(a) A sixty-year-old diabetic male presented to the emergency department with acute onset, central squeezing type of chest pain…

(a)(i) Diagnosis

Acute coronary syndrome, most probably acute myocardial infarction (STEMI or NSTEMI, decided by ECG). Diabetic autonomic neuropathy can blunt pain, so persistent central squeezing pain is an emergency.

(a)(ii) Investigations

• 12-lead ECG within 10 minutes: ST elevation, new left bundle branch block, ST depression or T inversion; repeat serially and add right-sided and posterior leads if needed.
• High-sensitivity troponin I or T (0 and 1–3 hour protocol); CK-MB if troponin is unavailable.
• Blood glucose, renal function, electrolytes, lipid profile and haemogram; chest X-ray.
• Bedside echocardiography for wall-motion abnormality, ejection fraction and mechanical complications.
• Coronary angiography is the definitive test of coronary anatomy.

(a)(iii) Management

1. Immediate: monitored bed, intravenous access, aspirin 325 mg chewed, sublingual nitrate if systolic pressure above 90 mmHg, oxygen only if SpO2 is below 90%, morphine cautiously for refractory pain.
2. Reperfusion in STEMI: primary PCI if achievable within 120 minutes of first medical contact. Otherwise give fibrinolysis (tenecteplase by weight, or streptokinase 1.5 million units over 60 minutes) within 12 hours of onset if no contraindication, then angiography within 2–24 hours; rescue PCI if ST resolution is under 50% at 60–90 minutes.
3. Antithrombotics: P2Y12 inhibitor (ticagrelor or clopidogrel, clopidogrel with fibrinolysis) plus enoxaparin or unfractionated heparin.
4. Early adjuncts: oral beta-blocker if there is no heart failure or shock, ACE inhibitor or ARB (diabetes, anterior infarct or low ejection fraction), high-intensity statin such as atorvastatin 80 mg.
5. Glycaemic control with insulin if glucose is above 180 mg/dL.
6. Watch for arrhythmias, heart failure, cardiogenic shock and mechanical complications.
7. Secondary prevention: stopping tobacco, cardiac rehabilitation, diet, exercise and diabetes and blood pressure control.

(b)(i) Diagnosis and severity

Severe acute malnutrition (marasmus): weight-for-length is far below −3 SD (the −3 SD weight at 72 cm is around 6 kg), mid-upper-arm circumference is below 11.5 cm, and subcutaneous fat is lost. With no oedema, infection or poor appetite it is uncomplicated SAM; with such features it is complicated SAM needing facility care.

(b)(ii) Complications

Hypoglycaemia, hypothermia, dehydration, electrolyte disturbances (hypokalaemia, hyponatraemia, hypomagnesaemia), infections (sepsis, pneumonia, UTI, tuberculosis), persistent diarrhoea, heart failure, anaemia, micronutrient deficiencies (vitamin A, zinc, iron), refeeding syndrome, and long-term stunting and developmental delay.

(b)(iii) Phases of treatment

• Stabilisation (days 1–7): treat hypoglycaemia with 10% glucose, warm the child, correct dehydration cautiously with ReSoMal, correct electrolytes, and give antibiotics. Start cautious feeds of F-75 at about 130 mL/kg/day (about 100 kcal/kg/day), given 2–3-hourly.
• Transition (days 3–7): change to F-100 or RUTF in the same volume, then raise gradually.
• Rehabilitation: F-100 or RUTF to 150–220 kcal/kg/day, with vitamin A, folic acid, zinc and potassium, sensory stimulation and mother counselling.
• Follow-up: discharge from a nutrition rehabilitation centre when weight-for-length reaches −2 SD or better without complications; continued home or community care, complementary feeding counselling and immunisation.

(c)(i) Atypical presentations of scabies

• Crusted (Norwegian) scabies in the immunocompromised, elderly or institutionalised, with thick crusts and millions of mites.
• Nodular scabies: persistent itchy nodules over the genitalia, axillae or buttocks.
• Bullous scabies, mimicking pemphigoid.
• Scabies incognito after topical steroids.
• Infantile scabies with face, scalp, palm and sole involvement and vesiculopustules.
• Secondary impetiginisation and eczematisation, and scabies in people who bathe often ("scabies of cleanliness").

(c)(ii) Management by age

• Neonate or infant under 2 months: 5–6% precipitated sulphur in petrolatum for 3 consecutive nights, or permethrin 5% under supervision, applied to the whole body including scalp, face and palms; avoid mouth and eyes.
• Child under 2 years: permethrin 5% cream (from 2 months of age) over the whole body, washed off after 8–12 hours and repeated after 7 days; oral ivermectin is avoided under 15 kg.
• Adult: permethrin 5% cream overnight, repeated in 7 days; alternatives are benzyl benzoate 25% or oral ivermectin 200 µg/kg in two doses a week apart.
• Pregnant woman: permethrin 5% is preferred; sulphur is an alternative; avoid ivermectin.
• For all: treat household contacts together, wash clothes and bedding hot, and give emollients and antihistamines for itch.

(c)(iii) Persistent itch after treatment

Post-scabetic hypersensitivity (itch can continue for up to 4 weeks despite mite death), treatment failure from wrong application or missing the second dose, reinfestation from untreated contacts or fomites, resistance, irritant or allergic contact dermatitis from the scabicide, secondary eczema or bacterial infection, nodular scabies, wrong diagnosis (atopic dermatitis, other itchy disorders) and delusional parasitosis.