Nihilistic delusion is a belief that part of the individual or external world does not exist or are meaningless. Extreme versions of this delusion may lead an individual to believe that no one is real, that a part of their body is “dead” or that they are not real or alive.Delusions of Reference is Interpreting publicly known events/celebrities as having direct reference to the patient.Persecutory delusions is the belief that others are trying to cause them harm.Somatic delusions is a belief that one has a physical defect/disorder.Delusions of Grandeur is an inflated sense of self.

• Aim of tocolytics is to delay preterm birth and reduce neonatal morbidity and mortality• Five types of tocolytics used in Australia: calcium channel blockers, beta-agonists, nitric oxide donors, prostaglandin synthetase inhibitors, and magnesium sulfate• Contraindications to tocolytics include chorioamnionitis, placental abruption and placenta previa, cervical dilatation > 4 cm, CTG suggesting non-reassuring status, preeclampsia and eclampsia, lethal congenital or chromosomal malformation, intrauterine fetal demise, allergies to tocolytics, gestational age < 24 weeks or > 34 weeks

The immediate cause of death is upper gastrointestinal hemorrhage.The process of medical death certification is a challenging and daunting task for most healthcare practitioners and physicians who are tasked with this responsibility. The death certificate is a public record that can be accessed by the decedent’s family, clinical researchers, lawyers, and insurance companies when there is litigation involved. It should document the immediate cause of death, which can be an event, clinical condition, or disease process, which is unsuitable for the continuation of life.The mechanism of death is not as important as the event or condition that precipitated the occurrence of death. The physiologic process of respiratory failure or cardiac failure does not explain the event preceding death. For this reason, clinicians are discouraged from using terminologies such as:Cardiac arrestRespiratory arrestCardiopulmonary arrestOld ageThe main purpose of death certification is for governmental agencies to compile vital statistics. This is used as official documentation of deaths and the causes of deaths. The death certificate is not intended to document the history of the present illness or the decedent’s clinical problems but rather to focus on the immediate cause of death. The World Health Organization (WHO) has a mission statement that includes collecting and classification data on mortality. The collection and classification allow researchers to compare data from different countries.The Cause of Death is the causal chain of events that ultimately leads to death.The Immediate Cause of Death is the final event in the sequences of events that lead to death. This is what is filled in as the top diagnosis in the death certificate.The Underlying Cause of Death is the initial event in the causal sequence that is the most remote from the time of death. This information is filled in last, at the bottom of the death certificate.The Manner of Death is how death is classified based on the circumstances surrounding the death.

Seborrhoeic dermatitis is a skin condition that primarily affects the scalp and skin folds of infants up to 12 months old. It is commonly referred to as cradle cap and is characterized by greasy, yellow plaques on the scalp. Treatment may include frequent shampooing with baby shampoo, applying an emollient to the scalp, and gentle scalp massage. If these measures are not effective, mild topical corticosteroids or antifungal shampoos may be prescribed.

A pleomorphic adenoma is also called a benign mixed tumour – this is the most common tumour of the parotid gland. It also causes over a third of all submandibular tumours. This type of a tumour is slow-growing and has no symptoms, which means it has great malignant potentiality.

– Patients with peripheral vascular disease who stop smoking have a twofold increase in their 5-year survival rate. – Diet modification and lipid-lowering drugs can slow progression, but not as dramatically. – Aspirin and pentoxifylline are minimally effective.

• CAP is a common diagnosis in the outpatient setting• Symptoms include cough, fever, pleuritic chest pain, dyspnea, nausea, vomiting, and diarrhea• No symptoms suggestive of asthma, COPD, lung cancer, or pulmonary embolism

The correct answer is Complete dilation of the uterine cervix.Labour occurs in 3 stages, which are:Stage 1: Cervical changes, ending with dilation to 10 cm. It consists of the latent phase which lasts less than 20 hours in primipara and less than 14 hours in multipara, and the active phase which consists of cervical dilation at the rate of 1.2 cm/hour. Stage 2: This begins with cervical dilation to 10 cm and ends with the delivery of the baby.Stage 3: Expulsion of the placenta.

SSRIs are the most appropriate first-line pharmacologic treatment for depression in nursing-home residents. Although other classes of non-tricyclic antidepressant may be effective and appropriate, the evidence for this is not as good as that for SSRIs.Amitriptyline, MAO inhibitors, doxepin, and clomipramine should be avoided in nursing-home patients. Olanzapine is an antipsychotic

Lead poisoning will show a microcytic anemia with an MCV < 80.Lead poisoning is often a chronic disorder and may not cause acute symptoms. In children, it is commonly caused by direct ingestion of leaded paint chips.Lead paint was common until 1960, used to some degree until the early 1970s, and mostly eliminated in 1978. It still poses some risk for a significant number of older housing units. Lead poisoning eventually has irreversible effects like progressive renal dysfunction, cognitive deficits, and peripheral neuropathy.

Sitagliptin is a dipeptidyl peptidase 4 inhibitor. It acts by decreasing inactivation of incretin hormones and therefore increases insulin release and reduces glucagon levels.Reducing the absorption of glucose in the gastrointestinal tract is the mechanism of action of SGLT1/SGLT2 (sodium-glucose linked transporter) inhibitors.Reduction of insulin resistance in the liver is achieved by Thiazolidinediones eg pioglitazone.Increased skeletal muscle glucose uptake and decrease insulin resistance at the skeletal muscle is the mechanism of action of SGLT2Is.Sitagliptin a DPP-4 inhibitors inhibit glucagon release. So the option saying it increases glucagon levels is incorrect.

Erectile dysfunction, also called as impotence, is the type of sexual dysfunction in which the penis fails to become or stay erect during sexual activity. Most common causes of Erectile dysfunction includes:- Blood flow disturbance- Nerve function problems- Testosterone deficiency- Use of medications (e.g., antidepressants, antihypertensives, NSAIDs) – Psychological issues.Beta-blockers is the drug of choice for this condition, but since this patient is able to achieve an erection, this patient has non-organic impotence and interpersonal conflict is common but rarely acknowledged cause for impotence in males. Couple counseling can be helpful in this case. – Beta-blockers used to treat hypertension are common causes of male ED. However, this patient’s history suggests he has non-organic impotence since he is able to achieve an erection. So, change his blood pressure medicine is an incorrect answer. – Check a testosterone level would be more appropriate in a patient who fails to develop an erection in the morning.- Prescribe Tadalafil or Vardenafil (Cialis or Levitra) would be recommended in patients requiring medication therapy, which is not the case with this particular patient with normal morning erection.- Reassurance would not be appropriate as it does not address the patient’s complaint.

The major constituents of breast milk are lactose, protein, fat and water. However, the composition of breast milk is not constant| early lactation differs from late lactation, one feed differs from the next, and the composition can even changeduring a feed. Artificial infant formulas cannot therefore be identical to breast milk. In addition to IgA, breast milk contains small amounts of IgM and IgG and other factors such as lactoferrin, macrophages, complement and lysozymes

Fibrocystic changes leads to the most commonly reported breast symptoms and have many causes. Fibrocystic disease is characterized by nondescript lumpiness, mastalgia, and breast cysts which could occur together or in isolation. The breasts feel nodular and dense and are often tender when palpated. It is a common condition and affects 30% to 60% of women of childbearing age (20 and 45 years of age).Carcinoma of the breast is more prevalent in women who are more than 40 years of age. Also, cancers have painless nodules and few present with pain. Although fibroadenomas are common in women of childbearing age, they are usually highly mobile on palpation and non-tender.This patient is nulligravida and since galactocele commonly occurs in lactating women, the option is incorrect. Intraductal papilloma are associated with nipple discharge (not present in this patient). Additionally, they are usually solitary, central, large and near the nipple.

Free fluid surrounding the ossicles with normal temporal bone and clear mastoid cells on the right is seen in acute otitis media not mastoditis.A normal CT scan is not seen with clinical mastoiditisWith mastoiditis, there is some free fluid around the ossicles when a suppurative effusion is present. Normal ossicles and temporal bone, with soft tissue swelling behind the right ear is therefore not correct.Periosteal thickening (not thinning), disruption of the periosteum is seen on CT scan of a patient with mastoditis.The classical triad of mastoiditis are otorrhea, tenderness to pressure over the mastoid, and retroauricular swelling with protruding ear. On CT scan of temporal bone, evidence of mastoiditis includes clouding due to the destruction of septa between mastoid cells with soft tissue swelling behind the affected ear. Destruction of the temporal bone with soft tissue abscesses may also be seen along.

A Pap smear, also called a Pap test, is a screening procedure for cervical cancer. It consists in collecting cells from the cervix and helps detecting the cancer earlier and giving the patient a chance for the cure. It is recommended to be done several times in case an individual has greater risks for developing sexual diseases or cancer. Therefore, since this patient had several sexual relationships and has cells that seem to be abnormal from her pap smears, it is most appropriate for her to undergo repeated pap smears in order to assess her case and set an adequate diagnosis and treatment.

– The given scenario is typical of lesion in internal capsule. – Memory impairment is caused by a hippocampal lesion, – Impairment of arousal, facial paresis, visual field defect, facial paresis, hemiataxia, and hemispacial neglect are just some of the conditions caused by thalamic lesion. – Brainstem stroke on the other hand causes breathing abnormality, altered consciousness, and blood pressure disorder.

The meningococcal vaccination is recommended for college freshmen (first-year students) living in residence halls. Vaccination with the currently available quadrivalent meningococcal polysaccharide vaccine will decrease their risk of meningococcal disease. The meningococcal vaccine prevents infection caused by the bacteria Neisseria meningitidis. These bacteria commonly spread from person to person through their saliva or spit. Close contact with an infected person plays a major role in its spread. This is why it is recommended for first-year college students living in closed spaces such as dormitories and campus residencies. There is also an increased risk of disease from certain meningococcal serotypes for college freshmen. It is recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that incoming and current college freshmen, and their parents, be informed about meningococcal disease and the benefits of vaccination. This is particularly true for those who live in dormitories and residence halls. The other vaccine options are incorrect as all vaccines are part of the routine immunization schedule, and the patient must have received them already. Boosters are not indicated in this case.

Obsessive-compulsive disorder (OCD) is often a disabling condition consisting of bothersome intrusive thoughts that elicit a feeling of discomfort. To reduce the anxiety and distress associated with these thoughts, the patient may employ compulsions or rituals. These rituals may be personal and private, or they may involve others participating| the rituals are to compensate for the ego-dystonic feelings of the obsessional thoughts and can cause a significant decline in function.In The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, which was published by the American Psychiatric Association (APA) in 2013, obsessive-compulsive disorder sits under its own category of obsessive-compulsive and related disorders where the following subcategories were placed:Obsessive-compulsive disorder (OCD)Body dysmorphic disorder (BDD)Hoarding disorderTrichotillomaniaExcoriation (skin-picking) disorderSubstance/medication-induced obsessive-compulsive and related disorderObsessive-compulsive and related disorder as a result of another medical conditionOther specified obsessive-compulsive and related disorderUnspecified obsessive-compulsive and related disorderA. Presence of obsessions, compulsions, or both:Obsessions are defined by the following two points:Recurrent thoughts, urges, or images that are experienced, at some time during the disturbance, as unwanted, and that in most individuals cause marked distress.The individual attempts to suppress such thoughts, urges, or images, with some other thought or action (i.e., by replacing them with a compulsion).Compulsions are defined by the following two points:Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession.The behaviors or mental acts aim at reducing anxiety or distress or preventing some dreaded situation| however, these behaviors or mental actions do not connect in a realistic way with what they are designed to prevent or are clearly excessive.B. The obsessions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.C. The obsessive-compulsive symptoms do not arise from the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.D. The symptoms of another mental disorder do not better explain the disturbance (e.g., excessive worries, as might be found in a generalized anxiety disorder| preoccupation with appearance, as seen in a body dysmorphic disorder| difficulty discarding or parting with possessions, as found in a hoarding disorder| hair pulling, as in trichotillomania a hair-pulling disorder| skin picking, as appears in excoriation [skin-picking] disorder| stereotypies, as found in a in stereotypic movement disorder| ritualized eating behavior, as found in eating disorders| preoccupation with substances or gambling, as seen in a in substance-related and addictive disorders| preoccupation with having an illness, as found in illness anxiety disorder| sexual urges or fantasies, as found in a paraphilic disorders| impulses, as seen in a disruptive, impulse-control, and conduct disorders| guilty ruminations, as occurs in a major depressive disorder| thought insertion or delusional preoccupations, as found in schizophrenia spectrum and other psychotic disorders| or repetitive behavior patterns, as found in an autism spectrum disorder). Obsessions are defined as intrusive thoughts or urges that cause significant distress| the patient attempts to neutralize this distress by diverting thoughts or performing rituals. Compulsions are actions the patient feels pressured to do in response to the anxiety/distress producing obsessions or to prevent an uncomfortable situation from occurring. These compulsions may be illogical or excessive.[1]The most common obsessions include fears of contamination, fears of aggression/harm, sexual fears, religious fears, and the need to make things “just right.” The compensatory compulsions for these obsessions include washing and cleaning, checking, reassurance-seeking, repeating, ordering, and arranging.

Myomectomy gives the best chance for a successful pregnancy when prior pregnancies had fibroid-related complications.Endometrial ablation eliminates fertility. The patients is planning another pregnancy so this is not ideal.Long-term data on fertility after uterine artery embolization are not available so this should be avoided in this patient.Observation alone would not remove the risk for complications during subsequent pregnancies.Hormonal therapies appear to be ineffective in treating uterine fibroids.

Decreasing both preload and afterload will cause a reduction in ventricular filling pressures by stimulating venous pooling, and also increase cardiac output by decreasing the total peripheral resistance.Agents indicated here include nitroprusside, prazosin, ACE inhibitors (choice E) and angiotensin II receptor blockers.Hydralazine and minoxidil are arteriolar smooth muscle relaxants which decrease afterload.The venodilators and diuretics decrease preload. Examples of venodilators are nitroglycerine and isosorbide dinitrate (ISDN). Hydralazine is an arteriole vasodilator (afterload), while ISDN is a venous vasodilator (preload). They are usually prescribed for use together in patients who are unable to tolerate ACE inhibitors.Furosemide, bumetanide and hydrochlorothiazide are examples of diuretics. They are indicated in the reduction of preload achieved by reducing blood volume. Dobutamine increases the contractility of myocardial muscle. It does not cause any significant alteration of total peripheral resistance.Note: Nitroglycerin: venodilation predominates at therapeutic doses which decreases preload. Arteriodilation at high doses (high therapeutic/toxic) which produces hypotension compensated by sympathetics (heart/vascular) to produce tachycardia.Key point: Nitroprusside, prazosin, ACE inhibitors, and angiotensin II receptor blockers are agents which are able to decreased both preload and afterload.

The combination of increased LDH and unconjugated bilirubin levels with an otherwise normal liver enzyme levels suggests hemolysis.Gilbert’s syndrome does not explain the raised LDH.With normal transaminase levels found in this patient, hepatitis (alcohol, C and steatohepatitis) is unlikely

Hypercalcemia is a common metabolic abnormality. More than 90% of the cases of hypercalcemia are due to primary hyperparathyroidism and malignancy-induced hypercalcemia. Malignancy remains the most common cause of hypercalcemia in hospitalized patients.Excessive secretion of parathyroid hormone-related protein (PTHrP) is the most common cause of hypercalcemia of malignancy. It is also known as humoral hypercalcemia of malignancy (HHM) and accounts for about 80% of the cases. It is usually seen in solid tumors and few cases of non-Hodgkin lymphoma. Lab findings are consistent with elevated PTHrP, low to normal PTH, and 1,25-dihydroxy vitamin D levels.

Contrast-related nephropathy (CIN) refers to kidney dysfunction that occurs 48 – 72 hours are the use of intravenous contrast. It is measured as a 25% increase in serum creatinine from the baseline.Isotonic intravenous fluids prior to and continued for several hours after contrast can reduce risks of developing CIN in cases where there are no contraindications to volume expansion.The use of acetylcysteine to reduce the risks of contrast nephropathy is controversial due to conflicting research findings. This lack of consensus means it is not generally recommended for use, however when it is indicated, the preferred dose is 1200 mg administered orally twice daily on the day before and the day of the procedure to patients at risk of contrast nephropathy.Mannitol is a diuretic and has not been proven to reduce risk of CIN, although there is some suggestion that furosemide therapy slightly increased the risk.Volume depletion or nonsteroidal anti-inflammatory drugs is wrong as they can both increase renal vasoconstriction.

• Patient presents with headache and nuchal rigidity• CSF studies reveal xanthochromia, red blood cells, mildly increased protein and low glycorrhachia• Subarachnoid hemorrhage is the most likely diagnosis, which refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes• Head CT scan can be useful to rule out elevated intracranial pressure before lumbar puncture• CSF analysis is important to evaluate meningitis

With the given presentation, malignant otitis externa (MOE) is the most likely diagnosis. MOE is often seen in diabetics and immunosuppressed patients, presents with ear discharge and a very intense ear pain, and fever is often present. The pain may radiate to the temporomandibular joint. Pseudomonas aeruginosa is the most common cause of malignant otitis externa.Although Aspergillus species, especially the fumigatus type, occasionally causes MOE, it is not the most common cause.Escherichia coli most likely causes Urinary tract infection not MOE.Streptococcus pneumoniae is the commonest cause of otitis media (not externa).Streptococcus pyogenes and Staphylococcus aureus are rarely responsible for this condition. However, they may be superimposed.Key point:Know the infections associated with diabetes well! Malignant otitis externa, erysipelas, cellulitis, mucormycosis, Fournier’s gangrene and emphysematous cholecystitis are frequently asked.Otitis Externa

The likely diagnosis of inflammatory bowel disease is high on the list of differentials considering this patient’s age, the nature of the abdominal pain and the perianal skin tags. In addition, the patient is likely to have Crohn disease as ulcerative colitis does not cause perianal skin tags. Unlike ulcerative colitis which is limited to the colon, Crohn disease may affect any part of the gastrointestinal system from the oral mucosa to the anus. Crohn disease is characterized by discontinuous lesions of the GI system (“skip lesions”) that usually spare the rectum (the rectum is often involved in ulcerative colitis), and in Crohn disease, transmural inflammation is seen. Patients often present with abdominal pain, abdominal mass, low-grade fever, weight loss, and watery diarrhea. Both ulcerative colitis and Crohn disease are associated with extraintestinal manifestations such as episcleritis/ uveitis, arthritis, erythema nodosum, and pyoderma gangrenosum. The workup for inflammatory bowel disease is multimodal. It includes complete blood count (CBC), imaging (abdominal X-ray and CT enterography), stool culture and stool assay for C. difficile, and colonoscopy. String sign is the correct answer, and is a radiologic finding suggestive of Crohn disease. This occurs as the terminal ileum often becomes stenotic secondary to full thickness bowel wall inflammation (transmural granulomatous) and fibrosis. As a result, the lumen of this portion of small bowel resembles a piece of string on plain X-ray after ingestion of high-density oral contrast material. Colonoscopy shows linear or stellate ulcers, strictures, cobblestoning, and skip lesions.Corkscrew sign is seen when there are simultaneous, lumen-obliterating, non peristaltic contractions within the esophagus. These abnormal contractions vary in amplitude and occur in diffuse esophageal spasm.Stack of coins usually indicates the presence of a small-bowel hematoma. This sign is seen on plain films and represents nearby, thickened folds with a sharp demarcation and crowding of the valvulae conniventes. It is usually observed frequently in patients on anticoagulation therapy.Bull’s eye lesion is seen in gastric metastatic lesions from melanoma, lymphoma, Kaposi’s sarcoma and carcinoid tumours. This is as a result of lesions within the stomach in which there are central collections of oral contrast within ulcerated intramural masses. These can produce a target or bull’s eye appearance on upper gastrointestinal barium examinations.Whirlpool’s sign is seen in midgut volvulus and represents the swirling pattern of the gut and the superior mesenteric vein as they wrap around the superior mesenteric artery (SMA) in a clockwise rotation.

• Symptoms of peripheral artery occlusive disease and intermittent claudication are caused by poor circulation in the extremities.• Ankle-Brachial Index (ABI) is a ratio of blood pressure in the legs to the blood pressure in the arms and a patient with an ABI < 0.9 is considered to have peripheral artery occlusive disease.• Diagnosis is confirmed through angiography.• Treatment of choice is Aspirin and Cilostazol.

The patient in question has an inflammatory myopathy, which is part of the polymyositis/dermatomyositis group. This is characterized by proximal muscle weakness and elevated levels of creatine kinase and aldolase. Corticosteroids are the recommended treatment for this condition.

– Characterised by partial or complete absence of one of the two X chromosomes (45,X karyotype)- Physical features include webbed neck, low hairline at back of neck, broad chest with wide-spaced nipples, and poorly developed nails- Amenorrhea and lack of puberty development- Short stature and obesity common