Calcium-channel blocker overdose is a serious matter and should always be treated as potentially life-threatening. The two most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

The toxic effects of calcium-channel blockers can be summarized as follows:

Cardiac effects:
– Excessive negative inotropy: causing myocardial depression
– Negative chronotropy: leading to sinus bradycardia
– Negative dromotropy: resulting in atrioventricular node blockade

Vascular smooth muscle tone effects:
– Decreased afterload: causing systemic hypotension
– Coronary vasodilation: leading to widened blood vessels in the heart

Metabolic effects:
– Hypoinsulinaemia: insulin release depends on calcium influx through L-type calcium channels in islet beta-cells
– Calcium channel blocker-induced insulin resistance: causing reduced responsiveness to insulin.

It is important to be aware of these effects and take appropriate action in cases of calcium-channel blocker overdose.

According to NICE guidelines, when it comes to imaging for cervical spine injury, CT is recommended as the primary modality for adults aged 16 and above, while MRI is recommended for children. This applies to patients who are either at high risk for cervical spine injury or are unable to actively rotate their neck 45 degrees to the left and right.

Further Reading:

When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

When addressing the management of long-term alcohol abuse and promoting self-care, it is important to start by exploring the reasons behind the patient’s previous relapses. This will help understand her beliefs and understanding of her condition and identify any simple, supportive measures that can aid in her efforts to stop drinking.

Referral to the Community Drug and Alcohol Team (CDAT) may be necessary at some point. Depending on the severity and duration of her alcohol abuse, she may be suitable for outpatient or community detox. However, if her drinking has been sustained and heavy for many years, she may require admission for additional support. It is important to note that there is often a long wait for available beds, so it would be more prudent to thoroughly explore her history before making this referral.

While arranging for her liver function to be tested could be part of the general work-up, it is unlikely to be necessary for a leg laceration. It is crucial to avoid suddenly abstaining or prescribing chlordiazepoxide, as these actions can be potentially dangerous. Abrupt detoxification may lead to delirium tremens, which can have catastrophic effects. Chlordiazepoxide may be used under the supervision of experienced professionals, but close monitoring and regular appointments with a GP or specialist are essential.

Phenoxymethylpenicillin is the preferred antibiotic for treating streptococcal sore throat, especially in patients with a CENTOR score of 3/4 and a FeverPAIN score of 4/5. In such cases, antibiotics are necessary to effectively treat the infection.

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.

The clinical manifestations of cannabis use encompass various aspects. Firstly, it can amplify pre-existing mood states, leading to feelings of euphoria, depression, or anxiety. Additionally, cannabis can distort one’s perception of time and space, creating a sense of disorientation. It also enhances the enjoyment of aesthetic experiences, making them more pleasurable. Visual hallucinations may also occur as a result of cannabis use. Physiological effects include dry mouth, coughing, and irritation of the respiratory tract. Furthermore, cannabis use often leads to an increased appetite and a decrease in body temperature. Reddened eyes and respiratory tract irritation are also common symptoms associated with cannabis use.

Full thickness burns are devoid of pain as they result in the complete destruction of the superficial nerve endings. These burns usually display characteristics such as a lack of sensation, a coloration of the burnt skin in shades of white, brown, or black, a texture that is waxy or leathery, and a dry appearance without any blistering.

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.

Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

Emotional incongruity, although not a primary symptom, is one of the negative symptoms that define chronic schizophrenia. These symptoms, as described by Kurt Schneider, are known as first-rank symptoms. They include auditory hallucinations such as hearing third-person voices discussing the patient, thought echo, and commentary on actions. Passivity phenomena, such as thought insertion, thought withdrawal, thought broadcast, and feelings of thoughts and actions being under external control, are also considered first-rank symptoms. Delusions, which can be primary or secondary, are another characteristic of schizophrenia.

Chronic schizophrenia is primarily characterized by negative symptoms. These symptoms include poor motivation and self-care, social withdrawal, depression, flat and blunted affect, emotional incongruity, decreased activity, poverty of thought and speech. On the other hand, symptoms like loss of inhibitions, pressure of speech, and grandiose delusions are more indicative of mania. Increased anxiety in social circumstances is often associated with social anxiety disorder.

In summary, emotional incongruity is a negative symptom of chronic schizophrenia, while the first-rank symptoms described by Kurt Schneider encompass auditory hallucinations, passivity phenomena, and delusions. It is important to differentiate these symptoms from those associated with mania or social anxiety disorder.

The primary way hepatitis A is transmitted is through the ingestion of fecal matter containing the virus. On the other hand, all the other organisms mentioned in this question are typically transmitted through sexual contact.

Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

Hyperkalaemia can be identified by certain signs, such as muscle weakness, cramps, and delayed deep tendon reflexes. Additionally, there are neurological signs that may be present, including flaccid paralysis, twitching, peripheral paresthesia, weakness, and hypo-reflexia.

Further Reading:

Vasoactive drugs can be classified into three categories: inotropes, vasopressors, and unclassified. Inotropes are drugs that alter the force of muscular contraction, particularly in the heart. They primarily stimulate adrenergic receptors and increase myocardial contractility. Commonly used inotropes include adrenaline, dobutamine, dopamine, isoprenaline, and ephedrine.

Vasopressors, on the other hand, increase systemic vascular resistance (SVR) by stimulating alpha-1 receptors, causing vasoconstriction. This leads to an increase in blood pressure. Commonly used vasopressors include norepinephrine, metaraminol, phenylephrine, and vasopressin.

Electrolytes, such as potassium, are essential for proper bodily function. Solutions containing potassium are often given to patients to prevent or treat hypokalemia (low potassium levels). However, administering too much potassium can lead to hyperkalemia (high potassium levels), which can cause dangerous arrhythmias. It is important to monitor potassium levels and administer it at a controlled rate to avoid complications.

Hyperkalemia can be caused by various factors, including excessive potassium intake, decreased renal excretion, endocrine disorders, certain medications, metabolic acidosis, tissue destruction, and massive blood transfusion. It can present with cardiovascular, respiratory, gastrointestinal, and neuromuscular symptoms. ECG changes, such as tall tented T-waves, prolonged PR interval, flat P-waves, widened QRS complex, and sine wave, are also characteristic of hyperkalemia.

In summary, vasoactive drugs can be categorized as inotropes, vasopressors, or unclassified. Inotropes increase myocardial contractility, while vasopressors increase systemic vascular resistance. Electrolytes, particularly potassium, are important for bodily function, but administering too much can lead to hyperkalemia. Monitoring potassium levels and ECG changes is crucial in managing hyperkalemia.

Central retinal vein occlusion (CRVO) typically leads to painless, one-sided vision loss. When examining the retina, it may appear similar to a ‘pizza thrown against a wall’, with swollen retinal veins, swelling of the optic disc, multiple flame-shaped hemorrhages, and cotton wool spots. Hypertension is present in about 65% of CRVO patients, and it is more common in individuals over the age of 65. Other known risk factors include being elderly, having chronic glaucoma, arteriosclerosis, and polycythemia.

In contrast, central retinal artery occlusion (CRAO) is characterized by a pale retina and a ‘cherry-red spot’ in the macula’s center, which is spared due to its blood supply from the underlying choroid. It is important to differentiate between CRVO and CRAO based on these distinct features.

Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function that leads to the accumulation of waste products and disturbances in fluid and electrolyte balance. This can occur in individuals with previously normal kidney function or those with pre-existing kidney disease (acute-on-chronic kidney disease). AKI is relatively common, affecting approximately 15% of adults admitted to hospitals in the UK.

The clinical presentation of AKI varies depending on the underlying cause and the severity of the condition. Typically, patients experience reduced urine output (oliguria or anuria) along with an increase in serum creatinine levels. AKI is diagnosed when at least one of the following criteria is met: a rise in serum creatinine of 26 μmol/L or more within 48 hours, a 50% or greater increase in serum creatinine (1.5 times the baseline) within the previous seven days, or a decrease in urine output to less than 0.5 mL/kg/hour for more than six hours.

Common symptoms of AKI include reduced urine output, which is usually oliguria or anuria. However, polyuria can also occur due to impaired fluid reabsorption by damaged renal tubules or the osmotic effect of accumulated metabolites. Abrupt anuria may indicate an acute obstruction, severe glomerulonephritis, or renal artery occlusion, while a gradual decrease in urine output may suggest a urethral stricture or bladder outlet obstruction, such as benign prostatic hyperplasia. Other symptoms may include nausea, vomiting, dehydration, and confusion.

Signs of AKI can include hypertension, a palpable bladder if urinary retention is present, dehydration with postural hypotension and no swelling, or fluid overload with elevated jugular venous pressure (JVP), pulmonary edema, and peripheral edema.

This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.

Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.

Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.

While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.

To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.

Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.

Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).

Mallory-Weiss syndrome is a condition characterized by a tear in the lining of the esophagus, specifically near the junction where the esophagus meets the stomach. This tear is typically caused by forceful retching and vomiting and is often associated with behaviors such as binge drinking, eating disorders, and hyperemesis gravidarum. Fortunately, the bleeding usually stops within 24-48 hours and invasive procedures like endoscopy are rarely necessary.

It is important to note that Mallory-Weiss syndrome should not be confused with Boerhaave’s syndrome, which is the spontaneous rupture of a healthy esophagus, usually following intense vomiting. Patients with Boerhaave’s syndrome experience respiratory collapse, subcutaneous emphysema, and acute abdominal pain. While Boerhaave’s syndrome is rare, it is more commonly observed in individuals who abuse alcohol.

The ratio of chest compressions to ventilations is 15:2. This ratio has not been proven through experiments, but it has been validated through mathematical studies. When performing chest compressions on a child, it is recommended to make them at least 1/3 of the depth of the child’s chest. Additionally, the optimal compression rate is between 100 and 120 compressions per minute.
To protect the airway of an unconscious child, the oropharyngeal (Guedel) airway is the best option. However, it should not be used on awake patients as there is a risk of vomiting and aspiration.
In children, asystole is the most common arrest rhythm. This occurs when the young heart responds to prolonged hypoxia and acidosis by progressively slowing down, eventually resulting in asystole.

Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

Crohn’s disease is characterized by skip lesions, which are not present in ulcerative colitis. Unlike ulcerative colitis, Crohn’s disease causes inflammation throughout the entire thickness of the intestinal wall, not just the mucosa. Interestingly, smoking increases the risk of developing Crohn’s disease but decreases the risk of ulcerative colitis. Additionally, having an appendicectomy before adulthood is believed to protect against ulcerative colitis, whereas it actually increases the risk of developing Crohn’s disease for about 5 years after the surgery.

Further Reading:

Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation of the intestinal tract and an imbalance of the intestinal microbiota. The two main forms of IBD are Crohn’s disease and ulcerative colitis (UC). In some cases, it is not possible to differentiate between Crohn’s disease and UC, and the term inflammatory bowel disease type-unclassified may be used.

Crohn’s disease is a chronic, relapsing-remitting inflammatory disease that can affect any part of the gastrointestinal tract, from the mouth to the anus. It most commonly involves the ileum and colon. The inflammation in Crohn’s disease affects all layers of the intestinal wall, leading to complications such as strictures, fistulas, and adhesions. Risk factors for developing Crohn’s disease include a family history, smoking, infectious gastroenteritis, appendicectomy, and the use of NSAIDs and oral contraceptive drugs. Symptoms of Crohn’s disease can vary but often include diarrhea, abdominal pain, weight loss, and perianal disease. Extraintestinal features, such as arthritis, erythema nodosum, and uveitis, can also occur.

Ulcerative colitis is a chronic, relapsing-remitting inflammatory disease that primarily affects the large bowel. The inflammation in UC is limited to the intestinal mucosa and does not involve skip lesions like in Crohn’s disease. Risk factors for developing UC include a family history, not smoking, and no appendix. Symptoms of UC include bloody diarrhea, urgency, tenesmus, and abdominal pain. Extraintestinal features, such as arthritis and uveitis, can also occur. Complications of UC include toxic megacolon, bowel obstruction, bowel perforation, strictures, fistula formation, anemia, malnutrition, and colorectal cancer.

Diagnosing IBD involves various investigations, including blood tests, stool microscopy and culture, fecal calprotectin testing, endoscopy with biopsy, and imaging modalities such as CT and MR enterography. The management of Crohn’s disease and UC is complex and may involve corticosteroids, immunosuppressive drugs, biologic therapy, surgery, and nutritional support. Patients with IBD should also be monitored for nutritional deficiencies, colorectal cancer, and osteoporosis.

Stool samples are recommended for children with diarrhea who have recently traveled, show signs of mucus or blood in their stools, or have had diarrhea for more than a week. This patient’s symptoms align with gastroenteritis. While stool microbiological testing is not typically necessary, it should be conducted if any of the following conditions are present: recent travel, prolonged diarrhea, immunocompromised state, suspected septicemia, presence of blood and/or mucus in the stool, or uncertainty regarding the diagnosis.

Further Reading:

Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

Patients who have bacterial tracheitis usually do not show any improvement when treated with steroids and adrenaline nebulizers. The symptoms of bacterial tracheitis include a prelude of upper respiratory tract infection symptoms, followed by a rapid decline in health with the presence of stridor and difficulty breathing. Despite treatment with steroids and adrenaline, there is no improvement in the patient’s condition. On the other hand, patients with epiglottitis commonly experience difficulty swallowing and excessive saliva production.

Further Reading:

Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

Target cells, also referred to as codocytes or Mexican hat cells, are a distinct type of red blood cells that display a unique appearance resembling a shooting target with a bullseye. These cells are commonly observed in individuals with sickle-cell disease, distinguishing it from the other conditions mentioned in the provided options. Hence, sickle-cell disease is the most probable diagnosis in this case. Additionally, target cells can also be associated with other conditions such as thalassaemia, liver disease, iron-deficiency anaemia, post splenectomy, and haemoglobin C disease.

Based on the clinical history and examination, it strongly indicates that the patient has developed a pulmonary embolism due to a deep vein thrombosis in his right leg.

The symptoms commonly associated with a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. These symptoms may also suggest the presence of a deep vein thrombosis. Other clinical features that may be observed are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

To treat serious arrhythmia caused by hypomagnesaemia, it is recommended to administer 2 g of magnesium sulphate intravenously over a period of 10-15 minutes.

Further Reading:

In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.

Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.

Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.

Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.

Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.

Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.

It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.

Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.

One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.

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.

Hyperkalemia is a condition where the level of potassium in the blood is higher than normal, specifically greater than 5.5 mmol/l. It can be categorized as mild, moderate, or severe depending on the potassium level. Mild hyperkalemia is when the potassium level is between 5.5-5.9 mmol/l, moderate hyperkalemia is between 6.0-6.4 mmol/l, and severe hyperkalemia is above 6.5 mmol/l. The most common cause of hyperkalemia is renal failure, which can be acute or chronic. Other causes include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.

In the treatment of hyperkalemia, calcium plays a crucial role. It works by counteracting the harmful effects of high potassium levels on the heart by stabilizing the cardiac cell membrane. Calcium acts quickly, with its effects seen within 15 minutes, but its effects are relatively short-lived. It is considered a first-line treatment for arrhythmias and significant ECG abnormalities caused by hyperkalemia. However, it is rare to see arrhythmias occur at potassium levels below 7.5 mmol/l.

It’s important to note that calcium does not lower the serum level of potassium. Therefore, when administering calcium, other therapies that actually help lower potassium levels, such as insulin and salbutamol, should also be used. Insulin and salbutamol are effective in reducing serum potassium levels.

When choosing between calcium chloride and calcium gluconate, calcium chloride is preferred when hyperkalemia is accompanied by hemodynamic compromise. This is because calcium chloride contains three times more elemental calcium than an equal volume of calcium gluconate.

Non-selective beta-blockers, like propranolol, can cause severe bronchospasm in individuals with asthma, particularly when taken in high doses. The current guidelines from the British Thoracic Society (BTS) recommend avoiding the use of beta-blockers in asthma patients. However, there is some evidence suggesting that the long-term use of cardioselective beta-blockers does not appear to trigger asthma attacks in individuals with mild or moderate asthma.

Beta-blockers play a crucial role in the treatment of patients who have a history of previous myocardial infarction or systolic dysfunction. In individuals with asthma and one of these diagnoses, it is unlikely that the potential benefits of beta-blockers outweigh the risks of worsening asthma symptoms.

Currently, there is no evidence to support the use of nebulised magnesium sulphate in the treatment of adults with asthma. For adults experiencing acute asthma, the recommended drug doses are as follows:

– Salbutamol: 5 mg administered through an oxygen-driven nebuliser.
– Ipratropium bromide: 500 mcg delivered via an oxygen-driven nebuliser.
– Prednisolone: 40-50 mg taken orally.
– Hydrocortisone: 100 mg administered intravenously.
– Magnesium sulphate: 1.2-2 g given intravenously over a period of 20 minutes.

Intravenous salbutamol may be considered (250 mcg administered slowly) only when inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation.

According to the current ALS guidelines, IV aminophylline can be considered in cases of severe or life-threatening asthma, following senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

The complete blood count findings indicate a severe case of iron deficiency anemia. The patient’s red blood cells are significantly reduced in number, and there is a noticeable hypochromic microcytic anemia. When examining the peripheral blood smear, variations in shape (poikilocytosis) and size (anisocytosis) can be observed, which are typical of iron deficiency anemia. Pencil cells are commonly seen in this condition. Additionally, it is common for iron deficiency anemia to be accompanied by thrombocytosis, an increase in platelet count.

This patient is experiencing a blockage in one nostril, hearing loss in one ear, and a newly developed hearing impairment. Additionally, there is a noticeable swollen lymph node in the upper jugular chain on the affected side. These symptoms strongly suggest the possibility of nasopharyngeal carcinoma.
Nasopharyngeal carcinoma is not very common in the U.K., but it has a higher occurrence in individuals from Southeast Asia. In this region, the disease is often linked to the Epstein-Barr virus (EBV). It typically affects individuals between the ages of 40 and 70.
The most common signs of nasopharyngeal carcinoma include a lump in the neck (present in approximately 80% of cases), one-sided nasal blockage (present in approximately 60% of cases), one-sided deafness (present in approximately 50% of cases), and post-nasal discharge (present in approximately 50% of cases). Lymph nodes in the upper jugular chain are often detectable.
It is crucial to refer this patient urgently using a suspected cancer referral pathway to ensure an appointment within two weeks.
For more information, please refer to the NICE guidelines on the recognition and referral of suspected cancer.