Cystic fibrosis is a life-threatening disorder that causes the build up of thick mucus in the lungs, digestive tract, and other areas of the body. It is a hereditary autosomal-recessive disease caused by mutations of the CFTR gene. Cystic fibrosis eventually results in bronchiectasis which is defined as a permanent dilatation and obstruction of bronchi or bronchioles.

The duodenum is the only organ in the list that would not be affect by the clumping of the splenic artery as it is supplied by common hepatic artery (through the gastroduodenal artery) and the superior mesenteric artery (through the inferior pancreaticoduodenal artery). The splenic artery is the artery that supplies the spleen with oxygenated blood. The splenic artery before reaching the spleen also gives off branches that supply the stomach and the pancreas. The greater curvature and the fundus of the stomach is supplied the short gastric artery which branches off from the splenic artery. The left portion of the greater curvature of the stomach together with the greater omentum is supplied by the left gastro-omental artery of the splenic artery. The body and tail of the pancreas is supplied by branches of the splenic artery through the dorsal and superior pancreatic arteries and the caudal pancreatic arteries respectively.

Spherocytes are small rounded RBCs. It is due to an inherited defect of the RBC cytoskeleton membrane tethering proteins. Membrane blebs form that are lost over time and cells become round instead of biconcave. As it is a normochromic anaemia, the MCV is normal. it is diagnosed by osmotic fragility test which reveals increased fragility in a hypotonic solution.

COPD leads to respiratory acidosis (chronic). This occurs due to hypoventilation which involves multiple causes, such as poor responsiveness to hypoxia and hypercapnia, increased ventilation/perfusion mismatch leading to increased dead space ventilation and decreased diaphragm function.

Septic arthritis, also known as infectious arthritis, may represent a direct invasion of the joint space by various microorganisms, most commonly caused by bacteria.
Neisseria gonorrhoeae remains the most common pathogen (75% of cases) among younger sexually active individuals.
Staphylococcus aureus infection causes the vast majority of acute bacterial arthritis cases in adults and in children older than 2 years.

Urea is reabsorbed in the inner medullary collecting ducts of the nephrons. The clearance (C) of any substance can be calculated as follows: C = (U × V)/P, where U and P are the urine and plasma concentrations of the substance, respectively and V is the urine flow rate. So, glomerular filtration rate = (0.220 × 2. 0)/0.005 = 88 ml/min.

Spermatocele, also known as a spermatic cyst is a cystic mass usually occurring at the upper pole of the testis. Differential diagnosis included hydrocele as both are cystic, painless and transilluminant. Ultrasound is a useful modality. If symptomatic or large, surgical excision can be done.

The different types of diarrhoea are:
1. Secretory diarrhoea – Due to increased secretion or decreased absorption. There is minimal to no structural damage in this type. The most common cause is cholera toxin which stimulates secretion of anions (especially chloride), with sodium and water.
2. Osmotic diarrhoea – Due to increased osmotic load, there is water loss. This occurs in cases of maldigestion syndromes, such as coeliac or pancreatic disease.
3. Motility-related diarrhoea – Occurs in cases of abnormal gastrointestinal motility. Due to increased motility, there is poor absorption and this leads to diarrhoea. This is seen post-vagotomy or in diabetic neuropathy.
4. Inflammatory diarrhoea – Due to damage to the mucosa or brush border, there is a loss of protein-rich fluids and poor absorption. Features of all the above three types can be seen in this type. Aetiology includes bacterial, viral, parasitic infections or autoimmune problems including inflammatory bowel disease.

Perihepatic packing is a surgical procedure used in connection with surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.

During this surgery laparotomy pads are placed around the site of the bleeding. The main purpose of hepatic packing is to prevent the person from succumbing to the trauma triad of death. Under- or over-packing of the liver can cause adverse outcomes, and if the bleeding cannot be controlled through this surgical method, the Pringle manoeuvre is an alternate technique that can be utilized.

Rebleeding, constant decline of haemoglobin and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels are a few factors which indicate the need for laparotomy.

The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt.

Vital capacity = inspiratory reserve volume + tidal volume + expiratory reserve volume. Thus, inspiratory reserve volume can be calculated if tidal volume, vital capacity and expiratory reserve volume are known.

The fundus of the stomach along with the greater curvature of the stomach receive blood supply from the short gastric artery. The short gastric artery arises from the end of the splenic artery. The ligation of the splenic artery therefore would cause a disruption of blood supply to the fundus of the stomach.

Sinus histiocytosis also referred to as reticular hyperplasia, refers to the enlargement, distention and prominence of the sinusoids of the lymph nodes. This is a non-specific form of hyperplasia characteristically seen in lymph nodes that drain tumours. The endothelial lining of the lymph node becomes markedly hypertrophied, along with an increase in the number of macrophages which results in the distortion, distention and enlargement of the sinus. In this scenario there is no evidence that an infection or another malignancy could account for the enlargement. Paracortical lymphoid hyperplasia is caused by an immune response.

AML, or acute myeloid leukaemia is the commonest acute leukaemia affecting adults. increasing in incidence with age. It is a malignancy of the myeloid line of white blood cells. It results in rapid proliferation of abnormal cells, which accumulate in the marrow. Interference with normal cell production leads to a drop in red blood cells, white blood cells and platelets. This causes symptoms such as tiredness, shortness of breath, tendency to bleed or bruise easily and recurrent infections. AML is known to progress quickly and can lead to death in weeks and months if not treated. Leukemic blasts of AML show presence of Auer rods. These are clumps of azurophilic granular material that form needles in the cytoplasm. Composed of fused lysosomes, these contain peroxidase, lysosomal enzymes and crystalline inclusions. Auer rods are classically present in myeloid blasts of M1, M2, M3 and M4 acute leukaemia. They also help to distinguish the preleukemia myelodysplastic syndromes.

Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. This accumulation may be accompanied by metabolic disturbances, such as metabolic acidosis and hyperkalaemia, changes in body fluid balance and effects on many other organ systems. Metabolic acidosis and hyperkalaemia are the two most serious biochemical manifestations of acute renal failure and may require medical treatment with sodium bicarbonate administration and antihyperkalaemic measures. If not appropriately treated these can be life-threatening. ARF is diagnosed on the basis of characteristic laboratory findings, such as elevated blood urea nitrogen and creatinine, or inability of the kidneys to produce sufficient amounts of urine.

Thrombomodulin is a protein cofactor expressed on the surface of endothelial cells. Thrombomodulin binds with thrombin forming a complex which activates protein C, initiating the anticoagulant pathway.

Elevated levels of MCV indicates megaloblastic anaemia, which are associated with hypersegmented neutrophils. Likely causes include vitamin B12 or folate deficiency. Megaloblastic anaemia results from defective synthesis of DNA. As RNA production continues, the cells enlarge with a large nucleus. The cytoplasmic maturity becomes greater than nuclear maturity. Megaloblasts are produced initially in the marrow, before blood. Dyspoiesis makes erythropoiesis ineffective, causing direct hyperbilirubinemia and hyperuricemia. As all cell lines are affected, reticulocytopenia, thrombocytopenia and leukopenia develop. Large, oval blood cells (macro-ovalocytes) are released in the circulation, along with presence of hypersegmented neutrophils.

Acetylcholine is released from the presynaptic membrane into the cleft where it binds to the ion gated channels on the post synaptic membrane, causing them to open. This results in sodium entering into the fibre and further depolarizing it, creating an action potential.

Infarction of the small bowel following a sudden and complete occlusion of the mesenteric artery can involve any portion of the bowel, whether small or a large. The splenic flexure is at most risk for infarction as it is the watershed area between the superior and inferior mesenteric vessels. Regardless of whether the arterial or the venous blood vessels are occluded, because of the blood reflow into the damaged portion, it will appear haemorrhagic. The bowel appearing congested at first and then becoming oedematous. If the artery is occluded then there will be a clear cut demarcation and in venous occlusion the dusky colour fades with the rest of the normal bowel. Wet gangrene is characteristic of ischaemic injury to the gut.

Boerhaave syndrome classically presents as the Mackler triad of chest pain, vomiting, and subcutaneous emphysema due to oesophageal rupture, although these symptoms are not always present.
The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.
These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.
Typically, hematemesis is not seen after oesophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.
Swallowing may precipitate coughing because of the communication between the oesophagus and the pleural cavity.

In the given problem, there is respiratory acidosis due to hypercapnia from a low respiratory rate and/or volume (hypoventilation). Causes of hypoventilation include conditions impairing the central nervous system (CNS) respiratory drive, impaired neuromuscular transmission and other causes of muscular weakness (drugs and sedatives), along with obstructive, restrictive and parenchymal pulmonary disorders. Hypoventilation leads to hypoxia and hypercapnia reduces the arterial pH. Severe acidosis leads to pulmonary arteriolar vasoconstriction, systemic vascular dilatation, reduced myocardial contractility, hyperkalaemia, hypotension and cardiac irritability resulting in arrhythmias. Raised carbon dioxide concentration also causes cerebral vasodilatation and raised intracranial pressure. Over time, buffering and renal compensation occurs. However, this might not be seen in acute scenarios where the rise in p(CO2) occurs rapidly.

Loperamide is an opioid-receptor agonist and acts on the mu opioid receptors in the myenteric plexus of large intestine. It works by decreasing the motility of the circular and longitudinal smooth muscles of the intestinal wall. It is often used for this purpose in gastroenteritis, inflammatory bowel disease, and short bowel syndrome.

The lymphatics from the anus, skin of the perineum and the scrotum end in the superficial inguinal nodes. In case of a malignant growth of the anus, the superficial inguinal lymph nodes would most likely be enlarge.

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.

Answer: Streptococcus pyogenes

Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. Most cases of bacterial tonsillitis are caused by group A beta-haemolytic Streptococcus pyogenes (GABHS).

Signs and symptoms
Tonsillitis

Individuals with acute tonsillitis present with the following:
Fever
Sore throat
Foul breath
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Tender cervical lymph nodes

Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnoea.

Peritonsillar abscess

Individuals with peritonsillar abscess (PTA) present with the following:
Severe throat pain
Fever
Drooling
Foul breath
Trismus (difficulty opening the mouth)
Altered voice quality (the hot-potato voice)

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever.

Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin may be helpful. GABHS infection obligates antibiotic coverage.

This patient may well develop raised ICP over the next few days and intracranial pressure monitoring will help with the
management.

Summary of guidelines:

For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
– GCS less than 13 on initial assessment in the emergency department.
– GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
– Suspected open or depressed skull fracture.
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
– Post-traumatic seizure.
– Focal neurological deficit.
– More than 1 episode of vomiting.
A provisional written radiology report should be made available within 1 hour of the scan being performed

For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:
– Age 65 years or older.
– Any history of bleeding or clotting disorders.
– Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
– More than 30 minutes’ retrograde amnesia of events immediately before the head injury.
A provisional written radiology report should be made available within 1 hour of the scan being performed.

– Intubate and ventilate all patients with GCS 8 or less requiring transfer to a neuroscience unit.
Intubate and ventilate the patient immediately in the following circumstances:
– Coma – not obeying commands, not speaking, not eye opening (that is, GCS 8 or less).
– Loss of protective laryngeal reflexes.
– Ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa).
– Spontaneous hyperventilation causing PaCO2 < 4 kPa.
– Irregular respirations.

Use the criteria below for admitting patients to hospital following a head injury:
– Patients with new, clinically significant abnormalities on imaging.
– Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results.
– When a patient has indications for CT scanning but this cannot be done within the appropriate period, either because CT is not available or because the patient is not sufficiently cooperative to allow scanning.
– Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the clinician.
– Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).
– Perform and record observations on a half-hourly basis until GCS equal to 15 has been achieved.
– Do not discharge patients presenting with head injury until they have achieved GCS equal to 15

The ova of Schistosoma haematobium are deposited in the wall of the bladder and ureters, where they evoke a granulomatous inflammatory reaction with eventual calcification of the bladder wall. The typical presentation is painful terminal haematuria. Secondary bacterial infection may occur, particularly with Pseudomonas, Proteus or Salmonella, especially following instrumentation of the bladder.

Within the nephron of the kidney, the ascending limb of the loop of Henle is a segment of the loop of Henle downstream of the descending limb, after the sharp bend of the loop. Both the thin and the thick ascending limbs of the loop of Henlé have very low permeability to water. Since there are no regulatory mechanisms to alter its permeability, it remains poorly permeable to water under all circumstances. Sodium and chloride are transported out of the luminal fluid into the surrounding interstitial spaces, where they are reabsorbed. Water must remain behind because it is not reabsorbed, so the solute concentration becomes less and less (the luminal fluid becomes more dilute). This is one of the principal mechanisms (along with diminution of ADH secretion) for the production of a dilute, hypo-osmotic urine (water diuresis).

Small-cell lung carcinoma (SCLC) is a type of highly malignant cancer that most commonly arises within the lung. SCLC usually metastasizes widely very early on in the natural history of the tumour, and in nearly all cases responds dramatically to chemotherapy and/or radiotherapy. Surgery has no role in the treatment of this disease.

This patient has presented with a classical picture of cardiac tamponade, suggested by Beck’s triad: hypotension, raised jugular venous pressure (JVP), and muffled heart sounds.

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent haemodynamic compromise. This condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.

Patients with cardiac tamponade have a collection of three medical signs known as Beck’s triad. These are low arterial blood pressure, distended neck veins, and distant, muffled heart sounds. The diagnosis may be further supported by specific ECG changes, chest X-ray, or an ultrasound of the heart. If fluid increases slowly, the pericardial sac can expand to contain more than 2 L; however, if the increase is rapid, as little as 200 mL can result in tamponade.

Management options may include pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy.

Folliculitis is the inflammation of the hair follicles. It is usually caused by Staphylococcus infection.

Signs and symptoms of thalamic syndrome include contralateral hemi anaesthesia, burning or aching sensation in one half of a body (hyperaesthesia), often accompanied by mood swings.

Oesophageal atresia encompasses a group of congenital anomalies comprising an interruption of the continuity of the oesophagus combined with or without a persistent communication with the trachea.
The diagnosis of oesophageal atresia may be suspected prenatally by the finding of a small or absent fetal stomach bubble on an ultrasound scan performed after the 18th week of gestation. Overall the sensitivity of ultrasonography is 42% but in combination with polyhydramnios, the positive predictive value is 56%. Polyhydramnios alone is a poor indicator of oesophageal atresia (1% incidence).
The newborn infant of a mother with polyhydramnios should always have a nasogastric tube passed soon after delivery to exclude oesophageal atresia. Infants with oesophageal atresia are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. At this stage, and certainly, before the first feed, a stiff wide-bore (10–12 French gauge) catheter should be passed through the mouth into the oesophagus. In oesophageal atresia, the catheter will not pass beyond 9–10 cm from the lower alveolar ridge. A plain X-ray of the chest and abdomen will show the tip of the catheter arrested in the superior mediastinum (T 2–4) while gas in the stomach and intestine signifies the presence of a distal tracheoesophageal fistula. The absence of gastrointestinal gas is indicative of isolated atresia. A fine bore catheter may curl up in the upper pouch giving the false impression of an intact oesophagus or rarely it may pass through the trachea and proceed distally into the oesophagus through the fistula. The X-ray may reveal additional anomalies such as a double bubble appearance of duodenal atresia, vertebral or rib abnormalities.
Delaying the diagnosis until the infant presents with coughing and choking during the first feed is no longer acceptable in modern paediatric practice.

Duodenal atresia is typically characterized by the onset of vomiting within hours of birth. While vomitus is most often bilious, it may be nonbilious because 15% of defects occur proximal to the ampulla of Vater.

Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is the most common cause of intestinal obstruction in infancy. IHPS occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a functional gastric outlet obstruction.
Classically, the infant with pyloric stenosis has nonbilious vomiting or regurgitation, which may become projectile (in as many as 70% of cases), after which the infant is still hungry.
Emesis may be intermittent initially or occur after each feeding.
Emesis should not be bilious as the obstruction is proximal to the common bile duct. The emesis may become brown or coffee colour due to blood secondary to gastritis or a Mallory-Weiss tear at the gastroesophageal junction.
As the obstruction becomes more severe, the infant begins to show signs of dehydration and malnutrition, such as poor weight gain, weight loss, marasmus, decreased urinary output, lethargy, and shock.
The infant may develop jaundice, which is corrected upon correction of the disease.

The scalp is the anatomical area bordered by the face at the front, and by the neck at the sides and back. The scalp is usually described as having five layers:
1. The skin which contains numerous sebaceous glands and hair follicles.
2. The connective tissue, a dense subcutaneous layer of fat and fibrous tissue that lies beneath the skin, containing the nerves and vessels of the scalp.
3. The aponeurosis or galea aponeurotica, a tough layer of dense fibrous tissue which runs from the frontalis muscle anteriorly to the occipitalis posteriorly.
4. The loose areolar connective tissue layer provides an easy plane of separation between the upper three layers and the pericranium.
5. The pericranium is the periosteum of the skull bones and provides nutrition to the bone and the capacity for repair.

This patient has possible urethral injury based on the history. Urethral catheterisation is contraindicated in this situation.

Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.

1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus

2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)

Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation.

Perioperative administration of antibiotics is very important for reducing the risks of postoperative wound infection. Clips make infections easier to manage but do not reduce the risks. Drains have no effect on the skin wounds in these cases.

Surgical site infections (SSI) comprise up to 20% of all healthcare-associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. SSIs may occur following a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. The organisms are mostly derived from the patient’s own body.

SSIs are a major cause of morbidity and mortality.
Some preoperative measures that may increase the risk of SSI include:
1. Shaving the wound using a razor (disposable clipper preferred)
2. Tissue hypoxia
3. Delayed administration of prophylactic antibiotics in tourniquet surgery

SSIs can be prevented by taking certain precautionary steps pre-, intra-, and postoperatively.

1. Preoperatively:
a. Do not remove body hair routinely
b. If hair needs removal, use electrical clippers (razors increase the risk of infection)
c. Antibiotic prophylaxis if:
– placement of prosthesis or valve
– clean-contaminated surgery
– contaminated surgery

2. Intraoperatively:
a. Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
b. Cover surgical site with dressing

3. Postoperatively:
a. Prevention of incisional infection by appropriate cleansing, skin care, and moisture management
b.Tissue viability advice for management of surgical wound healing by secondary intention

Structures that pass through the lesser sciatic foramen include:
– the pudendal nerve
– the nerve to obturator internus
– internal pudendal artery
– the tendon of obturator internus

Mesothelioma is a rare, aggressive form of cancer that develops in the lining of the lungs, abdomen or heart. It is linked to inhalation of asbestos commonly used in ship building and the insulation industry. It has no known cure and has a very poor prognosis.

Constant cerebral blood flow is maintained by autoregulation in the brain, which causes an increase in local vascular resistance to offset an increase in blood pressure. There will be an increase in cerebral blood flow (and decrease in resistance to cerebral blood flow) with a decrease in arterial oxygen or an increase in arterial CO2. Similarly, a decrease in viscosity will also increase the blood flow. Due to increased brain metabolism and activity during a seizure, there will also be an increase in the cerebral blood flow.

The sphenoid bone consists of two parts, a central part and two wing-like structures that extend sideways towards each side of the skull. It forms the base of the skull, and floor and sides of the orbit. On its central part lies the optic foramen. The foramen ovale, foramen spinosum and foramen rotundum lie on its great wing while the superior orbital fissure lies on its lesser wing.

Hypercalcaemia with hypophosphatemia indicates parathyroid disorder and adenomas are more common than hyperplasia. In this young age group, metastatic disease is unlikely. Solitary adenomas are responsible for 80-85% cases of primary hyperparathyroidism. 10-15% cases are due to parathyroid hyperplasia and carcinomas account for 2-3% cases. Symptoms include bone pain (bones), nephrolithiasis (stones), muscular aches, peptic ulcer disease, pancreatitis (groans), depression (moans), anxiety and other mental disturbances.

Pulmonary embolism (PE) is a blockage of an artery in the lungs by an embolus that has travelled from elsewhere in the body through the bloodstream. The change in cardiopulmonary function is proportional to the extent of the obstruction, which varies with the size and number of emboli obstructing the pulmonary arteries. The resulting physiological changes may include pulmonary hypertension with right ventricular failure and shock, dyspnoea with tachypnoea and hyperventilation, arterial hypoxaemia and pulmonary infarction. Consequent alveolar hyperventilation is manifested by a lowered pa(CO2). After occlusion of the pulmonary artery, areas of the lung are ventilated but not perfused, resulting in wasted ventilation with an increased ventilation/perfusion ratio – the physiological hallmark of PE – contributing to a further hyperventilatory state. The risk of blood clots is increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, oestrogen-based medication, pregnancy, obesity, and post surgery.

The flattened appearance of the face is a classical description of the dish-face deformity associated with Le Fort III fracture of the midface.

The term Le Fort fractures is applied to transverse fractures of the midface involving the maxillary bone and surrounding structures in either a horizontal, pyramidal, or transverse direction. There are three grades of Le Fort fractures:

1. Le Fort I
It is the horizontal fracture of the maxilla. Violent force over a more extensive area above the level of the
teeth will result in this type of fracture. Horizontal fracture line is seen above the apices of the maxillary teeth, detaching the tooth-bearing portion of the maxilla from the rest of the facial skeleton. Floating maxilla and Guerin’s sign is seen in such patients.

2. Le Fort II
It is a pyramidal or subzygomatic fracture. Violent force in the central region extending from glabella to the alveolus results in this type of fracture, resulting in ballooning or moon-face facial deformity.

3. Le Fort III
It is a high-level transverse or suprazygomatic fracture associated with craniofacial disjunction. The entire facial skeleton moves as a single block as a result of the trauma. The patient develops a characteristic panda facies and dish-face deformity.

At the upper and back part of the ulna, there exists a curved eminence which is the olecranon process. This process lodges in the olecranon fossa of the humerus. It’s posterior surface is subcutaneous and this triangular area is what you rest your elbow upon.

Answer: Excision biopsy of a lymph node

Hodgkin lymphoma is an uncommon cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body. In Hodgkin lymphoma, B-lymphocytes (a particular type of lymphocyte) start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties, making you more vulnerable to infection. The most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin.
A histologic diagnosis of Hodgkin lymphoma is always required. An excisional lymph node biopsy is recommended because the lymph node architecture is important for histologic classification.

Features of Hodgkin lymphoma include the following:

Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients)

Constitutional symptoms (unexplained weight loss [>10% of total body weight] within the past 6 months, unexplained fever >38º C, or drenching night sweats) are present in 40% of patients; collectively, these are known as B symptoms

Intermittent fever is observed in approximately 35% of cases; infrequently, the classic Pel-Ebstein fever is observed (high fever for 1-2 week, followed by an afebrile period of 1-2 week)

Chest pain, cough, shortness of breath, or a combination of those may be present due to a large mediastinal mass or lung involvement; rarely, haemoptysis occurs

Pruritus may be present

Pain at sites of nodal disease, precipitated by drinking alcohol, occurs in fewer than 10% of patients but is specific for Hodgkin lymphoma

Back or bone pain may rarely occur

A family history is also helpful; in particular, nodular sclerosis Hodgkin lymphoma (NSHL) has a strong genetic component and has often previously been diagnosed in the family.

Hernia containing Meckel’s diverticulum is termed as Littre’s hernia.

Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. A Littre’s hernia is an abdominal wall hernia that involves the Meckel’s diverticulum which is a congenital outpouching or bulge in the lower part of the small intestine and is a leftover of the umbilical cord.

Management of Littre’s hernia includes resection of the diverticulum followed by herniorrhaphy.

Ankle fractures most often occur by rotational mechanisms with the external forces transmitted through the foot via the talus to the malleoli. The specific pattern of fracture and ligamentous injury depends on the position of the foot and the direction of the force at the time of injury.

Reduce the ankle fracture as soon as possible once informed consent provided to the patient. Assess the neurovascular status of the limb before and after manipulation. Have splinting materials ready and measured out (use the uninjured, contralateral leg for measuring). Either a short leg splint or cast is applied based on fracture type, patient, surgical urgency, and surgeon preference.

Ensure adequate analgesia for the patient including NSAIDs, IV medications, hematoma block, or procedural sedation. Once reduced and splinted in place, recheck neurovascular status, elevate the leg and obtain a post-reduction X-ray.

Bladder cancer is the growth of abnormal or cancerous cells on the inner lining of the bladder wall. The staging is as follows; stage 0is (Tis, N0, M0): Cancerous cells in the inner lining tissue of the bladder only, stage I (T1, N0, M0): tumour has spread onto the bladder wall, stage II (T2, N0, M0): tumour has penetrated the inner wall and is present in muscle of the bladder wall, stage III (T3, N0, M0): tumour has spread through the bladder to fat around the bladder and stage IV: (T4, N0, M0): tumour has grown through the bladder wall and into the pelvic or abdominal wall. The stage of cancer in the case presented is T3 because of the invasion of perivesical fat.

The evaluation of a patient in whom hyperaldosteronism is first to determine that hyperaldosteronism is present (serum aldosterone) and, if it is present, to differentiate primary from secondary causes of hyperaldosteronism. The aldosterone-to-renin ratio (ARR) is the most sensitive means of differentiating primary from secondary causes of hyperaldosteronism as it is abnormally increased in primary hyperaldosteronism, and decreased or normal but with high renin levels in secondary hyperaldosteronism.

The small intestine extends from the pylorus to the ileocecal valve where It ends in the large intestine. It is surrounded on the sides and above by the large intestine. It is related anteriorly with the greater omentum and abdominal wall. Is connected to the vertebral column by a fold of peritoneum or otherwise known as the mesentery. Is divided into three portions: the duodenum, jejunum and ileum. The jejunum and ileum are supplied by the superior mesenteric artery that courses between the body and uncinate process of the pancreas before it gives off intestinal branches.

In most cases, the treatment of choice for acute cholecystitis is cholecystectomy performed early in the illness. The procedure can be carried out laparoscopically even when acute inflammation is present. Delayed surgery particularly around five to seven days after presentation is much more technically challenging and is often best deferred.

Up to 24% of women and 12% of men may have gallstones. Of these, up to 30% may develop local infection and cholecystitis. The classical symptom of cholecystitis is colicky right upper quadrant pain that occurs postprandially. Others include swinging pyrexia, and general feeling of being unwell. They are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.

Murphy’s sign is positive on examination. The standard diagnostic work-up consists of abdominal ultrasound and liver function tests. For management, cholecystectomy should ideally be done within 48 hours of presentation. In patients unfit for surgery, percutaneous drainage may be considered.

The spleen, left kidney, stomach, the splenic flexure of the colon and the suprarenal glands are all in the same quadrant- the left upper quadrant. However, the spleen is the most readily injured organ when there is fracture to the 10th, 11th and the 12th ribs because of its close association with these ribs. This patient exhibits a great indication of a ruptured spleen (tenderness on the left mid and posterior axillary line). The spleen is a thin capsulated organ with a spongy parenchyma, allowing it to bleed profusely in the event of injury. The liver, head of the pancreas and the duodenum are all in the right upper quadrant.

The musculocutaneous nerve supplies the biceps brachii and the brachialis muscles. The first one flexes the elbow and the shoulder. It is also involved in supination. The brachialis muscle flexes the forearm. The injury to the musculocutaneous nerve results in paralysis of these muscles.

Mitral valve stenosis is the most common cause of cardiac abnormality occurring in pregnant women. It is becoming less common in the UK population; however, it should be considered in women from countries where there is a higher incidence of rheumatic heart disease. Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate.

Mitral stenosis causes a mid-diastolic murmur which may be difficult to auscultate unless the patient is placed in the left lateral position. These patients are at risk of atrial fibrillation (up to 40%) which can also contribute to rapid decompensation such as pulmonary oedema (hence, whiteout of lungs seen on CXR). Balloon valvuloplasty is the treatment of choice in patients with mitral valve stenosis.

Pernicious anaemia is a type of autoimmune disease in which antibodies form against the parietal cells or intrinsic factor. Intrinsic factor is required for the absorption of vitamin B12. Blood testing typically shows a macrocytic, normochromic anaemia and low levels of serum vitamin B12. A Schilling test can then be used to distinguish between pernicious anaemia, vitamin B12 malabsorption and vitamin B12 deficiency. Symptoms include shortness of breath, pallor and diarrhoea etc.

Answer: Clostridium perfringens

Clostridium perfringens (C. perfringens) is a spore-forming gram-positive bacterium that is found in many environmental sources as well as in the intestines of humans and animals. C. perfringens is commonly found on raw meat and poultry. It prefers to grow in conditions with very little or no oxygen, and under ideal conditions can multiply very rapidly. Some strains of C. perfringens produce a toxin in the intestine that causes illness.
Beef, poultry, gravies, and dried or pre-cooked foods are common sources of C. perfringens infections. C. perfringens infection often occurs when foods are prepared in large quantities and kept warm for a long time before serving. Outbreaks often happen in institutions, such as hospitals, school cafeterias, prisons, and nursing homes, or at events with catered food.
People infected with C. perfringens develop diarrhoea and abdominal cramps within 6 to 24 hours (typically 8 to 12 hours). The illness usually begins suddenly and lasts for less than 24 hours. People infected with C. perfringens usually do not have fever or vomiting. The illness is not passed from one person to another.
Although C. perfringens may live normally in the human intestine, illness is caused by eating food contaminated with large numbers of C. perfringens bacteria that produce enough toxin in the intestines to cause illness.

C. perfringens can survive high temperatures. During cooling and holding of food at temperatures from 54°F–140°F (12°C–60°C), the bacteria grows. It can grow very rapidly between 109°F–117°F (43°C–47°C). If the food is served without reheating to kill the bacteria, live bacteria may be eaten. The bacteria produce a toxin inside the intestine that causes illness.

Three antibiotics are effective against Clostridium difficile:
Metronidazole 500 mg orally three times daily is the drug of choice, because of superior tolerability, lower price and comparable efficacy.
Oral vancomycin 125 mg four times daily is second-line therapy in particular cases of relapse or where the infection is unresponsive to metronidazole treatment.
Thirdly, the use of linezolid might also be considered.

According to Bohr’s equation, VD/VT = (pA(CO2) − pE(CO2))/pA(CO2), where pE(CO2) is mixed expired CO2 and pA(CO2) is alveolar CO2pressure. Normally, the pa(CO2) is virtually identical to pA(CO2). Thus, VD/VT = (pa(CO2)) − pE(CO2)/pa(CO2). By Fowler’s method, VD/VT= 0.25. In the given problem, (pa(CO2) − pE(CO2)/pa(CO2) = (40 − pE(CO2)/40 = 0.25. Thus, pE(CO2) = 30 mmHg. If there is a great perfusion/ventilation inequality, pE(CO2) could be significantly lower than 30 mm Hg, and the patient’s physiological dead space would exceed the anatomical dead space.

The duodenum is connected to the diaphragm by the suspensory ligament called the ligament of Treitz. It is a slip of skeletal muscle from the right crus of the diaphragm and a fibromuscular band of smooth muscle from the 3rd and 4th parts of the duodenum. It is an important landmark, used to divide the gastrointestinal tract into the upper and lower parts. Contraction of this ‘ligament’ leads to opening of the duodenojejunal flexure allowing the flow of chyme.

A small benign tumour, namely intraductal papilloma is most common in women between 35-55 years of age. It is also the commonest cause of spontaneous discharge from a single duct. A lump below the nipple may be sometimes palpable. Ultrasound and ductography are useful investigations., along with cytology of discharge to assess the presence of malignant cells. Confirmation is by breast biopsy.

Due to increased pressure on the heart as a result of hypertension and aortic stenosis, the myocardial fibres hypertrophied to adapt to the increased pressure and to effectively circulate blood around the body. Hyperplasia could not occur, as myocardial fibres are stable cells and cannot divide further.
Fat does not deposit in the heart due to volume overload.
Myocardial oedema is not characteristic of a myocardial injury.
Metaplasia is a change in the type of epithelium.
Atrophy would result in a decreased heart size and inability to function.

Polycythaemia is a condition that results in an increase in the total number of red blood cells (RBCs) in the blood. It can be due to myeloproliferative syndrome or due to chronically low oxygen levels or rarely malignancy. In primary polycythaemia/polycythaemia vera the increase is due to an abnormality in the bone marrow, resulting in increases RBCs, white blood cells (WBCs) and platelets. In secondary polycythaemia the increase occurs due to high levels of erythropoietin either artificially or naturally. The increase is about 6-8 million/cm3 of blood. A type of secondary polycythaemia is physiological polycythaemia where people living in high altitudes who are exposed to hypoxic conditions produce more erythropoietin as a compensatory mechanism for thin oxygen and low oxygen partial pressure.

Alveolar ventilation is the amount of air reaching the alveoli per minute. Alveolar ventilation = respiratory rate × (tidal volume – anatomical dead space volume). Thus, alveolar ventilation = 10 × (550 − 250) = 3000 ml/min.

The hypophyseal portal system links the hypothalamus and the anterior pituitary. With the help of this system, the anterior pituitary receives releasing and inhibitory hormones from the hypothalamus and regulates the action of other endocrine glands. One of the inhibitory hormones carried by this system is the prolactin-inhibitory hormone. In the absence of this hormone which might occur in case of a blockage of the system, prolactin secretion increases to about three times normal levels.

The gracile nucleus is located in the medulla oblongata and is one of the dorsal column nuclei involved in the sensation of fine touch and proprioception. It contains second-order neurons of the dorsal column–medial lemniscus system, that receive inputs from sensory neurones of the dorsal root ganglia and send axons that synapse in the thalamus.
The gracile nucleus and fasciculus carry epicritic, kinaesthetic and conscious proprioceptive information from the lower part of the body (below the level of T6 in the spinal cord). Similar information from the upper part of body (above T6, except for face and ear) is carried by the cuneate nucleus and fasciculus. The information from face and ear is carried by the primary sensory trigeminal nucleus.

The costodiaphragmatic recess is the lowest point of the pleural sac where the costal pleura becomes the diaphragmatic pleura. At the midclavicular line, this is found between ribs 6 and 8; at the paravertebral lines, between ribs 10 and 12 and between ribs 8 and 10 at the midaxillary line.
The cardiac notch: is an indentation of the heart on the left lung, located on the anterior surface of the lung.
Cupola: part of the parietal pleura that extends above the first rib.
Oblique pericardial sinus: part of the pericardial sac located posterior to the heart behind the left atrium.
Costomediastinal recess: a reflection of the pleura from the costal surface to the mediastinal surface, is on the anterior surface of the chest.
The inferior mediastinum: is the space in the chest occupied by the heart.

The transverse cervical nerve (superficial cervical or cutaneous cervical) arises from the second and third spinal nerves, turns around the posterior border of the sternocleidomastoid and, passing obliquely forward beneath the external jugular vein to the anterior border of the muscle, it perforates the deep cervical fascia, and divides beneath the platysma into the ascending and descending branches. It provides cutaneous innervation to this area.

Prostatic adenocarcinoma is the commonest solid malignancy and non-dermatological cancer in men above 50 years age. Increasing in incidence with age and the highest risk seen in the black population. About 75% of cases are seen in men over 65 years. Other tumours affecting the prostate include undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma, but these occur less commonly. Sarcomas usually affect children. Hormones play a role in the aetiology of prostate adenocarcinoma unlike the other types. Intraepithelial neoplasia is considered a precursor of invasive malignancy.

Carcinoid syndrome occurs in ∼20% of cases of well-differentiated endocrine tumours of the jejunum or ileum (midgut neuroendocrine tumours (NET) and consists of (usually) dry flushing (without sweating; 70% of cases) with or without palpitations, diarrhoea (50% of cases) and intermittent abdominal pain (40% of cases); in some patients, there is also lacrimation and rhinorrhoea.
Carcinoid syndrome occurs less often with NETs of other origins and is very rare in association with rectal NETs. It is usually due to metastasis to the liver, with the release of vasoactive compounds, including biogenic amines (e.g., serotonin and tachykinins), into the systemic circulation. However, it may also occur in the absence of liver metastases if there is direct retroperitoneal involvement, with venous drainage bypassing the liver. Pain due to hepatic enlargement may also be a presenting feature, as may upper right abdominal pain (similar to that of pulmonary infarction) secondary to either haemorrhage into, or necrosis of, a hepatic secondary tumour. Wheezing and pellagra are less common presenting features. CHD is present in ∼20% of patients at presentation and usually indicates that the syndrome has been present for several years.

The aim of treatment should be curative where possible but it is palliative in the majority of cases.
Surgery is the only curative treatment.
Administration of specific medications to treat symptoms should, therefore, start as soon as clinical and biochemical signs indicate the presence of hypersecretory NETs, even before the precise localisation of primary and metastatic lesions is confirmed.

The only proven hormonal management of NETs is by the administration of somatostatin analogues.
Somatostatin analogues bind principally to SSTR subtypes 2 (with high affinity) and 5 (with lower affinity), thus inhibiting the release of various peptide hormones in the gut, pancreas and pituitary; they also antagonise growth factor effects on tumour cells, and, at very high dosage, may induce apoptosis. The effects of somatostatin analogues are demonstrable as biochemical response rates (inhibition of hormone production) in 30–70% of patients and as symptomatic control in the majority of patients.
There are two commercially available somatostatin analogues: octreotide and lanreotide.

Electroencephalography (EEG) is the neurophysiological measurement of the electrical activity of the brain. It is done by placing electrodes on the scalp or subdurally. In reality, the electrical currents are not measured, but rather the voltage differences between different parts of the brain. Four major types of EEG activity are recognized, which are alpha, beta, delta and theta.
Alpha waves, also known as Berger’s waves ranges in frequency from 8-12 Hz. Best detected with eyes closed, alpha waves are characteristic of a relaxed, alert state of consciousness. An alpha-like normal variant called mu is sometimes seen over the motor cortex (central scalp) and attenuates with movement or, rather, with the intention to move.

The pain could have been caused by the urinary bladder, uterus/cervix/vagina or rectum as it involves the pelvic viscera.

The timing of platelet transfusion in a patient of ITP undergoing splenectomy should be carefully monitored, it should neither be done too soon or too late. If done too soon it will be rendered ineffective, if too late it will result in unnecessary bleeding. The ideal time for a platelet transfusion would be when the splenic artery has been ligated.

The ‘nutcracker effect’ is only seen in one part of the alimentary canal, and that is in the third part of the duodenum. This can happen when the superior mesenteric artery that passes across the duodenum and the aorta, posteriorly to the third part of the duodenum enlarges and starts compressing the duodenum. The result is an obstructed duodenum that inhibits passage of food.

The greatest amount of salt and water increase with cerebral oedema occurs within the white matter. Any swelling from oedema, haemorrhage or haematoma increases the intracranial pressure (ICP). As the ICP increases, the cerebral perfusion decreases and brain tissue can become ischaemic, even leading to brain death.

An increase in the frequency of sound waves results in a change in the position of maximal displacement of the basilar membrane in the cochlea. Low pitch sound produces maximal displacement towards the cochlear apex and greatest activation of hair cells there. With an increasing pitch, the site of greatest displacement moves towards the cochlear base. However, increased amplitude of displacement, increase in the number of activated hair cells, increased frequency of discharge of units in the auditory nerve and increase in the range of frequencies to which such units respond, are all seen in increases in the intensity or a sound stimulus.

Starvation is the most extreme form of malnutrition. Prolonged starvation can lead to permanent organ damage and can be fatal. Starved individuals eventually lose significant fat and muscle mass as the body uses these for energy.

The next appropriate step would be to perform an examination under anaesthesia and inject 15–30 units of botulinum toxin into the internal anal sphincter.

Anal fissures are commonly seen in the colorectal clinic and are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapse

Diagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.

For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms (however, up to 25% of the patients fail to respond). The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

A cerebral abscess can result from direct extension of cranial infections, penetrating head trauma, haematogenous spread, or for unknown causes. An abscess forms when an area of cerebral inflammation becomes necrotic and encapsulated by glial cells and fibroblasts. Oedema around the abscess can increase the intracranial pressure. Symptoms result from increased intracranial pressure and mass effects. In a CT scan, an abscess appears as an oedematous mass with ring enhancement.

Follicular thyroid cancer accounts for 15% of thyroid cancer and occurs more commonly in women over 50 years of age. Thyroglobulin (Tg) can be used as a tumour marker for well-differentiated follicular thyroid cancer. Follicular cells are the thyroid cells responsible for the production and secretion of thyroid hormones.

It is impossible to distinguish between follicular adenoma and carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis. Features for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumour cells. Capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid).

– Follicular carcinoma tends to metastasize to lung and bone via the bloodstream.
– Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes.
– HMGA2 has been proposed as a marker to identify malignant tumours.

Polycythaemia is a condition that results in an increase in the total number of red blood cells (RBCs) in the blood. It can be due to a myeloproliferative syndrome, chronically low oxygen levels or rarely malignancy. In primary polycythaemia/ polycythaemia vera the increase is due to an abnormality in the bone marrow, resulting in increased RBCs, white blood cells (WBCs) and platelets. In secondary polycythaemia the increase occurs due to high levels of erythropoietin either artificially or naturally. The increase is about 6-8 million/cm3 of blood. A type of secondary polycythaemia is physiological polycythaemia where people living in high altitudes who are exposed to hypoxic conditions produce more erythropoietin as a compensatory mechanism for thin oxygen and low oxygen partial pressure.

Giardia is a microscopic parasite that causes the diarrheal illness known as giardiasis. Giardia (also known as Giardia intestinalis, Giardia lamblia, or Giardia duodenalis) is found on surfaces or in soil, food, or water that has been contaminated with faeces from infected humans or animals.

Giardia is protected by an outer shell that allows it to survive outside the body for long periods of time and makes it tolerant to chlorine disinfection. While the parasite can be spread in different ways, water (drinking water and recreational water) is the most common mode of transmission.

Signs and symptoms may vary and can last for 1 to 2 weeks or longer. In some cases, people infected with Giardia have no symptoms.

Acute symptoms include:

Diarrhoea
Gas
Greasy stools that tend to float
Stomach or abdominal cramps
Upset stomach or nausea/vomiting
Dehydration (loss of fluids)
Other, less common symptoms include itchy skin, hives, and swelling of the eye and joints. Sometimes, the symptoms of giardiasis might seem to resolve, only to come back again after several days or weeks. Giardiasis can cause weight loss and failure to absorb fat, lactose, vitamin A and vitamin B12.

In children, severe giardiasis might delay physical and mental growth, slow development, and cause malnutrition.

The most likely vascular structure is the inferior vena cava. The inferior vena cava is formed by the joining of the two common iliac arteries, the right and the left iliac artery, at the level of the fifth lumbar vertebra( L5). The inferior vena cava passes along the right side of the vertebral column. It enters the thoracic cavity into the underside of the heart through the caval opening of the diaphragm at the level of the eight thoracic vertebra (T8).

Rh disease is also known as erythroblastosis fetalis and is a disease of the new-born. In mild states it can cause anaemia with reticulocytosis and in severe forms causes severe anaemia, morbus hemolytcus new-born and hydrops fetalis. RBCs of the Rh+ baby can cross the placenta and enter into the maternal blood. As she is Rh- her body will form antibodies against the D antigen which will pass through the placenta in subsequent pregnancies.

The azygos vein is formed by the union of the right subcostal veins and the ascending lumbar veins at the level of the 12th thoracic vertebra. It enters the thorax through the aortic hiatus to ascend in the posterior mediastinum and arching over the right main bronchus posteriorly at the root of the right lung to join the superior vena cava before it pierces the pericardium.
The basilic vein is a vein on the medial aspect of the arm that ascends to become the axillary vein.
The cephalic vein is also a vein of the arm.
The external jugular and brachiocephalic vein are not in the posterior mediastinum.
The median cubital vein is found in the cubital fossa of the arm.

Pulmonary vascular resistance (PVR) = (Mean pulmonary artery pressure – Pulmonary capillary wedge pressure) divided by Cardiac output. To get cardiac output, Fick’s principle needs to be applied which states that VO2 = (CO × CAO2) – (CO × CVO2) where VO2 = oxygen consumption, CO = cardiac output, CA = oxygen concentration of arterial blood and CVO2 = oxygen concentration of venous blood. Thus, CO = VO2/CAO2– CVO2, CO = 500/0.24–0.16, CO = 500/0.8, CO = 6.25 l/min. To calculate mean pulmonary artery pressure, we use the formula: Mean pulmonary artery pressure = Diastolic pressure + 1/3(Systolic pressure – Diastolic pressure). Thus, Mean pulmonary artery pressure = 15 + 1/3(25 – 15) = 15 + 3. 33 = 18.33. Substituting these values in the first formula, PVR = 18.3–5/6.25 = 13.5/5.25 = 2.0 resistance units (mmHg/l per min) approximately.

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome.

The posterior cricoarytenoid muscle, which is the sole abductor of the vocal folds, receives its innervation from the inferior laryngeal nerve which is a continuation of the recurrent laryngeal nerve.

Embryonal carcinoma is a non-seminomatous germ cell tumour of the testis, accounting for 25% testicular tumours. Other germ cell tumours include seminoma, teratoma and choriocarcinoma. Embryonal carcinomas are known to occur in men aged 25-35 years, and occasionally in teens. They are rarely seen in ovaries of females. It can spread to the vas deferens and also to the aortic lymph nodes. Embryonal carcinomas are known to have elements of fetal origin such as cartilage. Usually, the main tumour is about 2.5cm long, with an extension of 8-9cm along the testicular cord. Contiguous spread to the testicle is seen in less than 1% cases.

This patient is malnourished. Although surgery is imminent, it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation, total parenteral nutrition (TPN) is likely the best feeding modality.

The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.

Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 months

Following patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rate

Considering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding.

Answer: Infection with Staphylococcus aureus

Surgical site infections (SSIs) are among the most common healthcare-associated infections, and contribute significantly to patient morbidity and healthcare costs. Staphylococcus aureus is the most common microbial cause. The epidemiology of S. aureus is changing with the dissemination of newer clones and the emergence of mupirocin resistance. Pre-operative screening, using culture- or molecular-based methods, and subsequent decolonization of patients who are positive for methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) reduces SSIs and hospital stay. This applies especially to major clean surgery, such as cardiothoracic and orthopaedic, involving the insertion of implanted devices. However, it requires a multi-disciplinary approach coupled with patient education. Universal decolonization pre-operatively without screening for S. aureus may compromise the capacity to monitor for the emergence of new clones of S. aureus, contribute to mupirocin resistance, and prevent the adjustment of surgical prophylaxis for MRSA (i.e. replacement of a beta-lactam agent with a glycopeptide or alternative).

A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.

Symptoms include:
Redness and pain around the area where you had surgery
Drainage of cloudy fluid from your surgical wound
Fever

The carotid triangle is a portion of the anterior triangle of the neck. It is bounded superiorly by the posterior belly of the digastric muscle, antero-inferiorly by the superior belly of omohyoid and posteriorly by the sternocleidomastoid. The floor is formed by the thyrohyoid, hyoglossus, middle and inferior pharyngeal constrictors and the roof is formed by the skin, superficial fascia, platysma and deep fascia.

Familial adenomatous polyposis (FAP) is an autosomal dominant, hereditary colon cancer syndrome that is characterized by the presence of innumerable adenomatous polyps in the colon and rectum. Gardner’s syndrome is a variant of FAP, which in addition to the colonic polyps, also presents extracolonic manifestations, including desmoid tumours, osteomas, epidermoid cysts, various soft tissue tumours, and a predisposition to the thyroid and periampullary cancers.
Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.
Mutations of the APC gene are thought to be responsible for the development of FAP, and the location of the mutation on the gene is thought to influence the nature of the extracolonic manifestations that a given patient might develop.
Though patients are often asymptomatic, bleeding, diarrhoea, abdominal pain and mucous discharge frequently occur. Diagnostic tools include genetic testing, endoscopy, and monitoring for extra-intestinal manifestations.
If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. Besides, an increased risk exists for the development of other malignancies.
Currently, surgery is the only effective means of preventing progression to colorectal carcinoma. Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC/IPAA) with mucosectomy is the preferred surgical procedure since it attempts to eliminate all colorectal mucosa without the need for an ostomy. Periampullary carcinoma and intra-abdominal desmoid tumours are a significant cause of morbidity and mortality in these patients after colectomy. Frequent endoscopy is needed to prevent the former, while there is no definitive treatment available yet for the latter.

Mallory bodies (or ‘alcoholic hyaline’) are inclusion bodies in the cytoplasm of liver cells, seen in patients of alcoholic hepatitis; and also in Wilson’s disease. These pathological bodies are made of intermediate keratin filament proteins that are ubiquinated or bound by proteins like heat chock protein. Being highly eosinophilic, they appear pink on haematoxylin and eosin staining.

A mitochondria is a membrane bound organelle found in eukaryotic cells. They are called the powerhouse of the cell and are the place where ATP is formed from energy generated through metabolism. They are capable of replication as well as repair and regeneration.

Even in the era of gene-expression profiling, the nodal status still remains the primary prognostic discriminant in breast cancer patients. The exclusion of node involvement using non-invasive methods could reduce the rate of axillary surgery, thereby preventing from suffering complications.

Lymph node status is highly related to prognosis (chances for survival).

This wound should be managed by primary closure as there is minimal associated tissue loss and the surgery is minor and uncontaminated.

Primary wound closure is the fastest type of closures, and is also known as healing by primary intention. Wounds that heal by primary closure have a small, clean defect that minimizes the risk of infection and requires new blood vessels and keratinocytes to migrate only a small distance. Standard methods of suturing are usually sufficient for primary wound closure.

The muscles of the superficial posterior compartment of the leg form the characteristic ‘calf’ shape of the posterior leg and include the gastrocnemius, soleus and plantaris. The gastrocnemius and soleus together form a muscular mass which is occasionally described as the triceps surae; its tendon of insertion is the tendo calcaneus. The tendo calcaneus is the thickest and strongest in the body and together with the tendon of the plantaris muscle is inserted into the posterior part of the calcaneus.

Unilateral vocal fold paralysis (UVFP) occurs from a dysfunction of the recurrent laryngeal (inferior laryngeal nerve) or vagus nerve innervating the larynx. It causes a characteristic breathy voice often accompanied by swallowing disability, a weak cough, and the sensation of shortness of breath. This is a common cause of neurogenic hoarseness. When this paralysis is properly evaluated and treated, normal speaking voice is typically restored. Specifically, thyroidectomy, carotid endarterectomy, anterior cervical spine surgery, thoracic, or mediastinal surgery most often result in a presentation of UVFP.

A ‘claw hand’ is associated with injury to the ulnar nerve at the wrist affecting the interossei, lumbricals and hypothenar muscles of the hand. It is characterized by hypothenar eminence wasting, hyperextended metacarpophalangeal joints and flexed interphalangeal joints.

The preauricular sinus is a benign congenital malformation of the preauricular soft tissues. Mostly it is noted during routine ear, nose and throat examination, though can present as an infected and discharging sinus. Preauricular sinus is more often unilateral, only occasionally are bilateral forms inherited. The right side is more often involved and females more than males. Most sinuses are clinically silent, eventual, however not rare, appearance of symptoms is related to an infectious process. Erythema, swelling, pain and discharge are familiar signs and symptoms of infection. The most common pathogens causing infection are Staphylococcal species and, less frequently Proteus, Streptococcus and Peptococcus species.

Courses of treatment typically include the following:
– Draining the pus occasionally as it can build up a strong odour
– Antibiotics when infection occurs.
– Surgical excision is indicated with recurrent fistula infections, preferably after significant healing of the infection.
In case of a persistent infection, infection drainage is performed during the excision operation. The operation is generally performed by an appropriately trained specialist surgeon e.g. a otolaryngologist or a specialist General Surgeon.
The fistula can be excised as a cosmetic operation even though no infection appeared. The procedure is considered an elective operation in the absence of any associated complications.

Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule. It is the most common type of kidney cancer in adults, responsible for approximately 90–95% of cases. Renal cell carcinomas can be staged by using the American Joint Committee on Cancer (AJCC) TNM (tumour-node-metastasis) classification, as follows: Stage I: tumours that are 7 cm or smaller and confined to the kidney, Stage II: tumours that are larger than 7 cm but still confined to the kidney, Stage III: tumours extending into the renal vein or vena cava, involving the ipsilateral adrenal gland and/or perinephric fat, or which have spread to one local lymph node and Stage IV: tumours extending beyond Gerota’s fascia, to more than one local node, or with distant metastases Recent literature has questioned whether the cut-off in size between stage I and stage II tumours should be 5 cm instead of 7 cm. The patient’s cancer in this case is stage III.

Atrial fibrillation occurring after a colonic resection most likely represents an anastomotic leak. The best modality to visualize this would be an abdominal CT scan. Any bowel anastomosis can leak, sometimes as a result of technical failings and at other times, its patient factors such as background disease that contribute. As a general rule, rectal resections carry the highest risk of anastomotic leak. Indeed, low anterior resections are routinely defunctioned with loop ileostomy to mitigate the clinically effects of a leak. Left sided colonic resections carry a higher risk of anastomotic leak than right sided resections. The reason for this is that an ileocolic anastomosis (or indeed any small bowel anastomosis) has a very low risk of leak (provided the small bowel is otherwise healthy). Where a leak is suspected (new AF and raised inflammatory markers 5 days post resection), the correct course of action is to arrange cross sectional imaging with a CT scan. If a leak is confirmed and the patient is septic, then they should go back to theatre, the anastomosis taken down and the bowel ends exteriorized.

The correct order of structures from superficial to deep are: the skin and subcutaneous tissue, the external intercostals followed by internal intercostals, innermost intercostals and finally parietal pleura.

In children, more common causes of Urinary tract obstruction include the following:
UPJ or UVJ obstruction
Ectopic ureter
Ureterocoele
Megaureter
Posterior urethral valves

Posterior urethral valves:

During the early stages of embryogenesis, the most caudal end of the wolffian duct is absorbed into the primitive cloaca at the site of the future verumontanum in the posterior urethra. In healthy males, the remnants of this process are the posterior urethral folds, called plicae colliculi. Histologic studies suggest that PUVs are formed at approximately 4 weeks’ gestation, as the wolffian duct fuses with the developing cloaca.
Congenital obstructing posterior urethral membrane (COPUM) was first proposed by Dewan and Goh and was later supported by histologic studies by Baskin. This concept proposes that instead of a true valve, a persistent oblique membrane is ruptured by initial catheter placement and, secondary to rupture, forms a valve like configuration.
Indicators of possible PUVs later in childhood include the following:
Urinary tract infection (UTI)
Diurnal enuresis in boys older than 5 years
Secondary diurnal enuresis
Voiding pain or dysfunction
Abnormal urinary stream

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.

Substantia gelatinosa is one of the nuclei in the posterior grey column along side other posterior grey column nuclei like the nucleus dorsalis, nucleus proprius, and posteromarginal nucleus. These nuclei are a collection of cells in the posterior grey area found in throughout the spinal cord. The substantia gelatinosa receives direct input from the dorsal nerve roots (sensory), especially from thermoreceptors and nociceptors (receptors for temperature and pain).

This patient is likely to have paralytic ileus and the administration of antiemetic drugs, in this situation, will have no effect. It is, therefore, important to decompress the stomach with a wide bore nasogastric tube.

Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It commonly occurs after an abdominal surgery. Irrespective of the cause, paralytic ileus causes constipation, abdominal distention, nausea, and vomiting. It is a severe condition because if left untreated, an ileus can cut off blood supply to the intestines and cause tissue death.

The patient has a primary psoas abscess.

Psoas (or iliopsoas) abscess is a collection of pus in the iliopsoas muscle compartment. It may arise via contiguous spread from adjacent structures or by the haematogenous route from a distant site. Psoas abscesses may be either primary or secondary. Primary cases often develop in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may occur as a complication of intra-abdominal diseases such as Crohn’s disease.

Patients usually present with lower back pain and if the abscess is extensive, a mass that may be localised to the inguinal region or femoral triangle. In most cases, the diagnosis can be made clinically. Where it is not clear, an ultrasound scan is often the most convenient investigation.

Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.

The spleen in the human embryo arises in week 5 of intrauterine life. It appears as a proliferating mesenchyme above the pancreas. The spleen is one the organs that develops in the dorsal mesogastrium. When the stomach changes its position during development, the spleen is made to move behind the stomach and stays in contact with the left kidney. The spleen is found within the peritoneum of the abdominal cavity thus it is an intraperitoneal organ.

An Anal fissure is a cut or a tear in the anal canal typically caused by passing a hard stool. Patients often complain of severe anal pain and bleeding with bowel movements. On physical examination, you may see the fissure or just the sentinel tag. If the examination appears normal, you can elicit point tenderness. We recommend against continuing the digital rectal examination or anoscopy if the patient is having pain during the examination.
The primary goals of therapy are to properly bulk the stool with adequate fibre and relax the anal muscle. Specific steps include the following:
Properly bulk the stool with adequate fibre to minimize constipation and diarrhoea; both frequent bowel movements and hard bowel movements can lead to an anal fissure.
Temporary use of laxatives such as daily Miralax or senna. The dose of Miralax can be titrated up or down to achieve desired results. As the patient’s fibre supplementation increases, the need for Miralax will diminish.
Chronic use of laxatives should be avoided because it can lead to worsening colonic function and constipation.
Diltiazem 2% ointment is to be placed on the anal muscle 3 times daily—continue for a minimum of 8 weeks, even if symptoms improve earlier.
If a patient cannot tolerate diltiazem or is breastfeeding or pregnant, 0.2% nitroglycerin-compounded ointment can be prescribed. However, the proper dose of nitroglycerin is important as too high of a dose can cause severe headaches.
Do NOT prescribe haemorrhoid ointments or suppositories, especially steroid-based ones. Steroid ointments do not help. They do cause perianal skin thinning and dermatitis. At best, they act as a placebo, but they often are used chronically and cause unpleasant perianal skin changes.
Use mental anal muscle relaxation: Actively thinking about relaxing sphincter tone.
Consider sitz baths: Soaking the anal area in warm water induces relaxation. Warmer water induces more relaxation. No additives are needed.
Surgical intervention (such as Botox injections or sphincterotomy) is considered for patients whose symptoms do not improve with the above management strategies. It is imperative that the patient increases fibre and water intake so bowel movements are very soft before the surgical intervention to maximize chances of postoperative healing.

The combination of a high reticulocyte count and severe anaemia indicates aplastic crisis in patients with sickle cell anaemia. Another differential can be that of a transient aplastic crisis due to parvovirus. This is less likely as it causes reticulocytopenia rather than reticulocytosis.

Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production. People who have underlying haematologic abnormalities such as sickle cell anaemia are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. It is more common in people of African, Indian, and Middle Eastern backgrounds. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytosis.

The dural venous sinuses lies between the periosteal and meningeal layer of the dura mater. Dural venous sinuses is unique because it does not run parallel with arteries and allows bidirectional flow of blood intracranially as it is valve-less.

The normal glomerular filtration rate (GFR) in humans is 125 mL/min. After the age of 40, GFR decreases progressively by about 0.4–1.2 mL/min per year.

Glucose is reabsorbed almost 100% via sodium–glucose transport proteins (apical) and GLUT (basolateral) in the proximal convoluted tubule. Glycosuria or glucosuria is a condition of osmotic diuresis typical in those suffering from diabetes mellitus. Due to a lack of insulin, plasma glucose levels are above normal. This leads to saturation of receptors in the kidneys and glycosuria usually at plasma glucose levels above 11 mmol/l. Rarely, glycosuria is due to an intrinsic problem with glucose reabsorption within the kidneys (such as Fanconi syndrome), producing a condition termed renal glycosuria.

Increased alkaline phosphatase is indicative of cholestasis, with a 4x or greater increase seen 1-2 days after biliary obstruction. Its level can remain elevated several days after the obstruction is resolved due to the long half life (7 days). Increase up to three times the normal level can be seen in hepatitis, cirrhosis, space-occupying lesions and infiltrative disorders. Raised alkaline phosphatase with other liver function tests being normal can occur in focal hepatic lesions like abscesses or tumours, or in partial/intermittent biliary obstruction. However, alkaline phosphatase has several isoenzymes, which originate in different organs, particularly bone. An isolated rise can also be seen in malignancies (bronchogenic carcinoma, Hodgkin’s lymphoma), post-fatty meals (from the small intestine), in pregnancy (from the placenta), in growing children (from bone growth) and in chronic renal failure (from intestine and bone). One can differentiate between hepatic and non-hepatic cause by measurement of enzymes specific to the liver e.g. gamma-glutamyl transferase (GGT).
In an elderly, asymptomatic patient, isolated rise of alkaline phosphatase usually points to bone disease (like Paget’s disease). Presence of other symptoms such as jaundice, pale stools, weight loss suggests obstructive jaundice, most probably due to pancreatic carcinoma.

Based on the history and examination findings, the correct diagnosis is false aneurysm of the femoral artery. It may occur following arterial trauma in intravenous drug users.

A false aneurysm, or pseudoaneurysm of the vessels, occurs when a blood vessel wall is injured and the leaking blood collects in the surrounding tissue. It is not an enlargement of any of the layers of the vessel wall. Pseudoaneurysms usually present as a painful, tender, pulsatile mass. Diagnostic options include duplex scan, and CT angiogram or a conventional angiogram.

In a true aneurysm, the artery or vessel weakens and bulges, usually forming a blood-filled sac.

The pterion is the area where four bones, the parietal, frontal, greater wing of sphenoid and the squamous part of the temporal bone meet. It overlies the anterior branch of the middle meningeal artery on the internal aspect of the skull. The pterion is the weakest part of the skull. Slight trauma to this region can cause extradural hematoma.

The most potent stimulus for ADH release is increased plasma osmolarity. Decreased plasma volume is a less potent stimulus in comparison. However, decrease blood volume and arterial pressure due to severe haemorrhage does lead to ADH secretion. Hypothalamic releasing factors do not control the release of posterior pituitary hormones ADH and oxytocin.

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 abdomen is divided into nine regions for descriptive purposes. The epigastric region contains the first part of the duodenum, part of the stomach, part of the liver and pancreas. This would be the region that the surgeon would need to enter to access the ulcer.
The left inguinal region contains the sigmoid colon.
The left lumbar region contains the descending colon and kidney.
The right lumbar region contains the right kidney and descending colon.
The right hypochondrial region contains part of the liver and gall bladder.
The hypogastric region contains the urinary bladder and the rectum.

Hyaline thrombi are typically associated with thrombotic thrombocytopenic purpura (TTP), which is caused by non-immunological destruction of platelets. Platelet transfusion is contraindicated in TTP. Platelets and red blood cells also get damaged by loose strands of fibrin deposited in small vessels. Multiple organs start developing platelet-fibrin thrombi (bland thrombi with no vasculitis) typically at arteriocapillary junctions. This is known as ‘thrombotic microangiopathy’. Treatment consists of plasma exchange.

The mesangium is an inner layer of the glomerulus, within the basement membrane surrounding the glomerular capillaries. The mesangial cells are phagocytic and secrete the amorphous basement membrane-like material known as the mesangial matrix. They are typically separated from the lumen of the capillaries by endothelial cells. The other type of cells in the mesangium are the extraglomerular mesangial cells which form the juxtaglomerular apparatus in combination with two other types of cells: the macula densa of the distal convoluted tubule and juxtaglomerular cells of the afferent arteriole. This apparatus controls blood pressure through the renin–angiotensin–aldosterone system.

In females, the breasts and lungs are the most common primary disease sites; approximately 80% of cancers that spread to bone arise in these locations. In males, cancers of the prostate and lungs make up 80% of the carcinomas that metastasize to bone. The remaining 20% of primary disease sites in patients of both sexes are the kidney, gut, and thyroid, as well as sites of unknown origin.

On contrast-enhanced CT scans, RCC is usually solid, and decreased attenuation suggestive of necrosis is often present. Sometimes, RCC is a predominantly cystic mass, with thick septa and wall nodularity.
RCC may also appear as a completely solid and highly enhancing mass

Cardiac diastole refers to the time period when the heart is relaxed after contraction and is preparing to refill with blood. Both ventricular and atrial diastole are together known as complete cardiac diastole. At its beginning, the ventricles relax, causing a drop in the ventricular pressure. As soon as the left ventricular pressure drops below that in left atrium, the mitral valve opens and there is ventricular filling of blood. Similarly, the tricuspid valve opens filling the right atrium.

Cerebellar disease leads to intention tremors, which is absent at rest and appears at the onset of voluntary movements. In comparison, Parkinson’s tremor is present at rest. Frequency of tremor is a less reliable means to differentiate between the two as the oscillation amplitude of the tremor is not constant throughout a voluntary action.

In type II hypersensitivity the antibodies that are produced by the immune response bind to the patients own cell surface antigens. These antigens can be intrinsic or extrinsic. Destruction occurs due to antibody dependent cell mediated antibodies. Antibodies bind to the cell and opsonise the cell, activating phagocytes to destroy that cell e.g. autoimmune haemolytic anaemia, Goodpasture syndrome, erythroblastosis fetalis, pernicious anaemia, Graves’ disease, Myasthenia gravis and haemolytic disease of the new-born.

Sodium bicarbonate is indicated in the management of metabolic acidosis, which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis. Bicarbonate is given at 50-100 mmol at a time under scrupulous monitoring of the arterial blood gas readings. This intervention, however, has some serious complications including lactic acidosis, and in those cases, should be used with great care.

Spironolactone is a renal competitive aldosterone antagonist in a class of drugs called ‘potassium-sparing diuretics’, that is primarily used to treat fluid build-up due to heart failure, liver scarring, or kidney disease. It is also used in the treatment of high blood pressure, low blood potassium, early-onset puberty, and acne and excessive hair growth in women. Spironolactone inhibits the effect of aldosterone by competing for intracellular aldosterone receptors in the distal tubule cells. This increases the secretion of water and sodium, while decreasing the excretion of potassium.

High anion gap in metabolic acidosis is caused generally by the elevation of the levels of acids like ketones, lactate, sulphates in the body, which consume the bicarbonate ions. Other causes of a high anion gap include overdosing on salicylates, uraemia, rhabdomyolysis, hypocalcaemia, hypomagnesaemia, or ingestion of toxins such as ethylene glycol, methanol, propyl alcohol, cyanide and iron.

Factor XIII, also known as fibrin stabilizing factor, is an enzyme of the coagulation cascade that crosslinks fibrin. Deficiency of FXIII may cause bleeding tendency but paradoxically, it may also predispose to thrombosis.

There are usually 3 perforating arteries:
The first gives branches to the adductor brevis and magnus, biceps femoris and gluteus maximus and anastomoses with the inferior gluteal, medial and lateral femoral circumflex.
The second artery supplies the posterior femoral muscles and anastomose with the first and third perforating vessels.
The third supplies the posterior femoral muscles.

The internal vertebral veins are the most likely route of metastasis as they are valveless. They serve an important clinical role as they are the route of free travel for cancerous cells to other body structures. The other veins on the list have valves and would be the least likely routes for metastasis.

The forces of elastance (compliance), frictional resistance and inertia have been identified as the forces that oppose lung inflation and deflation. The normal relaxed state of the lung and chest is partially empty. Further exhalation requires muscular work. Inhalation is an active process requiring work. About 60–66% of the total work performed by the respiratory muscles is used to overcome the elastic or compliance characteristics of the lung–chest cage, 30–35% is used to overcome frictional resistance and only 2–5% of the work is used for inertia.

Burn depth is classified as first, second, third, or fourth degree, as follows:
First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.

The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation

Medications
See the list below:
– Silver sulfadiazine – Broad antibacterial spectrum; painless application
– Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
– Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
– Petrolatum – Bland and nontoxic
– Various debriding enzymes – Useful in selected partial-thickness wounds
– Various antibiotic ointments – Useful in many superficial partial-thickness wounds
Membranes
See the list below:
– Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
– Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
– Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
– Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
– Various semipermeable membranes – Provide vapour and bacteria barrier
– Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
– Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
– Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
– AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
– Integra R – Provides scaffold for neodermis; requires delayed thin autograft

Answer: 13

Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 point

Verbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 point

Motor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 point

He is seen to be disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. His score is therefore 13: 3 for eye opening response, 4 for verbal response and 6 for motor response.

On transmission of a loud sound into the central nervous system, an attenuation reflex occurs after a latent period of 40-80 ms. This reflex contracts the two muscles that pull malleus and stapes closer, developing a high degree of rigidity in the entire ossicular chain. This reduces the ossicular conduction of low frequency sounds to the cochlea by 30-40 decibels. In this way, the cochlea is protected from damage due to loud sounds (these are low frequency sounds) when they develop slowly.

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.

Epstein-Barr virus (EBV), also known as human herpes virus 4,is a member of the herpes virus family. EBV spreads most commonly through bodily fluids, primarily saliva. EBV can cause infectious mononucleosis. Symptoms of EBV can include fatigue, fever, inflamed throat, swollen lymph nodes in the neck, enlarged spleen, swollen liver and rash.

Cations: sodium, magnesium, calcium and potassium
Anions: chloride, phosphate, bicarbonate, lactate, sulphate and albumin

To determine compliance of the respiratory system, changes in transmural pressures (in and out) immediately across the lung or chest cage (or both) are measured simultaneously with changes in lung or thoracic cavity volume. Changes in lung or thoracic cage volume are determined using a spirometer with transmural pressures measured by pressure transducers. For the lung alone, transmural pressure is calculated as the difference between alveolar (pA; inside) and intrapleural (ppl; outside) pressure. To calculate chest cage compliance, transmural pressure is ppl (inside) minus atmospheric pressure (pB; outside). For the combined lung–chest cage, transmural pressure or transpulmonary pressure is computed as pA – pB. pA pressure is determined by having the subject deeply inhale a measured volume of air from a spirometer. Under physiological conditions the transpulmonary or recoil pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly negative to slightly positive as a person breathes.

Normal saline is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation. It is isotonic and has long been believed to be the safest fluid to give quickly in large volumes.

The endothoracic fascia is connective tissue that is between the costal parietal pleura and the inner aspect of the chest wall. Removing this layer of connective tissue would make it easy to separate the costal pleura from the thoracic wall.
Deep fascia: is not found around the lungs. It is a layer of connective tissue that invests a muscle or a group of muscles.
Parietal pleura: part of the pleura that lines the inner surface of the chest/thoracic cavity.
Visceral pleura: is the serous membrane that lines the surface of the lungs.
Transversus thoracis muscle fascia is associated only with the muscle transversus thoracis.
Peritracheal fascia: a layer of connective tissue that invests the trachea. It is not associated with the thoracic wall or the costal pleura.

The atmospheric pressure is lower at high altitudes as compared with sea level. This leads to a decrease in the partial pressure of oxygen. Once 2100 m (7000 feet) of altitude is reached, there is a drop in saturation of oxyhaemoglobin. The oxygen saturation of haemoglobin determines the oxygen content in the blood. The body physiological tries to adapt to high altitude by acclimatization. Immediate effects include hyperventilation, fluid loss (due to a decreased thirst drive), increase in heart rate and slightly lowered stroke volume. Long term effects include lower lactate production, compensatory alkali loss in urine, decrease in plasma volume, increased erythropoietin release and red cell mass, increased haematocrit, higher concentration of capillaries in striated muscle tissue, increase in myoglobin, increase in mitochondria, increase in aerobic enzyme concentration such as 2,3-DPG and pulmonary vasoconstriction.

The suprascapular nerve arises from the cervical spinal nerves 5 and 6 after coming together to form common trunk. This nerve supplies the supraspinatus and infraspinatus muscles giving off branches to the shoulder joint.

The clinical history combined with parathyroid hormone levels will reveal the cause of hypocalcaemia in the majority of cases

Causes

Vitamin D deficiency (osteomalacia)
Acute pancreatitis
Chronic renal failure
Hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
Pseudohypoparathyroidism (target cells insensitive to PTH)
Rhabdomyolysis (initial stages)
Magnesium deficiency (due to end organ PTH resistance)

Management

Acute management of severe hypocalcaemia is with intravenous replacement. The preferred method is with intravenous calcium chloride, 10ml of 10% solution over 10 minutes
ECG monitoring is recommended
Further management depends on the underlying cause
Calcium and bicarbonate should not be administered via the same route

Subtotal colectomy with ileostomy remains a safe and effective treatment for patients requiring urgent surgery for severe inflammatory bowel disease. As the patient is not hemodynamically stable, any anastomosis like ileorectal or ileoanal should not be done. The patient should be fully resuscitated and given antibiotics and thromboprophylaxis preoperatively.

A quarter to a half of patients with chronic subdural haematoma have no identifiable history of head trauma. If a patient does have a history of head trauma, it usually is mild. The average time between head trauma and chronic subdural haematoma diagnosis is 4–5 weeks. Symptoms include decreased level of consciousness, balance problems, cognitive dysfunction and memory loss, motor deficit (e.g. hemiparesis), headache or aphasia. Some patients present acutely. They usually result from tears in bridging veins which cross the subdural space, and may cause an increase in intracranial pressure (ICP).

Iron deficiency anaemia is the most common type of anaemia. It can occur due to deficiency of iron from decreased intake, increased loss or inadequate absorption. An MCV less than 80 will indicated iron deficiency anaemia. On the smear the RBCs will be microcytic hypochromic and will also show poikilocytosis. Iron profile tests are important to make a diagnosis. Clinically the patient will be pale and lethargic.

Osteochondromas, or osteocartilaginous exostoses, are the most common benign bone tumours, and tend to appear near the ends of long bones. The overgrowth can occur in any bone where cartilage forms bone, and they are capped by cartilage. They are most common in people between the ages of 10-20 years old.

This is likely to be a case of simple duct ectasia. Normal USS report coupled with normal examination would favour discharge from the clinic. Mammography is generally not helpful in this age group.

Possible causes of nipple discharge include:
1. Abscess
2. Birth control pills
3. Breast cancer
4. Ductal carcinoma in situ (DCIS)
5. Endocrine disorders
6. Excessive breast stimulation
7. Fibrocystic breasts (lumpy or rope-like breast tissue)
8. Galactorrhoea
9. Injury or trauma to the breast
10. Intraductal papilloma (benign, wart-like growth in a milk duct)
11. Mammary duct ectasia
12. Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)
13. Medication use
14. Menstrual cycle hormone changes
15. Paget’s disease of the breast
16. Periductal mastitis
17. Pregnancy and breast-feeding
18. Prolactinoma

Assessment and management of non-malignant nipple discharge includes:
1. Exclude endocrine disease
2. Nipple cytology is not carried out as it would be unhelpful
3. Smoking cessation advice given for duct ectasia
4. Total duct excision may be warranted for duct ectasia with severe symptoms

Capillaries are the smallest of the body’s blood vessels, measuring 5–10 μm and they help to enable the exchange of water, oxygen, carbon dioxide, and many other nutrients and waste substances between the blood and the tissues surrounding them. The walls of capillaries are composed of only a single layer of cells, the endothelium. Ion channels are pore-forming proteins that help to establish and control the small voltage gradient that exists across the plasma membrane of all living cells by allowing the flow of ions down their electrochemical gradient. An ion channel is an integral membrane protein or more typically an assembly of several proteins. The archetypal channel pore is just one or two atoms wide at its narrowest point. It conducts a specific ion such as sodium or potassium and conveys them through the membrane in single file.

Surgical site infection (SSI) by Staphylococcus aureus is the most likely cause in this scenario. In the UK from 2010–2011, 23% of wound infections were due to S. aureus. Infection with the other organisms, including Streptococcus pyogenes, are much rarer.

Surgical site infections (SSI) comprise up to 20% of all healthcare-associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. SSIs may occur following a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. The organisms are mostly derived from the patient’s own body.

SSIs are a major cause of morbidity and mortality.
Some preoperative measures that may increase the risk of SSI include:
1. Shaving the wound using a razor (disposable clipper preferred)
2. Tissue hypoxia
3. Delayed administration of prophylactic antibiotics in tourniquet surgery

SSIs can be prevented by taking certain precautionary steps pre-, intra-, and postoperatively.

1. Preoperatively:
a. Do not remove body hair routinely
b. If hair needs removal, use electrical clippers (razors increase the risk of infection)
c. Antibiotic prophylaxis if:
– placement of prosthesis or valve
– clean-contaminated surgery
– contaminated surgery

2. Intraoperatively:
a. Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
b. Cover surgical site with dressing

3. Postoperatively:
a. Prevention of incisional infection by appropriate cleansing, skin care, and moisture management
b.Tissue viability advice for management of surgical wound healing by secondary intention

The moderator band extends from the base of the anterior papillary muscle to the ventricular septum. It is the structure which carries part of the right AV bundle. Its role it to prevent overdistention of the ventricle.

Answer: Thoracotomy

Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMY

Indication:

Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).

Contraindications:
Definite loss of cardiac output for greater than 10 minutes.

Any patient who has a cardiac output, including hypotensive patients.

The peripheral blood findings suggest a leucoerythroblastic picture, the common causes of which in a 65-year old gentleman includes prostatic or lung malignancy.

If patients need IV fluids for routine maintenance alone, restrict the initial prescription to:
25–30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50–100 g/day of glucose to limit starvation ketosis.
Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in 24 hours). Potassium should not be added to intravenous fluid bags as this is dangerous.

Sodium chloride 0.9%, with or without additional potassium, is one of the most commonly used IV fluids in UK practice.

Glucose 5% solution provides a useful means of giving free water for, once the glucose is metabolised, the fluid is distributed throughout total body water. It is, therefore, a potentially useful means of correcting or preventing simple dehydration and the glucose content will also help to prevent starvation ketosis, although it is important to recognize that it will not make much of a contribution to covering patients overall nutritional needs. The use of 5% glucose, will increase risks of significant hyponatraemia, particularly in children, the elderly, patients on diuretics and those with excess ADH due to osmotic and non-osmotic stimuli (a problem is seen quite frequently in hospitalized patients). Nevertheless, hyponatremia is likely to be avoided by not exceeding recommended volumes of maintenance IV fluids and by careful monitoring of patients’ clinical volume status and electrolyte measurements.

The reason bacteria are either Gram-positive or Gram-negative is due to the structure of their cell envelope (the cell envelope is defined as the cell membrane and cell wall plus an outer membrane, if one is present.) Gram-positive bacteria, for example, retain the crystal violet due to the amount of peptidoglycan in the cell wall. It can be said therefore that the Gram-stain procedure separates bacteria into two broad categories based on structural differences in the cell envelope.

Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes.
The thyroid gland may become firm, large, and lobulated in Hashimoto’s thyroiditis, but changes in the thyroid can also be nonpalpable. Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis, rather than tissue hypertrophy.

Laboratory studies and potential results for patients with suspected Hashimoto thyroiditis include the following:
– Serum thyroid-stimulating hormone (TSH) levels: Sensitive test of thyroid function; levels are invariably raised in hypothyroidism due to Hashimoto thyroiditis and in primary hypothyroidism from any cause
– Free T4 levels: Needed to correctly interpret the TSH in some clinical settings; low total T4 or free T4 level in the presence of an elevated TSH level further confirms diagnosis of primary hypothyroidism
– T3 levels: Low T3 level and high reverse T3 level may aid in the diagnosis of nonthyroidal illness

Thyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative.
While their role in the initial destruction of the follicles is unclear, antibodies against thyroid peroxidase (TPO) (also called TPOAb) or thyroglobulin are relevant, as they serve as markers for detecting the disease and its severity. They are hypothesized to be the secondary products of the T cell mediated destruction of the gland.

Subacute bacterial endocarditis  is often due to streptococci of low virulence, mainly streptococcus viridans. It is a mild to moderate illness which progresses slowly over weeks and months (>2weeks) and has low propensity to hematogenously seed to extracardiac sites.

The posterior triangle (or lateral cervical region) is a region of the neck which has the following boundaries:
Apex: Union of the sternocleidomastoid and the trapezius muscles at the superior nuchal line of the occipital bone
Anterior: Posterior border of the sternocleidomastoid muscle
Posterior: Anterior border of the trapezius
Base: Middle one third of the clavicle
Roof: Investing layer of the deep cervical fascia
Floor: The anterolateral portion of prevertebral fascia

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.

Osteoarthritis is most common in older adults, predominating in women between the ages of 40 and 70; after this age, men and women are affected equally. It affects an entire joint, with disruption and potential loss of joint cartilage, along with other joint changes, including bone hypertrophy (osteophyte formation). The pain is usually gradual and is worse after activity, with occasional joint swelling. X-ray findings include marginal osteophytes, narrowing of the joint space, increased density of the subchondral bone, subchondral cyst formation, bony remodelling and joint effusions.

This patient requires immediate insertion of an intercostal chest tube and analgesia. In general, all cases of haemopneumothorax should be managed by intercostal chest drain insertion as it can develop into tension pneumothorax until the lung laceration has sealed.

Haemopneumothorax is most frequently caused by a trauma or blunt or penetrating injury to the chest followed by laceration of the lung with air leakage, or injury to the intercostal vessels or internal mammary artery. The main treatment for haemopneumothorax is chest tube thoracostomy (chest tube insertion). Surgical exploration is warranted if >1500ml blood is drained immediately.

Flail chest occurs when the chest wall disconnects from the thoracic cage. It usually follows multiple rib fractures (at least two fractures per rib in at least two ribs) and is associated with pulmonary contusion. Overhydration and fluid overload is avoided in such patients.

The inferior sagittal sinus is also known as the inferior longitudinal sinus. It courses along the inferior border of the falx cerebri, superior to the corpus callosum. It is cylindrical in shape and increases in size as it passes backward ending in the straight sinus. It receives blood from the deep and medial aspects of the cerebral hemispheres and drains into the straight sinus.

The mechanism of contraction of smooth muscles is different from that of skeletal muscles in which the contractile protein is troponin whilst in smooth muscle contraction is a protein called calmodulin. Calmodulin reacts with calcium ions and stimulates the formation of myosin crossbridges.

The immediate treatment of hypercalcaemia involves intravenous fluid resuscitation. This may be complemented with the use of bisphosphonates and sometimes, diuretics. However, fluids are administered first. Normal saline is usually preferred for this over other solutions.

Urgent management in hypercalcaemia is indicated if:
1. Serum calcium level >3.5 mmol/L
2. Reduced consciousness
3. Severe abdominal pain
4. Pre-renal failure

Management options include:
1. Intravenous fluid resuscitation with 3–6 litres of 0.9% normal saline in 24 hours
2. Concurrent administration of calcitonin to help lower calcium levels
3. Medical therapy (usually if corrected calcium >3.0mmol/L)

Bacteroides fragilis is an anaerobic, Gram-negative, rod-shaped bacterium. It is part of the normal flora of the human colon and is generally a commensal, but can cause infection if displaced into the bloodstream or surrounding tissue following surgery, disease, or trauma.

Nephrotic syndrome is a disorder in which the glomeruli have been damaged, characterized by:
– Proteinuria (>3.5 g per 1.73 m2 body surface area per day, or > 40 mg per square meter body surface area per hour in children)
– Hypoalbuminemia (< 2,5 g/dl)
– Hyperlipidaemia, and oedema (generalized anasarca).

Inhaled objects are more likely to enter the right lung for several reasons. First the right bronchus is shorter, wider and more vertical than the left bronchus. Also, the carina (a ridge-like structure at the point of tracheal bifurcation) is set a little towards the left. The superior segmental bronchus branches posteriorly off the intermediate bronchus or the inferior lobe bronchus and is thus more likely to receive the foreign body that enters the right main bronchus. The lingula is only found on the left lung. The terminal bronchiole is a very small space almost impossible for the tablet to lodge here.

The inferior epigastric artery comes from the external iliac artery just above the inguinal ligament to curve forward in the subperitoneal tissue and then ascend obliquely along the medial margin of the deep inguinal ring. It continues to ascend between the rectus abdominis and the posterior lamella of its sheath after piercing the fascia transversalis and passing anterior to the linea semicircularis. Finally it gives off numerous branches that anastomose above the umbilicus with the superior epigastric branch of the internal mammary artery and with the lower intercostal arteries. As this artery ascends obliquely upwards from its origin it lies along the lower medial margins of the deep inguinal ring and posterior to the start of the spermatic cord. It is found in the preperitoneal fat of the abdomen lying just superficial to the peritoneum and forms the lateral umbilical fold. Hernias that pass lateral to this are indirect and medial to this, direct hernias.
The deep circumflex artery travels along the iliac crest on the inner surface of the abdominal wall. It is very lateral to the abdominal wall and hernias would pass medial to it.
The superficial circumflex iliac, superficial epigastric, superficial external pudendal arteries are all superficial arteries found in the superficial fascia.

A patent urachus is one of the spectrum of congenital urachal anomalies. It has occasionally been termed urachal fistula. In an open (or patent) urachus, there is an opening between the bladder and the belly button (navel). The urachus is a tube between the bladder and the belly button that is present before birth. In most cases, it closes along its full length before the baby is born. An open urachus occurs mostly in infants. A patent urachus is often diagnosed in neonates when urine is noted leaking from the umbilicus. The umbilicus may also have an abnormal appearance on physical exam.

A patent urachus predisposes to infection. If the urachal disorder presents with an infection, the infection is treated first. This requires antibiotics, possible admission for intravenous antibiotics, and occasional surgical drainage of any infected cyst or poorly draining cavity. Once the infection is under control, excision of the urachus is usually performed. This can usually be done laparoscopically or with a small incision on the lower abdomen. Patients usually stay in the hospital 1-2 days after the surgery. The urachus can be excised because in normal development it usually obliterates anyway. The umbilicus is not removed.

Omphalitis is an infection of the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period. Omphalitis is primarily a disease of the neonate and is characterized by tenderness, erythema, and induration of the umbilicus and surrounding tissues. Early on, patients may only have superficial cellulitis but, if untreated, this can progress to involve the entire abdominal wall. Patients may also have purulent drainage or be bleeding from the umbilical cord stump. Foul-smelling drainage should raise the suspicion of anaerobic infection.

Patent vitellointestinal or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of population related with the embryonic yolk stalk. A persistent vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children.

An umbilical granuloma is a moist, red lump of tissue that can form on a baby’s navel (belly button). It can be seen in the first few weeks of life, after the umbilical cord has dried and fallen off. It’s usually a minor problem that looks worse than it is. An umbilical granuloma does not cause pain. It may ooze a small amount of fluid that can make the skin around it red and irritated.

In atrial fibrillation, the abnormal atrial contraction can cause blood to stagnate in the left atrium and form a thrombus, which may then embolize. The patient’s history of AF suggest an embolic disease, which lead to his death.

Lymphatic spread indicates poor prognosis. Presence of family history is not a prognostic factor despite being linked to higher incidence. Aneuploidy is a poor prognostic factor. A breast tumour positive for oestrogen receptors is a good prognostic factor as it increases the responsiveness of the tumour to certain therapies. In-situ tumours carry the best prognosis.

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.

The sigmoid colon is the most likely segment involved as it is mobile due to the presence of the sigmoid mesocolon. The descending colon, although on the left side, is a bit superior and is also retroperitoneal. The ascending colon and caecum are on the right side of the abdomen. The rectum is too inferior to enter the deep inguinal ring and the transverse colon is too superior to be involved.

Acidosis with high p(CO2) and normal standard bicarbonate indicates respiratory acidosis, commonly seen in acute worsening of COPD patients. Respiratory acidosis occurs due to alveolar hypoventilation which leads to increased arterial carbon dioxide concentration (p(CO2)). This in turn decreases the HCO3 –/p(CO2) and decreases pH. In acute respiratory acidosis, the p(CO2) is raised above the upper limit of normal (over 45 mm Hg) with a low pH. However, in chronic cases, the raised p(CO2) is accompanied with a normal or near-normal pH due to renal compensation and an increased serum bicarbonate (HCO3 – > 30 mmHg).

Beta-thalassaemia is due to decreased production of β-polypeptide chains, with an autosomal inheritance pattern. Carrier patients (heterozygotes) are asymptomatic and have mild to moderate microcytic anaemia. This is known as thalassaemia minor. Homozygotes (β-thalassaemia major, or Cooley’s anaemia) develop severe anaemia and marrow hyperactivity. The disease presents at 1-2 years of age with severe anaemia and transfusional and absorptive iron overload. Patients also present with jaundice, leg ulcers, massive splenomegaly and cholelithiasis. The disease can also lead to splenic sequestration leading to faster destruction of transfused red blood cells. Increased marrow activity causes thickening of cranial bones. Involvement of long bones is also seen, which can cause pathological fractures and growth impairment. There is iron deposition in various organs, which can lead to heart failure or hepatic failure (leading to cirrhosis). Thalassaemias are suspected in presence of family history, or signs suggesting microcytic haemolytic anaemia. Further test and quantitative haemoglobin studies are useful. In beta-thalassaemia, there is an increase in serum bilirubin, iron and ferritin levels. There is severe anaemia, often with haemoglobin < 6 g/dl. There is an elevated red blood cell count, which are microcytic. Peripheral blood smear is diagnostic with nucleated erythroblasts, target cells, small pale red blood cells, and punctate basophilia.

The thoracic duct is the main drainage of lymph in the body. It varies in length from 38 to 45 cm and extends from the second lumbar vertebra to the root of the neck.

Referred pain is felt at a point away from the source of the pain or the unpleasant sensation. It arises when a nerve is damaged or compressed at a point but the pain is felt at another site that is the territory of that nerve. Common abdominal causes of referred pain to the shoulder and the shoulder blade are the liver, duodenum and gall bladder.

The drainage of cerebral spinal fluid from the third ventricle to the fourth ventricle is carried out by the cerebral aqueduct. The cerebral aqueduct is the narrowest passageway in the entire ventricular system and thus forms the most common site of blockage of flow of cerebrospinal fluid. The interventricular foramen allows passage of CSF to the third ventricle. The foramen of Luschka and Magendie are located on the fourth ventricle and allow passage of CSF to the subarachnoid space from the ventricular system. The pontine cistern is a space located on the ventral aspect of the pons. The cisterna magna is an opening on the subarachnoid space between the pia matter and the arachnoid.