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Prasad Syndrome is a condition characterised by geophagia ( the habit of eating soil, clay etc), hypogonadism, growth retardation and zinc deficiency. Bitot spots are keratin fragments found/deposited on the conjunctiva; they are usually found due to Vitamin A deficiency. Zinc deficiency may also be involved with the pathogenesis of secondary vitamin A deficiency. Inadequate zinc can depress the hepatic synthesis of retinol-binding protein (RBP), which is required for mobilization of retinol from the liver. In addition, zinc may play a role in the conversion of beta-carotene to retinol via the enzyme 15-15 dioxygenase.
In iron deficiency, iron deficiency anemia will be observed ( brittle nails, soreness in the tongue, weakness, pale skin etc). Copper deficiency is seen in Menkes disease.
Occupational/ professional Rehabilitation involves specialized healthcare dedicated to improving, maintaining and restoring the physical strength, cognition and mobility with maximum results. It helps an individual to recover from addictions, injuries and disorders.
Social rehabilitation — a set of activities aimed at rehabilitation and improving the functional capability of people and their inclusion in the society.
Psychological rehabilitation focuses on restoring one’s mental status.
From the question stem, it is evident that she’s on the 12th day post-partum. On examination of the right mammary gland, there are clear signs of inflammation (mastitis) which is infiltrative with a fluctuation (Infiltrative-purulent)
Mastitis is a bacterial infection of the mammary gland. It occurs mostly in pregnant or postpartum women; due to lactation, the nipples present with some erosions and are enlarged making it easier for bacterial invasion. This infection is often characterised by the production of purulent exudates.
Notice that this patient has Progressing renal parenchyma arterial hypertension accompanied by edemas of the leg; she is already on a combined medication that includes Losartan ( Angiotensin receptor blocker) and Lercanidipine ( a calcium channel blocker). On the basis that this patient has suffered from glomerulonephritis, currently having a renal induced hypertension, presents with edema and does not have a diuretic prescribed as part of the complex treatment, the prefered drug of choice to intensify this treatment will be Torasemide ( a loop diuretic).
This patient is already on an Angiotensin receptor blocker, there is no need to use an ACE inhibitor ( Lisinopril); we need to try another class with a different mechanism of action.
Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine. The most common renal complication of ankylosing spondylitis is Renal amyloidosis. Amyloidosis is a collective term for the extracellular deposition of abnormal proteins, either in a single organ (localized amyloidosis) or throughout the body (systemic amyloidosis). The different subtypes of amyloidosis are categorized according to the origin of the deposited proteins (e.g., AA, AL). Renal amyloidosis is characterised by nephrotic syndrome; in this patient we can see a high level of proteinuria coupled with facial swelling and edema ( due to decreased oncotic pressure).
Hippocratic nails refer to a condition in which there is proliferation of the distal part of the fingers, especially the nail bed. Velcro Type crackles refer to bilateral crepitation heard especially during slow inspiration but can be associated with expiratory crackles. These types of crackles are seen in fibrotic interstitial lung diseases.
Hand-schuller-christain disease is characterised by a triad of single or multiple punched out bone lesions on the skull, uni/bilateral exophthalmos and diabetes insipidus. Other findings in this disorder include; infantilism, dwarfism and polyuria.
A positive Homan’s sign ( calf pain at the dorsiflexion of the foot ) indicates a case of Deep Vein Thrombosis (blood clot within a deep vein). Patients with DVT are mostly predisposed by (Virchow Triad)
Stasis - due to post operation (as in this case), long drive/flight.
Hypercoagulability- can be due to a defect in coagulation cascade proteins eg factor V Leiden; oral contraceptive use.
One major complication of DVT is pulmonary embolism.
Unfractionated heparin or LMWH are used for prophylaxis or acute management.
Vesiculopustulosis is a purulent inflammation found in newborns. Their causative agents include staphylococci, streptococci, e.coli etc. Clinical features – Evanescent vesicles (a few mm in diameter —> first transparent, later muddy content —> break down over 2-3 days —> small erosions, then crusts which disappear without pigmentation. Localization - skin of buttocks, hips, inguinal folders, head. Treatment is usually local – chlorhexidine, fucorcin, brilliant green.
Pemphigus neonatorum is characterised by the presence of erythematous patches coupled with the presence of vesicles and small bullaes usually localised in the lower abdomen and on extremities. The bullaes later form crusts but pigmentation is absent.
Miliaria is also called sweat rashes, in this case we see numerous very itchy rashes caused due to the blockage or clogging of sweat glands.
Note that the key finding here are the numerous wet crackles heard from the lungs; these crackles are heard when there is excess fluid in the airways. Pulmonary edema is usually seen in heart related issues ( in this case post MI); in this condition air sacs in the lungs are filled with fluid making it difficult to breathe.
Cardiogenic shock can also be caused by Myocardial Infarction but its clinical features include; Tachycardia, Hypotension, Cold/clammy extremities, weak pulse, slow capillary refill etc.
The blood pressure of this patient is 120/100 mmHg which rules out the option of hypertensive crisis, a condition in which the blood pressure is equal or greater than 180/120mmHg.
Kehr’s sign- pain in the left shoulder ( due to irritation of the under surface of the diaphragm).
Murphy’s sign- pain during inspiration while palpating the right subcostal region.
Ortner’s sign- painfulness at the easy pushing on the right costal arch by the edge of the palm.
These signs are positive in conditions related to the gallbladder eg cholecystitis, cholelithiasis etc. The presence of a normal amylase level rules out the option of acute or chronic pancreatitis. The results from Echo Cholecystography shows that the gallbladder underwent NO contraction thereby making the flow of bile (kinesis) restricted - this condition is referred to as a hypokinetic biliary dyskinesia.
Note that from the blood analysis, the key finding is the presence of Gumphrect shadow (Smudge cells). These cells are seen in Chronic lymphocytic leukemia (CLL).
Bladder exstrophy is a rare developmental abnormality that is present at birth (congenital) in which the bladder and related structures are turned inside out. Exstrophy means 'turned inside out'.
It is an abnormality of formation of the bladder and the bony pelvis. The bladder does not form into its normal round shape but instead is flattened and exposed on the abdominal wall. The pelvic bones are also widely separated. The remainder of the lower urinary tract may also be flattened and exposed, with abnormal formation of the prostate and penis.
Bladder exstrophy is a congenital abnormality that occurs when the skin over the lower abdominal wall (bottom part of the tummy) does not form properly. The bladder is open and exposed on the outside of the abdomen.
Writer’s cramp is a specific form of focal dystonia that affects the fingers, hand, or forearm. Focal dystonia of the hands is a neurological movement disorder.
Cortical agraphia is a neurological disorder in which an individual loses the ability to communicate either through writing or he/she forgets how to spell.
In most premature babies, due to the deficiency of surfactant or hyaline membrane ( immature lungs), the baby has severe difficulty in breathing ( respiratory distress). For the prevention of this disorder, the mother is given glucocorticoids (steroid injection) before delivery to stimulate fetal lung maturation. Dexamethasone is a glucocorticoid.
Misoprostol is a prostaglandin analogue indicated for stomach ulcers, to induce labor, stimulate abortion etc. Gynipral is a Beta 2 agonist used for the management of bronchial asthma.
Rubella virus infection in early pregnancy has been frequently associated with adverse pregnancy outcomes due to its teratogenic effects. The infection is most common in children, young adults, child bearing aged women and pregnant women. Acute rubella virus infection in early pregnancy has been associated with poor pregnancy outcome ranging from spontaneous abortion, stillbirth and multiple birth defects known as Congenital Rubella Syndrome (CRS). CRS includes auditory, sensorineural, cardiac and ocular abnormalities.
The management of rubella infection depends on the gestational age at the onset of infection.
• Infection before 18 Weeks of Gestation: The fetus is at high risk for infection and severe symptoms. Termination of pregnancy could be discussed and accepted, according to local legislation, particularly if the infection presented before 12 Weeks of Gestation.
• Infection after 18 Weeks of Gestation: The pregnancy could be continued with simple ultrasound monitoring. A specific pediatric examination of the newborn and testing for RV-IgM are recommended.
Since this pregnancy is at 8weeks then the option of Abortion can be chosen to avoid giving birth to a child with multiple congenital defects - cataract, deafness, congenital heart disease.
A manic episode is characterized by a sustained period of abnormally elevated or irritable mood, intense energy, racing thoughts, and other extreme and exaggerated behaviors. People can also experience psychosis, including hallucinations and delusions, which indicate a separation from reality. The symptoms of mania can last for a week or more and manic episodes may be spaced within periods of depression during which you may experience fatigue, sadness, and hopelessness.
Schizophrenia is mostly characterised by hallucinations, delusions, catatonic ( disorganised) behaviour and speech.
Although Digoxin helps in improving the ejection fraction in a patient with Heart failure, Notice that frequent polymorphic ventricular extrasystoles were detected. These polymorphic ventricular extrasystoles are usually caused by an elevation in calcium influx into myocardial cells. Recall that the mechanism of action of Digoxin involves the reversible inhibition of the Na-K ATPase enzyme, leading to various beneficial effects. The Na-K ATPase enzyme functions to maintain the intracellular environment by regulating the entry and exit of sodium, potassium, and calcium (indirectly). Na-K ATPase is also known as the sodium pump. The inhibition of the sodium pump by digoxin increases intracellular sodium and increases the calcium level in the myocardial cells, causing an increased contractile force of the heart. This improves the left ventricular ejection fraction (EF), an important measure of cardiac function. Therefore in order to stop these extrasystoles, Digoxin should be excluded from the therapy.
For a patient with respiratory tract infection that manifests with fever, cough, tachypnea (35 cycles per min) and dyspnea at rest coupled with a dull percussion sound on percussion, this patient clearly has pleural effusion. This is a case of massive right pleural effusion that extends from the lower margin of the scapula (shoulder blade) to the lower lung margin.
Common causes of Pleural Effusion include: cancer tumors; Pneumonia or other lung infection; Congestive heart failure; chronic lung diseases etc.
Pleural effusion is managed by performing a thoracentesis or Pleural tap. Thoracentesis, also known as a pleural tap, is a procedure done when there’s too much fluid in the pleural space. It could be diagnostic or therapeutic.
Diagnostic: This allows a pleural fluid analysis to be performed in the lab to figure out the cause of fluid accumulation around one or both of the lungs.
Therapeutic: Remove excess pleural fluid to assist respiration and provide symptomatic relief. This is what this patient needs to relieve the dyspnea.
The pleural space is the small space between the lungs and the chest wall.
Take Note of these significant lung sounds:
Dull percussion sounds - Consolidation (Pneumonia); Fluid (pleural effusion which could be hemothorax or pyothorax)
Crackles - Pleural Effusion
Wheeze - Bronchial Asthma
High resonance sounds - Pneumothorax
Facial (nerve) palsy is a neurological condition in which function of the facial nerve (cranial nerve VII) is partially or completely lost. Key findings include; Sensory disturbances : Painful sensation around or behind the ear, Impairment of taste in the anterior tongue , Hyperacusis; dropping of the mouth, dry mouth, Bell's phenomenon: a physiologic, reflexive movement of the eye (upward and outward) that occurs when the eyelid is actively closed, Lagophthalmos: The patient cannot fully close the eyes (due to paralysis of the orbicularis oculi muscle). Decreased lacrimation.
In neuropathy of the trigeminal nerve ( trigeminal neuralgia), the individual will feel excruciating pain at the slightest pressure applied on the face e.g. while brushing the teeth, yawning etc.
A young girl presented with upper respiratory tract infection and on percussion, a dull sound and wet crackles were heard. A normal lung will produce a resonance sound (high resonance - pneumothorax). Dull sound is often associated with Pneumonia which causes lung consolidation and can progress to form pleural effusion which produces the crackles.
Community-acquired pneumonia (CAP) refers to an acute infection of the pulmonary parenchyma acquired outside of the hospital. The main causative pathogens of Community-acquired pneumonia (CAP) are Streptococcus pneumoniae, influenza A, Mycoplasma pneumoniae and Chlamydophila pneumoniae. The clinical presentation of CAP varies, ranging from mild pneumonia characterized by fever and productive cough to severe pneumonia characterized by respiratory distress and sepsis.
Stenosing laryngotracheitis (Croup) - barking cough sound.
Acute bronchiolitis is more of an acute viral infection often associated with wheezing sound.
Bronchitis affects the airways (Bronchi) and produces a large amount of mucus with cough. It can produce wheezing sound also.
According to levels of specialization, types of medical care include: Emergency, Primary, Secondary, Tertiary, palliative, medical rehabilitation and dentistry.
Primary medical care: involves care given by nurses, midwives, general physicians, family doctors, in polyclinics etc. One major aspect of primary health care is preventive medicine - these include vaccination, teaching on methods for good living etc.
Secondary medical care: When your primary care provider refers you to a specialist, you are then in secondary care. Secondary care simply means you will be taken care of by someone who has more specific expertise eg cardiologist, endocrinologist etc
Notice that these symptoms begin to take place after the introduction of Semolina; a food product rich in gluten. Celiac disease, also referred to as celiac sprue or nontropical sprue, is a common condition characterized by a maladaptive immune response to gluten, a protein found in many grains (e.g., wheat). The underlying pathophysiology is believed to be a combination of gluten intolerance, which triggers an autoimmune reaction, and production of autoantibodies that target tissue transglutaminase, specifically within the proximal small intestine. Typical findings include changes in bowel habits and symptoms associated with malabsorption (e.g., fatigue, weight loss, vitamin deficiencies).
Irritable bowel syndrome is a functional disorder that affects mainly the large intestine and is characterized by bloating, abdominal cramps, diarrhea etc
Mucoviscidosis refers to cystic fibrosis of the pancreas.
This patient has been diagnosed with type 2 diabetes mellitus ( non-insulin dependent diabetes). The results from the current blood sugar level and glycated hemoglobin supports it ; Norm blood glucose 3.5-5.5 mmol/L; normal glycated hemoglobin -6 %. For the treatment of type 2 Diabetes, Metformin also known as Glucophage (a biguanide) is usually the first drug to be administered.
Recall that Ammonia is converted to urea ( via the ornithine/urea cycle). Urea is then excreted from the body through the urine. Notice that this patient has no urinary output, smell of ammonia from the mouth coupled with an increased urea level in the blood. Recall that ammonia and urea (at high blood concentration like in this case) can cross the blood brain barrier leading to encephalopathy and further loss of consciousness. N/B the blood glucose and osmolarity levels are also elevated but not enough to lead to their respective forms of coma.
This patient has a history of Atopic dermatitis and a family history of Atopic dermatitis; It is also stated that these signs usually arise in specific seasons- this helps us conclude that the reason behind the rhinitis is an allergy.
Allergic rhinitis is inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mould or flakes of skin from certain animals.
Henoch-schonlein purpura ( hemorrhagic/ IgA vasculitis) is a condition in which small blood vessels are inflamed. It is an acute immune complex-mediated small vessel vasculitis that most commonly occurs in children. typically presents with a tetrad of symptoms: palpable purpura, arthritis/arthralgia, abdominal pain, and renal disease; although not all patients show the complete four symptoms ( as in this case). Notice that this child presents with purpuras ( a rash that turns hemorrhagic), arthritis and abdominal pain- these help us put the diagnosis of Henoch-schonlein purpura.
Streptococcal impetigo is characterized by papules that evolve into pustules then thick crust which are golden or honey-coloured. These lesions are usually found on the face and extremities.
Scarlet fever also presents with hemorrhagic rash but arises on the background of a Streptococcal infection and also is characterised by a crimson red tongue.
The main external pelvic sizes:
D. Spinarun - distance between anterior superior iliac spines from both sides. It is 25-26 cm.
D. Cristarum – distance between iliac crista from both sides. It is 28-29 cm.
D. Trochanterica – distance between trochanter majors from both sides. It is 31-32 cm.
C. Externa - distance between midpoint of superior surface of the symphysis pubis and suprasacralis fossa. It is 20-21cm.
In the question stem, the 34 year old woman is 26-29-32-22 cm. This values correspond to the normal values for the above listed main external pelvic sizes. Fetal heart rate - 140/min is normal (norm: 110 - 170 beats per minute). Fetal weight is also normal. Therefore, even though, the fetus is in breech presentation, the delivery can still progress through the natural birth canal.
Observe that the intraocular pressure is 48mmHg ( norm is 10-21 mmHg). Glaucoma is a medical condition characterised by optic disc atrophy coupled with cupping, usually with an elevated intraocular pressure and progressive peripheral visual field loss if untreated.
Iridocyclitis is an inflammation of the anterior uveal tract ( iris and ciliary body) ; symptoms include blurred vision, eyes pain, photosensitivity, red eye ( conjunctival injection) etc.
Chvostek sign: twitching of the facial muscles in response to tapping over the area of the facial nerve. Trousseau's sign refers to carpopedal spasm and is seen in latent tetany
Rickets is a skeletal disorder that occurs due to vitamin D deficiency. Recall that vitamin D is necessary for the absorption of calcium( necessary for the formation of strong bones and teeth) and phosphorus. Signs of rickets include; weak and soft bones. Skeletal deformities, stunted growth etc.
Urticaria (hives) is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus. Individual lesions resolve without scarring in several hours. Most cases of urticaria are self-limited and of short duration; the eruption rarely lasts more than several days, but may be recurrent over weeks. Chronic urticaria is defined as urticaria with recurrent episodes lasting longer than 6 weeks. Mostly occurs as a reaction towards food, drugs, contact etc.
Urticaria pigmentosa is composed of persistent brown or red marks, made of collections of mast cells that swell and itch transiently when rubbed, similar to a hive.
Transvaginal ultrasound ( through the vagina ) is an ultrasound procedure used to examine the female reproductive organs. This includes the uterus, fallopian tubes, ovaries, cervix, and vagina.
Culdoscopy is used in examining the rectouterine pouch while colposcopy is restricted to examining the cervix, vagina and vulva.
In Somatoform Autonomic dysfunction, the symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory, and urogenital systems. Clinical and instrumental examination revealed no organic alterations in any system therefore indicating a somatoform autonomic dysfunction.
Organic brain syndrome is defined as a state of diffuse cerebral dysfunction associated with a disturbance in consciousness, cognition, mood, affect, and behavior in the absence of drugs, infection, or a metabolic cause
Notice that the carboxyhemoglobin level is 55% ( very high) - this indicates poisoning by carbon monoxide; the level of ethanol found in his blood is too little to cause poisoning or be the major reason behind his death.
In cohort study - both groups will have Ischemic Heart Disease, then you consider a risk factor that might have led to the Ischemic Heart Disease. In this question, you are studying overweight and normal weight in those with Ischemic Heart Disease and the study shows that overweight men developed ischemic heart disease more often.
In case control - you will compare those with Ischemic heart disease (Cases) and those without Ischemic Heart Disease (Control).
Premenstrual syndrome refers to a group of symptoms women experience a week or two weeks before menstruation. These symptoms may include; mood swings, abdominal pain , headaches, vomiting, vertigo, insomnia, changes in appetite and sex drive etc. Commonly prescribed medications for its management include; antidepressants, contraceptives, NSAIDs etc.
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids).
Algodysmennhorhea is characterised by painful menstruation or menstrual cramps.
Folic acid is needed during pregnancy to prevent neural tube defects ( spina bifida) . An important role of folic acid is the formation of methionine from homocysteine using vitamin B12 as a cofactor. Adequate folic acid intakes can normalize high homocysteine levels via increased remethylation of homocysteine to methionine via 5-methyltetrahydrofolate-homocysteine methyltransferase (a.k.a.; methionine synthetase). Reduced folic acid intake is associated with hyperhomocysteinemia. Hyperhomocysteinemia is recognized as an independent risk factor for atherosclerosis of the coronary, cerebral, and peripheral vasculature. There is mounting evidence that elevated plasma homocysteine (and therefore decreased serum methionine) contributes to congenital neural tube defects.
Cimacteric syndrome is seen in women in Perimenopausal or postmenopausal age; they experience a decrease in ovarian function and decrease in female haormones. Climacteric syndrome is defined as gradual changes of ovarian function that start before menopause. Notable signs include; insomnia, dizziness, anxiousness and nervousness, poor sleep quality, hot flashes etc,
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids).
Premenstrual syndrome refers to a group of symptoms women experience a week or two weeks before menstruation. These symptoms may include; mood swings, abdominal pain , headaches, vomitting, vertigo, insomnia, changes in appetite and sex drive etc.
Adrenogenital syndrome is also known as congenital adrenal hyperplasia.
In a normal situation, umbilical arterial flow should always be in the forward direction in both systole and diastole.
Reversal of umbilical artery end-diastolic flow (REDF) or velocity is often an ominous finding if detected after 16 weeks. The feature is seen as a result of a significant increase in resistance to blood flow within the placenta and often represents a "tip of the iceberg" where there is a much larger underlying pathology.
However, during the first 16 weeks, a reversal in end-diastolic flow can be a normal finding due to the low resistance arcuate arteries and intervillous spaces not yet being formed.
Abnormal umbilical artery flow with absent or reversed end-diastolic velocity during pregnancy is a strong indication of placental insufficiency. Another supporting information here is the fact that there is an intrauterine growth restriction (IUGR). A pregnancy of 34weeks should have the Uterine height at 32-36cm. Anything less is often indicative of IUGR and a value above this range could be a case of macrosomia.
In general, absent and reversed end-diastolic flow of the fetal umbilical arteries are associated with poor neonatal outcomes, ranging from premature delivery and stillbirth to postnatal neurodevelopmental impairment
So, in this case, an Urgent Cesarean section can save both the fetus and the mother.
A vacuum aspirator is used to induce abortion, evacuate incomplete miscarriage or retained pregnancy tissue and for endometrial biopsy. Notice that this patient underwent a medical abortion but the result from ultrasound detects the remains of the fertilised eggs in her uterine cavity - this is a direct indication to carry out vacuum aspiration.
Extirpation of the uterus also called total hysterectomy refers to the surgical removal of the entire uterus; it may also involve the cervix and ovaries.
Notice that this patient presents with a type 1 diabetes ( insulin dependent). in the absence of insulin, ,the body tends to release more glucose from the liver and free fatty acids from adipose tissue; these free fatty acids are then broken down into ketone bodies (acetoacetate and β-hydroxybutyrate) through the process of beta oxidation. Accumulation of these ketone bodies in the blood leads to metabolic acidosis due to the fact that ketone bodies reduce the blood pH level. The breath of a person with Diabetic ketoacidosis is usually associated with a specific smell ‘Fruity’ or “acetone”.
A diabetic hyperosmolar coma is caused by severe dehydration and very high blood glucose levels (hyperglycaemia). The kidneys respond to high levels of blood glucose by doing their best to remove it, along with a great deal of water. The person experiencing diabetic hyperosmolarity will be very thirsty coupled with a high level of osmolarity level from biochemical analysis.
Lactic academic coma occurs as a result of a buildup of lactic acid in the blood.
Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common, in this case an antibiotic may be administered to fight the infection.
The first line of treatment is self-help remedies, such as ensuring that the breast is drained properly during feeds by breastfeeding regularly or expressing the milk. And after a feed, gently express any leftover milk.
Every newborn should be fed on demand. No schedule should be followed. Whenever the baby wants the milk, breastfeeding should be allowed. Breastfeeding should not be stopped because of cracks or pain in the breast.
A thyroid fine needle aspiration biopsy is a procedure that removes a small sample of tissue from your thyroid gland. Cells are removed through a small, hollow needle. The sample is sent to the lab for analysis. In some cases, hard nodules form inside the gland. Most times, the nodules are not dangerous. But in some cases they can be thyroid cancer. A thyroid fine needle aspiration biopsy can take a sample from the nodule to test for cancer.
Thyroid scan (thyroid scintigraphy) is a nuclear medicine examination used to evaluate thyroid tissue. Clinical indications include; functional status of a thyroid nodule, thyrotoxicosis: differential diagnosis and thyroid cancer. Note that an ultrasound procedure has already been carried out therefore, carrying out a thyroid scintigraphy will just be a repetitive test.
Methemoglobinemia is an unusual and potentially fatal condition in which hemoglobin is oxidized to methemoglobin and loses its ability to bind and transport oxygen. The most common cause of methemoglobinemia is the ingestion or inhalation of oxidizing agents such as nitrates or nitrites. Signs include dizziness, headaches, cyanosis, dyspnea , tachycardia etc. Treatment of this condition involves the use of methylene blue and vitamin C; other substances that can cause this state (methemoglobinemia) include dapsone and benzocaine.
Lead poisoning is characterised by lead lines on the gingiva (burton lines), encephalopathy, erythrocyte basophilic stippling, abdominal colic, sideroblastic anemia and wrist or foot drop. Dimercaprol ( chelating agent) is used in treatment.
People with dependent personality disorder may submit to the will of others in a misguided attempt to extract a promise of care and protection. They may think of themselves, or present themselves, as unable to cope with everyday life on their own. At the same time, they may fear that a show of confidence or competence will lead to rejection and abandonment. They demand advice and reassurance when making even minor decisions. They take no initiative and let others assume responsibility for their lives.
Anankastic personality disorder is also known as Obsessive compulsive disorder (OCD),a disorder characterized by preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
Carbuncle: red, swollen, painful clusters of boil that are connected to each other under the skin.
Furuncle: refers to a Boil, forms around the hair follicle and contains pus.
Hydradenitis: ‘acne inversa’ , inflamed and swollen lumps found in the axillary region ( armpit), under the breast, groin. These lumps most times break open forming a fistula or tunnels
The background information here is that - this young lady with Type I Diabetes Mellitus presents with a 3cm swelling on the anterior surface of the hip.
Abnormal reaction in subcutaneous fat to insulin is called lipodystrophy which can be either hypertrophic or atrophic. Lipodystrophy is an exclusive complication of lean children and young Type 1 diabetic, although rarely can be seen in Type 2 diabetic.
Insulin lipohypertrophy denotes a benign tumor like swelling of fatty tissue at the injection site secondary to lipogenic effect of insulin, whereas lipoatrophy is considered an adverse immunological side effect of insulin therapy. Since the advent of recombinant human insulin and analogue, lipoatrophy, has virtually disappeared, whereas, lipohypertrophy still remains a serious local problem of insulin therapy.
With a swelling of 3cm, the best answer choice is development of hypertrophic lipodystrophy. Atrophic lipodystrophy will not have associated swelling, instead a depression should be observed.
Prevention, to avoid lipodystrophy, should take first place as there is little cure to it, and the best way is to educate the patient about rotating injection sites.
Notice that this patient presents with signs in relation to gallbladder or liver pathology ( bile in general). In order to get the correct diagnosis, an Ultrasound of the liver, gall bladder and surrounding abdominal organs should be carried out.
Location of Uterine Fundus in relation to term of Pregnancy.
Pubic Symphysis - 12-15 weeks
Umbilicus - 20-24 weeks
Xiphoid process of sternum- 36-40 weeks
Note that after 36 weeks of pregnancy, the fundus length is about 32- 36cm.
The presence of antithyroid antibodies helps us understand that there is an autoimmune attack on the thyroids- This refers to Hashimoto’s thyroiditis; the most common cause of hypothyroidism. It is characterised by lymphocyte infiltration of the stroma of the thyroid gland leading to its destruction and signs of hypothyroidism. Other antibodies that can be found include those against thyroid peroxidase and TSH receptors. For its treatment, a replacement therapy is carried out using L-thyroxine.
Notice that all these heart changes took place in the background of a ‘respiratory infection’. Viral infections are a leading cause of myocarditis. Inflammation occurs during the course of infection, putting stress on the heart that remains even after the infection is resolved. Cancer, bacterial infections and other contagious diseases can also cause myocarditis.
In hypertrophic cardiomyopathy, the heart muscles become abnormally thick ( hypertrophied); this leads to issues relating to the pumping ability of the heart.
Bronchiectasis is a condition in which damage to the airways causes them to widen and become flabby and scarred (X-ray findings - left lung root is deformed and dilated). The airways are tubes that carry air in and out of your lungs.
Bronchiectasis usually is the result of an infection or other condition that injures the walls of your airways or prevents the airways from clearing mucus.
The initial airway damage that leads to bronchiectasis often begins in childhood. However, signs and symptoms may not appear until months or even years after you start having repeated lung infections.
The most common signs and symptoms of bronchiectasis are:
A daily cough that occurs over months or years.
Daily production of large amounts of sputum (spit). Sputum, which you cough up and spit out, may contain mucus (a slimy substance), trapped particles, and pus.
Shortness of breath and wheezing (a whistling sound when you breathe).
Clubbing (the flesh under your fingernails and toenails gets thicker).
Over time, it may progress to more serious symptoms like coughing up blood (hemoptysis) or bloody mucus and feel very tired. Children may lose weight or not grow at a normal rate.
This patient is experiencing a sinus node dysfunction in combination with a tachyarrhythmia; this condition is referred to as a tachy-brady syndrome which is a major cause of intermittent bradycardia ( an indication for Pacemaker replacement). Sinus node dysfunction encompasses other pathologies which include; SA block, sinus arrest and sinus inhibition, sinus bradycardia etc. Other conditions that require a Pacemaker replacement include; High grade AV block, Hypersensitive carotid sinus syndrome and neurocardiogenic syncope, congenital heart disease etc.
Genital herpes is an infection caused by Herpes simplex 2 virus. It is characterised by a red, swollen, pruritic genital accompanied by an unusual discharge. Other findings include the presence of single or disseminated vesicular lesions; these lesions are usually found around the genitals and anus and are accompanied by an itchy and burning sensation.
Primary syphilis is characterised by the presence of a hard, painless chancre ( a painless genital ulcer).
Meningococcemia is defined as dissemination/spread of meningococci (Neisseria meningitidis) into the bloodstream. Patients with acute meningococcemia may present with (1) meningitis (2) meningitis with meningococcemia, or (3) meningococcemia without clinically apparent meningitis. This patient appears to have the third presentation, Clinical presentation include; petechial/hemorrhagic skin rash usually located on the trunk and legs and may rapidly evolve into purpura, malaise, weakness, myalgias, headache, nausea, vomiting, and arthralgias.
Henoch-schonlein purpura ( hemorrhagic/ IgA vasculitis) is a condition in which small blood vessels are inflamed. It is an acute immune complex-mediated small vessel vasculitis that most commonly occurs in children. typically presents with a tetrad of symptoms: palpable purpura, arthritis/arthralgia, abdominal pain, and renal disease; although not all patients show the complete four symptoms.
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy, a condition in which microthrombi, consisting primarily of platelets, form and occlude the microvasculature (i.e., the arterioles and capillaries).
An aortic aneurysm is a localised pathologic dilation of the aorta; may cause abdominal and/or back pain which is a sign of leaking, dissection or imminent rupture. This patient is most likely having an aneurysm of the abdominal aorta which usually presents as a palpable abdominal pulsatile mass - Notice that in this patient, abdominal pulsation is observed coupled with a volumetric formation in the mesogastrium.
As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence.
Randomized Clinical or Controlled Trials: Include a randomized group of patients in an experimental group and a control group. These groups are followed up for the variables/outcomes of interest. Randomized controlled trials (RCTs) are considered the gold standard in modern medicine for determining the efficacy of a treatment. Individual RCTs are level 1b evidence. Systematic reviews of homogenous RCTs are regarded as the highest level of evidence—level 1a. These systematic reviews consist of information synthesized from individual, well-designed RCTs where participants are similar and have equal chances of being assigned to an intervention group, a control group, or a placebo group.
Type of Study
Systematic review of (homogeneous) randomized
Individual randomized controlled trials (with narrow
Systematic review of (homogeneous) cohort studies
of "exposed" and "unexposed" subjects
Individual cohort study / low-quality randomized
Systematic review of (homogeneous) case-control studies
Individual case-control studies
Case series, low-quality cohort or case-control studies
Expert opinions based on non-systematic reviews of
results or mechanistic studies
Two things to remember:
1. Studies in which randomization occurs represent a higher level of evidence than those in which subject selection is not random.
2. Controlled studies carry a higher level of evidence than those in which control groups are not used.
Expert Consensus - Level D
Case Control studies - Level B
On the basis of evidence, it has been recommended that all babies born through thick meconium should have their tracheas intubated so that suctioning of their airways can be performed. The aim is to reduce the incidence and severity of meconium aspiration syndrome.
Meconium is the first stool of a newborn baby, greenish‐black in colour and rather sticky in consistency. If a baby is distressed before birth meconium may be passed into the amniotic fluid and if the baby then gasps the meconium‐stained fluid may pass into the lungs. Once in the lungs the meconium can make the baby ill by obstructing the airways and causing inflammation this is called meconium aspiration syndrome. It is possible to reduce the amount of meconium getting into the lungs by sucking it from the baby’s throat and windpipe (trachea) soon after birth.
Pertussis, or whooping cough, is a highly infectious disease of the respiratory tract caused by the gram-negative bacteria Bordetella pertussis. The disease is mainly transmitted via airborne droplets and most commonly occurs in children. Typically, pertussis manifests in three stages, with the second and third stage characterized by intense paroxysmal coughing that is followed by a distinctive whooping sound on inhalation (reprise) and, in some cases, vomiting.
From the description; dirty gray coating with unpleasant sweet smell, resembling raspberry jelly with moderate criterion on palpation - this fits the description of a Gangrenous infection (gangrene); an infectious process caused by Clostridium Perfringens. Cl. Perfringens is a gram positive, rod shaped, spore forming anaerobic bacteria which is a major cause of food poisoning and gas gangrene.
Blue pus bacillus refers to pseudomonas aeruginosa
At the end of the operation (suture plication), a drainage tube is inserted into the abdomen for two purposes: firstly, the detection of any fluid collections within the abdomen (intra‐abdominal collections), usually resulting from intestinal secretions; and secondly, as the treatment of intra‐abdominal collections, so that fluid collection decreases or, at least, does not worsen within the abdomen. The fluids from the drain can be tested for enzymes like amylase (one of the contents of the pancreatic juice which digests carbohydrates), bile secretions or intestinal juice to find out whether the fluid in the drain is because of a suture leak. A case of suture leaks often presents as a sequelae to suture incompetence.
If there is a high suspicion of a pancreatic/bile leak (as seen in this patient), further scans are performed to confirm it or to rule it out. If the leak is major and the patient is unwell, urgent reoperation may be required.
In resuscitating a patient, C-A-B sequence is very important.
C is to help maintain blood circulation; A - airway and B - Breathing.
Hemopneumothorax can be considered under these 3.
Hemo - active internal hemorrhage into the pleural cavity.
Pneumo - ongoing air leakage into the pleural cavity (rib fractures).
If these are not attended to first, eventually, the lungs will not be able to expand, hence, no gaseous exchange compromising both A- airway and B- breathing. If no action is taken, and the hemorrhage and air leakage into the pleural cavity continues, it will eventually lead to hypovolemia and the accumulated blood will compress the mediastinum which houses the heart thereby preventing the heart from contracting as well and eventually compromises C- circulation. Once this is attended to, the other injuries can receive proper care as well but hemopneumothorax comes first.
Now, considering this patient, there is no active external bleeding going on. Closed diaphyseal femur fracture just needs immobilization as first aid. It is not open and the question did not state that there is an injury to a major blood vessel. In Degloving shin injuries, if there is an active bleeding, the vessel can be ligated and the wound dressed.
The most common and least serious type of traumatic brain injury is called a concussion. A concussion is most often caused by a sudden direct blow or bump to the head.
The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement (stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.
The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. It takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.
The third stage of labor lasts from the birth of the fetus until the placenta is delivered.
The presented cervix is 6cm ( dilated to an extent), Major segment of the fetal head is engaged to the pelvic inlet - indicating either an active or transition phase.
pseudofurunculosis is observed in neonates and infants. The disease begins with the appearance of superficial pustules in the ostium of sweat glands (periporitis). Caused by staphylococcus aureus, which penetrates in the depth of the sweat gland and causes the forming of deep indurated painful nodules. The nodules are very similar to furuncles, but they have not got core in the center (hence the name pseudofurunculosis).
Vesiculopustulosis is a widespread purulent disease, which appears in the first years of life. In the ostium of the sweat glands numerous pustules appear, filled with white yellow matter, the size of a pin head to a small pea, they do not merge with each other and are surrounded by bright edematous circles.
Rubella ( accused by rubella virus) is an acute viral infection characterised by a short prodromal period, Exanthema ( rash) during three days and lymphadenopathy. The type of rash found is roseola and small macula-papula. Note that the rash elements do not merge ( non-merging spots) and are usually concentrated on the extensor surface of extremities, back, buttocks and outer surface of thigh.
Epstein-barr virus is one of the causative agents of Infectious mononucleosis- a disease characterised by prolonged fever, systemic lymphadenopathy, acute tonsillitis, acute adenoiditis, hepatosplenomegaly, along with typical blood changes such as lymphocytosis, monocytosis, presence of specific cells called atypical mononuclear cells or virocytes.
Mumps infection is a systemic disease characterised by hyperthermic syndrome, symmetrical or unilateral swelling of parotid glands, epididymo-orchitis etc
Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). Recall that the patient presents with dotted hemorrhages on the skin (petechiae) and on analysis, thrombocytopenia. Caused by the binding of an autoantibody (specifically IgG) to platelets leading to platelet destruction.
Placenta abruptio (also called placental abruption) is when the placenta separates from the inner wall of the uterus before the baby is born. Common symptoms include sudden-onset abdominal pain, contractions that seem continuous and do not stop, vaginal bleeding, enlarged uterus disproportionate to the gestational age of the fetus, decreased fetal movement, and decreased fetal heart rate. Notice that this patient complains of a sudden sharp abdominal pain, The uterus is tense and does not relax between the contractions, blood coloured amniotic fluid- indicating uterine bleeding; all these signs help indicate the Premature detachment of the normally positioned placenta ( Placenta abruptio).
In Placenta Previa, the placenta abnormally covers the cervix ( the uterine outlet); it is usually accompanied by a painless bright red vaginal bleeding.
The key finding here is the positive signs of peritoneal irritation which is usually seen in patients with peritonitis. Notice that this woman underwent an abortion 3 days ago; her current situation is a complication of the procedure carried out. Purulent discharge from the vagina indicates the presence of an infectious process. Pelviperitonitis refers to a pathology that involves the inflammation of the peritoneum and organs of the pelvis.
Metroendometritis – the inflammation of a muscular and mucous membrane of a uterine wall combining signs of a myometritis and an endometritis. The clinic of a sharp metroendometritis is defined by a hyperthermia, intoxication, pain in the bottom of a stomach, purulent bleach.
Salpingo oophoritis involves the inflammation of the uterine tubes and the ovaries.
For the temporary stop of hemorrhage; - the imposition of a pressure
- the elevated position of the limb;
- digital pressure of the artery
- maximum limb flexion in the joint;
- stop bleeding with a tourniquet;
- stop bleeding from the carotid artery according to the method of Mikulich. This patient is bleeding from the carotid artery ( bright red blood from the neck) therefore, the highlighted procedures should be followed.
This patient presents with Classical signs of Reactive arthritis ( He can’t See , Pee or Bend The Knee) ie, purulent discharge from the eyes, burning sensation while urinating and pain in his leg joints. Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. Chlamydia trachomatis is the most common bacteria that triggers Reactive arthritis.
Dysentery is an intestinal infection that causes severe diarrhea with blood. In some cases, mucus may be found in the stool. Dysentery is usually spread as a result of poor hygiene. For example, if someone who has dysentery doesn’t wash their hands after using the toilet, anything they touch is at risk.
The infection is also spread through contact with food or water that has been contaminated with fecal matter. Careful hand washing and proper sanitation can help prevent dysentery and keep it from spreading.
Shigellosis and amebic dysentery are very common examples. It spreads rapidly in environments where people who don’t have dysentery come into contact with fecal matter from people who do have dysentery.
This contact may be through: contaminated food; contaminated water and other drinks; poor hand washing by infected people; swimming in contaminated water, such as lakes or pools and physical contact.
Children are most at risk of shigellosis, but anyone can get it at any age. It’s easily spread through person-to-person contact and by contaminated food and drink.
So, it should be reported as urgent to prevent further spread and limit the number of people that will be infected so as to locate the source of infection and those infected can be isolated.
Infective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteremia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. From anamnesis, we understand that this patient is a drug addict and most likely uses non sterile injections. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs). Notice that this patient has a pansystolic (holosystolic) murmur (usually heard in tricuspid valve regurgitation which can be one of the cardiac changes in IE).
Lutembacher syndrome is a very rare disorder that involves a congenital atrial septal defect coupled with an acquired mitral stenosis.
Recall that one of the major functions of the liver is detoxification i.e., converting harmful metabolites in the body into less harmful products that can be easily excreted out eg Ammonia is converted in the liver to urea which is then excreted via the urine. In a case of hepatic cirrhosis, this function of the liver is affected leading to the accumulation of harmful metabolites in the body system. Ammonia itself can easily cross the blood brain barrier causing encephalopathy. Notice that this patient presents with signs that suggest a reduction in mental activities.
Aminolevulinic acid and coproporphyrin are amino acids necessary for the synthesis of Heme. The excretion of these constituents in urine indicates either an inherited or secondary Porphyria. One of the most frequent causes of the secondary form of this disease is Lead poisoning. An increased degradation of porphyrin will lead to a decrease in Hemoglobin synthesis. Also note that the patient experiences Asthenovegetative syndrome ( physical and nervous fatigue), pain in the hepatic area and stomach; these are classical signs of Lead poisoning.
Carbon monoxide poisoning will be characterised by headache, lethargy, dizziness, loss of consciousness etc.
An agenesis is the failure of an organ to develop. From the above analysis, we observe an undetected right kidney on palpation; an absent contrast on the right during excretory urography indicates no organ located ( supported by an incomplete bladder trigone) - coupled with the patient’s age, we can conclude that development of the right kidney never took place. A compensatory hypertrophy/ hyperplasia of the left kidney occurred in order to meet the body’s requirement.
This patient just experienced an Orthostatic syncope or collapse. She was in the horizontal position (lying down) and when she rose to the vertical (upright position) she fell down. Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure. Classic orthostatic hypotension occurs when there is a persistent reduction in blood pressure of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of standing or being upright.
When the body assumes an upright position, there is an immediate gravitational pooling of about 500 to 1000ml of blood to the lower extremities, splanchnic and pulmonary circulations. The decrease in venous return to the heart reduces cardiac output and eventually causes a drop in blood pressure. Baroreceptors in the carotid and aortic arteries sense this decrease in blood pressure and activate the sympathetic nervous system which leads to increased heart rate, systemic vasoconstriction, and increased cardiac muscle contractility all of which eventually increase blood pressure.
In a healthy individual, this sympathetic activation causes a physiological increase in heart rate by 10 to 20 bpm, diastolic blood pressure by 5mmHg, but minimal to no change in systolic blood pressure. In patients with autonomic dysfunction, there is an inadequate engagement of the autonomic nervous system in response to a decrease in blood pressure leading to persistent hypotension and in serious conditions just as we have here, it can result in collapse.
Dispersion is the separation or distribution of a given substance over a particular area. Dust is easily carried by and spread around by air.
Solubility refers to the ability of a given substance (the solute) to dissolve in another substance ( the solvent).
Ionization refers to any process by which electrically neutral atoms or molecules are converted to electrically charged atoms or molecules (ions).
An etiotropic treatment is one aimed at the causative agent. In this case a Virus - Influenza A. Oseltamivir is an antiviral drug aimed at the treatment of influenza A and B. It acts by inhibiting influenza neuraminidase ( an enzyme needed for influenza replication). Zanamavir also has this function.
Acyclovir is also an antiviral drug used mainly in treatment of the herpes Simplex virus and Varicella zoster virus.
Scabies is a parasitic skin infestation caused by the Sarcoptes scabiei. It is characterised by intense pruritus ( itching) at night; this characteristic and the location of the rashes helps us to diagnose scabies. The primary lesion found are usually papules, vesicles or burrows ( accompanied by excoriations and pustules) which are commonly seen in interdigital folds, flexor surfaces of the wrist, axillary folds, buttocks ( closed areas of the body). Additionally in children, elderly persons, and immunosuppressed patients: scalp, face, neck, under the nail, palms of hands, and soles of feet.
Neurodermatitis is also referred to as Lichen simplex chronicus; it is chracterised by chronic itching and scaling localised on the wrist, neck, forearm, legs and anal region.
The adult form of Taenia solium and T. saginata cause taeniasis, T. solium larvae cause cysticercosis. They are differentiated by the number of proglottids/ uterine branches 7-12 for T. solium and 17-35 for saginata.
Psoriasis is a common skin disorder characterised by the presence of papules and plaques with silvery scaling especially on the knees and elbows. Other characteristics include acanthosis, parakeratosis and pinpoint bleeding ( Auspitz sign). The patient presents with a thimble symptom which translates into a pitting or a psoriatic nail.
A Panaritium or Whitlow is an acute purulent inflammation of the tissues of the finger or toes. Onychomycosis is a fungal infection of the nails; signs are white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed; it is also known as tinea unguium.
The signs and symptoms of riboflavin (vitamin B2) deficiency typically include sore throat with redness and swelling of the mouth and throat mucosa, cheilosis and angular stomatitis (cracking of the lips and corners of the mouth), glossitis, seborrheic dermatitis or pseudo-syphilis, and a decreased red blood cell count with normal cell size and hemoglobin content (normochromic normocytic anemia).
Thiamine (vit B1) deficiency is known as Beri-beri, deficiency of ascorbic acid will lead to scurvy, easy bruising and bleeding are seen in such patients.
This patient presents with obvious signs of inflammation with an infective focus in the lumbar area. In children of this age group, they can be prone to some infections as their immune system is not yet strong enough to ward off pathogenic organisms.
Phlegmon is a medical term describing an inflammation of soft tissue that spreads under the skin or inside the body. It’s usually caused by an infection and produces pus. The name phlegmon comes from the Greek word phlegmone, meaning inflammation or swelling. Skin phlegmon can be: red, sore, swollen and painful.
Erysipelas most often involves the lymphatics. It is a red, spreading, indurated demarcated lesion involving the lymphatics of the skin and caused by streptococci.
Ortner’s sign- tenderness on light percussion on right costal margin by the edge of the palm
Mayo-Robson’s signs- pain while pressing at the top of the angle lateral to the erector spinae muscles and below the left 12th rib left costovertebral angle.
These signs are present in a patient with pancreatitis and can be confirmed by the elevation of Diastase level. Urine diastase is useful in diagnosing uncertain abdominal cases (especially when pancreatitis is suspected).
From anamnesis, we observe that this patient works in a very hot/ steaming environment; the signs shown by this patient ie. a red dry skin and a temperature of 39℃ indicates the effect of heat on the patient. Heat stroke is a form of hyperthermia in which the body temperature is elevated dramatically. The cause of heat stroke is an elevation in body temperature, often accompanied by dehydration.
The most common symptoms of CO (carbon monoxide) poisoning are headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion on the background of inhalation of fumes from cars, generators etc.
Fetor hepaticus is a strong musty smell observed from the breath of a patient whose liver is failing to detoxify a toxic substance. An acute liver failure is observed when the liver loses its function within days or weeks. Note that this patient started experiencing the expressed symptoms a few hours after consuming mushrooms; it can also be caused by infection, alcohol or drug induced.
Cytolytic syndrome is a type of liver disease that leads in cell destruction; the major cause of this disorder is paracetamol overdose.
Hepatolienal syndrome involves the reduction of kidney function accompanied by liver cirrhosis or liver failure.
Acute rheumatic fever typically occurs 2-3 weeks after Group A streptococcal pharyngitis. Diagnosis depends on a set of clinical signs that result from this infection ( Jones criteria)- these include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis. For biochemical analysis, certain key markers are used in diagnosis; these include C reactive protein ( an inflammatory marker), antistreptolysin O titer ( a marker that indicates a group A streptococcal infection ), ESR ( a marker from general blood analysis). Using these criterias, we can observe that this patient has arthritis, carditis and results from the biochemical analysis all appear positive for an acute rheumatic fever.
Reactive arthritis is also known as reiter’s syndrome and refers to the inflammation of joints as a result of a urogenital, intestinal or respiratory infection.
The description - a single round erythematous focus 3cm in diameter, asbestos like scales accompanied by itching and hair loss on the affected area is typical for Ringworm (tinea capitis in this case) also known as Microsporai; an infection caused by microsporum fungi.
Distinguishing Ulcerative Colitis from Crohn Disease
Only colon involved
Continuous inflammation extending proximally
Skip-lesions with intervening normal mucosa
Inflammation in mucosa and submucosa only
Perinuclear ANCA (pANCA) positive
Occult blood in stool is indicative of a hemorrhagic process from the colon, while the results from the colonoscopy indicates the pathology is located in the colon.
Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps (pain), change in form (consistency) and frequency of stool, constipation etc. . This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection.
The results from the x-ray shows the fracture of the skull coupled with the fact that this patient had a brief loss of consciousness; from the listed options, an immediate surgical intervention should be carried out.
Key point here is: QRS complexes DISCONNECTED with P waves.
This is the only information you need to answer this question.
Now let’s compare the answer choices. I won’t bore you with ECG images to avoid confusions.
Atrioventricular (AV) block is partial or complete interruption of impulse transmission from the atria to the ventricles. We have 3 degrees of heart block.
First Degree AV block: All normal P waves are followed by QRS complexes, but the PR interval is longer than normal (>0.20 second).
Second Degree AV block: Some normal P waves are followed by QRS complexes, but some are not. Two types exist:
Mobitz type I
Mobitz type II
In Mobitz type I 2nd-degree AV block, the PR interval progressively lengthens with each beat until the atrial impulse is not conducted and the QRS complex is dropped (Wenckebach phenomenon); AV nodal conduction resumes with the next beat, and the sequence is repeated.
In Mobitz type II 2nd-degree AV block, the PR interval remains constant. Beats are intermittently nonconducted and QRS complexes dropped, usually in a repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P wave.
Third Degree AV block: Heart block is complete in 3rd-degree AV block. There is no relationship between P waves and QRS complexes (AV dissociation) in 3rd-degree AV block.
There is no relationship between P wave and QRS complexes, which also means P wave is UNCONNECTED with QRS complexes.
The liver is the main organ responsible for the metabolism of drugs and toxic chemicals, and so is the primary target organ for many organic solvents. Work activities with hepatotoxins exposures are numerous and, moreover, organic solvents are used in various industrial processes. Organic solvents used in different industrial processes may be associated with hepatotoxicity.
Work activities with hepatotoxin exposure are numerous and include chemists, dry cleaners, farm workers, painters, health care workers, nurses, and printers. Exposure to hepatotoxins can occur through intentional or accidental ingestion in food or absorption of toxic contaminants through the skin.
The patient in question who works as a disinfector for 19 years and presented with signs of liver pathology (liver is enlarged, jaundice) most probably works in the farming industry or health care setting. Farmers and many workers in the agro-food chain are exposed to these substances as well as consumers who eat agri-cultural products that are not properly cleaned and decontaminated.
Among these substances, 1,1,1-trichloro-2,2-bis (p-chlorophenyl)-ethane (DDT) and its metabolite 1,1-dichloro-2,2-bis (p-chlorophenyl)-ethylene (DDE) have been extensively studied. DDT was used both in agriculture and for environmental disinfection until its use was later forbidden in both America and Europe because of its toxic effects on humans. In humans, DDT contamination occurs through con-tact with the skin, mucous membranes and inha-lation.
This patient is having an Anaphylactic reaction (Type I hypersensitivity reaction) after being stung by a bee. Notice that he is having inflammation of the airway, making it difficult to breath. For emergency care , this patient should be administered Intravenous epinephrine and glucocorticoids to reduce inflammation and help improve breathing.