Cardiac enzymes do not increase in unstable angina. However, if cardiac markers do rise, it is classified as a non-ST elevation myocardial infarction (NSTEMI). Both unstable angina and NSTEMI can have a normal ECG. An extended ventricular activation time indicates damage to the heart muscle. This occurs because infarcting myocardium conducts electrical impulses at a slower pace, resulting in a prolonged interval between the start of the QRS complex and the apex of the R wave. A positive troponin test indicates the presence of necrosis in cardiac myocytes.

Summary:
Marker | Initial Rise | Peak | Normal at
Creatine kinase | 4-8 hours | 18 hours 2-3 days | CK-MB = main cardiac isoenzyme
Myoglobin | 1-4 hours | 6-7 hours | 24 hours | Low specificity due to skeletal muscle damage
Troponin I | 3-12 hours | 24 hours | 3-10 days | Appears to be the most sensitive and specific
HFABP | 1-2 hours | 5-10 hours | 24 hours | HFABP = heart fatty acid binding protein
LDH | 10 hours | 24-48 hours | 14 days | Cardiac muscle mainly contains LDH

Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.

In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.

It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.

Benzodiazepines are commonly used in the UK to manage symptoms of alcohol withdrawal. Currently, only diazepam and chlordiazepoxide have been authorized for this purpose. Other benzodiazepines like alprazolam, clobazam, and lorazepam do not currently have authorization for treating alcohol withdrawal symptoms in the UK.

Carbamazepine is also used in the UK to manage alcohol-related withdrawal symptoms, but it does not have official authorization for this use.

Clomethiazole, on the other hand, does have UK marketing authorization for treating alcohol withdrawal symptoms, but it is only recommended for use in a hospital setting with close supervision. The product information for clomethiazole advises caution when prescribing it to individuals with a history of addiction or outpatient alcoholics. It is also not recommended for patients who continue to drink or abuse alcohol. Combining alcohol with clomethiazole, especially in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use. Therefore, clomethiazole should only be used in a hospital under close supervision or, in rare cases, by specialist units on an outpatient basis with careful monitoring of the daily dosage.

This patient has come in with worsening shortness of breath and coughing up blood. They have a long history of smoking, and the likely diagnosis is superior vena cava obstruction caused by a primary bronchial tumor.

The typical symptoms of superior vena cava obstruction include breathlessness, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

Given the severity of the symptoms, this man needs to be urgently referred and admitted to the hospital. To provide immediate relief, his head should be elevated and he should be given supplemental oxygen. Corticosteroids and diuretics may also be administered. Further investigation through CT scanning is necessary, and radiotherapy may be recommended as a treatment option.

There are various cooling techniques that are recommended, but currently, there is limited conclusive evidence on which approach is the most effective. Some possible methods include simple measures such as consuming cold beverages, using fans, applying ice water packs, and spraying tepid water. Cold water immersion therapy can also be beneficial, but it requires the patient to be stable and cooperative, making it impractical for very ill individuals. For patients who are in a more critical condition, advanced cooling techniques like administering cold intravenous fluids, using surface cooling devices (SCD), employing intravascular cooling devices (ICD), or utilizing extracorporeal circuits may be utilized.

An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.

The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically experience a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Headaches may also be present, and in rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may be affected.

It’s important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.

Pneumonia in newborns is typically caused by organisms that inhabit the mother’s genital tract. Despite the widespread use of chemoprophylaxis to prevent maternal carriage, Group B haemolytic Streptococcus remains a common culprit in early-onset infections in full-term and near-term infants aged less than three days. Among very low birth weight infants, Escherichia Coli is the most frequently encountered bacterial strain. Additionally, neonatal pneumonia can be caused by other bacteria such as Chlamydia trachomatis, Listeria monocytogenes, and Haemophilus influenzae.

Instances where confidentiality may be breached include situations where there is a legal obligation, such as informing the Health Protection Agency (HPA) about a notifiable disease. Another example is in legal cases where a judge requests information. Additionally, confidentiality may be breached when there is a risk to the public, such as potential terrorism or serious criminal activity. It may also be breached when there is a risk to others, such as when a patient expresses homicidal intent towards a specific individual. Furthermore, confidentiality may be breached in cases relevant to statutory regulatory bodies, such as informing the Driver and Vehicle Licensing Agency (DVLA) about a patient who continues to drive despite a restriction.

However, it is important to note that there are examples where confidentiality should not be breached. It is inappropriate to disclose a patient’s diagnosis to third parties without their consent, including the police. The police should only be informed about what occurs within a consultation if there is a serious threat to the public or an individual.

If there is a consideration to breach patient confidentiality, it is crucial to seek the patient’s consent first. If consent is refused, it is advisable to seek guidance from your local trust and your medical defence union.

For more information, you can refer to the General Medical Council (GMC) guidance on patient confidentiality.

Patients with myxoedema coma often exhibit several common ECG abnormalities. These include bradycardia, a prolonged QT interval, and T wave flattening or inversion. Additionally, severe hypothyroidism (myxoedema) is associated with other ECG findings such as low QRS voltage, conduction blocks, and T wave inversions without ST deviation.

Further Reading:

The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.

Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.

The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.

Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.

Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.

The primary reason for foetal death in trauma during pregnancy is maternal shock and maternal mortality. The second most prevalent cause of foetal death is placental abruption.

Tetracycline antibiotics, such as tetracycline and doxycycline, have the potential to cause staining on permanent teeth while they are still forming beneath the gum line. This staining occurs when the drug becomes calcified within the tooth during its development. It is important to note that children are vulnerable to tetracycline-related tooth staining until approximately the age of 8. Additionally, pregnant women should avoid taking tetracycline as it can affect the development of teeth in the unborn child.

Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the loin area caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with urinary tract stones. The pain typically starts in the flank or loin and radiates to the labia in women or to the groin or testicle in men.

The pain experienced during renal or ureteric colic is severe and comes in spasms, with periods of no pain or a dull ache in between. It can last for minutes to hours. Nausea, vomiting, and the presence of blood in the urine (haematuria) often accompany the pain. Many individuals describe this pain as the most intense they have ever felt, with some women even comparing it to the pain of childbirth.

People with renal or ureteric colic are restless and unable to find relief by lying still, which helps distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is a concurrent urinary infection. As the stone irritates the detrusor muscle, they may complain of dysuria (painful urination), frequent urination, and straining when the stone reaches the vesicoureteric junction.

To support the diagnosis, it is recommended to perform urine dipstick testing to check for evidence of a urinary tract infection. The presence of blood in the urine can also indicate renal or ureteric colic, although it is not a definitive diagnostic marker. Nitrite and leukocyte esterase in the urine suggest the presence of an infection.

In terms of pain management, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic. Intravenous paracetamol can be offered if NSAIDs are contraindicated or not providing sufficient pain relief. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective. Antispasmodics should not be given to individuals with suspected renal colic.

For more detailed information, refer to the NICE guidelines on the assessment and management of renal and ureteric stones.

Typically, children with viral gastroenteritis experience diarrhoea for a duration of 5-7 days. Vomiting, on the other hand, usually subsides within 1-2 days.

Further Reading:

Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

Tracheo-innominate fistula (TIF) should be considered as a possible diagnosis in patients experiencing bleeding after a tracheostomy. This bleeding, occurring between 3 days and 6 weeks after the tracheostomy procedure, should be treated as TIF until ruled out. While this complication is uncommon, it is extremely dangerous and often leads to death if not promptly addressed through surgical intervention. Therefore, any bleeding from a tracheostomy tube should be regarded as potentially life-threatening.

Further Reading:

Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.

According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.

NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).

For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.

For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option. If there are concerns about susceptibility or sepsis, it is advised to consult a local microbiologist for intravenous second-line

In pediatric patients who have sustained burns in a house fire, the presence of burns greater than 15% of the total body surface area should trigger the initiation of immediate fluid resuscitation.

Further Reading:

Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.

In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.

The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.

To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.

When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.

Peptic ulcer disease is a fairly common condition that can affect either the stomach or the duodenum. However, the duodenum is more commonly affected, and in these cases, it is caused by a break in the mucosal lining of the duodenum.

This condition is more prevalent in men and is most commonly seen in individuals between the ages of 20 and 60. In fact, over 95% of patients with duodenal ulcers are found to be infected with H. pylori. Additionally, chronic usage of nonsteroidal anti-inflammatory drugs (NSAIDs) is often associated with the development of duodenal ulcers.

When it comes to the location of duodenal ulcers, they are most likely to occur in the superior (first) part of the duodenum, which is positioned in front of the body of the L1 vertebra.

The typical clinical features of duodenal ulcers include experiencing epigastric pain that radiates to the back, with the pain often worsening at night. This pain typically occurs 2-3 hours after eating and is relieved by consuming food and drinking milk. It can also be triggered by skipping meals or experiencing stress.

Possible complications that can arise from duodenal ulcers include perforation, which can lead to peritonitis, as well as gastrointestinal hemorrhage. Gastrointestinal hemorrhage can manifest as haematemesis (vomiting blood), melaena (black, tarry stools), or occult bleeding. Strictures causing obstruction can also occur as a result of duodenal ulcers.

In cases where gastrointestinal hemorrhage occurs as a result of duodenal ulceration, it is usually due to erosion of the gastroduodenal artery.

There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.

The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. This score was created and tested in US Emergency Departments, specifically for adult patients.

The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.

According to the current NICE guidance, the Centor score can be used to guide management in the following way:
– A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
– A score of 3 to 4 indicates a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a backup prescription should be considered.

By utilizing these scoring systems, healthcare professionals can make more informed decisions regarding the management and treatment of patients with sore throat.

Unstable angina is characterized by the presence of one or more of the following symptoms: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The electrocardiogram (ECG) may appear normal or show T-wave/ST-segment changes, and cardiac enzymes are typically within normal range.

On the other hand, stable angina is defined by central chest pain that is triggered by activities such as exercise and emotional stress. This pain may radiate to the jaw or left arm and is relieved by resting for a few minutes. It is usually brought on by a predictable amount of exertion.

Prinzmetal angina, although rare, is a variant of angina that primarily occurs at rest between midnight and early morning. The attacks can be severe and tend to happen in clusters. This type of angina is caused by coronary artery spasm, and patients may have normal coronary arteries.

Decubitus angina, on the other hand, is angina that occurs when lying down. It often develops as a result of cardiac failure due to an increased volume of blood within the blood vessels, which places additional strain on the heart.

Lastly, Ludwig’s angina is an extremely serious and potentially life-threatening cellulitis that affects the submandibular area. It most commonly arises from an infection in the floor of the mouth, which then spreads to the submandibular space.

Eosinophilic oesophagitis (EoE), also known as allergic inflammatory condition of the oesophagus, is characterized by the presence of eosinophils. It was identified as a clinical condition about two decades ago but has gained recognition more recently. EoE is most commonly observed in middle-aged individuals, with an average age of diagnosis ranging from 30 to 50 years. It is more prevalent in men, with a male-to-female ratio of 3:1. Allergic conditions, particularly atopy, are often associated with EoE.

The clinical manifestations of EoE vary depending on the age of the patient. In adults, common symptoms include dysphagia, food bolus obstruction, heartburn, and chest pain. On the other hand, children with EoE may present with failure to thrive, food refusal, difficulty feeding, vomiting, and abdominal pain.

To diagnose EoE, it is crucial to consider the possibility of this condition in patients who have persistent heartburn and/or difficulty swallowing, especially if they have a history of allergies or atopic disease. Diagnosis is confirmed by identifying more than 15 eosinophils per high-power field on an oesophageal biopsy. Allergy testing is not effective as EoE is not mediated by IgE.

There are three main management options for EoE, all of which are considered first-line treatments. The first option is proton pump inhibitors (PPIs), which are effective in approximately one-third of patients. If an endoscopic biopsy confirms the presence of eosinophils, an 8-week trial of PPIs can be initiated. After the trial, a repeat endoscopy and biopsy should be performed to assess for persistent eosinophils. Patients who respond to PPIs are diagnosed with PPI responsive oesophageal eosinophilia, while those who do not respond are diagnosed with true eosinophilic oesophagitis.

The second management option is dietary manipulation, which can be effective in both children and adults. It can be used as an initial treatment or in combination with pharmacological therapy. The six most commonly implicated food groups in EoE are cow’s milk, wheat, egg, soy, peanut/tree nut, and fish/shellfish. There are four main approaches to dietary manipulation: elemental diet, six food elimination diet (SFED), four food elimination diet (FFED),

Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

Hypomagnesaemia frequently occurs alongside hypokalaemia. It is important to note that potassium levels may not improve with supplementation until the magnesium deficiency is addressed.

Further Reading:

Vasoactive drugs can be classified into three categories: inotropes, vasopressors, and unclassified. Inotropes are drugs that alter the force of muscular contraction, particularly in the heart. They primarily stimulate adrenergic receptors and increase myocardial contractility. Commonly used inotropes include adrenaline, dobutamine, dopamine, isoprenaline, and ephedrine.

Vasopressors, on the other hand, increase systemic vascular resistance (SVR) by stimulating alpha-1 receptors, causing vasoconstriction. This leads to an increase in blood pressure. Commonly used vasopressors include norepinephrine, metaraminol, phenylephrine, and vasopressin.

Electrolytes, such as potassium, are essential for proper bodily function. Solutions containing potassium are often given to patients to prevent or treat hypokalemia (low potassium levels). However, administering too much potassium can lead to hyperkalemia (high potassium levels), which can cause dangerous arrhythmias. It is important to monitor potassium levels and administer it at a controlled rate to avoid complications.

Hyperkalemia can be caused by various factors, including excessive potassium intake, decreased renal excretion, endocrine disorders, certain medications, metabolic acidosis, tissue destruction, and massive blood transfusion. It can present with cardiovascular, respiratory, gastrointestinal, and neuromuscular symptoms. ECG changes, such as tall tented T-waves, prolonged PR interval, flat P-waves, widened QRS complex, and sine wave, are also characteristic of hyperkalemia.

In summary, vasoactive drugs can be categorized as inotropes, vasopressors, or unclassified. Inotropes increase myocardial contractility, while vasopressors increase systemic vascular resistance. Electrolytes, particularly potassium, are important for bodily function, but administering too much can lead to hyperkalemia. Monitoring potassium levels and ECG changes is crucial in managing hyperkalemia.

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.

Jet ventilation through a needle cricothyroidotomy typically involves using a 1 bar (100 Kpa) oxygen source.

Further Reading:

Cricothyroidotomy, also known as cricothyrotomy, is a procedure used to create an airway by making an incision between the thyroid and cricoid cartilages. This can be done surgically with a scalpel or using a needle method. It is typically used as a short-term solution for establishing an airway in emergency situations where traditional intubation is not possible.

The surgical technique involves dividing the cricothyroid membrane transversely, while some recommend making a longitudinal skin incision first to identify the structures below. Complications of this procedure can include bleeding, infection, incorrect placement resulting in a false passage, fistula formation, cartilage fracture, subcutaneous emphysema, scarring leading to stenosis, and injury to the vocal cords or larynx. There is also a risk of damage to the recurrent laryngeal nerve, and failure to perform the procedure successfully can lead to hypoxia and death.

There are certain contraindications to surgical cricothyroidotomy, such as the availability of less invasive airway securing methods, patients under 12 years old (although a needle technique may be used), laryngeal fracture, pre-existing or acute laryngeal pathology, tracheal transection with retraction into the mediastinum, and obscured anatomical landmarks.

The needle (cannula) cricothyroidotomy involves inserting a cannula through the cricothyroid membrane to access the trachea. This method is mainly used in children in scenarios where ENT assistance is not available. However, there are drawbacks to this approach, including the need for high-pressure oxygen delivery, which can risk barotrauma and may not always be readily available. The cannula is also prone to kinking and displacement, and there is limited evacuation of expiratory gases, making it suitable for only a short period of time before CO2 retention becomes problematic.

In children, the cannula cricothyroidotomy and ventilation procedure involves extending the neck and stabilizing the larynx, inserting a 14g or 16g cannula at a 45-degree angle aiming caudally, confirming the position by aspirating air through a saline-filled syringe, and connecting it to an insufflation device or following specific oxygen pressure and flow settings for jet ventilation.

If a longer-term airway is needed, a cricothyroidotomy may be converted to

Chronic lymphocytic leukaemia (CLL) is the most common form of leukaemia in adults. It occurs when mature lymphocytes multiply uncontrollably. B-cell lineage accounts for about 95% of cases. CLL is typically slow-growing and is often discovered incidentally during routine blood tests. As the disease progresses, patients may experience swollen lymph nodes, enlarged liver and spleen, low red blood cell count, and increased susceptibility to infections. This condition primarily affects adult males, with over 75% of CLL patients being men over the age of 50.

Dressings that function as flutter valves are beneficial in the initial treatment of open pneumothorax. The first step involves applying an occlusive dressing that covers the wound, with one side intentionally left open to create a flutter-valve effect. Alternatively, a chest seal device can be used. The occlusive dressing should be square or rectangular in shape, with three sides securely sealed and one side left unsealed. When the patient inhales, the dressing is drawn against the chest wall, preventing air from entering the chest cavity. However, during exhalation, air can still escape through the open side of the dressing. Another option is to use a chest seal device that includes a built-in one-way (flutter) valve. Definitive management typically involves surgical intervention to repair the defect and address any other injuries. The Royal College of Emergency Medicine (RCEM) also recommends surgery as the definitive treatment, as inserting a chest drain may disrupt tissues that could otherwise be used to cover the defect with muscle flaps.

Further Reading:

An open pneumothorax, also known as a sucking chest wound, occurs when air enters the pleural space due to an open chest wound or physical defect. This can lead to ineffective ventilation, causing hypoxia and hypercarbia. Air can enter the pleural cavity passively or be sucked in during inspiration, leading to lung collapse on that side. Sucking wounds can be heard audibly as air passes through the chest defect, and entry wounds are usually visible.

To manage an open pneumothorax, respiratory compromise can be alleviated by covering the wound with a dressing or using a chest seal device. It is important to ensure that one side of the dressing is not occluded, allowing the dressing to function as a flutter valve and prevent significant air ingress during inspiration while allowing air to escape the pleural cavity. If tension pneumothorax is suspected after applying a dressing, the dressing may need to be temporarily removed for decompression.

Intubation and intermittent positive pressure ventilation (IPPV) can be used to ventilate the patient and alleviate respiratory distress. Definitive management involves either inserting a chest drain or surgically repairing the defect. Surgical repair is typically preferred, especially for large wounds.

Multiple myeloma is a cancerous growth of plasma cells, a type of white blood cell responsible for producing antibodies. It is more prevalent in men and typically occurs in individuals over the age of 60.

When a patient over 60 presents with an elevated ESR, unexplained anemia, hypercalcemia, renal impairment, and bone pain, the initial diagnosis is usually multiple myeloma until proven otherwise.

The most common symptoms of multiple myeloma include:

1. Anemia: This is caused by the infiltration of the bone marrow and suppression of blood cell production. It is typically normocytic and normochromic, but can also be macrocytic.

2. Bone pain: Approximately 70% of patients experience bone pain, which commonly affects the spine and ribs. Localized pain and tenderness may indicate a pathological fracture, and vertebral fractures can lead to spinal cord compression.

3. Renal failure: Acute or chronic renal failure occurs in about one-third of patients. This is generally due to the effects of light chains on the tubules.

4. Neurological symptoms: Hypercalcemia can cause weakness, lethargy, and confusion, while hyperviscosity can result in headaches and retinopathy. Amyloid infiltration can lead to peripheral neuropathies, with carpal tunnel syndrome being the most common.

5. Infection: The most common infections seen in multiple myeloma patients are pyelonephritis and pneumonia.

In addition to the routine blood tests already conducted, a suspected diagnosis of multiple myeloma should prompt further investigations, including:

– Plasma viscosity measurement
– Urinary protein electrophoresis to detect Bence-Jones proteins
– Serum electrophoresis to identify the type of paraprotein
– Quantitative immunoglobulin level testing
– Skeletal survey to look for lytic lesions
– Bone marrow aspirate and possibly biopsy

A diagnosis of multiple myeloma is confirmed by the presence of a monoclonal protein in the serum or urine, lytic lesions on X-ray, and an increased number of plasma cells in the bone marrow.

Conjunctivitis is the most common reason for red eyes, accounting for about 35% of all eye problems seen in general practice. It occurs when the conjunctiva, the thin layer covering the white part of the eye, becomes inflamed. Conjunctivitis can be caused by an infection or an allergic reaction.

Infective conjunctivitis is inflammation of the conjunctiva caused by a viral, bacterial, or parasitic infection. The most common type of infective conjunctivitis is viral, with adenoviruses being the main culprits. Bacterial conjunctivitis is also common and is usually caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.

The symptoms of infective conjunctivitis include sudden redness of the conjunctiva, discomfort described as a gritty or burning sensation, watering of the eyes, and discharge that may temporarily blurry vision. It can be challenging to differentiate between viral and bacterial conjunctivitis based on symptoms alone.

Here are some key features that can help distinguish between viral and bacterial conjunctivitis:

Features suggestive of viral conjunctivitis:
– Mild to moderate redness of the conjunctiva
– Presence of follicles on the inner surface of the eyelids
– Swelling of the eyelids
– Small, pinpoint bleeding under the conjunctiva
– Pseudomembranes (thin layers of tissue) may form on the inner surface of the eyelids in severe cases, often caused by adenovirus
– Less discharge (usually watery) compared to bacterial conjunctivitis
– Mild to moderate itching
– Symptoms of upper respiratory tract infection and swollen lymph nodes in front of the ears

Features suggestive of bacterial conjunctivitis:
– Purulent or mucopurulent discharge with crusting of the eyelids, which may cause them to stick together upon waking
– Mild or no itching
– Swollen lymph nodes in front of the ears, which are often present in severe bacterial conjunctivitis
– If the discharge is copious and mucopurulent, infection with Neisseria gonorrhoeae should be considered.

By considering these distinguishing features, healthcare professionals can better diagnose and manage cases of conjunctivitis.

The pupillary light reflex is a reflex that regulates the size of the pupil in response to the intensity of light that reaches the retina. It consists of two separate pathways, the afferent pathway and the efferent pathway.

The afferent pathway begins with light entering the pupil and stimulating the retinal ganglion cells in the retina. These cells then transmit the light signal to the optic nerve. At the optic chiasm, the nasal retinal fibers cross to the opposite optic tract, while the temporal retinal fibers remain in the same optic tract. The fibers from the optic tracts then project and synapse in the pretectal nuclei in the dorsal midbrain. From there, the pretectal nuclei send fibers to the ipsilateral Edinger-Westphal nucleus via the posterior commissure.

On the other hand, the efferent pathway starts with the Edinger-Westphal nucleus projecting preganglionic parasympathetic fibers. These fibers exit the midbrain and travel along the oculomotor nerve. They then synapse on post-ganglionic parasympathetic fibers in the ciliary ganglion. The post-ganglionic fibers, known as the short ciliary nerves, innervate the sphincter muscle of the pupils, causing them to constrict.

The result of these pathways is that when light is shone in one eye, both the direct pupillary light reflex (ipsilateral eye) and the consensual pupillary light reflex (contralateral eye) occur.

Lesions affecting the pupillary light reflex can be identified by comparing the direct and consensual reactions to light in both eyes. If the optic nerve of the first eye is damaged, both the direct and consensual reflexes in the second eye will be lost. However, when light is shone into the second eye, the pupil of the first eye will still constrict. If the optic nerve of the second eye is damaged, the second eye will constrict consensually when light is shone into the unaffected first eye. If the oculomotor nerve of the first eye is damaged, the first eye will have no direct light reflex, but the second eye will still constrict consensually. Finally, if the oculomotor nerve of the second eye is damaged, there will be no consensual constriction of the second eye when light is shone into the unaffected first eye.