Digoxin acts by inhibiting the Na+/K+ ATPase pump.
Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.

Mechanism of action:
It decreases the conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and atrial flutter.
It increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. It also stimulates the vagus nerve.

Digoxin toxicity:
Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. The likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.
Clinical feature of digoxin toxicity include a general feeling of unwell, lethargy, nausea & vomiting, anorexia, confusion, xanthopsia, arrhythmias (e.g. AV block, bradycardia), and gynaecomastia

Precipitating factors:
Hypokalaemia
Increasing age
Renal failure
Myocardial ischemia
Hypomagnesaemia, hypercalcemia, hypernatremia, acidosis
Hypoalbuminemia
Hypothermia
Hypothyroidism
Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in the distal convoluted tubule, therefore, reduce excretion), ciclosporin. Also, drugs that cause hypokalaemia e.g. thiazides and loop diuretics.

Management of digoxin toxicity:
Digibind
Correct arrhythmias
Monitor and maintain potassium levels within the normal limits.

Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome associated with the development of the following classic tumours: soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumours, adrenocortical carcinoma (ACC), and leukaemia. LFS is diagnosed in individuals meeting established clinical criteria or in those who have a germline pathogenic variant in TP53 regardless of family cancer history.

The most probable diagnosis of this patient is Cotard syndrome.

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.

Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.

Indications for surgery for the treatment of primary hyperparathyroidism:
1. Symptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation
2. End-organ disease (renal stones, fragility fractures or osteoporosis)
3. An albumin-adjusted serum calcium level of 2.85 mmol/litre or above.

Tricyclic compounds can’t be cleared by haemodialysis.

Drugs that can be cleared with haemodialysis include: (BLAST)
– Barbiturate
– Lithium
– Alcohol (inc methanol, ethylene glycol)
– Salicylates
– Theophyllines (charcoal hemoperfusion is preferable)

Drugs which cannot be cleared with haemodialysis include:
– Tricyclics
– Benzodiazepines
– Dextropropoxyphene (Co-proxamol)
– Digoxin
– Beta-blockers

Among the options provided, hypothermia is not a symptom of opioid withdrawal.

Symptoms of opioid withdrawal include dysphoric mood, yawning, insomnia, muscle aches, lacrimation/rhinorrhoea, papillary dilatation, piloerection, fever, sweating, nausea/vomiting, diarrhoea.
If the patient is having an opioid withdrawal reaction, then give 10 mg of methadone syrup and wait about 60 min to determine its effect.

COWS (Clinical Opioid Withdrawal Scale) assessment for opioid withdrawal is commonly used to determine the severity of opioid withdrawal.

This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.

Speaking to your consultant is the most appropriate first action to take in this scenario. They are best placed to be able to take action to try and amend the situation. The consultant is also ultimately responsible for patient care and hterefore have a right to know if you are struggling, as this may affect patient care.
Arriving early and taking time off sick do not address the problem.

The following are conditions commonly associated with pyoderma gangrenosum:
Inflammatory bowel disease:
– Ulcerative colitis
– Crohn’s disease
Arthritides:
– Rheumatoid arthritis
– Seronegative arthritis
Haematological disease:
– Myelocytic leukaemia[8]
– Hairy cell leukaemia
– Myelofibrosis
– Myeloid metaplasia
– Monoclonal gammopathy
Autoinflammatory disease:
– Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome)
– Granulomatosis with polyangiitis

11-beta hydroxylase is stimulated by ACTH and responsible for conversion of 11-deoxycortisol to cortisol and deoxycorticosterone to corticosterone.

In 11-beta hydroxylase deficiency, the previously mentioned conversions are partially blocked, leading to:
– Increased levels of ACTH
– Accumulation of 11-deoxycortisol (which has limited biological activity) and deoxycorticosterone (which has mineralocorticoid activity)
– Overproduction of adrenal androgens (DHEA, androstenedione, and testosterone)

In patients with polycystic ovarian syndrome (PCOS), FSH levels are within the reference range or low. Luteinizing hormone (LH) levels are elevated for Tanner stage, sex, and age. The LH-to-FSH ratio is usually greater than 3.

Women with PCOS have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis.
The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
– Hirsutism
– Infertility
– Obesity and metabolic syndrome
– Diabetes
– Obstructive sleep apnoea

Androgen excess can be tested by measuring total and free testosterone levels or a free androgen index. An elevated free testosterone level is a sensitive indicator of androgen excess. Other androgens, such as dehydroepiandrosterone sulphate (DHEA-S), may be normal or slightly above the normal range in patients with polycystic ovarian syndrome (PCOS). Levels of sex hormone-binding globulin (SHBG) are usually low in patients with PCOS.

Some women with PCOS have insulin resistance and an abnormal lipid profile (cholesterol >200 mg/dL; LDL >160 mg/dL). Approximately one-third of women with PCOS who are overweight have impaired glucose tolerance or type 2 diabetes mellitus by 30 years of age.

Henoch-Schönlein purpura (HSP) rashes are commonly found on the legs, feet, and buttocks while Immune thrombocytopenia (ITP) rashes manifest predominantly on the lower legs. HSP happens following a sore throat while ITP usually happens following an URTI or Flu. HSP is an inflammation of a blood vessel (vasculitis) while ITP is immune mediated insufficiency of platelets.

Acyclovir is the correct answer. There has been no documented evidence of harm in pregnancy yet. Chickenpox can cause fetal abnormalities, and varicella zoster Immunoglobulin should be given to the infant immediately after birth (not the mother, won’t help). Steroids will actually make the chicken pox worse. Painkillers only, is obviously the wrong answer and pose severe risk to foetus.

Steps required in performing the Wilcoxon signed rank test:

1 State the null hypothesis and, in particular, the hypothesized value for comparison
2 Rank all observations in increasing order of magnitude, ignoring their sign. Ignore any observations that are equal to the hypothesized value. If two observations have the same magnitude, regardless of sign, then they are given an average ranking
3 Allocate a sign (+ or -) to each observation according to whether it is greater or less than the hypothesized value (as in the sign test)
4 Calculate:
R+ = sum of all positive ranks
R- = sum of all negative ranks
R = smaller of R+ and R-
5 Calculate an appropriate P value What makes this test the most appropriate for this study is that the data is non-parametric, paired and comes from the same population.

Erythromycin is a bacteriostatic antibiotic. This means it stops the further growth of bacteria rather than directly destroying it. This is achieved by inhibiting protein synthesis. Erythromycin binds to the 23S ribosomal RNA molecule in the 50S subunit of the bacterial ribosome. This causes a blockage in the exiting of the peptide chain that is growing. Given that humans have 40S and 60S subunits, and do not have 50S subunits, erythromycin does not affect protein synthesis in human tissues.

The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli causing diarrhoea in these cases as well.

This man has a small-cell lung cancer (SCLC) and associated Lambert-Eaton myasthenic syndrome – a well-recognized paraneoplastic manifestation of SCLC. This classically affects the proximal muscles, especially in the legs, causing difficulty in standing from a seated position and climbing stairs. In contrast to myasthenia gravis, eye involvement is uncommon. Treatment with steroids is often helpful, which explains his transient symptomatic improvement during treatment for his COPD exacerbation. Steroid myopathy does not fit as the symptoms started well before his course of prednisolone. Although the patient is mildly hypercalcaemic, this would not be sufficient to produce his presenting symptoms, although it does reinforce the suspicion of lung malignancy. Motor neurone disease would be unlikely in this context and would not improve with steroids. Myasthenia gravis could produce these symptoms, but in the context of a new lung mass is a less viable diagnosis.

Hypovitaminosis B1, consistent with dry beriberi is crucially a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world. Dry beriberi or ‘acute nutritional polyneuropathy’ is considered to be rare in the western world. Rapid deterioration can occur, typically with weakness, paraesthesia and neuropathic pain. Striking motor nerve involvement can occur, mimicking Guillain-Barré syndrome (GBS). In the context of increasing alcohol abuse in the western world, it is possible that alcoholic neuropathy associated with abrupt deterioration due to concomitant nutritional hypovitaminosis B1 may be seen increasingly often.

Indapamide is a mild thiazide-like diuretic with hypotensive effect, and compared to other thiazides, it is reported to also have less metabolic derangements. However, it may have beneficial hypo-calciuric effects that are often associated with thiazides, thus, in this case, we would recommend prescribing this to the patient.

Seasonal affective disorder (SAD) is a type of depression that’s related to changes in seasons. SAD begins and ends at about the same time every year. For most people with SAD, the symptoms start in the fall and continue into the winter months, sapping the person’s energy and making him feel moody. Less often, SAD causes depression in the spring or early summer.

Treatment for SAD may include light therapy (phototherapy), medications and psychotherapy.

Signs and symptoms of SAD may include:
Feeling depressed most of the day, nearly every day
Losing interest in activities you once enjoyed
Having low energy
Having problems with sleeping
Experiencing changes in your appetite or weight
Feeling sluggish or agitated
Having difficulty concentrating
Feeling hopeless, worthless or guilty
Having frequent thoughts of death or suicide.

Seasonal affective disorder is diagnosed more often in women than in men. And SAD occurs more frequently in younger adults than in older adults.

Factors that may increase your risk of seasonal affective disorder include:
Family history. People with SAD may be more likely to have blood relatives with SAD or another form of depression.
Having major depression or bipolar disorder. Symptoms of depression may worsen seasonally if you have one of these conditions.
Living far from the equator. SAD appears to be more common among people who live far north or south of the equator. This may be due to decreased sunlight during the winter and longer days during the summer months.