If an adult with asthma is not able to control their symptoms with a short-acting beta agonist (SABA), the next step in their treatment plan should be to add a low-dose inhaled corticosteroid (ICS). This approach follows the guidelines set out by NICE for managing asthma.

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.

Investigations for Acute Interstitial Nephritis

Acute interstitial nephritis (AIN) can present with non-specific symptoms of acute kidney dysfunction, such as nausea, vomiting, and malaise. A decline in kidney function is typical, and a raised creatinine on U+ESs may already be present. A drug history, along with a raised eosinophilia on full blood count (FBC), can aid in the diagnosis of AIN. Common causes of AIN include drugs like proton-pump inhibitors, non-steroidal anti-inflammatories, and antibiotics, as well as autoimmune disorders or other systemic diseases.

Antinuclear antibody (ANA) testing should be performed to rule out systemic lupus erythematosus (SLE), which can coexist with AIN. However, a positive ANA test alone would not confirm a diagnosis of AIN.

Urinary dipstick testing for protein is not useful in diagnosing AIN, as patients with AIN typically do not have protein in their urine. Nephrotic syndrome can occur as a rare complication of AIN.

Renal biopsy may be necessary to confirm the diagnosis of AIN, as it is characterized by an inflammatory infiltrate in the kidney interstitium. However, if the patient’s condition is drug-induced, a renal biopsy may not be required if a raised creatinine and eosinophil count, along with the drug history, are sufficient for diagnosis.

Chest X-ray (CXR) may be necessary to investigate other potential causes of AIN, such as sarcoidosis. If sarcoidosis is suspected and the CXR is inconclusive, a computed tomography chest may be performed. However, if the patient has been exposed to a drug that predisposes them to AIN, a diagnosis of drug-induced interstitial nephritis is more likely than an underlying systemic disease.

Differential Diagnosis of Anaemia: Understanding the Causes

Anaemia is a common condition that can be caused by a variety of factors. Here, we will discuss some of the possible causes of anaemia and their corresponding laboratory findings.

Pernicious Anaemia: This type of anaemia is caused by a deficiency in vitamin B12 due to impaired intrinsic factor (IF) production. It is usually seen in adults aged 40-70 years and is characterized by megaloblastic changes in rapidly dividing cells. Anti-parietal cell antibodies are present in 90% of patients with pernicious anaemia. The Schilling test is useful in confirming the absence of IF. Treatment involves parenteral administration of cyanocobalamin or hydroxycobalamin.

Chronic Myeloid Leukaemia: CML is a myeloproliferative disorder that results in increased proliferation of granulocytic cells. Symptoms include fatigue, anorexia, weight loss, and hepatosplenomegaly. Mild to moderate anaemia is usually normochromic and normocytic. Diagnosis is based on histopathological findings in the peripheral blood and Philadelphia chromosome in bone marrow cells.

Iron Deficiency Anaemia: This type of anaemia is primarily a laboratory diagnosis and is characterized by microcytic and hypochromic erythropoiesis. It is caused by chronic iron deficiency and can be due to multiple causes, including chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate.

Crohn’s Disease: This chronic inflammatory process can affect any part of the GI tract and can cause anaemia due to chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate. However, the lack of GI symptoms in the clinical scenario provided is not consistent with a history of inflammatory bowel disease.

Autoimmune Hepatitis: This chronic disease is characterized by continuing hepatocellular inflammation and necrosis, with a tendency to progress to cirrhosis. Elevated serum aminotransferase levels are present in 100% of patients at initial presentation. Anaemia, if present, is usually normochromic. However, this clinical picture and laboratory findings are not consistent with the scenario given.

In conclusion, understanding the different causes of anaemia and their corresponding laboratory findings is crucial in making an accurate diagnosis and providing appropriate treatment.

The latest recommendations state that individuals should limit their alcohol consumption to no more than 14 units per week, regardless of gender. Additionally, it is suggested that individuals should spread out their drinking over a minimum of three days if they regularly consume 14 units per week.

Alcohol consumption guidelines were revised in 2016 by the Chief Medical Officer, based on recommendations from an expert group report. The most significant change was a reduction in the recommended maximum number of units of alcohol for men from 21 to 14, aligning with the guidelines for women. The government now advises that both men and women should not exceed 14 units of alcohol per week, and if they do, it is best to spread it evenly over three or more days. Pregnant women are advised not to drink alcohol at all, as it can cause long-term harm to the baby. One unit of alcohol is equivalent to 10 mL of pure ethanol, and the strength of a drink is determined by its alcohol by volume (ABV). Examples of one unit of alcohol include a 25ml single measure of spirits with an ABV of 40%, a third of a pint of beer with an ABV of 5-6%, and half a 175ml standard glass of red wine with an ABV of 12%. To calculate the number of units in a drink, multiply the number of millilitres by the ABV and divide by 1,000.

When a patient has normal blood tests except for low thyroid function, which is indicated by low TSH and low free-T4, and presents with symptoms of hypothyroidism, it may be a case of secondary hypothyroidism caused by pituitary failure. This is a rare condition that requires imaging of the pituitary gland to rule out any anatomical or vascular causes, such as a tumor.

Understanding the Causes of Hypothyroidism

Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.

In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.

Managing Asthma in Children: NICE Guidelines

Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

Sjögren syndrome is a condition characterized by dry eyes (keratoconjunctivitis sicca) and dryness in other areas such as the mouth, skin, or vagina. Enlargement of the salivary or parotid glands may also be present. Primary Sjögren syndrome occurs without any other autoimmune disease and is associated with HLA-B8/DR3 in about 50% of cases. Secondary Sjögren syndrome occurs in the presence of other autoimmune disorders, commonly rheumatoid arthritis (RA). Other symptoms may include arthralgia, Raynaud’s phenomenon, oesophageal dysmotility, vasculitis, polyneuropathy, and pulmonary diffusion defects and fibrosis. Diagnosis is based on the Schirmer tear test, Rose Bengal staining, and lab tests showing raised immunoglobulin levels, circulating immune complexes, and autoantibodies. Treatment is symptomatic with artificial tear and saliva replacement solutions, hydroxychloroquine, and corticosteroids if needed. Polymyositis, polyarteritis nodosa (PAN), mixed connective tissue disease (MCTD), and rheumatoid arthritis are other conditions that may present with similar symptoms but do not fit the clinical picture in this case.

To prevent the sebaceous cyst from recurring, it is necessary to surgically remove the entire structure. This can be done by a general practitioner or a surgical team, but funding for the procedure may be limited due to its lower clinical priority. Patients may opt to have the surgery done privately. Incision and drainage or fine needle aspiration may provide temporary relief, but the cyst is likely to return. Intralesional steroids are not recommended in this case, as there is no infection present. Oral antibiotics are also unnecessary. Complete surgical excision offers the best chance for long-term resolution of the patient’s symptoms.

Understanding Sebaceous Cysts

Sebaceous cysts refer to a group of cysts that include both epidermoid and pilar cysts. However, the term is not entirely accurate and should be avoided if possible. Epidermoid cysts occur when there is an overgrowth of epidermal cells in the dermis, while pilar cysts, also known as trichilemmal cysts or wen, originate from the outer root sheath of the hair follicle. These cysts can appear anywhere on the body, but are most commonly found on the scalp, ears, back, face, and upper arm, and will typically have a punctum.

To prevent recurrence, it is essential to remove the entire cyst wall during excision. While sebaceous cysts are generally harmless, they can become infected and cause discomfort or pain.

Assessing medications in elderly patients can be challenging, as they may be taking unnecessary or harmful drugs. The STOPP-START Criteria (Gallagher et al., 2008) provides guidance on medications that should be considered for discontinuation in the elderly. In this case, the patient has gout, which can be aggravated by bendroflumethiazide, an outdated thiazide diuretic that is no longer recommended by NICE. Additionally, her blood pressure is well below the target for her age, which is 150/90 mmHg in clinic. Ramipril is a more suitable antihypertensive medication to continue for now, but it may also be discontinued if her blood pressure remains low. The patient requires aspirin and atorvastatin for her ischemic heart disease, and allopurinol for her gout.

NICE Guidelines for Managing Hypertension

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

It is not recommended to prescribe anaesthetic eye drops to patients with corneal ulcers as it can potentially worsen the condition by slowing down the healing process.

Understanding Corneal Ulcers

A corneal ulcer is a condition that occurs when there is a defect in the cornea, which is usually caused by an infection. It is important to note that corneal abrasions, on the other hand, are typically caused by physical trauma. There are several risk factors that can increase the likelihood of developing a corneal ulcer, including contact lens use and vitamin A deficiency, which is particularly common in developing countries.

The pathophysiology of corneal ulcers can vary depending on the underlying cause. Bacterial, fungal, and viral infections can all lead to the development of a corneal ulcer. In some cases, contact lens use can also be associated with a type of infection called Acanthamoeba keratitis.

Symptoms of a corneal ulcer typically include eye pain, sensitivity to light, and excessive tearing. Additionally, a focal fluorescein staining of the cornea may be present.

Cavitating lung lesions can be caused by various factors, including infections and malignancies. In this case, the absence of a smoking history makes small cell and squamous cell lung cancers less likely. Small cell lung cancers typically affect the hilar or peri-hilar areas, while squamous cell lung cancers may present with pulmonary symptoms or paraneoplastic syndromes.

An aspergilloma is a fungal ball that forms in an existing lung cavity, often caused by conditions such as tuberculosis, lung cancer, or cystic fibrosis. While it may not cause any symptoms, it can lead to coughing and severe haemoptysis (coughing up blood). Diagnosis can be made through a chest x-ray, which will show a rounded opacity with a possible crescent sign, as well as high levels of Aspergillus precipitins. In some cases, a CT scan may also be necessary to confirm the presence of the aspergilloma.

Differential Diagnosis of a Patient with Depressive Symptoms

Depression is a common mental health condition that can present with a variety of symptoms. In this vignette, the patient shows signs of anhedonia, change in appetite, early morning awakening, psychomotor retardation, decreased sexual drive, poor concentration, ideas of worthlessness or guilt, and thoughts of death and suicide. To diagnose and classify depression, various assessment tools are available, such as the PHQ-9, Hospital Anxiety and Depression (HAD) Scale, and Beck Depression Inventory.

Other possible diagnoses that need to be ruled out include acute alcohol withdrawal, acute psychosis, hypomania, and schizophrenia. Acute alcohol withdrawal typically manifests with psychomotor agitation, anxiety, tremor, insomnia, nausea, vomiting, hallucinations, seizures, and autonomic instability. Delirium tremens is a severe complication of alcohol withdrawal that can be life-threatening. Acute psychosis is characterized by delusions, hallucinations, or thought disorder. Hypomania is a milder form of mania that features elated mood, pressure of speech, increased energy, activity, appetite, sexual desire, and pain threshold, but does not cause significant impairment. Schizophrenia is a chronic and severe mental disorder that involves a range of cognitive, emotional, and behavioral symptoms, including hallucinations, delusions, disorganized speech, and social withdrawal.

Therefore, a thorough evaluation of the patient’s history, physical examination, and mental status is necessary to arrive at an accurate diagnosis and develop an appropriate treatment plan. Collaborating with a mental health specialist may also be beneficial in managing complex cases of depression or other mental health conditions.

Alcohol consumption guidelines were revised in 2016 by the Chief Medical Officer, based on recommendations from an expert group report. The most significant change was a reduction in the recommended maximum number of units of alcohol for men from 21 to 14, aligning with the guidelines for women. The government now advises that both men and women should not exceed 14 units of alcohol per week, and if they do, it is best to spread it evenly over three or more days. Pregnant women are advised not to drink alcohol at all, as it can cause long-term harm to the baby. One unit of alcohol is equivalent to 10 mL of pure ethanol, and the strength of a drink is determined by its alcohol by volume (ABV). Examples of one unit of alcohol include a 25ml single measure of spirits with an ABV of 40%, a third of a pint of beer with an ABV of 5-6%, and half a 175ml standard glass of red wine with an ABV of 12%. To calculate the number of units in a drink, multiply the number of millilitres by the ABV and divide by 1,000.

Investigating and Diagnosing COPD

COPD is a condition that should be considered in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. To confirm a diagnosis of COPD, several investigations are recommended. These include post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, a full blood count to exclude secondary polycythaemia, and a calculation of body mass index (BMI).

The severity of COPD is categorized based on the post-bronchodilator FEV1/FVC ratio. If the ratio is less than 70%, the patient is diagnosed with COPD. The severity of the condition is then determined based on the FEV1 value. Stage 1 is considered mild, and symptoms should be present to diagnose COPD in these patients. Stage 2 is moderate, Stage 3 is severe, and Stage 4 is very severe.

It is important to note that measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction. The grading system for COPD severity has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is less than 0.7, the patient is classified as Stage 1 – mild.

If a child shows a preference for one hand before the age of 12 months, it may be a sign of cerebral palsy and should be addressed promptly. The appropriate course of action is to refer the child to a child development service for a comprehensive evaluation by a multidisciplinary team. Children with cerebral palsy typically receive specialized care from birth, but in some cases, the condition may be suspected in a primary care setting. According to NICE guidelines, delayed motor milestones such as not sitting by 8 months (adjusted for gestational age), not walking by 18 months (adjusted for gestational age), early asymmetry of hand function, and persistent toe-walking may indicate cerebral palsy. In this case, as the child is exhibiting hand preference before the age of 1 year and has a risk factor for cerebral palsy (low birth weight), an urgent referral is necessary. Other options are not appropriate and may delay diagnosis and treatment.

Common Developmental Problems and Possible Causes

Developmental problems can manifest in various ways, including referral points such as not smiling at 10 weeks, inability to sit unsupported at 12 months, and failure to walk at 18 months. Fine motor skill problems may also arise, such as abnormal hand preference before 12 months, which could indicate cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, as they can also be caused by environmental deprivation or general development delay.

It is important to recognize these developmental problems early on and seek appropriate interventions to address them. By doing so, children can receive the necessary support to reach their full potential and overcome any challenges they may face. With proper care and attention, many children with developmental problems can go on to lead happy and fulfilling lives.

Pregnant women at 16-32 weeks are given the option to receive the pertussis vaccine.

Whooping Cough: Causes, Symptoms, Diagnosis, and Management

Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.

Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.

Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.

To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.

Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.

Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and

If someone is stuck on the ground for an extended period after falling, they may develop rhabdomyolysis. This condition occurs when myoglobin, a toxic substance released from muscle tissue, damages the kidneys and causes acute kidney injury. Elevated levels of creatinine kinase and potassium are common indicators of rhabdomyolysis.

Rhabdomyolysis is a condition that may be presented in an exam scenario where a patient has experienced a fall or prolonged epileptic seizure and is discovered to have an acute kidney injury upon admission. The condition is characterized by a disproportionately elevated creatinine level, elevated creatine kinase (CK), myoglobinuria, hypocalcaemia (as myoglobin binds calcium), elevated phosphate (released from myocytes), hyperkalaemia (which may develop before renal failure), and metabolic acidosis. The causes of rhabdomyolysis include seizure, collapse or coma (such as an elderly patient collapsing at home and being found eight hours later), ecstasy use, crush injury, McArdle’s syndrome, and certain drugs, such as statins (especially if co-prescribed with clarithromycin).

The management of rhabdomyolysis involves administering intravenous fluids to maintain good urine output, and urinary alkalinization may be used in some cases. It is important to recognize the signs and symptoms of rhabdomyolysis early on to prevent further complications and ensure prompt treatment.

Medications for Urinary and Bowel Issues in Children

Overactive bladder and nocturnal enuresis are common urinary issues in children. Here are some medications that can be used to treat these conditions:

1. Oxybutynin: This medication relaxes the urinary smooth muscle and is used to treat overactive bladder in children over 5 years old.

2. Imipramine: A tricyclic antidepressant that is used as a second-line treatment for nocturnal enuresis.

3. Desmopressin: A vasopressin analogue that can be used to treat nocturnal enuresis in children.

4. Duloxetine: A serotonin and noradrenaline reuptake inhibitor (SNRI) used to treat stress urinary incontinence in women. It is not licensed for use in individuals under 18 years old.

In addition, loperamide is an opioid antimotility drug that can be used to treat diarrhoea caused by gastroenteritis or inflammatory bowel disease.

If all emergency measures fail to stop epistaxis, sphenopalatine ligation in a surgical setting may be necessary.

To manage epistaxis in an emergency, it is important to provide adequate first aid for at least 20 minutes by firmly squeezing both nasal ala and sitting forward. Ice in the mouth can also be helpful. Topical adrenaline and local anaesthetic, as well as topical tranexamic acid, can be applied. If these measures are unsuccessful, nasal packing with devices such as Rapid Rhino may be necessary. If the bleeding persists, a posterior pack or Foley catheter may be used. In cases where all of these measures fail, surgical intervention such as sphenopalatine artery ligation may be required.

Understanding Epistaxis: Causes and Management

Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.

Most cases of epistaxis are benign and self-limiting. However, certain factors can exacerbate the condition, such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia. Other causes include the use of cocaine, hereditary haemorrhagic telangiectasia, and granulomatosis with polyangiitis.

If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves asking the patient to sit with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Patients should be advised to avoid activities that increase the risk of re-bleeding.

In cases where emergency management fails, sphenopalatine ligation in theatre may be required. Patients with unknown or posterior sources of bleeding should be admitted to the hospital for observation and review. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing this condition.

Autoimmune Diseases: Understanding the Causes and Symptoms

Autoimmune diseases are conditions where the body’s immune system mistakenly attacks its own tissues. Here are some examples of autoimmune diseases and their causes and symptoms:

Coeliac Disease: This disease is caused by gluten sensitivity and results in chronic diarrhoea, weight loss, and fatigue. It is caused by an autoimmune reaction to glutenin or gliadin, which are gluten proteins found in wheat.

Pemphigus Vulgaris: This rare autoimmune disease causes blistering to the skin and mucosal surfaces. It is caused by autoantibodies against desmoglein.

Graves’ Disease: This autoimmune disease of the thyroid results in hyperthyroidism. It is associated with anti-thyroid-stimulating hormone receptor antibodies.

Systemic Lupus Erythematosus (SLE): SLE is a multisystem autoimmune disease associated with a wide number of autoantibodies, including anti-nuclear antibody (ANA), anti-double-stranded (ds) DNA, anti-Smith, anti-SSA, anti-ribosomal P, anti-RNP, and anti-histone antibodies.

Type I Diabetes Mellitus (T1DM): T1DM is an autoimmune disease resulting in destruction of the islet cells. Islet cell autoantibodies and antibodies to insulin have been described.

Understanding the causes and symptoms of autoimmune diseases can help with early diagnosis and treatment.

Understanding Pityriasis Versicolor

Pityriasis versicolor, also known as tinea versicolor, is a fungal infection that affects the skin’s surface. It is caused by Malassezia furfur, which was previously known as Pityrosporum ovale. This condition is characterized by patches that may be hypopigmented, pink, or brown, and it is most commonly found on the trunk. The patches may become more noticeable following a suntan, and scaling is a common symptom. Mild pruritus may also occur.

Pityriasis versicolor can affect healthy individuals, but it is more likely to occur in those who are immunosuppressed, malnourished, or have Cushing’s syndrome. Treatment typically involves the use of topical antifungal medications, with ketoconazole shampoo being the recommended option due to its cost-effectiveness for larger areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed. Scrapings may also be sent for confirmation of the diagnosis. Understanding the features, predisposing factors, and management of pityriasis versicolor can help individuals recognize and effectively treat this common fungal infection.

Understanding the Causes of Hearing Loss: A Comparison of Otosclerosis, Cholesteatoma, Ménière’s Disease, Otitis Externa, and Otitis Media

Hearing loss can be caused by a variety of factors, including otosclerosis, cholesteatoma, Ménière’s disease, otitis externa, and otitis media. When conducting a differential diagnosis, it is important to consider the patient’s age, symptoms, and medical history.

Otosclerosis is a common cause of hearing loss in young adults, typically presenting as unilateral conductive hearing loss that progresses bilaterally. A negative Rinne’s test is indicative of conductive deafness, and a pink tinge on the tympanic membrane (Schwartz’s sign) is a diagnostic indicator for otosclerosis.

Cholesteatoma, on the other hand, typically presents with unilateral conductive hearing loss and/or ear discharge. Given the patient’s bilateral symptoms and young age, cholesteatoma is less likely to be the cause of her hearing loss.

Ménière’s disease is characterized by sudden attacks of tinnitus, vertigo, a sensation of fullness in the ear, and fluctuating sensorineural hearing loss. This is not the likely cause of the patient’s conductive hearing loss.

Otitis externa is inflammation of the external ear canal, which can cause hearing loss in rare cases due to occlusion of the ear canal from inflammation. Otitis media, on the other hand, is inflammation of the middle ear and is more commonly seen in children. It may present with unilateral conductive deafness, but is unlikely to be the cause of the patient’s bilateral symptoms.

In conclusion, when considering the causes of hearing loss, it is important to take into account the patient’s age, symptoms, and medical history. Otosclerosis is the most likely cause of conductive hearing loss in young adults, while cholesteatoma, Ménière’s disease, otitis externa, and otitis media may also be potential causes depending on the individual case.

The CD4 count is a reliable way to measure the immune system’s response to HIV infection. In HIV-negative individuals, the CD4 count is usually maintained above 600-800 cells/µl. However, without antiretroviral therapy, HIV-positive individuals will experience a gradual decline in CD4 count over time. A CD4 count of less than 350 cells/µl increases the risk of opportunistic infections, while a count of less than 200 cells/µl indicates an 80% risk of developing an OI within three years. Some patients may remain well despite having a low CD4 count, depending on viral load and host immunity factors. Different OIs are more likely at different CD4 counts. The World Health Organization now recommends starting ART in every HIV-positive individual, regardless of CD4 count.

A CXR is usually normal in HIV-positive individuals without chronic respiratory disorders. Blood cultures may help diagnose an OI, but do not estimate the risk of developing OIs. HIV-positive individuals often have an abnormal FBC, but this does not help with risk assessment for OIs. TST is used to check for immunity to TB and diagnose LTBI. HIV-positive individuals are at higher risk of TB disease, but may have a muted response to TST due to their compromised immunity. TST can be useful in assessing eligibility for isoniazid preventive therapy, but not in assessing disease stage and risk of OIs in general.

Breastfeeding is classified as UKMEC category 4 if done for less than 6 weeks after giving birth, but it is categorized as UKMEC category 2 if done after this period.

The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

Diagnostic Tests for a Patient with Suspected Type II Diabetes Mellitus

Computed Tomography (CT) Abdomen:
A CT abdomen is recommended for any patient over the age of 60 with weight loss combined with a new onset of diabetes or abdominal or back pain, nausea, vomiting or change in bowel habit. This is because new-onset type II diabetes can be a presenting feature of pancreatic cancer in patients over the age of 60, especially those who have also experienced weight loss.

Pancreatic Autoantibodies:
Pancreatic autoantibodies include anti-glutamic acid decarboxylase, insulin autoantibodies and islet-cell antibodies, the presence of which would support a diagnosis of type I diabetes. These tests are usually carried out in secondary care for atypical presentations such as suspected type II diabetes in a child or a non-overweight person.

Glucose Tolerance Test:
Glucose tolerance test has a limited role in diagnosing type II diabetes now that HbA1c is an accepted diagnostic investigation. It is still used routinely to investigate pregnant women at risk of gestational diabetes.

Short Synacthen Test:
A short synacthen test is used to diagnose adrenal insufficiency. The history and investigation results do not suggest this as a likely diagnosis, so this test would not be indicated.

Ultrasound of the Urinary Tract:
Ultrasound is not indicated unless a structural problem is suspected. Although this man is experiencing polyuria, his urinalysis and PSA are both normal, which makes a urological cause for his symptoms less likely than the newly diagnosed diabetes. Diabetes can cause renal impairment, but this should be monitored with annual urine albumin : creatinine measurement and regular U&Es blood test.

Common Neonatal Gastrointestinal Disorders

There are several common gastrointestinal disorders that can affect newborns. These include pyloric stenosis, necrotising enterocolitis (NEC), congenital duodenal atresia, Hirschsprung’s disease, and tracheoesophageal fistula (TOF).

Pyloric stenosis is characterised by hypertrophy of the circular pyloric muscle, and typically presents with non-bilious, projectile vomiting in the third or fourth week of life. Constipation and dehydration may also occur, and biochemistry may show hypokalaemic metabolic alkalosis. Boys are more likely to be affected, especially if born into a family with affected girls.

NEC is a condition primarily seen in premature infants, where portions of the bowel undergo necrosis. Symptoms include bilious vomiting, distended abdomen, and bloody stools, with late signs including bowel perforation and multi-organ failure.

Congenital duodenal atresia is a congenital absence or complete closure of a portion of the lumen of the duodenum, and presents with bile-stained vomiting, abdominal distension, and inability to pass meconium.

Hirschsprung’s disease is characterised by the failure of ganglion cells to migrate into the hindgut, leading to functional intestinal obstruction. Symptoms include abdominal distension, bile-stained vomiting, and failure to pass meconium.

TOF refers to a communication between the trachea and oesophagus, usually associated with oesophageal atresia. Symptoms include choking, coughing, and cyanosis during feeding, excess mucus, and recurrent lower respiratory tract infections. Other congenital anomalies may also be present.

Overall, early recognition and management of these neonatal gastrointestinal disorders is crucial for optimal outcomes.

To manage symptoms in individuals with non-CF bronchiectasis, a combination of inspiratory muscle training and postural drainage can be effective.

Managing Bronchiectasis

Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency. The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease. The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.

Spacing:

Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency.

The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease.

The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.

Diagnostic Tests for Bacterial Vaginosis and Urinary Tract Infections

Bacterial vaginosis is a common vaginal infection caused by an overgrowth of Gardnerella vaginalis. The diagnosis of bacterial vaginosis is based on Amsel’s criteria, which includes thin, white-colored vaginal discharge, vaginal pH > 4.5, positive whiff test, and clue cells on microscopy. A vaginal swab for microscopy and culture is needed to confirm the diagnosis, especially if the patient meets two of the four criteria.

On the other hand, urine microscopy and culture are used to diagnose urinary tract infections, which share some symptoms with sexually transmitted infections. However, the presence of vaginal discharge makes a sexually transmitted infection more likely, and alternative investigations are more specific.

Blood culture and hysteroscopy and culture are not indicated in the diagnosis of bacterial vaginosis. Blood culture is not usually necessary, while hysteroscopy and biopsy are invasive procedures used to diagnose endometrial disorders.

Lastly, nucleic acid amplification testing is used to diagnose chlamydia, the most common sexually transmitted disease. Although chlamydia may cause symptoms similar to bacterial vaginosis, the presence of increased vaginal pH makes bacterial vaginosis more likely.

The appropriate surgical procedure for a patient with caecal, ascending or proximal transverse colon cancer is a right hemicolectomy. This involves removing the cecum, ascending colon, and proximal third of the transverse colon. If the cancer is located at the hepatic flexure, an extended right hemicolectomy may be necessary. Hartmann’s procedure is reserved for emergencies such as bowel obstruction or perforation and involves complete resection of the rectum and sigmoid colon with the formation of an end colostomy. A high anterior resection is used for upper rectal tumors, while a left hemicolectomy is used for distal two-thirds of the transverse colon and descending colon tumors. A low anterior resection is used for low rectal tumors, but none of these procedures are appropriate for a patient with a mass in the hepatic flexure.

Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Understanding Carpal Tunnel Syndrome: Symptoms and Examination Findings

Carpal tunnel syndrome (CTS) is a condition caused by compression of the median nerve in the carpal tunnel. One of the symptoms of CTS is the wasting of the thenar eminence, which is innervated by the median nerve. It is important to note that the hypothenar eminence, which is innervated by the ulnar nerve, is not affected by CTS.

During examination, weakness of thumb abduction (abductor pollicis brevis) is a common finding in CTS. Tapping along the problematic nerve causes paraesthesia, which is known as Tinel’s sign. Flexion of the wrist also causes symptoms, which is known as Phalen’s sign.

Treatment for CTS may include a corticosteroid injection, wrist splints at night, and surgical decompression through flexor retinaculum division.

Overall, understanding the symptoms and examination findings of CTS can help with early diagnosis and appropriate treatment.