Dumping syndrome is the effect of altered gastric reservoir function, abnormal postoperative gastric motor function, and/or pyloric emptying mechanism. Clinically significant dumping syndrome occurs in approximately 10% of patients after any type of gastric surgery and in up to 50% of patients after laparoscopic Roux-en-Y gastric bypass. Dumping syndrome has characteristic alimentary and systemic manifestations. It is a frequent complication observed after a variety of gastric surgical procedures, such as vagotomy, pyloroplasty, gastrojejunostomy, and laparoscopic Nissan fundoplication. Dumping syndrome can be separated into early and late forms, depending on the occurrence of symptoms in relation to the time elapsed after a meal.
Postprandially, the function of the body of the stomach is to store food and to allow the initial chemical digestion by acid and proteases before transferring food to the gastric antrum. In the antrum, high-amplitude contractions triturate the solids, reducing the particle size to 1-2 mm. Once solids have been reduced to this desired size, they are able to pass through the pylorus. An intact pylorus prevents the passage of larger particles into the duodenum. Gastric emptying is controlled by the fundic tone, antropyloric mechanisms, and duodenal feedback. Gastric surgery alters each of these mechanisms in several ways.

The late dumping syndrome is suspected in the person who has symptoms of hypoglycaemia in the setting of previous gastric surgery, and this late dumping can be proven with an oral glucose tolerance test (hyperinsulinemic hypoglycaemia), as well as gastric emptying scintigraphy, which shows the abnormal pattern of initially delayed and then accelerated gastric emptying.

The clinical presentation of dumping syndrome can be divided into GI symptoms and vasomotor symptoms. GI symptoms include early satiety, crampy abdominal pain, nausea, vomiting, and explosive diarrhoea. Vasomotor symptoms include diaphoresis, flushing, dizziness, palpitations, and an intense desire to lie down.

The expression of these symptoms varies in different individuals. Most patients with early dumping have both GI and vasomotor symptoms, while patients with late dumping have mostly vasomotor symptoms. Patients with severe dumping often limit their food intake to avoid symptoms. This leads to weight loss and, over time, malnutrition.

Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine, whereas late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness.

Early dumping systemic symptoms are as follows:
Desire to lie down
Palpitations
Fatigue
Faintness
Syncope
Diaphoresis
Headache
Flushing

Early dumping abdominal symptoms are as follows:
Epigastric fullness
Diarrhoea
Nausea
Abdominal cramps
Borborygmi

Late dumping symptoms are as follows:
Perspiration
Shakiness
Difficulty to concentrate
Decreased consciousness
Hunger

The glossopharyngeal nerve provides parasympathetic innervation for the parotid salivary gland via the auriculotemporal nerve. The facial nerve supplies the parasympathetic innervation of the lacrimal, nasal, sublingual and submandibular glands.

As the cochlea is embedded into bone, the vibrations from the bone are transmitted directly to the fluid in the cochlea. Hence, any damage to the ossicles or tympanic membrane will not show an abnormal result on bone conduction test.

This patient has developed a tension pneumothorax following a blunt trauma.

Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.

Signs and symptoms of tension pneumothorax include:
1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
2. Dyspnoea and progressive hypoxia
3. Tachycardia
4. Hyperventilation
5. Cough
6. Fatigue

On examination, hyper-resonant percussion note and tracheal deviation are typically found. Treatment is immediate without waiting for the CXR result and includes needle decompression and chest tube insertion.

Fat embolism is a life-threatening form of embolism in which the embolus consists of fatty material or bone marrow particles that are introduced into the systemic venous system. It may be caused by long-bone fractures, orthopaedic procedures, sickle cell crisis, parenteral lipid infusion, burns and acute pancreatitis. Patients with fat embolism usually present with symptoms that include skin, brain, and lung dysfunction.

Breast cancer frequently metastasizes to the skeleton, interrupting the normal bone remodelling process and causing bone degradation. Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.

Osteolytic lesions are the end result of osteoclast activity; however, osteoclast differentiation and activation are mediated by osteoblast production of RANKL (receptor activator for NFκB ligand) and several osteoclastogenic cytokines. Osteoblasts themselves are negatively affected by cancer cells as evidenced by an increase in apoptosis and a decrease in proteins required for new bone formation. Thus, bone loss is due to both increased activation of osteoclasts and suppression of osteoblasts. The clinical outcomes of bone pain, pathologic fractures, nerve compression syndrome, and metabolic disturbances leading to hypercalcemia and acid/base imbalance severely reduce the quality of life.

Answer: Flail chest injury

Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.

It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called paradoxical breathing is painful and increases the work involved in breathing.

Flail chest is usually accompanied by a pulmonary contusion, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory problems in people with both injuries.

Surgery to fix the fractures appears to result in better outcomes.

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.

Gaining venous access in small children is challenging most of the times especially in cases of trauma. Therefore, intraosseous infusions should be preferred in this setting. Broviac lines are long-term IV access systems with narrow lumens and, hence, would be unsuitable.

Intraosseous access is typically undertaken at the anteromedial aspect of the proximal tibia and provides access to the marrow cavity and circulatory system. Although traditionally preferred in paediatric practice, it may be used in adults as well, and a wide range of fluids can be infused using this approach.

Within the nephron of the kidney, the ascending limb of the loop of Henle is a segment of the loop of Henle downstream of the descending limb, after the sharp bend of the loop. Both the thin and the thick ascending limbs of the loop of Henlé have very low permeability to water. Since there are no regulatory mechanisms to alter its permeability, it remains poorly permeable to water under all circumstances. Sodium and chloride are transported out of the luminal fluid into the surrounding interstitial spaces, where they are reabsorbed. Water must remain behind because it is not reabsorbed, so the solute concentration becomes less and less (the luminal fluid becomes more dilute). This is one of the principal mechanisms (along with diminution of ADH secretion) for the production of a dilute, hypo-osmotic urine (water diuresis).

The primary tumour staging for testicular seminoma is as follows, according to AJCC guidelines:
Tis: intratubular germ cell neoplasia (carcinoma in situ)
T1: tumour limited to testis/epididymis without vascular or lymphatic invasion; the tumour can invade into the tunica albuginea but not the tunica vaginalis
T2: tumour limited to testis/epididymis with vascular or lymphatic invasion or tumour extending through the tunica albuginea with involvement of the tunica vaginalis
T3: tumour invading the spermatic cord, with or without vascular/lymphatic invasion
T4: tumour invading the scrotum, with or without vascular/lymphatic invasion.
According to these guidelines, the tumour in this case has a T2 stage.

The movement of leukocytes towards a chemical mediator is termed chemotaxis and the mediators likewise called chemoattractants.
Diapedesis is the squeezing of the leukocytes from the capillary wall into the intercellular space.
Endocytosis is engulfing of a small substance by the cells e.g. glucose, protein, fats.
Margination is lining of the WBC along the periphery of the blood vessel.
Adhesion is attachment with the vessel wall.
Phagocytosis is described as engulfing the bacteria or the offending substance.

Painful, bright red rectal bleeding is usually due to a fissure. Presence of pain and the sentinel tag suggests a posterior fissure-in-ano.

Anal fissures are a common cause of painful, bright red, rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapse

Diagnosis:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated with colonoscopy and EUA with biopsies of the area.

Treatment:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

The middle sacral artery arises from behind the aorta a little above the point of its bifurcation to descend down in front of L4,5, the sacrum and coccyx.

Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. Normally, arterial pa(CO2) increases by 0.5–0.7 mmHg for every 1 mEq/l increase in plasma bicarbonate concentration, a compensatory response that is very quick. If the change in pa(CO2) is not within this range, then a mixed acid–base disturbance occurs.

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%.

The common peroneal nerve divides beneath the peroneus longus muscle and gives off articular and lateral sural cutaneous nerves which supply muscular branches to the muscles of the anterior compartment of the leg which are the tibialis anterior, extensor digitorum, peroneus tertius and extensor hallucis longus.

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.

Atorvastatin is a member of the drug class of statins, used for lowering cholesterol. The mode of action of statins is inhibition of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. This enzyme is needed by the body to make cholesterol. The primary uses of atorvastatin is for the treatment of dyslipidaemia and the prevention of cardiovascular disease.

Wilms’ tumour is one of the most common malignant tumours of childhood but it can also rarely be found in adults. In biopsy, classical histopathological findings include the triphasic pattern composed by blastemal, epithelial, and stromal elements. First symptoms in children include an abdominal palpable mass, while in adults pain and haematuria are the most common complaints. Deletions of tumours’ suppressor genes on chromosome 11 are usually associated with Wilms’ tumour.