Differentiating between lumps and bumps: A guide to common masses

When it comes to lumps and bumps on the body, it can be difficult to determine what they are and whether they require medical attention. Here are some common types of masses and their characteristics to help differentiate between them:

Sebaceous cysts: These small, smooth lumps are caused by a blocked hair follicle and have a central punctum. They are attached to the skin and may develop a horn. If infected, they can become tender and erythematous.

Lipomas: These deep masses are typically soft, doughy, and mobile. An ultrasound or biopsy may be needed to rule out sarcoma or liposarcoma.

Sternocleidomastoid tumors: This congenital lump appears within the first few weeks of life and is located beneath the sternocleidomastoid muscle. It restricts contralateral head movement.

Thyroid carcinoma: A hard, firm, non-tender mass close to the midline that moves up with swallowing may indicate thyroid cancer.

Thyroid goitre: A smooth or multi-nodular enlargement close to the midline that moves up with swallowing may indicate a thyroid goitre. Symptoms associated with thyroid diseases may also be present.

Knowing the characteristics of these common masses can help individuals determine when to seek medical attention.

Behçet’s disease is a rare autoimmune condition that causes painful recurrent mouth and genital ulcers leading to scarring. Diagnosis is often delayed due to the absence of a definitive diagnostic test. This patient has had a rash associated with Behçet’s disease and an episode of acute red eye, which may have been anterior uveitis, another symptom of the condition. Herpes simplex infection, Crohn’s disease, coeliac disease, and lichen planus are all conditions that can cause similar symptoms but can be ruled out based on the patient’s medical history and physical examination.

Bacterial vaginosis during pregnancy can lead to various pregnancy-related issues, such as preterm labor. In the past, it was advised to avoid taking oral metronidazole during the first trimester. However, current guidelines suggest that it is safe to use throughout the entire pregnancy. For more information, please refer to the Clinical Knowledge Summary provided.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

Targeting Hormones in Prolactinoma Treatment

Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.

The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.

To calculate the breakthrough dose, we need to first convert oral codeine to oral morphine by dividing by 10. For example, 10mg of oral codeine is equivalent to 1mg of oral morphine.

If a person takes 30mg of oral codeine four times a day, this equals 12mg of oral morphine. If they also take 20mg of oral morphine four times a day, the total daily dose of morphine is 92mg (12mg + 80 mg).

To determine the breakthrough dose, we divide the total daily dose of morphine by 6. In this case, the breakthrough dose would be 15mg of morphine.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

If a patient with tachyarrhythmia has a systolic BP below 90 mmHg, immediate DC cardioversion is necessary. This is because hypotension indicates an unstable tachyarrhythmia that can lead to shock, heart failure, syncope, or myocardial ischemia. Vagal maneuvers and adenosine are not recommended in cases of severe hypotension, and amiodarone is used for pharmacological cardioversion in broad complex tachycardia.

Management of Peri-Arrest Tachycardias

The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.

The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.

For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.

Port wine stain and naevus flammeus are two different conditions that are often confused with each other. While they both present as red or purple birthmarks, port wine stains are caused by a malformation of blood vessels in the skin, while naevus flammeus is a type of capillary malformation.

Understanding Strawberry Naevus

Strawberry naevus, also known as capillary haemangioma, is a type of skin condition that usually develops in infants within the first month of life. It is characterized by raised, erythematous, and multilobed tumours that commonly appear on the face, scalp, and back. While it is not present at birth, it can grow rapidly and reach its peak size at around 6-9 months before regressing over the next few years. In fact, around 95% of cases resolve before the child reaches 10 years of age. However, there are potential complications that may arise, such as obstructing visual fields or airway, bleeding, ulceration, and thrombocytopaenia.

Capillary haemangiomas are more common in white infants, particularly in female and premature infants, as well as those whose mothers have undergone chorionic villous sampling. In cases where treatment is necessary, propranolol is now the preferred choice over systemic steroids. Topical beta-blockers like timolol may also be used. It is important to note that there is a deeper type of capillary haemangioma called cavernous haemangioma. Understanding the nature of strawberry naevus is crucial in managing its potential complications and providing appropriate treatment.

Left bundle branch block is typically indicative of underlying ischaemic or structural heart disease and is never considered normal. However, there are several normal variants that can appear on an ECG, such as sinus arrhythmia, right axis deviation (common in tall and thin individuals), left axis deviation (common in short, obese individuals), and partial right bundle branch block. Additionally, athletes may exhibit certain normal variants due to their high vagal tone, such as sinus bradycardia and 1st degree atrioventricular block.

Normal Variants in Athlete ECGs

Athletes may exhibit certain ECG changes that are considered normal variants. These include sinus bradycardia, junctional rhythm, first degree heart block, and Mobitz type 1 (Wenckebach phenomenon). Sinus bradycardia refers to a slower than normal heart rate originating from the sinus node, which is the natural pacemaker of the heart. Junctional rhythm occurs when the heart’s electrical impulses originate from the junction between the atria and ventricles, rather than the sinus node. First degree heart block is a delay in the electrical conduction between the atria and ventricles, resulting in a prolonged PR interval on the ECG. Mobitz type 1, also known as Wenckebach phenomenon, is a type of heart block where there is a progressive lengthening of the PR interval until a beat is dropped. These ECG changes are considered normal in athletes and do not necessarily indicate any underlying cardiac pathology.

Eye Conditions in Immunocompromised Patients

Cytomegalovirus (CMV) retinitis, acute glaucoma, age-related macular degeneration, molluscum contagiosum of eyelids, and uveitis are all potential eye conditions that can affect immunocompromised patients.

CMV retinitis is a common cause of eye disease in patients with HIV, causing necrotising retinitis with visual loss. Fundoscopy demonstrates a characteristic ‘pizza pie’ picture, with flame-shaped haemorrhages and retinal infarction. Treatment involves local and/or systemic delivery of antiviral agents such as ganciclovir, valganciclovir, or foscarnet.

Acute glaucoma is a medical emergency that presents with sudden onset of severe unilateral eye pain, vomiting, red-eye, and seeing lights distorted by haloes and decreasing vision. It is not associated with HIV/low CD4+ counts.

Age-related macular degeneration is a chronic and progressive condition affecting older people, resulting in a gradual loss of vision, particularly of the central vision. It is not related to HIV and typically presents as a chronic condition.

Molluscum contagiosum of eyelids is a viral skin infection that is more common in immunocompromised hosts. However, it tends to occur on the trunk, extremities, or abdomen, and involvement of the eyelid and buccal mucosa is uncommon.

Uveitis presents with eye pain, photophobia, blurring vision with loss of peripheral vision in some patients, redness in the eye, and possibly floaters in the vision. It is associated with HLA-B27, autoimmune conditions such as Crohn’s disease, and infections such as toxoplasmosis, tuberculosis, and Lyme disease. It is not associated with HIV, and pain and photophobia are normally very prominent symptoms.

Bone marrow suppression, which can be fatal, is a potential risk associated with the use of azathioprine as a second-line treatment for Crohn’s disease. Budesonide, a corticosteroid medication primarily used for asthma prevention, may be considered as a second-line option for inducing remission in Crohn’s patients. Mesalazine, which acts locally on the colon’s mucous membrane and has various anti-inflammatory effects, is less effective than glucocorticoids but can be used as a second-line option to induce remission. Methotrexate, a folate derivative that inhibits enzymes responsible for nucleotide synthesis, is the second-line medication used to maintain remission in Crohn’s patients. However, in this case, there is no indication to use second-line management instead of first-line treatment.

Managing Crohn’s Disease: Guidelines and Treatment Options

Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.

To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.

To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.

Comparing Beta Blockers for Heart Failure: Efficacy and Evidence

Beta blockers are a class of medications commonly used in the treatment of heart failure. Among them, bisoprolol and carvedilol have the strongest evidence of efficacy in reducing mortality rates in heart failure patients, according to data from the CIBIS and CASA-2 trials. Atenolol, although cardioselective, has less evidence to support its use in heart failure. Labetalol is primarily used for hypertension in pregnancy, while propranolol has the most evidence of benefit after a myocardial infarction but is not always preferred due to its twice-daily dosing. Sotalol, a first-generation beta blocker, is not cardioselective and is not recommended for heart failure. Overall, the choice of beta blocker for heart failure should be based on the available evidence and individual patient factors.

Adhesive capsulitis is a condition that may occur in diabetic patients, as well as those with a history of myocardial infarction, lung disease, or neck disease. It is more common in females aged 40-60 years, and typically affects the non-dominant hand. Prolonged immobilization or disuse of the arm due to pain from another cause may also lead to adhesive capsulitis. There is no known correlation with activity.

Understanding Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

To improve treatment of tonsillitis and otitis media without relying on antibiotics, medical guidelines suggest waiting 2-3 days before considering treatment if symptoms do not improve. This approach is especially important when a patient has a fever, indicating systemic involvement. Therefore, recommending regular paracetamol is not appropriate in this case. While erythromycin can be a useful alternative for patients with a penicillin allergy, it should not be the first choice for those who can take penicillin. Penicillin V is the preferred antibiotic for tonsillitis, as amoxicillin can cause a rash in cases of glandular fever. However, it is not typically used for otitis media. For otitis media, amoxicillin is the recommended first-line medication at a dosage of 500mg TDS for 7 days. Co-amoxiclav is only used as a second-line option if amoxicillin is ineffective, and is not recommended as a first-line treatment according to current medical guidelines. These recommendations are based on NICE Guidelines and Clinical Knowledge Summaries.

Acute Otitis Media: Causes, Symptoms, and Management

Acute otitis media is a common condition in young children, with around 50% experiencing three or more episodes by the age of 3 years. While viral upper respiratory tract infections often precede otitis media, bacterial infections, particularly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, are the primary cause. Viral infections disrupt the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear through the Eustachian tube.

Symptoms of acute otitis media include ear pain, fever, hearing loss, and recent viral upper respiratory tract infection symptoms. Otoscopy may reveal a bulging tympanic membrane, opacification or erythema of the tympanic membrane, perforation with purulent otorrhoea, or decreased mobility when using a pneumatic otoscope. Diagnosis is typically based on the acute onset of symptoms, otalgia or ear tugging, the presence of a middle ear effusion, bulging of the tympanic membrane, otorrhoea, decreased mobility on pneumatic otoscopy, or inflammation of the tympanic membrane.

Acute otitis media is generally self-limiting and does not require antibiotic treatment. However, antibiotics should be prescribed if symptoms last more than four days or do not improve, if the patient is systemically unwell but not requiring admission, if the patient is immunocompromised or at high risk of complications, if the patient is younger than 2 years with bilateral otitis media, or if there is otitis media with perforation and/or discharge in the canal. Amoxicillin is the first-line antibiotic, but erythromycin or clarithromycin should be given to patients with penicillin allergy.

Common sequelae of acute otitis media include perforation of the tympanic membrane, unresolved acute otitis media with perforation leading to chronic suppurative otitis media, hearing loss, and labyrinthitis. Complications may include mastoiditis, meningitis, brain abscess, and facial nerve paralysis. Parents should seek medical help if symptoms worsen or do not improve after three days.

Platelet transfusions have the highest risk of bacterial contamination due to their short shelf life and refrigeration. This patient requires both red blood cells and platelets, but caution should be taken with platelet transfusions due to the risk of contamination. Cryoprecipitate and plasma have lower contamination risks and can be stored for longer periods. Packed red cells can also be used and have a longer shelf life.

Platelet Transfusion Guidelines for Active Bleeding and Pre-Invasive Procedures

Platelet transfusions are recommended for patients with thrombocytopenia and clinically significant bleeding, such as haematemesis, melaena, or prolonged epistaxis, with a platelet count of less than 30 x 10 9. For severe bleeding or bleeding at critical sites, such as the CNS, platelet thresholds for transfusion are higher, with a maximum of less than 100 x 10 9. However, it should be noted that platelet transfusions have a higher risk of bacterial contamination compared to other types of blood products.

For pre-invasive procedures, platelet transfusions are recommended to maintain platelet levels of greater than 50 x 10 9/L for most patients, 50-75 x 10 9/L for those at high risk of bleeding, and greater than 100 x 10 9/L for surgeries at critical sites. However, if there is no active bleeding or planned invasive procedure, a threshold of 10 x 10 9/L is recommended, unless platelet transfusion is contraindicated or there are alternative treatments available for the patient’s condition.

It is important to note that platelet transfusions should not be performed for chronic bone marrow failure, autoimmune thrombocytopenia, heparin-induced thrombocytopenia, or thrombotic thrombocytopenic purpura. These guidelines aim to provide appropriate and safe platelet transfusion practices for patients with thrombocytopenia.

Seborrhoeic dermatitis can lead to common complications such as otitis externa and blepharitis. The patient is experiencing eczema-like plaques and dry skin in areas rich in sebum, which he has been treating with over-the-counter antifungal shampoos. However, his complaint of earache may be due to otitis externa, which is associated with seborrhoeic dermatitis. A full ear examination should be performed to rule out other diagnoses. Contact dermatitis is unlikely to present in this distribution and would not cause otalgia. Eczema herpeticum is a severe primary infection by herpes-simplex-virus 1 or 2, commonly seen in children with atopic eczema. Guttate psoriasis commonly affects children after Streptococcal upper respiratory tract infection and will clear over the course of ,3 months without treatment. Irritant dermatitis is unlikely to cause such focal areas of irritation.

Understanding Seborrhoeic Dermatitis in Adults

Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.

Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.

For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.

Although females in this age group can be affected by SLE and rheumatoid arthritis, the most probable diagnosis for this patient is psoriatic arthritis due to the presence of dactylitis and a first-degree relative with psoriasis. Furthermore, rheumatoid factor and antinucleur antibody are typically positive in rheumatoid arthritis, while antinucleur antibody is mainly positive in SLE. Gout usually targets the first metatarsophalangeal joint of the first toe.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

A suitable medication would have been a DDP-4 inhibitor, glitazone, or sulfonylurea. The use of GLP-1 receptor agonists is not appropriate, as it is only recommended when triple therapy with metformin and two other oral drugs has failed.

NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

Carbimazole: Side Effects and Mechanism of Action

Carbimazole is a medication used to treat hyperthyroidism by inhibiting the production of thyroid hormones. However, it can also cause several side effects that patients should be aware of.

The most serious side effect is bone marrow suppression, which can lead to neutropenia and agranulocytosis. Patients should report any symptoms of infection immediately, as routine monitoring of white cell count is not useful. Cholestatic jaundice and drug-induced hepatitis are also possible side effects, but usually reversible upon discontinuation of the drug. Hypoprothrombinaemia, a rare side effect, can increase the risk of bleeding in patients on anticoagulant therapy.

Carbimazole works by inhibiting the enzyme thyroperoxidase, which is responsible for the synthesis of thyroid hormones. However, its onset of clinical effects is slow because it takes time to deplete the large store of pre-formed thyroid hormones in the thyroid gland.

In addition to its anti-thyroid effect, carbimazole also has a modest immunosuppressive activity, reduces the serum level of thyroid-stimulating hormone antibody, and can cause a reduction in clotting factor prothrombin. However, these effects are not thought to contribute significantly to its efficacy.

Overall, patients taking carbimazole should be aware of its potential side effects and report any symptoms to their healthcare provider promptly.

A blockage in the left middle cerebral artery (MCA) is a common cause of cerebral infarction. The symptoms experienced will depend on the extent of the infarct and which hemisphere of the brain is dominant. In right-handed individuals, over 95% have left-sided dominance. Symptoms may include weakness on the opposite side of the body, particularly in the face and arm, as well as sensory loss and homonymous hemianopia. If the left MCA is affected, the patient may experience expressive dysphasia in the anterior MCA territory (Broca’s area) if it is their dominant side, or neglect if it is their non-dominant side. A tumour in the left cerebral hemisphere or thalamus would have a more gradual onset of symptoms, while an occlusion of the right anterior cerebral artery would produce left-sided weakness. The region affected and presentation of each type of artery involvement is summarized in a table.