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.

Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.

Surgical incision and drainage is the most common treatment for anal abscesses. About 50% of patients with an anal abscess will develop a complication called a fistula. Diabetes is a risk factor for an anal abscess.

Patients with a recent cerebrovascular incident (less than 60 days) are at very high risk of cardiac complications when under general anaesthesia. Complications like MI, heart failure and even death. Elective surgery should be postponed till stabilization of the cardiac condition is achieved.

History of fever is suggestive of an infective focus. A straight nasal bones excludes a nasal bone fracture. A nasal septal abscess is defined as a collection of pus between the cartilage or bony septum and it is an uncommon disease which should be suspected in a patient with acute onset of nasal obstruction and recent history of nasal trauma.

Bleeding oesophageal varices secondary to portal hypertension can cause a massive gastrointestinal haemorrhage resulting in shock. Perforated ulcer is less likely in this age group. Mallory Weiss tear would not likely result in a massive haemorrhage. Aorto-intestinal fistula is more common in older patients with abdominal aneurysms. Boerhaave’s syndrome is a result of a ruptured oesophagus following excessive vomiting.

Pneumonitis is a serious and unpredictable side-effect of treatment with methotrexate (MTX) that may become life-threatening. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxaemia and tachypnoea are always present and crackles are frequently audible. Chest radiography reveals a diffuse interstitial or mixed interstitial and alveolar infiltrate, with a predilection for the lower lung fields. Pulmonary function tests show a restrictive pattern with diminished diffusion capacity. Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar damage pattern accompanied by perivascular inflammation. Most patients present in the first few months of starting methotrexate. It is important that all patients receiving methotrexate be educated concerning this potential adverse reaction and instructed to contact their physicians should significant new pulmonary symptoms develop while undergoing therapy. If methotrexate pneumonitis is suspected, methotrexate should be discontinued, supportive measures instituted and careful examination for different causes of respiratory distress conducted. This may be treated with corticosteroids once underlying infection has been excluded.

The most appropriate test for a hydatiform mole is serum beta hCG levels, which are consistently raised in these patients. The levels return to normal when the pregnancy is terminated.

ACE inhibitors effectively reduce systemic vascular resistance in patients with hypertension, heart failure or chronic renal disease. This antihypertensive efficacy probably accounts for an important part of their long term renoprotective effects in patients with diabetic and non-diabetic renal disease. Systemic and renal haemodynamic effects of ACE inhibition, both beneficial and adverse, are potentiated by sodium depletion. Consequently, sodium repletion contributes to the restoration of renal function in patients with ACE inhibitor-induced acute renal failure. On the other hand, co-treatment with diuretics and sodium restriction can improve therapeutic efficacy in patients in whom the therapeutic response of blood pressure or proteinuria is insufficient. Patients at the greatest risk for renal adverse effects (those with heart failure, diabetes mellitus and/or chronic renal failure) also can expect the greatest benefit. Therefore, ACE inhibitors should not be withheld in these patients, but dosages should be carefully titrated, with monitoring of renal function and serum potassium levels. The optimum period to check this is one to two weeks after starting the medication.

SSRIs such as fluoxetine are commonly associated with delayed ejaculation.

Urologic injury is the most common injury at the time of either obstetric or gynaecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during caesarean section include previous caesarean delivery, adhesions, emergency caesarean delivery, and caesarean section performed during the second stage of labour.

Endometrial hyperplasia most often is caused by excess oestrogen without progesterone. If ovulation does not occur, progesterone is not made, and the lining is not shed. The endometrium may continue to grow in response to oestrogen. The cells that make up the lining may crowd together and may become abnormal. This condition, called hyperplasia, may lead to cancer in some women. Endometrial hyperplasia usually occurs after menopause, when ovulation stops and progesterone is no longer made. It also can occur during peri-menopause, when ovulation may not occur regularly. Listed as follows are other situations in which women may have high levels of oestrogen and not enough progesterone:
– Use of medications that act like oestrogen
– Long-term use of high doses of oestrogen after menopause (in women who have not had a hysterectomy)
– Irregular menstrual periods, especially associated with polycystic ovary syndrome or infertility
– Obesity

Transvaginal ultrasound may be done to measure the thickness of the endometrium. To exclude carcinoma an endometrial biopsy, dilation and curettage, or hysteroscopy may be done.

CMV infection is usually asymptomatic in adults. However, if the mother is infected for the first time during pregnancy then there is high chances of this infection passing on to the foetus. CMV infection can cause blindness, deafness, learning difficulties, restricted growth etc. Hepatitis B, herpes simplex, syphilis and HIV do not present with these classical signs of CMV infection in new-borns. It is estimated that 10 stillbirths occur in England and Wales every year due to CMV infection. The foetus is most at risk in early pregnancy. There is no effective prevention.

Carbamazepine and oxcarbazepine are the most common antiepileptics which induce hyponatremia in patients with epilepsy. Other antiepileptics such as eslicarbazepine, sodium valproate, lamotrigine, levetiracetam and gabapentin have also been reported to cause hyponatremia. So the most suitable answer is Carbamazepine.

The carotid artery divides itself into two parts: the internal carotid and the external carotid. The internal carotid continues down as the middle cerebral and gives rise to the ophthalmic branch. For this reason, middle cerebral occlusion may give rise to partial visual loss but not complete mono-ocular blindness. Middle cerebral artery occlusion causes paralysis or weakness of contralateral face and arm (faciobracheal). It also causes sensory loss of the contralateral face and arm. Anterior cerebral artery occlusion causes paralysis or weakness of the contralateral foot and leg. Again, sensory loss is experienced at the contralateral foot and leg.

From a metabolic perspective, the functional unit is the hepatic acinus (terminal acinus), each of which is centred on the line connecting two portal triads and extends outwards to the two adjacent central veins. The periportal zone I is nearest to the entering vascular supply and receives the most oxygenated blood, making it least sensitive to ischemic injury while making it very susceptible to viral hepatitis. Conversely, the centrilobular zone III has the poorest oxygenation, and will be most affected during a time of ischemia.

The ductus venosus is open at the time of the birth and closes during the first week of life in most full-term neonates; however, it may take much longer to close in pre-term neonates. After it closes, the remnant is known as ligamentum venosum. If the ductus venosus fails to occlude after birth, it remains patent (open), and the individual is said to have a patent ductus venosus and thus an intrahepatic portosystemic shunt (PSS).

All of the symptoms observed in this patient are typical of bronchial carcinoma.

A variety of proteins compose the structure of microfibrils, the most prominent of which are the two fibrillins. Fibrillin-1 a scaffolding protein is encoded by FBN1 on human chromosome 15q21 and fibrillin-2 is encoded by FBN2 on 5q23. Mutations in FBN1 produce Marfan syndrome, a pleiotropic autosomal dominant connective tissue disorder with prominent manifestations in the skeleton, eye and cardiovascular system. A number of conditions related to Marfan syndrome are also due to FBN1 mutations.

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 most commonly requested biochemistry tests for renal function are the urea and electrolytes. They supply important information when it comes to homeostasis and excretion. Glomerular filtration rate is also the essential standard marker of kidney health and is assessed by checking the creatinine levels. In this case as the child has lost fluids and electrolytes, this test will indicate the extent of the loss and allow for more appropriate replacement.

Corticosteroids are well known for their ocular complications such as glaucoma and cataracts.

Prolonged use of corticosteroids causes cataracts and this would be the reason for his presentation. B2 agonists, diuretics and Theophylline can cause blurred vision.

Scabies is a parasitic skin infestation caused by Sarcoptes scabiei mite, which is primarily transmitted via direct human-to-human contact. The female scabies mite burrows into the superficial skin layer, causing severe pruritus, particularly at night. Primary lesions commonly include erythematous papules, vesicles, or burrows. Treatment involves topical medical therapy (e.g. permethrin) and decontamination of all clothing and textiles.

Dysrhythmias are the most frequent MI complication. The patient seems to have a post MI atrial fibrillation which is treated, in an emergency context, with DC shock.

Between 9-12weeks of gestation, suction curettage is usually the most appropriate method of termination of pregnancy. Termination of pregnancy must be decided and performed as early as possible. An abortion after 24 weeks of gestation is illegal in the UK.

The main problem with infants having gastroenteritis is dehydration. So they should be admitted to the hospital for IV fluids if they are not tolerating oral fluids.

Congenital hypothyroidism is one of the most important diseases of the new-born, which may lead to mental and physical retardation when treatment is delayed or an appropriate dosage of thyroxine is not administered. The most alarming and earliest sign is jaundice, especially when it is prolonged, during the neonatal period.

Dominant R wave in V1 can be a normal variant in children and young adults. Other causes are right ventricular hypertrophy, pulmonary embolus, persistence of left to right shunt, Right Bundle Branch Block (RBBB), posterior myocardial infarction (ST elevation in Leads V7, V8, V9), Wolff-Parkinson-White (WPW) Type A, Incorrect lead placement (e.g. V1 and V3 reversed), dextrocardia, hypertrophic cardiomyopathy and dystrophy (myotonic dystrophy and Duchenne Muscular dystrophy).

Urticaria is a group of disorders that share a distinct skin reaction pattern, namely the occurrence of itchy wheals anywhere on the skin. Wheals are short-lived elevated erythematous lesions ranging from a few millimetres to several centimetres in diameter and can become confluent. The itching can be prickling or burning and is usually worse in the evening or night time. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear.

Turner’s syndrome is characterised by a webbed neck, short stature, primary amenorrhea and cardiac, renal and muscular defects. Gene analysis shows a single X chromosome in the patients. Downs syndrome has certain cognitive and physical abnormalities, whereas in Klinefelter syndrome there are widely spaced nipples, long arms and infertility and it only occurs in men.

Calcium-containing stones are relatively radio dense, and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder (KUB film). Some 60% of all renal stones are radiopaque. In general, calcium phosphate stones have the greatest density, followed by calcium oxalate and magnesium ammonium phosphate stones. Cystine calculi are only faintly radio dense, while uric acid stones are usually entirely radiolucent.

Uric acid is the relatively water-insoluble end product of purine nucleotide metabolism. It poses a special problem because of its limited solubility, particularly in the acidic environment of the distal nephron of the kidney. It is problematic because humans do not possess the enzyme uricase, which converts uric acid into the more soluble compound allantoin. Three forms of kidney disease have been attributed to excess uric acid: acute uric acid nephropathy, chronic urate nephropathy, and uric acid nephrolithiasis. These disorders share the common element of excess uric acid or urate deposition, although the clinical features vary.

Lithium is the medication used for a wide range of mental illnesses such as schizophrenia, depression, and bipolar disorders. It is famous for its side effects which includes a number of thyroid disorders (hypothyroidism, hyperthyroidism, and thyroiditis).

Ganser syndrome is a condition in which a person acts as if he is suffering from a specific psychological disorder in order to gain sympathy and relief.

The Afro-Caribbean population is found to have an increased sensitivity of blood pressure to salt intake as well as a reduced tendency to excrete the ingested salt, associated with low renin levels. ACE inhibitors will then be an ineffective group of anti-hypertensive drugs for this specific population.

A local exam might not help in locating the cause of the bleeding because it might be underneath the superficial structures. A thorough examination should be done under GA to accurately locate the source of bleeding.

Carcinoid syndrome is a paraneoplastic syndrome comprising of signs and symptoms that occur secondary to carcinoid tumours. Diarrhoea, dermatitis, bronchospasm and right sided cardiac valve lesions (tricuspid insufficiency and pulmonary stenosis) are characteristic of carcinoid syndrome.

Rheumatoid factor is an IgM antibody that targets the Fc portion of IgG.

Findings suggest a haemothorax which is very likely to happen, in the absence of a haemo-pneumothorax.

Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.