Patients experiencing an anaphylactic reaction should be observed for a minimum of 6 hours. However, according to the Royal College of Emergency Medicine (RCEM), certain situations require a 24-hour observation period. These situations include patients with a history of biphasic reactions or known asthma, cases where there is a possibility of ongoing absorption of the allergen, limited access to emergency care, presentation during the evening or night, and severe reactions with a slow onset caused by idiopathic anaphylaxis. It is important to note that the National Institute for Health and Care Excellence (NICE) recommends that patients under the age of 16 be admitted under the care of a pediatrician for observation.

Further Reading:

Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.

When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.

The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.

In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.

Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.

Malignant otitis externa (MOE), also known as necrotising otitis externa, is a rare type of ear infection that primarily affects older individuals with diabetes, particularly if their diabetes is poorly managed.

MOE initially starts as an infection in the ear canal and gradually spreads to the surrounding bone and soft tissues. In about 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

Typically, MOE presents with intense ear pain and persistent inflammation of the ear canal that does not respond well to topical antibiotics. The pain is often described as constant and tends to worsen at night. Even after the swelling of the ear canal subsides with the use of topical antibiotics, the pain may persist. Other symptoms that may be present include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may also be affected.

If left untreated, MOE can be life-threatening, and serious complications may arise, such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

To diagnose MOE, technetium scanning and contrast-enhanced CT scanning are typically performed. Treatment usually involves long-term administration of intravenous antibiotics.

Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).

On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.

Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.

It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.

Naseptin, a topical antiseptic cream containing chlorhexidine and neomycin, has been found to be just as effective as silver nitrate cautery in treating recurrent nosebleeds in children. This means that using Naseptin can help prevent future nosebleeds in children with this condition. It is important to note that silver nitrate cautery can cause more pain and should only be used if a specific bleeding vessel can be identified.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

The drugs that have the highest association with the development of drug-induced lupus are procainamide and hydralazine. While some of the other medications mentioned in this question have also been reported to cause drug-induced lupus, the strength of their association is much weaker.

The most commonly observed change in the electrocardiogram (ECG) during a tricyclic antidepressant (TCA) overdose is sinus tachycardia. Additionally, other ECG changes that can be seen in TCA overdose include prolongation of the PR interval, broadening of the QRS complex, prolongation of the QT interval, and the occurrence of ventricular arrhythmias in cases of severe toxicity. The cardiotoxic effects of TCAs are caused by the blocking of sodium channels, which leads to broadening of the QRS complex, and the blocking of potassium channels, which results in prolongation of the QT interval. The severity of the QRS broadening is associated with adverse events: a QRS duration greater than 100 ms is predictive of seizures, while a QRS duration greater than 160 ms is predictive of ventricular arrhythmias.

This patient is displaying symptoms consistent with a malabsorption syndrome, which is supported by the findings of subtotal villous atrophy in his small bowel biopsy. Based on this information, the possible causes can be narrowed down to tropical sprue, coeliac disease, and giardiasis.

Considering that the patient was previously healthy before his trip to Nepal, it is unlikely that he has coeliac disease. Additionally, tropical sprue is rare outside of the regions around the equator and is uncommon in Nepal. On the other hand, giardiasis is prevalent in Nepal and is the most probable cause of the patient’s symptoms.

Giardiasis is a chronic diarrheal illness caused by a parasite called Giardia lamblia. Infection occurs when individuals ingest cysts present in contaminated food or water. Common symptoms associated with giardiasis include chronic diarrhea, weakness, abdominal cramps, flatulence, smelly and greasy stools, nausea, vomiting, and weight loss.

Stool culture often yields negative results, so the preferred diagnostic test is a stool ova and parasite (O&P) examination. This test should be repeated three times for accuracy. Additionally, the small bowel biopsy should be re-evaluated to check for the presence of Giardia lamblia.

The standard treatment for giardiasis involves antibiotic therapy with a nitroimidazole antibiotic, such as metronidazole.

Chronic myeloid leukaemia (CML) is a type of blood disorder that arises from an abnormal pluripotent haemopoietic stem cell. The majority of CML cases, more than 80%, are caused by a cytogenetic abnormality called the Philadelphia chromosome. This abnormality occurs when there is a reciprocal translocation between the long arms of chromosomes 9 and 22.

CML typically develops slowly over a period of several years, known as the chronic stage. During this stage, patients usually do not experience any symptoms, and it is often discovered incidentally through routine blood tests. Around 90% of CML cases are diagnosed during this stage. In the bone marrow, less than 10% of the white cells are immature blasts.

Symptoms start to appear when the CML cells begin to expand, which is known as the accelerated stage. Approximately 10% of cases are diagnosed during this stage. Between 10 and 30% of the blood cells in the bone marrow are blasts at this point. Common clinical features during this stage include tiredness, fatigue, fever, night sweats, abdominal distension, left upper quadrant pain (splenic infarction), splenomegaly (enlarged spleen), hepatomegaly (enlarged liver), easy bruising, gout (due to rapid cell turnover), and hyperviscosity (which can lead to complications like stroke, priapism, etc.).

In some cases, a small number of patients may present with a blast crisis, also known as the blast stage. During this stage, more than 30% of the blood cells in the bone marrow are immature blast cells. Patients in this stage are generally very ill, experiencing severe constitutional symptoms such as fever, weight loss, and bone pain, as well as infections and bleeding tendencies.

Laboratory findings in CML include a significantly elevated white cell count (often greater than 100 x 109/l), a left shift with an increased number of immature leukocytes, mild to moderate normochromic, normocytic anaemia, variable platelet counts (low, normal, or elevated), presence of the Philadelphia chromosome in more than 80% of cases, and elevated levels of serum uric acid and alkaline phosphatase.

This patient has developed a non-ST elevation myocardial infarction (NSTEMI). The electrocardiogram (ECG) reveals widespread ST depression, indicating widespread subendocardial ischemia. Additionally, the troponin test results are positive, indicating myocyte necrosis.

The acute coronary syndromes consist of unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).

Unstable angina is characterized by one or more of the following: angina of effort occurring over a few days with increasing frequency, angina episodes occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The ECG may show T-wave/ST-segment changes, similar to this case. Cardiac enzymes are typically normal, and the troponin test is negative in unstable angina.

Non-ST elevation myocardial infarction (NSTEMI) typically presents with sustained cardiac chest pain lasting more than 20 minutes. The ECG often shows abnormalities in T-waves or ST-segments. Cardiac enzymes are elevated, and the troponin test is positive.

ST-elevation myocardial infarction (STEMI) usually presents with typical cardiac chest pain suggestive of an acute myocardial infarction. The ECG reveals ST-segment elevation and the development of Q waves. Cardiac enzymes are elevated, and the troponin test is positive.

Gilbert’s syndrome is the most common hereditary cause of elevated bilirubin levels and can be found in up to 5% of the population. It is characterized by an isolated increase in unconjugated bilirubin without any detectable liver disease. In most cases, it is inherited in an autosomal recessive manner, although there have been some instances of autosomal dominant inheritance, particularly in Asian populations.

The elevated bilirubin levels in Gilbert’s syndrome do not have any serious consequences and typically occur during times of stress, physical exertion, fasting, or infection. While it is often asymptomatic, some individuals may experience symptoms such as fatigue, decreased appetite, nausea, and abdominal pain.

The underlying cause of the elevated bilirubin levels is a decrease in the activity of the enzyme glucuronyltransferase, which is responsible for conjugating bilirubin. In Gilbert’s syndrome, the bilirubin levels are generally less than three times the upper limit of normal, with more than 70% of the bilirubin being unconjugated. Liver function tests and LDH (lactate dehydrogenase) levels are typically within the normal range.

The zone of hyperaemia, located at the outermost part of the burn, experiences heightened tissue perfusion. Typically, this area will return to its normal tissue state.

Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

Children who have been diagnosed with Rubella, also known as German measles, should be advised to stay away from school for a period of 5 days from the onset of the rash. It is important to be familiar with the guidelines for excluding children from school due to infectious diseases that present with a rash.

Further Reading:

Rubella, also known as German measles, is a viral infection caused by the togavirus. It used to be more common before the introduction of the MMR vaccine, but now it is rare. Outbreaks of rubella are more common during the winter and spring seasons. The incubation period for rubella is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4-5 days after the onset of the rash.

The features of rubella include a prodrome, which may include symptoms such as low-grade fever. The rash associated with rubella is maculopapular and initially appears on the face before spreading to the whole body. The rash usually fades by the 3-5 day. Lymphadenopathy, specifically suboccipital and postauricular, is also commonly seen in rubella cases.

Complications of rubella can include arthritis, thrombocytopenia, encephalitis, and myocarditis. However, these complications are rare. Rubella can be particularly dangerous if contracted during pregnancy, as it can lead to congenital rubella syndrome. The risk of fetal damage is highest during the first 8-10 weeks of pregnancy, with a risk as high as 90%. Fetal damage is rare after 16 weeks. Congenital rubella syndrome can result in various complications such as sensorineural deafness, congenital cataracts, congenital heart disease, growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

Diagnosis of rubella can be made by testing for raised IgM antibodies in women who have recently been exposed to the virus. Serological or PCR testing is the gold standard investigation for rubella. A testing kit can be obtained from the Local Health Protection Unit (HPU).

There is no specific treatment for rubella. Antipyretics can be used to manage fever. It is advised to exclude individuals with rubella from school for 5 days from the onset of the rash. Infection during pregnancy should prompt referral to obstetrics. Rubella is a notifiable disease, meaning that it requires notification of the local authority or UKHSA health protection team.

According to the Royal College of Emergency Medicine (RCEM), Prilocaine is the preferred choice for intravenous regional anesthesia. This is because Bupivacaine and lidocaine have a higher risk of causing harmful side effects.

Further Reading:

Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

Ceftriaxone is currently one of the limited antibiotics that effectively treats gonorrhoea. It is typically administered alongside azithromycin or doxycycline to enhance its effectiveness.

Nitrous oxide should not be used in cases where there is trapped air, such as pneumothorax. This is because nitrous oxide can diffuse into the trapped air and increase the pressure, which can be harmful. This can be particularly dangerous in conditions like pneumothorax, where the trapped air can expand and affect breathing, or in cases of intracranial air after a head injury, trapped air after a recent underwater dive, or recent injection of gas into the eye.

Further Reading:

Entonox® is a mixture of 50% nitrous oxide and 50% oxygen that can be used for self-administration to reduce anxiety. It can also be used alongside other anesthesia agents. However, its mechanism of action for anxiety reduction is not fully understood. The Entonox bottles are typically identified by blue and white color-coded collars, but a new standard will replace these with dark blue shoulders in the future. It is important to note that Entonox alone cannot be used as the sole maintenance agent in anesthesia.

One of the effects of nitrous oxide is the second-gas effect, where it speeds up the absorption of other inhaled anesthesia agents. Nitrous oxide enters the alveoli and diffuses into the blood, displacing nitrogen. This displacement causes the remaining alveolar gases to become more concentrated, increasing the fractional content of inhaled anesthesia gases and accelerating the uptake of volatile agents into the blood.

However, when nitrous oxide administration is stopped, it can cause diffusion hypoxia. Nitrous oxide exits the blood and diffuses back into the alveoli, while nitrogen diffuses in the opposite direction. Nitrous oxide enters the alveoli much faster than nitrogen leaves, resulting in the dilution of oxygen within the alveoli. This can lead to diffusion hypoxia, where the oxygen concentration in the alveoli is diluted, potentially causing oxygen deprivation in patients breathing air.

There are certain contraindications for using nitrous oxide, as it can expand in air-filled spaces. It should be avoided in conditions such as head injuries with intracranial air, pneumothorax, recent intraocular gas injection, and entrapped air following a recent underwater dive.

Adrenaline is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) once chest compressions have been resumed. The recommended dose is 1 mg, which can be administered as either 10 mL of 1:10,000 or 1 mL of 1:1000 concentration. Subsequently, adrenaline should be given every 3-5 minutes, alternating with chest compressions, and it should be administered without interrupting the compressions. While there is no evidence of long-term benefit from the use of adrenaline in cardiac arrest, some studies have shown improved short-term survival, which justifies its continued use.

The FeverPAIN score is a clinical scoring system that helps determine the likelihood of a streptococcal infection and whether antibiotic treatment is necessary. It consists of several criteria that are assessed to assign a score.

Firstly, if the patient has a fever higher than 38°C, they score 0 or 1 depending on the presence or absence of this symptom.

Secondly, the presence of purulence, such as pharyngeal or tonsillar exudate, results in a score of 1.

Thirdly, if the patient sought medical attention within 3 days or less, they score 1.

Fourthly, if the patient has severely inflamed tonsils, they score 1.

Lastly, if the patient does not have a cough or coryza (nasal congestion), they score 1.

By adding up the scores from each criterion, the FeverPAIN score can help healthcare professionals determine the likelihood of a streptococcal infection and guide the decision on whether antibiotic treatment is necessary. In this particular case, the patient has a score of 4.

Further Reading:

Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can

The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. The dosage should be adjusted based on how the individual responds to the medication and their ability to tolerate it. If the initial treatment does not provide relief or is not well tolerated, one of the remaining three medications can be considered as an alternative option.

Infectious mononucleosis, also known as glandular fever, is a condition that is not clearly defined in medical literature. It is characterized by symptoms such as a sore throat, swollen tonsils with a whitish coating, enlarged lymph nodes in the neck, fatigue, and an enlarged liver and spleen. This condition is caused by a specific virus.

Further Reading:

Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.

The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.

Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.

Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.

Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.

Based on the child’s medical history, it appears that they have multiple areas of infected eczema. In such cases, the NICE guidelines recommend starting treatment with flucloxacillin as the first-line option for bacterial infections. This is because staphylococcus and/or streptococcus bacteria are the most common causes of these infections. Swabs should only be taken if there is a likelihood of antibiotic resistance or if a different pathogen is suspected. In cases where the child is allergic to flucloxacillin, erythromycin can be used as an alternative. If the child cannot tolerate erythromycin, clarithromycin is the recommended option. For more information, you can refer to the NICE Clinical Knowledge Summary on the management of infected eczema.

Hypercalcaemia is often linked to feelings of sadness and low mood, while hypocalcaemia does not typically have this association. Temporal arteritis is known to cause sudden episodes of psychosis, but it is not commonly associated with depression. On the other hand, hyperkalaemia does not have a connection to depression. Lastly, when someone experiences a deficiency in thiamine, they may exhibit symptoms of acute confusion, but depression is not typically one of these symptoms.

This patient is clearly experiencing pyelonephritis with systemic involvement, which may indicate sepsis. According to NICE guidelines, it is recommended to admit individuals to the hospital if they exhibit any symptoms or signs that suggest a more serious illness or condition, such as sepsis. In cases of acute pyelonephritis, it is advisable to consider referring or seeking specialist advice for individuals who are significantly dehydrated or unable to consume oral fluids and medications, pregnant women, those at a higher risk of developing complications (e.g., individuals with known or suspected structural or functional abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression), and individuals who have recurrent episodes of urinary tract infections (e.g., two or more episodes within a 6-month period). Additionally, it is recommended to consider referral for men who have experienced a single episode without an obvious cause and women with recurrent pyelonephritis. For more information, please refer to the NICE Clinical Knowledge Summary on the management of acute pyelonephritis.

Hepatic encephalopathy is a condition caused by the accumulation of nitrogenous waste products in the body due to impaired liver function. These waste products cross the blood brain barrier and contribute to the production of glutamine, leading to changes in astrocyte osmotic pressure, brain edema, and neurotransmitter dysfunction.

To address hepatic encephalopathy, the first-line drugs used are Rifaximin and lactulose. Rifaximin is an oral antibiotic that helps reduce the presence of ammonia-producing bacteria in the intestines. Lactulose, on the other hand, converts soluble ammonia into insoluble ammonium and aids in relieving constipation.

It is important to note that Chlordiazepoxide, a benzodiazepine, may be used to treat alcohol withdrawal but should be avoided in cases of hepatic encephalopathy as it can worsen the condition.

Further Reading:

Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.

Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.

The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.

Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.

Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.

Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.

Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.

A recognized criterion for referral to the burns unit is when a burn involves the upper limb, any burn that has not healed in 7 days, any burn with significant blistering, a burn with a pain score on presentation greater than 8 out of 10 on a visual analogue scale, or a burn that covers 3% or more of the total body surface area in an adult.

Further Reading:

Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.

Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.

To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.

When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.

Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.

To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.

For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.

To treat low sodium levels, a solution of sodium chloride is administered. It is important to regularly monitor plasma sodium levels every 2 hours during this treatment, but it is crucial to avoid taking samples from the arm where the IV is inserted. The increase in serum sodium should not exceed 2 mmol/L per hour and should not exceed 8 to 10 mmol/L within a 24-hour period. Hypertonic saline is administered intravenously until neurological symptoms improve.

Further Reading:

Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.

There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.

The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.

Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.

It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.

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.

This patient has come in with worsening breathlessness and coughing, along with coughing up blood, all of which are occurring on top of their existing lung cancer. The diagnosis in this case is superior vena cava obstruction, which is being caused by the primary bronchial neoplasm.

The typical clinical presentation of superior vena cava obstruction includes breathlessness and coughing, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

Given the urgency of the situation, this man will require immediate treatment. Upon initial presentation, it is important to elevate his head and provide supplemental oxygen to alleviate symptoms. Additionally, corticosteroids and diuretics may be administered. Further investigation will be necessary through CT scanning, and radiotherapy may be recommended as a potential course of action.

Hepatitis B surface antigen (HBsAg) is a protein found on the surface of the hepatitis B virus. It can be detected in high levels in the blood during both acute and chronic hepatitis B virus infections. The presence of HBsAg indicates that the person is capable of spreading the infection to others. Normally, the body produces antibodies to HBsAg as part of the immune response to the infection. HBsAg is also used to create the hepatitis B vaccine.

Hepatitis B surface antibody (anti-HBs) indicates that a person has recovered from the hepatitis B virus infection and is now immune to it. This antibody can also develop in individuals who have been successfully vaccinated against hepatitis B.

Total hepatitis B core antibody (anti-HBc) appears when symptoms of acute hepatitis B begin and remains present for life. The presence of anti-HBc indicates that a person has either had a previous or ongoing infection with the hepatitis B virus, although the exact time frame cannot be determined. This antibody is not present in individuals who have received the hepatitis B vaccine.

IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates a recent infection or acute hepatitis B. If this antibody is present, it suggests that the infection occurred within the past six months.