Carbon Monoxide Poisoning

Carbon monoxide poisoning is a serious condition that can have severe consequences if left untreated. This type of poisoning occurs when carbon monoxide binds with haemoglobin in the blood, displacing oxygen and causing tissue hypoxia. The symptoms of mild poisoning include headaches, tiredness, nausea, dizziness, and poor concentration. As the levels of carboxy haemoglobin increase, vomiting, weakness, impaired consciousness, hypertension, tachycardia, and flushing may occur. In severe cases, convulsions, coma, respiratory depression, and even death can occur.

The treatment for carbon monoxide poisoning involves administering 100% oxygen through a tight-fitting, non-rebreathing face mask at a flow rate of 10 L/min. In severe cases, intubation and mechanical ventilation may be necessary. Hyperbaric oxygen therapy may also be used in some cases.

Diagnostic Steps for Suspected Marrow Infiltration in Hodgkin’s Disease

When a patient with stages I and II of Hodgkin’s disease presents with symptoms of anaemia, low white cell count, and thrombocytopenia, the suspicion of marrow infiltration arises. To confirm the diagnosis, a PET CT guided identification of a metabolic active lesion and excision biopsy of a lymph node is required. Following this, a CT scan of the thorax, abdomen, and pelvis is usually performed, along with bone marrow investigation. However, a deoxyglucose-labelled PET scan is combined with CT for staging of Hodgkin’s, rather than being the initial investigation. While LDH is a non-specific marker of haematological malignancy, it won’t help establish the underlying diagnosis. Instead, biopsy of an axillary lymph node is the preferred next step, as splenectomy carries significant morbidity.

Mitral valve prolapse is a common condition among ADPKD patients, with the majority of them experiencing it. Although most patients with mitral valve prolapse do not exhibit any symptoms, an echocardiogram should be conducted if symptoms are present. In this patient, the ‘click’ sound, combined with their underlying ADPKD, indicates a mitral valve prolapse. If left untreated, the prolapse can worsen and lead to secondary mitral regurgitation, resulting in symptoms like shortness of breath. Additionally, the narrow pulse pressure observed suggests the presence of left ventricular dysfunction.

Understanding Mitral Valve Prolapse

Mitral valve prolapse is a common condition that affects around 5-10% of the population. While it is often idiopathic, meaning it has no known cause, it can also be associated with a variety of cardiovascular diseases and other conditions. Some of these include congenital heart disease, cardiomyopathy, Turner’s syndrome, Marfan’s syndrome, Fragile X, osteogenesis imperfecta, pseudoxanthoma elasticum, Wolff-Parkinson White syndrome, long-QT syndrome, Ehlers-Danlos Syndrome, and polycystic kidney disease.

Patients with mitral valve prolapse may experience atypical chest pain or palpitations. A mid-systolic click may also be present, which occurs later if the patient is squatting. Additionally, a late systolic murmur may be heard, which is longer if the patient is standing. Complications of mitral valve prolapse can include mitral regurgitation, arrhythmias (including long QT), emboli, and sudden death.

Overall, understanding mitral valve prolapse and its potential associations and complications is important for proper diagnosis and management of the condition.

It is important to avoid prescribing co-trimoxazole with methotrexate as both medications can interfere with folate metabolism, leading to severe bone marrow suppression. However, there are no known interactions between corticosteroids and the other medications listed, including tazocin, aciclovir, clarithromycin, and methotrexate. It is important to monitor for potential toxicity if ciprofloxacin is prescribed with methotrexate.

Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

A young man has been diagnosed with subarachnoid haemorrhage, which is believed to be caused by an aneurysm. His family history reveals a pattern of renal and adrenal cancer, suggesting the presence of a genetic disorder. Two potential conditions that could be responsible for the SAH are PKD and VHL.

Understanding Von Hippel-Lindau Syndrome

Von Hippel-Lindau (VHL) syndrome is a genetic condition that increases the risk of developing tumors. It is caused by a mutation in the VHL gene located on chromosome 3. This condition is inherited in an autosomal dominant pattern, which means that a person only needs to inherit one copy of the mutated gene from either parent to develop the syndrome.

The features of VHL syndrome include cerebellar and retinal hemangiomas, which can cause bleeding and vision problems. Renal cysts are also common in people with VHL syndrome, and they can develop into clear-cell renal cell carcinoma, a type of kidney cancer. Other types of cysts can also occur in the pancreas, liver, and epididymis. Additionally, VHL syndrome increases the risk of developing endolymphatic sac tumors and pheochromocytoma, a rare tumor of the adrenal gland.

It is important for people with VHL syndrome to receive regular medical check-ups and screenings to detect any tumors early. Treatment options may include surgery, radiation therapy, or medication. With proper management, people with VHL syndrome can live long and healthy lives.

Vertebral Artery Dissection

Vertebral artery dissection is a condition that typically affects young individuals, with an average age of 40 years. It is characterized by severe occipital headache and neck pain following a recent head or neck injury, which is often associated with some form of cervical distortion. About 85% of patients develop focal neurological signs due to ischaemia of the brain stem or cerebellum. The most common neurological manifestations are symptoms attributable to lateral medullary dysfunction, also known as Wallenberg’s syndrome.

The symptoms and signs of vertebral artery dissection include ipsilateral facial pain and/or numbness, vertigo, dysarthria or hoarseness, ipsilateral loss of taste, hiccups, nausea and vomiting, diplopia or oscillopsia, and dysphagia. Depending on which areas of the brain stem or cerebellum are affected, clinical signs may include limb or truncal ataxia, nystagmus, ipsilateral Horner syndrome, ipsilateral impairment of fine touch and proprioception, contralateral impairment of pain and thermal sensation in the extremities, contralateral hemiparesis, lateral medullary syndrome, tongue deviation to the side of the lesion, and internuclear ophthalmoplegia.

Risk factors associated with the development of vertebral artery dissection include judo, yoga, ceiling painting, nose blowing, minor neck trauma, chiropractor manipulation, hypertension, oral contraceptive use, and female sex. It is important to be aware of these risk factors and to seek medical attention if any of the symptoms or signs of vertebral artery dissection are present. Early diagnosis and treatment can help prevent serious complications and improve outcomes.

Blood Pressure Targets for Chronic Kidney Disease Patients

Chronic kidney disease patients with proteinuria equivalent to ACR ≥70 mg/mmol should aim for a blood pressure target range of 120-129/<80 mmHg, according to the NICE guidelines on the management of Chronic kidney disease (CG182). The same target range applies to patients with diabetes. Non-diabetic patients with chronic kidney disease and an ACR <70 mg/mmol should aim for a blood pressure target range of 120-139/<90 mmHg. It is important to note that aiming for lower systolic (<120 mmHg) or diastolic (<60 mmHg) blood pressures can increase the risk of mortality, cardiovascular disease, congestive cardiac failure, and progression of chronic kidney disease. On the other hand, systolic or diastolic blood pressures above the target ranges are associated with an increased risk of a doubling in serum creatinine, end-stage renal failure, and death. In summary, chronic kidney disease patients should aim for specific blood pressure targets based on their proteinuria levels and diabetes status. It is crucial to avoid aiming for excessively low or high blood pressure levels, as this can lead to negative health outcomes.

Unusual Symptoms Point to Functional Diagnosis

This patient’s symptoms do not fit into a clear pattern or lesion. She has complete paralysis of her left arm and leg, but without hyperreflexia or hypertonia. The reflexes in her left leg are suppressed, likely due to sustained rigidity. The area of anaesthesia on her cheek does not correspond to any particular branch of the trigeminal nerve and is likely insignificant without other cranial nerve palsies.

The diagnosis is likely functional in origin, as there are no associated features or past history of headaches to suggest complex migraine. While multiple sclerosis can present with odd sensory disturbances, there is no true neurology to be found in this patient. The presence of oligoclonal bands in both cerebrospinal fluid and serum is of less significance.

A pontine infarct would cause crossed signs, with ipsilateral cranial nerve palsies and contralateral long-tract signs. A right carotid artery dissection would cause a total anterior circulation stroke with motor and sensory disturbance, homonymous hemianopia, and dysphasia.

Overall, this patient’s symptoms suggest a functional diagnosis, as they do not fit into a clear neurological pattern or lesion.

The Diurnal Rhythm of STEMI and Ischaemic Heart Disease

The incidence of ST-elevation myocardial infarction (STEMI) and death due to ischaemic heart disease both peak at around 8-9 am, which is associated with various physiological and haematological factors that increase the risk of vasospasm, infarction, and death. These factors include heightened adrenergic activity, elevated plasma fibrinogen levels, reduced fibrinolysis inhibition, and increased platelet adhesiveness. This prothrombotic and adrenergic environment, combined with atherosclerosis, can lead to infarction. Interestingly, non-ST-elevation myocardial infarctions (NSTEMIs) do not exhibit this diurnal rhythm to the same extent. Precipitating factors for an infarct can include heavy or modest physical exertion, surgical procedures, rest, sleep, and emotional stressors.

This patient is experiencing fatigue and pain in her limbs, and has a history of PBC which puts her at high risk for osteomalacia. However, her LFTs are normal and her PBC does not appear to have progressed. While she is iron deficient, she is not anemic. Her mildly elevated ESR suggests polymyalgia, but her low levels of phosphate and calcium point to malabsorption and potential vitamin D deficiency. This can lead to osteomalacia, which can cause fatigue and bone pain. X-rays may confirm this diagnosis, and high dose vitamin D replacement is recommended. Depression should be considered as a diagnosis of exclusion.

Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.