The costodiaphragmatic recess is the lowest point of the pleural sac where the costal pleura becomes the diaphragmatic pleura. At the midclavicular line, this is found between ribs 6 and 8; at the paravertebral lines, between ribs 10 and 12 and between ribs 8 and 10 at the midaxillary line.
The cardiac notch: is an indentation of the heart on the left lung, located on the anterior surface of the lung.
Cupola: part of the parietal pleura that extends above the first rib.
Oblique pericardial sinus: part of the pericardial sac located posterior to the heart behind the left atrium.
Costomediastinal recess: a reflection of the pleura from the costal surface to the mediastinal surface, is on the anterior surface of the chest.
The inferior mediastinum: is the space in the chest occupied by the heart.

The levator veli palatini is the elevator muscle of the soft palate. During swallowing, it contracts, elevating the soft palate to help prevent food from entering the nasopharynx. It arises by a flat lamella from the scaphoid fossa at the base of the medial pterygoid plate, from the spina angularis of the sphenoid and from the lateral wall of the cartilage of the auditory tube. Descending vertically between the medial pterygoid plate and the medial pterygoid muscle, it ends in a tendon which winds around the pterygoid hamulus, being retained in this situation by some of the fibres of origin of the medial pterygoid muscle. Between the tendon and the hamulus is a small bursa. The tendon then passes medialward and is inserted onto the palatine aponeurosis and the surface behind the transverse ridge on the horizontal part of the palatine bone.

Inhaled objects are more likely to enter the right lung for several reasons. First the right bronchus is shorter, wider and more vertical than the left bronchus. Also, the carina (a ridge-like structure at the point of tracheal bifurcation) is set a little towards the left. The terminal bronchiole is a very small space and impossible for the seed to lodge here.

Acetylsalicylic acid, or aspirin, is a nonsteroidal anti-inflammatory drug that is widely used as an analgesic and antipyretic. Aspirin is as a cyclo-oxygenase inhibitor that leads to decreased prostaglandin production. Decreased platelet aggregation is another effect of this drug, achieved by long-lasting use of aspirin.

Created by the small intestinal cells, chylomicrons are large lipoprotein molecules which transport lipids to the liver, adipose, cardiac and skeletal tissue. Chylomicrons are mainly composed of triglycerides (,85%) along with some cholesterol and cholesteryl esters. Apo B-48 is the main apolipoprotein content.

The facial nerve is the seventh of the twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla. It controls the muscles of facial expression and supplies taste fibres to the anterior two-thirds of the tongue. It also supplies preganglionic parasympathetic fibres to several head and neck ganglia. Its branches and distribution are as follows:
Inside the facial canal (proximal to the stylomastoid foramen):
– Greater petrosal nerve – provides parasympathetic innervation to the lacrimal gland, as well as special taste sensory fibres to the palate via the nerve of pterygoid canal
– Nerve to stapedius – provides motor innervation for the stapedius muscle in the middle ear
– Chord tympani – provides parasympathetic innervation to the submandibular and sublingual glands and special sensory taste fibres for the anterior two-thirds of the tongue
Outside the skull (distal to the stylomastoid foramen):
– Posterior auricular nerve – controls the movements of some of the scalp muscles around the ear
– Five major facial branches (in the parotid gland), from top to bottom: temporal branch, zygomatic branch, buccal branch, marginal mandibular branch and cervical branch. From the description given above it is obvious that injury to the facial nerve distal to the stylomastoid foramen will affect facial expression.

Streptokinase belongs to a group of medications known as ‘fibrinolytics’ and is an extracellular metallo-enzyme produced by beta-haemolytic streptococci, used as an effective clot-dissolving medication in patients with myocardial infarction and pulmonary embolism. As Streptokinase is a bacterial product, the body has the ability to build up an immunity to it. Therefore, it is recommended that this medication should not be used again after four days from the first administration, as it may not be as effective and may also cause an allergic reaction.

Fat necrosis is necrosis of adipose tissue with subsequent deposition of calcium, giving it a white chalky appearance. It is seen characteristically in trauma to the breast and the pancreas with subsequent involvement of the peripancreatic fat. In the breast it may present as a palpable mass with is usually painless or as an incidental finding on mammogram. Fatty acids are released from the traumatic tissue which combine with calcium in a process known as saponification, this is an example of dystrophic calcification in which calcium binds to dead tissue. The central focus is surrounded by macrophages and neutrophils initially, followed by proliferation of fibroblasts, neovascularization and lymphocytic migration to the site of the insult.

Based on the aforementioned findings in this case, the most likely diagnosis is medullary carcinoma of the thyroid associated with multiple endocrine neoplasia (MEN).

Medullary thyroid cancer is a tumour of the parafollicular cells (C cells) of the thyroid and is neural crest in origin. It may be familial and occur as part of the MEN 2A disease spectrum. Less than 10% of thyroid cancers are of this type with patients typically presenting as children or young adults. Diarrhoea occurs in 30% of the cases. In association with MEN syndromes, medullary thyroid cancers are always bilateral and multicentric. Spread may either be lymphatic or haematogenous, and as these tumours are not derived primarily from thyroid cells, they are not responsive to radioiodine.

Toxic nodular goitre is very rare. In sporadic medullary carcinoma of the thyroid, patients typically present with a unilateral solitary nodule and it tends to spread early to the lymph nodes in neck.

Causes of massive splenomegaly include chronic myelogenous leukaemia, chronic lymphocytic leukaemia, lymphoma, hairy cell leukaemia, myelofibrosis, polycythaemia vera, sarcoidosis, Gaucher’s disease and malaria.

Hyperbilirubinemia can be caused due to increased bilirubin production, decreased liver uptake or conjugation, or decreased biliary excretion. Normal bilirubin level is less than 1.2 mg/dl (<20 μmol/l), with most of it unconjugated. Elevated unconjugated bilirubin (indirect bilirubin fraction >85%) can occur due to haemolysis (increased bilirubin production) or defective liver uptake/conjugation (Gilbert syndrome). Such increases are less than five-fold usually (<6 mg/dl or <100 μmol/l) unless there is coexistent liver disease.

Answer: Bochdalek hernia

A Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).

In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).

Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.

Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications.

Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.

Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapse

Only ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:

Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both
Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

Skin, fibular collateral ligament, popliteus muscle tendon and lateral meniscus is the correct order of structures covering the lateral aspect of the knee joint from a superficial to deep.

The passage of extremely loose and watery stools is characteristic of Vibrio cholera infection. Most of the other gastroenteric infections do not produce such watery motions.

Vibrio cholerae is a Gram-negative, comma-shaped bacterium. It’s natural habitat is brackish or saltwater. Some strains of V. cholerae cause the disease cholera.

Transmission occurs through the ingestion of contaminated water or food. Sudden large outbreaks are usually caused by a contaminated water supply. Outbreaks and endemic and sporadic cases are often attributed to raw or undercooked seafood.

Symptoms of the disease include sudden onset of effortless vomiting and profuse watery diarrhoea. Correction of fluid and electrolyte losses are the mainstay of treatment. Most cases resolve shortly afterwards, and therefore, antibiotics are not generally indicated.

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.

The arterial anastomoses of the elbow joint is contributed by branches of the brachial artery and the Profunda brachii artery. The brachial artery gives off the superior ulnar collateral artery and the inferior collateral artery. On the other hand, the Profunda brachii gives off the radial and medial recurrent arteries.

Azlocillin, like piperacillin, is an acylampicillin antibiotic with an extended spectrum of activity and greater in vitro potency than the carboxypenicillins. Azlocillin is similar to mezlocillin and piperacillin. It demonstrates antibacterial activity against a broad spectrum of bacteria, including Pseudomonas aeruginosa.

Increased alkaline phosphatase is indicative of cholestasis, with a 4x or greater increase seen 1-2 days after biliary obstruction. Its level can remain elevated several days after the obstruction is resolved due to the long half life (7 days). Increase up to three times the normal level can be seen in hepatitis, cirrhosis, space-occupying lesions and infiltrative disorders. Raised alkaline phosphatase with other liver function tests being normal can occur in focal hepatic lesions like abscesses or tumours, or in partial/intermittent biliary obstruction. However, alkaline phosphatase has several isoenzymes, which originate in different organs, particularly bone. An isolated rise can also be seen in malignancies (bronchogenic carcinoma, Hodgkin’s lymphoma), post-fatty meals (from the small intestine), in pregnancy (from the placenta), in growing children (from bone growth) and in chronic renal failure (from intestine and bone). One can differentiate between hepatic and non-hepatic cause by measurement of enzymes specific to the liver e.g. gamma-glutamyl transferase (GGT).
In an elderly, asymptomatic patient, isolated rise of alkaline phosphatase usually points to bone disease (like Paget’s disease). Presence of other symptoms such as jaundice, pale stools, weight loss suggests obstructive jaundice, most probably due to pancreatic carcinoma.

The costodiaphragmatic recess is the lowest point of the pleural sac where the costal pleura becomes the diaphragmatic pleura. At the midclavicular line, this is found between ribs 6 and 8; at the paravertebral lines, between ribs 10 and 12 and between ribs 8 and 10 at the midaxillary line.
The cardiac notch: is an indentation of the heart on the left lung, located on the anterior surface of the lung.
Cupola: part of the parietal pleura that extends above the first rib.
Oblique pericardial sinus: part of the pericardial sac located posterior to the heart behind the left atrium.
Costomediastinal recess: a reflection of the pleura from the costal surface to the mediastinal surface, is on the anterior surface of the chest.
The inferior mediastinum: is the space in the chest occupied by the heart.

Metabolic alkalosis is a primary increase in bicarbonate (HCO3−) with or without compensatory increase in carbon dioxide partial pressure (Pco2); pH may be high or nearly normal. Metabolic alkalosis occurs as a consequence of a loss of H+ from the body or a gain in HCO3 -. In its pure form, it manifests as alkalemia (pH >7.40). As a compensatory mechanism, metabolic alkalosis leads to alveolar hypoventilation with a rise in arterial carbon dioxide tension p(CO2), which diminishes the change in pH that would otherwise occur. Normally, arterial p(CO2) increases by 0.5–0.7 mmHg for every 1 mmol/l increase in plasma bicarbonate concentration, a compensatory response that occurs very rapidly. If the change in p(CO2) is not within this range, then a mixed acid–base disturbance occurs. Likewise, if the increase in p(CO2) is less than the expected change, then a primary respiratory alkalosis is also present. However an elevated serum bicarbonate concentration can also occur due to a compensatory response to primary respiratory acidosis. A bicarbonate concentration greater than 35 mmol/l is almost always caused by metabolic alkalosis (as is the case in this clinical scenario). Calculation of the serum anion gap can also help to differentiate between primary metabolic alkalosis and the metabolic compensation for respiratory acidosis. The anion gap is frequently elevated to a modest degree in metabolic alkalosis because of the increase in the negative charge of albumin and the enhanced production of lactate. However, the only definitive way to diagnose metabolic alkalosis is by performing a simultaneous blood gases analysis, which reveals elevation of both pH and arterial p(CO2) and increased calculated bicarbonate.

Acetaminophen, NSAIDs, and opiates are recommended in the basic approach to cancer pain associated with bone metastases. They should provide patients with adequate analgesia when used appropriately. NSAIDs including COX2 inhibitors are especially useful for patients with bone pain. Acetaminophen is an effective analgesic but is a weak anti-inflammatory agent. Ketorolac tromethamine is a potent NSAID capable of relieving moderate to severe acute bone pain.

Answer: 8

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 opens his eyes to pain and groans or grunts. He flexes his forearms away from the painful stimuli This gives him a Glasgow score of 8: eye opening response of 2, verbal response 2 and motor response 4.

The left colic flexure is the bend of the transverse colon as it continues to form the descending colon on the left upper quadrant. The spleen is located on the superior aspect of the left colic flexure. It is commonly referred to as the splenic flexure because of its relation o the spleen superiorly.

Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at the sites of previous trauma.

Dermatofibromas are small, noncancerous (benign) skin growths that can develop anywhere on the body but most often appear on the lower legs, upper arms, or upper back. These nodules are common in adults but are rare in children. They can be pink, grey, red, or brown in colour and may change colour over the years. They are firm and often feel like a stone under the skin. When pinched from the sides, the top of the growth may dimple inward. These lesions feel larger than they appear visually.

Dermatofibromas are usually painless, but some people experience tenderness or itching. Most often, a single nodule develops, but some can develop numerous dermatofibromas.

Risk factors for Recurrent Inguinal Hernia with a moderate level of evidence include the presence of a sliding hernia, a diminished collagen type I/III ratio, increased systemic matrix metalloproteinase levels, obesity and open hernia repair under local anaesthesia by general surgeons.
The incorrect surgical technique is likely the most important reason for recurrence after primary IH repair.

According to the guidelines:
– Laparo-endoscopic recurred inguinal hernia repair is strongly recommended after failed anterior tissue or Lichtenstein repair (evidence: moderate; recommendation: strong).
– Anterior repair is recommended after a failed posterior repair (evidence: moderate; recommendation: strong).
– An expert hernia surgeon should repair a recurrent Inguinal Hernia after failed anterior and posterior repair. Choice of technique depends on patient and surgeon specific factors (evidence: low; recommendation: strong upgraded).

The EHS guidelines recommended for bilateral primary inguinal hernia repair, either a bilateral Lichtenstein or endoscopic approach.

The vagus nerve (cranial nerve X) innervates both the palatoglossus and levator veli palatini muscles.

Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal glomerular capillaries into the Bowman’s capsule per unit time. Clinically, this is often measured to determine renal function. Inulin was originally used as it is not reabsorbed by the kidney after glomerular filtration, therefore its rate of excretion is directly proportional to the rate of filtration of water and solutes across the glomerular filter. However, in clinical practice, creatinine clearance is used to measure GFR. Creatinine is an endogenous molecule, synthesised in the body, that is freely filtered by the glomerulus (but also secreted by the renal tubules in very small amounts). Creatinine clearance exceeds GFR due to creatinine secretion, and is therefore a close approximation of the GFR.

Inflammatory breast cancer is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumour cells. Most commonly a ductal carcinoma.
Clinical features include erythematous and oedematous (peau d’orange) skin plaques over a rapidly growing breast mass. Tenderness, burning sensation, blood-tinged nipple discharge. Axillary lymphadenopathy is usually present. 25% of patients have metastatic disease at the time of presentation.
Differential diagnosis includes mastitis, breast abscess, Paget disease of the breast
Treatment is usually done with chemotherapy + radiotherapy + radical mastectomy. This type of cancer is usually associated with a poor prognosis. 5-year survival with treatment: ∼ 50% (without treatment: < 5%)

Primary aldosteronism, also known as primary hyperaldosteronism or Conn’s syndrome, is excess production of the hormone aldosterone by the adrenal glands resulting in low renin levels. Most patients with primary aldosteronism (Conn’s syndrome) have an adrenal adenoma. The increased plasma aldosterone concentration leads to increased renal Na+ reabsorption, which results in plasma volume expansion. The increase in plasma volume suppresses renin release from the juxtaglomerular apparatus and these patients usually have low plasma renin levels. Salt restriction and upright posture decrease renal perfusion pressure and therefore increases renin release from the juxtaglomerular apparatus. Secondary aldosteronism is due to elevated renin levels and may be caused by heart failure or renal artery stenosis.

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.