Indications for IV fluids include:
– Resuscitation and circulatory support
– Replacing on-going fluid losses
– Maintenance fluids for children for whom oral fluids are not appropriate
– Correction of electrolyte disturbances

According to the NICE guidelines, if children and young people need IV fluid resuscitation, use glucose‑free crystalloids that contain sodium in the range 131–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre‑existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.

All the others are contraindicated according to the guidelines as they are either made of glucose or are colloids.
Gelofusine is a 4% w/v solution of succinylated gelatine (also known as modified fluid gelatine) used as an intravenous colloid, and behaves much like blood filled with albumins.
Dextrose solution is a mixture of dextrose (glucose) and water. It is used to treat low blood sugar or water loss without electrolyte loss. Intravenous sugar solutions are in the crystalloid family of medications. They come in a number of strengths including 5%, 10%, and 50% dextrose.
0.45% saline/ 5% glucose solution also contains glucose hence it is contraindicated.

Crohn’s disease is a chronic, inflammatory disease that can affect any part of the gastrointestinal tract but is usually seen in the distal ileum and colon. It is transmural and symptoms include chronic diarrhoea, abdominal pain, fever, anorexia and weight loss. On examination, there is usually abdominal tenderness with a palpable mass or fullness seen occasionally. Rectal bleeding is uncommon (except in isolated colonic involvement) which manifests like ulcerative colitis. Differential diagnosis includes acute appendicitis or intestinal obstruction. 25%-33% patients also have perianal disease in the form of fissure or fistulas.
Extra intestinal manifestations predominate in children, and include: arthritis, pyrexia, anaemia or growth retardation. Histologically, the disease shows crypt inflammation and abscesses initially, which progress to aphthoid ulcers. These eventually develop into longitudinal and transverse ulcers with interspersed mucosal oedema, leading to the characteristic ‘cobblestoned appearance’. Transmural involvement leads to lymphoedema and thickening of bowel wall and mesentery, leading to extension of mesenteric fat on the serosal surface of bowel and enlargement of mesenteric nodes. There can also be hypertrophy of the muscularis mucosae, fibrosis and stricture formation, which can cause bowel obstruction. Abscesses are common and the disease can also leas to development of fistulas with various other organs, anterior abdominal wall and adjacent muscles. Pathognomonic non-caseating granulomas are seen in 50% cases and they can occur in nodes, peritoneum, liver, and in all layers of the bowel wall. The clinical course does not depend on the presence of granulomas. There is sharp demarcation between the diseased and the normal bowel (skip areas).
35% cases show only the ileal involvement, whereas in 45% cases, both the ileum and colon are involved with a predilection for right side of colon. 20% cases show only colonic involvement, often sparing the rectum (unlike ulcerative colitis). In occasional cases, there is jejunoileitis – involvement of the entire small bowel. The stomach, duodenum and oesophagus are rarely involved, although there has been microscopic evidence of disease involving the gastric antrum in younger patients. The affected small bowel segments show increased rick of cancer. Moreover, patients with colonic disease show a long-term risk of cancer similar to that seen in ulcerative colitis.

The administration of antibiotics is best considered therapeutic, rather than prophylactic, because of the high risk of infection in the absence of antibiotics.

Although debate still surrounds some aspects of antibiotic administration for open fractures, the following generalizations can be made:

– All patients with open fractures should receive cefazolin or equivalent gram-positive coverage; this may be sufficient
– Type II or type III injuries likely benefit from the addition of adequate gram-negative coverage, typically with an aminoglycoside
– Injuries at risk for anaerobic infections (e.g., farm injuries, severe tissue necrosis) probably benefit from the addition of penicillin or clindamycin.

Digital photos are helpful for documenting the initial appearance of the extremity and can be a valuable addition to the medical record. Digital imaging allows other members of the treatment team to see the wound preoperatively without repeated manipulations of the wound.
Gauze swabs soaked in normal saline are frequently used as dressing on open wounds.

The Oxford Handbook for Medical school recommends that open fractures should be sealed with saline-soaked gauze and impermeable dressing after removal of gross contaminants.

The characteristic cells in granulomatous inflammation are giant cells, formed from merging macrophages and epithelioid cells elongated with granular eosinophilic cytoplasm. Granulomatous reactions are seen in patients with tuberculosis. A tuberculous/caseating granuloma is characterised by a zone of central necrosis lined with giant multinucleated giant cells (Langhans cells) and surrounded by epithelioid cells, lymphocytes and fibroblasts. The caseous zone is present due to the damaged and dead giant cells and epithelioid cells.
Mast cells are only few in number and fibroblasts lay down collagen.
Basophils are not present.
The giant cell made up of macrophages are the most abundant cells in this inflammatory process.

Answer: Spontaneous bacterial peritonitis

The presence of periorbital and facial oedema with normal blood pressure in this toddler indicates that he has nephrotic syndrome. Nephrotic syndrome can be associated with a series of complications that can affect an individual’s health and quality of life:
Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent development in children but very rarely found in adults.

Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.

The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.

Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.

These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.

Arterioles are also known as the resistance vessels as they are responsible for approximately half the resistance of the entire systemic circulation. They are richly innervated by the autonomic nervous system and hence, will bring about the maximum increase in peripheral resistance on sympathetic stimulation.

This is a case of Brown-Sequard syndrome.

Brown-Sequard syndrome is caused by hemisection of the spinal cord following stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract), and also loss of proprioception and fine discrimination(dorsal columns). Pain and temperature sensations are lost on the contralateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.

The ST segment lies between the QRS complex and the T-wave. The normal duration of the ST segment is 0.08 s. ST-segment elevation or depression may indicate myocardial ischaemia or infarction.

The patient has Haemorrhoid Disease
A total of 40% of individuals with haemorrhoids are asymptomatic.
For internal haemorrhoids, bleeding is the most commonly reported symptom. The occurrence of bleeding is usually associated with defecation and almost always painless. The blood is bright red and coats the stool at the end of defection.
Another frequent symptom is the sensation of tissue prolapse. Prolapsed internal haemorrhoids may accompany mild faecal incontinence, mucus discharge, a sensation of perianal fullness, and irritation of perianal skin. Pain is significantly less common with internal haemorrhoids than with external haemorrhoids but can occur in the setting of prolapsed, strangulated internal haemorrhoids that develop gangrenous changes due to the associated ischemia.
In contrast, external haemorrhoids are more likely to be associated with pain, due to activation of perianal innervations associated with thrombosis. Patients typically describe a painful perianal mass that is tender to palpation. This painful mass may be initially increasing in size and severity over time. Bleeding can also occur if ulceration develops from necrosis of the thrombosed haemorrhoid, and this blood tends to be darker and more clotted than the bleeding from the internal disease. Painless external skin tags often result from previous oedematous or thrombosed external haemorrhoids.

Lifestyle and dietary modification are the mainstays of conservative medical treatment of haemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise. Diet recommendations should include increasing fibre intake, which decreases the shearing action of passing a hard stool.
Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures.
For internal haemorrhoids, rubber band ligation, sclerotherapy, and infrared coagulation are the most common procedures but there is no consensus on optimal treatment. Overall, the goals of each procedure are to decrease vascularity, reduce redundant tissue, and increase hemorrhoidal rectal wall fixation to minimize prolapse.
Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal haemorrhoids.

The baroreflex or baroreceptor reflex is one of the body’s homeostatic mechanisms for regulating blood pressure. It provides a negative feedback response in which an elevated blood pressure will causes blood pressure to decrease; similarly, decreased blood pressure depresses the baroreflex, causing blood pressure to rise. The system relies on specialised neurones (baroreceptors) in the aortic arch, carotid sinuses and elsewhere to monitor changes in blood pressure and relay them to the brainstem. Subsequent changes in blood pressure are mediated by the autonomic nervous system. Baroreceptors include those in the auricles of the heart and vena cava, but the most sensitive baroreceptors are in the carotid sinuses and aortic arch. The carotid sinus baroreceptors are innervated by the glossopharyngeal nerve (CN IX); the aortic arch baroreceptors are innervated by the vagus nerve (CN X).

Buspirone is an anxiolytic agent and a serotonin-receptor agonist that belongs to the azaspirodecanedione class of compounds. It shows no potential for addiction compared with other drugs commonly prescribed for anxiety, especially the benzodiazepines. The development of tolerance has not been noted. It is primarily used to treat generalized anxiety disorders. It is also commonly used to augment antidepressants in the treatment of major depressive disorder.

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.

The presence or absence of the mesentery determines mobility of abdominal contents. Structures like the stomach, transverse colon and appendix have mesenteries and thus are relatively mobile. In contrast, the pancreas is a retroperitoneal (behind the peritoneum) structure and therefore is fixed. The greater omentum is a large mobile fold of omentum that hangs down from the stomach .

The diaphragmatic openings are:
T8 – opening for the inferior vena cavaand the right phrenic nerve
T10 – opening for the oesophagusand the left gastric artery and vein
T12 – opening for the aorta, the thoracic duct and azygos vein.

The boundaries of the posterior mediastinum are: the superiorly through the sternal angle and T4/5, inferiorly, the diaphragm, anteriorly, by the middle mediastinal structures and posteriorly by the spinal cord. Structures in the posterior mediastinum include the descending thoracic aorta, the azygos system, oesophagus, thoracic duct and lymph nodes. The great vessels and structures at the root of the lung are part of the middle mediastinum. The oesophagus is the only structure in the posterior mediastinum among the choices.

On transmission of a loud sound into the central nervous system, an attenuation reflex occurs after a latent period of 40-80 ms. This reflex contracts the two muscles that pull malleus and stapes closer, developing a high degree of rigidity in the entire ossicular chain. This reduces the ossicular conduction of low frequency sounds to the cochlea by 30-40 decibels. In this way, the cochlea is protected from damage due to loud sounds (these are low frequency sounds) when they develop slowly.

The AJCC uses a TNM system to stage prostatic cancer, with categories for the primary tumour, regional lymph nodes and distant metastases:
TX: cannot evaluate the primary tumour T0: no evidence of tumour
T1: tumour present, but not detectable clinically or with imaging T1a: tumour was incidentally found in less than 5% of prostate tissue resected (for other reasons)
T1b: tumour was incidentally found in more than 5% of prostate tissue resected
T1c: tumour was found in a needle biopsy performed due to an elevated serum prostate-specific antigen
T2: the tumour can be felt (palpated) on examination, but has not spread outside the prostate
T2a: the tumour is in half or less than half of one of the prostate gland’s two lobes
T2b: the tumour is in more than half of one lobe, but not both
T2c: the tumour is in both lobes
T3: the tumour has spread through the prostatic capsule (if it is only part-way through, it is still T2)
T3a: the tumour has spread through the capsule on one or both sides
T3b: the tumour has invaded one or both seminal vesicles
T4: the tumour has invaded other nearby structures.
In this case, the tumour has a T1c stage.

The thymus is located superficially in the anterior mediastinum. The left brachiocephalic vein courses through the mediastinum to join the right brachiocephalic vein and form the superior vena cava on the right side of the thorax. The left brachiocephalic vein, being superficial, courses just deep to the thymus so that it may be susceptible to compression by an adjacent tumour. The left pulmonary vein, left bronchial vein and right pulmonary artery are deep, and enter and exit the lung at its root, thus are not near the thymus. The right superior intercostal vein drains the 2nd to the 4th intercostal spaces and drains into the arch of the azygos vein. It is not, therefore, closely related with the thymus.

A renogram, which may also be known as a MAG3 scan, allows a nuclear medicine physician or a radiologist to visualize the kidneys and learn more about how they are functioning.
After injection into the venous system, the compound is excreted by the kidneys and its progress through the renal system can be tracked with a gamma camera. A series of images are taken at regular intervals.

If the kidney is not getting blood for example, it will not be viewed at all, even if it looks structurally normal in medical ultrasonography or magnetic resonance imaging. If the kidney is getting blood, but there is an obstruction inferior to the kidney in the bladder or ureters, the radioisotope will not pass beyond the level of the obstruction, whereas if there is a partial obstruction then there is a delayed transit time for the MAG3 to pass. More information can be gathered by calculating time activity curves; with normal kidney perfusion, peak activity should be observed after 3–5 minutes. The relative quantitative information gives the differential function between each kidney’s filtration activity.

Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in the collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability.
Most compartment syndromes associated with a burn injury do not present in the immediate postburn period unless there is associated with traumatic injury or the patient presents in a delayed fashion. As such, compartment syndromes after burns are not commonly observed in the emergency department. Instead, they develop during the first 6–12 h of the initial volume resuscitation period as the administered intravascular volume goes into the interstitial and intracellular spaces resulting in tissue oedema in or under the burned tissue.

Patients with compartment syndrome typically present with pain whose severity appears out of proportion to the injury. The pain is often described as burning. The pain is also deep and aching in nature and is worsened by passive stretching of the involved muscles. The patient may describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of the diagnosis. In severe trauma, such as an open fracture, it is difficult to differentiate between pain from the fracture and pain resulting from increased compartment pressure.
Paraesthesia or numbness is an unreliable early complaint; however, decreased 2-point discrimination is a more reliable early test and can be helpful to make the diagnosis.
The traditional 5 P’s of acute ischemia in a limb (i.e., pain, paraesthesia, pallor, pulselessness, poikilothermia) are not clinically reliable; they may manifest only in the late stages of compartment syndrome, by which time extensive and irreversible soft tissue damage may have taken place.

Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise

Retroperitoneal liposarcoma (RLS) is a rare, biologically heterogeneous tumour that presents considerable challenges due to its size and deep location.
RPS generally measure >5 cm, and mostly >10 cm diameter at presentation

Liposarcoma occurs in three main biologic forms: (1) well-differentiated liposarcoma; (2) myxoid and/or round cell; and (3) pleomorphic. The latter is a rare high-grade type with a high recurrence rate and poor prognosis.

CT scanning is superior to MRI in detailing cortical bone erosion and tumour mineralization, whereas MRI is useful in providing views of the long axis of the limb and in depicting the fatty nature of the tumour.
Most liposarcomas have well-defined and mostly lobulated margins. The well-differentiated liposarcomas are composed of mainly fat with septa or nodules.
Chest radiography may be used as an initial screening for pulmonary metastases; however, the definitive test for detection of pulmonary metastases is chest CT scanning.

Abdominal Ultrasound is the imaging method of choice for varicocele.
A varicocele is abnormal dilation and enlargement of the scrotal venous pampiniform plexus which drains blood from each testicle. While usually painless, varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology. Varicoceles are far more common (80% to 90%) in the left testicle. If a left varicocele is identified, there is a 30% to 40% probability it is a bilateral condition.

There are three theories as to the anatomical cause:

– The Nutcracker effect which occurs when the left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
– Failure of the anti-reflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.
– Angulation at the juncture of the left internal spermatic vein and the left renal vein.

Varicoceles are usually asymptomatic. The patient may describe a bag of worms if the varicocele is large enough. Varicoceles present as soft lumps above the testicle, usually on the left side of the scrotum. Patients may sometimes complain of pain or heaviness in the scrotum.
A sudden onset of varicocele in a man over the age of 30 years requires the exclusion of renal tumours, particularly in elderly patients. In such cases it is necessary to extend diagnostic ultrasonography with abdominal examination. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva manoeuvre.

This individual has acute cholecystitis. This is demonstrated by well-localized pain in the right upper quadrant, usually with rebound and guarding; frequent presence of fever and peritonism. Ultrasonography is the procedure of choice in suspected gallbladder or biliary disease. A bile duct measuring 4mm is usually normal.
Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated (typically, laparoscopic cholecystectomy is the first-line therapy at centres with experience in this procedure).

Acute aortic dissection is a serious condition in which the inner layer of the aorta tears and the blood flows in between the inner and middle layers of the aorta causing their separation (dissection). Aortic dissection can lead to rupture or decreased blood flow to organs. Clinical manifestations most often include the sudden onset of severe, tearing or ripping chest pain that can radiate to the shoulder, back or neck; syncope; altered mental status; dyspnoea; pale skin; stroke symptoms etc. The diagnosis of acute aortic dissection is based on clinical findings, imaging studies, electrocardiography and laboratory analysis.

An increase in the frequency of sound waves results in a change in the position of maximal displacement of the basilar membrane in the cochlea. Low pitch sound produces maximal displacement towards the cochlear apex and greatest activation of hair cells there. With an increasing pitch, the site of greatest displacement moves towards the cochlear base. However, increased amplitude of displacement, increase in the number of activated hair cells, increased frequency of discharge of units in the auditory nerve and increase in the range of frequencies to which such units respond, are all seen in increases in the intensity or a sound stimulus.

In the mid-thorax, the azygos vein, thoracic duct and aorta (in this order from right to the left) are all located posterior to the oesophagus. The superior vena cava, left internal jugular vein and trachea are not found in the mid thorax.

Answer: Thoracotomy

Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMY

Indication:

Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).

Contraindications:
Definite loss of cardiac output for greater than 10 minutes.

Any patient who has a cardiac output, including hypotensive patients.

The musculoskeletal nerve supplies the muscles of the anterior compartment of the arm including the coracobrachialis, biceps brachii and the greater part of the brachialis. This nerve derives its fibres from the fifth, sixth and seventh cervical nerves and arises from the lateral cord of the brachial plexus. It also provides a branch to the elbow joint.

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome.

Stage IIB describes invasive breast cancer in which: the tumour is larger than 2 centimetres but no larger than 5 centimetres; small groups of breast cancer cells — larger than 0.2 millimetre but not larger than 2 millimetres — are found in the lymph nodes OR the tumour is larger than 2 centimetres but no larger than 5 centimetres; cancer has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the breastbone (found during a sentinel node biopsy) OR the tumour is larger than 5 centimetres but has not spread to the axillary lymph nodes.