Type 1 Diabetes
A chronic autoimmune disorder resulting in the metabolic inability to produce insulin.
You have symptoms of type 1 diabetes, including unexplained rapid weight loss, persistent thrush, or extreme lethargy.
Call 999 immediately if:
- You are experiencing uncontrolled vomiting or gastric distress.
- Your breath has a chemical, fruity, or acetone odor.
- You are breathing deeply and rapidly (Kussmaul breathing).
- You feel disoriented, aggressive, or are losing consciousness.
Aetiology and Management
Type 1 diabetes is caused by an autoimmune-mediated destruction of the insulin-secreting β-cells in the islets of Langerhans within the pancreas. Unlike Type 2 diabetes, this condition is not influenced by BMI or lifestyle factors and requires exogenous insulin therapy for survival.
Primary Treatment Pillars:
- Basal-Bolus Insulin Regimen: Use of long-acting (basal) insulin such as insulin glargine or degludec to regulate background glucose levels throughout the day and night, combined with rapid-acting (bolus) insulin like insulin aspart or lispro for mealtime coverage and correction doses.
- Glycaemic Monitoring: Continuous Glucose Monitoring (CGM) systems provide real-time glucose readings and trend data, or frequent Capillary Blood Glucose (CBG) testing using finger-prick blood samples to maintain levels between 4.0 and 7.0 mmol/L preprandially and below 9.0 mmol/L postprandially.
- Carbohydrate Quantification: Precise calculation of grams of carbohydrates in meals to determine appropriate insulin-to-carbohydrate ratios (ICR), typically ranging from 1:5 to 1:15 depending on individual sensitivity and time of day.
- Insulin Sensitivity Factor: Understanding correction factors (how much 1 unit of insulin lowers blood glucose) to make adjustments when readings are outside target range.
Monitoring and Targets:
Patients should aim for an HbA1c (glycated haemoglobin) level below 48 mmol/mol (6.5%), which represents average blood glucose control over the preceding 8-12 weeks. Regular monitoring includes:
- Daily glucose monitoring 4-10 times per day or continuous monitoring via CGM
- Quarterly HbA1c blood tests
- Annual screening for retinopathy, nephropathy, and neuropathy
- Regular foot examinations to detect early signs of diabetic foot complications
Hypoglycaemia (Low Blood Sugar)
A "hypo" occurs when blood glucose levels fall below 4.0 mmol/L. This is one of the most common acute complications of insulin therapy and can be caused by excessive insulin dosing, delayed or missed meals, increased physical activity without adequate carbohydrate intake, or alcohol consumption.
Classification of Hypoglycaemia:
- Mild (3.0-3.9 mmol/L): Patient is conscious and able to self-treat
- Moderate (Below 3.0 mmol/L): Requires assistance but conscious
- Severe: Requires third-party assistance, potential loss of consciousness or seizures
Symptoms:
Early warning signs (autonomic): Sweating, trembling, shaking, palpitations, hunger, anxiety, and pallor. These occur as the body releases adrenaline in response to falling glucose levels.
Neuroglycopenic symptoms: Confusion, difficulty concentrating, blurred or double vision, slurred speech, irritability, aggression, and coordination problems. These occur when the brain is deprived of adequate glucose.
Severe hypoglycaemia: Can lead to seizures, loss of consciousness, or "hypo-unawareness" where the patient cannot detect the drop in glucose due to impaired counterregulatory response.
Immediate Correction Protocol:
- Stop all activity and sit down immediately
- Administer 15-20g of fast-acting glucose (glucose tablets, 150-200ml of fruit juice, or 4-5 glucose sweets)
- Wait 15 minutes and retest blood glucose
- If still below 4.0 mmol/L, repeat step 2
- Once above 4.0 mmol/L, consume a slow-release carbohydrate such as a sandwich, cereal bar, or biscuits to prevent recurrence
Diabetic Ketoacidosis (DKA)
DKA is a life-threatening metabolic crisis caused by an absolute lack of insulin. Without insulin, cells cannot utilize glucose for energy, forcing the body to break down fats through lipolysis. This produces acidic ketone bodies (acetoacetate, beta-hydroxybutyrate, and acetone), which accumulate in the bloodstream, causing metabolic acidosis. If left untreated, the blood pH can drop to dangerously low levels (below 7.3), leading to coma and death.
Triggers for DKA:
- Missed or insufficient insulin doses
- Acute illness or infection (urinary tract infections, pneumonia)
- New diagnosis of Type 1 diabetes (presenting symptom in 25-30% of cases)
- Insulin pump malfunction or infusion set failure
- Myocardial infarction or stroke
Clinical Presentation:
Patients typically present with polyuria (excessive urination), polydipsia (extreme thirst), nausea, vomiting, abdominal pain, and profound dehydration. The characteristic fruity or acetone breath odor is caused by exhaled acetone. Kussmaul breathing (deep, rapid respirations) represents the body's attempt to eliminate carbon dioxide and compensate for metabolic acidosis.
Diagnostic Criteria (All three must be present):
- Blood glucose greater than 11.0 mmol/L
- Blood ketones greater than 3.0 mmol/L or urine ketones 2+ or more
- Venous pH less than 7.3 or bicarbonate less than 15 mmol/L
Home Monitoring:
Patients should monitor blood ketone levels using a blood ketone meter if their blood glucose is consistently above 11.0 mmol/L or if they feel unwell. A ketone reading above 1.5 mmol/L indicates an increased risk of DKA and requires immediate medical consultation. Readings above 3.0 mmol/L constitute a medical emergency requiring immediate hospital admission.
Long-term Clinical Complications
Chronic hyperglycaemia can cause extensive damage to the vascular system and nerves:
- Retinopathy: Damage to the blood vessels in the retina, potentially leading to blindness.
- Nephropathy: Progressive kidney damage that may eventually require dialysis or transplant.
- Neuropathy: Nerve damage, typically starting in the extremities, which can lead to foot ulcers and amputation.
- Cardiovascular Disease: Significantly increased risk of myocardial infarction (heart attack) and stroke.
Bacterial Meningitis
Acute bacterial infection of the meninges surrounding the central nervous system.
You have a high temperature, neck stiffness, and a persistent headache.
Call 999 immediately if:
- A rash appears that does not disappear under pressure (Non-blanching).
- The patient is experiencing seizures or extreme photophobia.
- A child or infant is unusually drowsy, floppy, or has a high-pitched cry.
Clinical Urgency
Bacterial meningitis is an inflammatory process of the leptomeninges caused by various bacteria, most commonly Neisseria meningitidis. It is a medical emergency due to the risk of rapid progression to septicaemia, which can cause multi-organ failure and death within hours.
Immediate treatment involves high-dose intravenous antibiotics and often supportive intensive care to manage intracranial pressure.
Identifying the Non-Blanching Rash
The septicaemic rash associated with meningitis is caused by blood leaking under the skin. It often starts as small petechiae (red pinpricks) and develops into purpura (bruise-like marks).
The Glass Test: Press the side of a clear glass firmly against the rash. If the marks remain visible through the glass and do not fade, this is a non-blanching rash and indicates a 999 emergency.
Stroke (Cerebrovascular Accident)
Acute disruption of blood supply to the brain causing neurological deficit.
Call 999 immediately using the FAST test:
- Face: Can the person smile? Has their mouth or eye drooped?
- Arms: Can they raise both arms and keep them up?
- Speech: Is their speech slurred? Can they repeat a simple sentence?
- Time: If you see ANY of these signs, call 999 immediately.
Pathophysiology
A stroke occurs when blood supply to part of the brain is interrupted, preventing oxygen delivery. Brain cells begin dying within minutes.
Ischaemic Stroke (85%):
Caused by a blockage in a brain artery through thrombosis or embolism.
Haemorrhagic Stroke (15%):
Caused by bleeding into or around the brain when a vessel ruptures.
TIA (Transient Ischaemic Attack):
Stroke-like symptoms resolving within 24 hours. Serious warning sign requiring urgent assessment - 20% progress to full stroke within 90 days.
Emergency Treatment
Time is critical - "time is brain." Approximately 1.9 million neurons die every minute during ischaemic stroke.
Thrombolysis:
IV alteplase dissolves clots if given within 4.5 hours, ideally within 3 hours.
Mechanical Thrombectomy:
Physical clot removal via catheter, effective up to 24 hours in selected cases.
Rehabilitation
Recovery varies by stroke severity and affected brain area. Multidisciplinary team includes physiotherapy, occupational therapy, speech therapy, and psychology. Most recovery occurs within 3-6 months, though improvement can continue for years through neuroplasticity.
Secondary Prevention:
- Antiplatelet or anticoagulation therapy
- Blood pressure control (target <130/80 mmHg)
- Statin therapy
- Lifestyle modifications
Asthma
Chronic inflammatory disorder of the airways causing reversible airflow obstruction.
You need your reliever inhaler 3+ times weekly, wake at night with symptoms, or symptoms interfere with daily activities.
Call 999 immediately if:
- Your reliever inhaler isn't helping or symptoms return within 3 hours
- You're too breathless to speak, eat, or sleep
- Peak flow below 50% of best/predicted value
- Lips or fingers turning blue
Understanding Asthma
Asthma causes airways to become hypersensitive, leading to bronchospasm, inflammation, and mucus hypersecretion. These changes are reversible, distinguishing asthma from COPD.
Common Triggers
- Allergens: Dust mites, pet dander, pollen, mold
- Infections: Colds and flu
- Irritants: Smoke, pollution, perfumes, cold air
- Exercise: Can trigger bronchoconstriction
- Medications: Beta-blockers, aspirin, NSAIDs
Treatment Approach
Preventers (Daily):
- Inhaled Corticosteroids: First-line (beclometasone, budesonide)
- LABA: Added if needed (salmeterol, formoterol)
- LAMA: Third-line (tiotropium)
- Biologics: For severe asthma (omalizumab, mepolizumab)
Relievers (As Needed):
SABA (salbutamol) for rapid symptom relief. If needed >2x/week, treatment needs reviewing.
Asthma Attack Management
Immediate Self-Management:
- Sit upright, stay calm, breathe slowly
- Take 1 puff of reliever every 30-60 seconds (up to 10 puffs)
- If no improvement after 5-10 minutes, call 999
- Continue using reliever while waiting
Severity Signs:
Severe: Peak flow 33-50%, can't complete sentences, RR≥25, HR≥110
Life-threatening: Peak flow <33%, oxygen <92%, silent chest, altered consciousness
Atopic Eczema
Chronic inflammatory skin condition with dry, itchy skin and recurrent flares.
Understanding Eczema
Atopic eczema typically begins in childhood (affects 15-20% of children) and is part of the "atopic march" with asthma and allergies. Results from skin barrier dysfunction and immune dysregulation.
Key Features:
- Intensely itchy skin causing itch-scratch cycle
- Infants: Face, scalp, extensor surfaces
- Children/Adults: Flexures (elbows, knees)
- Adults: Lichenified plaques on hands, eyelids
Triggers and Flares
Environmental:
- Soaps, detergents, bubble bath, chlorine
- Cold dry air, low humidity, overheating
- Wool and synthetic fabrics
Physiological:
- Stress and emotions
- Viral infections
- Hormonal changes
Infected Eczema Signs:
Weeping, crusting, pustules, sudden worsening. Requires antibiotics (flucloxacillin).
Treatment Strategy
Emollients (Foundation):
Apply liberally 3-4 times daily, especially after bathing. Use 250-500g/week for adults. Choose acceptable consistency - best emollient is one that gets used.
Topical Corticosteroids:
- Mild: Hydrocortisone 0.5-1% (face, children)
- Moderate: Clobetasone 0.05% (body)
- Potent: Betamethasone 0.1% (severe flares, not face)
Apply once-twice daily to active areas only, using fingertip unit method. Continue 48 hours after clearing.
Additional Options:
- Calcineurin inhibitors for sensitive areas
- Wet wraps for severe flares
- Phototherapy for widespread disease
- Systemic immunosuppression for severe cases
Migraine
Neurological condition with recurrent severe headaches and other symptoms.
Classification
Affects 15% of population, women 3x more than men. Typically begins in adolescence/early adulthood.
Migraine Without Aura (75%):
Headaches lasting 4-72 hours with at least two of:
- Unilateral location
- Pulsating quality
- Moderate-severe intensity
- Aggravated by activity
Plus nausea/vomiting or photophobia/phonophobia.
Migraine With Aura (25%):
Preceded by neurological symptoms developing over 5-20 minutes, lasting <60 minutes:
- Visual: Zigzag lines, blind spots, flashing lights
- Sensory: Tingling, numbness in limbs/face
- Speech: Difficulty finding words
- Motor: Weakness (rare, hemiplegic migraine)
Chronic Migraine:
≥15 headache days/month for >3 months, with ≥8 days having migraine features.
Common Triggers
- Hormonal: Menstruation, oral contraceptives, HRT
- Dietary: Missed meals, dehydration, alcohol (especially red wine), caffeine changes, aged cheese, processed meats
- Environmental: Bright/flickering lights, loud noises, strong smells, weather changes
- Sleep: Too much, too little, irregular patterns
- Stress: During or after stressful periods
- Physical: Intense exercise, poor posture
Acute Treatment
First-line:
- Analgesics: Paracetamol 1000mg, ibuprofen 400-600mg, aspirin 900mg at first sign
- Anti-emetics: Metoclopramide or domperidone help nausea and improve analgesic absorption
Triptans:
Specific migraine medications (sumatriptan, rizatriptan, zolmitriptan). Most effective when taken early. Can combine with NSAID for better efficacy.
Self-Management:
- Rest in quiet, dark room
- Apply cold compress to head
- Stay hydrated
- Avoid medication overuse (<10 days/month)
Preventive Treatment
Consider if ≥4 migraine days/month or significant disability despite acute treatment.
First-line Preventives:
- Beta-blockers: Propranolol 80-240mg daily
- Anticonvulsants: Topiramate 50-100mg daily (avoid in pregnancy)
- Antidepressants: Amitriptyline 10-75mg at night
- Candesartan: 16mg daily (antihypertensive)
Specialist Treatments:
- CGRP antagonists: Monthly injections (erenumab, fremanezumab) for chronic migraine
- Botulinum toxin: Injections every 12 weeks for chronic migraine
Lifestyle Measures:
- Regular sleep schedule
- Regular meals, adequate hydration
- Regular moderate exercise
- Stress management techniques
- Avoid identified triggers
Acute Appendicitis
Inflammation of the appendix requiring urgent surgical intervention.
You have severe abdominal pain that's getting worse, particularly in the lower right side.
Call 999 if:
- Sudden severe pain across entire abdomen (suggests perforation)
- Abdomen is rigid and painful to touch
- Signs of shock: rapid pulse, rapid breathing, confusion, pale/clammy skin
Understanding Appendicitis
Acute appendicitis is inflammation of the appendix, a small pouch attached to the large intestine. It's one of the most common surgical emergencies, affecting approximately 1 in 15 people during their lifetime, most commonly between ages 10-30.
Pathophysiology:
Appendicitis typically occurs when the appendix lumen becomes obstructed by:
- Faecolith (hard, stone-like stool)
- Lymphoid hyperplasia (swollen lymph tissue)
- Foreign body or parasite (rare)
- Tumor (very rare)
Obstruction leads to increased intraluminal pressure, reduced blood flow, bacterial overgrowth, and inflammation. If untreated, the appendix can perforate within 24-72 hours, releasing bacteria into the peritoneal cavity and causing peritonitis.
Classic Symptom Progression:
- Initial phase (0-24 hours): Vague periumbilical (around belly button) pain, loss of appetite, nausea
- Migration (12-24 hours): Pain localizes to right lower quadrant (McBurney's point - 1/3 distance from right hip bone to belly button)
- Established (24+ hours): Sharp, constant pain worsened by movement, coughing, or palpation. Fever develops.
Clinical Diagnosis
Physical Examination Signs:
- McBurney's point tenderness: Maximal tenderness in right lower quadrant
- Rovsing's sign: Pain in RLQ when LLQ is pressed
- Rebound tenderness: Pain when pressure suddenly released
- Guarding: Involuntary abdominal muscle contraction
- Psoas sign: Pain with right hip extension (retrocaecal appendix)
- Obturator sign: Pain with internal rotation of flexed right hip
Diagnostic Investigations:
- Blood tests: Elevated white cell count (leucocytosis) and C-reactive protein (CRP) indicate inflammation
- Urine analysis: To exclude urinary tract infection or kidney stones
- Pregnancy test: Essential in women of childbearing age to exclude ectopic pregnancy
- Ultrasound: First-line imaging, particularly in children and pregnant women. Can visualize inflamed appendix (>6mm diameter)
- CT scan: Gold standard imaging with 95% accuracy. Shows appendix inflammation, abscess, or perforation
Scoring Systems:
Alvarado Score: Clinical prediction tool using symptoms, signs, and lab values to assess appendicitis likelihood (score 0-10, >7 suggests high probability).
Management and Surgery
Initial Management:
- Nil by mouth (NBM) pending surgery
- Intravenous fluids for hydration
- Analgesia (usually avoid opioids initially as may mask symptoms)
- IV antibiotics if perforation suspected
- Anti-emetics for nausea/vomiting
Surgical Options:
Laparoscopic Appendicectomy (preferred):
- Keyhole surgery through 3 small incisions
- Benefits: Smaller scars, less pain, faster recovery, better visualization
- Hospital stay: 1-2 days for uncomplicated cases
- Return to normal activities: 1-2 weeks
- Return to strenuous activity/sports: 4-6 weeks
Open Appendicectomy:
- Single larger incision in right lower quadrant
- Used if laparoscopy not feasible (pregnancy, severe peritonitis)
- Longer recovery: 2-4 weeks
Conservative Management:
Some cases of uncomplicated appendicitis may be treated with IV antibiotics alone, but this has higher recurrence rates (up to 25% within 1 year) and is not standard practice. Reserved for specific circumstances such as appendiceal abscess with phlegmon formation, where interval appendicectomy may be performed 6-12 weeks later.
Complications
Perforation (15-30% of cases):
Occurs when inflamed appendix ruptures, spilling bacteria and fecal matter into peritoneal cavity. Risk increases with delayed presentation. Signs include:
- Sudden severe pain spreading across abdomen
- High fever and rapid heart rate
- Rigid, board-like abdomen
- Signs of sepsis
Requires urgent surgery, prolonged antibiotics, and extended hospital stay.
Appendiceal Abscess:
Walled-off collection of pus around perforated appendix. May be treated with antibiotics and percutaneous drainage, followed by interval appendicectomy.
Post-operative Complications:
- Wound infection: 5-10% of cases. Higher risk with perforation.
- Intra-abdominal abscess: Rare, presents with persistent fever and pain post-op
- Adhesions: Scar tissue causing potential bowel obstruction (rare)
- Stump appendicitis: Very rare inflammation of remaining appendix tissue
Differential Diagnoses:
Conditions that can mimic appendicitis:
- Gastroenteritis or food poisoning
- Mesenteric adenitis (inflamed lymph nodes in abdomen, common in children)
- Ectopic pregnancy or ovarian cyst torsion in women
- Pelvic inflammatory disease
- Kidney stones or urinary tract infection
- Inflammatory bowel disease (Crohn's disease)
- Meckel's diverticulitis