Education Articles from the Student BMJ April 2010

Vitamin D deficiency

Causes Rickets in children and osteomalacia in adults. More than 50% of adults in the UK reportedly have a deficiency in vitamin D and the highest rates in the UK are in Scotland. Vitamin D is sourced from sunlight and from 1,25 dihydroxyvitamin D3 (calcitriol). Vitamin D status is best determined by assay of serum 25-hydroxyvitamin D (25-OHD). Vitamin D deficiency is associated with increased mortality and increased risk of common conditions such as cancer, cardiovascular disease and type 2 diabetes. Anyone who lives in a northern latitude country has an increased risk of vitamin D deficiency. At these latitudes, pigmented skin is also a risk factor.

Children: may present with bony deformity (Rickets), bowing of the legs (genu varum), irritability and reluctancy to weight bear. Height is more affected than weight. Management is with oral calciferol or colecalciferol to relplenish vitamin D stores.

Adults: present with proximal muscle weakness, bony pain, muscular aches, muscle weakness. Dif dx - fibromyalgia. Hypocalcaemia and hypophosphataemia may be present. Treat with calciferol.


Minor Eye Trauma

This was really a revision article in the student BMJ this week regarding the most common eye injuries which a junior doctor should have an idea about how to manage. Must rule out a head injury and must assess vision in both eyes and document this (legal requirement).

Corneal Abrasion - symptoms of intense pain, a watering eye and foreign body sensation with a clear history of a scratch / trauma eg 'A twig hit my eye'. To look for corneal abrasions, stain the cornea with flourescein dye. Treat with oral analgesics and topical antibiotics (sparingly because they delay wound healing).

Corneal, conjunctival and sub-tarsal foreign bodies
Feeling of 'something in my eye', symptoms of watering, red eye, pain, photophobia and FB sensation. Normally vision is unaffected. Metallic FBs leave behind a 'rust ring'. Examination should include eversion of the eyelids. Irrigate the eye using saline. Removing a FB usually requires a slit lamp and should be left to an opthalmologist.

Traumatic Subconjunctival Haemorrhage
Bleeding from the conjunctiva or episcleral blood vessels into the subconjunctival space. The eye is usually asymptomatic. If no co-existing injury the patient can be reassured. The blood usually disappears in 1 - 2 weeks.

Blunt-Eyeball trauma
eg. from squash balls. Can cause hyphaemas, retinal, choroidal tears, bony fractures. If vision is impaired - see an opthalmologist immediately. A fracture implies a severe injury.

Blow-Out Fracture of the Orbital Floor
Often occurs when a large object hits the face, commonly during sport or an assault. Patient may complain of diplopia, epistaxis, cheek numbness and a desire to blow the nose (which should be avoided). Assess ABC, rule out a head/neck injury and control any epistaxis.