/resection, leads to a
reduction in the total bile acid pool size and an increase
in biliary cholesterol saturation. In patients with
ulcerative or Crohn’s colitis, or who have undergone
colectomy, the bile acid malabsorption is less than that
in those with ileal dysfunction or resection, but the risk
of gallstone formation is still increased, allegedly by the
same mechanism.

The term subarachnoid haemorrhage (SAH) refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes. SAH constitutes half of all spontaneous atraumatic intracranial haemorrhages; the other half consists of bleeding that occurs within the brain parenchyma.
Intracranial saccular aneurysms (“berry aneurysms”) represent the most common aetiology of nontraumatic SAH; about 80% of cases of SAH result from ruptured aneurysms.

Lymphovenous anastomosis – Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Causes of lymphoedema:
Primary:
Sporadic, Milroy’s disease, Meige’s disease
Secondary:
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis

Other options given:
Homans operation – Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.

Charles operation – All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.

Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures.

Answer: Surgery over the next few days

Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort.

Iatrogenic perforation of the gastrointestinal tract
related to diagnostic or therapeutic endoscopy is
a rare but severe adverse event, associated with
significant morbidity and mortality

Conservative treatment may be suitable for patients with limited oesophageal injury and contained leakage. Such patients include those suffering endoscopic iatrogenic perforation, as the patient is likely to be fasted and the diagnosis made promptly. They must remain nil by mouth, with appropriate antibiotic cover, and proton pump inhibitor therapy, total parenteral nutrition, and continued observation. Similarly, medical treatment might be suitable for cases of inoperable malignant stricture, that is, palliation.

Fractures of the distal radius account for up to 20% of all fractures treated in the emergency department. Initial assessment includes a history of the mechanism of injury, associated injury and appropriate radiological evaluation
Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.
The basic principle of fracture treatment is to obtain accurate fracture reduction and then to use a method of immobilization that will maintain and hold that reduction. While the goal of treatment in fracture distal end of the radius is the restoration of normal function, the precise methods to achieve that desired outcome are controversial. Intra-articular fractures of the distal end of the radius can be difficult to treat, at times, with a traditional conservative method. A number of options for treatment are available to prevent the loss of reduction in an unstable fracture of the distal end of the radius.
One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.
The first group includes the two-part shear fracture (Barton fracture), which actually is a radio-carpal fracture-dislocation. Although the anatomical reduction is possible by closed means in some cases, these fractures are very unstable and difficult to control in plaster. The second group includes complex intra-articular fractures in which the articular fragments are displaced, rotated or impacted and are not amenable to reduction through limited operative exposure.

Juvenile polyps are benign hamartomas with neoplastic potential that are the most frequent gastrointestinal polyp of childhood, with the peak incidence between 3 and 5 years of age.. The presence of multiple juvenile polyps may indicate a premalignant condition commonly named juvenile polyposis coli or juvenile polyposis syndrome (JPS). In contrast, single or solitary juvenile polyps generally are considered benign sporadic lesions that confer little to no future risk of malignancy. Most frequent presentation is painless rectal bleeding. Other features include a prolapsing rectal mass and abdominal pain.

Branchial cleft cysts are congenital anomalies that usually arise from second cleft/pouch, with remnants of the third and fourth pouch are rare. Children are typically born with these congenital lesions; however, they may not be evident for weeks, months, or possibly years. The lesions present as fistulae, cyst, sinus tracts, or cartilaginous remnants due to incomplete obliteration during embryogenesis.

They are often asymptomatic, but can often become tender, enlarged, or inflamed with possible abscess formation during episodes of upper respiratory tract infections.
The patient can present with purulent drainage of the sinus to skin or pharynx from spontaneous rupture of branchial cleft cyst abscess. The most concerning symptoms include dysphagia, dyspnoea, and stridor due to cyst compression of the upper airway.

The physical examination will differ depending on the location of the branchial cleft cyst:
– A primary branchial cleft cyst is typically smooth, non-tender, fluctuant mass found between the external auditory canal and submandibular area. It is usually with the parotid gland and facial nerve. Two types of lesions exist. Type 1 is rare and characterized as duplication of the membranous external auditory canal. Type 2 lesions contain both ectoderm and mesoderm elements including cartilage. The patient usually presents with soft tissue mass or draining sinus located on the angle of the mandible or otorrhea, making an otologic exam critical in these cases.
– A secondary branchial cleft cyst is located between the lower anterior border of the sternocleidomastoid and the tonsillar fossa of the pharynx. It can be in proximity to the glossopharyngeal and hypoglossal nerve as well as carotid vessels. Compared to the primary branchial cleft cysts, secondary cysts are tender if secondarily inflamed or infected. If it is associated with a sinus tract, a mucoid or purulent discharge may be present on the skin or into the pharynx.

The treatment of a branchial cleft cyst is typically elective excision due to the risk of infection or present infection, further enlargement, or malignancy.

– Carotid Body Tumour: Painless oropharyngeal or upper anterior triangle of the neck; pulsatile, compressible with a bruit or thrill, mobile from medial to lateral direction.
– Bartonella henselae infection is Isolated, mobile, fluctuant, tender, warm, erythematous, > 2 cm near the site of inoculation.
– Thyroglossal duct cyst: In the Midline, adjacent to the hyoid bone; rises with deglutition.

Answer: Spontaneous bacterial peritonitis

The presence of periorbital and facial oedema with normal blood pressure in this toddler indicates that he has nephrotic syndrome. Nephrotic syndrome can be associated with a series of complications that can affect an individual’s health and quality of life:
Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent development in children but very rarely found in adults.

Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.

The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.

Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.

These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.

Answer: Acute subdural haematoma

An acute subdural haematoma (SDH) is a clot of blood that develops between the surface of the brain and the dura mater, the brain’s tough outer covering, usually due to stretching and tearing of veins on the brain’s surface. These veins rupture when a head injury suddenly jolts or shakes the brain.
Traumatic acute SDHs are among the most lethal of all head injuries. Associated with more severe generalized brain injury, they often occur with cerebral contusions.
SDHs are seen in 10 percent to 20 percent of all traumatic brain injury cases and occur in up to 30 percent of fatal injuries.
Diagnosis:

SDHs are best diagnosed by computed tomography (CT) scan. They appear as a dense, crescent-shaped mass over a portion of the brain’s surface.
Most patients with acute SDHs have low Glasgow Coma Scale (GCS) scores on admission to the hospital.

Acute traumatic subdural haematoma often results from falls, violence, or motor vehicle accidents. Suspect acute subdural haematoma whenever the patient has experienced moderately severe to severe blunt head trauma. The clinical presentation depends on the location of the lesion and the rate at which it develops. Often, patients are rendered comatose at the time of the injury. A subset of patients remain conscious; others deteriorate in a delayed fashion as the haematoma expands.
A GCS score less than 15 after blunt head trauma in a patient with no intoxicating substance use (or impaired mental status baseline) warrants consideration of an urgent CT scan. Search for any focal neurologic deficits or signs of increased ICP. Any abnormality of mental status that cannot be explained completely by alcohol intoxication or the presence of another mind-altering substance should increase suspicion of subdural hematoma in the patient with blunt head trauma.

The clinical presentation of a patient with an acute subdural haematoma depends on the size of the hematoma and the degree of any associated parenchymal brain injury. Symptoms associated with acute subdural haematoma include the following:

Headache

Nausea

Confusion

Personality change

Decreased level of consciousness

Speech difficulties

Other change in mental status

Impaired vision or double vision

Weakness

On noncontrast CT scan, an acute subdural haematoma appears as a hyperdense (white), crescent-shaped mass between the inner table of the skull and the surface of the cerebral hemisphere.

The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for paediatric hydroceles (typically, communicating). If a testicular tumour is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumours may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumours.

This is a case of diffuse axonal injury (DAI) which occurs when the head is rapidly accelerated or decelerated.

DAI is a form of traumatic brain injury which occurs when the brain rapidly shifts inside the skull as an injury is occurring. The long connecting fibres in the brain called axons are sheared as the brain rapidly accelerates and decelerates inside the hard bone of the skull. There are two components of DAI:
1. Multiple haemorrhages
2. Diffuse axonal damage in the white matter

Up to two-thirds of the changes occurs at the junction of the grey and white matter due to the different densities of the tissue. These are mainly histological and axonal damage is secondary to biochemical cascades. Often, there are no signs of a fracture or contusion. DAI typically causes widespread injury to the brain leading to loss of consciousness. The changes in the brain are often very tiny and can be difficult to detect using CT or MRI scans.

von Hippel-Lindau (VHL) disease, or von Hippel-Lindau syndrome, is a rare genetic disorder characterized by visceral cysts and benign tumours in multiple organ systems that have a subsequent potential for malignant change.
Clinical hallmarks of VHL disease include the development of retinal and central nervous system (CNS) hemangioblastomas (blood vessel tumours), pheochromocytomas, multiple cysts in the pancreas and kidneys, and an increased risk for malignant transformation of renal cysts into renal cell carcinoma. The wide age range and the pleiotropic manner in which VHL disease presents complicates diagnosis and treatment in affected individuals, as well as their at-risk relatives.

Because VHL disease is a multiple-organ disease that widely varies in clinical presentation, various manifestations may lead to the diagnosis. Criteria are the following:
More than one hemangioblastoma in the CNS (brain, spinal cord) or eye
A single hemangioblastoma in the CNS or retina, plus a visceral manifestation (multiple renal, pancreatic, or hepatic cysts; pheochromocytoma; renal cancer)
Positive family history plus any one of the above clinical manifestations
Elucidation of a deleterious mutation in the VHL gene

The intragastric balloon aids weight loss by slowing the rate at which food enters the stomach and by stimulating gastric stretch receptors. But lifestyle changes, including behaviour modification, exercise and a healthy diet, are crucial for maintaining weight loss once the device is removed. Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution and is associated with a high failure rates and complications.

Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.

Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more long-term weight loss than gastric banding.

Sleeve gastrectomy: body and fundus resected to leave a small section of stomach

Rejection is related primarily to activation of T cells, which, in turn, stimulate specific antibodies against the graft. Various clinical syndromes of rejection can be correlated with the length of time after transplantation.

Hyperacute rejection
Hyperacute rejection of the renal allograft happens in the operating room within hours of the transplant, when the graft becomes mottled and cyanotic. This type of rejection is due to unrecognized compatibility of blood groups A, AB, B, and O (ABO) or to a positive T-cell crossmatch (class I human leukocyte antigen [HLA] incompatibility).
It is thought that IgG antibodies from the host bind to HLA-1 antigen of the donated organ.
No treatment exists, and nephrectomy is indicated.

Acute rejection
Acute rejection appears within the first 6 months after transplantation and affects approximately 15% of transplanted kidneys. Rejection is secondary to prior sensitization to donor alloantigens (occult T-cell crossmatch) or a positive B-cell crossmatch.
Acute tubular interstitial cellular rejection is the most common type of rejection reaction, with an incidence of approximately 20-25%. Typically, it occurs between 1 and 3 months after transplantation. It is T-cell mediated, and injury is directed to the renal tubules. The standard for diagnosis is renal allograft biopsy. Mild rejections may be successfully reversed with corticosteroids alone, whereas moderate or severe rejections may require the use of anti–T-cell antibodies, either polyclonal or monoclonal.
Late acute rejection is strongly correlated with the scheduled withdrawal of immunosuppressive therapy 6 months after transplantation.

Chronic rejection
Chronic rejection occurs more than 1 year after transplantation and is a major cause of allograft loss. It is a slow and progressive deterioration in renal function characterized by histologic changes involving the renal tubules, capillaries, and interstitium. Its precise mechanism is poorly defined and is an area of intense study. Diagnosis is by renal biopsy, and treatment depends on the identified cause if any. Application of conventional antirejection agents (e.g., corticosteroids or anti–T-cell antibodies) does not appear to alter the progressive course.

This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve. Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury.
The recurrent laryngeal nerves control all intrinsic muscles of the larynx except for the cricothyroid muscle. These muscles act to open, close, and adjust the tension of the vocal cords, and include the posterior cricoarytenoid muscles, the only muscle to open the vocal cords. The nerves supply muscles on the same side of the body, with the exception of the interarytenoid muscle, which is innervated from both sides.

The nerves also carry sensory information from the mucous membranes of the larynx below the lower surface of the vocal fold, as well as sensory, secretory and motor fibres to the cervical segments of the oesophagus and the trachea.

Dysphagia that is episodic and nonprogressive and varies between solids and liquids is more likely to represent a motility disorder. It may also associated with retrosternal chest pain.

Motility disorder is a condition where the nerves and muscles in the gastrointestinal tract are not working together correctly, which cause difficulty in the digestive process. These conditions include chronic intractable constipation, gastroesophageal reflux disease (GERD), chronic intestinal pseudo-obstruction, gastroparesis, Hirschsprung’s disease, and oesophageal achalasia, among other disorders.

In addition to imaging studies, these conditions are usually evaluated with manometry studies which measure the pressure in different areas of the gastrointestinal tract.

This is a case of Brown-Sequard syndrome.

Brown-Sequard syndrome is caused by hemisection of the spinal cord following stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract), and also loss of proprioception and fine discrimination(dorsal columns). Pain and temperature sensations are lost on the contralateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.