This patient is most likely suffering from hand, foot mouth disease which is caused by coxsackie virus A16. Its incubation period ranges from 5-7 days and only symptomatic treatment is required.

Adverse effects due to IFN-alpha have been described in almost every organ system. Many side-effects are clearly dose-dependent. Taken together, occurrence of flu-like symptoms, haematological toxicity, elevated transaminases, nausea, fatigue, and psychiatric sequelae are the most frequently encountered side effects.

CMV infection is usually asymptomatic in adults. However, if the mother is infected for the first time during pregnancy then there is high chances of this infection passing on to the foetus. CMV infection can cause blindness, deafness, learning difficulties, restricted growth etc. Hepatitis B, herpes simplex, syphilis and HIV do not present with these classical signs of CMV infection in new-borns. It is estimated that 10 stillbirths occur in England and Wales every year due to CMV infection. The foetus is most at risk in early pregnancy. There is no effective prevention.

Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix. They can be seen in other organs, including the lungs, mediastinum, thymus, liver, bile ducts, pancreas, bronchus, ovaries, prostate, and kidneys. While carcinoid tumours tend to grow slowly, they have the potential to metastasise.
Signs and symptoms seen in larger tumours may include the following:
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome.
– Cutaneous flushing: Early and frequent (94%) symptom; typically affects head and neck.
– Diarrhoea and malabsorption (84%): Watery, frothy, or bulky stools, gastrointestinal (GI) bleed or steatorrhea; may or may not be associated with abdominal pain, flushing, and cramps.
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension.
– Wheezing or asthma-like syndrome (25%): Due to bronchial constriction; some tremors are relatively indolent and result in chronic symptoms such as cough and dyspnoea.
– Pellagra with scale-like skin lesions, diarrhoea and mental disturbances.
– Carcinoid crisis can be the most serious symptom of the carcinoid tumours and life-threatening. It can occur suddenly or after stress, including chemotherapy and anaesthesia.

This is a case of a transient ischemic attack. It is better investigated by carotid duplex to exclude carotid artery stenosis or atherosclerotic changes.

Hypothermia is defined as a core body temperature of < 35 °C.
Hypothermia may produce the following ECG changes:
-Bradyarrhythmia
-Osborne Waves (= J waves)
-Prolonged PR, QRS and QT intervals
-Shivering artefact
-Ventricular ectopics
-Cardiac arrest due to VT, VF or asystole

Normally blood glucose is filtered out by the kidneys, however as glucose levels exceed 180 mg/dL, the renal tubules become saturated and additional reabsorption is not possible. Glucose remains in the renal tubules, causing additional water and electrolytes to diffuse into the renal system and be excreted as urine (also known as osmotic diuresis). Excessive urine production results in electrolyte loss, and dehydration. Thus an important part of managing these patients is fluid replacement. Initially a litre of 0.9% NaCl over the 1st hour is given which may followed by either 0.45 or 0.9% NaCl, depending on the corrected serum sodium and the hemodynamic status of the patient.

CURB-65 is a clinical prediction score that has been validated for predicting mortality in community-acquired pneumonia. It is comprised of five features which are given a point if present on the patient.
C=confusion
U=urea >7mmol/L
R=respiratory rate >30/min or more
B=blood pressure (SBP)<90mmHg or (DBP)<60mmHg.
Lastly, the patient gets a point if he/she is 65-year-old or older. The score provides guidance for management:
0-1: Treat as an outpatient
2: Consider a short stay in hospital or watch very closely as an outpatient
3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit.

The burning sensation described is typical of a neuropathy affecting the small unmyelinated and thinly myelinated nerve fibres. General neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. Neuropathy affecting the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.

Oligomenorrhoea and BMI of 40.4 is suggestive of Polycystic ovary syndrome (PCOS). To diagnose PCOS 2 out of following 3 criteria should be present : oligo/anovulation, hyperandrogenism, clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone) and polycystic ovaries on ultrasound.

Subacute thyroiditis (De Quervain’s thyroiditis) is a self-limiting thyroid condition presenting with three clinical courses of hyperthyroidism, hypothyroidism, and return to normal thyroid function. In subacute thyroiditis serum thyroglobulin (TG) levels are elevated. ESR is usually greater than 50 mm/h, often exceeding 100 mm/h. Radio-iodine uptake is low or nil. Antithyroperoxidase antibodies are associated with autoimmune thyroiditis

Curling’s ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The medical management of patients with stress ulcers is more or less similar to the management of peptic ulcer disease in general. The medication targeting acid peptic disease includes proton pump inhibitors, antihistamines, and ulcer-healing drugs like sucralfate. Patients with overt GI bleeding from ulceration will require endoscopic evaluation and management of the stress ulcers. Endoscopic therapies may include epinephrine injection, electro-cauterization, or clipping of the bleeding vessels. Bleeding ulcers refractory to localized endoscopic treatment may need embolization of the culprit vessel or rarely surgical intervention as a last resort. Surgical interventions are commonly indicated for patients with refractory bleeding despite endoscopic or angiographic treatment or patients with unstable hemodynamics to undergo endoscopic or angiographic procedures. Surgeries are performed as an ultimate life-saving approach.

Blood tests do not help in the diagnosis of jaundice except of course by telling the level of jaundice (bilirubin) and providing some corroborative evidence such as autoantibodies, tumour markers or viral titres in the case of hepatitis. Classifying causes of jaundice on the basis of ultrasound provides a quick and easy schema for diagnosing jaundice which is applicable in primary care as well as hospital based practice.

Drug metabolism can be broadly classified into:
Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.

Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.

Acquired asplenia or hyposlenia can occur following splenectomy. Hyposplenism is used to describe reduced (‘hypo-‘) splenic functioning and is associated with increased risk of sepsis from polysaccharide encapsulated bacteria. In particular, patients are at risk from Streptococcus pneumoniae, Haemophilus influenzae, and meningococcus. The risk is elevated as much as 350-fold.

Bombesin is a tumour marker elevated in small cell lung carcinomas, as well as in gastric carcinomas and retinoblastomas.

Tumour markers can be divided into:
1. Monoclonal antibodies
CA 125: Ovarian cancer, primary peritoneal cancer
CA 19-9: Pancreatic cancer
CA 15-3: Breast cancer

2. Tumour specific antigens
Prostate specific antigen (PSA): Prostatic carcinoma
Alpha-feto protein (AFP): Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA): Colorectal cancer
S-100: Melanoma, schwannomas
Bombesin: Small cell lung carcinoma, gastric cancer

3. Enzymes
Alkaline phosphatase (ALP)
Neuron specific enolase (NSE)

4. Hormones
Calcitonin
Antidiuretic hormone (ADH)
Human chorionic gonadotropin (hCG)

Acamprosate (calcium acetyl-homotaurine) helps to restore the normal activity of glutaminergic neurons, which usually become hyperexcited following chronic alcohol exposure.

Fabry disease (Angiokeratoma corporis diffusum) is an X-linked lysosomal disorder which occurs due to deficiency or absence of alpha-galactosidase A (?-GAL A) activity as a result of a genetic mutation in the GLA gene. As Fabry’s disease follows X-linked genetics it manifestis predominantly in men. Ongoing burning, tingling pain and discomfort, known as acroparesthesia, mainly affecting the hands and feet is the most debilitating symptom in childhood.

Clinical criteria for the diagnosis of Buerger’s disease are:
1 – smoking history
2 – onset before the age of 50 years
3 – infrapopliteal arterial occlusions
4 – either upper limb involvement or phlebitis migrans
5 – absence of atherosclerotic risk factors other than smoking Confident clinical diagnosis of Buerger’s disease may be made only when all five requirements have been fulfilled.

As the patient has early menopause, hormone replacement therapy (HT) is considered to be the first line of choice for prevention of bone loss and fracture in the early postmenopausal period for 5 years.