Understanding Hair Loss: Causes and Symptoms

Hair loss is a common concern for many individuals, causing anxiety and worry. There are various causes of hair loss, each with their own unique symptoms. Alopecia areata is a chronic inflammatory disease that affects the hair follicles, resulting in patchy, non-scarring hair loss on the scalp. Androgenic alopecia, on the other hand, is more common in men and causes a receding hairline and loss of hair from the top and front of the head. Fungal infections, such as tinea capitis, can also cause hair loss accompanied by scaling, itching, and pain. Scalp psoriasis can range from mild scaling to severe crusted plaques covering the entire scalp, while erosive pustular dermatosis of the scalp affects elderly individuals with scarring and yellow-brown crusts. It is important to understand the various causes and symptoms of hair loss in order to properly diagnose and treat the condition.

The CD4 count is a reliable way to measure the immune system’s response to HIV infection. In HIV-negative individuals, the CD4 count is usually maintained above 600-800 cells/µl. However, without antiretroviral therapy, HIV-positive individuals will experience a gradual decline in CD4 count over time. A CD4 count of less than 350 cells/µl increases the risk of opportunistic infections, while a count of less than 200 cells/µl indicates an 80% risk of developing an OI within three years. Some patients may remain well despite having a low CD4 count, depending on viral load and host immunity factors. Different OIs are more likely at different CD4 counts. The World Health Organization now recommends starting ART in every HIV-positive individual, regardless of CD4 count.

A CXR is usually normal in HIV-positive individuals without chronic respiratory disorders. Blood cultures may help diagnose an OI, but do not estimate the risk of developing OIs. HIV-positive individuals often have an abnormal FBC, but this does not help with risk assessment for OIs. TST is used to check for immunity to TB and diagnose LTBI. HIV-positive individuals are at higher risk of TB disease, but may have a muted response to TST due to their compromised immunity. TST can be useful in assessing eligibility for isoniazid preventive therapy, but not in assessing disease stage and risk of OIs in general.

The most likely diagnosis for a woman who suddenly experiences the sensation of smelling roses while at work, while remaining conscious throughout, is a focal aware seizure. This type of seizure affects a small part of one of the brain’s lobes, and in this case, it is likely originating from the temporal lobe. Focal aware seizures can lead to hallucinations, such as olfactory, auditory, or gustatory, as well as epigastric rising and automatisms.

Other options, such as absence seizure, focal impaired awareness seizure, and olfactory hallucination due to cannabis use, are not applicable in this case. Absence seizures typically occur in children and involve impaired consciousness, while focal impaired awareness seizures involve impaired consciousness as well. Olfactory hallucination due to cannabis use is unlikely, as the patient is receiving help for their cannabis-use disorder and there are no other signs of psychosis.

Epilepsy is classified based on three key features: where seizures begin in the brain, level of awareness during a seizure, and other features of seizures. Focal seizures, previously known as partial seizures, start in a specific area on one side of the brain. The level of awareness can vary in focal seizures, and they can be further classified as focal aware, focal impaired awareness, or awareness unknown. Focal seizures can also be motor, non-motor, or have other features such as aura. Generalized seizures involve networks on both sides of the brain at the onset, and consciousness is lost immediately. They can be further subdivided into motor and non-motor types. Unknown onset is used when the origin of the seizure is unknown. Focal to bilateral seizures start on one side of the brain in a specific area before spreading to both lobes and were previously known as secondary generalized seizures.

Loratadine and cetirizine are antihistamines that are not likely to cause sedation, unlike chlorpheniramine which is known to be more sedating.

While loratadine may still cause sedation, it is less likely to do so compared to other antihistamines such as chlorphenamine and promethazine. Buclizine, on the other hand, is primarily used as an anti-emetic for migraines but also has antihistamine properties. Mirtazapine, although it has antihistamine properties, is mainly used as an antidepressant and appetite stimulant.

Antihistamines for Allergic Rhinitis and Urticaria

Antihistamines, specifically H1 inhibitors, are effective in treating allergic rhinitis and urticaria. Sedating antihistamines such as chlorpheniramine have antimuscarinic properties that can cause side effects like urinary retention and dry mouth. On the other hand, non-sedating antihistamines like loratidine and cetirizine are less likely to cause drowsiness. However, there is some evidence that cetirizine may still cause more drowsiness compared to other non-sedating antihistamines. Overall, antihistamines are a valuable treatment option for those suffering from allergic rhinitis and urticaria.

Conversion disorder is a condition that often results in the loss of motor or sensory function and is believed to be triggered by stress.

Psychiatric Terms for Unexplained Symptoms

There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

The patient has symptoms of median nerve palsy, which can be caused by carpal tunnel syndrome, a known risk factor during pregnancy. Tinel’s sign and Phalen’s sign can reproduce the symptoms, and Froment’s sign is associated with ulnar nerve palsies.

Understanding Carpal Tunnel Syndrome

Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.

During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.

Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.

Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.

The most probable diagnosis for this gentleman’s condition is infrapatellar bursitis, which is often associated with kneeling, particularly in clergymen. Although prepatellar bursitis may also be a possible cause, it is more commonly observed in housemaids who kneel in a more upright position. Osteoarthritis, which is characterized by knee pain and a feeling of instability, is more prevalent in individuals over the age of forty-five, making it less likely for this patient. Cruciate ligament damage, meniscal tear, and ruptured bursa are also potential causes, but they are typically associated with a history of trauma.

Knee problems are common among older adults, and it is important to be aware of the key features of each condition. Osteoarthritis of the knee is often seen in patients over 50 years of age who are overweight. This condition can cause severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling. Anterior cruciate ligament injuries may be caused by twisting of the knee, and patients may have heard a popping noise. Rapid onset of knee effusion and a positive draw test are also common features. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as during a car accident. Collateral ligament injuries can cause tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and can cause locking and giving-way, as well as tenderness along the joint line.

Management of Primary Anal Fissure: Treatment Options and Referral Guidelines

Primary anal fissure is a common condition that can cause significant pain and discomfort. The National Institute for Health and Care Excellence (NICE) provides guidelines for the management of this condition, which include prescribing rectal topical glyceryl trinitrate (GTN) 0.4% ointment for 6-8 weeks to relieve pain and aid healing. Referral to a colorectal surgeon is warranted if the fissure does not heal after this period. Botulinum toxin injections can be considered in secondary care settings for chronic and recurrent cases, but only after a trial of topical GTN. Taking no action is not recommended, as it can lead to chronic non-healing ulcers. Trying different laxatives, such as senna, is also unlikely to help and should not be the first-line treatment for anal fissure. Overall, early intervention with topical GTN and appropriate referral can improve outcomes for patients with primary anal fissure.

Management of Fever in a High-Risk Child

When managing a child with fever, it is important to consider their age and any accompanying symptoms. According to the NICE guideline on ‘Fever in under 5s’, children aged <3 months with a temperature of 38°C are at high risk for serious illness. In such cases, it is recommended to refer the child urgently to a paediatric specialist. Encouraging fluids may be useful, but it should not be relied upon to rule out serious underlying illness. Similarly, antipyretics may be given before the child is seen by the paediatric team, but it is important to consult the NICE guideline for appropriate dosages. Blind prescription of oral antibiotics or IM benzylpenicillin is not recommended without a clear source of infection and discussion with the on-call paediatric team. Therefore, it is crucial to refer high-risk children to the paediatric on-call team for further management.

Pediatric Abdominal Mass: Possible Causes and Symptoms

When a child presents with an abdominal mass, it can be a sign of various conditions, including malignancies. Here are some possible causes and symptoms to consider:

1. Burkitt’s lymphoma: This aggressive non-Hodgkin’s lymphoma commonly affects children and presents with abdominal pain, an abdominal mass, splenomegaly, and B symptoms such as fever and weight loss.

2. Wilms’ tumour: This malignant kidney tumour usually affects young children and presents with an asymptomatic abdominal mass, hypertension, haematuria, or urinary tract infection. Splenomegaly is not expected.

3. Hepatoblastoma: This rare malignant liver tumour usually presents with an asymptomatic abdominal mass in the right upper quadrant. However, if the child has symptoms and splenomegaly, it may suggest a haematological malignancy.

4. Neuroblastoma: This rare malignancy commonly affects children under five and presents with an abdominal mass. Symptoms are rare in early disease, but if present, may suggest a haematological malignancy.

5. Phaeochromocytoma: This rare tumour releases excessive amounts of catecholamines and commonly arises in the adrenal glands. It presents with headache, palpitations, tremor, and hyperhidrosis, but not with splenomegaly or a palpable abdominal mass.

In summary, a pediatric abdominal mass can be a sign of various conditions, including malignancies. It is important to consider the child’s symptoms and other clinical findings to determine the appropriate diagnosis and management.