Understanding Addison’s Disease

Addison’s disease is a rare condition caused by adrenal insufficiency, with the most common cause being autoimmune destruction of the adrenal glands. It affects a small percentage of the population, making it difficult to diagnose due to its vague symptoms. Patients may experience chronic fatigue, weight loss, and muscle weakness, among other symptoms. Differential diagnoses should be considered, including type 1 diabetes, eating disorders, and chronic fatigue syndrome.

Clinical examination and blood tests can provide clues to the presence of Addison’s disease. Postural hypotension, hyponatremia, and hyperkalemia are common features. A serum cortisol level done at 8-9 am can also be helpful in diagnosing the condition. Levels below 100 nanomol/L require hospital admission, while levels between 100 and 500 nanomol/L merit endocrinology referral for further investigation.

It is important to have a high degree of suspicion when considering a diagnosis of Addison’s disease, as early detection and treatment can prevent acute crises and improve patient outcomes.

Hospital Admission Necessary for Patient with Asthma and Pneumonia

There are several indicators that suggest hospital admission is necessary for this patient. Despite already taking preventative measures for his asthma with Beclomethasone diproprionate 100 mcg/Formetorol fumarate 6 mcg, his usage of salbutamol has increased and he has a productive cough with fevers, indicating a potential bacterial infection. Additionally, his oxygen levels are low, requiring oxygen therapy and monitoring of his oxygen saturations. He is also febrile with evidence of a focal infection and tachycardic. His CRB-65 score of 2, due to his blood pressure being <60 diastolic and his age being >65, further supports the need for hospitalization. Furthermore, his peak flow is less than 50%, indicating both pneumonia and an acute asthma attack.

While other options may be reasonable, such as adjusting his medication or providing home care, this patient requires intravenous antibiotics, oxygen therapy, and monitoring of his oxygen saturations and steroids, all of which can only be provided in a hospital setting.

Understanding Organophosphate Insecticide Poisoning

Organophosphate insecticide poisoning is a condition that occurs when an individual is exposed to insecticides containing organophosphates. This type of poisoning inhibits acetylcholinesterase, leading to an increase in nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic organophosphorus compound that has similar effects.

The symptoms of organophosphate poisoning can be predicted by the accumulation of acetylcholine, which can be remembered using the mnemonic SLUD. These symptoms include salivation, lacrimation, urination, defecation/diarrhea, cardiovascular issues such as hypotension and bradycardia, small pupils, and muscle fasciculation.

The management of organophosphate poisoning involves the use of atropine to counteract the effects of acetylcholine accumulation. The role of pralidoxime in treating this condition is still unclear, as meta-analyses to date have failed to show any clear benefit.

The patient is likely suffering from acute renal colic due to a calcium-containing renal stone. IM diclofenac is the initial step in management, along with increased fluid intake and arranging for a urology opinion. Antispasmodics should not be offered. Assess response to initial treatment and admit if no response within 1 hour. Offer urgent imaging to confirm diagnosis and assess likelihood of spontaneous stone passage. Offer NSAIDs for pain relief, and consider opioids if necessary. Do not offer antispasmodics. Provide written information on renal and ureteric stones.

Assessment and Severity of Acute Asthma

Questions about the assessment and severity of acute asthma are common in exams. To address this, the British Thoracic Society (BTS) has provided clear guidance on the assessment and management of acute asthma. It is important to familiarize oneself with this document.

Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of the patient’s best or predicted rate, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or the inability to complete sentences in one breath. It is important to note that there is no fixed numerical peak flow rate for all patients, as it depends on their usual best reading or predicted peak flow reading. If their actual peak flow is 33-50% of this figure, then it is a marker of an acute severe attack.

According to BTS guidance, pulsus paradoxus is not an adequate indicator of the severity of an acute asthma attack and should not be used. A pulse of 101/min would not be considered a marker of acute severe asthma because the threshold is 110/min or greater. However, a respiratory rate of 26/min is clearly above the threshold advised by BTS and would be a marker of an acute severe attack. If any of these features of an acute severe asthma attack persist after initial treatment, then the patient should be admitted.

Superior Vena Caval Obstruction (SVCO)

Superior Vena Caval Obstruction (SVCO) is a condition where there is an obstruction of blood flow in the superior vena cava. This can be caused by extraluminal compression or thrombosis within the vein. The most common cause of SVCO is malignancy, particularly lung cancer and lymphoma. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

The typical features of SVCO include facial/upper body oedema, facial plethora, venous distention, and increased shortness of breath. Other symptoms may include dizziness, syncopal attacks, and headache due to pressure effect. Prompt recognition of SVCO on clinical grounds and immediate referral for specialist assessment is crucial. If there is any stridor or laryngeal oedema, SVCO is considered a medical emergency.

Management of SVCO involves treatment with steroids and radiotherapy. Chemotherapy and stent insertion may also be indicated. It is important to address the underlying cause of SVCO to prevent further complications.

Anaphylactic Reactions: Causes, Symptoms, and Management

Anaphylactic reactions can vary in severity and may be delayed by several hours. The most common triggers are foods, bee and wasp stings, and drugs. Symptoms may include itching, redness, and swelling. Beta-blockers can worsen the reaction by blocking the response to adrenaline. Unlike a vasovagal attack, anaphylaxis is usually accompanied by a rapid heartbeat.

Initial management of anaphylaxis involves administering high-flow oxygen, laying the patient flat, and elevating their legs to combat hypotension. If the patient is experiencing respiratory distress or shock, epinephrine should be given intramuscularly. It is recommended that practices have vials of epinephrine 1:1000 solution on hand, along with the necessary syringes and needles.

The recommended doses of epinephrine vary by age, with adults and children over 12 years receiving 0.5 ml (500 micrograms), children aged 6-12 receiving 0.3 ml (300 micrograms), and children under 6 receiving 0.15 ml (150 micrograms). Chlorpheniramine and hydrocortisone may also be given intramuscularly, but hydrocortisone is of secondary value in the initial management of anaphylaxis.

Paradoxical JVP Rise in Pericardial Effusion

Pericardial effusion, which may be infective as a result of previous tuberculosis, can cause a paradoxical rise in the jugular venous pressure (JVP) during inspiration. This is in contrast to the typical fall in JVP seen with inspiration. Treatment for pericardial effusion depends on the underlying cause, with an echocardiogram being the crucial initial investigation. If the effusion is particularly large and causing haemodynamic compromise, it may need to be tapped. Additionally, re-treatment with anti-tuberculous therapy is necessary. Proper diagnosis and management of pericardial effusion are essential to prevent further complications.

Harmful Levels of Paracetamol

When it comes to harmful levels of paracetamol, patients are divided into two groups: those who have taken an acute overdose and those who have taken a staggered overdose, which includes patients who may have taken therapeutic excess over a period of time. Surprisingly, even modest amounts of paracetamol can be harmful, especially for frail elderly patients.

According to the British National Formulary, a staggered overdose involves ingesting a potentially toxic dose of paracetamol over more than one hour, with the possible intention of causing self-harm. Therapeutic excess is the inadvertent ingestion of a potentially toxic dose of paracetamol during its clinical use. In these cases, patients who have taken more than 150 mg/kg of paracetamol in any 24-hour period are at risk of toxicity and should be commenced on acetylcysteine immediately, unless it is more than 24 hours since the last ingestion, the patient is asymptomatic, the plasma-paracetamol concentration is undetectable, and liver function tests, serum creatinine and INR are normal.

It’s important to note that there is no set number of tablets that can cause toxicity as it depends on the patient’s weight. Rarely, toxicity can occur with paracetamol doses between 75-150 mg/kg in any 24-hour period, and clinical judgement of the individual case is necessary to determine whether to treat those who have ingested this amount of paracetamol. For small adults, this may be within the licensed dose, but ingestion of a licensed dose of paracetamol is not considered an overdose. The doctor may not be informed until after the event, so familiarity with the timescales is also important.

Diagnosis of Panic Attack

The ECG and pulse oximetry tests were normal, and the clinical context and examination findings all point to the diagnosis of a panic attack. It is appropriate to explain the diagnosis to the patient and provide reassurance.

Psychological symptoms of an anxiety state include irritability, intolerance of noise, poor concentration/memory, fearfulness, apprehensiveness, restlessness, and continuous worrying thoughts. On the other hand, physical symptoms of an anxiety state include dry mouth, difficulty in swallowing, chest pain, shakiness, diarrhoea, urinary frequency, paraesthesiae, and hot flashes. Physical signs of an anxiety state include tenseness, sweating, shaking, pallor, restlessness, and sighing.

It is important to recognize the symptoms and signs of a panic attack to provide appropriate care and support to the patient.