Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

The connection between latex sensitivity and food allergy is commonly known as the latex-fruit syndrome. Foods that have been found to be allergenic in relation to latex are categorized into high, moderate, or low risk groups.

High risk foods include banana, avocado, chestnut, and kiwi fruit.

Moderate risk foods include apple, carrot, celery, melon, papaya, potato, and tomato.

Citrus fruits and pears are considered to have a low risk of causing allergic reactions in individuals with latex sensitivity.

Hypothermia occurs when the core body temperature drops below 35°C. It is categorized as mild (32-35°C), moderate (28-32°C), or severe (<28°C). Rescuers at the scene can use the Swiss staging system to describe the condition of victims. The stages range from clearly conscious and shivering to unconscious and not breathing, with death due to irreversible hypothermia being the most severe stage. There are several risk factors for hypothermia, including environmental exposure, unsatisfactory housing, poverty, lack of cold awareness, drugs, alcohol, acute confusion, hypothyroidism, and sepsis. The clinical features of hypothermia vary depending on the severity. At 32-35°C, symptoms may include apathy, amnesia, ataxia, and dysarthria. At 30-32°C, there may be a decreased level of consciousness, hypotension, arrhythmias, respiratory depression, and muscular rigidity. Below 30°C, ventricular fibrillation may occur, especially with excessive movement or invasive procedures. Diagnosing hypothermia involves checking the core temperature using an oesophageal, rectal, or tympanic probe with a low reading thermometer. Rectal and tympanic temperatures may lag behind core temperature and are unreliable in hypothermia. Various investigations should be carried out, including blood tests, blood glucose, amylase, blood cultures, arterial blood gas, ECG, chest X-ray, and CT head if there is suspicion of head injury or CVA. The management of hypothermia involves supporting the ABCs, treating the patient in a warm room, removing wet clothes and drying the skin, monitoring the ECG, providing warmed, humidified oxygen, correcting hypoglycemia with IV glucose, and handling the patient gently to avoid VF arrest. Rewarming methods include passive Rewarming with warm blankets or Bair hugger/polythene sheets, surface Rewarming with a water bath, core Rewarming with heated, humidified oxygen or peritoneal lavage, and extracorporeal Rewarming via cardiopulmonary bypass for severe hypothermia/cardiac arrest. In the case of hypothermic cardiac arrest, CPR should be performed with chest compressions and ventilations at standard rates.

This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.

Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.

This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.

If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.

Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.

The Zika virus is a newly emerging virus that is transmitted by mosquitoes. It was first discovered in humans in Uganda in 1952. Recently, there has been a significant outbreak of the virus in South America.

When a person contracts the Zika virus, about 1 in 5 individuals will experience clinical illness, while the rest will show no symptoms at all. The most common symptoms of the virus include fever, rash, joint pain, and conjunctivitis. These symptoms typically last for no more than a week.

While not completely conclusive, the evidence from the recent outbreak strongly suggests a connection between Zika virus infection and microcephaly.

Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.

In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.

The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.

To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.

When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.

The patient in this case has been diagnosed with type 1 autoimmune hepatitis, also known as classic type autoimmune hepatitis. This condition is characterized by inflammation of the liver due to reduced levels of regulatory T-cells (Treg cells), leading to the production of autoantibodies against hepatocyte surface antigens. It primarily affects women (70%) between the ages of 15 and 40.

Autoimmune hepatitis causes chronic and progressive hepatitis, which eventually progresses to cirrhosis. Patients typically experience non-specific symptoms of malaise, but in some cases, the disease may present in its later stages with jaundice and severe illness. During this stage, liver function tests often show significantly elevated transaminases (ALT and AST), usually more than ten times the normal levels, and a normal or slightly elevated alkaline phosphatase (ALP). Around 80% of cases show positive antinuclear antibodies (ANA), while approximately 70% show positive smooth muscle antibodies (SMA). Antimitochondrial antibodies are usually low or absent.

There are four recognized subtypes of autoimmune hepatitis:
1. Type 1 (Classic type): Positive ANA and SMA, and grossly elevated IgG
2. Type 2: Positive liver kidney microsomal antibodies (affects children)
3. Type 3: Positive soluble liver antigen antibodies
4. Type 4: Seronegative

Treatment for autoimmune hepatitis involves the use of corticosteroids and/or azathioprine. Remission can be achieved in approximately 70% of cases. In some cases where drug therapy is not effective, liver transplantation may be necessary.

Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing progressive inflammation and obstruction. It is characterized by recurrent episodes of cholangitis and progressive scarring of the bile ducts. PSC can ultimately lead to liver cirrhosis, liver failure, and hepatocellular carcinoma. There is a known association between PSC and ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis.

Primary biliary cirrhosis (PBC) is an autoimmune disease that results in the progressive destruction of the small bile ducts in the liver, primarily affecting the intralobular ducts. This leads to cholestatic jaundice, liver fibrosis, and eventually cirrhosis. PBC is more common in females (90%)

When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.

For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.

When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.

In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.

For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140

The ECG shows the following findings:
– There is ST depression in leads V1-V4 and aVR.
– There is ST elevation in leads V5-V6, II, III, and aVF.
– There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
These ECG changes indicate that there is an acute inferoposterior myocardial infarction.

In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.

Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.

Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.

Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.

By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.