The bronchial circulation is part of the systemic circulation and receives about 2% of the cardiac output from the left heart. Bronchial arteries arise from branches of the aorta, intercostal, subclavian or internal mammary arteries. The bronchial arteries supply the tracheobronchial tree with both nutrients and O2. It is complementary to the pulmonary circulation that brings deoxygenated blood to the lungs and carries oxygenated blood away from them in order to oxygenate the rest of the body.

A 1 day history suggests the purulent discharge is due to acute inflammation. Acute inflammation has 3 features:
1) the affected area is occupied by a purulent discharge composed of proteins, fluids and cells from local blood vessels
2) the infective agent i.e. bacteria is present in the affected area
3) the damaged tissue can be liquified and the debris removed from the site.
If the inflammation lasts over weeks or months, then it is termed as chronic inflammation.
Granulomatous inflammation is characterised by the presence and formation of granulomas.
Exudate is not a feature of resolution or a complication of inflammation.
Abscess formation takes more than 1 day to form and is usually within a capsule/cavity.

A pancreatic pseudocyst is a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue, typically located in the lesser sac of the abdomen. Pancreatic pseudocysts are usually complications of pancreatitis, although in children they frequently occur following abdominal trauma. Pancreatic pseudocysts account for approximately 75% of all pancreatic masses.
Signs and symptoms of pancreatic pseudocyst include abdominal discomfort and indigestion.

Diagnosis of Pancreatic pseudocyst can be based on cyst fluid analysis:
Carcinoembryonic antigen (CEA) and CEA-125 (low in pseudocysts and elevated in tumours);
Fluid viscosity (low in pseudocysts and elevated in tumours);
Amylase (usually high in pseudocysts and low in tumours)

The most useful imaging tools are:

-Ultrasonography – the role of ultrasonography in imaging the pancreas is limited by patient habitus, operator experience and the fact that the pancreas lies behind the stomach (and so a gas-filled stomach will obscure the pancreas).
-Computerized tomography – this is the gold standard for initial assessment and follow-up.
-Magnetic resonance cholangiopancreatography (MRCP) – to establish the relationship of the pseudocyst to the pancreatic ducts, though not routinely used.

Dicloxacillin is a narrow-spectrum beta-lactam antibiotic. It is used to treat infections caused by susceptible Gram-positive bacteria and most effective against beta-lactamase-producing organisms such as Staphylococcus aureus. To decrease the development of resistance, dicloxacillin is recommended to treat infections that are suspected or proven to be caused by beta-lactamase-producing bacteria.

Answer: Adrenaline 1:1000 IM

Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. IM Injection:

Adults: The usual dose is 500 micrograms (0.5ml of adrenaline 1/1000). If necessary, this dose may be repeated several times at 5-minute intervals according to blood pressure, pulse and respiratory function.

Additional measures

Beta2-agonists for bronchospasm: administer salbutamol or terbutaline by aerosol or nebuliser.

Antihistamines: administer both H1and H2receptor blockers slowly intravenously:
promethazine 0.5-1 mg/kg
and
ranitidine 1 mg/kg or famotidine 0.4 mg/kg or cimetidine 4 mg/kg
Corticosteroids: administer intravenously: hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg
Nebulised adrenaline (5 mL of 1:1000) may be tried in laryngeal oedema and often will ease upper airways obstruction. However, do not delay intubation if upper airways obstruction is progressive.

Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils. The classic form involves prior sensitization to an allergen with later reexposure, producing symptoms via an immunologic mechanism.

Anaphylaxis most commonly affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. The skin or mucous membranes are involved in 80-90% of cases. A majority of adult patients have some combination of urticaria, erythema, pruritus, or angioedema. However, for poorly understood reasons, children may present more commonly with respiratory symptoms followed by cutaneous symptoms. It is also important to note that some of the most severe cases of anaphylaxis present in the absence of skin findings.

Initially, patients often experience pruritus and flushing. Other symptoms can evolve rapidly, such as the following:

Dermatologic/ocular: Flushing, urticaria, angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, and swelling

Respiratory: Nasal congestion, coryza, rhinorrhoea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnoea

Cardiovascular: Dizziness, weakness, syncope, chest pain, palpitations

Gastrointestinal: Dysphagia, nausea, vomiting, diarrhoea, bloating, cramps

Neurologic: Headache, dizziness, blurred vision, and seizure (very rare and often associated with hypotension)

Other: Metallic taste, feeling of impending doom

Factor XIII, also known as fibrin stabilizing factor, is an enzyme of the coagulation cascade that crosslinks fibrin. Deficiency of FXIII may cause bleeding tendency but paradoxically, it may also predispose to thrombosis.

Antibody-mediated rejection (AMR) is defined as allograft rejection caused by antibodies of the recipient directed against donor-specific HLA molecules and blood group antigens. Although the mechanism by which HLA I antibodies promote inflammation and proliferation has been revealed by experimental models, the pathogenesis of HLA II antibodies is less defined. Antibodies to HLA II frequently accompany chronic rejection in renal transplants. AMR has been recognized as the leading cause of graft loss after kidney transplant if there is a donor-host antigenic disparity. Antibodies can be produced against epitopes of the antigen that differ from self by as little as one amino acid. Pre-existing antibodies or the development of de novo antibodies after transplantation has become a biomarker for AMR graft loss. HLA antibodies are risk factors for hyperacute, acute, and chronic allograft rejections.

The specificity of HLA antibodies can be determined using single-antigen luminex beads that consist of fluorescent microbeads conjugated to single recombinant HLA class I and class II molecules. Complement-fixing ability would be assessed by the binding of C1q to HLA antibodies present in the serum. In several studies, C1q-positive DSA had associated with antibody-mediated rejection in renal transplantation compared with antibodies identified only by IgG. Complement-fixing ability is relevant to hyperacute and acute rejections. Hyperacute rejection is predominantly complement-mediated severe allograft injury occurring within hours of transplantation. It is caused by high titre of pre-existing HLA or non-HLA antibodies in presensitized patients. But the incidence of hyperacute rejection is reduced due to improved DSA detection methods and desensitization protocols.

Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. EDH results from a traumatic head injury, usually with an associated skull fracture and arterial laceration. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the haemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient’s preoperative neurologic condition.

Birds, with their broad geographic ranges and close association with humans, have historically played an important role as carriers of human disease and as reservoirs for drug-resistant bacteria.
The highest diversity of bacteria were found on birds in natural habitats. The most frequently reported bacteria were Escherichia coli, Salmonella enterica, and Campylobacter jejuni. Of the bacteria species reported, 54% have shown pathogenicity toward humans. Percentage-wise, more pathogens were found in tropical (vs. temperate) habitats and natural (vs. suburban, urban, or agricultural) habitats.

Campylobacter jejuni is usually the most common cause of community-acquired inflammatory enteritis.

The symptoms and severity of the gastroenteritis produced can vary.
Patients may have a history of ingestion of inadequately cooked poultry, unpasteurized milk, or untreated water. The incubation period is 1-7 days and is probably related to the dose of organisms ingested.
A brief prodrome of fever, headache, and myalgias lasting up to 24 hours is followed by crampy abdominal pain, fever as high as 40°C, and as many as 10 watery, frequently bloody, bowel movements per day. Fever, which develops in more than 90% of patients, maybe low or high grade and can persist for a week.
Patients with C jejuni infection who report vomiting, bloody diarrhoea, or both tend to have a long illness and require hospital admission.
Abdominal pain and tenderness may be localized. Pain in the right lower quadrant may mimic acute appendicitis (pseudo appendicitis).
Tenesmus occurs in approximately 25% of patients.

The efferent lymphatics from the anal canal proceed to the internal iliac lymph nodes. This would most likely form the site of enlargement in the lymphatics.

Sodium nitroprusside is a potent peripheral vasodilator that affects both arterioles and venules. It is often administered intravenously to patients who are experiencing a hypertensive emergency. It reduces both total peripheral resistance as well as venous return, so decreasing both preload and afterload. For this reason it can be used in severe cardiogenic heart failure where this combination of effects can act to increase cardiac output. It is administered by intravenous infusion. Onset is typically immediate and effects last for up to ten minutes. The duration of treatment should not exceed 72 hours.

Infection by Ascaris lumbricoides usually occurs after individuals have visited places like sub-Saharan Africa or the Far East. Unlike Ancylostoma duodenale infection, there is usually an evidence of both worms and eggs in the stool. The absence of pruritus makes Enterobius vermicularis less likely.

Ascariasis occurs due to infection with a roundworm Ascaris lumbricoides. It begins in the gut following ingestion, then penetrates the duodenal wall to migrate to the lungs, is coughed up and swallowed, and the cycle begins again.

Diagnosis is made by identification of worms or eggs within the faeces. Treatment is with mebendazole.

Typical pilonidal sinus disease (PSD) occurs in the natal cleft i.e. sacrococcygeal region.
However, some occupation related pilonidal sinuses occurs in webs of fingers e.g. hairdresser, sheep shearer, dog groomer, slaughterman or milker.
Other locations where pilonidal sinuses may occur include penis shaft, axilla, intermammary area, groin, nose, neck, clitoris, suprapubic area, occiput, prepuce, chin, periungual region, breast, face and umbilicus.

Although the pilonidal disease may manifest as an abscess, a pilonidal sinus, a recurrent or chronic pilonidal sinus, or a perianal pilonidal sinus, the most common manifestation of pilonidal disease is a painful, fluctuant mass in the sacrococcygeal region.
Initially, 50% of patients first present with a pilonidal abscess that is cephalad to the hair follicle and sinus infection. Pain and purulent discharge from the sinus tract is present 70-80% of the time and are the two most frequently described symptoms. In the early stages preceding the development of an abscess, only cellulitis or folliculitis is present. The abscess is formed when a folliculitis expands into the subcutaneous tissue or when a pre-existing foreign body granuloma becomes infected.
The diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, which can be palpated as an area of deep induration beneath the skin in the sacral region. These tracts most commonly run in the cephalad direction. When the tract runs in the caudal direction, perianal sepsis may be present.

The ideal treatment for a pilonidal sinus varies according to the clinical presentation of the disease. First, it is important to divide the pilonidal disease into the following three categories, which represent different stages of the clinical course:
– Acute pilonidal abscess
– Chronic pilonidal disease
– Complex or recurrent pilonidal disease

Acute pilonidal abscess:
A pilonidal abscess is managed by incision, drainage, and curettage of the abscess cavity to remove hair nests and skin debris. This can be accomplished in the surgical office or the emergency department, using local anaesthesia.
If possible, the drainage incision should be made laterally, away from the midline. Wounds heal poorly in the deep, intergluteal natal cleft, for two reasons. The first is the frictional motion of the deep cleft, which creates continuous irritation to the healing wound; the second is the midline nature of the wound, which is a product of constant lateral traction during sitting.

Chronic pilonidal disease is the term applied when patients have undergone at least one pilonidal abscess drainage procedure and continue to have a pilonidal sinus tract. The term also refers to a pilonidal sinus that is associated with a chronic discharge without an acute abscess. Surgical options for management of a noncomplicated chronic pilonidal sinus include the following:
Excision and laying open of the sinus tract
Excision with primary closure
Wide and deep excision to the sacrum
Incision and marsupialization
Bascom procedure
Asymmetrical incisions
Skin flaps have also been described to cover a sacral defect after wide excision. Similarly, this keeps the scar off the midline and flattens the natal cleft.

At the base of the skull the foramen ovale is one of the larger of the several holes that transmit nerves through the skull. The following structures pass through foramen ovale: mandibular nerve, motor root of the trigeminal nerve, accessory meningeal artery, lesser petrosal nerve, a branch of the glossopharyngeal nerve, emissary vein connecting the cavernous sinus with the pterygoid plexus of veins and occasionally the anterior trunk of the middle meningeal vein.

The atmospheric pressure is lower at high altitudes as compared with sea level. This leads to a decrease in the partial pressure of oxygen. Once 2100 m (7000 feet) of altitude is reached, there is a drop in saturation of oxyhaemoglobin. The oxygen saturation of haemoglobin determines the oxygen content in the blood. The body physiological tries to adapt to high altitude by acclimatization. Immediate effects include hyperventilation, fluid loss (due to a decreased thirst drive), increase in heart rate and slightly lowered stroke volume. Long term effects include lower lactate production, compensatory alkali loss in urine, decrease in plasma volume, increased erythropoietin release and red cell mass, increased haematocrit, higher concentration of capillaries in striated muscle tissue, increase in myoglobin, increase in mitochondria, increase in aerobic enzyme concentration such as 2,3-DPG and pulmonary vasoconstriction.

The medial umbilical fold is made by the medial umbilical ligament-which is the obliterated portion of the umbilical artery, while the lateral umbilical fold is a fold of peritoneum over the inferior epigastric vessels. The median umbilical fold is a midline structure made by the median umbilical ligament i.e. the obliterated urachus. The medial inguinal fossa is the space on the inner abdominal wall between the medial umbilical fold and the lateral umbilical fold. It is place in the abdominal wall where there is an area of weak fascia i.e. the inguinal triangle through which direct inguinal hernias break through. The lateral inguinal fossa on the other hand is a space lateral to the lateral umbilical fold. Indirect inguinal hernias push through this space.

The radial artery branches into the arteria princeps pollicis as it turns medially into the deep part of the hand. The arteria princeps pollicis is distributed to the skin and subcutaneous tissue of the thumb.

After a patient has undergone total colectomy and ileostomy, the volume of ileal discharge, along with its water content gradually decreases over time. Post surgery, most patients can live a normal life. Iron and vitamin B12 absorption do not take place in the colon and hence are not affected significantly by a colectomy.

The glossopharyngeal nerve, known as the ninth cranial nerve (CN IX), is a mixed nerve that carries afferent sensory and efferent motor information. The glossopharyngeal nerve has five distinct general functions:
– The branchial motor (special visceral efferent), supplies the stylopharyngeus muscle.
– The visceral motor (general visceral efferent), provides parasympathetic innervation of the parotid gland via the otic ganglion.
– The visceral sensory (general visceral afferent), carries visceral sensory information from the carotid sinus and carotid body.
– The general sensory (general somatic afferent), provides general sensory information from the inner surface of the tympanic membrane, upper pharynx (GVA), and the posterior one-third of the tongue.
– The visceral afferent (special visceral afferent), provides taste sensation from the posterior one-third of the tongue, including the circumvallate papillae.

QT interval extends from beginning of the QRS complex till the end of he T-wave and normally lasts for 0.40 s. It is important in the diagnosis of long-QT and short-QT syndrome. The QT interval varies on the basis of heart rate and may need to be corrected.

The vagus nerve (cranial nerve X) innervates both the palatoglossus and levator veli palatini muscles.

Situated at the upper part of the thorax beneath the pectoralis major, is a thin pectoralis minor, triangular muscle. It originates from the third, fourth and fifth ribs, near the cartilage and from the aponeurosis which covers the intercostals. These fibres move upwards and laterally to join and form a flat tendon. This is inserted into the medial border and upper surface of the coracoid process of the scapula. Through this medial anterior thoracic nerve, fibres from the pectoralis minor are received from the eighth cervical and first thoracic nerves. This pectoralis minor pushes down on the point of the shoulder (glenoid fossa), drawing the scapula downward and medially towards the thorax which throws the inferior angle backwards.

Staghorn calculi refer to branched stones that fill all or part of the renal pelvis and branch into several or all of the calyces. They are most often composed of struvite (magnesium ammonium phosphate) and/or calcium carbonate apatite. These stones are often referred to as ‘infection stones’ since they are strongly associated with urinary tract infections with urea splitting organisms. Small struvite and/or calcium carbonate apatite stones can grow rapidly over a period of weeks to months into large staghorn calculi involving the calyces and entire renal pelvis. If left untreated, this can lead to deterioration of kidney function and end-stage renal disease. In addition, since the stones often remain infected, there is a risk of developing sepsis. Thus, most patients require definitive surgical treatment.

Struvite stones account for 15% of renal calculi. They are associated with chronic urinary tract infection (UTI) with gram-negative, urease-positive organisms that split urea into ammonia, which then combines with phosphate and magnesium to crystalize into a calculus. Usual organisms include Proteus, Pseudomonas, and Klebsiella species. Escherichia coli is not capable of splitting urea and, therefore, is not associated with struvite stones. Because ammonia, a base, is produced during the catalytic process, the urine pH is typically greater than 7.
Underlying anatomical abnormalities that predispose patients to recurrent kidney infections should be sought and corrected. UTI does not resolve until the stone is removed entirely.
This patient has a urine pH of 7.8 which is very alkaline.

Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at the sites of previous trauma.

Dermatofibromas are small, noncancerous (benign) skin growths that can develop anywhere on the body but most often appear on the lower legs, upper arms, or upper back. These nodules are common in adults but are rare in children. They can be pink, grey, red, or brown in colour and may change colour over the years. They are firm and often feel like a stone under the skin. When pinched from the sides, the top of the growth may dimple inward. These lesions feel larger than they appear visually.

Dermatofibromas are usually painless, but some people experience tenderness or itching. Most often, a single nodule develops, but some can develop numerous dermatofibromas.

Hypovolemia will result in the activation of the sympathetic adrenal discharge resulting is a decrease pulmonary artery pressure and an elevated pulmonary vascular resistance.

Cerebellar disease leads to intention tremors, which is absent at rest and appears at the onset of voluntary movements. In comparison, Parkinson’s tremor is present at rest. Frequency of tremor is a less reliable means to differentiate between the two as the oscillation amplitude of the tremor is not constant throughout a voluntary action.

The sinus venosus is a large quadrangular cavity which precedes the atrium on the venous side of the chordate heart. It exists distinctly only in the embryonic heart (where it is found between the two venae cavae); however, the sinus venosus persists in the adult. In the adult, it is incorporated into the wall of the right atrium to form a smooth part called the sinus venarum, which is separated from the rest of the atrium by a ridge of fibres called the crista terminalis. The sinus venosus also forms the SA node and the coronary sinus.

Hodgkin’s lymphoma is a disease characterized by malignant proliferation of cells of the lymphoreticular system. It can be localized or disseminated, and can involve the nodes, spleen, liver and marrow. Symptoms of the disease include non-tender lymphadenopathy, fever, night sweats, weight loss, itching and hepatosplenomegaly. Histologically, the involved nodes show the presence of Reed-Sternberg cells, which are large, binucleated cells, in a heterogenous cellular infiltrate of histiocytes, lymphocytes, monocytes, plasma cells and eosinophils.

Perihepatic packing is a surgical procedure used in connection with surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.

During this surgery laparotomy pads are placed around the site of the bleeding. The main purpose of hepatic packing is to prevent the person from succumbing to the trauma triad of death. Under- or over-packing of the liver can cause adverse outcomes, and if the bleeding cannot be controlled through this surgical method, the Pringle manoeuvre is an alternate technique that can be utilized.

Rebleeding, constant decline of haemoglobin and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels are a few factors which indicate the need for laparotomy.

The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt.

Malignant hyerpyrexia occurs in 1 in 150,000. All inhalational anaesthetic agents and suxamethonium, except nitrous oxide can cause malignant hyperpyrexia.

The costodiaphragmatic recess is the part of the pleural cavity where the costal pleura is in continuity with the diaphragmatic pleura. It forms the lowest extent of the pleural cavity.
Costomediastinal recess: a tiny recess that is anteriorly located, where the costal pleura becomes continuous with the mediastinal pleura.
The cupola is the pleural cavity that extends above the first rib.
The inferior mediastinum refers to the posterior, middle and anterior mediastinal divisions together.
The pulmonary ligament on the other hand, is a pleural fold that is situated beneath the root of the lung on the medial aspect of the lung.
Oblique pericardial sinus is not part of the pleural cavity.

Cheyne-Stokes breathing is an abnormal breathing pattern with breathing periods of gradually waxing and waning tidal volumes, with apnoeic periods interspersed. It is usually the first breathing pattern to be seen with a rise in intracranial pressure and is caused by failure of the respiratory centre in the brain to compensate quickly enough to changes in serum partial pressure of oxygen and carbon dioxide. The aetiology includes strokes, head injuries, brain tumours and congestive heart failure. It is also a sign of altitude sickness in normal people, a symptom of carbon monoxide poisoning or post-morphine administration. Biot’s respiration (cluster breathing) is characterized by cluster of quick, shallow inspirations followed by regular or irregular periods of apnoea. It is different from ataxic respiration, which has completely irregular breaths and pauses. It results due to damage to the medulla oblongata by any reason (stroke, uncal herniation, trauma) and is a poor prognostic indicator. Kussmaul breathing, also known as ‘air hunger’, is basically respiratory compensation for metabolic acidosis and is characterized by quick, deep and laboured breathing. It is most often seen in in diabetic ketoacidosis. Due to forced inspiratory rate, the patients will show a low p(CO2). Ondine’s curse is congenital central hypoventilation syndrome or primary alveolar hypoventilation, which can be fatal and leads to sleep apnoea. It involves an inborn failure to control breathing autonomically during sleep and in severe cases, can affect patients even while awake. It is known to occur in 1 in 200000 liveborn children. Treatment includes tracheostomies and life long mechanical ventilator support.

The large intestine doesn’t have a continuous layer of longitudinal muscle. Instead, it has three strips of longitudinal muscle called taenia coli. The large intestine is covered with omental appendages that are fat filled. It is also folded into sacculations called haustrations. Serosa is a general term for the outermost coat or serous layer of a visceral structure that lies in the body cavities of the abdomen or thorax.
Complete circular folds are only found in the small intestine.
Valvulae conniventes or valves of Kerckring are the circular folds which are large valvular flaps projecting into the lumen of the small bowel.

Hyperphosphatemia is an electrolyte disturbance in which there is an abnormally elevated level of phosphate in the blood. It is caused by conditions that impair renal phosphate excretion (ex: renal insufficiency, hypoparathyroidism, parathyroid suppression) and conditions with massive extracellular fluid phosphate loads (ex: rapid administration of exogenous phosphate, extensive cellular injury or necrosis, transcellular phosphate shifts).

The moderator band extends from the base of the anterior papillary muscle to the ventricular septum. It is the structure which carries part of the right AV bundle. Its role it to prevent overdistention of the ventricle.

Excessively high levels of prolactin in the blood is called hyperprolactinaemia. Normally, prolactin levels are less than 580 mIU/l in females and less than 450 mIU/l in men. The biologically inactive macroprolactin can lead to a false high reading. However, the patient remains asymptomatic. Dopamine down-regulates prolactin whereas oestrogen upregulates it. Hyperprolactinaemia can be caused due to lack of inhibition (compression of pituitary stalk or low dopamine levels), or increased production due to a pituitary adenoma (prolactinoma). Either of these causes can lead to a prolactin level of 1000-5000 mIU/l. However, levels more than 5000mIU/l are usually associated due to an adenoma and >100,000 mIU/l are seen in macroadenomas (tumours < 1cm in diameter). Increased prolactin causes increased dopamine release from the arcuate nucleus of hypothalamus. This increased dopamine in turn, inhibits the GnRH (Gonadotrophin Releasing Hormone) thus blocking gonadal steroidogenesis resulting in the symptoms of hyperprolactinaemia. In women, it includes hypoestrogenism, anovulatory infertility, decreased or irregular menstruation or complete amenorrhoea. It can even cause production of breast milk, loss of libido, vaginal dryness and osteoporosis. In men, the symptoms include impotence, decreased libido, erectile dysfunction and infertility. In men, treatment can be delayed due to late diagnosis as they have no reliable indicator such as menstruation that might indicate a problem. Most of the male patients seek help only when headaches and visual defects start to surface.

Cisterns refers to a system of intercommunicating pools formed by the subarachnoid space at the base of the brain and around the brainstem. Cisterna basalis/basal cistern (interpeduncular cistern) is found at the base of the brain between the two temporal lobes and it contains the arterial circle of Willis. The lumbar cistern is contained in the spinal canal while the foramen magna refers to the opening at the base of the skull though which the spinal cord enters into the skull.

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.

This patients is most likely experiencing an acute rejection. It is a cell mediated attack against the organ that has been transplanted. Antigens are either presented by blood borne cells with in the graft or antigen presenting cells in the body may be presenting class I and class II molecules that have been shed by the graft. Class I will activate CD8 and class II, CD4 cells, both of which will attack the graft.
Chronic rejection is a slow process which occurs months to years after the transplant. The exact mechanism is not very well understood but it probably involves a combination of Type III and Type IV hypersensitivity directed against the foreign MHC molecules which look like self-MHC presenting a foreign antigen.
Hyperacute Transplant Rejection occurs almost immediately and is often evident while you are still in surgery. It is caused by accidental ABO Blood type mismatching of the donor and recipient which almost never happens anymore. This means the host has preformed antibodies against the donated tissue.

Based on the history and examination findings, the correct diagnosis is false aneurysm of the femoral artery. It may occur following arterial trauma in intravenous drug users.

A false aneurysm, or pseudoaneurysm of the vessels, occurs when a blood vessel wall is injured and the leaking blood collects in the surrounding tissue. It is not an enlargement of any of the layers of the vessel wall. Pseudoaneurysms usually present as a painful, tender, pulsatile mass. Diagnostic options include duplex scan, and CT angiogram or a conventional angiogram.

In a true aneurysm, the artery or vessel weakens and bulges, usually forming a blood-filled sac.