Combined oral contraceptive pills have an anti ovulatory function and also reduce the pain of menstruation.

Based on the clinical scenario provided, the most probable nerve injured in this patient would be the trochlear nerve. The trochlear nerve has a relatively long intracranial course, and this makes it vulnerable to injury in head trauma. Head trauma is the most frequent cause of acute fourth nerve palsy. A 4th nerve palsy is the most common cause of vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking downstairs.

The injury described in question leads to an abnormal communication between the orbit and the ipsilateral maxillary sinus – this is termed as a blow-out fracture of the orbit.The maxillary sinuses are found in the maxillary bone, inferior to the orbit. They are the largest of the paranasal air sinuses. The maxillary bone forms the floor of the orbit. This layer of bone separates the orbit from the maxillary sinus. As such, fractures of the floor of the orbit can be associated with herniation of the orbital contents into the maxillary sinus. Other options:- The ethmoidal air cells are a collection of smaller air cells in the ethmoid bone. They lie lateral to the anterior superior nasal cavity. They are separated from the orbit by a very thin plate of ethmoid bone called the lamina papyracea, which is found on the medial wall of the orbit. The thin nature of this bone means it is commonly fractured in orbital trauma. However, this is the incorrect answer to the above question as a communication between the ethmoidal air cells, and the orbit is associated with fractures of the medial wall of the orbit, not the floor. – The frontal sinuses are found in the frontal bones, above the orbits on each side of the head. A large portion of the roof of the orbit is composed of the frontal bone and separates the orbit from the frontal sinus. Fractures of the roof of the orbit can be associated with communication between the frontal sinus and orbit. The frontal bones are strong, and so fracture is associated with high-impact anterior trauma, such as a road traffic accident. – The sphenoid sinuses are found in the posterior portion of the roof of the nasal cavity. The pituitary gland lies nestled within the hypophyseal fossa, with only a thin wall of bone separating it from the sphenoid sinus below. As such, neurosurgeons can gain access to the pituitary gland via the sphenoid sinus, in a procedure called transsphenoidal hypophysectomy. – The nasal cavity extends from the nares to the nasopharynx. It is found more medial and inferior than the orbits. It does not lie adjacent to the orbit at any point and so is unlikely to be involved in an orbital fracture.

Although all of the options may lead to an acute red scrotum, torsion of the hydatid of Morgagni is the most common cause at this age (age 12-16 years).

The presenting features and the surgical site provided in the clinical scenario are highly suggestive of ipsilateral hypoglossal nerve injury.Note:Three cranial nerves may be injured during submandibular gland excision.- Marginal mandibular branch of the facial nerve- Lingual nerve- Hypoglossal nerveHypoglossal nerve damage may result in the paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at higher risk of injury. However, the effects of lingual nerve injury are predominantly sensory rather than motor.Thus, the most appropriate answer is the hypoglossal nerve.

The CSF picture in bacterial meningitis has the following characteristics: several polymorphs, cells, protein that is maximum 5g/l, a few lymphocytes and glucose that accounts for the two thirds of the blood level.

WHO states that diabetes can be diagnosed from a single fasting glucose of > 7.0 mmol/l with characteristic symptoms or a glucose level of > 11.1 mmol/l 2 hours after a glucose load. Two fasting glucose levels of > 7.0 mmol/l on separate occasions can also fit the diagnosis in the absence of characteristic symptoms.

Tetralogy of Fallot (TOF), a congenital heart defect, includes the following: right ventricular hypertrophy, ventricular septal defect, abnormal position of the aorta and pulmonary valve stenosis. The O2 saturation in patients with TOF is typically lower than normal and the condition usually becomes symptomatic early in life. A feature of the disease with high diagnostic significance is squatting or crouching of the infant as a compensatory mechanism to increase the peripheral vascular resistance.

Distal renal tubular acidosis (dRTA) is characterised by a decreased hydrogen ion excretion from the alpha intercalated cells of the collecting duct of the distal nephron. The resultant acidosis causes calcium and phosphates to be released from bones to buffer the acidosis causing hypercalciuria. This precipitates calcium compounds in the kidney, predisposing it to renal stone formation. On the other hand, proximal renal tubular acidosis is characterised by an impairment in bicarbonate resorption. Both types lead to metabolic acidosis and electrolyte imbalances including potassium depletion. Children often present with failure to thrive. One way to differentiate between the two conditions is with an acid challenge test. In proximal RTA (type 2) administering an ammonium chloride load will decrease the urinary pH whereas in distal disease (type 1), the urine pH will not decrease below 5.3.

Due to malaria’s incubation period being between 7 and 30 days, malaria prophylaxis cannot provide a patient with confirmed protection. Prophylaxis treatment also often fails. The symptoms such as neck stiffness, fever, and vomiting are also consistent with the cerebral malaria diagnosis.

Pulmonary surfactant is a mixture of lipids and proteins which is secreted by the epithelial type II cells into the alveolar space.

Identify babies as being more likely to develop significant hyperbilirubinemia if they have any of the following factors:- gestational age under 38 weeks- a previous sibling with neonatal jaundice requiring phototherapy- mother’s intention to breastfeed exclusively- visible jaundice in the first 24 hours of life.

Frequent regurgitation of milk and microcytic anaemia is suggestive of a hiatus hernia. The reflux causes regurgitation of milk and frequent ulceration of the lower oesophageal mucosa potentially resulting in blood loss and anaemia. Duodenal atresia usually presents with bilious vomiting and pyloric stenosis presents with projectile vomiting. Alpha 1 antitrypsin deficiency and cystic fibrosis usually do not present with vomiting.

Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.

Developmental dysplasia (DDH) of the hip refers to patients who are born with a dislocated or unstable hip due to abnormal development of the hip. Female infants and first born infants are most likely to present with DDH. Other risk factors for DDH include, breech positioning, oligohydramnios, high birth weight or post date babies.

Henoch-Schönlein purpura (HSP) rashes are commonly found on the legs, feet, and buttocks while Immune thrombocytopenia (ITP) rashes manifest predominantly on the lower legs. HSP happens following a sore throat while ITP usually happens following an URTI or Flu. HSP is an inflammation of a blood vessel (vasculitis) while ITP is immune mediated insufficiency of platelets.

Somatropin is a recombinant human growth hormone used to treat growth failure conditions associated with natural growth hormone deficiencies. According to the UK National Institute for Health and Care Excellence, these conditions include, Prader-Willi syndrome, Noonan syndrome, short stature Homeobox (SHOX) gene deficiency, Turner’s syndrome, chronic renal insufficiency and children who are small for gestational age. Treatment of short stature in achondroplasia has not seen any significant changes with somatotropin.

Ewing’s sarcoma is formed by small, round, blue cells, and is common in children. The usually develop in limbs, and clinical findings include pain and inflammation, with lytic destruction showing up on X-rays.

Hyposplenism is associated with thrombocytosis. Other features of hyposplenism are: – Howell-Jolly bodies and acanthocytosis, occurring secondary to haemolysis.- Pappenheimer bodies: These are granular deposits of iron found within the RBCs.- Lymphocytosis and monocytosis.Causes for hyposplenism include:- Congenital asplenia- Iatrogenic splenectomy: Following trauma or treatment for ITP, thalassemia or spherocytosis).- Autosplenectomy: Secondary to sickle cell anaemia, coeliac disease, dermatitis herpetiformis, essential thrombocythemia or splenic arterial thrombosis).

Cleansing and debridement is paramount in dealing with tetanus-prone wounds (severe crushing injuries, piercing wounds, blisters and burns are outstanding examples, particularly if contaminated with dirt, grass or other debris).Prophylaxis then is relatively easy in persons who have been actively immunized by toxoid injections. For them, a “booster” injection is indicated. There is experimental evidence that antibiotics of the tetracycline group, given soon after injury, may have prophylactic effect against tetanus.

Glandular fever (Infectious Mononucleosis) is caused by Epstein–Barr virus (EBV). Leucocytosis rules in infectious mononucleosis and thrombocytopenia is not an uncommon association. ESR is elevated in most of the cases. Paul-Bunnell test is a rapid test for infectious mononucleosis due to Epstein–Barr virus (EBV).

The chance of having appendicitis again after appendix mass is around 17% in children. While the traditional teachings by Hamilton Bailey recommend following the conservative Ochsner-Sherren regimen followed by an interval appendicectomy six weeks after the discharge of the patient, there remains a looming controversy whether to perform an interval appendicectomy or not.

The normal human pancreas contains about 1,000,000 islets. The islets consist of four distinct cell types, of which three (alpha, beta, and delta cells) produce important hormones| the fourth component (C cells) has no known function.The most common islet cell, the beta cell, produces insulin.The alpha cells of the islets of Langerhans produce an opposing hormone, glucagon.The delta cells produce somatostatin, a strong inhibitor of somatotropin, insulin, and glucagon.

Turners syndrome is a chromosomal syndrome affecting the development of females. In this condition, all or part of the X chromosome gets deleted, producing the Karyotype 45 XO or 45XO/46XX. Spontaneous foetal loss is common in the first trimester, but foetuses which survive are born small for date, and may have lymphedema, and poor feeding in the neonatal period. These patients face numerous medical and developmental problems throughout their lifetimes including growth and puberty failure due to premature ovarian failure/ hypergonadotropic hypogonadism. However spontaneous puberty can be seen in up to 20% of females with Turner’s syndrome.

Intrauterine growth restriction refers to the failure of the fetus to grow in accordance with the weeks of gestation. There are two types of growth restriction, symmetrical and asymmetrical. Causes include various genetic abnormalities, fetal infections, maternal health conditions, etc. Risk factors for the development of IUGR include fetal echogenic bowel, maternal age above 40 years, low PAPP-A levels, maternal smoking or cocaine use, etc. Fetal echogenic bowel implies a brighter than usual fetal intestines on ultrasonography. It is a marker associated with trisomy 21, which is a cause of IUGR.

Kawasaki disease is an acute febrile illness of early childhood characterized by vasculitis of the medium-sized arteries. Diagnostic criteria include fever of at least 5 days duration along with 4 or 5 of the principal clinical features – extremity changes, polymorphous rash, oropharyngeal changes, conjunctival injection and unilateral nonpurulent cervical lymphadenopathy.

Unprotected anal or vaginal sexual intercourse with an infected individual is by far the most common (95%) route by which HIV is transmitted. Other options:- Blood transfusion is an extremely rare cause of HIV transmission in the UK. – While HIV can be transmitted from mother to baby either during birth or via breastfeeding, the transmission rate is only 5 – 20%.- Sharing contaminated needles does put individuals at risk of getting HIV, although public health measures are in place to reduce this risk. – Although HIV can be transmitted via this route, it is around ten times less likely to result in transmission than unprotected anal or vaginal intercourse with an infected individual.

The most overt phenotypic features of Klinefelter syndrome are caused by testosterone deficiency and, directly or indirectly, by unsuppressed follicle-stimulating and luteinizing hormones. Affected men typically have (in decreasing order of frequency): infertility, small testes, decreased facial hair, gynecomastia, decreased pubic hair, and a small penis. Because of their long legs, men with Klinefelter syndrome often are taller than predicted based on parental height. Body habitus may be feminized. In childhood, when there is a relative quiescence in the hormonal milieu, ascertainment of the syndrome may be difficult because the effects of hypogonadism (i.e., small external genitalia and firm testes) may be subtle or not present at all.

Jacob is likely to be four years old as demonstrated by his activities throughout the day. Most 4 year olds are able to run well, jump and hop, but find skipping a little more difficult. They are able to brush their teeth and dress themselves with supervision, and go to the toilet alone.

The best answer is Polycystic Ovarian Syndrome (PCOS), supported by amenorrhea, obesity and acne. High insulin levels are indicative of PCOS and exclude Cushing syndrome (as this is associated with low insulin levels).