Alcoholic ketoacidosis
- non-diabetic euglycaemic form of ketoacidosis
- alcoholics will not eat regularly and may vomit food > episodes of starvation
- Once malnourished, after an alcohol binge the body can start to break down body fat, producing ketones
- Metabolic acidosis
- Elevated anion gap
- Elevated serum ketone levels
- Normal or low glucose concentration
- IV saline and thiamine
Alcohol excess are often deficient in thiamine
- cause Wernicke’s encephalopathy, a neuro-psychiatric condition causing ataxia, confusion, nystagmus and ophthalmoplegia
- Korsakoff psychosis
hypoglycaemia
- over-administration of insulin/ sulfonylureas
- insulinomas
- Addison’s disease
- alcoholic ketoacidosis
Diabetic ketoacidosis
- metabolic acidosis
- complication of type 1 diabetes
- present with hyperglycaemia
- treat with IV saline and insulin infusion
Addison’s disease
- destruction of the adrenal cortex, resulting in glucocorticoid and mineralocorticoid deficiency
- present with nausea, vomiting and drowsiness, hyperpigmentation and weight loss
- acute exacerbation of Addison’s disease (e.g. from infection or steroid withdrawal) can lead to Addisonian crisis, resulting in hypotension and hypoglycaemia
Addisonian crisis
IV hydrocortisone and 0.9% saline
Hyperosmolar hyperglycemic state (HHS)
- complication of type 2 diabetes, resulting from hyperglycaemia
- diagnosing HHS requires hyperglycaemia in the absence of ketonaemia or acidosis
- hypovolaemia and hyperosmolarity
- treated with IV 0.9% saline and LMWH
hypoglycaemia of blood glucose < 4mmol/L
Fast-acting carbohydrate
anticoagulation treatment should not be used routinely for the treatment of acute stroke
risk of haemorrhagic transformation
AF who develop a stroke or TIA (not haemorrhagic)
anticoagulation therapy started two weeks after the event
- warfarin
- or direct thrombin/factor Xa inhibitor
Children with new-onset purpura should be referred immediately
investigations to exclude ALL and meningococcal disease
suspected meningococcal disease
- high fever
- spreading purpura
- lethargy
- vomiting
- sudden deterioration
> > blood polymerase chain reaction testing (EDTA sample) for N.meningitidis to confirm a diagnosis
Henoch-Scholein purpura
- multi-system vasculitis that can cause acute kidney injury
- A blood pressure and urine dipstick should be performed in all patients
- purpura is typically symmetrical, over extensor surfaces and over the legs and buttocks and they often have associated joint pain and swelling, and abdominal pain
Dx: child presenting with purpura
- Meningococcal septicaemia
- Acute lymphoblastic leukaemia
- Congenital bleeding disorders
- Immune thrombocytopenic purpura
- Henoch-Schonlein purpura
- Non-accidental injury
Dx: adults with purpura
- Immune thrombocytopenic purpura
- Bone marrow failure (secondary to leukaemias, myelodysplasia or bone metastases)
- Senile purpura
- Drugs (quinine, antiepileptics, antithrombotics)
- Nutritional deficiencies (vitamins B12, C and folate)
Three main patterns of presentation may be seen in patients with peripheral arterial disease:
- intermittent claudication
- critical limb ischaemia
- acute limb-threatening ischaemia
Intermittent claudication
- aching or burning in the leg muscles following walking
- patients can typically walk for a predictable distance before the symptoms start
- usually relieved within minutes of stopping
- not present at rest
Assessment: Intermittent claudication
- check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses
- check ankle brachial pressure index (ABPI)
> 0.6-0.9 = Claudication
> 0.3-0.6 = Rest pain
> <0.3 = Impending - duplex ultrasound is the first line investigation
- magnetic resonance angiography (MRA) should be performed prior to any intervention
Carer’s allowance
- over 16 years old who spend at least 35 hours per week caring for someone
- Have been in England, Scotland or Wales for at least 2 of the last 3 years
- You normally live in England, Scotland or Wales, or you live abroad as a member of the armed forces
- You’re not in full time education or studying for 21 hours a week or more
- You earn no more than £110 a week (after taxes, care costs while you’re at work and 50% of what you pay into your pension)
Non-means tested benefits
- Carer’s credit
- Attendance Allowance
- Personal Independence Payment and Disability Living Allowance (now converted to PIP)
Alopecia areata
- presumed autoimmune condition
- causing localised, well demarcated patches of hair loss
- At the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs
- Managed conservatively: Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually
- Other treatment options include:
> topical or intralesional corticosteroids
> topical minoxidil
> phototherapy
> dithranol
> contact immunotherapy
> wigs
Reversible causes of cardiac arrest:
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade – cardiac
- Toxins
non-shockable rhythm
absence of a carotid pulse in the presence of sinus tachycardia
only shockable rhythms
- ventricular fibrillation
- ventricular tachycardia
