Tinea cruris, commonly known as ‘jock itch’, is a fungal infection that affects the groin area. It is primarily caused by Trichophyton rubrum and is more prevalent in young men, particularly athletes. The typical symptoms include a reddish or brownish rash that is accompanied by intense itching. Pustules and vesicles may also develop, and there is often a raised border with a clear center. Notably, the infection usually does not affect the penis and scrotum.

It is worth mentioning that patients with tinea cruris often have concurrent tinea pedis, also known as athlete’s foot, which may have served as the source of the infection. The infection can be transmitted through sharing towels or by using towels that have come into contact with infected feet, leading to the spread of the fungus to the groin area.

Fortunately, treatment for tinea cruris typically involves the use of topical imidazole creams, such as clotrimazole. This is usually sufficient to alleviate the symptoms and eradicate the infection. Alternatively, terbinafine cream can be used as an alternative treatment option.

Blood transfusion is a crucial medical treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur. One common adverse reaction is febrile transfusion reactions, which present as an unexpected rise in temperature during or after transfusion. This can be caused by cytokine accumulation or recipient antibodies reacting to donor antigens. Treatment for febrile transfusion reactions is supportive, and other potential causes should be ruled out.

Another serious complication is acute haemolytic reaction, which is often caused by ABO incompatibility due to administration errors. This reaction requires the transfusion to be stopped and IV fluids to be administered. Delayed haemolytic reactions can occur several days after a transfusion and may require monitoring and treatment for anaemia and renal function. Allergic reactions, TRALI (Transfusion Related Acute Lung Injury), TACO (Transfusion Associated Circulatory Overload), and GVHD (Graft-vs-Host Disease) are other potential complications that require specific management approaches.

In summary, blood transfusion carries risks and potential complications, but efforts have been made to improve safety procedures. It is important to be aware of these complications and to promptly address any adverse reactions that may occur during or after a transfusion.

Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

Neisseria gonorrhoeae is a type of bacteria that causes the sexually transmitted infection known as gonorrhoea. It is a Gram-negative diplococcus, meaning it appears as pairs of bacteria under a microscope. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important characteristic of Neisseria gonorrhoeae is its ability to undergo antigenic variation, which means that recovering from an infection does not provide immunity and reinfection is possible.

When Neisseria gonorrhoeae infects the body, it first attaches to the genitourinary epithelium using pili, which are hair-like structures on the surface of the bacteria. It then invades the epithelial layer and triggers a local acute inflammatory response. In men, the clinical features of gonorrhoea often include urethritis (inflammation of the urethra) in about 80% of cases, dysuria (painful urination) in around 50% of cases, and mucopurulent discharge. Rectal infection may also occur, usually without symptoms, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is usually asymptomatic in men.

In women, the clinical features of gonorrhoea commonly include vaginal discharge in about 50% of cases, lower abdominal pain in around 25% of cases, dysuria in 10-15% of cases, and pelvic/lower abdominal tenderness in less than 5% of cases. Endocervical discharge and/or bleeding may also be present. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge, and pharyngitis is usually asymptomatic in women as well.

Complications of Neisseria gonorrhoeae infection can be serious and include pelvic inflammatory disease (PID) in women, epididymo-orchitis or prostatitis in men, arthritis, dermatitis, pericarditis and/or myocarditis, hepatitis, and meningitis.

To diagnose gonorrhoea, samples of pus from the urethra, cervix, rectum, or throat should be collected and promptly sent to the laboratory in specialized transport medium. Traditionally, diagnosis has been made using Gram-stain and culture techniques, but newer PCR testing methods are becoming more commonly used.

The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.

Neutropenic sepsis is a serious complication that can arise when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is commonly seen in individuals undergoing treatments such as cytotoxic chemotherapy or taking immunosuppressive drugs. Other causes of neutropenia include infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, as well as nutritional deficiencies.

To diagnose neutropenic sepsis, doctors look for specific criteria in patients receiving anticancer treatment. These criteria include having a neutrophil count of 0.5 x 109 per liter or lower, along with either a body temperature higher than 38°C or other signs and symptoms that indicate a clinically significant sepsis.

A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.

To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.

The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.

To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.

Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an increased awareness of these risks and improved reporting systems, transfusion errors and serious adverse reactions still occur and may go unreported.

One specific transfusion reaction is transfusion-associated circulatory overload (TACO), which occurs when a large volume of blood is rapidly infused. It is the second leading cause of transfusion-related deaths, accounting for about 20% of fatalities. TACO is more likely to occur in patients with diminished cardiac reserve or chronic anemia, particularly in the elderly, infants, and severely anemic patients.

The typical clinical features of TACO include acute respiratory distress, tachycardia, hypertension, acute or worsening pulmonary edema on chest X-ray, and evidence of positive fluid balance. The B-type natriuretic peptide (BNP) can be a useful diagnostic tool for TACO, with levels usually elevated to at least 1.5 times the pre-transfusion baseline.

In many cases, simply slowing the transfusion rate, placing the patient in an upright position, and administering diuretics can be sufficient for managing TACO. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.

This patient has presented with acute closed-angle glaucoma, which is a medical emergency in the field of ophthalmology. It occurs when the iris bows forward and blocks the fluid access to the trabecular meshwork, which is located at the entrance to Schlemm’s canal. As a result, the intraocular pressure rises and leads to glaucomatous optic neuropathy.

The main clinical features of acute closed-angle glaucoma include severe eye pain, loss of vision or decreased visual acuity, congestion and redness around the cornea, corneal swelling, a fixed semi-dilated oval-shaped pupil, nausea and vomiting, and preceding episodes of blurred vision or seeing haloes.

The diagnosis can be confirmed by tonometry, which measures the pressure inside the eye. The normal range of intraocular pressure is 10-21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.

Management of acute closed-angle glaucoma should include providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous administration of acetazolamide 500 mg is recommended to reduce intraocular pressure. Treatment with a topical miotic, like pilocarpine 1% or 2%, should be initiated approximately one hour after starting other measures, as the pupil may initially be paralyzed and unresponsive.

On the other hand, chronic open-angle glaucoma is a more common presentation than acute closed-angle glaucoma. It affects approximately 1 in 50 people over the age of 40 and 1 in 10 people over the age of 75. In this condition, there is a partial blockage within the trabecular meshwork, which hinders the drainage of aqueous humor and gradually increases intraocular pressure, leading to optic neuropathy. Unlike acute closed-angle glaucoma, chronic open-angle glaucoma does not cause eye pain or redness. It presents gradually with a progressive loss of peripheral vision, while central vision is relatively preserved.

If you have missed one pill, which means it has been 48-72 hours since you took the last pill in your current packet or you started the first pill in a new packet 24-48 hours late, you need to take the missed pill as soon as you remember. Make sure to continue taking the remaining pills at your usual time. Emergency contraception is generally not necessary in this situation, but it may be worth considering if you have missed pills earlier in the packet or during the last week of the previous packet.

HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.

The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.

Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.

Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.

Cluster headaches are a type of headache that is commonly seen in young men in their 20s. The male to female ratio for this condition is 6:1. Smoking is also known to increase the risk of developing cluster headaches. These headaches occur in clusters, usually lasting for a few weeks every year or two. The pain experienced is severe and typically affects one side of the head, often around or behind the eye. It tends to occur at the same time each day and can cause the patient to become agitated, sometimes resorting to hitting their head against a wall or the floor in an attempt to distract from the pain.

In addition to the intense pain, cluster headaches are also associated with autonomic involvement. This can manifest as various symptoms on the same side as the headache, including conjunctival injection (redness of the eye), rhinorrhea (runny nose), lacrimation (tearing of the eye), miosis (constriction of the pupil), and ptosis (drooping of the eyelid).

On the other hand, migraine with typical aura presents with temporary visual disturbances, such as hemianopia (loss of vision in half of the visual field) or scintillating scotoma (a visual aura that appears as a shimmering or flashing area of distorted vision). Migraine without aura, on the other hand, needs to meet specific criteria set by the International Headache Society. These criteria include having at least five headache attacks lasting between 4 to 72 hours, with the headache having at least two of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and aggravation by routine physical activity.

During a migraine headache, the patient may also experience symptoms such as nausea and/or vomiting, as well as sensitivity to light (photophobia) and sound (phonophobia). It is important to note that these symptoms should not be attributed to another underlying disorder.

If a patient over the age of 50 presents with a new-onset headache, it raises the possibility of giant cell arteritis (temporal arteritis). Other symptoms and signs that may be associated with this condition include jaw claudication (pain in the jaw when chewing), systemic upset, scalp tenderness, and an elevated erythrocyte sedimentation rate (ESR).

Medication overuse headache is a condition that is suspected when a patient is using multiple medications, often at low doses, without experiencing any relief from their headaches.

This individual has developed Dupuytren’s contracture, which is a hand deformity characterized by a fixed flexion caused by palmar fibromatosis. The only anticonvulsant treatment believed to be connected to the development of Dupuytren’s contracture is phenytoin. Additionally, other conditions associated with its occurrence include liver cirrhosis, diabetes mellitus, alcoholism, and trauma.

This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.

Hemorrhage can be categorized into four different classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.

In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.

In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure remains normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.

The patient in this case is in class III hemorrhage, with a blood loss of 1500-2000 mL or 30-40% of the blood volume. The pulse rate is elevated, ranging from 120-140 beats per minute, and the systolic blood pressure is decreased. The pulse pressure is also decreased, and the respiratory rate is elevated to 30-40 breaths per minute. The urine output decreases significantly to 5-15 mL per hour, and the patient may experience anxiety and confusion.

Class IV hemorrhage represents the most severe level of blood loss, with a loss of over 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is decreased, and the respiratory rate is over 40 breaths per minute. The urine output becomes negligible, and the patient may become confused and lethargic.

This ECG indicates changes that are consistent with an acute inferoposterior myocardial infarction (MI). There is ST elevation in leads I, II, aVF, and V6, along with reciprocal ST depression in leads V1-V4 and aVR. Additionally, there are tall dominant R waves in leads V2-V3 and upright T waves in leads V2-V3. Based on these findings, the most likely vessel involved in this case is the right coronary artery.

To summarize the vessels involved in different types of myocardial infarction see below:
ECG Leads – Location of MI | Vessel involved
V1-V3 – Anteroseptal | Left anterior descending
V3-V4 – Anterior | Left anterior descending
V5-V6 – Anterolateral | Left anterior descending / left circumflex artery
V1-V6 – Extensive anterior | Left anterior descending
I, II, aVL, V6 – Lateral | Left circumflex artery
II, III, aVF – Inferior | Right coronary artery (80%), Left circumflex artery (20%)
V1, V4R – Right ventricle | Right coronary artery
V7-V9 – Posterior | Right coronary artery

An abdominal aortic aneurysm (AAA) is a condition where the abdominal aorta becomes enlarged, either in a specific area or throughout its length, reaching 1.5 times its normal size. Most AAAs are found between the diaphragm and the point where the aorta splits into two branches. They can be classified into three types based on their location: suprarenal, pararenal, and infrarenal. Suprarenal AAAs involve the origin of one or more visceral arteries, pararenal AAAs involve the origins of the renal arteries, and infrarenal AAAs start below the renal arteries. The majority of AAAs (approximately 85%) are infrarenal. In individuals over 50 years old, a normal infrarenal aortic diameter is 1.7 cm in men and 1.5 cm in women. An infrarenal aorta with a diameter greater than 3 cm is considered to be an aneurysm. While most AAAs do not cause symptoms, an expanding aneurysm can sometimes lead to abdominal pain or pulsatile sensations. Symptomatic AAAs have a high risk of rupture. In the UK, elective surgery for AAAs is typically recommended if the aneurysm is larger than 5.5 cm in diameter or if it is larger than 4.5 cm in diameter and has increased in size by more than 0.5 cm in the past six months.

A central venous catheter (CVC) is a type of catheter that is inserted into a large vein in the body, typically in the neck, chest, or groin. It has several important uses, including CVP monitoring, pulmonary artery pressure monitoring, repeated blood sampling, IV access for large volumes of fluids or drugs, TPN administration, dialysis, pacing, and other procedures such as placement of IVC filters or venous stents.

When inserting a central line, it is ideal to use ultrasound guidance to ensure accurate placement. However, there are certain contraindications to central line insertion, including infection or injury to the planned access site, coagulopathy, thrombosis or stenosis of the intended vein, a combative patient, or raised intracranial pressure for jugular venous lines.

The most common approaches for central line insertion are the internal jugular, subclavian, femoral, and PICC (peripherally inserted central catheter) veins. The internal jugular vein is often chosen due to its proximity to the carotid artery, but variations in anatomy can occur. Ultrasound can be used to identify the vessels and guide catheter placement, with the IJV typically lying superficial and lateral to the carotid artery. Compression and Valsalva maneuvers can help distinguish between arterial and venous structures, and doppler color flow can highlight the direction of flow.

In terms of choosing a side for central line insertion, the right side is usually preferred to avoid the risk of injury to the thoracic duct and potential chylothorax. However, the left side can also be used depending on the clinical situation.

Femoral central lines are another option for central venous access, with the catheter being inserted into the femoral vein in the groin. Local anesthesia is typically used to establish a field block, with lidocaine being the most commonly used agent. Lidocaine works by blocking sodium channels and preventing the propagation of action potentials.

In summary, central venous catheters have various important uses and should ideally be inserted using ultrasound guidance. There are contraindications to their insertion, and different approaches can be used depending on the clinical situation. Local anesthesia is commonly used for central line insertion, with lidocaine being the preferred agent.

The FeverPAIN score is a clinical scoring system that helps determine the probability of streptococcal infection and the necessity of antibiotic treatment. NICE recommends using either the CENTOR or FeverPAIN clinical scoring systems to assess the likelihood of streptococcal infection and the need for antibiotics. The RSI score is utilized to evaluate laryngopharyngeal reflux, while the CSMCPI is employed to predict clinical outcomes in patients with upper gastrointestinal bleeding. Lastly, the Mallampati score is used to assess the oropharyngeal space and predict the difficulty of endotracheal intubation.

Further Reading:

Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can

If you have missed one pill, which means it has been 48-72 hours since you took the last pill in your current packet or you started the first pill in a new packet 24-48 hours late, you need to take the missed pill as soon as you remember. Make sure to continue taking the remaining pills at your usual time. Emergency contraception is generally not necessary in this situation, but it may be worth considering if you have missed pills earlier in the packet or during the last week of the previous packet.

Dementia with Lewy bodies (DLB) is characterized by several key features, including spontaneous fluctuations in cognitive abilities, visual hallucinations, and Parkinsonism. Visual hallucinations are particularly prevalent in DLB and Parkinson’s disease dementia, which are considered to be part of the same spectrum. While visual hallucinations can occur in other forms of dementia, they are less frequently observed.

Further Reading:

Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

If someone consumes at least 75 mg of paracetamol per kilogram of body weight within a 24-hour period, it is considered to be a significant ingestion. Ingesting more than 150 mg of paracetamol per kilogram of body weight within 24 hours poses a serious risk of harm.

Further Reading:

Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

Thyroid storm is a rare condition that affects only 1-2% of patients with hyperthyroidism. However, it is crucial to diagnose it promptly because it has a high mortality rate of approximately 10%. Thyroid storm is often triggered by a physiological stressor, such as stopping antithyroid therapy prematurely, recent surgery or radio-iodine treatment, infections (especially chest infections), trauma, diabetic ketoacidosis or hyperosmolar diabetic crisis, thyroid hormone overdose, pre-eclampsia. It typically occurs in patients with Graves’ disease or toxic multinodular goitre and presents with sudden and severe hyperthyroidism. Symptoms include high fever (over 41°C), dehydration, rapid heart rate (greater than 140 beats per minute) with or without irregular heart rhythms, low blood pressure, congestive heart failure, nausea, jaundice, vomiting, diarrhea, abdominal pain, confusion, agitation, delirium, psychosis, seizures, or coma.

To diagnose thyroid storm, various blood tests should be conducted, including a full blood count, urea and electrolytes, blood glucose, coagulation screen, CRP, and thyroid profile (T4/T3 and TSH). A bone profile/calcium test should also be done as 10% of patients develop hypocalcemia. Blood cultures should be taken as well. Other important investigations include a urine dipstick/MC&S, chest X-ray, and ECG.

The management of thyroid storm involves several steps. Intravenous fluids, such as 1-2 liters of 0.9% saline, should be administered. Airway support and management should be provided as necessary. A nasogastric tube should be inserted if the patient is vomiting. Urgent referral for inpatient management is essential. Paracetamol (1 g PO/IV) can be given to reduce fever. Benzodiazepines, such as diazepam (5-20 mg PO/IV), can be used for sedation. Steroids, like hydrocortisone (100 mg IV), may be necessary if there is co-existing adrenal suppression. Antibiotics should be prescribed if there is an intercurrent infection. Beta-blockers, such as propranolol (80 mg PO), can help control heart rate. High-dose carbimazole (45-60 mg/day) is recommended.

Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.

The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.

Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.

Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.

Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.

Ulcerative colitis can lead to various complications, although the development of fistulae is rare and less likely compared to other complications. Perianal complications associated with ulcerative colitis are uncommon and typically occur in cases with more extensive inflammation and a severe disease course.

The complications of ulcerative colitis can be categorized into localized and systemic complications. Localized complications include bleeding, electrolyte imbalance, toxic megacolon, perforation, an increased risk of colonic carcinoma, an increased risk of lymphoma, and the rare occurrence of stricture and fistula formation.

On the other hand, systemic complications of ulcerative colitis involve malnutrition and weight loss, iron-deficiency anemia, vitamin B12 deficiency, hypoproteinaemia, primary sclerosing cholangitis, primary biliary cirrhosis, chronic active hepatitis, joint pain or arthropathy, ankylosing spondylitis, pyoderma gangrenosum, and erythema nodosum. Additionally, ulcerative colitis can also lead to complications affecting the eyes, such as iritis, episcleritis, and uveitis.

Overall, while ulcerative colitis can present with various complications, the development of fistulae is rare and less likely compared to other complications. Perianal complications are infrequent and typically associated with more extensive inflammation and a severe disease course.

This individual, who has been smoking for a long time, is likely to have squamous cell carcinoma of the lung located at the right apex. This particular type of cancer is causing Pancoast’s syndrome. Pancoast’s syndrome typically presents with rib erosion, leading to severe shoulder pain, as well as Horner’s syndrome due to the infiltration of the lower part of the brachial plexus. Additionally, there may be hoarseness of the voice and a ‘bovine cough’ due to a concurrent recurrent laryngeal nerve palsy.

The classic description of Horner’s syndrome includes the following clinical features on the same side as the tumor: miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (lack of sweating), and enophthalmos (sunken appearance of the eye). A chest X-ray would be able to detect the presence of the apical tumor and confirm the diagnosis.

Normal pressure hydrocephalus is a condition characterized by the classic triad of symptoms: gait instability, urinary incontinence, and dementia. Gait apraxia, which is a common feature, presents as a slow and cautious gait, difficulty initiating movement, unsteadiness, a widened standing base, reduced stride length, shuffling gait, falls, and freezing. The onset of symptoms typically occurs over a period of 3-6 months. This condition is a form of communicating hydrocephalus, where there is a gradual buildup of cerebrospinal fluid (CSF) due to impaired CSF absorption. As a result, the ventricles in the brain enlarge and intracranial pressure increases, leading to compression of brain tissue and neurological complications. Normal pressure hydrocephalus is more commonly seen in individuals over the age of 65, and a CT head or MRI is usually the initial diagnostic test.

Further Reading:

Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

Reperfusion after a frostbite injury can be extremely painful, so it is important to provide strong pain relief. If there are clear blisters, they should be opened and aloe vera should be applied every 6 hours. However, if there are blisters with blood, they should not be opened, but aloe vera can still be used topically. Taking 400 mg of ibuprofen orally, if there are no contraindications, can help reduce inflammation and improve the outcome of frostbite. Technetium-99m pertechnetate scintigraphy is the preferred method for assessing blood flow in the affected area. To treat frostbite, it is recommended to re-warm the affected areas by immersing them in warm water.

Further Reading:

Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

Migraine without aura typically needs to meet the specific criteria set by the International Headache Society. These criteria include experiencing at least five attacks that meet the requirements outlined in criteria 2-4. The duration of these headache attacks should last between 4 to 72 hours. Additionally, the headache should exhibit at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation or avoidance of routine physical activity. Furthermore, during the headache, individuals should experience at least one of the following symptoms: nausea and/or vomiting, photophobia, and phonophobia. For more detailed information, you can refer to the guidelines provided by The British Association for the Study of Headache.

Congenital adrenal hyperplasia (CAH) is a group of inherited disorders that are caused by autosomal recessive genes. The majority of affected patients, over 90%, have a deficiency of the enzyme 21-hydroxylase. This enzyme is encoded by the 21-hydroxylase gene, which is located on chromosome 6p21 within the HLA histocompatibility complex. The second most common cause of CAH is a deficiency of the enzyme 11-beta-hydroxylase. The condition is rare, with an incidence of approximately 1 in 500 births in the UK. It is more prevalent in the offspring of consanguineous marriages.

The deficiency of 21-hydroxylase leads to a deficiency of cortisol and/or aldosterone, as well as an excess of precursor steroids. As a result, there is an increased secretion of ACTH from the anterior pituitary, leading to adrenocortical hyperplasia.

The severity of CAH varies depending on the degree of 21-hydroxylase deficiency. Female infants often exhibit ambiguous genitalia, such as clitoral hypertrophy and labial fusion. Male infants may have an enlarged scrotum and/or scrotal pigmentation. Hirsutism, or excessive hair growth, occurs in 10% of cases.

Boys with CAH often experience a salt-losing adrenal crisis at around 1-3 weeks of age. This crisis is characterized by symptoms such as vomiting, weight loss, floppiness, and circulatory collapse.

The diagnosis of CAH can be made by detecting markedly elevated levels of the metabolic precursor 17-hydroxyprogesterone. Neonatal screening is possible, primarily through the identification of persistently elevated 17-hydroxyprogesterone levels.

In infants presenting with a salt-losing crisis, the following biochemical abnormalities are observed: hyponatremia (low sodium levels), hyperkalemia (high potassium levels), metabolic acidosis, and hypoglycemia.

Boys experiencing a salt-losing crisis will require fluid resuscitation, intravenous dextrose, and intravenous hydrocortisone.

Affected females will require corrective surgery for their external genitalia. However, they have an intact uterus and ovaries and are capable of having children.

The long-term management of both sexes involves lifelong replacement of hydrocortisone (to suppress ACTH levels).