Answer: Myoglobin

When muscle is damaged, a protein called myoglobin is released into the bloodstream. It is then filtered out of the body by the kidneys. Myoglobin breaks down into substances that can damage kidney cells.
Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.
Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

A fracture.
A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player’s helmet.
Re-established blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
Crush injuries.
Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages.

Carpal tunnel syndrome tends to occur in women between the ages of 30-50. There are many risk factors, including diabetes, hypothyroidism, obesity, pregnancy, and repetitive wrist work. Symptoms include pain in the hand and wrist, tingling, and numbness distributed along the median nerve (the palmar side of the thumb, the index and middle fingers, and the radial half of the ring finger), which worsens at night.

Dysphagia that is episodic and nonprogressive and varies between solids and liquids is more likely to represent a motility disorder. It may also associated with retrosternal chest pain.

Motility disorder is a condition where the nerves and muscles in the gastrointestinal tract are not working together correctly, which cause difficulty in the digestive process. These conditions include chronic intractable constipation, gastroesophageal reflux disease (GERD), chronic intestinal pseudo-obstruction, gastroparesis, Hirschsprung’s disease, and oesophageal achalasia, among other disorders.

In addition to imaging studies, these conditions are usually evaluated with manometry studies which measure the pressure in different areas of the gastrointestinal tract.

Carbon tetrachloride (CCl4) is a common agent used in the dry cleaning industry and is thought to cause the formation of free radicals. It causes rapid breakdown of the endoplasmic reticulum due to decomposition of lipids and severe liver cell injury. Within less than 30 mins, hepatic protein synthesis declines, lipid export is reduced due to lack of apoprotein and there is an influx of calcium and cell death.

Colles’ fracture is a distal fracture of the radius that is a known cause of carpal tunnel syndrome (compression of the median nerve in the carpal tunnel). It rarely results in ulnar nerve compression. A Colles’ fracture is extra-articular and does not extend into the wrist joint, otherwise this would make it an intra-articular fracture (Barton’s fracture). The distal fragment in a Colles’ fracture is displaced dorsally, unlike in a Smith’s fracture where the distal fragment is displaced volarly (ventrally). Associated fracture of the ulnar styloid process may occur and is a common associated injury.

The drainage of cerebral spinal fluid from the third ventricle to the fourth ventricle is carried out by the cerebral aqueduct. The cerebral aqueduct is the narrowest passageway in the entire ventricular system and thus forms the most common site of blockage of flow of cerebrospinal fluid. The interventricular foramen allows passage of CSF to the third ventricle. The foramen of Luschka and Magendie are located on the fourth ventricle and allow passage of CSF to the subarachnoid space from the ventricular system. The pontine cistern is a space located on the ventral aspect of the pons. The cisterna magna is an opening on the subarachnoid space between the pia matter and the arachnoid.

Hypoventilation (or respiratory depression) causes an increase in carbon dioxide (hypercapnia) and respiratory acidosis. It can result due to drugs such as alcohol, benzodiazepines, barbiturates, opiates, mechanical conditions or holding ones breath. Strong opioids such as heroin and fentanyl are commonly implicated and can lead to respiratory arrest. In recreational drug overdose, acute respiratory acidosis occurs with an increase in p(CO2) over 45 mm Hg and acidaemia (pH < 7.35)

Typhoid fever is caused by virulent bacteria called Salmonella typhi. Salmonella typhi spread through contaminated food or water and occasionally through direct contact with someone who is infected.

Burkitt’s lymphoma is a type of non-Hodgkin’s lymphoma. Histologically it is characterised by a starry sky appearance due to numerous neoplastic macrophages which are required to clear the rapidly dividing tumour cells/blast cells. Burkitt’s lymphoma commonly affects the jaw bone, forming a huge tumour mass. It is associated with translocation of c-myc gene and has three types: 1) endemic/African type, 2)sporadic and 3)immunodeficiency-associated. The first type is strongly associated with EBV.

The pectineus is supplied by the second, third and fourth lumbar nerves through the femoral nerve and by the third lumbar through the accessory obturator when it exists. The anterior surface of the thigh receives its innervation from the femoral nerve as well, thus this is the nerve most likely to be injured

Jaundice can occur due to any of the possible causes and treatment depends upon diagnosing the correct condition. Mild hyperbilirubinemia with normal levels of aminotransferase and alkaline phosphatase is often unconjugated (e.g., due to haemolysis or Gilbert’s syndrome rather than hepatobiliary disease). Moderate or severe hyperbilirubinemia along with increased urinary bilirubin (bilirubinuria), high alkaline phosphatase or aminotransferase levels suggest hepatobiliary disease. Hyperbilirubinemia produced by any hepatobiliary disease is largely conjugated. In this case, other blood tests include hepatitis serology for suspected hepatitis, prothrombin time (PT) or international normalised ratio (INR), albumin and globulin levels, and antimitochondrial antibody levels (suspected primary biliary cirrhosis). Low albumin and high globulin levels suggest chronic rather than acute liver disease. In cases where there is only a an elevation of alkaline phosphatase, γ-glutamyl transpeptidase (GGT) levels should be checked – the levels of which will be found high in hepatobiliary disease, but not in bone disorder which can also lead to elevated alkaline phosphatase levels. In diseases of hepatobiliary origin, aminotransferase elevations > 500 units suggest a hepatocellular cause, whereas disproportionate increases of alkaline phosphatase (e.g., alkaline phosphatase > 3 times normal and aminotransferase < 200 units) suggest cholestasis. Because hepatobiliary disease alone rarely causes bilirubin levels > 30 mg/dl, higher levels are suggestive of a combination of severe hepatobiliary disease and haemolysis or renal dysfunction. Imaging is best for diagnosing infiltrative and cholestatic causes of jaundice. Liver biopsy is rarely needed, but can be of use in intrahepatic cholestasis and in some types of hepatitis.

The thoracic duct is the main drainage of lymph in the body. It varies in length from 38 to 45 cm and extends from the second lumbar vertebra to the root of the neck.

The rate of filtration at any point along a capillary depends on a balance of forces sometimes called Starling’s forces after the physiologist who first described their operation in detail. The Starling principle of fluid exchange is key to understanding how plasma fluid (solvent) within the bloodstream (intravascular fluid) moves to the space outside the bloodstream (extravascular space). Fluid movement = k[(pc– pi)–(Πc– Πi)] where k = capillary filtration coefficient, pc = capillary hydrostatic pressure, pi= interstitial hydrostatic pressure, Πc = capillary colloid osmotic pressure, Πi = interstitial colloid osmotic pressure. Therefore: 1 × [capillary hydrostatic pressure (17) – interstitial fluid hydrostatic pressure (–3)] – [plasma colloid osmotic pressure (28) – interstitial fluid colloid osmotic pressure (8)] = 0 mmHg

Achalasia is a rare neurological deficit of the oesophagus that produces an impaired relaxation of the lower oesophageal sphincter and decreased motility of the oesophageal body. Achalasia is generally accepted to be a pre-malignant disorder, since, particularly in the mega-oesophagus, chronic irritation by foods and bacterial overgrowth may contribute to the development of dysplasia and carcinoma.
When oesophageal cancer develops in patients with underlying achalasia, diagnosis tends to be in the more advanced stages of cancer, compared to cases with no achalasia, because both physicians and patients often regard symptoms such as dysphagia and chest discomfort as attributable to the achalasia, rather than to other causes. Therefore, additional approaches that would lead to earlier diagnosis might be pursued less aggressively.
Achalasia is a predisposing factor for oesophageal squamous cell carcinoma.

Complications in wound healing can originate due to abnormalities in the repair process. These abnormalities are :
1) Deficient scar formation: insufficient granulation tissue can lead to wound dehiscence and ulceration. Dehiscence or wound rupture is seen most commonly in abdominal surgery due to increased intraabdominal pressure. Ulcerations are common in extremity wounds due to inadequate vascularization.
2) Excessive formation of repair components: collagen being laid down may begin normally however later lead to a raised scar also called a hypertrophic scar, which can extend beyond its boundaries to form a keloid and
3) Formation of contractures.

Hirschsprung’s disease (also known as aganglionic megacolon) leads to colon enlargement due to bowel obstruction by an aganglionic section of bowel that starts at the anus. A blockage is created by a lack of ganglion cells needed for peristalsis that move the stool. 1 in 5000 children suffer from this disease, with boys affected four times more commonly than girls. It develops in the fetus in early stages of pregnancy. Symptoms include not having a first bowel movement (meconium) within 48 hours of birth, repeated vomiting and a swollen abdomen. Two-third of cases are diagnosed within 3 months of birth. Some children may present with delayed toilet training and some might not show symptoms till early childhood. Diagnosis is by barium enema and rectal biopsy (showing lack of ganglion cells).

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)

The transverse colon is supplied by the middle colic artery which is a branch from the superior mesenteric artery. If the inferior mesenteric artery was occluded, branches from the middle colic may go to the marginal artery which supplies the descending colon, sigmoid colon and rectum.. Ileocolic and right colic arteries also branch from the superior mesenteric artery that supply the colon but the middle colic, which serves the more distal part of the colon is the better answer. The gastroduodenal artery branches off the common hepatic artery, which supplies part of the duodenum, pancreas and stomach. The splenic artery supplies the spleen, pancreas and curvature of the stomach.

This patient is likely to have paralytic ileus and the administration of antiemetic drugs, in this situation, will have no effect. It is, therefore, important to decompress the stomach with a wide bore nasogastric tube.

Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It commonly occurs after an abdominal surgery. Irrespective of the cause, paralytic ileus causes constipation, abdominal distention, nausea, and vomiting. It is a severe condition because if left untreated, an ileus can cut off blood supply to the intestines and cause tissue death.

The cranial nerves emerge directly from the brain and the brain stem. They provide sensory, motor or both motor and sensory innervation. Here is a summary of the cranial nerves and their function:
Olfactory – Purely sensory
Optic – Sensory
Oculomotor – Mainly motor
Trochlear – Motor
Trigeminal – Both sensory and motor
Abducens – Mainly motor
Facial – Both sensory and motor
vestibulocochlear – Mostly sensory
Glossopharyngeal – Both sensory and motor
Vagus – Both sensory and motor
Accessory – Mainly motor
Hypoglossal – Mainly motor

The foramen magnum is found in the most inferior part of the posterior cranial fossa . It is traversed by vital structures including the medulla oblongata . Its contents include the following: medulla oblongata, meninges (arachnoid, dura and pia mater), spinal root of the accessory nerve, vertebral arteries, anterior and posterior spinal arteries, tectorial membrane and alar ligaments .

Answer: 13

Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 point

Verbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 point

Motor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 point

He is seen to be disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. His score is therefore 13: 3 for eye opening response, 4 for verbal response and 6 for motor response.

Thromboangiitis obliterans, also known as Buerger’s disease, is a rare type of occlusive peripheral arterial disease, usually seen in smokers, most commonly in men aged 20 to 40. Symptoms most often include intermittent claudication, skin changes, painful ulcers on extremities, pain in the extremities during rest and gangrene. Diagnosis is based on clinical findings, arteriography, echocardiography, and computed tomography angiography. A difference in blood pressure between arms, or between the arms and legs is a common finding. Electrocardiographic findings include nonspecific abnormality or normal results.

The sternocleidomastoid muscle is an important landmark in the neck as it divides the neck into two; anterior and posterior triangles. These triangles help in the location of the structures of the neck including the carotid artery, head and neck lymph nodes, accessory nerve and the brachial plexus. It originates from the manubrium and medial portion of the clavicle and inserts on the mastoid process of the temporal bone, superior nuchal line. The sternocleidomastoid receives blood supply from the occipital artery and the superior thyroid artery. It is innervated by the accessory nerve (motor)
and cervical plexus (sensory).

Total peripheral resistance = Mean arterial pressure/Cardiac output. And the mean arterial pressure = Diastolic pressure + 1/3 (Systolic pressure – Diastolic pressure), i.e., 70 + 1/3 (130-70) = 90 mmHg. Therefore, total peripheral resistance = 90 mmHg/5 l per min = 18 mmHg × min/l.

During strenuous exercise there is an increase in:
– Heart rate, stroke volume and therefore cardiac output. (CO = HR x SV)
– Respiratory rate (hyperventilation) which will lead to a reduction in Paco2.
– Oxygen demand of skeletal muscle, therefore leading to a reduction in mixed venous blood oxygen concentration.
Renal blood flow is autoregulated, so renal blood flow is preserved and will tend to remain the same. Mean arterial blood pressure is a function of cardiac output and total peripheral resistance and will increase with exercise, mainly as a result of the increase in cardiac output that occurs.

The likely diagnosis is megaloblastic anaemia, which also shows the presence of hypersegmented neutrophils.

Langhans giant cells are characteristically seen in granulomatous inflammation. They form when epithelioid cells fuse together. They usually contain a nuclei with a horseshoe-shaped pattern in the periphery of the cell.

The costo-diaphragmatic recess is the lowest extent of the pleural cavity or sac. Any fluid in the pleura will by gravity accumulate here when a patient is standing erect.

This muscle arises from the medial two-thirds of the supraspinatus fossa and from the supraspinatus fascia. It is inserted into the highest impression on the greater tubercle of the humerus after passing over the upper part of the shoulder joint. It works with the deltoid to raise the arm from the side of the trunk and initiate abduction. It also assists in fixation of the head of the humerus in the glenoid cavity.