Hello, can someone help me out with my daughter's rash? 16 years old, generally fit and healthy and on a combined contraceptive pill for dysmenorrhea. She is getting these itchy rashes/urticaria (see photo) whenever doing activities like swimming in rivers, springs or the sea. Even sometimes when it is raining and cold outside, but not when she showers. We have tried antihistamines but it doesn't help. She has also had a sun allergy since childhood. Is it some sort of allergic reaction? Are the two conditions linked? Anything to give her for symptomatic relief? 

I have a 60-year-old woman with hyperlipidemia who was started on atorvastatin 10 mg, but she came back complaining of muscle aches within a week. She insists she can’t tolerate it but has never tried another statin. CK levels are normal. Is this true intolerance or a nocebo effect? Would you trial a lower dose, a different statin, or just drop it and try ezetimibe

A 28 year old male, type 1 diabetic usually requires an average of 110 units of insulin daily. However, since getting Covid-19 infection three months ago, his requirements have gone up to nearly double. Hba1c is also slightly increased. Fortunately, he has never suffered from complications of hyperglycaemia as he is very well educated and understands how to control his blood glucose quite well. This is not his first Covid-19 infection, he has had two previous infections and both times his insulin requirements went back to normal within 2-3 weeks. Is there anything that can be done to help his control?

Dear Colleagues!

Have You noticed remarkable changes after Covid-era? I know there other modifying factors, too, wars next and far to us, globalisation, new rules etc , but Covid made a strong fingerprint on all of us, 

Have your and coworkers and patients attitude, feelings or healthcare indicators changed? 

We meet more younger ones and older patients with highrisk comorbidity requiring polihistiric attitude in mean stream internal medicine, neurology and psychiatry, more emergency occurances and more difficoult social problems .

I feel all around exhaustion, anxiety, the loss of presumed safty.

What about You?

Best regards

A 4-year-old girl was recently referred to my occupational therapy clinic due to developmental delays in fine motor skills, self-care tasks, and play activities. Assessments revealed below-average hand-eye coordination, grasping difficulties, and sensory processing issues, particularly under-responsiveness to tactile input. Observations showed struggles with buttons, zippers, and utensil use, as well as limited engagement in imaginative play, favoring solitary activities.

In the care and management of this patient, what goals must we prioritize in her treatment and do you have any specific interventions that you think would be appropriate for her case? 

I would be grateful if you could help me with a case.. A 45-year-old female patient, previously very active, has been attending with persistent, debilitating pain in her muscles and joints, lasting for over a year following COVID-19 infection. Extensive imaging and blood work, have ruled out autoimmune conditions and neurological disorders. The patient has tried a range of treatments ranging from simple pain relief, physical therapy, and low-dose SSRIs, with minimal relief. The pain significantly impacts her daily functioning - she has gained 15kgs since due to inactivity. What would you recommend as the next step in her treatment plan?

Hey friends! I had an interesting case this week in my clinic which I presented to my students and I thought why not share it here as well. A 45-year-old female patient presented with severe facial swelling and acute pain in the lower left mandibular region. Clinical examination revealed a partially erupted third molar (#17) with significant pericoronitis, along with trismus and lymphadenopathy. 

How would you proceed with patient management and what are the most critical next steps in care? 

A 22 year old female with medical records of ovarian cysts and 'seizures' has been in and out of hospital with chronic abdominal pain. The gynecologists say her ovarian cysts are too small to cause pain and she has had many investigations and surgical review. Still, no cause has been found.. She has been manipulating us for opioid drugs, often switching between being very nice to very mean and destructive to get what she wants. Her seizures have never been shown on any tests and in my opinion don't look like a seizures. They are always 'triggered' when it takes us too long to get her painkillers or when the doctors refuse to increase the dosages of her opioids. She is unpredictable and has lied,  said that she hasn't been given her morphine when it is clearly written in her charts that she was given the dose. Would you consider a diagnosis of ficticious disorder or boderderline personality disorder? A referral to pschiatry? 

A few days ago, an 81-year-old COPD patient was caught smoking by his hospital window while on O2. When warned about the danger, she shrugged, saying, "finally Ill be reunited with my husband." She's widowed, lives alone, and is anxious about her new dependence on oxygen. 

Do you think she has a serious risk of suicide and should have a psych consult?

My boss is forcing me to increase my patient load by 30%. For this and so many additional reasons, I am ready to quit. For reference, I am a urologist with 13 years’ experience, working 45 hours a week in an outpatient clinic. I pride myself on my high standard of care and if I see more patients, it will obviously lower it. What should I do? I don't want the patients to suffer

A 69-year-old woman was diagnosed with seropositive RA in 2003. having bad prognostic factors (high level of inflammatory markers and rheumatoid factor, polyarticular erosive disease). She was treated with levothyroxine from 2012. and had no other significant comorbidity. From beginning she was given methotrexate along with antimalarial and intermittent glucocorticosteroid depo intramuscular injections. In 2009. methotrexate was withdrawn because of significant transaminases elevation. She also had side effects using leflunomide and sulphasalazine. She used infliximab from 2013. to 2014. and was stopped because of psoriasis induction. From March 2015. tocilizumab was introduced as a second biologic with different mechanism and which could also be used as monotherapy. After a year of tocilizumab use she had PPD3 positivity and continued biologic along with incomplete latent tuberculosis chemoprophylaxis with izoniazide which also induced significant transaminases elevation. Her tocilizumab dosing was influenced by her neutropenias, lymphopaenias and thrombocytopaenias, so she often had less then a preplanned dose. In the winter of 2019. after clinical suspicion on drug induced lupus (DIL) based on cytopaenias, appearance of alopecia and malar rush and history of anti-TNF and izoniazide use, she had laboratory evaluation discovering homogeneous pattern antinuclear antibodies (ANA) 1/160, high level of antihistone antibody, anti-DNA antibody with low c3 component. After systemic evaluation, no other organs were affected. Patient developed overlap between old RA and newly diagnosed SEL. tocilizumab was stopped at the beginning of 2020. She had transient arthritis flare, now well controlled with baricitinib.

A 63-year-old woman with advanced cancer refuses chemotherapy, believing that prayer alone will heal her. Her oncologist struggles with the ethical dilemma—should he push for treatment, knowing it might extend her life, or respect her faith-based decision, even if it means a shorter prognosis? These are the tough realities many doctors face, where science meets belief, and the right course of action isn’t always clear.

For many patients, illness is not just a medical experience—it’s a deeply spiritual one. Research shows that up to 78% of patients with cancer consider spirituality important in their healthcare journey, and many make medical decisions based on religious beliefs. Some refuse blood transfusions, others fast despite health risks, and many look for divine intervention when medicine reaches its limits. Yet, despite this profound influence, modern medicine often treats spirituality as an afterthought, leaving a critical gap in holistic patient care.

Consider a young Muslim patient diagnosed with diabetes who insists on fasting during Ramadan, despite the dangers. His endocrinologist has two options: firmly advise against fasting or work with him to adjust his insulin schedule to minimize risks. Many physicians are trained to focus solely on medical facts, but real-world medicine isn’t always that simple. Sometimes, patient-centered care means meeting patients where they are—faith and all. Studies even show that when doctors acknowledge a patient’s religious beliefs, patients report greater satisfaction with their care. However, most physicians aren’t trained for these conversations, leading to missed opportunities for trust and collaboration.

And then there’s end-of-life care. A devout Christian man in the ICU insists that his doctors “do everything possible” to keep him alive, even as his organs fail and his suffering increases. His family clings to hope, praying for a miracle. The medical team knows that aggressive interventions may only prolong pain, but how do you tell a grieving family that their faith in divine healing won’t change the inevitable? Studies suggest that patients who receive spiritual support from their medical teams are more likely to opt for palliative care over aggressive interventions, leading to better quality of life in their final days. But when spiritual needs are ignored, patients and families may feel abandoned or misunderstood, adding emotional distress to an already difficult situation.

So, what’s the right approach? Should doctors engage with patients’ spirituality, or is that crossing a professional line? Have you faced a situation where religion shaped a medical decision in ways you didn’t expect?

A 19-year-old college student presented with recurrent episodes of palpitations, dizziness, and shortness of breath lasting several minutes. He denied chest pain or syncope. On examination, his heart rate and rhythm were normal. A 12-lead ECG revealed a shortened PR interval and a delta wave. No structural abnormalities were noted on echocardiography. What is the ECG abnormality? 

I have a 40-year-old healthy woman with mild normocytic anemia found on routine examination – Hb is 9.5, MCV 80. She is asymptomatic except for maybe a little tiredness, with no history of heavy periods, gastro symptoms, chronic disease, or significant blood loss. Iron studies, B12, and folate are normal, as are renal and liver function tests. Celiac antibodies are negative, and  gastroscopy& colonoscopy showed no abnormalities, no hemolytic signs in lab. I am considering peripheral smear, reticulocyte count, because there is no clear cause. What else would you suggest I do?

78% of parents rely on news reports to stay informed about bird flu, 31% turn to social media, and only 11% consult healthcare providers for guidance, according to a recent University of Michigan Health C.S. Mott Children’s Hospital National Poll. The survey included 2,021 parents of children aged 18 years or younger, with just 43% reporting confidence in their ability to access accurate information about the H5N1 virus.

These results are particularly troubling given this week's warning from the UN's Food and Agriculture Organization, which described the current bird flu threat as 'unprecedented' due to the H5N1 virus jumping to mammals. Globally, health experts have expressed concern about increasing bird flu cases, especially in the US, where an outbreak affecting poultry and dairy cows has resulted in 67 human infections and one death. Since first detected in 1997, this clade has caused 954 human cases across 24 countries, though no cases have yet been reported in Europe, according to the European Commission.

How confident do you feel in advising your patients about bird flu?

Gravida 1,31 weeks, 26 years, complaints of epigastric pain, bleeding per gum and petechiae hemorrhage for 1 day; high-grade fever for 5 days prior to admission, first seen at antenatal clinic (12 weeks pregnancy), no abnormality detected. Nothing history. 37°c, bp110/80 mmHg, pulse 80/mim and respiratory rate 20/min. Mild dehydration. Liver enlarged 1 cm below the right costal margin with mild tenderness. Fundal height - 31 weeks' gestation, fetal heart rate 144 beats/min, Petechiae1–2 mm d. found on face, forearms and both pretibial areas.

Labs: hgb 11.9 g/dl, hematocrit 35%, white blood cells 7,440/mm3 50% neutrophil, 45% lymphocytes; 3% atypical lymphocytes; platelet 10,100 /mm3. Intravenous fluid replacement, under close observation bleeding precaution. After 24h, epigastric pain disappeared, vital signs normal. Hematocrit 30% , platelet  6,320 /mm3. Day 3, gradually recovered and had an itching convalescent rash on both pretibial areas. Hematocrit 31%, platelet 15,000 /mm3. She was discharged day 4. After 1 week, she was healthy and hematocrit 32% with platelet 354,000 /mm3. After that, she had an uneventful antenatal care. At the 39 weeks' gestation, she delivered a healthy female baby weighing 2,630 grams by vaginal route with APGAR scores 9 and 10 at 1 and 5 minutes, respectively. No abnormality in newborn was detected.

Most likely diagnosis of this condition?