Advantages of LMWHGreater ability to inhibit factor Xa directly, interacting less with platelets and so may have a lesser tendency to cause bleedingGreater bioavailability and longer half-life in plasma making once daily subcutaneous administration possibleMore predictable dose response avoiding the need for routine anticoagulant monitoringLower associated risk of heparin-induced thrombocytopenia or of osteoporosis

ACE inhibitors should be used with caution in patients of Afro-Caribbean descent who may respond less well; calcium channel blockers are first line for hypertension in these patients. ACE inhibitors have a role in the management of diabetic nephropathy. ACE inhibitors are contraindicated in pregnant women. ACE inhibitors inhibit the breakdown of bradykinin; this is the cause of the persistent dry cough. Blocking ACE also diminishes the breakdown of the potent vasodilator bradykinin which is the cause of the persistent dry cough. Angiotensin-II receptor blockers do not have this effect, therefore they are useful alternative for patients who have to discontinue an ACE inhibitor because of persistent cough.

A blowout fracture is an isolated fracture of the orbital walls without compromise of the orbital rims. The common mechanisms are falls, high-velocity ball-related sports, traffic accidents, and interpersonal violence.

The frontal, ethmoidal, sphenoid, zygomatic, and lacrimal bones form the bony structures of the orbit. Medially, the maxillary and the lacrimal bone form the lacrimal fossa. Together with the lamina papyracea of the ethmoid bone, they form the medial wall. The sphenoid bone forms the posterior wall and houses the orbital canal. Lateral to the orbital canal lies the superior orbital fissure housing cranial nerves III, IV, V, and VI. The zygomatic bone forms the lateral wall. Superior and inferior borders are the frontal and maxillary bones. Located around the globe of the eye and attached to it are 6 extraocular muscles; the 4 rectus muscles and the superior and inferior oblique muscles. The fat and connective tissue around the globe help to reduce the pressure exerted by the extraocular muscles.

The goal of treatment is to restore aesthetics and physiological function. The problem with orbital blowout fractures is that the volume of the orbit can be increased, resulting in enophthalmos and hypoglobus. In addition, the orbital tissue and inferior rectus muscle can become trapped by the bony fragments leading to diplopia, limitation of gaze, and tethering. Finally, the orbital injury can lead to retinal oedema, hyphema, and significant loss of vision.

While some cases may be managed with conservative care, others may require some type of surgical intervention.

Chlorhexidine is an anti-staphylococcal agent. Cleaning is the removal of foreign material from areas or objects to a point at which they are visually free from debris.  Disinfection is the reduction in the number of infectious particles. Isopropyl alcohol is not effective against C. difficile spores. Autoclaving is a method of sterilisation.

Gluteus maximus is the main extensor muscle of the hip and assists with lateral rotation of the thigh at the hip joint. It also acts as a hip adductor, steadies the thigh, and assists in raising the trunk from a flexed position.
Gluteus maximus is innervated by the inferior gluteal nerve.

Non-steroidal anti-inflammatory medications (NSAIDs) have slight differences in anti-inflammatory activity, but there is a lot of diversity in individual response and tolerance to these treatments. Approximately 60% of patients will respond to any NSAID; those who do not respond to one may well respond to another. Pain relief begins soon after the first dose, and a full analgesic effect should be achieved within a week, whereas an anti-inflammatory effect may take up to three weeks to achieve (or to be clinically assessable). If the desired results are not reached within these time frames, another NSAID should be attempted.

By inhibiting the enzyme cyclo-oxygenase, NSAIDs limit the generation of prostaglandins. They differ in their selectivity for inhibiting various types of cyclo-oxygenase; selective inhibition of cyclo-oxygenase-2 is linked to reduced gastrointestinal discomfort. Susceptibility to gastrointestinal effects is influenced by a number of different parameters, and an NSAID should be chosen based on the frequency of side effects.
Ibuprofen is an anti-inflammatory, analgesic, and antipyretic propionic acid derivative. Although it has fewer side effects than other non-selective NSAIDs, its anti-inflammatory properties are less effective. For rheumatoid arthritis, daily doses of 1.6 to 2.4 g are required, and it is contraindicated for illnesses characterized by inflammation, such as acute gout.

Because it combines strong efficacy with a low incidence of adverse effects, Naproxen is one of the top choices. It is more likely to cause negative effects than ibuprofen.
Similar to ibuprofen, ketoprofen and diclofenac have anti-inflammatory characteristics, however they have additional negative effects.

Indomethacin has a similar or better effect to naproxen, however it comes with a lot of side effects, such as headaches, dizziness, and gastrointestinal problems.

In atrial flutter, ventricular rate control is usually used as a stopgap measure until sinus rhythm can be restored. A beta-blocker (such as bisoprolol), diltiazem, or verapamil can be used to lower the heart rate.

Electrical cardioversion, pharmacological cardioversion, or catheter ablation can all be used to restore sinus rhythm. Cardioversion should not be attempted until the patient has been fully anticoagulated for at least three weeks if the duration of atrial flutter is unknown or has lasted for more than 48 hours. Emergency electrical cardioversion is the treatment of choice when there is an acute presentation with haemodynamic compromise. For the treatment of recurrent atrial flutter, catheter ablation is preferred.

Amiodarone is an anti-arrhythmic medication that can be used to treat both ventricular and atrial arrhythmias. It’s a class III anti-arrhythmic that works by blocking a variety of channels, including Na+ and K+ channels, as well as beta-adrenoreceptors. As a result, it slows conduction through the SA and AV nodes and prolongs phase 3 of the cardiac action potential (slowing repolarisation).

Klebsiellais a genus of non-motile,Gram-negative, rod-shaped bacteriawith a prominent polysaccharide-based capsule. They are routinely found in the nose, mouth and gastrointestinal tract as normal flora, however, they can also behave as opportunistic pathogens.
Infections with Klebsiella spp. areusually nosocomial. They are an important cause of ventilator-associated pneumonia (VAP), urinary tract infection, wound infection and bacteraemia. Outbreaks of infections with Klebsiellaspp. in high-dependency units have been described and are associated with septicaemia and high mortality rates. Length of hospital stay and performance of invasive procedures are risk factors forKlebsiellainfections.
Primary pneumonia withKlebsiella pneumoniaeis a rare,severe, community-acquired infection associated with a poor outcome.
Klebsiella rhinoscleromatis causes a progressive granulomatous infection of the nasal passages and surrounding mucous membranes. This infection is mainly seen in the tropics.
Klebsiella ozanae is a recognised cause of chronic bronchiectasis.
Klebsiella organisms are resistant to multiple antibiotics including penicillins. This is thought to be a plasmid-mediated property. Agents with high intrinsic activity againstKlebsiellapneumoniaeshould be selected for severely ill patients. Examples of such agents include third-generation cephalosporins (e.g cefotaxime), carbapenems (e.g. imipenem), aminoglycosides (e.g. gentamicin), and quinolones (e.g. ciprofloxacin). These agents may be used as monotherapy or combination therapy. Aztreonam may be used in patients who are allergic to beta-lactam antibiotics.
Species with ESBLs (Extended spectrum beta-lactamase) are resistant to penicillins and also cephalosporins such as cefotaxime and ceftriaxone
.

Theophylline and Ethylenediamine are combined in a 2:1 ratio to form Aminophylline. Its solubility is improved by the addition of Ethylenediamine. It has a lower potency and a shorter duration of action than Theophylline.
It is used to treat the following conditions:
Heart failure
It is used to treat the following conditions:
COPD
Bradycardias

Aminophylline has the following properties:
Phosphodiesterase inhibitor that increases intracellular cAMP and relaxes smooth muscle in the bronchial airways and pulmonary blood vessels.
Mast cell stabilization is achieved by using a non-selective adenosine receptor antagonist.
It has slight positive inotropic and chronotropic effects, increasing cardiac output and decreasing systemic vascular resistance, lowering arterial blood pressure. It has been used historically in the treatment of refractory heart failure and is indicated by the current ALS guidelines as a substitute treatment for bradycardia.

The daily oral dose for adults is 900 mg, divided into 2-3 doses. For severe asthma or COPD, a loading dosage of 5 mg/kg over 10-20 minutes is given, followed by a continuous infusion of 0.5 mg/kg/hour. The therapeutic range is small (10-20 microgram/ml), hence assessments of aminophylline plasma concentrations are useful during long-term treatment.

Loop diuretics are drugs used to manage and treat fluid overload associated with CHF, liver cirrhosis, and renal disease. The drugs commonly used are:

• Furosemide
• Bumetanide
• Torsemide
• Ethacrynic Acid

Loop diuretics inhibit the Na-K-Cl pump in the ascending loop of Henle, resulting in salt-water excretion. This relieves congestion and reduces oedema.

The contra-indications to the use of loop diuretics are:
1. Anuria
2. Comatose and precomatose states associated with liver cirrhosis
3. Renal failure due to nephrotoxic or hepatotoxic drugs
4. Severe hypokalaemia
5. Severe hyponatremia
6. History of hypersensitivity to furosemide, bumetanide, or torsemide (or sulphonamides)

The following conditions or states are not contraindications, but loop diuretics needs to be used cautiously in these conditions:
1. Diabetes (but hyperglycaemia less likely than with thiazides)
2. Gout
3. Hypotension (correct before initiation of treatment)
4. Hypovolaemia (Correct before initiation of treatment)

Ciprofloxacin is a cytochrome P450 enzyme inhibitor that raises theophylline levels in the blood. As a result, co-prescribing theophylline should be avoided.

The medicines that typically impact theophylline’s half-life and plasma concentration are listed in the table below:
Drugs that increase the levels of theophylline in the blood
Drugs that lower theophylline levels in the blood
Calcium channel blockers e.g. Verapamil
Fluconazole
Cimetidine
Quinolones, e.g. ciprofloxacin
Methotrexate
Barbiturates
Carbamazepine
Phenobarbital
Macrolides, e.g. erythromycin
Phenytoin (and fosphenytoin)
Rifampicin
St. John’s wort

Muscles of the posterior compartment of the leg, innervated by the tibial nerve, perform plantar flexion of the foot at the ankle joint. The fibularis longus (innervated by the superficial fibular nerve) assists in plantar flexion but is not the most important.

The extensor digitorum longus is innervated by the deep fibular nerve (L5, S1), a branch of the common fibular nerve.

When the vagus nerve is damaged, the soft palate is paralyzed and the uvula is shifted away from the affected side. The vagus nerve innervates the uvulae muscle, which forms the uvula’s core. If only one side is innervated, contraction of the active muscle will draw the uvula towards it.

Arm oedema is one of the sequelae after breast cancer surgery and radiation therapy. Arm oedema in the breast cancer patient is caused by interruption of the axillary lymphatic system by surgery or radiation therapy, which results in the accumulation of fluid in subcutaneous tissue in the arm, with decreased distensibility of tissue around the joints and increased weight of the extremity. Chronic inflammatory changes result in both subcutaneous and lymph vessel fibrosis.

The most common cause of microcytic anaemia and of any anaemia worldwide is iron deficiency anaemia.

Lymphoma is a cancer of the lymphatic system, which is part of the body’s germ-fighting network. They are a group of diseases that are caused by malignant lymphocytes. These malignant cells accumulate in lymph nodes and other lymphoid tissue, giving rise to the characteristic clinical feature of lymphadenopathy.
They can be subdivided into Hodgkin lymphoma (HL) which are characterised by the presence of Reed-Sternberg cells, and non-Hodgkin lymphoma (NHL).
Characteristics of HL include:
1. can present at any age but is rare in children and has a peak incidence in young adults,
2. almost 2:1 male predominance.
3. presents with painless, asymmetrical, firm and discrete enlargement of superficial lymph nodes.
4. cervical node involvement in 60-70% of cases,
5. axillary node involvement in 10-15%
6. inguinal node involvement in 6-12%.
7. modest splenomegaly during the course of the disease in 50% of patients
8. may occasionally have liver enlargement
9. bone marrow failure involvement is unusual in early disease.
Approximately 85% of patients are cured, but the prognosis depends on age, stage and histology.
Two well‐known but rare symptoms in HL are alcohol‐induced pain and pruritus.

Phyllocontin continues contains aminophylline, a bronchodilator used in the management of asthma and COPD.

The index patient is exhibiting symptoms of theophylline toxicity. This may have been triggered by the antibiotic he took. Macrolide antibiotics, like erythromycin and quinolone antibiotics, like ciprofloxacin and levofloxacin, increases the plasma concentration of theophyllines and can lead to toxicity.

Factors that enhance theophylline clearance include cigarette smoking, carbamazepine, phenobarbital, phenytoin, primidone, and rifampin.
Medications that inhibit clearance include ethanol, ciprofloxacin, erythromycin, verapamil, propranolol, ticlopidine, tacrine, allopurinol, and cimetidine.

Angina pectoris is the most common symptom of ischemic heart disease and presents with chest pain relieved by rest and nitro-glycerine.

Nitrates are the first-line treatment to relieve chest pain caused by angina. The commonly used nitrates are:
1. Nitro-glycerine (NTG) – angina pectoris (treatment/prophylaxis), acute coronary syndrome, heart failure, hypertension
2. Isosorbide mononitrate (ISMN) – chronic angina pectoris (treatment)
3. Isosorbide dinitrate (ISDN) – angina pectoris (treatment/prophylaxis)

The nitrate drugs cause vasodilation via the action of nitric oxide.

The contraindications to the use of nitrate are the following:
1. Allergy to nitrates
2. Concomitant use of phosphodiesterases (PDE) inhibitors such as tadalafil and sildenafil
3. Right ventricular infarction
4. Hypertrophic cardiomyopathy
5. Cardiac tamponade
6. Constrictive pericarditis
7. Hypotensive conditions
8. Hypovolaemia
9. Marked anaemia
10. Mitral stenosis
11. Raised intracranial pressure due to cerebral haemorrhage or head trauma
12. Toxic pulmonary oedema

Overdosing on calcium-channel blockers should always be taken seriously and regarded as potentially fatal. Verapamil and diltiazem are the two most lethal calcium channel blockers in overdose. These work by binding the alpha-1 subunit of L-type calcium channels, preventing calcium from entering the cell. In cardiac myocytes, vascular smooth muscle cells, and islet beta-cells, these channels play an important role.

The standard ABC approach should be used to resuscitate all patients as needed. If life-threatening toxicity is expected, intubation and ventilation should be considered early on. If hypotension and shock are developing, early invasive blood pressure monitoring is recommended.

The primary goal of specific treatments is to support the cardiovascular system. These are some of them:

1. Fluid resuscitation: Give up to 20 mL of crystalloid per kilogramme of body weight.

2. Calcium supplementation
This can be a good way to raise blood pressure and heart rate temporarily.
via central venous access: 10% calcium gluconate 60 mL IV (0.6-1.0 mL/kg in children) or 10% calcium chloride 20 mL IV (0.2 mL/kg in children)
Boluses can be given up to three times in a row.
To keep serum calcium >2.0 mEq/L, consider a calcium infusion.

3. Atropine: 0.6 mg every 2 minutes up to 1.8 mg is an option, but it is often ineffective.

4. HIET (high-dose insulin-euglycemic therapy):
The role of HIET in the step-by-step management of cardiovascular toxicity has changed.

5. Vasoactive infusions:
This was once thought to be a last-ditch measure, but it is now widely recommended that it be used sooner rather than later.
Insulin with a short half-life 50 mL of 50 percent glucose IV bolus plus 1 U/kg bolus (unless marked hyperglycaemia present)
Short-acting insulin/dextrose infusions should be continued.
Glucose should be checked every 20 minutes for the first hour, then hourly after that.
Regularly check potassium levels and replace if they fall below 2.5 mmol/L.
Titrate catecholamines to effect (inotropy and chronotropy); options include dopamine, adrenaline, and/or noradrenaline infusions.

6. Sodium bicarbonate: Use 50-100 mEq sodium bicarbonate (0.5-1.0 mEq/kg in children) in cases where a severe metabolic acidosis develops.

7. Cardiac pacing: It can be difficult to achieve electrical capture, and it may not improve overall perfusion.
Bypass AV blockade with ventricular pacing, which is usually done at a rate of less than 60 beats per minute.

8. Intralipid transport
Calcium channel blockers are lipid-soluble agents, so they should be used in refractory cases.

Gastric lipase, commonly known as LIPF, is an acidic lipase released by gastric chief cells, which are found deep within the stomach lining’s mucosal layer. It’s an enzymatic protein that’s in charge of fat digestion in the stomach.

Angiotensin II acts to:
Stimulate release of aldosterone from the zona glomerulosa of the adrenal cortex (which in turn acts to increase sodium reabsorption)
Cause systemic vasoconstriction
Cause vasoconstriction of the renal arterioles (predominant efferent effect thus intraglomerular pressure is stable or increased, thereby tending to maintain or even raise the GFR)
Directly increase Na+reabsorption from the proximal tubule (by activating Na+/H+antiporters)
Stimulate synthesis and release of ADH from the hypothalamus and posterior pituitary respectively
Stimulate the sensation of thirst
Potentiate sympathetic activity (positive feedback)
Inhibit renin production by granular cells (negative feedback)

Plasmodium falciparum is a parasite that is vector-borne which is transmitted by the female Anopheles mosquito.

Bordetella pertussis is transmitted through the respiratory tract, via respiratory droplets or direct contact with infectious secretions.

Mycobacterium tuberculosis is transmitted via inhalation of infected respiratory droplets.

HIV may be transmitted via sexual contact, vertical transmission from mothers to infants, and among injection drug users sharing infected needles, as well as through transfusion of infected blood products.

Treponema pallidum transmission normally occurs during direct sexual contact with an individual who has an active primary or secondary syphilitic lesion.

ALL is the most common leukaemia in children, with a peak incidence between the ages of 2 and 5.
ALL has a wide range of clinical symptoms, but many children present with an acute illness that resembles coryza or a viral infection. ALL also has the following features:
Weakness and sluggishness all over
Muscle, joint, and bone pain that isn’t specific
Anaemia
Petechiae and unexplained bruising
Oedema
Lymphadenopathy
Hepatosplenomegaly

The following are typical features of a full blood count in patients with ALL:
Anaemia (normocytic or macrocytic)
Leukopenia affects about half of the patients (WCC 4 x 109/l).
Around 25% of patients have leucocytosis (WCC > 10 x 109/l).
Around 25% of patients have hyperleukocytosis (WCC > 50 x 109/l).
Thrombocytopaenia

The endocervix is the most common site of Neisseria gonorrhoeae infection in women. Symptoms of infection, when present, include dysuria, cervical discharge, and lower abdominal pain. However, 50% of cases in women may be asymptomatic leading to complications such as pelvic inflammatory disease (PID), which may cause sterility, ectopic pregnancy, or perihepatitis.

PID is also known as Fitz-Hugh-Curtis syndrome is defined as an inflammation of the upper genital tract due to an infection in women. The disease affects the uterus, fallopian tubes, and ovaries. It is typically an ascending infection, spreading from the lower genital tract.

The recommended intramuscular or oral regimens for PID are as follows:

Ceftriaxone at 500 mg IM in a single dose (for persons weighing ≥150 kg, administer 1 g of ceftriaxone); plus doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days.

Amiodarone is a class III potassium channel blocker used to treat multiple types of arrhythmias.

Side effects include:
1. pulmonary fibrosis
2. blue discolouration of the skin
3. phototoxicity
4. corneal deposits
5. hepatic necrosis
6. thyroid dysfunction
7. sleep disturbances
8. peripheral neuropathy.

Xanthopsia is a condition where the patient complains of seeing yellow lines and is seen in digoxin overdose.

Primary wound healing, or healing by first intention, occurs within hours of repairing a full-thickness surgical incision. This surgical insult results in the mortality of a minimal number of cellular constituents. Healing by first intention can occur when the wound edges are opposed, the wound is clean and uninfected and there is minimal loss of cells and tissue i.e. surgical incision wound. The wound margins are joined by fibrin deposition, which is subsequently replaced by collagen and covered by epidermal growth.

All of the above answers are non-parametric tests.

The release of cytokines from Reed-Sternberg cells can cause fever in patients with Hodgkin lymphoma, which increases and decreases in a cyclical pattern of 1 to 2 weeks. This is called Pel-Ebstein or Ebstein-Cardarelli fever, specifically seen in Hodgkin lymphoma. The fever is always high grade and can reach 40 degrees or higher.

Cyclical fever in other conditions is common but is not termed as Pel-Ebstein fever. This term is reserved only with Hodgkin lymphoma.