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.

Bursae are potential cavities that contain synovial fluid, found in areas where friction occurs. Their function is to minimise friction and facilitate movement. Bursitis is the inflammation of one or more bursae, and they can occur in the shoulder, elbow, knee, ischium, amongst other joints. Acute bursitis can appear after strenuous exercise or activity, and chronic bursitis can develop following previous bursitis or trauma. Acute bursitis causes pain, tenderness, and swelling.

With a constant blood flow to a given tissue bed, there will be an increase in oxygen extraction by the tissue with the following; an increase in tissue metabolism and oxygen requirements: warming (or fever), exercise, catecholamines and thyroxine. With cooling, the demand for oxygen decreases, leading to decreased oxygen extraction.

Carbimazole was not found to cause gynaecomastia.

Drugs frequently causing gynecomastia:
Antiandrogens – Bicalutamide, flutamide, finasteride, dutasteride
Antihypertensive – Spironolactone
Antiretroviral – Protease inhibitors (saquinavir, indinavir, nelfinavir, ritonavir, lopinavir), reverse transcriptase inhibitors (stavudine, zidovudine, lamivudine)
Environmental exposure – Phenothrin (antiparasitic)
Exogenous hormones – Oestrogens, prednisone (male teenagers)
Gastrointestinal drugs – H2 histamine receptor blockers (cimetidine)

Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE

M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide

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.

Adrenocortical carcinomas are rare tumours with reported incidence being only two in a million. However, they have a poor prognosis. These are large tumours and range from 4-10 cm in diameter. They arise from the adrenal cortex and 10% cases are bilateral. 50-80% are known to be functional, leading to Cushing syndrome. Even though the tumour affects both sexes equally, functional tumours are slightly commoner in women and non-functional tumours are commoner in men. As compared to women, men also develop this tumour at an older age and seem to have a poorer prognosis.

In atrial fibrillation, the abnormal atrial contraction can cause blood to stagnate in the left atrium and form a thrombus, which may then embolize. The patient’s history of AF suggest an embolic disease, which lead to his death.

Blood that bypasses the ventilated parts of lung and enters the arterial circulation directly is known as shunted blood. It happens in normal people due to mixing of arterial blood with bronchial and some myocardial venous blood (which drains into the left heart). Diffusion limitation and reaction velocity with haemoglobin are immeasurably small. CO2 unloading will not affect the difference between alveolar and arterial p(O2). A large VSD will result in much lower arterial O2 as compared to alveolar O2.

Usually a parasitic infection will be associated with a type I hypersensitivity reaction.
Amyloid deposition will not cause an immune reaction.
Organic dust will lead to a type III hypersensitivity reaction.
Cell mediated as well as humoral immune mechanism play a part in syphilis, but they are do not specifically cause a type I reaction.
Malaria is cause by plasmodium and is not cause of a hypersensitivity reaction.
Atopic dermatitis will not be accompanied by eosinophilia.

In the kidney, the macula densa is an area of closely packed specialised cells lining the region of the distal convoluted tubule (DCT) lying next to the glomerular vascular pole. The cells of the macula densa are sensitive to the ionic content and water volume of the fluid in the DCT, producing signals that promote renin secretion by other cells of the juxtaglomerular apparatus.

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.

Answer: Instillation of warmed intra peritoneal fluid

Hypothermia describes a state in which the body’s mechanism for temperature regulation is overwhelmed in the face of a cold stressor. Hypothermia is classified as accidental or intentional, primary or secondary, and by the degree of hypothermia.
Active central rewarming is the fastest and most invasive method of rewarming. It involves use of warm IV fluids, gastric lavage and peritoneal dialysis by warm fluids. Peritoneal dialysis can be safely done with crystalloid dialysate at 40 to 42°C and it raises the body temperature by 4 to 6°C/hour.

Ectoderm derivatives include the adrenal medulla, posterior pituitary, the epidermis of the skin, nails, hair, sweat glands, mammary glands, sebaceous glands, the central nervous system, the peripheral nervous system, the retina and lens of eye, the pupillary muscle of the iris, melanocytes, Schwann cells and odontoblasts.

Perhaps the most important aspect in the treatment of open fractures is the initial surgical intervention with irrigation and meticulous debridement of the injury zone. Irrigation, along with debridement, is absolutely crucial in the management of open fractures.
Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation—all vital principles of fracture fixation. Skeletal traction and external fixation are the quickest fixation constructs to employ. The use of skeletal traction should be reserved only for selected open fracture types (i.e., pelvis fractures and very proximal femur fractures) and if used, it should only be for a short selected time. External fixation is a valuable tool in the surgeon’s arsenal for acute open fracture management. Indications for external fixation are grossly contaminated open fractures with extensive soft-tissue compromise, the Type IIIA-C injuries, and when immediate fixation is needed for physiologically unstable patients.

The common carotid arteries are present on the left and right sides of the body. These arteries originate from different sources, but follow symmetrical courses. The right common carotid originates in the neck from the brachiocephalic trunk; the left from the aortic arch in the thorax. These split into the external and internal carotid arteries at the upper border of the thyroid cartilage, at around the level of the fourth cervical vertebra.

The Meckel’s diverticulum is a vestigial remnant of the omphalomesenteric duct. This structure is also referred to as the vitelline and contains two types of ectopic tissue, namely; gastric and pancreatic.

The patient has Denis B fracture, unstable fracture requiring open reduction and internal fixation (ORIF)
open reduction internal fixation indications:
– any talar displacement
– displaced isolated medial malleolar fracture
– displaced isolated lateral malleolar fracture
– bimalleolar fracture and bimalleolar-equivalent fracture
– posterior malleolar fracture with > 25% or > 2mm step-off
– Bosworth fracture-dislocations
– open fractures
– malleolar non-union

Danis-Weber classification:
type A
below the level of the talar dome
usually transverse
tibiofibular syndesmosis intact
deltoid ligament intact
medial malleolus occasionally fractured
usually stable if medial malleolus intact
type B
the distal extent at the level of the talar dome; may extend some distance proximally
usually spiral
tibiofibular syndesmosis usually intact, but a widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury
medial malleolus may be fractured
the deltoid ligament may be torn, indicated by a widening of the space between the medial malleolus and talar dome
variable stability, dependent on the status of medial structures (malleolus/deltoid ligament) and syndesmosis; may require ORIF
Weber B fractures could be further subclassified as 9
B1: isolated
B2: associated with a medial lesion (malleolus or ligament)
B3: associated with a medial lesion and fracture of the posterolateral tibia
type C
above the level of the ankle joint
tibiofibular syndesmosis disruption with a widening of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury often present
a fracture may arise as proximally as the level of the fibular neck and not visualized on ankle films, requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture)
unstable: usually requires ORIF
Weber C fractures can be further subclassified as 6
C1: diaphyseal fracture of the fibula, simple
C2: diaphyseal fracture of the fibula, complex
C3: proximal fracture of the fibula
a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint
usually associated with an injury to the medial side

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.

The basilic vein is one of two veins found in the forearm, the other is the cephalic vein. These veins originate from the deep venous arch of the hand. The cephalic vein ascends along the lateral side of the forearm, and the basilic vein runs up the medial side of the forearm.

The musculocutaneous nerve supplies the biceps brachii and the brachialis muscles. The first one flexes the elbow and the shoulder. It is also involved in supination. The brachialis muscle flexes the forearm. The injury to the musculocutaneous nerve results in paralysis of these muscles.

Allograft coronary artery disease (CAD) can begin right after the transplant and is the major cause of later death in cardiac transplant recipients. This form of atherosclerosis progresses quickly resulting in allograft failure. Due to lack of premonitory symptoms CAD may lead to sudden death.

The inferior alveolar nerve (sometimes called the inferior dental nerve) is a branch of the mandibular nerve, which is itself the third branch of the trigeminal nerve. The inferior alveolar nerves supply sensation to the lower teeth of the mandible.

Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm.

The classification of priapism is conventionally divided into three main groups. The commonest classification is into non‐ischaemic (high flow), ischaemic (low flow), and stuttering (recurrent) subtypes.

The EAU guidelines refer to the subtypes as ischaemic (low flow, veno‐occlusive) and arterial (high flow, non‐ischaemic). Of these, ischaemic priapism is the commonest, with refractory cases at risk of smooth muscle necrosis in the corpus cavernosum leading to sequelae of corporal fibrosis and erectile dysfunction (ED).

One of the key considerations in the management of priapism is the duration of the erection at presentation.
The EAU guidelines do differentiate the periods such that the intervention varies accordingly, which is particularly important for prolonged episodes that are refractory to pharmacological interventions and allow a step‐wise intervention.

Ischaemic priapism is a medical emergency as the progressive ischaemia within the cavernosal tissue is associated with time‐dependent changes in the corporal metabolic environment, which eventually leads to smooth muscle necrosis. As the duration of the penile erection becomes pathologically prolonged, as in the case of low‐flow priapism, the partial pressure of oxygen (pO2) progressively falls as the closed compartment prevents replenishment of stagnant blood with freshly oxygenated arterial blood.
Investigations using corporal blood aspiration, that in itself can be a therapeutic intervention leading to partial or complete penile detumescence, helps to differentiate ischaemic from non‐ischaemic priapism subtypes based on the pO2, pCO2 and pH levels. The AUA guidelines state that typically the blood gas analysis would give a pO2 of <30 mmHg and pCO2 of >60 mmHg and a pH of <7.25 in ischaemic priapism, whereas non‐ischaemic blood gas analysis would show values similar to venous blood. Once the diagnosis of priapism has been made, the initial management involves corporal blood aspiration followed by instillation of α‐agonists directly into the corpus cavernosum.
The EAU guidelines recommend several possible agents for intracavernosal injection, as well as oral terbutaline after intracavernosal injection.
Phenylephrine – 200 μg every 3–5 min to a maximum of 1 mg within 1 h.
Etilephrine – 2.5 mg diluted in 1–2 mL saline.
Adrenaline – 2 mL of 1/100 000 solution given up to 5 times in a 20‐min period.
Methylene blue – 50–100 mg intracavernosal injection followed by aspiration and compression.

Shunt surgery allows diversion of blood from the corpus cavernosum into another area such as the corpus spongiosum (glans or urethra) or the venous system (saphenous vein). Both the EAU and AUA guidelines recommend surgical intervention using firstly distal shunts and then proximal shunts in cases where aspiration and instillation of pharmacological agents fails to achieve penile detumescence. The EAU guidelines recommend that distal shunts should be attempted before proximal shunts, although the specific technique is left to the individual surgeon’s preference. The EAU guidelines also define a time point (36 h) when shunt surgery is likely to be ineffective in maintaining long‐term erectile function and may serve to reduce pain only. This is an important consideration when contemplating early penile prosthesis placement.

The lower leg is made up of four fascial compartments separated from one another by septa that contain the muscles of the lower leg. The four compartments are ; anterior, lateral, deep posterior and superficial posterior compartments.
These are the compartments and there contents:
i) Anterior compartment: Tibialis anterior muscle, extensor hallucis longus muscle, extensor digitorum longus muscle, peroneus tertius muscles, deep fibular nerve and anterior tibial blood vessels
ii) Lateral compartment: Fibularis longus muscle, brevis muscles and superficial fibular nerve
iii) Deep posterior compartment: Tibialis posterior m., flexor hallucis longus m., flexor digitorum longus m. ,popliteus m. , tibial nerve, posterior tibial artery and posterior tibial vessels such as the fibular artery.
iv) Superficial posterior compartment: Gastrocnemius m., soleus m., plantaris m., medial sural cutaneous nerve

The scaphoid bone is the most commonly fractured carpal bone and has an increased risk of avascular necrosis.
The lunate is the most commonly dislocated carpal bone. The displaced bone may compress the median nerve in the carpal tunnel.

Idiopathic thrombocytopenic purpura (ITP) is a disease caused due to development of an antibody against a platelet antigen (autoantibody). In childhood disease, the autoantibody gets triggered by binding of viral antigen to the megakaryocytes. Presentation includes unexplained thrombocytopenia, petechiae and bleeding from mucosal surfaces. The spleen usually does not enlarge in size. However, splenomegaly can occur due to coexisting viral infection. Marrow examination reveals normal or increased number of megakaryocytes. Diagnosis is by exclusion of other thrombocytopenic disorders.

Steps involved in leukocyte arrival and function include:
1. margination: cells migrate from the centre to the periphery of the vessel.
2. rolling: selectins are upregulated on the vessel walls.
3. adhesion: upregulation of the adhesion molecules ICAM and VCAM on the endothelium interact with integrins on the leukocytes. Interaction of these results in adhesion.
4. diapedesis and chemotaxis: diapedesis is the transmigration of the leukocyte across the endothelium of the capillary and towards a chemotactic product.
5. phagocytosis: engulfing the offending substance/cell.

A teratoma is a tumour containing tissue elements that are similar to normal derivatives of more than one germ layer. They usually contain skin, hair, teeth and bone tissue and are more common in children, behaving as a benign tumour. After puberty, they are regarded as malignant and can metastasise.

At the superficial inguinal ring, the pubic tubercle would be felt as a bony prominence lateral to the edge of the spermatic cord. This tubercle is the point of attachment of the inguinal ligament that makes up the floor of the inguinal canal.
Pecten pubis is the ridge on the superior surface of the superior pubic ramus and the point of attachment of the pectineal ligament.
The pubic symphysis is the joint between the two pubic bones and the iliopubic eminence is a bony process on the pubis found near the articulation of the pubis and the ilium.
The iliopectineal line is formed by the arcuate line of the ilium and the pectineal line of the pubis. It is the line that marks the transition between the abdominal and pelvic cavity.
The sacral promontory is found on the posterior wall of the pelvis and would not be felt through the inguinal ring.

Answer: Stress fracture

A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient’s history usually reveals a recent increase in either training volume or intensity. Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

Normal bone remodelling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodelling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodelled.
Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or oedema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.

A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.

Freiberg disease is a degenerative process involving the epiphyses resulting in osteonecrosis of subchondral cancellous bone. If the process is altered in such a way as to restore normal physiology, this may be followed by regeneration or recalcification. If not, the process continues to subchondral collapse and eventual fragmentation of the joint surface.
Patients who have Freiberg disease typically present with complaints of activity-related forefoot pain. Walking alone is often sufficient to cause pain. Some patients describe an extended (months to years) history of chronic forefoot pain with episodic exacerbation, whereas others present with pain of recent onset that is related to a specific injury or event. A history of trauma may not be noted. Patients may present with stiffness and a limp. The pain is often vague and poorly localized to the forefoot. Some patients describe the sensation of a small, hard object under the foot.

Physical examination typically reveals a limited range of motion (ROM), swelling, and tenderness with direct palpation of the metatarsophalangeal (MTP) joint. In early stages of the disease, MTP tenderness may be the only finding. In later stages, crepitus or deformity may be present. A skin callus may be seen on the plantar surface of the affected metatarsal head.

Radiography
Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.