Metabolic acidosis is associated with cocaine overdose.
In overdose, cocaine leads to agitation, tachycardia, hypertension, sweating, hallucinations, and finally convulsions.
Metabolic acidosis, hyperthermia, rhabdomyolysis, and ventricular arrhythmias also occur.
Chronic use may be associated with premature coronary artery disease, dilated cardiomyopathy, and increased risk of cerebral haemorrhage.
There are 3 stages for acute cocaine toxicity:
Stage I: CNS symptoms of headache, vertigo, pseudo hallucinations, hyperthermia, hypertension.
Stage II: increased deep tendon reflexes, tachypnoea, irregular breathing, hypertension.
Stage III: Areflexia, coma, fixed and dilated pupils, hypotension, ventricular fibrillation, apnoea, and respiratory failure.

Treatment:
– Airway, breathing, and circulation to be secured. The patient’s fever should be managed, and one should rule out hypoglycaemia as a cause of the neuropsychiatric symptoms.
– Cardiovascular toxicity and agitation are best-treated first-line with benzodiazepines to decrease CNS sympathetic outflow.
– The mixed beta/alpha blocker labetalol is safe and effective for treating concomitant cocaine-induced hypertension and tachycardia.
– Non-dihydropyridine calcium channels blockers such as diltiazem and verapamil have been shown to reduce hypertension reliably, but not tachycardia.
– Dihydropyridine agents such as nifedipine should be avoided, as reflex tachycardia may occur.
– The alpha-blocker phentolamine has been recommended but only treats alpha-mediated hypertension and not tachycardia.

The cause of Vitiligo is typically unknown. It is believed to be due to genetic susceptibility that is triggered by an environmental factor such that an autoimmune disease occurs. This results in the destruction of skin pigment cells. Risk factors include a family history of the condition or other autoimmune diseases, such as hyperthyroidism, alopecia areata, and pernicious anaemia. Vitiligo is classified into two main types: segmental and non-segmental. Most cases are non-segmental meaning they affect both sides and typically get worse with time. The prevalence of vitiligo is 0.5-1% of populations worldwide. Typical sites include backs of hands, wrists, knees, neck and around body orifices. The Koebner phenomenon refers to skin lesions appearing on lines of trauma. This occurs in vitiligo secondary to scratching.

Relief of symptoms with food suggests duodenal ulceration, for which the pain gets worse on an empty stomach. In chronic pancreatitis, you would expect worsening of symptoms with food.

Indications for permanent pacemaker implantation

-Sinus node dysfunction
-Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
-Chronic bifascicular block
-After acute phase of myocardial infarction
-Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
-Post cardiac transplantation
-Hypertrophic cardiomyopathy
-Pacing to detect and terminate tachycardia
-Cardiac resynchronization therapy in patients with severe systolic heart failure
-Patients with congenital heart disease

Senile cataract is an age-related, vision-impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye. Patients with senile cataracts often present with a history of gradual progressive visual deterioration and disturbance in night and near vision.

When a patient presents with an illness (unrelated to the liver) or a stressful event on the body, and develops asymptomatic jaundice, think Gilbert’s syndrome. It is autosomal dominant. It is an unconjugated hyperbilirubinemia from impaired glucuronyl transferase. Classically, Crigler-Najjar would be in infants, and it would be symptomatic. It is also an unconjugated hyperbilirubinemia.

Posterior vitreous detachment is thought to occur in up to 50-75% of the population over 65 years and is the most likely diagnosis here. Patients should be reviewed by an ophthalmologist to assess the risk of progressing to retinal detachment. Flashes of light (photopsia) occur in the peripheral field of vision while floaters often occur on the temporal side of the central vision.

The Koebner phenomenon refers to skin lesions appearing on lines of trauma, exposure to a causative agents including: molluscum contagiosum, warts and toxicodendron dermatitis or secondary to scratching rather than an infective or chemical cause include vitiligo, psoriasis, lichen planus, lichen nitidus, pityriasis rubra pilaris, and keratosis follicularis (Darier disease).

Patients with diabetes often develop ophthalmic complications, the most common and potentially most blinding of these complications is diabetic retinopathy.
The following are the 5 stages in the progression of diabetic retinopathy:
1. Dilation of the retinal venules and formation of retinal capillary microaneurysms.
2. Increased vascular permeability.
3. Vascular occlusion and retinal ischemia.
4. Proliferation of new blood vessels on the surface of the retina.
5. Vitreous haemorrhage and contraction of the fibrovascular proliferation.
The first 2 stages of diabetic retinopathy are known as background or nonproliferative retinopathy. Initially, the retinal venules dilate, then microaneurysms (tiny red dots on the retina that cause no visual impairment) appear. As the microaneurysms or retinal capillaries become more permeable, hard exudates appear, reflecting the leakage of plasma.

Mild nonproliferative diabetic retinopathy (NPDR) or background diabetic retinopathy is indicated by the presence of at least 1 microaneurysm, while neovascularization is the hallmark of Proliferative Diabetic Retinopathy (PDR).

The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.

An odds ratio (OR) is a measure of the association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. Odds ratios are most commonly used in case-control studies, however they can also be used in cross-sectional and cohort study designs as well (with some modifications and/or assumptions). Where

a = Number of exposed cases

b = Number of exposed non-cases

c = Number of unexposed cases

d = Number of unexposed non-cases

OR=(a/c) / (b/d) = ad/bc

Patients with compressive neuropathy of the ulnar nerve typically describe numbness and tingling of the ulnar-sided digits of the hand, classically in the small finger and ulnar aspect of the ring finger. Among the general population, symptoms usually begin intermittently and are often worse at night, particularly if the elbow is flexed while sleeping. As the disease progresses, paraesthesia may occur more frequently and during the daytime.

The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.

Sunlight, especially its ultraviolet radiation component, can cause increased or additional types of damage in predisposed individuals, such as those taking certain phototoxic drugs, or those with certain conditions associated with photosensitivity, including:
– Psoriasis
– Atopic eczema
– Erythema multiforme
– Seborrheic dermatitis
– Autoimmune bullous diseases (immunobullous diseases)
– Mycosis fungoides
– Smith–Lemli–Opitz syndrome
– Porphyria cutanea tarda
Also, many conditions are aggravated by strong light, including:
– Systemic lupus erythematosus
– Sjögren’s syndrome
– Sinear Usher syndrome
– Rosacea
– Dermatomyositis
– Darier’s disease
– Kindler-Weary syndrome
Acute intermittent porphyria (AIP) belongs to the group inborn errors of metabolism and most patients with AIP are not light sensitive.

Although this patient’s left ventricular function is normal at the time of examination, there is chance of deterioration of it due to aortic regurgitation. It is found that ACE inhibitors slow the development of left ventricular dysfunction. So this patient should be started on an ACE inhibitor.

The patient most likely has Klinefelter’s syndrome.
Klinefelter syndrome (KS) refers to a group of chromosomal disorders in which the normal male karyotype, 46,XY, has at least one extra X chromosome. XXY aneuploidy, the most common human sex chromosome disorder. It is also the most common chromosomal disorder associated with male hypogonadism and infertility.
Klinefelter syndrome is characterized by hypogonadism (micro-orchidism, oligospermia/azoospermia), gynecomastia in late puberty, hyalinization and fibrosis of the seminiferous tubules, elevated urinary gonadotropin levels, and behavioural concerns.

The two statements that fit the characteristics of doxapram are, epilepsy is a contraindication for doxapram use and concurrent use with theophylline may increase agitation.

Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.

Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.

Drug interactions:
Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.

Anticholinergic syndrome occurs following overdose with drugs that have prominent anticholinergic activity including tricyclic antidepressants, antihistamines and atropine. Features include dry, warm, flushed skin, urinary retention, tachycardia, mydriasis (dilated pupils) and agitation.

The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.

Turner syndrome (TS) is one of the most common genetic disorders; occurs with an incidence of I: 2,500 female live births. It results from complete or partial chromosome X monosomy. TS is associated with abnormalities of the X chromosome and characteristic clinical features of short stature, gonadal dysgenesis, sexual developmental deficiencies, cardiac and/or renal defects, webbed neck, low-set ears, skeletal deformities including cubitus valgus, a propensity to ear infections and hearing deficits.

Increased WBC count and CRP suggest infection. But with the fluctuating hard neurological signs, there is suspicion of the presence of a cerebral mass, which is an indication for requesting for a CT scan with contrast, to rule out an abscess or haematoma. The lumbar puncture can be considered after the CT scan.

Chronic obstructive pulmonary disease (COPD) is a complex and progressive chronic lung disease. Typically, COPD includes emphysema and chronic bronchitis. COPD is characterized by the restriction of airflow into and out of the lungs. The obstruction of airflow makes breathing difficult. The causes of COPD include smoking, long-term exposure to air pollutants and a rare genetic disorder.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) developed the GOLD Staging System. In the GOLD System, the forced expiratory volume in one second (FEV1) measurement from a pulmonary function test is used to place COPD into stages. Often, doctors also consider your COPD symptoms.

COPD has four stages. The stages of COPD range from mild to very severe. COPD affects everyone differently. Because COPD is a progressive lung disease, it will worsen over time.
The Stages of COPD:
Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

This patient has a FEV1 percent of 63 which falls within the stage 2 or moderate COPD.

This patient has Klumpke’s paralysis due to damage to the T1 nerve root. This root eventually supplies the median and ulnar nerves. The ulnar nerve supplies all of the intrinsic hand muscles except for those of the thenar eminence and the first and second lumbricals, which are innervated by the median nerve.

Relative Risk = (Probability of event in exposed group) / (Probability of event in not exposed group)
Experimental event rate, EER = 10 / 200 = 0.05

Control event rate, CER = 12 / 600 = 0.02

Therefore the relative risk = EER / CER = 0.05 / 0.02 = 2.5

Uhthoff’s phenomenon is worsening of vision following a rise in body temperature.
Lhermitte’s sign describes paraesthesia in the limbs on neck flexion.
Oppenheim’s sign is seen when scratching of the inner side of leg leads to extension of the toes. It is a sign of cerebral irritation and is not related to multiple sclerosis.
Werdnig-Hoffman’s disease is also known as spinal muscular atrophy.

The patient’s history of recent weight loss and malaise, paired with enlarged kidneys and renal failure, as well as a suspected central pelvic mass on ultrasound, gives a suspicion of cervical carcinoma.

Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
The most recent update to the NICE guidelines for management of neuropathic pain occurred in 2013: first-line treatment* includes amitriptyline. If the first-line drug treatment does not work then move on to one of the other 3 drugs: duloxetine, gabapentin or pregabalin. Tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain. Topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia). Pain management clinics may be useful in patients with resistant problems.

*please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia.

Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.

Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.

The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.

The Stages of COPD:
Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

This patient has a FEV1 percent of 40 which falls within the stage 2 or moderate COP

Arthrocentesis should usually be done when there is a suspicion of pseudogout or septic arthritis as in this case which leads to an early diagnosis and prompt treatment. Polarized microscopy demonstrates weakly positively birefringent rhomboid crystals which are blue when parallel to light and yellow when perpendicular to light. Elevated serum uric acid levels that cause gout are usually found after large consumption of alcohol or meat, or post surgery. Autoimmune diseases like SLE, RA etc require an autoimmune screen.