Osteoporosis is a condition characterized by weak and brittle bones, making them more prone to fractures. In this case, the patient’s sudden onset of central back pain and the X-ray findings of anterior wedging of the L2 vertebra suggest the possibility of undiagnosed osteoporosis.

One correct statement about osteoporosis is that it is defined as a T-score of less than -2.5. The T-score is a measure of bone density and is used to diagnose osteoporosis. A T-score of -2.5 or lower indicates a significant decrease in bone density and an increased risk of fractures.

Skeletal scintigraphy is not used to diagnose osteoporosis. Instead, it is commonly used to evaluate for other conditions such as bone infections or tumors.

The pubic rami is not the most common site for osteoporotic fractures. Osteoporotic fractures commonly occur in the spine (vertebral fractures), hip, and wrist.

Osteoporosis is not characterized by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase. This description is more consistent with a condition called Paget’s disease of bone.

The prevalence of osteoporosis is not approximately 10% at 50 years of age. The prevalence of osteoporosis increases with age, and it is estimated that around 50% of women and 25% of men over the age of 50 will experience an osteoporotic fracture in their lifetime.

Further Reading:

Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

Chickenpox is a highly contagious illness caused by the varicella-zoster virus, a DNA virus from the Herpesviridae family. Most cases are mild to moderate, and the infection usually resolves on its own. Severe complications are rare but can occur, especially in individuals with weakened immune systems or underlying health conditions.

The incubation period for chickenpox is typically between 14 to 21 days. It is contagious from a few days before the rash appears until about a week after the first lesions show up.

The common clinical features of chickenpox include:

– Fever, which lasts for approximately 3-5 days.
– The initial rash starts as flat red spots and progresses into raised bumps.
– These bumps then turn into fluid-filled blisters and eventually form pustules surrounded by redness.
– The lesions are extremely itchy.
– The rash reaches its peak around 48 hours in individuals with a healthy immune system.
– The rash tends to be more concentrated on the face and trunk, with fewer lesions on the limbs.
– The blisters eventually dry up and form crusts, which can lead to scarring if scratched.
– Headache, fatigue, and abdominal pain may also occur.

Chickenpox tends to be more severe in teenagers and adults compared to children. Antiviral treatment should be considered for these individuals if they seek medical attention within 24 hours of rash onset. The recommended oral dose of aciclovir is 800 mg taken five times a day for seven days.

Immunocompromised patients and those at higher risk, such as individuals with severe cardiovascular or respiratory disease or chronic skin disorders, should receive antiviral treatment for ten days, with at least seven days of intravenous administration.

Although most cases are relatively mild, if serious complications like pneumonia, encephalitis, or dehydration are suspected, it is important to refer the patient for hospital admission.

For more information, you can refer to the NICE Clinical Knowledge Summary on Chickenpox.
https://cks.nice.org.uk/topics/chickenpox/

A massive haemothorax occurs when more than 1500 mL of blood, which is about 1/3 of the patient’s blood volume, rapidly accumulates in the chest cavity. The classic signs of a massive haemothorax include decreased chest expansion, decreased breath sounds, and dullness to percussion. Both tension pneumothorax and massive haemothorax can cause decreased breath sounds, but they can be differentiated through percussion. Hyperresonance indicates tension pneumothorax, while dullness suggests a massive haemothorax.

The first step in managing a massive haemothorax is to simultaneously restore blood volume and decompress the chest cavity by inserting a chest drain. In most cases, the bleeding in a haemothorax has already stopped by the time management begins, and simple drainage is sufficient. It is important to use a chest drain of adequate size (preferably 36F) to ensure effective drainage of the haemothorax without clotting.

The Blatchford score, also known as the Glasgow-Blatchford Bleeding Score, is a commonly used tool to evaluate individuals who present with an acute upper gastrointestinal bleed. It is recommended by NICE (National Institute for Health and Care Excellence) that healthcare professionals use specific risk assessment scores for patients with this condition. The Blatchford score is used for initial assessment, while the full Rockall score is used after endoscopy.

The Blatchford score consists of 9 criteria, including gender, urea levels, hemoglobin levels, systolic blood pressure, pulse rate, presence of melena (black, tarry stools) at presentation, syncope (fainting) at presentation, presence of hepatic disease, and presence of cardiac failure. These criteria are used to determine the patient’s risk level. A calculator for the Blatchford score can be found in the links section.

Further Reading:

Peptic ulcer disease (PUD) is a condition characterized by a break in the mucosal lining of the stomach or duodenum. It is caused by an imbalance between factors that promote mucosal damage, such as gastric acid, pepsin, Helicobacter pylori infection, and NSAID drug use, and factors that maintain mucosal integrity, such as prostaglandins, mucus lining, bicarbonate, and mucosal blood flow.

The most common causes of peptic ulcers are H. pylori infection and NSAID use. Other factors that can contribute to the development of ulcers include smoking, alcohol consumption, certain medications (such as steroids), stress, autoimmune conditions, and tumors.

Diagnosis of peptic ulcers involves screening for H. pylori infection through breath or stool antigen tests, as well as upper gastrointestinal endoscopy. Complications of PUD include bleeding, perforation, and obstruction. Acute massive hemorrhage has a case fatality rate of 5-10%, while perforation can lead to peritonitis with a mortality rate of up to 20%.

The symptoms of peptic ulcers vary depending on their location. Duodenal ulcers typically cause pain that is relieved by eating, occurs 2-3 hours after eating and at night, and may be accompanied by nausea and vomiting. Gastric ulcers, on the other hand, cause pain that occurs 30 minutes after eating and may be associated with nausea and vomiting.

Management of peptic ulcers depends on the underlying cause and presentation. Patients with active gastrointestinal bleeding require risk stratification, volume resuscitation, endoscopy, and proton pump inhibitor (PPI) therapy. Those with perforated ulcers require resuscitation, antibiotic treatment, analgesia, PPI therapy, and urgent surgical review.

For stable patients with peptic ulcers, lifestyle modifications such as weight loss, avoiding trigger foods, eating smaller meals, quitting smoking, reducing alcohol consumption, and managing stress and anxiety are recommended. Medication review should be done to stop causative drugs if possible. PPI therapy, with or without H. pylori eradication therapy, is also prescribed. H. pylori testing is typically done using a carbon-13 urea breath test or stool antigen test, and eradication therapy involves a 7-day triple therapy regimen of antibiotics and PPI.

When giving chest compressions to an adult, it is important to compress the sternum to a depth of 5-6 cm. The resuscitation council updated their guidance in 2015 and now recommends a ratio of 30 chest compressions to 2 rescue breaths. It is worth noting that according to the algorithm, checking for a pulse is no longer necessary in the latest BLS sequence. The chest compressions should be administered at a rate of 100-120 per minute, with a ratio of 30 compressions to 2 rescue breaths.

Further Reading:

Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

A person’s level of consciousness is determined by their alertness. In this case, the score for alertness is 0, indicating that the person is not alert. Based on the scoring system, a total score of 4 suggests a moderate case of croup. Moderate croup is typically diagnosed when the scores range from 3 to 5.

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

Healthcare workers responding to contaminated casualties must prioritize their own safety by wearing appropriate personal protective equipment. This is crucial because secondary contamination can occur. Additionally, if working in contaminated areas, healthcare workers should maximize ventilation and use breathing equipment. Ensuring the safety of healthcare workers is essential as they cannot effectively help the casualties without it.

The first step in managing contaminated casualties is early skin decontamination. It is important to move the casualties to a safe area and remove all contaminated clothing to minimize further exposure. The skin should then be thoroughly rinsed with water to physically remove the nerve agent. After rinsing, it should be washed with an alkaline solution of soap and water or a 0.5% hypochlorite solution to chemically neutralize the nerve agent. To prevent ongoing absorption through the eyes, contact lenses should be removed and the eyes irrigated.

Resuscitation should be initiated using an ABCDE approach, and casualties should be supported and transferred to the hospital as quickly as possible. Ventilation may be necessary in some cases. Nerve agent antidote autoinjectors can be utilized, and the use of these should be guided by local policy for prehospital personnel.

Mitral regurgitation is characterized by a continuous murmur throughout systole that is often heard loudest at the apex and can be heard radiating to the left axilla.

Further Reading:

Mitral Stenosis:
– Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
– Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
– Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
– Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

Mitral Regurgitation:
– Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
– Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
– Signs of acute MR: Decompensated congestive heart failure symptoms
– Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
– Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

Corneal microdeposits are found in almost all individuals (over 90%) who have been taking amiodarone for more than six months, particularly at doses higher than 400 mg/day. These deposits generally do not cause any symptoms, although approximately 10% of patients may experience a perception of a ‘bluish halo’ around objects they see.

Amiodarone can also have other effects on the eye, but these are much less common, occurring in only 1-2% of patients. These effects include optic neuropathy, nonarteritic anterior ischemic optic neuropathy (N-AION), optic disc swelling, and visual field defects.

Acute cholecystitis occurs when a stone becomes stuck in the outlet of the gallbladder, causing irritation of the wall and resulting in chemical cholecystitis. This leads to the accumulation of pus within the gallbladder, which is typically sterile at first. However, there is a possibility of secondary infection with enteric organisms like Escherichia coli and Klebsiella spp.

The clinical features of acute cholecystitis include severe pain in the right upper quadrant or epigastrium, which can radiate to the back and lasts for more than 12 hours. Fevers and rigors are often present, along with common symptoms like nausea and vomiting. Murphy’s sign is a useful diagnostic tool, as it has a high sensitivity and positive predictive value for acute cholecystitis. However, its specificity is lower, as it can also be positive in biliary colic and ascending cholangitis.

In cases of acute cholecystitis, the white cell count and C-reactive protein (CRP) levels are usually elevated. AST, ALT, and ALP may also show elevation, but they can often be within the normal range. Bilirubin levels may be mildly elevated, but they can also be normal. If there is a significant increase in AST, ALT, ALP, and/or bilirubin, it may indicate the presence of other biliary tract conditions such as ascending cholangitis or choledocholithiasis.

It is important to note that there is some overlap in the presentation of biliary colic, acute cholecystitis, and ascending cholangitis. To differentiate between these diagnoses, the following list can be helpful:

Biliary colic:
– Pain duration: Less than 12 hours
– Fever: Absent
– Murphy’s sign: Negative
– WCC & CRP: Normal
– AST, ALT & ALP: Normal
– Bilirubin: Normal

Acute cholecystitis:
– Pain duration: More than 12 hours
– Fever: Present
– Murphy’s sign: Positive
– WCC & CRP: Elevated
– AST, ALT & ALP: Normal or mildly elevated
– Bilirubin: Normal or mildly elevated

Ascending cholangitis:
– Pain duration: Variable
– Fever: Present
– Murphy’s sign: Negative
– WCC & CRP: Elevated
– AST, ALT & ALP: Elevated