Gynaecomastia may occur as a side effect of using GnRH agonists like goserelin for prostate cancer management. Tamoxifen can be prescribed to address gynaecomastia.

Understanding Gynaecomastia: Causes and Drug Triggers

Gynaecomastia is a medical condition that occurs when males develop an abnormal amount of breast tissue. This condition is usually caused by an increased ratio of oestrogen to androgen. It is important to differentiate the causes of galactorrhoea, which is due to the actions of prolactin on breast tissue, from those of gynaecomastia.

There are several causes of gynaecomastia, including physiological changes that occur during puberty, syndromes with androgen deficiency such as Kallman’s and Klinefelter’s, testicular failure, liver disease, testicular cancer, ectopic tumour secretion, hyperthyroidism, and haemodialysis. Additionally, certain drugs can trigger gynaecomastia, with spironolactone being the most common drug cause. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids.

It is important to note that while drug-induced gynaecomastia is rare, there are still some drugs that can trigger this condition. Some of the very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa. Understanding the causes and drug triggers of gynaecomastia can help individuals seek appropriate medical attention and treatment.

While acanthosis nigricans may occur on its own in individuals with dark skin, it is typically a sign of insulin resistance and associated conditions such as type 2 diabetes, polycystic ovarian syndrome, Cushing’s syndrome, and hypothyroidism. Certain medications, including corticosteroids, insulin, and hormone medications, can also cause this condition. If acanthosis nigricans appears suddenly and in unusual areas such as the mouth, it may indicate the presence of an internal malignancy, particularly gastric cancer.

Acanthosis nigricans is a condition characterized by the presence of symmetrical, brown, velvety plaques on the neck, axilla, and groin. This condition can be caused by various factors such as type 2 diabetes mellitus, gastrointestinal cancer, obesity, polycystic ovarian syndrome, acromegaly, Cushing’s disease, hypothyroidism, familial factors, Prader-Willi syndrome, and certain drugs like the combined oral contraceptive pill and nicotinic acid. The pathophysiology of acanthosis nigricans involves insulin resistance, which leads to hyperinsulinemia. This, in turn, stimulates the proliferation of keratinocytes and dermal fibroblasts through interaction with insulin-like growth factor receptor-1 (IGFR1).

The common peroneal nerve is a branch of the sciatic nerve that provides motor and sensory innervation to the lateral and anterior compartments of the leg, as well as the dorsum of the foot. Damage to this nerve, often caused by fibular neck fracture, results in footdrop and sensory loss in the affected areas.

The sciatic nerve, which originates from the lumbosacral plexus, innervates the posterior compartment of the thigh and indirectly innervates the posterior leg/calf muscles and some intrinsic muscles of the feet. It also provides sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Sciatica, a common condition that causes pain radiating down the leg, is often caused by irritation of the sciatic nerve root.

The posterior tibial nerve, another branch of the sciatic nerve, supplies motor innervation to the posterior compartment of the leg and sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Damage to this nerve, often caused by compression or trauma, results in ankle and sole of foot paraesthesiae.

The L5 root innervates muscles responsible for ankle and great toe dorsiflexion, hip abduction, and sensory innervation to the buttocks, posterolateral thigh, and lateral calf. L5 radiculopathy, which causes pain radiating from the lower back to the foot, is a common condition associated with damage to this root.

The deep peroneal nerve, a branch of the common peroneal nerve, innervates the muscles responsible for foot dorsiflexion and provides sensory innervation to the area between the first and second toes. Damage to this nerve, often caused by conditions such as LMD or diabetes, results in footdrop with minimal sensory loss and preserved eversion.

Differential diagnosis of spinal cord-related symptoms in cancer patients

Spinal cord-related symptoms can be a medical emergency in cancer patients, requiring prompt diagnosis and treatment. Several conditions can cause similar symptoms, including spinal cord compression, spinal tuberculosis, peripheral neuropathy secondary to carcinomatosis, paraneoplastic myelopathy, and secondary spinal tumor deposit.

Spinal cord compression is a common complication of metastatic cancer, especially from breast, bronchus, prostate, multiple myeloma, and high-grade non-Hodgkin’s lymphoma. The classic triad of symptoms includes bilateral leg weakness, sensory loss, and bladder/bowel dysfunction, but back pain may be absent or delayed. Imaging studies, such as plain radiographs and MRI, are essential for diagnosis, and treatment options include steroids, neurosurgery, and radiotherapy.

Spinal tuberculosis is a rare but serious infection that can affect the spine and cause bone or joint pain, back pain, or swelling. It usually requires a combination of antibiotics and surgery to cure.

Peripheral neuropathy secondary to carcinomatosis is a gradual and often mild onset of nerve damage caused by cancer cells or cancer treatments. It can present with various sensory, motor, or autonomic symptoms, depending on the location and extent of nerve involvement.

Paraneoplastic myelopathy is a rare but potentially severe neurological disorder that can occur in some cancer patients, especially those with small-cell or squamous cell lung cancer. It is caused by an abnormal immune response to cancer cells, leading to inflammation and damage to the spinal cord.

Secondary spinal tumor deposit is a less common cause of spinal cord-related symptoms than spinal cord compression, but it can also occur in cancer patients with metastatic disease. It may present with similar symptoms and require similar diagnostic and therapeutic approaches.

In summary, cancer patients with spinal cord-related symptoms should undergo a thorough evaluation to determine the underlying cause and appropriate management. Early recognition and treatment can improve outcomes and quality of life.

After giving birth, women need to use contraception only after 21 days.

As the woman in the question is only 14 days post-partum, she does not need emergency contraception. Therefore, the advice to her would be that emergency contraception is not necessary.

After giving birth, women need to use contraception after 21 days. The progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

The risk of Down’s syndrome is 1 in 1,000 at the age of 30, and this risk decreases by a factor of 3 for every 5 years.

Down’s Syndrome: Epidemiology and Genetics

Down’s syndrome is a genetic disorder that occurs when there is an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age. At 20 years old, the risk is 1 in 1,500, but by 45 years old, the risk increases to 1 in 50 or greater. To remember this, one can start with a risk of 1/1,000 at 30 years old and divide the denominator by 3 for every extra 5 years of age.

There are three main types of Down’s syndrome: nondisjunction, Robertsonian translocation, and mosaicism. Nondisjunction accounts for 94% of cases and occurs when the chromosomes fail to separate properly during cell division. The risk of recurrence is 1 in 100 if the mother is under 35 years old. Robertsonian translocation occurs when part of chromosome 21 attaches to another chromosome, usually chromosome 14. This accounts for 5% of cases and has a higher risk of recurrence if the mother or father is a carrier. Mosaicism accounts for 1% of cases and occurs when there are two genetically different populations of cells in the body.

In summary, Down’s syndrome is a genetic disorder that is more common with increasing maternal age. The risk of recurrence depends on the type of Down’s syndrome and whether the parents are carriers. It is important for individuals to understand the genetics and epidemiology of Down’s syndrome to make informed decisions about family planning.

When medical therapy fails to improve COPD exacerbations, patients should be given BiPAP non-invasive ventilation. Before starting non-invasive ventilation, an arterial blood gas should be taken. BiPAP delivers two different pressures for inhalation and exhalation, making it a useful tool for patients who need help with ventilation, such as those in type II respiratory failure. On the other hand, CPAP delivers one pressure setting and is more helpful in increasing oxygen saturation and intrathoracic pressure to reduce preload and cardiac workload in chronic heart failure or sleep apnea. While intravenous magnesium sulfate is part of the management for severe asthma exacerbation, there is currently insufficient evidence to support its use in COPD exacerbation. If non-invasive ventilatory support fails, intubation and ventilation may be necessary.

Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.

Common Elbow Pain Symptoms and Their Features

Elbow pain can be caused by various conditions, each with its own set of symptoms. Here are some common elbow pain symptoms and their features:

1. Lateral Epicondylitis (Tennis Elbow)
– Pain and tenderness localized to the lateral epicondyle
– Pain worsens on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
– Episodes typically last between six months and two years; patients tend to have acute pain for 6-12 weeks
– Pain aggravated by wrist flexion and pronation

2. Medial Epicondylitis (Golfer’s Elbow)
– Pain and tenderness localized to the medial epicondyle
– Pain aggravated by wrist flexion and pronation
– Symptoms may be accompanied by numbness/tingling in the fourth and fifth fingers due to ulnar-nerve involvement

3. Cubital Tunnel Syndrome
– Initially intermittent tingling in the fourth and fifth fingers
– Pain worsens when the elbow is resting on a firm surface or flexed for extended periods
– Later numbness in the fourth and fifth fingers with associated weakness

4. Carpal Tunnel Syndrome
– Pain worsens when the wrists are in complete flexion for at least 30 seconds
– The Phalen test is done to investigate its presence

5. Olecranon Bursitis
– Swelling over the posterior aspect of the elbow with associated pain, warmth, and erythema
– Typically affects middle-aged male patients

Understanding Common Symptoms of Elbow Pain

The best course of action to reduce sedation in a patient taking mirtazapine at a low dose (e.g. 15mg) is to increase the dose (e.g. to 45mg). Adding an SSRI or advising the patient to take mirtazapine on alternate days would not be ideal options. Halving the dose of mirtazapine may even worsen daytime somnolence. Stopping mirtazapine and switching to another medication is not recommended if the patient has responded well to mirtazapine.

Mirtazapine: An Effective Antidepressant with Fewer Side Effects

Mirtazapine is an antidepressant medication that functions by blocking alpha2-adrenergic receptors, which leads to an increase in the release of neurotransmitters. Compared to other antidepressants, mirtazapine has fewer side effects and interactions, making it a suitable option for older individuals who may be more susceptible to adverse effects or are taking other medications.

Mirtazapine has two side effects that can be beneficial for older individuals who are experiencing insomnia and poor appetite. These side effects include sedation and an increased appetite. As a result, mirtazapine is typically taken in the evening to help with sleep and to stimulate appetite.

Overall, mirtazapine is an effective antidepressant that is well-tolerated by many individuals. Its unique side effects make it a valuable option for older individuals who may have difficulty sleeping or eating.

Imaging Modalities for Multiple Sclerosis Diagnosis

To diagnose multiple sclerosis, imaging modalities are necessary to assess for acute demyelination and anatomical changes in the grey and white matter. The preferred imaging modality is magnetic resonance imaging (MRI) with contrast, which can visualize acute inflammatory changes and demyelinating lesions. Dopamine Active Transfer scan (DaTscan) is not useful for multiple sclerosis diagnosis but can confirm Parkinson’s disease. Computed tomography (CT) with contrast is best for vascular lesions, while CT without contrast is only appropriate for acute trauma. MRI without contrast is the second-best option but cannot differentiate between acute and chronic lesions. Both brain and spine should be imaged to avoid missing the lesion responsible for the patient’s symptoms.

Management of Otitis Externa: Recommended Actions and Guidelines

Otitis externa is a common condition that affects the outer ear canal. The management of this condition depends on the severity of the inflammation and the presence of other symptoms. Here are some recommended actions and guidelines for managing otitis externa:

1. Start topical antibiotic and steroid: This is recommended for patients with acute otitis externa who present with more severe inflammation. The treatment should last for seven days.

2. Start topical acetic acid 2% spray: This is recommended for patients with mild otitis externa who do not have hearing loss or discharge.

3. Refer to ENT urgently: This is not part of initial management but should be considered for patients with chronic diffuse otitis externa when treatment is prolonged beyond two to three months.

4. Start oral amoxicillin: Oral antibiotics are rarely indicated for otitis externa. They should only be considered for patients with severe infection or at high risk of severe infection.

5. Take an ear swab and start topical antibiotic: Ear swab is not recommended as first-line management. It should only be done if there is no response to initial treatment or in recurrent infections.

In summary, the management of otitis externa depends on the severity of the inflammation and the presence of other symptoms. Following these recommended actions and guidelines can help improve patient outcomes.

Category 2 caesarean sections should be performed within 75 minutes of the decision being made. This is because these cases involve maternal or fetal compromise that is not immediately life-threatening, allowing the medical team to manage the emergency and plan the surgery to minimize risks to both the mother and the baby. A timeframe of 2 hours is incorrect as it would delay the necessary intervention. On the other hand, a timeframe of 30 minutes is only applicable to category 1 caesarean sections, where there is an immediate threat to the life of the mother or baby. A timeframe of 5 minutes is too short and may increase the risk of errors during the procedure.

Caesarean Section: Types, Indications, and Risks

Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

It is common for newborn males to have communicating hydroceles, which usually resolve on their own. This is due to the processus vaginalis remaining open. Parents should be reassured that the hydroceles typically disappear within a few months. However, if the hydrocele persists beyond one year, it is recommended to refer the child to a urologist for possible repair. Ultrasound is not necessary to confirm the diagnosis. It is important to note that hydroceles do not impact fertility, but undescended testes can affect fertility if not treated.

Common Scrotal Problems and Their Features

Epididymal cysts, hydroceles, and varicoceles are the most common scrotal problems seen in primary care. Epididymal cysts are usually found posterior to the testicle and are separate from the body of the testicle. They may be associated with conditions such as polycystic kidney disease, cystic fibrosis, and von Hippel-Lindau syndrome. Diagnosis is confirmed by ultrasound, and management is usually supportive, although surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

Hydroceles, on the other hand, describe the accumulation of fluid within the tunica vaginalis. They may be communicating or non-communicating, and may develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors. Hydroceles are usually soft, non-tender swellings of the hemi-scrotum that transilluminate with a pen torch. Diagnosis may be clinical, but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated. Management depends on the severity of the presentation, with infantile hydroceles generally repaired if they do not resolve spontaneously by the age of 1-2 years.

Varicoceles, on the other hand, are abnormal enlargements of the testicular veins that are usually asymptomatic but may be associated with subfertility. They are much more common on the left side and are classically described as a bag of worms. Diagnosis is confirmed by ultrasound with Doppler studies, and management is usually conservative, although surgery may be required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility.

Hoover’s sign is a useful clinical tool that can quickly differentiate between organic and non-organic leg paresis. In cases of non-organic paresis, pressure is felt under the affected leg when the unaffected leg is lifted against pressure. This is due to involuntary contralateral hip extension.

Based on this scenario, the likely diagnosis is a conversion disorder, which is characterized by the loss of motor function in the leg without any organic cause. The positive result of Hoover’s sign supports this diagnosis.

Babinski’s sign is a reflex that involves dorsiflexion of the big toe upon plantar stimulation. It is indicative of an upper motor neuron lesion of the corticospinal tract.

Brudziński’s sign is a reflex that involves the flexion of the hips with forced flexion of the neck. It is typically associated with meningitis but can also be present in patients with subarachnoid hemorrhage and encephalitis.

The glabellar tap sign, also known as Myerson’s sign, involves tapping the area above the nose and between the eyebrows (glabella) repeatedly. Healthy patients usually blink in response to the first 2-3 taps, but if a patient is unable to resist blinking beyond this, it can be indicative of early Parkinson’s disease.

The straight leg raise test, also known as Lasègue’s sign, involves raising the straight leg to reproduce radiating leg pain. A positive result indicates a likely lumbar disc herniation.

Psychiatric Terms for Unexplained Symptoms

There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

The patient is likely suffering from frontotemporal dementia, which is also known as Pick’s disease. This type of dementia is characterized by a change in personality and social disinhibition, and it often has a positive family history. In contrast, Alzheimer’s disease typically presents with a decline in episodic memory and visuospatial awareness, while Lewy body dementia is characterized by fluctuating confusion and hallucinations. Creutzfeldt-Jakob disease is a rare condition that causes rapid neurodegeneration and may present with cognitive decline and personality changes, as well as additional symptoms such as abnormal movements and loss of coordination.

Understanding Frontotemporal Lobar Degeneration

Frontotemporal lobar degeneration (FTLD) is a type of cortical dementia that is the third most common after Alzheimer’s and Lewy body dementia. There are three recognized types of FTLD: Frontotemporal dementia (Pick’s disease), Progressive non-fluent aphasia (chronic progressive aphasia, CPA), and Semantic dementia. Common features of frontotemporal lobar dementias include onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems.

Pick’s disease is the most common type of FTLD and is characterized by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviors. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease. Macroscopic changes seen in Pick’s disease include atrophy of the frontal and temporal lobes. Microscopic changes include Pick bodies, spherical aggregations of tau protein (silver-staining), gliosis, neurofibrillary tangles, and senile plaques.

In contrast, CPA is characterized by non-fluent speech, with short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia, on the other hand, is characterized by fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s, memory is better for recent rather than remote events.

In terms of management, NICE does not recommend the use of AChE inhibitors or memantine in people with frontotemporal dementia. Understanding the different types of FTLD and their characteristics can aid in early diagnosis and appropriate management.

Biliary Colic and Other Abdominal Conditions: A Brief Overview

Biliary colic, diverticulitis, chronic pancreatitis, ulcerative colitis, and coeliac disease are all conditions that can cause abdominal pain and discomfort. Understanding the risk factors, symptoms, and diagnostic criteria for each can help healthcare professionals make accurate diagnoses and provide appropriate treatment. Biliary colic, for example, is characterized by severe, constant pain in the epigastrium or right upper quadrant, often accompanied by nausea and vomiting. Diverticulitis, on the other hand, typically presents with left lower quadrant pain and changes in bowel habits. Chronic pancreatitis is associated with intermittent attacks of severe pain in the mid-abdomen or left upper abdomen, while ulcerative colitis is characterized by rectal bleeding, frequent stools, and mucus discharge. Coeliac disease, the most common food intolerance worldwide, can present with a range of gastrointestinal and extraintestinal symptoms. By understanding the unique features of each condition, healthcare professionals can provide effective care and improve patient outcomes.

Cystic fibrosis is a genetic disorder that follows an autosomal recessive pattern of inheritance. The carrier frequency is estimated to be 1 in 25 individuals, while the prevalence of the disease is 1 in 2500 newborns. Having a positive family history is the only known risk factor for CF, and parents should receive appropriate counseling before conception or during pregnancy if they are carriers.

Understanding Cystic Fibrosis and the Organisms that Affect Patients

Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

Diagnostic Tests for Lower Limb Ischaemia

Lower limb ischaemia is a medical emergency that requires prompt diagnosis and treatment. Several diagnostic tests can be used to determine the cause and severity of the condition. Here are some of the most common tests:

1. Lower limb angiography: This test can identify the site of arterial occlusion and help plan the appropriate treatment, such as embolectomy or fasciotomy.
2. Focused assessment with sonography for trauma (FAST) scan of the abdomen: This test is useful in cases of trauma or suspected abdominal aortic aneurysm rupture.
3. Ankle-brachial pressure index (ABPI): This quick and easy test can provide an early indication of the severity of ischaemia. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.
4. Echocardiogram: This test can rule out a cardiac source of embolisation, but lower limb angiography is the priority in cases of acute ischaemia.
5. Lower limb Doppler: This test can be used to assess arterial or venous flow, depending on the suspected cause of ischaemia.

In summary, a combination of these diagnostic tests can help diagnose and treat lower limb ischaemia effectively.

To evaluate the effectiveness of treatment, a fasting lipid profile may be examined as part of the monitoring process.

Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.

Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.

Management of Sickle Cell Disease: Antibiotic Prophylaxis, B12 and Iron Supplementation, and Malaria Prophylaxis

Sickle cell disease is a condition that increases the risk of infections, particularly pneumococcal infections, respiratory tract infections, urinary tract infections, and osteomyelitis. To prevent severe infections or sepsis, the National Institute for Health and Care Excellence (NICE) recommends lifelong antibiotic prophylaxis with penicillin V or amoxicillin for people with sickle cell disease, starting ideally at three months of age. Pneumococcal vaccination every five years is also crucial. Co-amoxiclav is not the antibiotic of choice for prophylaxis. B12 supplementation is indicated only if a person with sickle cell disease has B12 deficiency. Folate supplementation is recommended for all people with sickle cell anaemia due to high folate turnover associated with haemolysis. Lifelong iron supplementation is not recommended unless there is proven iron deficiency that would require 3-month supplements rather than lifelong treatment. Finally, sickle cell disease does not protect against malaria, and people with sickle cell disease planning to travel to an area where malaria is endemic should take the standard recommended malaria prophylaxis for that area.

The base of the skull is made up of three bony fossae: the anterior, middle, and posterior. These structures provide support for various internal structures within the cranium. If these bones are fractured, it can result in damage to associated neurovascular structures, which can have external manifestations in areas such as the nasal cavity or auditory canal. Bleeding from ruptured vessels can lead to haemotympanum or Battle’s sign in the mastoid area, while ruptured CSF spaces can cause CSF rhinorrhoea and otorrhoea. Stellwag’s sign, on the other hand, is not related to base of skull trauma and refers to reduced blinking.

Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/frusemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.

Understanding Optic Neuritis: Symptoms and Differential Diagnosis

Optic neuritis is a condition that can be either idiopathic or secondary to multiple sclerosis. Patients with optic neuritis typically experience periocular pain associated with eye movement, as well as a loss of color vision. Visual field defects, such as a central scotoma, can also occur. If the other eye is uninvolved, there is typically a relative afferent pupillary defect.

It is important to differentiate optic neuritis from other conditions that can cause similar symptoms. A stroke, for example, would not typically cause eye pain or affect color vision. Acute-angle-closure glaucoma can also be ruled out if intraocular pressure is within the normal range. Cerebral venous thrombosis would usually cause sudden painless loss of vision with severe retinal hemorrhages on fundoscopy. In cases of raised intracranial pressure, papilledema would be seen in both optic discs.

Overall, understanding the symptoms and differential diagnosis of optic neuritis is crucial for proper diagnosis and treatment.

The patient’s hypertension, hypokalaemia, and hypernatremia suggest a diagnosis of hyperaldosteronism, where high levels of aldosterone cause increased water and sodium reabsorption in the kidneys and potassium loss. The recommended treatment for primary hyperaldosteronism due to bilateral adrenal disease is a mineralocorticoid antagonist, with spironolactone as the primary agent and eplerenone as an alternative. Losartan, an angiotensin receptor blocker, is an alternative to angiotensin-converting enzyme inhibitors for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. Nifedipine, a calcium-channel blocker, is a first-line drug for essential hypertension in patients aged 55 years or older or Afro-Caribbean patients. Perindopril, an ACEi, is a first-line drug for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. However, it is not appropriate for treating hyperaldosteronism, where spironolactone is the preferred option. Unilateral laparoscopic adrenalectomy is recommended for cases of hyperaldosteronism due to unilateral adrenal diseases, but not for bilateral adrenal disease like in this patient.

Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.

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.

Children born in areas with a high prevalence of tuberculosis (TB) or with parents/grandparents from such areas, as well as individuals under the age of 35 at high risk of occupational exposure to TB, are administered the BCG vaccine. However, there is no evidence to support the effectiveness of the BCG vaccine for individuals over the age of 35, and therefore it is not administered to them.

The BCG Vaccine: Who Should Get It and How It’s Administered

The Bacille Calmette-Guérin (BCG) vaccine is a vaccine that provides limited protection against tuberculosis (TB). In the UK, it is given to high-risk infants and certain groups of people who are at risk of contracting TB. The vaccine contains live attenuated Mycobacterium bovis and also offers limited protection against leprosy.

The Greenbook provides guidelines on who should receive the BCG vaccine. It is recommended for all infants living in areas of the UK where the annual incidence of TB is 40/100,000 or greater, as well as infants with a parent or grandparent who was born in a country with a high incidence of TB. The vaccine is also recommended for previously unvaccinated tuberculin-negative contacts of cases of respiratory TB, new entrants under 16 years of age who were born in or have lived for a prolonged period in a high-risk country, healthcare workers, prison staff, staff of care homes for the elderly, and those who work with homeless people.

Before receiving the BCG vaccine, any person being considered must first be given a tuberculin skin test, except for children under 6 years old who have had no contact with tuberculosis. The vaccine is given intradermally, normally to the lateral aspect of the left upper arm. It can be given at the same time as other live vaccines, but if not administered simultaneously, there should be a 4-week interval.

There are some contraindications for the BCG vaccine, including previous BCG vaccination, a past history of tuberculosis, HIV, pregnancy, and a positive tuberculin test (Heaf or Mantoux). It is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.

Childhood Vaccination Schedule in the UK

In the UK, childhood vaccinations are an important part of ensuring the health and wellbeing of children. Here is a breakdown of the vaccination schedule:

8, 12, and 16 weeks: The 6-in-1 vaccine is given as a single injection to protect against diphtheria, hepatitis B, Haemophilus influenza B, polio, tetanus, and pertussis. This vaccine is given at eight, 12, and 16 weeks old.

One year: At one year, children receive the MMR vaccine, Hib/Men C vaccine, and third dose of the meningitis B and pneumococcal vaccines.

8, 12, and 16 months: There are three doses given, however at eight, 12, and 16 weeks of age, not months.

24 months: From 2-9 years old, children will receive the annual flu vaccine via nasal spray.

It is important to follow the vaccination schedule to ensure that children are protected against serious illnesses. Talk to your healthcare provider for more information.

The symptoms of keratoconjunctivitis sicca include a sensation of dryness, burning, and grittiness in the eyes, which is caused by a reduction in the production of tears.

Rheumatoid Arthritis and Its Effects on the Eyes

Rheumatoid arthritis is a chronic autoimmune disease that affects various parts of the body, including the eyes. In fact, ocular manifestations of rheumatoid arthritis are quite common, with approximately 25% of patients experiencing eye problems. These eye problems can range from mild to severe and can significantly impact a patient’s quality of life.

The most common ocular manifestation of rheumatoid arthritis is keratoconjunctivitis sicca, also known as dry eye syndrome. This condition occurs when the eyes do not produce enough tears, leading to discomfort, redness, and irritation. Other ocular manifestations of rheumatoid arthritis include episcleritis, scleritis, corneal ulceration, and keratitis. Episcleritis and scleritis both cause redness in the eyes, with scleritis also causing pain. Corneal ulceration and keratitis both affect the cornea, with corneal ulceration being a more severe condition that can lead to vision loss.

In addition to these conditions, patients with rheumatoid arthritis may also experience iatrogenic ocular manifestations. These are side effects of medications used to treat the disease. For example, steroid use can lead to cataracts, while the use of chloroquine can cause retinopathy.

Overall, it is important for patients with rheumatoid arthritis to be aware of the potential ocular manifestations of the disease and to seek prompt medical attention if they experience any eye-related symptoms. Early diagnosis and treatment can help prevent vision loss and improve overall quality of life.

Pregnant women with bacterial conjunctivitis should use topical fusidic acid eye drops for treatment. It is not recommended to use chloramphenicol ointment or eye drops in pregnant patients. Oral antibiotics are typically unnecessary for treating bacterial conjunctivitis, and steroid eye drops are not effective. While viral conjunctivitis can be monitored without treatment, bacterial conjunctivitis requires prompt treatment with topical antibiotics to prevent a secondary bacterial infection.

Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.