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Fungal nail infections

Onychomycosis is a fungal nail infection that causes discolouration, thickening and separation from the nail bed ( Westerberg 2013 )

How common

Happens in 10 % of general population 0.7 % in patients younger than 19 20 % in those older than 60 50 % of those older than 70 Men are affected more than women Only 50 % of nail problems are caused by onychomycosis

What is the cause

Dermatophyte fungi 
( ringworm) Nondermatophyte fungi Yeasts cause about 5 % of infections

Dermatophyte-Trichophyton.rubrum- responsible for >

Serum Protein Electrophoresis -Interpretation

Serum protein electrophoresis separates proteins based on their charge, size and shape. Albumin is the major component of serum protein and constitutes the first peak on left

In electrophoreis Gamma zone comprises mainly of Immunoglobulins which are made of two protein moeties called heavy and light chains Antibodies are made of gamma globulin called an Immunoglobulin Immunoglobulins are glycoprotein molecules –

Thrombocytopenia ( Low platelet count )

Approach to Thrombocytopenia or low platelet count on

definitions –Count below the 2.5 th lower percentile of the normal platelet count distribution.
Traditional cut-off is < 150 x 109
 National Cancer Institute – severity criteria

 Grade 1 From 75000 to 150 , 000 Grade 2 From 50,000 to < 75,000 Grade 3 From 25,000 to <

Nausea-vomiting in pregnancy ( NVP )

Typically begins by 4th week and disappears by the 16th Peaks at approx 9 th week 75-80 % of pregnant ♀ experience this
♦ varying intensity
♦ various length of time Symptoms subside by 20th week in 90 % cases About 0.3 % – 1 % develop hyperemesis gravidarum ( HG )

Hyperemesis Gravidarum is severe form of NVP- requires hospital admission.

Enuresis ( Bedwetting )

Enuresis refers to the involuntary loss of urine during sleep that occurs at least twice a week in children older than 5 yrs of age ( or the developmental equivalent ) for atleast 3 months ( NE- denoted nocturnal enuresis )

Monssymptomatic , Non-monosymptomatic , primary and secondary-Primary monosymptomatic nocturnal enuresis ( PMNE ) is the most commonly seen variant

How common –Widespread and common condition Prevalence of NE is generally quoted as
20 % at 5 yrs of age
5 % at age 10 yrs
0.1 to 1 % among teenagers / young adults Prevalence similar across cultures More common in boys with a ratio of 3 :1- this difference tends to reduce after 10 yrs of age NE –

Ulcerative Colitis Flare Pathway

Ulcerative colitis flare pathway

Exclusions: age under 16, have a stoma or fistula, have had surgery, or on
biological therapy (e.g. Humira).These patients should have access to an IBD
specialist—please contact their team before
making any medication changes.

Ask about triggers. Check adherence to medication. Stop NSAIDs. Consider self-care for mild symptoms including dietary advice and
reducing stress.

Cow’s Milk Protein Allergy

A hypersensitivity reaction to cow’s milk protein ( CMP ) involving the immune 
system can be called CMPA ( European Academy for Allergy and Clinical Immunology and World Allergy Organization )

IgE Medicated –Reactions are acute Frequently have rapid onset From minutes- up to 2 hrs after allergen ingestion

Non IgE Mediated –Generally delayed Non-acute Type 4 type delayed hypersensitivity Up to 48 hrs and up to
 1 week after consuming cow’s milk protein

Mixed- Mixed IgE and Non-IgE Mixed reponses

How common –Most common childhood food allergy in children is CMPA
second to egg allergy Highest prevalence in 1st year- seen less commonly in older children and adults 
( often outgrown ) Prevalence of 2-3 % in the infant population which falls to <

Thrombocytosis-elevated platelet count

Thrombocytosis or raised -Platelet count of greater than 450 x 109 also called Thrombocythaemia

Try and determine the cause – present in 1.5 to 2.2 % of 
the people aged > 40 seen in primary care REACTIVE-Overproduction of platelets- acute phase reactants More common ↑↑ cytokines due to any reason Platelet count normalizes or is expected to return to normal once the condition resolves Acute and chronic infection Haemorrhage Trauma ,

Crohn’s Disease Flare Pathway

Flare pathway for adults with known Crohn’s Disease without a stoma or an individual care plan. Exclusions : age under 16 , have a stoma or fistula , have had surgery or are on immunomodulators – azathioprine , mercaptopurine , methotrexate or a biological therapy ( e.g. Humira )

Exclude intercurrent gastrointestinal infection .

Constipation in children- Assessment

What is constipation – currently the most widely accepted definitions for childhood functional constipation are the Rome III definitions. These are different based on age groups

 Functional constipation is an umbrella term that encompasses a group of disorders associated with persistent difficulty , infrequent or seemingly incomplete defecation without evidence of a structural or biochemical explanation (Manu R Sood ,