This is a case of Vit. B12 or folic acid deficiency. The anaemia with angular stomatitis is highly suggestive of Vit. B12 or folate deficiency. The absence of koilonychia excludes Iron deficiency anaemia.

Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.

Submandibular LNs are four or five nodes that lie in relationship to the mandible and the submandibular gland; they receive vessels from the face below the eye and from the tongue and drain into the superior deep cervical nodes, particularly the jugulodigastric node. These nodes are part of the pericervical collar of lymph nodes that initially receive drainage from the head.

A 10 year old child, with a history of URTI and haematuria, presents a picture consistent with a diagnosis of IgA nephropathy. This condition can present with proteinuria and generalized swelling. However, an important differentiating point from rapidly progressive GN is the duration. IgA nephropathy is usually <10 days (commonly 4-5 day history of infection).

There are three branches of the ulnar nerve that are responsible for its sensory innervation. The palmar cutaneous branch innervates the medial half of the palm. The dorsal cutaneous branch innervates the dorsal surface of the medial one and a half fingers, and the associated dorsal hand area. The superficial branch innervates the palmar surface of the medial one and a half fingers. According to the given history, the superficial branch of ulnar nerve has been affected.

The prognosis for croup is excellent, and recovery is almost always complete with complications being quite rare. The possible complications are pneumonia, bacterial tracheitis, pulmonary oedema, pneumothorax, pneumomediastinum, lymphadenitis or otitis media. Bacterial tracheitis is a life-threatening infection that can arise after the onset of an acute viral respiratory infection.

The history is suggestive of cerebral stroke and the investigation of choice at most hospitals would be a CT brain. Non-contrast CT scanning is the most commonly used form of neuroimaging in the acute evaluation of patients with apparent acute stroke. MRI scan is more sensitive but availability and cost make this a less likely option.

In psychology and psychiatry, insight can mean the ability to recognize one’s own mental illness. A person with very poor recognition or acknowledgment is referred to as having poor insight. The most extreme form is anosognosia, the total absence of insight into one’s own mental illness. Insight can be defined not only in terms of people’s understanding of their illness, but also in terms of understanding how the illness affects individuals’ interactions with the world. The term ‘insight’ encompasses a complex concept which should not be considered as an isolated symptom which is present or absent. Instead, it may be more appropriate to think of insight as a continuum of thinking and feeling, affected by numerous internal and external variables. Different psychiatric disorders involve different mechanisms in the process of impairment of insight; this may influence the ways in which insight should be assessed in clinical practice.

Cefuroxime is the best choice in the case of gut surgery as it is very effective in preventing infections against gut anaerobes, enterococci and coliforms.

The jugular venous pulsation has a biphasic waveform.

– The a wave corresponds to right atrial contraction and ends synchronously with the carotid artery pulse. The peak of the ‘a’ wave demarcates the end of atrial systole.
– The c wave corresponds to right ventricular contraction causing the tricuspid valve to bulge towards the right atrium during RV isovolumetric contraction.
– The x’ descent follows the ‘c’ wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole (ventricular ejection/atrial relaxation). (As stroke volume is ejected, the ventricle takes up less space in the pericardium, allowing relaxed atrium to enlarge). The x’ (x prime) descent can be used as a measure of right ventricle contractility.
– The x descent follows the ‘a’ wave and corresponds to atrial relaxation and rapid atrial filling due to low pressure.
– The v wave corresponds to venous filling when the tricuspid valve is closed and venous pressure increases from venous return – this occurs during and following the carotid pulse.
– The y descent corresponds to the rapid emptying of the atrium into the ventricle following the opening of the tricuspid valve.

History and examination findings are suggestive of facial injury and intracranial haemorrhage is unlikely. To exclude any facial fracture, an X-ray is suggested.

The age of the patients together with sudden loss of vision, remission and relapse of optic neuritis, focal neurological symptoms and exaggerated reflexes all suggest multiple sclerosis. This is treated with corticosteroids.

The motor functions of the intrinsic tongue muscles, as well as the genioglossus, hyoglossus, and styloglossus muscles, are all innervated by the hypoglossal nerve. These muscles are essential for swallowing and speech. To test nerve function, the physical examiner has a patient protrude his or her tongue. In intranuclear, or lower motor neuron lesions, the tongue deviates toward the injured side, as the contralateral genioglossus is acting unopposed. In contrast, supranuclear (upper motor neuron) lesions result in deviation away from the lesion. In addition to causing deviation toward the lesion, an injury involving a hypoglossal nucleus may result in tongue atrophy and fasciculation

Infection of chickenpox in the first half of pregnancy can result in congenital varicella syndrome. It presents as cerebral, cortical and cerebellar hypoplasia with convulsions and rudimentary digits. Prevention is by administering varicella vaccine, even before pregnancy. Varicella immunoglobulin is administered to pregnant women who are exposed to infection. Infection during pregnancy is treated with acyclovir.

Oxycodone is a semi-synthetic opioid with effects similar to
morphine. It is an alternative to morphine for severe pain
at step three on the WHO analgesic ladder.
Clinical trials indicate that oxycodone is as effective as
morphine at controlling cancer pain but with no significant
difference in overall tolerability. There is no evidence that
oxycodone is superior to morphine for chronic, non-cancer
pain.
There is some evidence that there is individual variation
in analgesic response and sensitivity to the adverse
effects of opioids. Oxycodone can be considered for
the small number of patients who experience allergy or
ongoing neurotoxic adverse effects to morphine, such
as hallucinations. Oxycodone may have a place in the
management of complex pain syndromes.

This case is highly suggested of PID or Pelvic Inflammatory disease with chlamydia as the more common infective agent. Tetracyclines are used for treatment.

Exercise induced asthma is characterised by sudden onset wheezing, cough and shortness of breath while performing hectic physical activity. The best investigation to perform is a chest X-ray.

The history of smoking with a cough and bone pain is suggestive of bronchogenic carcinoma. CXR findings are also supportive of this diagnosis. In COPD, a cough with dyspnoea and wheezing is prominent.

In young patients with good skin, pre-tibial lacerations may be sutured, usually with non-absorbable sutures that are removed after 7-10 days. In elderly patients with thin skin, or those on warfarin or steroids, the skin is frequently too fragile to suture. For these patients the wound should be thoroughly cleaned and meticulously steristripped to best aid skin healing. A non-adherent dressing and a light bandage can be applied and the patient should be encouraged to elevate the leg. Patients should be reviewed after a week. The laceration may take many months to heal and some require skin grafting procedures.

The accessory nerve innervates the trapezius muscle which is involved in shoulder movements. Any injury to this nerve will result in the difficulty of movements around the shoulder.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

Impaired glucose tolerance means that blood glucose is raised beyond normal levels, but not high enough to warrant a diabetes diagnosis. With impaired glucose tolerance you face a much greater risk of developing diabetes and cardiovascular disease. Impaired glucose tolerance is defined as 2-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients.

Premature ovarian failure presents before the age of 40 in females with a triad of symptoms: amenorrhea, hypergonadism and low oestradiol. This triad is present in the patient.

The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.

The patient is experiencing an acute myocardial infarction and percutaneous angiography is the next most appropriate step in management. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and multivessel coronary artery disease (CAD).

The patient has what is known as ‘honeymoon cystitis’.
Most common presentation of schistosomiasis is haematuria.
Patients with kidney trauma also present with haematuria following a positive history for such injury.
Pain due to calculi are colicky in nature and severe.

The clinical picture is very suggestive of pneumonia. Pneumonia presents with chest pain exacerbated by deep breathing, fever and localized crackles or consolidation.

All the symptoms this patient is suffering from are the classic features of a hypothyroid state.

Pulmonary embolism (PE) is the obstruction of one or more pulmonary arteries by solid, liquid, or gaseous masses. In most cases, the embolism is caused by blood thrombi, which arise from the deep vein system in the legs or pelvis (deep vein thrombosis) and embolize to the lungs via the inferior vena cava.

Risk factors include: immobility, inherited hypercoagulability disorders, being overweight or obese, smoking cigarettes, taking birth control pills (oral contraceptives) or hormone replacement therapy, having diseases such as stroke, paralysis, chronic heart disease, or high blood pressure, pregnancy, and recent surgery.

The clinical presentation is variable and, depending on the extent of vessel obstruction, can range from asymptomatic to cardiogenic shock. Symptoms are often nonspecific, including chest pain, coughing, dyspnoea, and tachycardia.

The diagnosis of PE is based primarily on the clinical findings and is confirmed by detection of an embolism in contrast CT pulmonary angiography (CTA). Arterial blood gas analysis typically shows evidence of respiratory alkalosis with low partial oxygen pressure, low partial carbon dioxide pressure, and elevated pH. Another commonly performed test is the measurement of D-dimer levels, which can rule out PE if negative.

Acute bacterial sinusitis usually occurs following an upper respiratory infection that results in obstruction of the osteomeatal complex, impaired mucociliary clearance, and overproduction of secretions. Sinusitis can be treated with antibiotics, decongestants, steroid drops or sprays, mucolytics, antihistamines, and surgery (lavage). Studies have shown that 70% of cases of community-acquired acute sinusitis in adults and children are caused by Streptococcus pneumoniae and Haemophilus influenzae. Most guidance favours amoxicillin as first line treatment. There seems to be little evidence base for this, however. BMJ’s clinical evidence website found three RCTs which showed no difference between amoxicillin and placebo (in patients without bacteriological or radiological evidence of sinusitis). However, there were no RCTs examining the effects of co-trimoxazole, cephalosporins, azithromycin, and erythromycin. Second line therapies include ciprofloxacin and co-amoxiclav. First and second generation cephalosporins are not generally favoured.