Neuroleptic malignant syndrome (NMS) is a life-threatening syndrome associated with the use of dopamine-receptor antagonist medications or with the rapid withdrawal of dopaminergic medications. NMS has been associated with virtually every neuroleptic agent but is more commonly reported with the typical antipsychotics like haloperidol and fluphenazine.Classic clinical characteristics include mental status changes, fever, muscle rigidity, and autonomic instability. While uncommon, NMS remains an important part of the differential diagnosis of fever and mental status changes because it requires early diagnosis and treatment to prevent significant mortality and death. Treatment involves immediately discontinuing the offending agent, aggressive supportive care to manage and prevent complications, and pharmacologic therapy in severe cases.The main risk factor for developing NMS is the initiation or increase in the dosage of neuroleptic medication. High-potency and long-aging neuromuscular depot forms carry the greatest risk. The concurrent use of multiple neuroleptic agents or lithium also increases the risk. Abrupt withdrawal of dopaminergic agents is a less common but important cause of NMS. Symptoms of NMS develop over one to three days and include distinctive clinical features: fever, muscle rigidity, mental status changes, and autonomic rigidity.The DSM-V criteria for diagnosing NMS are as follows:Major Criteria (all required):Exposure to dopamine-blocking agentSevere muscle rigidityFeverOther Criteria (at least two required):DiaphoresisDysphagiaTremorIncontinenceAltered level of consciousnessMutismTachycardiaElevated or labile blood pressureLeukocytosisElevated creatine phosphokinase

Pneumothorax is a condition in which air accumulates in the pleural space, causing the lung to collapse. It can be caused by trauma, medical procedures, or underlying lung pathology. Symptoms of pneumothorax include sudden onset of chest pain, decreased or absent breath sounds on one side, tachycardia, tachypnea, and hypotension. Immediate treatment is required, and the first step is the insertion of a large-gauge needle into the fifth intercostal space anterior to the midclavicular line of the affected side. This is known as needle thoracostomy. Following needle thoracostomy, a chest tube can be inserted, and a chest X-ray can be performed. Pericardiocentesis is not recommended in this case, as the patient does not have cardiac tamponade.

ADHD commonly cause secondary problems in addition to its primary feature of inattention and hyperactivity. Risk of parental abuse increases as there is difficulty in disciplining the child which leads to frustration and disappointment. Peers rejection and social withdrawal is seen as children with ADHD has difficulty in communicating and getting along with others. Inattention, hyperactivity and impulsiveness increases risk of accidents. Children with ADHD might have normal adult functioning, as its outcome is variable.

A biopsy is required to rule out cervical carcinoma when a red, elevated, friable lesion on the cervix is seen, and treatment for chronic cervicitis should not begin until the biopsy findings are known. If there is a clinically evident lesion, a Papanicolaou test alone is insufficient, as false-negatives occur in 10% to 50% of tests.A biopsy guided by a colposcopy is frequently diagnostic. If this is not the case, a cone biopsy is required. If the abnormal tissue cannot be detected with colposcopy but was discovered in cells taken from a cervical canal biopsy, or if the abnormal tissue identified with colposcopy reaches high into the cervical canal, a cone biopsy may be performed.

This patient has jaundice, right upper quadrant pain and tenderness, and fever. His symptoms are suggestive of acute ascending cholangitis due to choledocholithiasis and the symptom complex is known as the Charcot’s triad. If patients develop septic shock accompanied by altered sensorium and hypotension, the symptoms are referred to as Reynolds pentad. Charcot’s triad is most commonly seen in acute ascending cholangitis. Acute ascending cholangitis may occur when a gallstone blocks the common bile duct and cause obstruction. Biliary stasis promotes bacterial proliferation and causes infection associated with fever, chills and rigors, and jaundice. It may also lead to biliary pancreatitis and is a devastating complication of gallstones. Effective treatment includes removal or retrieval of the stone causing the obstruction and cholecystectomy should be performed before discharging the patient. Ultrasound abdomen, complete blood count, and liver function tests are helpful initial diagnostic investigations. ultrasonography showing gallstones and dilated common bile duct confirm the diagnosis of acute cholangitis. Findings in these patients include cholestatic jaundice with elevated alkaline phosphatase. Gallstone ileus is incorrect. It occurs when a gallstone obstructs the small intestine. It usually occurs at the level of the ileocecal valve. Acute cholecystitis is associated with obesity. Patients present with right upper quadrant pain radiating to the tip of the right shoulder. Pain is associated with vomiting, fever, and leukocytosis and occurs after having a fatty meal. Murphy’s sign is positive and is demonstrated by rebound abdominal tenderness on palpation of the right upper quadrant. This patient has a negative Murphy’s sign. Biliary pancreatitis or gallstone-induced acute pancreatitis is incorrect. Although it is a complication of cholelithiasis, it is associated with epigastric pain and elevated amylase and lipase. In the presence of normal amylase, it is unlikely. Cholestatic hepatitis is incorrect. Drug-induced cholestasis is characterized by elevated alkaline phosphatase and bilirubin levels and is caused by antibiotics like penicillin, azithromycin, and erythromycin. It occurs a few weeks (2-12 weeks) after initiating the offending drug and improves on drug withdrawal. Key point: Charcot’s triad (Jaundice, fever, and right upper quadrant abdominal pain) is pathognomonic of ascending acute cholangitis. It can be confirmed on ultrasonography, an ERCP, or magnetic resonance cholangiopancreatography.

Case-Control studies are an ideal method for quickly determining the source of an outbreak. They compare cases (people with a particular outcome or disease) with controls (people from a similar group without the outcome or disease). Advantages of this method include its speed and cost-effectiveness, as well as its ability to be used for rare diseases. However, there are some disadvantages, such as the possibility of recall bias, confounding bias, selection bias, and difficulty in establishing temporality. Additionally, only one outcome can be measured and record keeping may be unreliable.

– Tenderness in the anatomic snuff box suggests possibility of scaphoid fracture- Negative radiographs should not lead away from diagnosis- Immobilization of wrist and thumb is necessary to reduce risk of complications- Volar wrist splint or thumb spica splint/cast should be worn until further imaging evaluation can be performed

The most probable diagnosis is coarctation of the aorta, suggested by a discrepancy in the blood pressure measured in the upper and lower limbs, as well as the continuous machine-like murmur (possible patent ductus arteriosus) heard on auscultation.Coarctation of the aorta (CoA) is a narrowing of the aorta that usually occurs in the thoracic area, distal to the point of origin of the left subclavian artery, but can also occur in the lower thoracic or abdominal aorta. CoA can occur in isolation or in relation to other lesions, most commonly bicuspid aortic valve and ventricular septal defect (VSD).Its description is usually in relation to the ductus arteriosus, which can be:Pre-ductal: Referring to a coarctation occuring proximal to the ductus arteriosus. It is most common in infantsJuxtaductal: Referring to a coarctation occuring at the point of the ductus arteriosus.Post-ductal: Referring to a coarctation occurring distal to the ductus arteriosus. It is most common in adults.The initial presentation in this case is normal due to the patent ductus arteriosus (PDA) which allows cardiac output to be uninterrupted by the coarctation. The condition will become symptomatic after its closure, causing her condition to deteriorate. The ductus arteriosus is able to stay patent in utero as a result of hypoxia, mild acidosis and placental prostaglandins. These disappear post-delivery, triggering its closure which will result in poor perfusion, metabolic acidosis, shock, dyspnea, diaphoresis, and congestive heart failure. Prostaglandin E1 (alprostadil) is the first line of management as it keeps the PDA open. This stabilizes their condition allowing a thorough assessment to be conducted so the appropriate clinical decision can be made. Once the neonate is stabilized, surgical repair can be conducted.Dobutamine is indicated in a child with coarctation of the aorta that presents as heart failure, so it is not appropriate here as the child is asymptomatic in presentation.Indomethacin can cause inhibition of prostaglandins, and is indicated in the closure of a PDA in children who do not require it for survival.Latanoprost is an analogue of prostaglandin (PGF2α) most commonly used for the treatment of an open-angle glaucoma. Methylprednisolone can cause inhibition of prostaglandins which would cause closure of the PDA.Key point: In children with coarctation of the aorta, the closure of the PDA will cause poor perfusion, metabolic acidosis, shock, dyspnea, diaphoresis, and congestive heart failure. Prostaglandin E1 is administered to keep the PDA open, in an attempt to stabilize the neonate’s condition for the surgical repair..

Serotonin Syndrome is a condition caused by the overstimulation of serotonin receptors in the body, and can be caused by a variety of serotonergic agents, such as SSRIs. Symptoms range from mild to severe, and treatment should be adjusted accordingly. Mild cases can be managed with supportive care, discontinuation of the drug, and benzodiazepines. Moderately ill patients may benefit from a 5-HT2A antagonist such as cyproheptadine, and those with hyperthermia should receive all of these treatments, as well as immediate sedation, neuromuscular paralysis, and orotracheal intubation. Propranolol, a non-selective beta blocker, may be used to treat tachycardia, but can cause hypotension and shock in patients with autonomic instability. Bromocriptine and Dantrolene are not recommended treatments, and may even contribute to the development of the syndrome.

• Professional boundaries must be maintained in the physician-patient relationship.• Romantic or sexual relationships with patients are forbidden.• Sexual misconduct includes any sexual activity with a current or former patient, making sexual remarks or suggestive comments, discussing sexual problems of the physician, touching patients in a sexual way, and engaging in a sexual behaviour with another person in front of the patient.• Under no circumstances should the physician pursue a romantic relationship with a current or former patient.