In adults, the most common primary site of tumour is in the lungs, compared to children wherein the most common primary site is the blood.

Catheter-directed thrombolysis (CDT) is recommended as the next step of management for patients with proximal upper-extremity deep vein thrombosis (UEDVT) of recent onset or severe symptoms.

Primary UEDVT is less common than secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in otherwise healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Duplex scan: investigation of choice
5. D-dimer testing
6. CT scan: for VTOS

Treatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

2. Early thrombus removal and restoration of venous patency should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

A massive blood transfusion is defined as the replacement of a patient’s total blood volume in <24 h
The abnormalities which result include effects upon coagulation status, serum biochemistry, acid-base balance and temperature homeostasis.
One of the complications is Transfusion-related acute lung injury
(TRALI) which is the most common cause of major morbidity and death after transfusion. It presents as an acute respiratory distress syndrome (ARDS) either during or within 6 h of transfusion.

Clinical features
Hypoxaemia, dyspnoea, cyanosis, fever, tachycardia and hypotension result from non-cardiogenic pulmonary oedema. The radiographic appearance is of bilateral pulmonary infiltration, characteristic of pulmonary oedema. It is important to differentiate TRALI from other causes of ARDS such as circulatory overload or myocardial or valvular heart disease. Invasive monitoring in TRALI demonstrates normal intracardiac pressures

Pathogenesis
Two different mechanisms for the pathogenesis of TRALI have been identified: immune (antibody-mediated) and non-immune. Immune TRALI results from the presence of leucocyte antibodies in the plasma of donor blood directed against human leucocyte antigens (HLA) and human neutrophil alloantigens (HNA) in the recipient. Antibodies present in the recipient only rarely cause TRALI. In up to 40% of patients, leucocyte antibodies cannot be detected in either donor or recipient. In these cases, it is possible that reactive lipid products released from the membranes of the donor blood cells act as the trigger. This is known as non-immune TRALI.
The target cell in both forms of TRALI is the neutrophil granulocyte. On activation of their acute phase cycle, these cells migrate to the lungs where they become trapped within the pulmonary microvasculature. Oxygen-free radicals and other proteolytic enzymes are then released which destroy the endothelial cells of the lung capillaries. A pulmonary capillary leak syndrome develops with the exudation of fluid and protein into the alveoli resulting in pulmonary oedema. The majority of reactions are severe, and often life-threatening; 70% require mechanical ventilation and 6–9% are fatal. A definitive diagnosis requires antibody detection. The mortality in non-immune TRALI is lower, and the syndrome is encountered predominantly in critically ill patients.
Other Complications of blood transfusion
Early:
– Haemolytic reactions
Immediate
Delayed
– Non-haemolytic febrile reactions
– Allergic reactions to proteins, IgA
– Reactions secondary to bacterial contamination
– Circulatory overload
– Air embolism
– Thrombophlebitis
– Hyperkalaemia
– Citrate toxicity
– Hypothermia
– Clotting abnormalities (after massive transfusion)
Late:
– Transmission of infection
– Viral (hepatitis A, B, C, HIV, CMV)
– Bacterial (Treponeum pallidum, Salmonella)
– Parasites (malaria, toxoplasma)
– Graft-vs-host disease
– Iron overload (after chronic transfusions)
– Immune sensitization (Rhesus D antigen)

Ulcer bleeding stops spontaneously in about 80% of patients. Only a small percentage require specific measures to stop bleeding. surgery remains the most definitive method of controlling ulcer haemorrhage, and is indicated when endoscopic haemostasis fails to control the bleeding, or when rebleeding occurs. The morbidity and mortality of emergency surgery for ulcer bleeding is high. In principle, the operation performed should be the minimum compatible with permanent haemostasis. The choice of operations is determined by the site and size of the ulcer as well as the experience and preference of the surgeon. Most bleeding duodenal ulcers may be managed by underrunning the bleeding vessel together with vagotomy and pyloroplasty.

Patients with paralysis of the right pterygoid muscle are unable to move their mandible laterally to the left.

Indirect inguinal hernias have a higher risk of strangulation. The risk of strangulation and obstruction is lowest for direct inguinal hernias as they have a wide neck, which can often be monitored and managed conservatively. A study conducted showed that the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years.

Various vagotonic manoeuvres (e.g. Valsalva manoeuvre, carotid sinus massage, pressure on eyeballs, ice-water facial immersion, swallowing of ice-cold water) result in increased parasympathetic tone through the vagus nerve which results in a decrease in heart rate. These manoeuvres may be clinically useful in terminating supraventricular arrhythmias.

Answer: Aortic rupture

Aortic rupture is typically the result of a blunt aortic injury in the context of rapid deceleration. After traumatic brain injury, blunt aortic rupture is the second leading cause of death following blunt trauma. Thus, this condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock, exsanguination, and death. Traumatic aortic transection or rupture is associated with a sudden and rapid deceleration of the heart and the aorta within the thoracic cavity.
Features on plain chest radiography that suggest aortic injury and can help guide the further use of angiography include; an abnormal aortic arch contour, left apical cap, loss of the aorticopulmonary window, rightward deviation of the trachea, depression of the left main stem bronchus, and a wide left paravertebral pleural stripe. Also, widening of the mediastinum (greater than 8 cm) has a reported sensitivity of 81% to 100% and a specificity of 60%.

Answer: Cystine stone

Cystinuria is a genetic cause of kidney stones with an average prevalence of 1 in 7000 births. Cystine stones are found in 1 to 2 percent of stone formers, although they represent a higher percentage of stones in children (approximately 5 percent). Cystinuria is an inherited disorder. Inherited means it is passed down from parents to children through a defect in a specific gene. In order to have cystinuria, a person must inherit the gene from both parents.
Cystine is a homodimer of the amino acid cysteine. Patients with cystinuria have impairment of renal cystine transport, with decreased proximal tubular reabsorption of filtered cystine resulting in increased urinary cystine excretion and cystine nephrolithiasis. The cystine transporter also promotes the reabsorption of dibasic amino acids, including ornithine, arginine, and lysine, but these compounds are soluble so that an increase in their urinary excretion does not lead to stones. Intestinal cystine transport is also diminished, but the result is of uncertain clinical significance.

Cystinuria only causes symptoms if you have a stone. Kidney stones can be as small as a grain of sand. Others can become as large as a pebble or even a golf ball. Symptoms may include:

Pain while urinating
Blood in the urine
Sharp pain in the side or the back (almost always on one side)
Pain near the groin, pelvis, or abdomen
Nausea and vomiting

Struvite stones are a type of hard mineral deposit that can form in your kidneys. Stones form when minerals like calcium and phosphate crystallize inside your kidneys and stick together. Struvite is a mineral that’s produced by bacteria in your urinary tract. Bacteria in your urinary tract produce struvite when they break down the waste product urea into ammonia. For struvite to be produced, your urine needs to be alkaline. Having a urinary tract infection can make your urine alkaline. Struvite stones often form in women who have a urinary tract infection.

Calcium oxalate stones are the most common type of kidney stone. Kidney stones are solid masses that form in the kidney when there are high levels of calcium, oxalate, cystine, or phosphate and too little liquid. There are different types of kidney stones. Your healthcare provider can test your stones to find what type you have. Calcium oxalate stones are caused by too much oxalate in the urine.

What is oxalate and how does it form stones?
Oxalate is a natural substance found in many foods. Your body uses food for energy. After your body uses what it needs, waste products travel through the bloodstream to the kidneys and are removed through urine. Urine has various wastes in it. If there is too much waste in too little liquid, crystals can begin to form. These crystals may stick together and form a solid mass (a kidney stone). Oxalate is one type of substance that can form crystals in the urine. This can happen if there is too much oxalate, too little liquid, and the oxalate “sticks” to calcium while urine is being made by the kidneys.

Uric acid stones are the most common cause of radiolucent kidney stones in children. Several products of purine metabolism are relatively insoluble and can precipitate when urinary pH is low. These include 2- or 8-dihydroxyadenine, adenine, xanthine, and uric acid. The crystals of uric acid may initiate calcium oxalate precipitation in metastable urine concentrates.
Uric acid stones form when the levels of uric acid in the urine is too high, and/or the urine is too acidic (pH level below 5.5) on a regular basis. High acidity in urine is linked to the following causes:
Uric acid can result from a diet high in purines, which are found especially in animal proteins such as beef, poultry, pork, eggs, and fish. The highest levels of purines are found in organ meats, such as liver and fish. Eating large amounts of animal proteins can cause uric acid to build up in the urine. The uric acid can settle and form a stone by itself or in combination with calcium. It is important to note that a person’s diet alone is not the cause of uric acid stones. Other people might eat the same diet and not have any problems because they are not prone to developing uric acid stones.
There is an increased risk of uric acid stones in those who are obese or diabetic.
Patients on chemotherapy are prone to developing uric acid stones.

Only cystine stone is inherited.

There are usually 3 perforating arteries:
The first gives branches to the adductor brevis and magnus, biceps femoris and gluteus maximus and anastomoses with the inferior gluteal, medial and lateral femoral circumflex.
The second artery supplies the posterior femoral muscles and anastomose with the first and third perforating vessels.
The third supplies the posterior femoral muscles.

The umbilicus is a key landmark for the lymphatic and venous drainage of the abdominal wall. Above it, lymphatics drain into the axillary lymph nodes and the venous blood drains into the superior epigastric vein, into the internal thoracic vein. Below it, lymphatics drain into the superficial inguinal lymph nodes while venous blood drains into the inferior epigastric vein and the external iliac vein.

At the upper and back part of the ulna, there exists a curved eminence which is the olecranon process. This process lodges in the olecranon fossa of the humerus. It’s posterior surface is subcutaneous and this triangular area is what you rest your elbow upon.

Tazobactam is a compound which inhibits the action of bacterial beta-lactamases. It is added to the extended-spectrum beta-lactam antibiotic piperacillin to broaden the spectrum of piperacillin by making it effective against organisms that express beta-lactamase and would normally degrade piperacillin.

The primary somatic sensory cortex is located in the postcentral gyrus and is the largest cortical receiving area for information from somatosensory receptors. Through corticocortical fibres, it then sends the information to other areas of the neocortex and further analysis takes place in the posterior parietal association cortex.

An increase in the rate of renal blood flow (RBF) greatly increases the glomerular filtration rate (GFR). The more plasma available (from increased RBF), the more filtrate is formed. Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman’s capsule per unit time. Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles.

The second pharyngeal arch or hyoid arch, is the second of six pharyngeal arches that develops in fetal life during the fourth week of development and assists in forming the side and front of the neck. Derivatives:
Skeletal – From the cartilage of the second arch arises:
Stapes,
Temporal styloid process,
Stylohyoid ligament, and
Lesser cornu of the hyoid bone.
Muscles:
Muscles of face
Occipitofrontalis muscle
Platysma
Stylohyoid muscle
Posterior belly of Digastric
Stapedius muscle
Auricular muscles
Nerve supply: Facial nerve

The combined effort of the lateral pterygoid muscles results in the protrusion of the mandible. The lateral pterygoid muscle is a muscle of mastication located superiorly to the medial pterygoid muscle and has two heads. The superior head originates on the infratemporal surface and infratemporal crest of the greater wing of the sphenoid bone, and the inferior head on the lateral surface of the lateral pterygoid plate. The insertion of this muscle is on the front margin of the articular disc of the temporomandibular joint. The unilateral contraction of the pterygoid muscle results in the laterotrusion of the mandible. It is important to note that the lateral pterygoid muscle is the only muscle of mastication that can open the jaw.

Sarcoidosis is an inflammatory disease of unknown aetiology that affects multiple organs but predominantly the lungs and intrathoracic lymph nodes. Systemic and pulmonary symptoms may both be present. Pulmonary involvement is confirmed by a chest X-ray and other imaging studies. The main histological finding is the presence of non-caseating granulomas.

Concentrating ability of kidneys is assessed by measuring the urine specific gravity. Normal values of urine specific gravity fall between 1.002 and 1.030 g/ml.

THE correct answer is A. The posterior cord derives its fibres from the spinal nerves C5,C6,C7,C8,T1. This cord is formed from the fusion of the posterior divisions of the upper, lower, and middle trunks.

Tracheobronchial lymph nodes are located at the bifurcation of the trachea and are in three groups i.e. the right superior, left superior and inferior. The aorta arches over the left bronchus near the point of tracheal bifurcation. Thus, the nerves that are closely associated with the aorta might be irritated if these nodes become inflamed. The left recurrent laryngeal nerve is such a nerve. The phrenic nerves, both the left and the right, are lateral and thus would not be affected. The right recurrent nerve loops around the right subclavian artery and is distant from this area. The right vagus artery is not associated with the aorta and the sympathetic chain is located in the posterior chest parallel to the vertebra, also not associated with the tracheobronchial tree.

Laparoscopic surgery involves insufflation of a gas (usually carbon dioxide) into the peritoneal cavity producing a pneumoperitoneum. This causes an increase in intra-abdominal pressure (IAP). Carbon dioxide is insufflated into the peritoneal cavity at a rate of 4–6 litre min−1 to a pressure of 10–20 mm Hg. The pneumoperitoneum is maintained by a constant gas flow of 200–400 ml min−1.

Carbon dioxide is the most frequently used gas for insufflation of the abdomen as it is colourless, non-toxic, non-flammable and has the greatest margin of safety in the event of a venous embolus (highly soluble). It is absorbed readily from the peritoneum, causing an increase in PaCO2. This has direct, as well as indirect (by raising catecholamine levels), effects on the cardiovascular system. Thus, tachycardia, increased cardiac contractility and reduction in the diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischaemia.

Fick’s principle states that the total uptake (or release) of a substance by peripheral tissues is equal to the product of the blood flow to the peripheral tissues and the arterial– venous concentration difference (gradient) of the substance. It is used to measure the cardiac output, and the formula is Cardiac output = oxygen consumption divided by arteriovenous oxygen difference. Assuming there are no shunts across the pulmonary system, the pulmonary blood flow equals the systemic blood flow. The arterial and venous blood oxygen content is measured by sampling from the pulmonary artery (low oxygen content) and pulmonary vein (high oxygen content). Peripheral arterial blood is used as a surrogate for the pulmonary vein.

Primary syphilis is transmitted via sexual contact. Lesions on genitalia, called a chancre occur after an asymptomatic incubation period of 10-90 days (average 21 days) after exposure. This chancre is a typically solitary (can be multiple), firm, painless, ulceration over the skin at the point of exposure to spirochete, seen on penis, vagina or rectum. It heals spontaneously after 4-6 weeks. Local lymphadenopathy can be seen.
Diagnosis is made by microscopy of fluid from lesion using dark-field illumination, taking care to not confuse with other treponemal disease. Screening tests include rapid plasma regain (RPR) and Venereal Diseases Research Laboratory (VDRL) tests. False positives are known to occur with these tests and can be seen in viral infections like hepatitis, varicella, Epstein-Barr virus, tuberculosis, lymphoma, pregnancy and IV drug use. More specific tests should therefore be carried out in case these screening tests are positive. The Treponema pallidum hemagglutination assay (TPHA) and the fluorescent treponemal antibody absorption (FTAABS) test are based on monoclonal antibodies and immunofluorescence and are more specific. However, they can too show false positives with other treponemal diseases like yaws or pinta. Other confirmatory tests include those based on enzyme-linked immunoassays.

Epidural haematomas are usually caused by arterial bleeding, classically due to damage to the middle meningeal artery by a temporal bone fracture. Symptoms develop within minutes to several hours after the injury and consist of increasing headache, decreased level of consciousness, hemiparesis and pupillary dilation with loss of light reactivity. Around 15–20% of epidural hematomas are fatal.

Hypertension in a young patient without any obvious cause should be investigated.

A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.

Pheochromocytoma is said to follow a 10% rule:

,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification

Under basal conditions, most of the energy needed by cardiac muscle for metabolism is derived from fats (60%), 35% by carbohydrates, and 5% by ketones and amino acids. However, after intake of large amounts of glucose, lactate and pyruvate are mainly used. During prolonged starvation, fat acts as the primary source. 50% of the used lipids are sourced from circulating fatty acids.

The most potent stimulus for ADH release is increased plasma osmolarity. Decreased plasma volume is a less potent stimulus in comparison. However, decrease blood volume and arterial pressure due to severe haemorrhage does lead to ADH secretion. Hypothalamic releasing factors do not control the release of posterior pituitary hormones ADH and oxytocin.

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.

The primary intestinal loop is formed from the midgut which gives rise to the distal half of the duodenum, the jejunum, ascending colon, proximal two thirds of the transverse colon and the ileum.