The presence of blown right pupil is a sign of the third cranial nerve compression. The most likely cause is an extradural bleed. However, since this option is not listed, transtentorial herniation would be the most applicable answer. Intraventricular bleeds are typically more common in premature neonates and deterioration due to hydrocephalus is more chronic. Subdural haematoma has a slower onset of symptoms.

Transtentorial herniation is a type of cerebral herniaton. It is further divided into two types with the uncal herniation being the most common.
1. Descending transtentorial herniation: more frequently known as uncal herniation
2. Ascending transtentorial herniation: less common than uncal herniation

Uncal (transtentorial) herniation is herniation of the medial temporal lobe from the middle into the posterior fossa, across the tentorial opening. The cardinal signs are an acute loss of consciousness associated with ipsilateral oculomotor nerve palsy with a fixed and dilated pupil (blown pupil) and contralateral hemiparesis.

A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:
Type I – transverse fracture through the growth plate (also referred to as the physis): 6% incidence
Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.
Type III – A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 10% incidence
Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray): 1% incidence
Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)
Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)
Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
Type IX – Injury of the periosteum which may impair intramembranous ossification

The mnemonic SALTER can be used to help remember the first five types.
N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II – A = Above. The fracture lies above the physis, or Away from the joint.
III – L = Lower. The fracture is below the physis in the epiphysis.
IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V – R = Rammed (crushed). The physis has been crushed.
Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’.

This is likely a case of epididymo-orchitis which usually occurs due to infection with gonorrhoea or chlamydia in this age group (<35 years). Epididymo-orchitis is an acute inflammation of the epididymis and often involves the testis. It is usually caused by bacterial infection which spreads from the urethra or bladder. Amiodarone is a recognised non-infective cause of epididymitis, which resolves on stopping the drug. On examination, tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

Upper gastrointestinal (GI) bleeding is usually defined by a bleeding source proximal to the ligament of Treitz although some may also include a bleeding source in the proximal jejunum. Upper GI bleeding emergencies are characterized by hematemesis, melena, haematochezia (if the bleeding is massive and brisk) and evidence of hemodynamic compromise such as dizziness, syncope episodes and shock. The most commonly used endoscopic haemostatic interventions include epinephrine (adrenaline) injection, thermal coagulation and endoscopic clipping at the ulcer site to constrict, compress and/or destroy the bleeding vessel. Injection of 30 mL diluted epinephrine (1:10 000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.

A thyroglossal duct cyst (TGDC) is the most common mass found in the midline of the neck. The mass is usually located at or below the level of the hyoid bone, although a TGDC can be located anywhere from the foramen cecum to the level of the thyroid gland.
Most patients with a TGDC present with asymptomatic masses in the midline of the neck.
Recurrent inflammation associated with infection of a TGDC is not uncommon. When an infection is present, the cyst often enlarges and an abscess may form. Spontaneous rupture with secondary sinus tract formation can also occur.

The surgical treatment of choice for thyroglossal cysts is the Sistrunk operation, in which an en block resection of the sinus tract and above (including the midportion of the hyoid bone) is performed. Recurrence is approximately 3-5% and is increased by incomplete excision and a history of recurrent infections.

Answer: Inflammatory bowel disease

The inflammatory bowel diseases (IBDs), including ulcerative colitis and Crohn disease, are chronic inflammatory disorders of the gastrointestinal tract most often diagnosed in adolescence and young adulthood, with a rising incidence in paediatric populations. Inflammatory bowel disease is caused by a dysregulated mucosal immune response to the intestinal microflora in genetically predisposed hosts. Although children can present with the classic symptoms of weight loss, abdominal pain, and bloody diarrhoea, many present with nonclassical symptoms of isolated poor growth, anaemia, or other extraintestinal manifestations.

Colorectal Carcinoma (CRC) is rare in patients less than 20 years of age.

In most cases of atresia, dissection into the porta hepatis and creation of a Roux-en-Y anastomosis with a 35 to 40-cm retro colic jejunal segment is the procedure of choice.
In the unusual circumstance of distal patency of the common duct with acceptable proximal luminal calibre, a modified portoenterostomy may be considered in place of the traditional Kasai procedure. However, the clinician must be aware that progression of disease pathophysiology may occur.

Biliary atresia is characterized by obliteration or discontinuity of the extrahepatic biliary system, resulting in obstruction to bile flow. Regardless of aetiology, the clinical presentation of neonatal cholestasis is remarkably similar in most infants.

Typical symptoms include variable degrees of jaundice, dark urine, and light stools. In the case of biliary atresia, most infants are full-term, although a higher incidence of low birthweight may be observed. In most cases, acholic stools are not noted at birth but develop over the first few weeks of life. Appetite, growth, and weight gain may be normal.

Physical findings do not identify all cases of biliary atresia. No findings are pathognomonic for the disorder. Infants with biliary atresia are typically full term and may manifest normal growth and weight gain during the first few weeks of life.

Hepatomegaly may be present early, and the liver is often firm or hard to palpation. Splenomegaly is common, and an enlarging spleen suggests progressive cirrhosis with portal hypertension.

Direct hyperbilirubinemia is always an abnormal finding and it is typically present from birth in the foetal/embryonic form. Consider biliary atresia in all neonates with direct hyperbilirubinemia.

In the more common postnatal form, physiologic jaundice frequently merges into conjugated hyperbilirubinemia. The clinician must be aware that physiologic unconjugated hyperbilirubinemia rarely persists beyond 2 weeks. Infants with prolonged physiologic jaundice must be evaluated for other causes.

The posterior drawer test is a physical exam technique that is done to assess the integrity of the posterior cruciate ligament (PCL). The PCL is attached to the posterior intercondylar area of the tibia and passes anteriorly, medially, and upward to attach to the lateral side of the medial femoral condyle.
This ligament prevents backward displacement of the tibia or forward sliding of the femur. Injury to the ligament allows displacement of the tibia

Prolonged cold ischemia time (CIT) may contribute to the perception of the graft as being suboptimal since donation after circulatory death (DCD) kidneys may be considered less tolerant of CIT. In fact, previous reports recommend restriction of CIT to 12 to 18 hours when transplanting DCD kidneys and a recent UK registry analysis identified increased risks of DCD graft failure with CIT longer than 12 hours.
The donated kidney in this case had a CIT of 26 hours and the patient presented with symptoms 10 days later which would lead to acute rejection.

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

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

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

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

As the stone is smaller in size, there is a strong likelihood (75%) of it to be passed spontaneously. Furthermore, distally sited stones are more likely to pass spontaneously than proximally sited ones. Hence, it should be arranged to review the patient in two weeks with a KUB X-ray.

Urolithiasis affects up to 15% of the population worldwide. The development of sudden-onset, colicky loin to groin pain is a classical feature in the history. It is nearly always associated with haematuria that is either micro- or macroscopic. The most sensitive and specific diagnostic test is helical, non-contrast CT scanning.

Management options for urolithiasis are:
1. Most renal stones measuring <5mm in maximum diameter typically pass within four weeks of onset of symptoms. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney, and previous renal transplant.
2. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters, and ureteric stent placement.
3. In the non-emergency setting, the preferred options for treatment include extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, and open surgery (selected cases). Minimally invasive options are the most popular first-line treatment.

The classic symptom of subarachnoid haemorrhage is thunderclap headache (a headache described as like being kicked in the head, or the worst ever, developing over seconds to minutes). This headache often pulsates towards the occiput (the back of the head). About one-third of people have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid haemorrhage. Vomiting may be present, and 1 in 14 have seizures. Confusion, decreased level of consciousness or coma may be present, as may neck stiffness and other signs of meningism.
In 85 percent of spontaneous cases the cause is a cerebral aneurysm—a weakness in the wall of one of the arteries in the brain that becomes enlarged. They tend to be located in the circle of Willis and its branches. While most cases are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture. Aspirin also appears to increase the risk.
In 15–20 percent of cases of spontaneous SAH, no aneurysm is detected on the first angiogram. About half of these are attributed to non-aneurysmal perimesencephalic haemorrhage, in which the blood is limited to the subarachnoid spaces around the midbrain (i.e. mesencephalon). In these, the origin of the blood is uncertain. The remainder are due to other disorders affecting the blood vessels (such as cerebral arteriovenous malformations), disorders of the blood vessels in the spinal cord, and bleeding into various tumours.
Genetics may play a role in a person’s disposition to SAH; risk is increased three- to fivefold in first-degree relatives of people having had a subarachnoid haemorrhage. But lifestyle factors are more important in determining overall risk. These risk factors are smoking, hypertension (high blood pressure), and excessive alcohol consumption.
The absence of trauma and skull fracture rules out the other types of haemorrhages and haematomas.

The operation aims to remove most of your large bowel including the blood supply and associated lymph glands and leave the rectum behind. It is most commonly recommended for inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

It is also recommended for other bowel conditions like familial adenomatous polyposis, and when there is more than one bowel cancer.

In inflammatory bowel disease such as ulcerative colitis the small bowel is brought out to the skin of the tummy as an ileostomy and the remaining bowel (rectum) is closed off and left inside. In other conditions where possible, the two ends of the remaining healthy bowel (small bowel to rectum) are re-joined (an anastomosis). Most
people therefore do not require a stoma. However some people benefit from having a stoma made depending on circumstances regarding:
1) Their general state of health (heart disease, lung disease, diabetes, vascular disease, smoking, steroid medications, being undernourished);
2) Factors which cannot be seen until the surgeon can see inside your tummy (more extensive disease than originally thought, extensive pelvic scarring from previous surgery or other treatment, excessive bleeding).
Temporary stomas are made to divert faeces away from the join (de-functioning) to give the best chance to heal if there is concern it may be slow to heal.

Emergency indications for surgical intervention in severe UC include free perforation, haemorrhage or systemic instability. An urgent indication for colectomy is a severe attack that is unresponsive to medical therapy.

In the setting of severe UC, the procedure of choice is subtotal colectomy and ileostomy. The residual rectal disease is controllable in most patients. In general, there are advantages to the subtotal colectomy approach, including a lower morbidity if pelvic dissection is not performed, preservation of the rectum so that reconstructive procedures can be performed later, and allowing the definitive procedure to be deferred to an optimal situation when the patient is off immunosuppressive medications and has improved nutritional status. Usually, the staged reconstruction with IPAA or definitive total proctocolectomy is performed several months later.

Chronic cholecystitis can be a surgical challenge due to an inflammatory process that creates multiple adhesions, complicates dissection, and can hamper recognition of normal anatomical structures. In such cases cholecystostomy can be performed in order to alleviate the acute symptoms. Tube cholecystostomy allows for resolution of sepsis and delay of definitive surgery. Interval laparoscopic cholecystectomy can be safely performed once sepsis and acute infection has resolved.

The classic presentation of a ureteric colic is acute, colicky flank pain radiating to the groin. The pain is often described as the worst pain the patient has ever had experienced. Ureteric colic occurs as a result of obstruction of the urinary tract by calculi at the narrowest anatomical areas of the ureter: the pelviureteric junction (PUJ), near the pelvic brim at the crossing of the iliac vessels and the narrowest area, the vesicoureteric junction (VUJ). Location of pain may be related but is not an accurate prediction of the position of the stone within the urinary tract. As the stone approaches the vesicoureteric junction, symptoms of bladder irritability may occur.

Calcium stones (calcium oxalate, calcium phosphate and mixed calcium oxalate and phosphate) are the most common type of stone, while up to 20% of cases present with uric acid, cystine and struvite stones.

Physical examination typically shows a patient who is often writhing in distress and pacing about trying to find a comfortable position; this is, in contrast to a patient with peritoneal irritation who remains motionless to minimise discomfort. Tenderness of the costovertebral angle or lower quadrant may be present. Gross or microscopic haematuria occurs in approximately 90% of patients; however, the absence of haematuria does not preclude the presence of stones.

Indications for a simple mastectomy with a concomitant axillary procedure, which may be either a sentinel node biopsy or an axillary clearance, are as follows:

– Locally advanced breast cancer
– Multifocal breast cancer
– Large tumour relative to the size of the breast, excision of which may compromise final cosmesis
– Extensive ductal carcinoma in situ (DCIS)

Multifocality and multicentricity (MFMC) are frequently used descriptors to assess the extent of disease in patients presenting breast cancer. The presence of two or more foci of cancer within the same breast quadrant is defined as multifocal, while the presence of two or more foci of cancer in different quadrants of the same breast is defined as multicentric. A simple mastectomy involves removing the breast along with an ellipse of skin that encompasses the nipple-areola complex. Unlike a radical mastectomy, it does not involve removal of the underlying muscles and uninvolved lymph nodes.

Patient unsuitability for breast-conserving approaches as a result of contraindications for radiation therapy – Such contraindications include a previous history of chest wall irradiation, either after previous breast-conserving therapy or in mantle field radiation therapy for lymphoma; severe skin disorders, such as scleroderma and psoriasis; and severe pulmonary dysfunction

Patient preference for mastectomy – A patient who is a suitable candidate for breast conservation may opt for a mastectomy instead.

Suspected penile fractures should be surgically explored and the injury repaired.

Penile fractures are a rare type of urological trauma. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classical history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination, a tense haematoma is most commonly noted, and if the urethra is injured, blood may be seen at the meatus.

The correct management involves surgical exploration and repair of the injury. A circumferential incision is made immediately inferior to the glans and the penile shaft is inspected. Injuries are usually sutured and the urethra is repaired over a catheter.

Answer: Surgery over the next few days

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

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

Congenital neck masses are developmental anomalies typically seen in infants or children. Common conditions include thyroglossal duct cysts, branchial cleft cysts, and cystic hygromas. These malformations present as painless neck masses, which can cause dysphagia, respiratory distress, and neck pain due to compression of surrounding structures. The location of the mass depends on the embryological structure the cysts arise from. Diagnosis is made based on clinical findings and imaging results (ultrasound, CT, MRI), which also help in surgical planning. Treatment consists of complete surgical resection to prevent recurrence and complications such as infection or abscess formation.
The thyroglossal cyst is present from birth and usually detected during early childhood. It presents as a painless, firm midline neck mass, usually near the hyoid bone, which elevates with swallowing and tongue protrusion. May cause dysphagia or neck/throat pain if the cyst enlarges.

Severe abdominal pain tends to favour infection with Campylobacter jejuni.

Infection with Campylobacter jejuni is one of the most common causes of gastroenteritis worldwide. In developed countries, the incidence of Campylobacter jejuni infections peaks during infancy and, again, during early adulthood. Most infections are acquired by the consumption and handling of poultry. A typical case is characterized by diarrhoea, fever, and severe abdominal cramps. Obtaining cultures of the organism from stool samples remains the best way to diagnose this infection. Complications of C. jejuni infections are rare, and most patients do not require antibiotics. Careful food preparation and cooking practices may prevent some Campylobacter infections.

Patients with breast implants present the radiologist with specific challenges, such as the identification and distinction of implant and breast tissue, diagnosis of implant defects and implant-related complications as well as diagnosis and follow-up of unrelated breast diseases such as mastitis or breast cancer.
Whereas mammography is the first-line method before surgery, ultrasound is the mainstay of post-procedural imaging, unless there is concern about rupture.
Although mammography and ultrasonography are the standard first steps in the diagnostic workup, magnetic resonance imaging (MRI) is the most useful imaging modality for the characterisation of breast implants because of its high spatial resolution and contrast between implants and soft tissues and absence of ionising radiation.

Peptic ulcer disease can involve the stomach or duodenum. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. Epigastric pain is the most common symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours afterward with duodenal ulcers.

Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test in the evaluation of patients with suspected peptic ulcer disease. At endoscopy, gastric ulcers appear as discrete mucosal lesions with a punched-out smooth ulcer base, which often is filled with whitish fibrinoid exudate. Ulcers tend to be solitary and well circumscribed and usually are 0.5-2.5 cm in diameter.
Treatment of peptic ulcers varies depending on the aetiology and clinical presentation. The initial management of a stable patient with dyspepsia differs from the management of an unstable patient with upper gastrointestinal (GI) haemorrhage. In the latter scenario, failure of medical management not uncommonly leads to surgical intervention.

Treatment options include empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.

In this case, there is no delay in treatment and the mechanism by which the fracture occurred fits accidental fracture.

A statement from the parent or guardian and any witnesses regarding how the child sustained the injury will help determine whether the injury is accidental or abusive. A statement from the parent or guardian explaining why he or she delayed in seeking medical treatment is important to the investigation because caretakers often postpone medical treatment or fail to provide treatment for an injured child to hide physical abuse. The abusing parent or caregiver may also put a child in oversized clothing or keep the child inside a residence for extended periods of time in an attempt to conceal the child’s injuries.

Parents who inflict fractures on their children tend to minimize the severity of the accident purported to cause the fracture, whereas many parents of children with accidental fractures will relate a history of high-energy events.

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.

Hyperacute rejection occurs almost immediately following organ implantation and necessitates immediate explant of the organ. Hyperacute rejection is uncommon with pre-transplantation cross-matches and screening. Hyperacute rejection (HAR) of the kidney was first recognized 20 years ago in cases of donor-recipient incompatibility for the major blood group and tissue antigen systems. Classic pathological changes described include early accumulation of PMNs in glomeruli and peritubular capillaries, progressive glomerular thrombosis, tubular necrosis, and eventual cortical necrosis. Reaction of host humoral antibodies with antigens on donor cells serves as one trigger of the clotting mechanism, which then proceeds in a nonspecific fashion.

Antigen systems other than the ABO groups that contribute to HAR reactions are leukocyte antigens, endothelial and monocyte antigens, and B cell antigens. It is also documented that glomerular thrombosis identical to HAR may occur secondary to endothelial damage after pulsatile perfusion. However, in such cases no specific deposition of immunoglobulins and complement is detected.

Iron deficiency anaemia (IDA) is the most common form of anaemia worldwide and can be due to inadequate intake, decreased absorption (e.g., atrophic gastritis, inflammatory bowel disease), increased demand (e.g., during pregnancy), or increased loss (e.g., gastrointestinal bleeding, menorrhagia) of iron. Prolonged deficiency depletes the iron stores in the body, resulting in decreased erythropoiesis and anaemia.
Symptoms are nonspecific and include fatigue, pallor, lethargy, hair loss, brittle nails, and pica. Diagnostic lab values include low haemoglobin, microcytic, hypochromic red blood cells on peripheral smear, and low ferritin and iron levels. Once diagnosed, the underlying cause should be determined. Patients at risk for underlying gastrointestinal malignancy should also undergo a colonoscopy.
Iron deficiency anaemia is treated with oral (most common) or parenteral iron supplementation. Severe anaemia or those with concomitant cardiac conditions may also require blood transfusions. The underlying cause of IDA should also be corrected. IDA may manifest as Plummer-Vinson syndrome (PVS): triad of postcricoid dysphagia, upper oesophageal webs, and iron deficiency anaemia

The following history findings are associated with acute epididymitis and orchitis:
– Gradual onset of scrotal pain and swelling, usually unilateral, often developing over several days (as opposed to hours for testicular torsion)
– Dysuria, frequency, or urgency
– Fever and chills (in only 25% of adults with acute epididymitis but in up to 71% of children with the condition)
Usually, no nausea or vomiting (in contrast to testicular torsion)
– Urethral discharge preceding the onset of acute epididymitis (in some cases)

Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. Physical findings associated with acute epididymitis may include the following:
– Tenderness and induration occurring first in the epididymal tail and then spreading
– Elevation of the affected hemiscrotum
– Normal cremasteric reflex
– Erythema and mild scrotal cellulitis
– Reactive hydrocele (in patients with advanced epididymo-orchitis)
– Bacterial prostatitis or seminal vesiculitis (in post pubertal individuals)
– With tuberculosis, focal epididymitis, a draining sinus, or beading of the vas deferens
– In children, an underlying congenital anomaly of the urogenital tract
Findings associated with orchitis may include the following:
– Testicular enlargement, induration, and a reactive hydrocele (common)
– Non-tender epididymis
In 20-40% of cases, association with acute epididymitis

This individual has acute cholecystitis. This is demonstrated by well-localized pain in the right upper quadrant, usually with rebound and guarding; frequent presence of fever and peritonism. Ultrasonography is the procedure of choice in suspected gallbladder or biliary disease. A bile duct measuring 4mm is usually normal.
Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated (typically, laparoscopic cholecystectomy is the first-line therapy at centres with experience in this procedure).

A breast cyst is a fluid-filled sac within the breast. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but can also feel firm.

Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. They are also common in adolescents. Breast cysts can be part of fibrocystic disease. The pain and swelling is usually worse in the second half of the menstrual cycle or during pregnancy.

The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas.

The presence of a necrotic and infected forefoot with necrosis of the heel and a boggy indurated swelling anterior to the ankle joint in a patient with sepsis secondary to diabetic foot ulcer indicates that a below knee amputation is the best option.

Based on Wagner’s Classification of Diabetic Foot Ulcers, this patient has a grade of 5 where there is gangrene or necrosis of large portion of the foot
requiring major limb amputation.

Infection in a diabetic foot is usually secondary to ulceration. Rarely, infection itself causes ulceration. It can either be local or systemic. Treatment requires early incision and drainage or debridement and empirical broad-spectrum antibiotic therapy. If there is co-exiting gangrene or extensive tissue loss, early amputation at the appropriate level should be considered to remove the focus of infection.