Successful administration of median nerve block can be confirmed by the inability to abduct the thumb. The median nerve supplies all the muscles in the anterior compartment of the forearm, apart from the flexor carpi ulnaris and the flexor digitorum profundus to the outer two fingers: so these two fingers can still be flexed. There is a sensory loss to the thumb, index, middle and half of the ring fingers. Absence of thumb abduction due to paralysis of abductor pollicis brevis is a good test for median nerve paralysis.Other options:- The radial nerve supplies the extensors -hence wrist drop does not occur in this scenario. – The ulnar nerve supplies the skin of the ulnar side of the hand. Hence anaesthesia will not affect this area. – The ulnar nerve also supplies the interossei muscles of the hand, which affect abduction and adduction of the fingers.

Injuries to the peroneal nerve can cause numbness, tingling, pain, weakness and foot drop. The branches of the common peroneal nerve innervate and control the muscles in the legs that lift the ankle and toes upward (dorsi flexion).

Pulmonary surfactant is a lipoprotein complex that is responsible for preventing the collapse of alveoli and increasing lung compliance.It is produced in the endoplasmic reticulum and secreted from the lamellar bodies of type 2 pneumocytes.Surfactant is essential for reducing surface tension at the air-water interface in the alveoli, thus preventing the collapse of alveoli during expiration. It is composed of dipalmitoyl phosphatidylcholine (DPPC), which is a phospholipid.In fetal development, production of surfactant begins around 26 weeks of gestation and reaches mature levels by 35 weeks.The deficiency of surfactant can result in neonatal respiratory distress syndrome or hyaline membrane disease, particularly in premature new-born babies.

Haemolytic Uremic Syndrome affects children and is characterised by abdominal pain, a purpuric rash over the body, generalized pallor, haematuria and bloody diarrhoea. There is always a history of preceding diarrhoea caused usually by E.coli and it affects the renal system causing haematuria and deranged renal function tests.

Human breast milk composition changes with the progressive age of the infant. Breastmilk produced for a preterm baby often has a higher caloric content than breastmilk for a term baby. After the production of colostrum in the first days of life, the milk continues to mature. by week 4-6 milk can be considered fully mature. The average calories found in mature breastmilk are about 70kcal/100ml

A drooping eyelid is called ptosis or blepharoptosis. In ptosis, the upper eyelid falls to a position that is lower than normal. Severe ptosis may cover part or all of the pupil and interfere with vision, resulting in amblyopia.Visual development in a child can be permanently impaired when there is deprivation of visual stimulation or when the oculomotor function is impaired. Congenital ptosis can represent both these components

Nissl body is a neuron-specific cellular structure. It is composed of rough endoplasmic reticulum and fine granules. The rough endoplasmic reticulum contains free ribosomes, and are the hub of protein synthesis. When these substances are exposed to a cresyl violet solution, they show selective-staining by turning purple-blue. In pathologic processes, they may undergo chromatolysis.

A transverse lie is a common malpresentation. It occurs when the fetal longitudinal axis is perpendicular to the long axis of the uterus. The location of the spine determines if the foetus is back up (the curvature of the spine is in the upper part of the uterus) or back down (the curvature of the spine is in the lower part of the uterus).Good antenatal care, ECV, and elective caesarean section are the mainstay of the management.Spontaneous delivery of a term foetus is impossible with a persistent transverse lie and, in general, the onset of labour is an indication for the lower segment caesarean section (LSCS) in a case of a transverse lie.

Puberty is when a child’s body begins to develop and change as they become an adult.The average age for girls to begin puberty is 11, while for boys the average age is 12.It’s completely normal for puberty to begin at any point from the ages of 8 to 14. The process can take up to 4 years.

Puberty is the general term for the transition from sexual immaturity to sexual maturity. There are two main physiological events in puberty:- Gonadarche is the activation of the gonads by the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH).- Adrenarche is the increase in production of androgens by the adrenal cortex. It is the term for the maturational increase in adrenal androgen production that normally becomes biochemically apparent at approximately six years of age in both girls and boysA number of other terms describe specific components of puberty:- Thelarche is the appearance of breast tissue, which is primarily due to the action of oestradiol from the ovaries. – Menarche is the time of first menstrual bleed. – Pubarche is the appearance of pubic hair, which is primarily due to the effects of androgens from the adrenal gland. The term is also applied to first appearance of axillary hair, apocrine body odour, and acne.The earliest detectable secondary sexual characteristic on physical examination in most girls is breast/areolar development (thelarche). Ovarian enlargement and growth acceleration typically precede breast development but are not apparent on a single physical examination. Oestrogen stimulation of the vaginal mucosa causes a physiologic leukorrhea, which is a thin, white, non-foul-smelling vaginal discharge that typically begins 6 to 12 months before menarche. Menarche occurs, on average, 2 to 2.5 years after the onset of puberty

Based on the clinical presentation, the child probably has orthostatic proteinuria.Orthostatic proteinuria occurs when the kidneys can conserve urine when the patient is recumbent, such as sleeping at night, but leak protein with standing or in exercise. This results in early morning urine being negative for protein but late in the day urine being positive. It is mostly seen in tall thin adolescents and is benign. Other options:- Alport’s syndrome is a hereditary condition associated with haematuria and deafness. – Urinary tract infections can cause proteinuria, but leucocyte esterase and nitrites would also be expected in a child of this age. – Nephritic syndrome can be associated with proteinuria, but haematuria would also be present. – In nephrotic syndrome, proteinuria would be present on all occasions and associated with oedema.

The study described in the question is a ‘cohort’ study.Other options:A prospective observational study – When groups are classified according to one or more factors at a given time and followed forward to determine outcomes (usually some health status)- Although there is in one sense a control group (those who do not develop the health problem), this is not generally called a ‘controlled’ trial. – An ecological study would look at outcomes in different groups (countries or regions usually) who follow different practices.

In case control studies, observational studies are made to compare two groups, individuals with a certain condition, to those without the condition, with all other factors being equal. In the situation presented by the question, the study was to determine whether a prior risk factor, a low birth weight, was associated with later developing adolescent hypertension, using a paired t-test to statistically determine whether there was indeed a significant association between the two conditions. Case control studies only help to draw associations between two groups and therefore cannot indicate causation. In this scenario we are also not given the p value to determine whether the association is statistically significant. Therefore there is not enough evidence to conclude whether or not birthweight affects the development of adolescent hypertension.

Congenital heart diseases such as complete atrioventricular septal defects are most likely to cause large left to right shunts leading to faltering growth due to chronic severe hypoxia, pulmonary oedema, and feeding problems. Isolated atrial septal defects or ventricular septal defects result in relatively smaller shunts. Pulmonary stenosis and bicuspid aortic valve do not cause chronic systemic hypoxia. People with these conditions are often asymptomatic and only show some symptoms with intense physical activity.

Based on the clinical scenario provided, the most probable diagnosis is Peutz-Jeghers syndrome.Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles.Genetic basis: It follows an autosomal dominant inheritance, and the gene responsible encodes serine-threonine kinase LKB1 or STK11.Classical features of PJS include:- Hamartomatous polyps in the GI tract (mainly small bowel)- Pigmented lesions on lips, oral mucosa, face, palms and soles- Intestinal obstruction, e.g. intussusception- Gastrointestinal bleedingThe treatment is mainly conservative unless complications develop.Note:Hereditary haemorrhagic telangiectasia can also be associated with mucocutaneous lesions and iron-deficiency anaemia, but intestinal polyps are not a feature.

Congenital heart defects are common (40-50%); they are frequently observed in patients with Down syndrome who are hospitalized (62%) and are a common cause of death in this aneuploidy in the first 2 years of life.The most common congenital heart defects are the following:- Endocardial cushion defect (43%), which results in atrioventricular septal defect (AVSD)/AV canal defect- Ventricular septal defect (32%)- Secundum atrial septal defect (10%)- Tetralogy of Fallot (6%)- Isolated patent ductus arteriosus (4%).About 30% of patients have more than one cardiac defect. The most common secondary lesions are patent ductus arteriosus (16%), atrial septal defect, and pulmonic stenosis (9%). About 70% of all endocardial cushion defects are associated with Down syndrome.Valve abnormalities, such as mitral valve prolapse or aortic regurgitation may develop in up to 40-50% of adolescents and adults who were born without structural heart disease.

A low serum free T4 level with a low, or normal serum TSH level would indicate secondary hypothyroidism. A normal TSH response to TRH is a rise at 20 minutes post-dose and then a fall by 60 minutes, while a normal prolactin response would be a rise at 20 minutes and then a fall by 60 minutes. A continued rise of TSH at 60 minutes implies hypothalamic damage. Secondary hypothyroidism is indicated by a low baseline TSH level, while primary hypothyroidism is demonstrated by a raised TSH.

Fragile X syndrome is a genetic syndrome associated with neuro-developmental problems such as learning disabilities and cognitive impairment, with many affected children having mild to moderate intellectual disability. About a third of children have features of autism spectrum disorder and ADHD which affects their communication skills and social interactions. As such, affected individuals usually have delayed speech development and poor nonverbal skills such as gaze aversion. Symptoms tend to worsen with age into adolescence as the demands on their intellect becomes greater. Pre-mutation carriers, who posses smaller genetic repeat expansions, have been found to be associated with some neurodevelopment and other medical problems.

Protein energy malnutrition often presents in two common forms, Kwashiorkor and Marasmus. Kwashiorkor is characterised by a protein deficiency with an additional inadequate calorie intake. As a result, affected children present with oedema, muscular atrophy, and their weight for age is 60-80% of the expected weight. Their cutaneous tissue is however preserved. Marasmus on the other hand is characterised by a severe calorie deficiency leading to atrophy of the muscles and adipose tissue, with weight loss being less than 60% of the normal. In both cases, if the child is not promptly rehabilitated, the malnutrition could cause irreversible damage, such as hepatic, cardiac and renal impairments.

Effective treatment can cure gonorrhoea and help prevent long-term complications. CDC recommends a single dose of 250mg of intramuscular ceftriaxone AND 1g of oral azithromycin. It is important to take all of the medication prescribed to cure gonorrhoea.

Infants exposed to maternal HIV and with positive results require immediate management with co-trimoxazole prophylaxis, regardless of their CD4 levels. Antiretroviral treatment is necessary as well but it could wait until further work-up is complete.

The history is suggestive of mumps. Mumps is a viral disease with initial signs and symptoms including fever, muscle pain, headache, poor appetite, and feeling tired. This is then usually followed by painful swelling of one or both parotid salivary glands. Mumps is a self-limiting condition treated only for symptomatic relief. As he currently is taking analgesics for pain relief, one should only offer reassurance.

Prepubertal atrophic vaginitis is due to a lack of vaginal oestrogen. The pathophysiology behind prepubertal atrophic vaginitis:1.The proximity of the vagina to the anus2.Lack of oestrogen – leads to thinning of the vaginal mucosa3.Lack of pubic hair to protect the area4.Lack of labial fat pads

Developmental milestones at the age of 2 months are as follows:Social and Emotional:- Begins to smile at people – Can briefly calm herself (may bring hands to mouth and suck on hand)- Tries to look at the parents Language/Communication:- Coos, makes gurgling sounds – Turns head toward sounds Cognitive (learning, thinking, problem-solving):- Pays attention to faces – Begins to follow things with eyes and recognize people at a distance – Begins to act bored (cries, fussy) if an activity doesn’t changeMovement/Physical Development:- Can hold head up and begins to push up when lying on tummy – Makes smoother movements with arms and legs

Toe walking refers to a pattern of walking in which the infants walk on the balls of their feet, without putting the heel of the feet on the ground. It is considered normal under the age of 2 years, but if it continues beyond that, it can signify some underlying pathology. The diseases that can be associated with toe walking include unilateral hip dislocation, Spinal tumours, Duchenne muscular dystrophy, prematurity, and cerebral palsy. Waardenburg’s syndrome is an autosomal dominant disorder, causing sensorineural deafness, and heterochromatic irises. Toe walking is not a feature.

Henoch-Schonlein purpura (HSP), also known as IgA vasculitis, is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children. In the skin, the disease causes palpable purpura (small, raised areas of bleeding underneath the skin), often with joint pain and abdominal pain. It is an acute immunoglobulin A (IgA)-mediated disorder. The tetrad of purpura, arthritis, kidney inflammation, and abdominal pain is often observed.

The swelling and bruising on the mandible needs to be checked for fractures. A facial X-ray can adequately visualize this.

Among the options provided, the most characteristic finding that can be expected in his patient’s urine microscopy is RBC casts. Red cell casts are a characteristic feature of acute nephrotic syndrome. Other options:- Hyaline casts may be seen in normal urine, particularly after exercise. – Coarse granular casts occur in glomerular and tubular disease. – Tubular cell casts may be seen in patients with acute tubular necrosis. – The presence of 10 or more white blood cells/mm3 is abnormal and indicates an inflammatory reaction, most commonly due to infection.

Based on the presented clinical scenario, the most probable diagnosis for the patient would be testicular torsion.Rationale:The gubernaculum is the structure responsible for aiding the descent of the testicles from the abdomen into the scrotum. The processus vaginalis precedes the descent of the testes and then undergoes closure. Abnormalities such as the persistence of a patent processus vaginalis, known as bell clapper deformity, predispose to testicular torsion.Other options:- Varicocele: Nutcracker syndrome occurs where the left renal vein becomes compressed in between the superior mesenteric artery and the aorta. Since the left gonadal vein drains into the left renal vein, this results in a varicocele. – Epididymitis and mumps orchitis are differentials for acute testicular pain but are not due to a defect in the processus vaginalis. – An incarcerated inguinal hernia presents mainly with signs of bowel obstruction which are not mentioned in the clinical scenario.The descent of testes:- Until the end of foetal life, the testicles are located within the abdominal cavity. – They are initially located on the posterior abdominal wall on a level with the upper lumbar vertebrae (L2). – Attached to the inferior aspect of the testis is the gubernaculum testis which extends caudally to the inguinal region, through the canal and down to the superficial skin. – It is interesting to note that both the testis and the gubernaculum are extra-peritoneal.- As the foetus grows, the gubernaculum becomes progressively shorter. It carries the peritoneum of the anterior abdominal wall (the processus vaginalis). As the processus vaginalis descends the testis is guided by the gubernaculum down the posterior abdominal wall and the back of the processus vaginalis into the scrotum.- By the third month of foetal life the testes are located in the iliac fossae, by the seventh they lie at the level of the deep inguinal ring.Usually, the processus vaginalis closes after birth but may persist predisposing to indirect hernias. On the other hand, a partial closure may result in the development of cysts on the cord.

Lead Poisoning Symptoms: Abdominal pain, bluish line on the gums (Burton line), wrist/foot drop, anaemia, nephropathy, encephalopathy, cognitive impairmentDiagnosis: Detectable in bloodBasophilic stippling of erythrocytes (disorder of heme synthesis) on smearTreatment: Succimer, Dimercaprol, EDTA