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Answer2715. #EXPLANATION ⦁ Left lower lobe pneumonia would not typically cause an elevated right hilum. Pneumonia tends to manifest with airspace opacification in the affected lung segment, but it wouldn't cause a change in the position of the hilum on the chest X-ray. #Highyield ⦁ Usually the left hilum is at a higher level than the right hilum or both hila are at the same level. Left hilum situated lower than the right is always pathological. ⦁ For the left hilum to be situated lower, it is either that the left hilum pulled down or that the right hilum is pulled up. ⦁ Considering the above listed options, right upper lobe collapse and presence of an endobronchial growth in the right upper lobe bronchus can pull the right hilum upwards leaving the left hilum at a lower level. ⦁ Similarly, left lower lobe collapse will pull the left hilum from below. Pneumonic consolidation has no effect on the level of hila. Reference: Grainger and Allison’s Diagnostic Radiology, 7th Edition, Page No. 274 Ans. C. Left lower lobe pneumonia

Answer2714. #EXPLANATION ⦁ The history of diffuse bone pain and increasing head size in conjunction with the physical examination findings of frontal bossing and tibial bowing are suspicious for Paget’s disease. ⦁ The skull x-rays reveal the classic “cotton wool” appearance found in patients with Paget’s disease. #Highyield ⦁ Paget disease of the bone is a common, chronic ⦁ metabolic bone disorder characterized by excessive abnormal bone remodeling. The classically described radiological appearances are expanded bone with a coarsened trabecular pattern. The pelvis, spine, skull, and proximal long bones are most frequently affected. Characteristic Skull findings in Paget’s disease Osteoporosis Circumscripta: Large, Well-Defined Lytic Lesions Involving The Inner Aspect Of The Outer Table Of The Skull (Stage One) With A Preserved Inner Table. Cotton Wool Appearance: Mixed Lytic And Sclerotic Lesions Of The Skull. Diploic Widening: Both Inner And Outer Calvarial Tables Are Involved, With The Former Usually More Extensively Affected Tam O' Shanter Sign: ⦁ Platybasia And ⦁ Basilar Invagination With The Appearance Of The Skull Falling Over The Facial Bones, Like A Tam O' Shanter Hat; This Is Said To Be A Pathognomonic Appearance shown below Other options: ⦁ Option A is incorrect. This disorder is associated with ankylosis/fusion of joints, and does not fit well with the description and findings above. Ankylosing spondylitis typically presents in the late teens and early 20s with hip pain and lower back pain that is worst in the morning and improves with activity. ⦁ Option C is incorrect. Hormone imbalances associated with pituitary adenomas may manifest in a number of ways including acromegalic bony changes. However, the history and findings (including the bilateral bowing of the tibias) above are most consistent with Paget’s disease. ⦁ Option D is incorrect. Rickets, or osteomalacia, is the weakening and softening of bones that is frequently associated with decreased vitamin D or calcium intake. Though it can occur in adults, it occurs most frequently in early childhood. This is particularly common in developing countries as a result of famine and malnourishment. Reference: Grainger and Allison’s Diagnostic Radiology, 7th Edition, Page No. 1347 Ans. B. Paget’s disease

Answer2713. #EXPLANATION ⦁ All the above options are characteristic of antemortem drowning #HIGHYIELD Signs of antemortem drowning External findings ⦁ Cadaveric spasm holding grass, gravel and sand in hand ⦁ Fine, copious white like froth at mouth and nostrils ( most characteristic antemortem external finding ) Internal findings ⦁ Presence of froth mixed with sand particles in the trachea & bronchi (particularly in the lower airways) ⦁ Emphysema aquosum: flooding of lungs with airless water and no formation of froth, It develops only when conscious victim of drowning struggles for survival ⦁ Presence of water in stomach & small intestine (Small intestine may contain water in about 20% cases. This is regarded as positive evidence of death by drowning as it depends on peristaltic movement, which is a vital phenomenon) ⦁ Presence of water and hemorrhage in middle ear is claimed to be one of the positive proof of antemortem drowning Lab tests: ⦁ Diatoms test ⦁ Presence of diatoms in lung substance , blood stream , liver , kidneys , bone marrow of femur ( best site for analysis ) , ⦁ Gettler’s test ⦁ Normal chloride content of right and left side of heart is almost same ( 600 mg/ 100 mL ⦁ If difference is 25 mg% or more , it is suggestive of antemortem drowning Reference: Review Of Forensic Medicine And Toxicology ( Including Clinical And Pathological Aspects) , Gautam Biswas, 2nd Edition , Page No 158 , 159 Ans. D. NONE OF THE ABOVE

Answer2711. #EXPLANATION ⦁ The clinical features are symptoms of bowel obstruction and barium enema shows apple core sign in the distal portion of descending colon, which is typical of colorectal carcinoma , producing eccentric thickening of colon wall. #HIGHYIELD ⦁ Large bowel obstruction (LBO) is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. ⦁ The most common is colorectal cancer which accounts for over 60% of all LBOs. Other common etiologies include volvulus of the cecum or sigmoid and diverticular disease which account for 10 to 15% and 5 to 10% of all LBOs, respectively. ⦁ Following the initial evaluation, an acute abdominal x-ray series should be obtained, which includes supine and erect views of the abdomen. ⦁ The diagnosis is confirmed with the presence of dilated loops of bowel with the presence of air-fluid levels. These plain films may also suggest the location of the obstruction (small vs. large intestine). ⦁ Abdominal ultrasonography has a limited role in the diagnosis or management of intestinal obstruction. Serum electrolyte determination helps in identifying the electrolyte disturbances that have taken place. ⦁ Fluid loss needs to be corrected with rehydration, and nasogastric suction helps in decreasing abdominal distention. ⦁ If on initial assessment, the patient has peritonitis with evidence of sepsis, and/or imaging showing evidence of perforation, imminent impending perforation, or ischemic bowel then immediate surgical intervention is needed after initial resuscitation is complete. OTHER OPTIONS: ⦁ Option A. Diverticulosis , most common site is sigmoid colon and presenting features are distension , flatulence , sense of heaviness in lower abdomen , irritable bowel syndrome. Barium enema is the investigation of choice and it shows saw tooth appearance. ⦁ Option B. Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. This condition is frequent in children and presents with the classic triad of cramping abdominal pain, bloody diarrhea and a palpable tender mass. Barium enema examination may be useful in patients with colon-colic or ileo-colic intussusception, during which a “cup-shaped” filling defect or “spiral” or “coil-spring” appearances are characteristically demonstrated ⦁ Option C. In volvulus , patient most commonly presents with acute large bowel obstruction, pain lower abdomen, distension, obstipation , vomiting and on Barium enema ‘bird of prey’ sign is seen Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653360/ Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292007/ Reference: Srb Manual Of Surgery ,6th Edition, Page No. 908 Ans. D. Carcinoma of the colon

Answer2712. #EXPLANATION ⦁ In a case of paradoxical undressing , terminal hallucinations do occur. All the other statements are correct #HIGHYIELD ⦁ Paradoxical undressing is a condition seen in accidental hypothermia, particularly in old patients and the persons may take off some or all of their clothing ⦁ It may be due to long exposure to severe cold producing paralysis of thermal regulatory mechanism resulting in failure of vasoconstriction of arterioles of skin which results in flow of blood from core of body , giving exaggerated sensation of warmth ⦁ Terminal hallucinations do occur and because of extreme discomfort the person may undress himself and in such case , there may be suspicion of sexual offense EXTRA EDGE: HIDE AND DIE SYNDROME ( Terminal burrowing behavior ) ⦁ A disoriented , dying , hypothermia victim who while attempting to protect himself from cold , hide himself in corners , cupboards or under piles or furniture or household goods ⦁ Signs of hypothermia are usually found and problem arises to whether the victim becomes hypothermic first which lead to mental confusion causing strange behavior or whether due to some mental aberration , person behaving abnormally Reference: Ks Narayan Reddy , Essentials Of Forensic Medicine And Toxicology , 33rd Edition , Page No. 318 Ans. D. Terminal hallucinations are absent

Q2715. A 65 year old chronic smoker presented with complaints of cough, weight loss, hemoptysis and breathlessness since 3 months. A frontal chest radiograph was done which revealed that the right hilum is situated at a higher level than the left hilum. All the following diagnoses are possible except: a. Right upper lobe collapse b. Left lower lobe collapse c. Left lower lobe pneumonia d. Endobronchial growth in the right upper lobe bronchus Comment your answer

Q2714. A 55-year-old white man presents to the ED complaining of diffuse, constant bone pain for the past 3 months. He is a schoolteacher, and denies any recent history of trauma or infection. He does note that his favorite fitted baseball hat no longer fits. His temperature is 37.6°C (99.7°F), blood pressure is 120/75 mm Hg, pulse is 85/min, and respiratory rate is 22/min. Physical examination reveals no focal points of tenderness. Mild frontal bossing and bilateral tibial bowing are noted. A skull film is shown in the image. What is the most likely diagnosis? a. Ankylosing spondylitis b. Paget’s disease c. Pituitary adenoma d. Rickets Comment your answer

Q2711. A 58-year-old man comes to the hospital. For the past few weeks he has had constipation with distension and vomiting and pain over the last 5 days. He undergoes barium enema examination. The findings on barium enema, shown in Image, are most compatible with which of the following diagnoses? a. Diverticulosis b. Intussusception c. Volvulus d. Carcinoma of the colon Comment your answer