Bulbar palsy and pseudobulbar palsy are rare types of a motor neuron disease that affect the cranial motor nerves. Bulbar palsy is a lower motor neuron palsy that affects the nuclei of the 9th to 12th cranial nerves. Pseudobulbar palsy is an upper motor neuron palsy that affects the corticobulbar tracts of the 5th, 7th and 9th to 12th cranial nerves. Any condition which disrupts or damages the cranial nerve nuclei or corticobulbar tracts can cause bulbar or pseudobulbar palsy (e.g., stroke, multiple sclerosis, infections, brain stem tumours). Both bulbar and pseudobulbar palsy are seen mainly in men over 75 years old and present with progressive dysarthria and dysphagia. In addition, patients with pseudobulbar palsy present with a lack of facial expression, difficulty chewing, and emotional lability. Lower motor neuron signs (atrophy and fasciculations of the tongue, absent gag reflex) differentiate bulbar palsy from pseudobulbar palsy, which presents with upper motor neuron signs (spastic tongue, exaggerated gag, and jaw jerk reflexes). Diagnosis is mainly clinical and treatment mostly supportive with a poor prognosis. Life expectancy is around 1–3 years following diagnosis.

Liver failure results in decreased production of all proteins. This causes a decreased albumin: globulin ratio and coagulation dysfunction due to decreased production of coagulation factors. Decreased storage capacity and enzyme reduction affects glucose level regulation and also decreased bile production decreases fat absorption. Liver failure causes blood urea levels to rise due to decreased metabolism and conversion to more soluble forms.

Patients suffering from Addison’s disease have low aldosterone. Aldosterone increases Na+ absorption and excretion of K+. So in these patients there would be decreased Na+ and increased K+ levels.

Thiazides and beta-blockers have been most commonly linked to the development of diabetes mellitus.

Erythropoietin is necessary for normal Hb levels. Reduced levels of erythropoietin in renal failure leads to anaemia in these patients.

The respiratory depression and miosis in this patient indicate opiate poisoning. For this, the best treatment is naloxone.

Essential tremors are usually symmetrical and generalized. It often affects the head and the voice of the patient. Usually it is first noticed by first degree relatives. It is improved by benzodiazepines and beta blockers. On the other hand, Parkinsonism tends to develop in older patients. It is characterised by bradykinesia and rigidity. It improves by L-dopa and dopamine agonists. A simple test is to ask the patient to write a short sentence. Parkinsonism shows micrographiam whilst essential tremors will have tremulous writing.

Muscle weakness and the inability to climb the stairs are consistent with a diagnosis of polymyositis. The condition usually affects those between 30-50 years of age and individuals present with stiffness in the muscles closest to the trunk which gradually worsens over time. Difficulty swallowing may be experienced if the muscle in the oesophagus is affected.

In hyperemesis gravidarum, IV corticosteroids can be given to reduce vomiting, if the patient is not responding to standard anti emetics.

Coxsackie viruses are a group of RNA viruses with over 20 serotypes; depending on specific viral characteristics, these serotypes are further divided into groups A and B. Infection is associated with a wide range of symptoms, which are dependent on the exact serotype. Hand, foot, and mouth disease (HFMD) and herpangina are commonly caused by group A coxsackie viruses, while pleurodynia and myocarditis are caused by group B coxsackie viruses. Both groups may cause viral meningitis, conjunctivitis, or flu‑like symptoms. Diagnostic procedures and treatment should be tailored to the specific disease manifestation.
Coxsackie A :
Herpangina
Hand, foot, and mouth disease
Characteristics: highly contagious
Clinical presentation
General symptoms: fever, reduced general condition
Skin/mucosa
Maculopapular and partially vesicular rash on the hands and feet
Oral ulcers
Diagnosis: clinical
Treatment: symptomatic
Prognosis: almost always self‑limiting

Atrial septal defect (ASD) is one of the more commonly recognized congenital cardiac anomalies presenting in adulthood. ASD is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, size of the shunt, and associated anomalies, this can result in a spectrum of disease ranging from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, and even atrial arrhythmias.

With the routine use of echocardiography, the detection and, therefore, the incidence of ASD is increased compared to earlier incidence studies using catheterization, surgery, or autopsy for diagnosis. The subtle physical examination findings and often minimal symptoms during the first 2-3 decades of life contribute to a delay in diagnosis until adulthood, the majority (more than 70%) of which is detected by the fifth decade of life.

Haematuria and abdominal swelling may indicate either polycystic kidney disease or a tumour. Because of the patient’s age, the likelihood of a tumorous growth is small, thus an ultrasound is the best choice for this case.

Polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness in older persons, generally is treated with prednisone. Dosages of 15 to 25 mg of prednisone per day can reduce inflammation considerably, although many patients relapse when therapy is tapered. Long-term (18 to 36 months) steroid treatment has been recommended by several studies, but this can result in multiple side effects, including osteoporosis, hypertension, cataracts, and hyperglycaemia. Methotrexate has been used to reduce inflammation in rheumatoid arthritis, systemic vasculitis, and giant cell arteritis, and in some studies has been combined with prednisone to treat polymyalgia rheumatica, decreasing the duration of treatment.

Testicular teratomas are best monitored with the following tumour markers: Alpha-fetoprotein (AFP), beta-hCG, and PLAP (placental like isoenzyme of alkaline phosphatase). For ovarian tumours, we use CA125, pancreatic tumours we use CA19-9, CA15-3 for breast carcinoma and carcinoembryonic antigen (CEA) for colonic tumours.

This presentation is known as ‘Saturday night palsy’. When someone falls asleep with a arm hanging over the arm rest of a chair, the radial nerve compresses and causes wrist drop and loss of sensation at the web of the thumb.

The patient has a history of MI and thus ischemic heart disease. This together with her age and progressive decline in cognitive functions and memory suggest vascular dementia.
Pick’s dementia presents with personality and behavioural changes.
Lewy body dementia is associated with frequent syncopal episodes, while Huntington’s disease presents with gait abnormalities.
Alzheimer’s dementia usually starts before the age of 65 and an ischemic heart disease history is not necessary.

These symptoms represent hemiballismus which is common in diabetic patients after the infarction of contralateral subthalmic nucleus. These symptoms are usually present during activity phase and resolve while resting.

The most common adverse effect of lithium is fine hand tremors. It is also an early sign of toxicity.

Photosensitivity is a common adverse effect of cardiology drugs including amiodarone and thiazide diuretics. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin 2 receptor blockers (A2RBs) commonly also cause rashes only some of which appear to be photosensitive.

People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive immunoglobulin. Intramuscular immunoglobulin should be given to all infants younger than 12 months of age who have been exposed to measles. For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure.

From the given answers, IBD and IBS are the causes for chronic diarrhoea. Pyelonephritis and ureteric colic are associated with urinary symptoms. Tenderness of pyelonephritis is at the loin region. Perianal disease is associated with fifty percent of patients with Crohn’s disease.

Cholecystokinin is synthesized and secreted by enteroendocrine cells in the duodenum, the first segment of the small intestine, and causes the release of digestive enzymes and bile from the pancreas and gallbladder, respectively. It also acts as a hunger suppressant. Release of CCK is stimulated by monitor peptide released by pancreatic acinar cells as well as CCK-releasing protein, a paracrine factor secreted by enterocytes in the gastrointestinal mucosa. In addition, release of acetylcholine by the parasympathetic nerve fibers of the vagus nerve also stimulate its secretion.

Duchenne muscular dystrophy has an X-linked recessive pattern of inheritance. Since the first son is affected by the disease, it means that the mother is a carrier. The male children will inherit the Y chromosome from their father and the X chromosome from their mother, having 50% chances of inheriting the X chromosome with the affected gene.

Old age, persistent backache, weight loss, and osteosclerotic lesions make prostatic adenocarcinoma the most likely diagnosis. The sequelae include severe pain, pathological fractures, hypercalcemia and cord compression. Prostatic adenocarcinoma is detected by elevated levels of prostate specific antigen. Positive serology for borrelia burgdorferi would hint at Lyme disease which does not cause osteosclerotic bone lesions, neither would Neisseria gonorrhoeae have such a presentation.

Cervical cancer results from genital infection with HPV. PV infections can be transmitted via nonsexual routes, but the result from sexual contact. So the best contraceptive method in relation to prevention of cervical cancer is the barrier method. But it will not prevent cervical cancer a 100%.

Portal venous pressure is the blood pressure in the hepatic portal vein, and is normally between 5-10 mmHg

Pregnant women need to get enough folic acid. The vitamin is important to the growth of the foetus’s spinal cord and brain. Folic acid deficiency can cause severe birth defects known as neural tube defects. The Recommended Dietary Allowance (RDA) for folate during pregnancy is 600 micrograms (µg)/day.

A history of measles, whooping cough, or other severe lung infections like tuberculosis (TB) and pneumonia can lead to airway damage and possibly bronchiectasis.

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

A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. The fracture is usually transverse or oblique and above the medial and lateral condyles and epicondyles. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. They are historically associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. Important arteries and nerves ( median nerve, radial nerve, brachial artery, and ulnar nerve) are located at the supracondylar area and can give rise to complications if these structures are injured. Most vulnerable structure to get damaged is Median Nerve. Damage/occlusion of the brachial artery is the cause of an absent radial pulse.

Acamprosate (calcium acetyl-homotaurine) helps to restore the normal activity of glutaminergic neurons, which usually become hyperexcited following chronic alcohol exposure.

The patient is in an altered psychological state; thus, no verbal nor a written consent is required from her. Consent from the carer or the court of law can be obtained but this will require some time while a prompt action is needed in this case and the carer is also unable to make a decision on the behalf of the patient. Therefore, the doctor should act without consent.

Many of the symptoms favour blast cells: the patient’s young age; a reoccurring sore throat caused by neutropenia and abnormal lymphoblasts; pale conjunctiva due to reduced production of red blood cells (this is because the marrow has been occupied by blast cells). There are no risk factors present for aplastic anaemia, and congenital aplastic anaemia would present itself earlier in life. A bone marrow aspiration would be needed to confirm the diagnosis.

Chronic alcoholism leads to increased levels of uric acid in the blood. Gout is caused by high levels of uric acid.

People with Systemic Juvenile Idiopathic Arthritis (also known as Stills disease) can have recurrent fevers, a macular rash, joint pain, joint deformities, an enlarged liver and/or spleen, and can occasionally have polyserositis, lung involvement or pericardial effusions. Rheumatoid factor and antinuclear antibodies are usually negative. Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) and the prognosis is better than for adult rheumatoid arthritis.
In pauciarticular Still’s disease, antinuclear antibodies are present. Large joints are affected and most patients develop classic features of seronegative spondylarthritis.

Weight loss is most commonly linked to hyperthyroidism. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea. In this scenario, we would carry out thyroid function tests.

History is suggestive of right sided tension pneumothorax. It can’t be a simple pneumothorax because of tracheal deviation and engorged veins.

Patients with cirrhosis are mostly hyponatraemic due to increased water retention.

Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.

Confusion and disorientation indicate that the patient has grade 3 hepatic encephalopathy. According to King’s College criteria for liver transplantation low pH (< 7.3), features of acute kidney injury (creatinine > 3.4 mg/dL), grade 3-4 hepatic encephalopathy and coagulopathy (INR >6.5 ) are positive criteria for this patient.

In secretory OM, effusion in the middle ear is present which does not produce any pain to the patient in comparison to acute OM which produces otalgia. The family members are the ones to notice hearing loss as the patient usually is not aware of it. On otoscopy, the features described in the question are prominent. Otitis externa is usually painful and it also produces an itching sensation. Chronic otitis media is painful and may interfere with balance problems. Cholesteatoma is an abnormal cystic growth in the middle ear that usually discharges foul-smelling fluids and as it grows, otalgia can appear.

Respiratory depression is the most well-known and dangerous side-effect of opioid analgesics. The prevalence of such side effects is influenced by the extent of disease, the patient’s age, the presence of coexistent renal and hepatic disease, pulmonary disease, and cognitive dysfunction, a prior opioid history, use of polypharmacy, dose of opioid drug being administered, and the route of administration. Anticholinergics are usually given for the respiratory symptoms.

The history is suggestive of acute Epididymo-orchitis. The treatment option is antibiotics.

Gentamicin is a nephrotoxic agent. Its dose should be monitored carefully in elderly or renal patients. If gentamicin starts accumulating in the body (above 2mg/L) then the next dose of gentamicin should be stopped. Otherwise it may cause acute tubular necrosis of the kidneys. Hepatotoxicity, retinopathy, peripheral neuropathy and encephalopathy are not usually associated with gentamicin toxicity.

According to WHO, initial pain management for patients with malignancy involves NSAIDs and weak opioids. After their pain stops responding to them, stronger opioids such as oxycodone and morphine are prescribed.

Palpitations can be due to many reasons. As palpitations are not constant in this case, a 24 hr ECG is important to isolate these episodes and find any cardiac cause. Drugs depend on the cause for the palpitations.

This patient is suffering from pancreatitis. Points favouring pancreatitis includes alcoholism, past history of gallstones and state of shock. Serum lipase and amylase should be performed to rule out the disease.

Haemolytic Uremic Syndrome affects children and is characterised by abdominal pain, a purpuric rash over the body, generalized pallor, haematuria and bloody diarrhoea. There is always a history of preceding diarrhoea caused usually by E.coli and it affects the renal system causing haematuria and deranged renal function tests.

Campylobacter is the most likely cause of diarrheal illness often due to undercooked meat being ingested. It is also a major cause of traveller’s diarrhoea. Sufficient fluid replacement and anti-emetics are indicated first followed by the antibiotic, Erythromycin although antibiotic treatment in adults is still in question. Ciprofloxacin and Tetracycline may also be effective.

Prochlorperazine is an anti-sickness drug which acts to reduce the impact of the abnormal signals coming from the balance organ helping to relieve the symptoms of nausea, vomiting and vertigo associated with Meniere’s disease, labyrinthitis and other inner ear disorders. It is a prescription only medication available as a tablet, injection and buccal preparation. It is usually taken as needed, rather than on a regular basis. Prochlorperazine affects the dopamine receptors in an area of the brain that controls nausea and vomiting. Prochlorperazine controls nausea and vomiting by blocking dopamine receptors found in the trigger zone and prevents it from sending messages to the vomiting centre that would otherwise cause nausea and vomiting.