Interpretation of FBC Results

When analyzing a full blood count (FBC), a microcytosis with low mean corpuscular volume (MCV) and anaemia (low Hb) is indicative of iron deficiency anaemia. To confirm this, a ferritin test should be requested, followed by an investigation into the source of blood loss if iron deficiency is confirmed. If faecal occult blood is positive, an endoscopy may be necessary. On the other hand, macrocytic anaemia with elevated MCV is caused by folate and B12 deficiency, while hypothyroidism is associated with elevated MCV. While a bone marrow biopsy can also show iron deficiency, it is an invasive procedure and is not necessary in a primary care setting. Therefore, interpreting FBC results requires a thorough of the different types of anaemia and their associated causes.

The Role of Hormone Assays in Confirming Pregnancy

Beta-HCG is a hormone produced by the placenta during pregnancy. There are highly sensitive assays available to detect the presence of beta-HCG, which can confirm pregnancy. In fact, some manufacturers of pregnancy tests claim that their tests are more accurate than ultrasound dating in determining gestation during the early stages of pregnancy.

While alpha-fetoprotein may also be elevated in pregnancy, particularly in cases of neural tube defects, it is not the primary focus of pregnancy testing. Hormone assays for oestrogen, progesterone, or testosterone levels are not reliable methods for confirming pregnancy. Therefore, beta-HCG remains the most reliable hormone to test for when confirming pregnancy.

It is important to note that while hormone assays can confirm pregnancy, they cannot determine the viability of the pregnancy or the presence of any complications. Ultrasound imaging and other diagnostic tests may be necessary to assess the health of the pregnancy and the developing fetus.

Performing any form of female genital cutting/modification for non-medical reasons, including reinfibulation of a woman with type 3 FGM after vaginal delivery, is illegal according to the Female Genital Mutilation Act 2003. It is strictly prohibited to carry out such procedures under any circumstances. However, discussing the topic is not illegal.

Understanding Female Genital Mutilation

Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

Common Medical Assessment Tools

Various medical assessment tools are available to assist healthcare professionals in diagnosing and treating patients. These tools have been validated and proven effective in detecting specific conditions. The Morisky scale, for instance, is a medication adherence questionnaire that has been validated in hypertension and is useful in assessing adherence. The Montreal Cognitive Assessment (MOCA) is a cognitive screening test that helps detect mild cognitive impairment and Alzheimer’s disease. The Patient Health Questionnaire (PHQ-9) is a depression screening tool, while the CAGE questionnaire is used to detect alcohol dependence. The Wells score, on the other hand, is a tool that risk-stratifies patients for deep vein thrombosis (DVT). It incorporates clinical gestalt and alternative diagnosis to determine the likelihood of DVT. These assessment tools are essential in providing accurate diagnoses and effective treatment plans for patients.

Treatment Algorithm for Anaphylaxis: Medications and IV Fluids

Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate treatment. The following medications and IV fluids are part of the treatment algorithm for anaphylaxis:

1. 0.5 mg of 1 in 1000 adrenaline intramuscular (IM) injection: This should be given to treat anaphylaxis, repeated after five minutes if the patient is no better. An IV injection should only be used by experienced practitioners.

2. Hydrocortisone 200 mg intravenous (IV): Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

3. 1 mg of 1 in 10 000 adrenaline im injection: The recommended initial dose of adrenaline is 0.5 mg im of 1 in 1000 strength.

4. IV fluids through a wide-bore cannula: Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

5. Promethazine 50 mg IV: Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

It is important to note that administration of adrenaline should not be delayed and the patient’s airway, breathing, and circulation should be assessed before administering any medication. IV access should also be obtained as soon as possible to administer the necessary medications and fluids.

Limited cutaneous systemic sclerosis is a form of systemic sclerosis where the skin hardening is limited to the face and distal limbs, below the elbows. In contrast, diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs. Sclerodactyly specifically refers to skin hardening of the fingers or toes. Dermatomyositis and systemic lupus erythematosus are inflammatory conditions that do not typically cause skin hardening. Psoriasis is a skin condition characterized by red, scaly patches of skin covered with silvery scales.

Understanding Systemic Sclerosis

Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.

When a patient presents with clinical symptoms of a hip fracture, it is necessary to conduct further imaging. Repeating plain films is unlikely to yield any new information. While radioisotope bone scans can detect areas of high bone turnover and osteoblastic activity, they are not very sensitive. Although CT scans are widely available, the recommended first line investigation for occult hip fractures is an MRI, as per NICE guidelines.

Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.

Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.

Lesions and their corresponding visual field defects

Lesions in different areas of the visual pathway can cause specific visual field defects. A lesion in the left occipital visual cortex can result in a right homonymous hemianopia with macular sparing. This is because the visual cortex typically presents with macular sparing. On the other hand, a lesion in the left temporal lobe optic radiation can cause a right superior quadrantanopia. An optic chiasm lesion can lead to bitemporal hemianopia, while a right optic tract lesion can cause a left homonymous hemianopia. Finally, a right parietal lobe optic radiation lesion can result in a left inferior quadrantanopia. Understanding these different visual field defects can aid in localizing the site of a lesion in the visual pathway.

Pharmacology of Commonly Used Drugs

Nifedipine is a medication that relaxes vascular muscle tone and is commonly used to treat angina and hypertension. Endothelial cells have the ability to mediate both contractile and relaxant responses, with nitric oxide (NO) being a key factor in the latter. NO is synthesized from L-arginine by nitric oxide synthases (NOS), which are calcium- and calmodulin-dependent. Calmodulin is a calcium-binding protein that regulates various cellular functions, including smooth muscle contraction and inflammation.

Amiloride is a diuretic that works by blocking the epithelial sodium channel in the kidneys, promoting the loss of sodium and water without depleting potassium. Doxazosin is an alpha-1 adrenergic receptor blocker that relaxes vascular smooth muscle tone by inhibiting the binding of norepinephrine to alpha-1 receptors. Enalapril is an angiotensin converting enzyme inhibitor that is used to treat hypertension and chronic heart failure. Finally, loperamide is an opioid-receptor agonist that is used to treat diarrhea by decreasing the activity of the myenteric plexus in the large intestine, allowing for more water absorption from fecal matter.

Epididymo-orchitis is likely caused by enteric organisms, such as E. coli, in individuals with a low risk of sexually-transmitted infections (STIs), such as married men in their 50s with a single long-term partner. Therefore, the most appropriate next step would be to arrange a mid-stream urine sample for microscopy and culture to guide antibiotic treatment. This patient has subacute onset of testicular pain and swelling with associated dysuria, and his pain is relieved when elevating the testis (positive Prehn’s sign), making a diagnosis of testicular torsion less likely. A urethral swab sample for microscopy and culture is no longer the initial investigation of choice, and a urine sample for nucleic acid amplification tests (NAAT) is not appropriate in this case. Urgent referral for a same-day testicular ultrasound scan is also not necessary as testicular torsion is rare in patients over 35 years of age and does not present with dysuria.

Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.