De Clerambault’s syndrome, also known as Erotomania, is characterized by a delusion that a famous person is in love with the individual, without any other accompanying psychotic symptoms.

De Clerambault’s Syndrome: A Delusional Belief in Famous Love

De Clerambault’s syndrome, also referred to as erotomania, is a type of paranoid delusion that has a romantic aspect. This condition is commonly observed in single women who believe that a well-known individual is in love with them. In simpler terms, the patient has a false belief that a celebrity or public figure is romantically interested in them. This delusion can be so intense that the patient may even stalk or harass the object of their affection. De Clerambault’s syndrome is a rare condition that requires professional medical attention to manage.

For a child aged 1-9 years, the recommended single dose of benzylpenicillin sodium prior to hospitalisation is 600mg, provided that it doesn’t cause any delay in transferring the child to the hospital. Any other dosage would be inappropriate for children in this age group.

When suspected bacterial meningitis is being investigated and managed, it is important to prioritize timely antibiotic treatment to avoid negative consequences. Patients should be urgently transferred to the hospital, and if meningococcal disease is suspected in a prehospital setting, intramuscular benzylpenicillin may be given. An ABC approach should be taken initially, and senior review is necessary if any warning signs are present. A key decision is when to attempt a lumbar puncture, which should be delayed in certain circumstances. Management of patients without indication for delayed LP includes IV antibiotics, with cefotaxime or ceftriaxone recommended for patients aged 3 months to 50 years. Additional tests that may be helpful include blood gases and throat swab for meningococcal culture. Prophylaxis needs to be offered to households and close contacts of patients affected with meningococcal meningitis, and meningococcal vaccination should be offered to close contacts when serotype results are available.

Prevalence of Long-Term Health Conditions in England: Insights from the General Practice Patient Survey

The General Practice Patient Survey is a nationwide survey conducted by the National Health Service in England, which collects data from patients aged over 16 presenting to General Practitioners. The survey results indicate that over half of the patients surveyed in 2021 reported at least one long-term physical or mental health condition. Arthritis or ongoing problems with the back and joints were the most common conditions reported. Diabetes was the fifth most prevalent condition, reported by 7.4% of participants. Alzheimer’s disease or other causes of dementia and autism spectrum disorder were reported by 0.6% and 1.1% of participants, respectively. Cancer was the eighth most prevalent condition, reported by 3.1% of participants. While the survey was conducted in England, the results are likely generalizable to the rest of the United Kingdom.

Salmon patches are a type of birthmark caused by excess blood vessels, but they typically go away on their own without treatment. These birthmarks are often found in symmetrical patterns on the forehead, eyelids, or nape of the neck.

Cafe-au-lait spots are another type of birthmark that appear as brown patches on the skin. While they are common, they can sometimes be a sign of an underlying medical condition.

Cherry angiomas are small, red bumps that tend to develop later in life.

Port-wine stains are a rare type of birthmark that can darken over time and are often asymmetrical in appearance.

Strawberry naevi are raised, red lesions that typically appear within the first few weeks of life.

Understanding Salmon Patches in Newborns

Salmon patches, also known as stork marks or stork bites, are a type of birthmark that can be found in approximately 50% of newborn babies. These marks are characterized by their pink and blotchy appearance and are commonly found on the forehead, eyelids, and nape of the neck. While they may cause concern for new parents, salmon patches typically fade over the course of a few months. However, marks on the neck may persist. These birthmarks are caused by an overgrowth of blood vessels and are completely harmless. It is important for parents to understand that salmon patches are a common occurrence in newborns and do not require any medical treatment.

The patient is showing classic signs of bilateral otitis media with effusion, which is common in children with Down syndrome or a cleft palate. The NICE recommends immediate referral to an ENT specialist for children with these conditions presenting with otitis media with effusion. For other children, watchful waiting for three months is advised, with hearing tests and tympanometry carried out during this period. Antibiotics are not recommended for the treatment of otitis media with effusion, and topical antibiotics have no role in treatment. Intranasal corticosteroids are not recommended for this condition, as their efficacy has not been proven.

When to Refer a Death to the Coroner

When someone dies, it is important to know when to refer the death to the coroner. A coroner is an independent judicial office holder who investigates certain types of deaths. According to the Ministry of Justice website, deaths should be referred to the coroner in circumstances where no doctor attended the deceased during their last illness, the cause of death is unknown, the death occurred during an operation or before recovery from the effects of an anaesthetic, the death was sudden or unexpected, the death was unnatural, the death was due to violence or neglect, or the death occurred in prison, police custody, or other state detention.

Additionally, medical practitioners completing cremation forms must notify the coroner of any suspicious circumstances or if they suspect the death was unnatural, violent, sudden with unknown cause, or occurred less than 24 hours since the deceased was admitted to the hospital.

However, if the cause of death is a myocardial infarction and the patient was known to have had heart disease or had been in the hospital for more than 24 hours, the death certificate can be signed without referring the death to the coroner. It is important to understand when to refer a death to the coroner to ensure proper investigation and documentation of the circumstances surrounding the death.

Understanding Common Variable Immunodeficiency: Prevalence, Diagnosis, and Delayed Treatment

Common variable immunodeficiency (CVID) is the most prevalent primary antibody deficiency, affecting approximately 1 in 25,000 individuals. However, due to its rarity, only a small fraction of healthcare professionals will encounter a patient with CVID during their career. This, coupled with a delay in diagnosis, increases the risk of irreversible lung damage and bronchiectasis.

Defects in humoral immunity account for 50% of primary immunodeficiencies, with combined humoral and cellular deficiencies making up 20-30% of cases. Inherited single-gene disorders are the most common cause of primary immune deficiencies. While many of these defects present in infancy and childhood, CVID typically presents after the age of five, with a peak in the second or third decade of life.

A diagnosis of CVID is based on defective functional antibody formation, accompanied by decreased serum immunoglobulin levels (IgG and IgA), generally decreased serum IgM, and exclusion of other known causes of antibody deficiency. Identifying defective functional antibody formation may involve measuring the response to a vaccine such as the pneumococcal vaccine.

Overall, understanding the prevalence, diagnosis, and delayed treatment of CVID is crucial in providing appropriate care for individuals with this rare but potentially debilitating condition.

When the common peroneal nerve is damaged, it can lead to weakness in the muscles responsible for dorsiflexion and eversion of the foot. This nerve supplies the peroneal and anterior muscles in the leg and provides sensation to the top of the foot. It runs through the popliteal fossa and loops around the head of the fibula, which can be felt in some cases. Peroneal neuropathy can occur due to habitual leg crossing, prolonged bed rest, hyperflexion of the knee, pressure in obstetric stirrups, or conditioning in ballet dancers, which can compress the nerve against the head of the fibula. Temporary neurapraxia can result from transient trauma, while permanent foot drop can occur from prolonged or severe trauma.

Understanding Common Peroneal Nerve Lesion

A common peroneal nerve lesion is a type of nerve injury that often occurs at the neck of the fibula. This condition is characterized by foot drop, which is the most common symptom. Other symptoms include weakness of foot dorsiflexion and eversion, weakness of extensor hallucis longus, sensory loss over the dorsum of the foot and the lower lateral part of the leg, and wasting of the anterior tibial and peroneal muscles.

Regardless of whether a person has had Chickenpox or shingles previously, Zostavax should still be administered.

Varicella-Zoster Vaccination: Protection Against Chickenpox and Shingles

Varicella-zoster is a herpesvirus that causes Chickenpox and shingles. There are two types of vaccines available to protect against these infections. The first type is a live attenuated vaccine that prevents primary varicella infection or Chickenpox. This vaccine is recommended for healthcare workers who are not immune to VZV and for individuals who are in close contact with immunocompromised patients.

The second type of vaccine is designed to reduce the incidence of herpes zoster or shingles caused by reactivation of VZV. This live-attenuated vaccine is given subcutaneously and is offered to patients aged 70-79 years. The vaccine is also available as a catch-up campaign for those who missed out on their vaccinations in the previous two years of the program. However, the shingles vaccine is not available on the NHS to anyone aged 80 and over because it seems to be less effective in this age group.

The main contraindication for both vaccines is immunosuppression. Side effects of the vaccines include injection site reactions, and less than 1 in 10,000 individuals may develop Chickenpox. It is important to note that vaccination is the most effective way to prevent varicella-zoster infections and their complications.

Importance of Examining Joints Above and Below in Orthopaedic Cases

This case emphasizes the significance of examining the joints above and below when an orthopaedic issue arises. The patient reports experiencing pain in the elbow and triceps region, with a history of tennis elbow. However, there are no clinical indications that suggest a recurrence of this problem.

In such cases, it is crucial to examine the shoulder as well. For instance, if the patient is diabetic and has a stiff or sore arm with nocturnal pain in the upper arm, it could be a frozen shoulder. Therefore, examining the joints above and below the affected area is essential to identify the root cause of the problem and provide appropriate treatment. Proper examination and diagnosis can help prevent further complications and ensure a speedy recovery.

Implants are considered a UKMEC 2 option for contraception in patients with epilepsy. However, there are also UKMEC 1 options available.

Contraception for Women with Epilepsy

Women with epilepsy need to consider several factors when choosing a contraceptive method. The effectiveness of anti-epileptic medication can be affected by the contraceptive, and vice versa. Additionally, if a woman becomes pregnant while taking anti-epileptic medication, there is a risk of teratogenic effects on the fetus. To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends the consistent use of condoms in addition to other forms of contraception.

For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends using the combined oral contraceptive pill (COCP) or progestogen-only pill (POP) with a UK Medical Eligibility Criteria (UKMEC) rating of 3. The implant has a UKMEC rating of 2, while the Depo-Provera injection, intrauterine device (IUD), and intrauterine system (IUS) have a UKMEC rating of 1.

For women taking lamotrigine, the FSRH recommends using the COCP with a UKMEC rating of 3 or the POP, implant, Depo-Provera injection, IUD, or IUS with a UKMEC rating of 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol.

In summary, women with epilepsy should carefully consider the potential interactions between their anti-epileptic medication and their chosen contraceptive method. Using condoms consistently in addition to other forms of contraception can help reduce the risk of unintended pregnancy and potential teratogenic effects on the fetus.

Understanding Erythema Multiforme: Symptoms and Characteristics

Erythema multiforme is a skin condition that typically begins with lesions on the hands and feet before spreading to other areas of the body. The upper limbs are more commonly affected than the lower limbs, and the palms and soles may also be involved. The initial lesions are red or pink macules that become raised papules and gradually enlarge to form plaques up to 2-3 cm in diameter. The center of a lesion darkens in color and may develop blistering or crusting. The typical target lesion of erythema multiforme has a sharp margin, regular round shape, and three concentric color zones. Atypical targets may show just two zones and/or an indistinct border. The rash is polymorphous, meaning it can take many forms, and lesions may be at various stages of development. The rash usually fades over 2-4 weeks, but recurrences are common. In more severe cases, there may be blistering of mucous membranes, which can be life-threatening. Some consider erythema multiforme to be part of a spectrum of disease that includes Stevens-Johnson syndrome and toxic epidermal necrolysis, while others argue that it should be classified separately as it is associated with infections rather than certain drugs.

Understanding Hepatitis E

Hepatitis E is a type of RNA hepevirus that is transmitted through the faecal-oral route. Its incubation period ranges from 3 to 8 weeks. This disease is common in Central and South-East Asia, North and West Africa, and in Mexico. It causes a similar illness to hepatitis A, but with a higher mortality rate of about 20% during pregnancy. Unlike other types of hepatitis, Hepatitis E doesn’t cause chronic disease or an increased risk of hepatocellular cancer. Although a vaccine is currently in development, it is not yet widely available.

Schizophrenia: Symptoms and Features

Schizophrenia is a mental disorder that is characterized by a range of symptoms. One of the most prominent classifications of these symptoms is Schneider’s first rank symptoms. These symptoms can be divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can include thought insertion, thought withdrawal, and thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or experiences that are imposed on the individual or influenced by others. Delusional perceptions can involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that not all individuals with schizophrenia will experience all of these symptoms, and the severity of symptoms can vary from person to person.

Oral allergy syndrome is closely associated with pollen allergies and exhibits seasonal fluctuations. It occurs when allergens in certain foods cross-react with pollens, causing the body to react to the food proteins as if they were pollen. This results in a localized reaction around the mouth, such as an itchy mouth or throat, and sometimes hives. As the patient experiences symptoms with various fruits, it is not a pure kiwi allergy. Urticaria is characterized by an itchy rash triggered by an allergen, but there is no mention of a rash in this case. Anaphylaxis is a severe allergic reaction that causes swelling of the throat and tongue, as well as breathing difficulties. However, since there is only mild lip swelling and no breathing difficulties, anaphylaxis is unlikely.

Understanding Oral Allergy Syndrome

Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.

It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.

OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.

In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.

Calculating Units of Alcohol

To calculate the number of units of alcohol in a drink, you need to multiply the percentage of alcohol (ABV) by the volume in millilitres and then divide by 1000. However, there are potential pitfalls to watch out for, such as converting volumes from centilitres to millilitres and adjusting for daily or weekly consumption.

For example, if a person drinks two 330ml bottles of lager per day with a 3% ABV, the calculation would be 3% x 330ml = 9.9ml, divided by 1000 = 0.99 units per bottle, rounded up to 1 unit. This equates to 14 units per week. If they also drink one 750ml bottle of wine per week with a 12% ABV, the calculation would be 12% x 750ml = 90ml, divided by 1000 = 9 units per bottle. Therefore, the total amount of units consumed per week would be 23 units.

It is important to check the units of volume and duration when calculating units of alcohol. The UK recommendations are for no more than 14 units per week for both sexes. While these calculations may seem simple, it is important to be prepared for any eventuality in an exam setting.

Aspirin Overdose: Symptoms and Management

Aspirin overdose can be potentially fatal, as its effects are dose-related. Unlike with paracetamol, there are many early clinical features of aspirin overdose. These include nausea and vomiting, sweating, hyperventilation, vertigo, and tinnitus. More severe manifestations of overdose include lethargy, coma, seizures, hypotension, heart block, and pulmonary edema.

Immediate referral to the hospital and close monitoring with supportive measures are necessary for managing aspirin overdose. In severe cases, dialysis may be indicated.

Sheehan Syndrome: A Rare Cause of Hypopituitarism

Sheehan syndrome is a rare condition that occurs as a result of severe hypotension caused by massive hemorrhage during or after childbirth, leading to necrosis of the pituitary gland. This condition is more common in underdeveloped and developing countries. Patients with Sheehan syndrome have varying degrees of anterior pituitary hormone deficiency, which can present progressively with symptoms such as failure to lactate, breast involution, and amenorrhea.

In this case, the patient suffered from hypotension and blood loss during an emergency Caesarean section, leading to pituitary infarction and symptoms of hypoadrenalism. Treatment includes fluid rehydration and emergency steroid replacement with intravenous hydrocortisone, as well as thyroxine replacement for pituitary-dependent hypothyroidism. Restoration of fertility may require pulsed delivery of pituitary sex-axis hormones.

Other potential causes of the patient’s symptoms, such as dehydration, hypothyroidism, and postnatal depression, were ruled out based on the lack of relevant history and electrolyte abnormalities. While primary adrenal failure can also cause hypoadrenalism, the preceding events make Sheehan syndrome a more likely diagnosis.

Diagnosis of CKD and Hypertension: NICE Guidelines

The National Institute for Health and Care Excellence (NICE) has provided guidelines for the diagnosis of chronic kidney disease (CKD) and hypertension. To diagnose CKD, more than one estimated glomerular filtration rate (eGFR) reading below 60 is required over a period of three months. Similarly, hypertension should not be diagnosed based on a single blood pressure reading, but rather through ambulatory or home blood pressure monitoring. Acute kidney injury is characterized by a significant increase in serum creatinine or oliguria, and eGFR is not a reliable indicator for its diagnosis. NICE also recommends using eGFRcystatinC to confirm or rule out CKD in individuals with an eGFR of 45-59 ml/min/1.73 m2, sustained for at least 90 days, and no proteinuria or other markers of kidney disease.

Macroorchidism is a common feature of Fragile X syndrome, which also presents with delayed developmental milestones and learning difficulties (typically with an IQ less than 70). Physical characteristics include a high forehead, facial asymmetry, a large jaw, and long ears. Diagnosis is often made by age 3 due to developmental delays. Life-threatening cardiovascular issues and full lips are not associated with FXS, but are seen in William’s syndrome. Down’s syndrome is characterized by decreased muscle tone and hypothyroidism.

Fragile X Syndrome: A Genetic Disorder

Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects males more severely than females, with symptoms including learning difficulties, large low set ears, a long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also common in males with this syndrome. Females who have one fragile chromosome and one normal X chromosome may have a range of symptoms from normal to mild.

Diagnosis of fragile X syndrome can be made antenatally through chorionic villus sampling or amniocentesis. Analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis is also used to diagnose this disorder. Proper diagnosis and management can help individuals with fragile X syndrome lead fulfilling lives.

If a woman is fully or almost fully breastfeeding, under 6 months postpartum, and not experiencing periods yet, lactational amenorrhoea can be a highly effective form of contraception. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) recommends that if these conditions are met, there may be no need for an alternative contraceptive method at this time.

After giving birth, women need to use contraception after 21 days. The Progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first 2 days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the Combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than 6 weeks postpartum. If breastfeeding is between 6 weeks to 6 months postpartum, it is UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk postpartum. After day 21, additional contraception should be used for the first 7 days.

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks. Meanwhile, the Lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than 6 months postpartum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

Malaria: Diagnosis and Management

Malaria is a febrile illness caused by Plasmodium species, which can lead to periodic febrile paroxysms every 48 or 72 hours, with asymptomatic intervals and a tendency to relapse. The symptoms and signs of malaria are nonspecific, making it difficult to diagnose. Therefore, it is important to exclude malaria by conducting repeated thick and thin blood smears in patients with acute fever and a history of exposure. If the patient is severely ill or symptoms persist, a therapeutic trial of antimalarial chemotherapy should not be delayed. This article discusses the diagnosis and management of malaria.

Interpretation of Patient’s Symptoms

This patient is exhibiting symptoms that suggest hypercalcaemia, which is a clinically significant condition. It is important to note that the free T4 level is at the lower end of the normal range, which is common during pregnancy. Therefore, TSH is a better indicator of thyroid function. Additionally, hyperprolactinaemia and detectable urinary human chorionic gonadotrophin are normal findings during pregnancy. It is also typical for serum alkaline phosphatase levels to increase up to four times the normal range due to increased placental production.

Overall, it is essential to consider the patient’s pregnancy status when interpreting their symptoms and laboratory results.

If a patient with Bell’s palsy doesn’t show any improvement in paralysis after 3 weeks, it is recommended to urgently refer them to an ENT specialist. This will allow for further investigation into other potential causes of facial weakness, including neuroimaging. It is not appropriate to reassure the patient that symptoms can take up to 3 months to resolve if there has been no improvement. Prescribing a further course of prednisolone or treating with oral aciclovir is not recommended. Referring to a plastic surgeon may be appropriate for facial reconstructive surgery, but usually only after a longer period of residual paralysis.

Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.

Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.

The 7-Point Checklist for Detecting Skin Cancer

The 7-point weighted checklist is a tool used by clinicians to identify suspicious skin lesions that may be cancerous. It comprises three major features, including a change in size, irregular shape, and irregular colour, as well as four minor features, such as inflammation and oozing. Major features score 2 points each, while minor features score 1 point each. Lesions scoring 3 or more points are considered suspicious and should be referred for further evaluation, even if the score is less than 3.

The incidence of malignant melanoma is increasing rapidly, particularly among young people, and early detection is crucial for successful treatment. High-risk patients include those with fair skin, freckling or light hair, users of sunbeds, atypical or dysplastic naevi, a family history of melanoma, and a history of blistering sunburn. Clinicians should also offer safe sun advice and encourage patients to seek medical attention if they have any concerns.

The 7-point checklist can be found in the NICE referral guidelines for suspected cancer and is an important tool for detecting skin cancer early. By being aware of the risk factors and using this checklist, clinicians can help to improve outcomes for patients with skin cancer.

Distinguishing Achilles Tendon Rupture from Other Lower Leg Injuries

Achilles tendon rupture is a common injury that can be easily misdiagnosed as other lower leg injuries. The hallmark of Achilles tendon rupture is a sudden onset of pain followed by a dull ache. A palpable defect in the Achilles tendon may be present on examination, but bruising can mask the defect. Active plantar flexion is weak or absent, and Thompson’s test can confirm a complete tendon rupture. Treatment options include surgical repair or non-surgical approaches such as casting or splinting.

It is important to differentiate Achilles tendon rupture from other lower leg injuries such as Achilles tendinopathy, deep vein thrombosis, retrocalcaneal bursitis, and rupture of a Baker’s cyst. Achilles tendinopathy is a chronic overuse injury with gradual onset of pain and tenderness between 2-6 cm above the calcaneal insertion. Deep vein thrombosis presents with limb pain and tenderness along the deep veins, unilateral calf or leg swelling, and pitting edema. Retrocalcaneal bursitis causes pain on the back of the heel and swelling medial or lateral to the tendon. Rupture of a Baker’s cyst can mimic deep vein thrombosis with pain and swelling of the calf, but may also cause bruising below the medial malleolus of the ankle.

Presbycusis is characterized by a bilateral loss of high-frequency hearing. This type of age-related hearing loss affects the inner ear and is often accompanied by difficulty hearing in noisy environments. In sensorineural hearing loss, air conduction is more effective than bone conduction, which is the opposite of conductive hearing loss. Therefore, the correct answer is ‘Bilateral high-frequency hearing loss. Air conduction is more effective than bone conduction.’

Understanding Presbycusis: Age-Related Hearing Loss

Presbycusis is a type of hearing loss that affects older individuals. It is a sensorineural hearing loss that typically affects high-frequency hearing bilaterally, leading to difficulties in understanding conversations, especially in noisy environments. The condition progresses slowly as the sensory hair cells and neurons in the cochlea atrophy over time. Although certain factors are associated with presbycusis, it is distinct from noise-related hearing loss.

The prevalence of presbycusis increases with age, with an estimated 25-30% of 65-74 year-olds and 40-50% of those over 75 years experiencing impaired hearing in the USA. The exact cause of presbycusis is unknown, but it is likely multifactorial. Arteriosclerosis, diabetes, accumulated exposure to noise, drug exposure, stress, and genetics are some of the factors that may contribute to the development of presbycusis.

Patients with presbycusis typically present with a chronic, slowly progressing history of difficulty understanding speech, increased volume needed for television or radio, difficulty using the telephone, loss of directionality of sound, and worsening of symptoms in noisy environments. Hyperacusis, a heightened sensitivity to certain frequencies of sound, and tinnitus, a ringing or buzzing in the ears, may also occur but are less common.

To diagnose presbycusis, otoscopy is performed to rule out other causes of hearing loss, such as otosclerosis or conductive hearing loss. Tympanometry is used to assess middle ear function, and audiometry is used to confirm bilateral sensorineural hearing loss. Blood tests may also be performed to rule out other underlying conditions.

In summary, presbycusis is an age-related hearing loss that affects a significant portion of the elderly population. Although the exact cause is unknown, it is likely due to a combination of factors. Patients with presbycusis may experience difficulty understanding speech, increased volume needed for audio devices, and other symptoms. Diagnosis is made through a combination of physical examination and hearing tests.

If a patient is suspected of having a TIA and is taking warfarin, a DOAC, or has a bleeding disorder, they must be admitted immediately for imaging to rule out a haemorrhage.

For patients without these conditions, administering 300 mg of aspirin immediately and then evaluating them by a specialist within 24 hours is recommended. The primary secondary prevention method is taking clopidogrel 75 mg once daily.

Referring patients to neurology as a routine measure would cause an unnecessary delay in treatment.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

Spice, a synthetic cannabinoid, is a type of new psychoactive substance (NPS) that is often referred to as a legal high despite being prohibited by the Psychoactive Substances Act 2016 and the Misuse of Drugs Act 1971. NPS use has become increasingly common in the UK, particularly among young men who mistakenly believe that they are safer than traditional illicit drugs. Spice is typically consumed as a herbal smoking mixture and is responsible for over half of all NPS use. While it produces similar effects to cannabis, it is more potent and can cause negative side effects such as dizziness, agitation, paranoia, and seizures. Based on the symptoms described in this scenario and the negative toxicology screen for other illicit drugs, Spice is the most likely cause.

Possible Diagnoses for Abdominal Pain and Shock with Neurological Symptoms

Abdominal pain and shock with neurological symptoms can be indicative of several medical conditions. One possible diagnosis is a ruptured aortic aneurysm, which may cause a pulsatile mass in the abdomen and involve the spinal arteries. Acute pancreatitis may also cause abdominal pain and shock, but it would not typically produce neurological symptoms. Biliary colic, on the other hand, may cause pain in the epigastrium or right upper quadrant that radiates to the back, but it usually resolves within 24 hours. Acute myocardial infarction (MI) is another emergency presentation that may produce abdominal pain and shock, but it would also involve chest or jaw pain/heaviness and ECG changes. Finally, a perforated duodenal ulcer may cause abdominal pain and shock, but it would also involve marked tenderness and rigidity. Therefore, a ruptured aortic aneurysm is the most likely diagnosis in this case.