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 jugular foramen is a large foramen in the base of the skull. It is located behind the carotid canal and is formed in front by the petrous portion of the temporal bone, and behind by the occipital bone. Cranial nerves IX, X, and XI and the internal jugular vein pass through the jugular foramen.

The fundus of the stomach along with the greater curvature of the stomach receive blood supply from the short gastric artery. The short gastric artery arises from the end of the splenic artery. The ligation of the splenic artery therefore would cause a disruption of blood supply to the fundus of the stomach.

Fractures of the distal tibia and fibula may result in loss of stability of the ankle joint. They may present as a fracture only, fracture and ligamentous injury, multiple fractures or a fracture dislocation.

Isolated fibular fractures at the level of the syndesmosis (Weber B) without associated medial injury should be placed in a short leg backslab (ankle at plantargrade) and remain NWB (non-weight bearing).

With medial malleolus fractures care should be taken to rule out any other fracture or injury around the ankle. The entire length of the fibula should be palpated and x-rayed to rule out any Maisonneuve type injuries. Any other fracture, ligament injury or talar shift indicate the fracture is likely to be unstable and should be reviewed by orthopaedics.

If medial malleolar injury is truly isolated then a short leg backslab (below knee plaster cast) should be applied and the patient is to remain NWB until orthopaedic review.

Urinary incontinence is the involuntary excretion of urine from one’s body. It is often temporary and it almost always results from an underlying medical condition. Several types include:
– Stress incontinence is the voiding of urine following increased abdominal pressure e.g. laughing, coughing, pregnancy etc. It is the most common form of incontinence in women, most commonly due to pelvic floor muscle weakness, physical changes from pregnancy, childbirth and menopause. In men it is a common problem following a prostatectomy. Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.
– Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence are involuntary and inappropriate detrusor muscle contractions.
– Functional incontinence – occurs when a person does not recognise the need to go to the toilet, recognise where the toilet is or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity or unwillingness. t
– Overflow incontinence – sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine.

Treatment of Crohn’s disease is based on the disease site, pattern, activity, and severity. The general goals of treatment for Crohn’s disease are as follows:
To achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medication.
To permit the patient to function as normally as possible.
Therapy for mild Crohn’s disease is typically administered in a sequential “step-up” approach, in which less aggressive and less toxic treatments are initiated first, followed by more potent medications or procedures if the initial therapy fails.
Patients are treated with preparations of 5-aminosalicylic acid (5-ASA), antibiotics, and nutritional therapy. However, the use of 5-ASA for the treatment of Crohn’s disease is controversial; only a small subset of patients may benefit from this agent. Although 5-ASA is effective for reducing disease activity in active Crohn’s disease, it typically has a lower efficacy for Crohn’s disease than for ulcerative colitis, and its efficacy for maintenance of remission remains unproven.

If no response occurs or if the disease is more severe than initially thought, corticosteroids and inhibitors of DNA synthesis (i.e., immunomodulators) with 6-mercaptopurine (6-MP)/azathioprine or methotrexate are administered. Finally, biologic agents (infliximab, adalimumab, certolizumab pegol, and natalizumab) and surgical therapies can be useful.

For the treatment of moderate to severe Crohn’s disease, current recommendations include the “top-down” approach, which differs from the conventional step-up approach in that more potent agents are administered initially. Top-down therapies include biologic agents and steroids as needed versus combination therapy with both biologic drugs and immunomodulatory agents.

Azathioprine or 6-MP is effective for maintenance of remission in Crohn’s disease; each is effective for avoiding surgery and for preventing postoperative and endoscopic relapse. Both agents can be used in combination with infliximab.

If medical therapy for active Crohn’s disease fails, surgical resection of the inflamed bowel, with the restoration of continuity, is indicated.

Recommended indications for surgical intervention include the following:
Failed medical therapy
Persistent symptoms despite high-dose corticosteroid therapy
Treatment-related complications, including intra-abdominal abscesses
Medically intractable fistulae
Fibrotic strictures with obstructive symptoms
Toxic megacolon
Intractable haemorrhage
Perforation
Cancer

For Rectal Crohn’s: Proctectomy is appropriate, and in published series, it is required in 10 to 20% of cases. Unfortunately, proctectomy can be complicated by poor wound healing and perineal sinus formation in up to 25 to 50% of patients. A gracillis flap can be helpful.

Two major types of intestinal contractions are segmentation and peristalsis:
Segmentation occurs most frequently and primarily involves circular muscle. It is essentially a contraction of 2- or 3-cm long intestinal segments while the muscle on either side of it relaxes. Chyme in the segment is displaced in both orad and aborad directions. As the contracted segment relaxes, the previously relaxed segments on either side may contract. This efficiently mixes the chyme with the digestive secretions and exposes the mucosal absorptive surface to the luminal contents. It also serves a propulsive function and contributes to the aborad movement of chyme.
Peristalsis is a propulsive wave of contraction that is initiated by intestinal distension. It is short lived and travels only a few centimetres before dying out. The combined effects of intestinal peristalsis and segmentation provide for both adequate mixing of the intestinal contents and slow, steady movement of chyme.

A prolonged bleeding time is seen in platelet disorders like thrombocytopenia. Patients with haemophilia A or B have a prolonged PTT but not a prolonged bleeding time.
Ca2+ is necessary for coagulation.
von Willebrand factor is an important part of the factor VIII complex and promotes platelet adhesion and aggregation.
DIC results in depleted coagulation factors and accumulation of fibrin.

A neuroendocrine tumour of the chromaffin cells in adrenal medulla, pheochromocytoma secretes excessive catecholamines – adrenaline (epinephrine) and noradrenaline (norepinephrine). Pheochromocytomas are also known as the ‘10% tumour’. This is because 10% of them are bilateral, 10% are malignant, and 10% are extra-adrenal. Extra-adrenal paragangliomas (also known as extra-adrenal pheochromocytomas) are less common than pheochromocytomas and arise in the ganglia of sympathetic nervous system. Around 25% of pheochromocytomas are familial. Symptoms are described as feeling of ‘impending doom’, and include tachycardia, hypertension, palpitations, anxiety, headaches and pallor. Orthostatic hypertension is typically seen where there is a more than 100 mmHg fall in systolic pressure when the patient stands up. Pheochromocytomas can also lead to malignant hypertension. Diagnosis is by measurement of catecholamines and metanephrines in blood or in 24-hour urine, after exclusion of other possible causes such as stress, hypoglycaemia and drugs (methyldopa, dopamine agonists, ganglion-blocking antihypertensive). Imaging is also needed to localize the tumour. Localization of the tumour can also be done by Iodine-131 meta-iodobenzylguanidine (I131-MIBG) imaging.

The posterior relations of the head of the pancreas include: the inferior vena cava, the common bile duct, the renal veins, the right crus of the diaphragm and the aorta.

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.

At the superficial inguinal ring, the pubic tubercle would be felt as a bony prominence lateral to the edge of the spermatic cord. This tubercle is the point of attachment of the inguinal ligament that makes up the floor of the inguinal canal.
Pecten pubis is the ridge on the superior surface of the superior pubic ramus and the point of attachment of the pectineal ligament.
The pubic symphysis is the joint between the two pubic bones and the iliopubic eminence is a bony process on the pubis found near the articulation of the pubis and the ilium.
The iliopectineal line is formed by the arcuate line of the ilium and the pectineal line of the pubis. It is the line that marks the transition between the abdominal and pelvic cavity.
The sacral promontory is found on the posterior wall of the pelvis and would not be felt through the inguinal ring.

Hepatic angiosarcomas are associated with particular carcinogens which includes: arsenic , thorotrast, and polyvinyl chloride. With exposure to this three agents, there is a very long latent period of many years between exposure and the development of tumours.

Hepatitis A is a viral liver disease that can cause mild to severe illness. The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands). Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is often fatal.
Prodrome
In the prodrome, patients may have mild flulike symptoms of anorexia, nausea and vomiting, fatigue, malaise, low-grade fever (usually < 39.5°C), myalgia, and mild headache. Smokers often lose their taste for tobacco, like persons presenting with appendicitis. Icteric phase
In the icteric phase, dark urine appears first (bilirubinuria). Pale stool soon follows, although this is not universal. Jaundice occurs in most (70%-85%) adults with acute HAV infection; it is less likely in children and is uncommon in infants. The degree of icterus also increases with age. Abdominal pain occurs in approximately 40% of patients. Itching (pruritus), although less common than jaundice, is generally accompanied by jaundice.

Arthralgias and skin rash, although also associated with acute HAV infection, are less frequent than the above symptoms. Rash more often occurs on the lower limbs and may have a vasculitic appearance.

Relapsing hepatitis A
Relapsing hepatitis A is an uncommon sequela of acute infection, is more common in elderly persons, and is characterized by a protracted course of symptoms of the disease and a relapse of symptoms and signs following apparent resolution.

The cholera toxin (CTX or CT) is an oligomeric complex made up of six protein subunits: a single copy of the A subunit (part A), and five copies of the B subunit (part B), connected by a disulphide bond. The five B subunits form a five-membered ring that binds to GM1 gangliosides on the surface of the intestinal epithelium cells. The A1 portion of the A subunit is an enzyme that ADP-ribosylates G proteins, while the A2 chain fits into the central pore of the B subunit ring. Upon binding, the complex is taken into the cell via receptor-mediated endocytosis. Once inside the cell, the disulphide bond is reduced, and the A1 subunit is freed to bind with a human partner protein called ADP-ribosylation factor 6 (Arf6). Binding exposes its active site, allowing it to permanently ribosylate the Gs alpha subunit of the heterotrimeric G protein. This results in constitutive cAMP production, which in turn leads to secretion of H2O, Na+, K+, Cl−, and HCO3− into the lumen of the small intestine and rapid dehydration. The gene encoding the cholera toxin was introduced into V. cholerae by horizontal gene transfer.

Answer: Surgery over the next few days

Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort.

The most common cause of hypovolaemic hyponatraemia include: liver cirrhosis, congestive heart failure and nephrotic syndrome. In hypovolaemic hyponatraemia, both sodium and water content increase: Increase in sodium content leads to hypervolemia and water content to hyponatraemia.

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

Pancreatic cancer typically has a poor prognosis, partly because the cancer usually initially remains symptomless, leading to locally advanced or metastatic disease at the time of diagnosis. Median survival from diagnosis is around 3–6 months. Even in those suitable for resectional surgery, 5-year survival rates are still only 30 per cent.

Grey platelet syndrome (GPS) is a rare inherited bleeding disorder associated with an almost total absence of α-granules and their contents. The syndrome is characterised by thrombocytopenia, enlarged platelets that have a grey appearance, myelofibrosis, and splenomegaly. Alpha granules store proteins and growth factors that promote platelet adhesiveness and wound healing. Patients with GPS develop symptoms and signs such as easy bruising, prolonged bleeding, and nose bleeds.

To determine compliance of the respiratory system, changes in transmural pressures (in and out) immediately across the lung or chest cage (or both) are measured simultaneously with changes in lung or thoracic cavity volume. Changes in lung or thoracic cage volume are determined using a spirometer with transmural pressures measured by pressure transducers. For the lung alone, transmural pressure is calculated as the difference between alveolar (pA; inside) and intrapleural (ppl; outside) pressure. To calculate chest cage compliance, transmural pressure is ppl (inside) minus atmospheric pressure (pB; outside). For the combined lung–chest cage, transmural pressure or transpulmonary pressure is computed as pA – pB. pA pressure is determined by having the subject deeply inhale a measured volume of air from a spirometer. Under physiological conditions the transpulmonary or recoil pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly negative to slightly positive as a person breathes.

Hodgkin’s lymphoma is a disease characterized by malignant proliferation of cells of the lymphoreticular system. It can be localized or disseminated, and can involve the nodes, spleen, liver and marrow. Symptoms of the disease include non-tender lymphadenopathy, fever, night sweats, weight loss, itching and hepatosplenomegaly. Histologically, the involved nodes show the presence of Reed-Sternberg cells, which are large, binucleated cells, in a heterogenous cellular infiltrate of histiocytes, lymphocytes, monocytes, plasma cells and eosinophils.

For this procedure:
Following the preparation of the patient, a Rutherford-Morison incision was made at the right or left iliac fossa to access to the iliac vessels. Heparin (2500-4000 IU bolus) was given intravenously prior to the clamping of the iliac vessels. The renal artery was first anastomosed in an end-to-side fashion to the external iliac artery. The corner sutures (6/0 Prolene) were placed while the kidney allograft was first placed at the medial side of the incision. The lateral side of the renal artery was anastomosed by continuous suture using the 6/0 Prolene suture. The kidney allograft was then flipped to the lateral side and the medial side of the renal artery was anastomosed to the external iliac artery. The anastomosis was checked by placing a small vascular bulldog to the renal artery and the vascular clamp was released over the external iliac artery.

Following the renal artery anastomosis, the renal vein was anastomosed in an end-to-side fashion to the external iliac vein. Two corner sutures (5/0 Prolene) were placed first, then the lateral side of renal vein anastomosis was performed with continuous sutures from inside the lumen, and then a medial side anastomosis was performed by continuous sutures from the outside of the lumen (Figure ​(Figure2).2). Similarly, the anastomosis was checked by placing a vascular clamp over the renal vein and then releasing the vascular clamp on the external iliac vein.

The patient is in hypovolemic shock, he is transfused with blood to replace the volume lost. It is important not only to replace fluids but stop active bleeding in resuscitation. Fluid replacement will result in a decreased sympathetic discharge and adequate ventricular filling thus reducing total peripheral resistance and increasing cardiac output and cardiac filling pressures.

The distinction between a benign renal adenoma and renal adenocarcinoma is commonly made on the basis of size. Tumours less than 2 cm in size rarely become malignant as opposed to those greater than 3 cm.

Chest pain, hypoxia, and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism (PE).

PE is one of the leading causes of mortality in pregnancy. Evaluation with low-dose perfusion scintigraphy may be preferable to computed tomographic pulmonary angiography (CTPA).
PE is treated with LMWH throughout pregnancy and for 4–6 weeks after childbirth. Warfarin is contraindicated in pregnancy (though may be continued in women with mechanical heart valves due to a significant risk of thromboembolism).

Erection is a function of the parasympathetic nerves. Of the nerves listed, only the pelvic splanchnic nerves have parasympathetic fibres that innervate the smooth muscles and glands of the pelvic viscera.

Lipofuscin , also known as lipochrome, is a wear and tear pigment or an aging pigment. It represents free radical injury or lipid peroxidation. On microscopic examination is appears as a yellowish brown pigment around the nucleus (perinuclear pigment). It is often seen in cells which are undergoing regressive changes, commonly in the liver and heart of old patients or patients with cancer, cachexia or severe malnutrition.

Gap junctions are attachments between cells that permit intercellular communication e.g. they permit current flow and electrical coupling between myocardial cells. They allow direct electrical transmission among cells and also permit certain substance to pass through as well. They are either homotypic, formed by two identical hemichannels or heterotypic, formed by different hemichannels.

This patient had endoscopy and biopsy done by different doctors and proton pump inhibitor therapy followed by repeat endoscopy and biopsy six months later which had no definite evidence of dysplasia.

British Society of Gastroenterology (BSG) guidelines state that for patients with Barrett’s oesophagus (BO) but without dysplasia, the recommended surveillance protocols are two yearly, four quadrant biopsies every 2 cm, but jumbo biopsies are not required.

Codman’s triangle is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone. The main causes for this sign are osteosarcoma, Ewing’s sarcoma, eumycetoma, and a subperiosteal abscess.

Answer: Fitz Hugh Curtis syndrome

Fitz-Hugh-Curtis syndrome is a rare disorder that occurs almost exclusively in women. It is characterized by inflammation of the membrane lining the stomach (peritoneum) and the tissues surrounding the liver (perihepatitis). The muscle that separates the stomach and the chest (diaphragm), which plays an essential role in breathing, may also be affected. Common symptoms include severe pain in the upper right area (quadrant) of the abdomen, fever, chills, headaches, and a general feeling of poor health (malaise). Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID), a general term for infection of the upper genital tract in women. Infection is most often caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Fitz-Hugh-Curtis syndrome is characterized by the onset of sudden, severe pain in the upper right area of the abdomen. Pain may spread to additional areas including the right shoulder and the inside of the right arm. Movement often increases pain. The upper right area may be extremely tender.

Additional symptoms may occur in some cases including fever, chills, night sweats, vomiting and nausea. Some affected individuals may develop headaches, hiccupping, and a general feeling of poor health (malaise).

Some affected individuals may have symptoms associated with pelvic inflammatory disease including fever, vaginal discharge, and lower abdominal pain. Lower abdominal pain may precede, follow, or occur simultaneously with upper abdominal pain.

Most cases of Fitz-Hugh-Curtis syndrome are caused by infection with the bacterium Chlamydia trachomatis, which causes Chlamydia or the organism Neisseria gonorrhoeae, which causes gonorrhoea. Chlamydia and gonorrhoea are common sexually transmitted diseases (STDs). Researchers believe that more cases of Fitz-Hugh-Curtis syndrome are caused by infection with Chlamydia trachomatis than with Neisseria gonorrhoeae.

The exact process by which such infections cause Fitz-Hugh-Curtis syndrome (pathogenesis) is not completely understood. Some researchers believe that it occurs because of infection of the liver and surrounding tissue, which may result from bacteria traveling from the pelvis directly to the liver or via the bloodstream or lymphatic system. Fitz-Hugh-Curtis syndrome is characterized by the developed of string-like, fibrous scar tissue (adhesions) between the liver and the abdominal wall or the diaphragm.

Laparoscopy is the gold standard for diagnosing FHCS and PID. In the setting of PID, laparoscopy can show oedema with exudates on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess. FHCS can be diagnosed directly via visualization of adhesions between the diaphragm and liver or liver and the anterior abdominal wall.

As a reconstructive option after extensive surgery, pedicled musculocutaneous flaps offer several advantages in the setting of previous radiotherapy. Rotational skin flaps will comprise of irradiated tissue and thus won’t heal well.

The external carotid artery is a branch of the common carotid artery that supplies parts of the neck, head and face. It branches off from the common carotid artery at the level of the thyroid cartilage. The external carotid, at the level of the mandible divides into the maxillary artery and the superficial temporal. The superficial temporal artery is the posterior branch of these two arteries. It starts off, somewhat, as a continuation of the external carotid artery at the substance of the parotid gland. Anterior cerebral and middle cerebral arteries are branches of the internal carotid artery.

Containment of fistula output and skin protection should be instituted as soon as the diagnosis is made as it will decrease local skin excoriation and inflammation, pain and infection. While low output fistulas may be controlled with a simple absorbent dressing, complex fistulas often require advanced techniques including barrier creams, powders, and sealants to protect the skin from auto-digestion as well as bridging for fistula isolation, topographical enhancements, and complex pouching systems with or without sump drainage
Fistulas arising from the oesophagus, duodenal stump after gastric resection, pancreaticobiliary tract, and jejunum are more likely to close without operative intervention. Additionally, those with long tracts and small enteric wall defects are associated with higher spontaneous closure rates. Fistulas in the colon show favourable rates of spontaneous resolution.

The Fick’s principle states that the uptake of a substance by an organ equals the arteriovenous difference of the substance multiplied by the blood flowing through the organ. We can thus calculate the pulmonary blood flow with pulmonary arterial (i.e., mixed venous) oxygen content, aortic oxygen content and oxygen uptake. The pulmonary blood flow, systemic blood flow and cardiac output can be considered the same assuming there are no intracardiac shunts. Thus, we can calculate the cardiac output. Cardiac output = oxygen uptake/(aortic − mixed venous oxygen content) = 200 ml/min/(15 ml O2/100 ml − 10 ml O2/100 ml) = 200 ml/min/(5 ml O2/100 ml) = 200 ml/min/0.05 = 4000 ml/min.
It is crucial to remember to use pulmonary arterial oxygen content and not peripheral vein oxygen content, when calculating the cardiac output by Fick’s method.

Bowel preparation is a significant aspect of the flexible sigmoidoscopy procedure. Clear visibility of the bowel mucosa is critical for a thorough examination. The combination of a light breakfast in the morning and the application of 1 or 2 phosphate enemas a few hours before the examination is a safe and commonly used method of preparing a patient for a flexible sigmoidoscopy procedure.

The percentages of body water contained in various fluid compartments add up to total body water (TBW). This water makes up a significant fraction of the human body, both by weight and by volume. Ensuring the right amount of body water is part of fluid balance, an aspect of homeostasis. The extracellular fluid (ECF) includes all fluids outside the cells. This fluid can be divided into three fluid departments: interstitial (in the tissue spaces) fluid, blood plasma and lymph, and specialised compartments called transcellular fluid. The extracellular fluid surrounds all the cells in the body and is in equilibrium with the intracellular fluid. So, its composition must remain fairly constant even though substances are passing into and out of the cells. The interstitial fluid, though called a fluid, is in a reality a gel-like composition made up of: water, proteoglycan molecules and collagen. The extracellular fluid constitutes 40% of total body water, with intracellular fluid making up the remaining 60%. It is relatively rich in glucose.

Extradural haematoma (EDH) is defined as an acute bleed between the dura mater and the inner surface of the skull. This then causes increased intracranial pressure, which puts vital brain structures at risk. The question asks for the least likely cause, and extradural hematoma would be acute in onset.

At the base of the skull the foramen ovale is one of the larger of the several holes that transmit nerves through the skull. The following structures pass through foramen ovale: mandibular nerve, motor root of the trigeminal nerve, accessory meningeal artery, lesser petrosal nerve, a branch of the glossopharyngeal nerve, emissary vein connecting the cavernous sinus with the pterygoid plexus of veins and occasionally the anterior trunk of the middle meningeal vein.

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.

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 lingual artery arises from the external carotid between the superior thyroid artery and facial artery. It can be located easily on the lower surface of the tongue. The terminal branch of the lingual artery is the deep lingual artery. On its course the lingual artery gives off side branches: dorsal lingual branches that supply the dorsum of the tongue till the epiglottis; sublingual artery that supplies the sublingual gland.

Osteochondromas, or osteocartilaginous exostoses, are the most common benign bone tumours, and tend to appear near the ends of long bones. The overgrowth can occur in any bone where cartilage forms bone, and they are capped by cartilage. They are most common in people between the ages of 10-20 years old.

Boundaries of the posterior mediastinum include:
Superior: a plane through the sternal angle and T4/5
Inferior: the diaphragm
Anterior: the middle mediastinal structures
Posterior 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. In this case, the lymph nodes is the correct answer.

The operation aims to remove most of your large bowel including the blood supply and associated lymph glands and leave the rectum behind. It is most commonly recommended for inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

It is also recommended for other bowel conditions like familial adenomatous polyposis, and when there is more than one bowel cancer.

In inflammatory bowel disease such as ulcerative colitis the small bowel is brought out to the skin of the tummy as an ileostomy and the remaining bowel (rectum) is closed off and left inside. In other conditions where possible, the two ends of the remaining healthy bowel (small bowel to rectum) are re-joined (an anastomosis). Most
people therefore do not require a stoma. However some people benefit from having a stoma made depending on circumstances regarding:
1) Their general state of health (heart disease, lung disease, diabetes, vascular disease, smoking, steroid medications, being undernourished);
2) Factors which cannot be seen until the surgeon can see inside your tummy (more extensive disease than originally thought, extensive pelvic scarring from previous surgery or other treatment, excessive bleeding).
Temporary stomas are made to divert faeces away from the join (de-functioning) to give the best chance to heal if there is concern it may be slow to heal.

Emergency indications for surgical intervention in severe UC include free perforation, haemorrhage or systemic instability. An urgent indication for colectomy is a severe attack that is unresponsive to medical therapy.

In the setting of severe UC, the procedure of choice is subtotal colectomy and ileostomy. The residual rectal disease is controllable in most patients. In general, there are advantages to the subtotal colectomy approach, including a lower morbidity if pelvic dissection is not performed, preservation of the rectum so that reconstructive procedures can be performed later, and allowing the definitive procedure to be deferred to an optimal situation when the patient is off immunosuppressive medications and has improved nutritional status. Usually, the staged reconstruction with IPAA or definitive total proctocolectomy is performed several months later.

Foreign bodies including sutures will delay wound healing, however due to the net affect being helpful they are used. Secondary wound infection will delay healing and is a potential post op complication. Corticosteroids depresses the wound healing ability of the body. Poor nutrition will also delay healing leading to decreased albumin, vit D and vit C. Diabetic patients with atherosclerosis with poor perfusion of tissues have notoriously delayed/poor healing.

The gastroduodenal artery is the artery that lies just behind the first portion of the duodenum. The gastroduodenal artery would be the most likely artery to be perforated by a cancer in this area. The perforation is as a result of the spillage of the acidic content of the chyme in the duodenum. All the other blood vessels in the list would less likely be affected by the gastric expellant from the duodenum. The coronary vein is located in the lesser curvature of the stomach. The inferior pancreaticoduodenal arcade is located inferiorly to the first part of the duodenum on the head of the pancreas. The hepatic artery proper is a branch of the common hepatic artery that is located superior to the first portion of the duodenum. The splenic vein arises from the spleen; it forms the portal vein by joining the superior mesenteric vein. It is laterally detached from the duodenum. Both the left gastric vein and the splenic vein are located superior to the first portion of the duodenum.

Gout is a rheumatic disease caused by the precipitation of monosodium urate crystals into tissues, usually joints. This causes acute or chronic pain; the acute illness initially affects only one joint, often the first metatarsophalangeal joint. The diagnosis of the disease requires the identification of crystal in the synovial fluid. These crystals are needle-shaped and strongly negatively birefringent.

A mid diastolic murmur at the apex is a classical description of a mitral stenosis (MS) murmur.
MS a valvular anomaly of the mitral valve that leads to obstruction of blood flow into the left ventricle. The most common cause of MS is rheumatic fever. The clinical manifestations depend on the extent of stenosis: reduced mitral opening leads to progressive congestion behind the stenotic valve. Acute decompensation can cause pulmonary oedema. Echocardiography is the main diagnostic tool for evaluating the mitral valve apparatus, left atrial size, and pulmonary pressure. In the event of high grade and/or symptomatic stenosis, percutaneous valvuloplasty or surgical valve replacement is often required.

Types and causes of murmurs:
Ejection systolic: Aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan-systolic: Mitral regurgitation, tricuspid regurgitation, VSD
Late systolic: Mitral valve prolapse, coarctation of aorta
Early diastolic: Aortic regurgitation, Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic: Mitral stenosis, Austin-Flint murmur (severe aortic regurgitation)