Understanding Postpartum Mental Health: Depression, Psychosis, and Maternity Blues

Postpartum mental health can be a challenging experience for new mothers. Within the first year of pregnancy, postpartum depression can occur, which is similar to major depression at other times of life. However, postpartum psychosis is a severe mental illness that usually occurs suddenly within the first two weeks after delivery and is often associated with confusion and disorientation. While delusions of something being wrong with the baby are relatively common in postpartum psychosis, depression is also associated with anxiety about the baby.

On the other hand, maternity blues is relatively common and occurs within a few days of delivery. It consists of irritability and tearfulness without features of a major depressive episode. It is essential to understand the differences between these conditions to provide appropriate support and treatment for new mothers.

It is worth noting that there is no mention of schizophrenia in this woman’s history or any suggestion of current illicit drug use. By understanding the different types of postpartum mental health conditions, we can better support new mothers and ensure they receive the care they need.

Common Rashes and Their Characteristics

Roseola infantum is a viral infection caused by herpesvirus 6. It is known to cause a rash with lymphadenopathy. The rash is macular in nature and is usually seen in infants and young children.

Erythema multiforme is a skin condition that causes target lesions with blistering. It is often caused by an allergic reaction to medication or an infection.

Idiopathic thrombocytopenia is a condition that causes a petechial rash. This rash is caused by a low platelet count and can be seen in individuals of all ages.

Henoch-Schönlein purpura is a condition that causes a purpuric rash on the buttocks and lower limbs. It is often seen in children and is caused by inflammation of the blood vessels.

Meningococcal septicaemia is a serious bacterial infection that can cause a non-blanching purpuric rash. This rash is a medical emergency and requires immediate treatment.

To manage poorly controlled hypertension in a patient who is already taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic with a potassium level of >4.5mmol/l, the appropriate medication to add would be an alpha- or beta-blocker. Bisoprolol is the correct choice in this scenario. Furosemide is not indicated for hypertension alone, and indapamide is contraindicated as the patient is already taking a thiazide-like diuretic. While an ARB like losartan could replace an ACE inhibitor, it should not be used in combination with one. Spironolactone is not the appropriate choice as the patient’s potassium level is already elevated.

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 calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Referral Criteria for Breast Cancer Screening

Breast cancer is a serious health concern that affects many individuals worldwide. To ensure early detection and prompt treatment, it is important to identify individuals who are at a higher risk of developing breast cancer. The following referral criteria have been established to identify individuals who should be referred to secondary care for breast cancer screening:

– One first degree female relative diagnosed with breast cancer under the age of 40 years
– One first degree male relative diagnosed with breast cancer at any age
– One first degree relative with bilateral breast cancer where the first primary was diagnosed under the age of 50 years
– Two first degree relatives, or one first degree and one second degree relative, diagnosed with breast cancer at any age
– One first degree or second degree relative diagnosed with breast cancer at any age and one first degree or second degree relative diagnosed with ovarian cancer at any age (one of these should be a first degree relative)
– Three first degree or second degree relatives diagnosed with breast cancer at any age.

By identifying individuals who meet these criteria, healthcare providers can ensure that they receive appropriate screening and monitoring for breast cancer. Early detection and treatment can significantly improve outcomes and reduce the risk of complications associated with breast cancer.

The baby is displaying signs that suggest infantile colic, which typically begins in the first few weeks of life and resolves by 3-4 months of age. The crying usually occurs in the late afternoon or evening, and the baby may arch their back or draw their knees up to their abdomen while crying. The symptoms appear to be ongoing but occasional, as the baby is happy during the day.

Although antimuscarinics have been shown to be effective, they come with serious adverse effects and are not recommended. Simeticone (Infacol) is commonly used, but there is no evidence to support its use and it is not recommended by CKS. Gaviscon is not necessary as there is no indication of gastro-oesophageal reflux. Low-lactose formula and paracetamol are also not recommended.

Since the baby is happy during the day, it is unlikely that they have cow’s milk protein allergy, which is rare in breastfed infants. Therefore, there is no need for the mother to exclude dairy from her diet.

Understanding Infantile Colic

Infantile colic is a common condition that affects infants under three months old. It is characterized by excessive crying and pulling up of the legs, usually worse in the evening. This condition affects up to 20% of infants, and its cause is unknown.

Despite its prevalence, the use of simeticone and lactase drops is not recommended by NICE Clinical Knowledge Summaries. These drops are commonly used to alleviate the symptoms of infantile colic, but their effectiveness is not supported by evidence. Therefore, it is important to seek medical advice before using any medication to treat infantile colic.

Immunisations in Pregnancy

Pregnant women are advised to get immunised against influenza and pertussis, but there are some differences to note. The influenza vaccine is recommended during flu season and can be taken at any stage of pregnancy. On the other hand, the pertussis vaccine is recommended from 16 weeks and can be taken at any time of the year.

It is important for candidates to understand these differences and advise their patients accordingly. While there is no specific recommendation to immunise healthy pregnant women against HPV, MenACWY or pneumococcus, it is always best to consult with a healthcare professional to determine the best course of action for each individual case. By staying informed and up-to-date on immunisation recommendations, candidates can provide the best care for their patients during pregnancy.

In statistical hypothesis testing, a type I error occurs when the null hypothesis is rejected when it is actually true. This is also known as a false positive. For example, if a student found a significant effect of previous covid-19 infection on task performance when there actually was no effect, this would be a type I error.

A false negative, on the other hand, is when no significant result is found when there actually is one. This is the same as a type II error. For instance, if the student found no effect of previous covid-19 infection on task performance when actually there was an effect, this would be a false negative or a type II error.

Sampling errors can occur when there is a systematic error in recruiting research participants, resulting in a sample population that is not representative of the population to which the results will be applied. However, there is no indication that this is the case in this scenario.

A type II error occurs when the null hypothesis is accepted when it is actually false. In this case, if the student found no effect of previous covid-19 infection on task performance when later research demonstrates there is an effect, this would be a type II error.

Finally, a type III error is not commonly used. It occurs when the null hypothesis is rejected correctly but for the wrong reason.

Significance tests are used to determine the likelihood of a null hypothesis being true. The null hypothesis states that two treatments are equally effective, while the alternative hypothesis suggests that there is a difference between the two treatments. The p value is the probability of obtaining a result by chance that is at least as extreme as the observed result, assuming the null hypothesis is true. Two types of errors can occur during significance testing: type I, where the null hypothesis is rejected when it is true, and type II, where the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

Facial Pain Syndromes: Types and Characteristics

Facial pain syndromes are a group of conditions that cause pain in the face and head. Here are some of the most common types and their characteristics:

Trigeminal Neuralgia: This syndrome causes recurrent and chronic pain that is usually unilateral and follows the sensory distribution of the trigeminal nerve. The pain is often accompanied by a brief facial spasm or tic and is triggered by activities such as eating, brushing teeth, or exposure to cold air. Carbamazepine is the drug of choice for treatment.

Atypical Facial Pain: This syndrome is more common than trigeminal neuralgia and is characterized by mild-to-moderate throbbing dull pain that can last for hours or days. It is precipitated by stress or cold and tends to occur along the territory of the trigeminal nerve. Patients are often misdiagnosed or attribute the pain to a prior event such as a dental procedure. Depression and anxiety are common.

Cluster Headaches: These headaches are usually unilateral and last longer than other facial pain syndromes. They are accompanied by conjunctival injection and a watering eye.

Migraine: Migraines are also usually unilateral and last longer than other facial pain syndromes. They are accompanied by photophobia and gastrointestinal symptoms.

Temporomandibular Joint Dysfunction: This syndrome is relatively common and is characterized by facial pain, restricted jaw function, and joint noise. Pain located in front of the tragus, projecting to the ear, temple, cheek, and along the mandible is highly diagnostic for TMJ dysfunction. Pain is chronic rather than spasmodic.

In conclusion, facial pain syndromes can be difficult to diagnose and treat. It is important to seek medical attention if you are experiencing any type of facial pain.

Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

Medications for Alcohol Withdrawal: Types and Uses

Alcohol withdrawal can be a challenging process, and medications are often used to manage symptoms and prevent complications. Here are some common medications used for alcohol withdrawal:

Chlordiazepoxide: This long-acting benzodiazepine is used to reduce withdrawal symptoms in people with moderate alcohol dependence.

Lorazepam: For people with liver impairment, lorazepam is suggested as it requires limited liver metabolism. It is also used intravenously for alcohol withdrawal seizures.

Acamprosate: This medication is effective in preventing relapse in patients with alcohol dependence.

Clomethiazole: While licensed for use in acute alcohol withdrawal, benzodiazepines are preferred. Clomethiazole should only be used in an inpatient setting and not prescribed if the patient is likely to continue drinking alcohol.

Haloperidol: Antipsychotic drugs like haloperidol or olanzapine may be prescribed as adjunctive therapy to benzodiazepines for patients with marked agitation or hallucinations and those at risk of delirium tremens.

It is important to note that these medications should only be used under the guidance of a healthcare professional and in conjunction with other forms of treatment, such as therapy and support groups.

Emergency Treatment in Primary Care

Potentially life-threatening situations are rare in primary care, but prompt action by a vigilant GP can save lives. Both NICE/CKS and the BNF are reference sources for the AKT exam, and they recommend admitting the person to the hospital as an emergency by calling 999. Treatment should not delay transfer to the hospital, and a single dose of parenteral benzylpenicillin should be administered as soon as possible, provided that it doesn’t delay urgent transfer to the hospital.

Emergency treatment is a crucial topic for the exam, and candidates have performed poorly in the past. It is essential to have benzylpenicillin, a suitable diluent, needles and syringes, and to be familiar with the correct doses for the age range. It is also crucial to ensure that the medicines in the emergency drug bag have not expired and to know who pays for them. More general GP admin and management issues appear to be a weak area for Registrars. If you are unsure about any of the questions posed, ask your trainer who pays for emergency drugs and whether the cost can be claimed back.

Statin-Associated Myopathy and Drug Interactions

Statin-associated myopathy is a potential side effect that affects up to 5% of individuals taking statins. This condition can be exacerbated by the co-prescription of certain drugs, including calcium channel blockers, macrolide antibiotics, fibrates, amiodarone, and grapefruit juice. Even patients who tolerate statins well may experience myopathy or rhabdomyolysis when these agents are added to their treatment regimen.

It is important for healthcare providers to be aware of these potential drug interactions and to monitor patients closely for signs of myopathy. Additionally, NICE guidance on Myocardial infarction: secondary prevention (NG185) advises against the use of omega-3 capsules to prevent another MI. By staying informed and following evidence-based guidelines, healthcare providers can help ensure the safety and well-being of their patients.

Hepatitis B and Pregnancy: Screening and Prevention

During pregnancy, all women are offered screening for hepatitis B. If a woman is found to be chronically infected with hepatitis B or has had acute hepatitis B during pregnancy, her baby should receive a complete course of vaccination and hepatitis B immunoglobulin. Studies are currently being conducted to evaluate the effectiveness of oral antiviral treatment, such as Lamivudine, in the latter part of pregnancy.

There is little evidence to suggest that a caesarean section reduces the transmission rates of hepatitis B from mother to baby. It is important to note that hepatitis B cannot be transmitted through breastfeeding, unlike HIV. Therefore, mothers with hepatitis B can safely breastfeed their babies without fear of transmission.

Overall, screening for hepatitis B during pregnancy and taking appropriate preventative measures can greatly reduce the risk of transmission from mother to baby. It is important for healthcare providers to educate pregnant women about the importance of screening and prevention to ensure the health and safety of both mother and baby.

Understanding Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a condition that affects the bile ducts, causing inflammation and fibrosis. The cause of this disease is unknown, but it is often associated with ulcerative colitis, with 4% of UC patients having PSC and 80% of PSC patients having UC. Crohn’s disease and HIV are also less common associations.

Symptoms of PSC include cholestasis, jaundice, pruritus, raised bilirubin and ALP levels, right upper quadrant pain, and fatigue. To diagnose PSC, doctors typically use endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), which show multiple biliary strictures giving a ‘beaded’ appearance. A positive p-ANCA test may also be indicative of PSC.

Liver biopsy may show fibrous, obliterative cholangitis, often described as ‘onion skin’, but it has a limited role in diagnosis. Complications of PSC include an increased risk of cholangiocarcinoma (in 10% of cases) and colorectal cancer.

Overall, understanding the symptoms, associations, and diagnostic methods for PSC is crucial for early detection and management of this condition.

Unruptured Abdominal Aortic Aneurysm: Symptoms, Risks, and Treatment Options

Abdominal Aortic Aneurysm (AAA) is a condition that often goes unnoticed due to the lack of symptoms. It is usually discovered incidentally during abdominal examinations or scans. However, bimanual palpation of the supra-umbilical region can detect a significant number of aneurysms. While most patients do not experience any pain, severe lumbar pain may indicate an impending rupture. The risk of rupture increases with the size of the aneurysm, with an annual rupture rate of 0.5-1.5% for aneurysms between 4.0 and 5.5 cm, and 5-15% for those between 5.5 and 6.0 cm.

The natural history of a small AAA is gradual expansion, with an annual rate of approximately 10% of the initial arterial diameter. The mortality rate from a ruptured AAA is high, at 80%. However, elective repair can significantly reduce the risk of rupture. The overall mortality rate for elective repair in the UK is 2.4%, with a lower mortality rate for endovascular aneurysm repair (EVAR) than open surgery.

It is important for drivers to notify the DVLA of any AAA, as it may affect their ability to drive. Group 1 drivers should notify the DVLA of an aneurysm >6 cm, while >6.5 cm would disqualify them from driving. Group 2 drivers should notify the DVLA of an aneurysm of any size, and an aortic diameter >5.5 cm would disqualify them from driving.

In conclusion, while most patients with unruptured AAA do not experience any symptoms, it is important to be aware of the risks and treatment options. Early detection and elective repair can significantly reduce the risk of rupture and improve outcomes.

Parotid Tumour with Facial Palsy

The presence of a hard, nodular mass over the tail of the parotid gland and facial palsy strongly suggest a parotid tumour with nerve infiltration. Urgent referral to a hospital for surgical review and possible biopsy under ultrasound guidance is necessary. Unfortunately, facial nerve function recovery is unlikely.

There is no indication of zoster infection or underlying inflammation, so aciclovir and prednisolone are not appropriate treatments. Sialography is useful for investigating salivary gland ducts and stones, but not for neoplastic disease.

Lactational Amenorrhoea Method (LAM) as a Contraceptive

Breastfeeding can be used as a form of contraception through the lactational amenorrhoea method (LAM). This method works by suppressing ovarian activity, which prevents the return of menstrual periods after childbirth. For LAM to be effective, a woman must engage in full breastfeeding, which includes exclusive or almost exclusive breastfeeding with no other liquids or solids given.

If the frequency or duration of breastfeeding decreases, the risk of menstrual periods and fertility increases. Women who experience bleeding within the first six months after childbirth have a higher risk of pregnancy than those who remain amenorrhoeic. To use LAM as a contraceptive, a woman must meet all three criteria: fully or nearly fully breastfeeding day and night, no long intervals between feeds, and amenorrhoeic and less than six months postpartum.

When the rules of LAM are strictly followed, failure rates are less than 2%. Therefore, LAM can be an effective and natural form of contraception for women who choose to breastfeed their infants.

Understanding Haemochromatosis: Investigation and Management

Haemochromatosis is a genetic disorder that causes iron accumulation in the body due to mutations in the HFE gene. The best investigation to screen for haemochromatosis is still a topic of debate. For the general population, transferrin saturation is considered the most useful marker, while genetic testing for HFE mutation is recommended for testing family members. Diagnostic tests include molecular genetic testing for the C282Y and H63D mutations and liver biopsy using Perl’s stain.

A typical iron study profile in patients with haemochromatosis includes high transferrin saturation levels, raised ferritin and iron, and low TIBC. The first-line treatment for haemochromatosis is venesection, which involves removing blood from the body to reduce iron levels. Transferrin saturation should be kept below 50%, and the serum ferritin concentration should be below 50 ug/l to monitor the adequacy of venesection. If venesection is not effective, desferrioxamine may be used as a second-line treatment. Joint x-rays may also show chondrocalcinosis, which is a characteristic feature of haemochromatosis.

It is important to note that there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene. As HFE gene analysis becomes less expensive, guidelines for investigating and managing haemochromatosis may change.

The man in question is displaying symptoms of acute anterior uveitis, which can be caused by a variety of underlying systemic diseases or may be idiopathic. Non-granulomatous uveitis is often associated with diseases related to HLA-B27, such as ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, psoriatic arthritis, and Behçet’s disease. Sarcoidosis, syphilis, toxoplasmosis, and tuberculosis can also cause uveitis, but each has its own unique ocular manifestations and symptoms.

Dermatological Conditions: Granuloma Annulare, Necrobiosis Lipoidica, Fungal Infection, Scabies, and Erythema Multiforme

Granuloma Annulare is a skin condition that presents as groups of papules forming an arc or ring around a slightly depressed center. It is usually found on the dorsal surfaces of hands, feet, fingers, and extensor surfaces of arms and legs. The generalised form of this condition presents similar but bigger rings that are more widely disseminated. A subcutaneous form also exists that presents as nodules. Although an association with diabetes has been suggested, it is not always present. The local type is self-limiting and doesn’t require treatment, while a large number of treatments are described for the generalised form but have little evidence to support them.

Necrobiosis Lipoidica is another condition that occurs in patients with type 1 diabetes mellitus. It is characterised by firm, red-yellow plaques that occur over the shins. This condition may pre-date the development of diabetes by many years.

Fungal infections, such as tinea or ringworm, are epidermal conditions that produce scaling. On the other hand, scabies presents as crusted linear itchy lesions on the hands and web spaces, plus a generalised itchy nonspecific rash. Erythema Multiforme presents as multiple erythematous lesions with a darker or vesicular centre, particularly on the hands and feet.

In summary, these dermatological conditions have distinct presentations and require different treatments. It is important to seek medical advice for proper diagnosis and management.

Principles for End-of-Life Decision Making

When making decisions regarding end-of-life care, it is important to adhere to certain principles. These principles include equality and human rights, which dictate that patients approaching the end of their life should receive the same quality of care as all other patients. Additionally, there should be a presumption in favor of prolonging life, meaning that decisions about potentially life-prolonging treatments should not be motivated by a desire to bring about the patient’s death. It is also important to presume capacity in terminally ill patients and to maximize their capacity to make decisions through shared decision making. Finally, when a patient lacks capacity, the overall benefit of a potentially life-prolonging treatment must be weighed against the burdens and risks for the patient, with consultation from those close to the patient. By following these principles, end-of-life decisions can be made with the patient’s best interests in mind.

Referral to a nephrologist is necessary if there is a sustained decrease in eGFR of 15 mL/min/1.73 m2 or more within 12 months. However, in the case of this patient with a normal urine dip, a urology referral would not be necessary. According to NICE guidelines, treatment for hypertension should be followed if the patient has an ACR of <30 mg/mmol, and ACE-i can be started in non-diabetic patients. Aspirin is not recommended for primary prevention of cardiovascular disease. Chronic kidney disease is often without symptoms and is typically identified through abnormal urea and electrolyte levels. However, some individuals with advanced, undetected disease may experience symptoms. These symptoms may include swelling in the ankles, weight gain, increased urination, fatigue, itching due to uraemia, loss of appetite leading to weight loss, difficulty sleeping, nausea and vomiting, and high blood pressure.

Correct and Incorrect Management Options for Anaphylaxis

Anaphylaxis is a potentially life-threatening allergic reaction that requires immediate management. The correct management options include administering adrenaline 1:1000 intramuscularly (IM) at appropriate doses based on the patient’s age and weight. However, there are also incorrect management options that can be harmful to the patient.

One incorrect option is administering chlorphenamine IM. While it is a sedating antihistamine, it should not be used as a first-line intervention for airway, breathing, or circulation problems during initial emergency treatment. Non-sedating oral antihistamines may be given following initial stabilisation.

Another incorrect option is advising the patient to go to the nearest Emergency Department instead of administering immediate drug management. Out-of-hours centres should have access to emergency drugs, including adrenaline, and GPs working in these settings should be capable of administering doses in emergencies.

It is also important to administer the correct dose of adrenaline based on the patient’s age and weight. Administering a dose that is too high, such as 1000 µg for a 7-year-old child, can be harmful.

In summary, the correct management options for anaphylaxis include administering adrenaline at appropriate doses and avoiding incorrect options such as administering chlorphenamine IM or advising the patient to go to the nearest Emergency Department without administering immediate drug management.

According to current guidelines, doctors on the General Medical Council Specialist Register are the only ones allowed to prescribe unlicensed cannabis-based products. They should only prescribe these products for disorders within their specialty when there is clear evidence or published guidelines. Bedrocan is an unlicensed cannabis-based product that can be prescribed by specialists in line with current evidence and guidance. Therefore, it is recommended to refer the patient to a specialist for consideration, rather than prescribing it yourself. Nabilone, a synthetic cannabinoid, is licensed for nausea and vomiting associated with chemotherapy and is not suitable for this scenario. It is not safe to advise the patient to purchase an unlicensed medication online, and there is no reason to involve the police.

Cannabis-Based Medicinal Products: Guidelines and Available Products

Cannabis-based medicinal products can now be prescribed for therapeutic use under specialist supervision, following a Department of Health review in 2018. These products are defined as medicinal preparations or products that contain cannabis, cannabis resin, cannabinol, or a cannabinol derivative, and are produced for use in humans. Initial prescriptions must be made by a specialist medical practitioner with experience in the condition being treated, and subsequent prescriptions can be issued by another practitioner under a shared care agreement.

Cannabis-based medicinal products can be used to manage various conditions, including chemotherapy-induced nausea and vomiting, chronic pain, spasticity in adults with multiple sclerosis, and severe-treatment resistant epilepsy. However, current NICE guidance advises against using cannabis-based medicines for chronic pain, except if already initiated and under specialist supervision until appropriate to stop.

Several cannabis-based products and cannabinoids are available, including Bedrocan, Tilray, Sativex, Epidiolex, Dronabinol, and Nabilone. However, unlicensed cannabis-based products can only be prescribed by doctors on the General Medical Council Specialist Register, and doctors should prescribe products only for disorders within their specialty when there is clear evidence or published guidelines.

It is important to consider current available evidence, interactions with other prescribed or non-prescribed medication, and the potential for patients to seek or use non-medicinal products lacking safety and quality assurance when considering prescribing cannabis-based products. Patients should also be advised of the risks of impaired driving, as cannabis-based products may impair a patient’s ability to drive safely.

Common side effects associated with cannabis-based medicines include disorientation, dizziness, euphoria, confusion, dry mouth, nausea, somnolence, fatigue, vomiting, drowsiness, loss of balance, and hallucination. Rare adverse events include psychosis and seizures.

Mild cases of pelvic inflammatory disease do not require removal of intrauterine contraceptive devices.

Pelvic inflammatory disease (PID) is a condition where the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. It is typically caused by an infection that spreads from the endocervix. The most common causative organism is Chlamydia trachomatis, followed by Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and Gonorrhoea. However, these tests may often be negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole. In mild cases of PID, intrauterine contraceptive devices may be left in, but the evidence is limited, and removal of the IUD may be associated with better short-term clinical outcomes according to recent guidelines.

Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis, infertility (with a risk as high as 10-20% after a single episode), chronic pelvic pain, and ectopic pregnancy.

Consider Lyme disease as a possible diagnosis for patients presenting with vague and unexplained symptoms such as fever, night sweats, headache, or paraesthesia. These symptoms may also include inflamed lymph nodes, neck pain, and joint/muscle aches. The causative agent of Lyme disease is Borrelia burgdorferi. Malaria is unlikely in patients with no travel history and symptoms lasting for 4 months. Scabies typically presents with an itchy rash, which is not evident in the scenario. Glandular fever may cause fatigue and muscle aches, but the absence of a sore throat and the need for a blood test for diagnosis make it less likely. Toxoplasma gondii is usually asymptomatic but may cause flu-like symptoms and muscle aches, and it is not associated with a rash.

Lyme Disease: Symptoms and Progression

Lyme disease is a bacterial infection that is transmitted through the bite of an infected tick. The disease progresses in two stages, with early and later features. The early features of Lyme disease include erythema migrans, which is a small papule that often appears at the site of the tick bite. This papule develops into a larger annular lesion with central clearing, resembling a bulls-eye. This occurs in 70% of patients and is accompanied by systemic symptoms such as malaise, fever, and arthralgia.

As the disease progresses, it can lead to more severe symptoms. The later features of Lyme disease include cardiovascular symptoms such as heart block and myocarditis, as well as neurological symptoms such as cranial nerve palsies and meningitis. Patients may also experience polyarthritis, which is inflammation in multiple joints.

Diagnosis and Management of Hypothyroidism

In this case, the patient presents with symptoms of tiredness, weight gain, and bradycardia on examination, along with a smooth non-tender goitre and low sodium on U&E testing. These clues suggest a diagnosis of hypothyroidism, which can be confirmed through thyroid function testing. C reactive protein is a nonspecific result that may indicate possible infection or inflammation, while a chest x-ray can help rule out chest pathology as an alternative cause for the hyponatraemia. If the thyroid function testing is normal and the chest x-ray is unremarkable, an ENT referral may be appropriate. Ultrasound is indicated if there is a suspicion of nodularity within the thyroid gland. By following these steps, healthcare professionals can effectively diagnose and manage hypothyroidism in patients.

A visual field defect known as left homonymous hemianopia indicates a loss of vision to the left side, which is caused by a lesion in the right optic tract. Homonymous quadrantanopias, which affect the parietal-inferior and temporal-superior areas, are also a type of visual field defect. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by lesions in the optic radiation or occipital cortex.

Understanding Visual Field Defects

Visual field defects can occur due to various reasons, including lesions in the optic tract, optic radiation, or occipital cortex. A left homonymous hemianopia indicates a visual field defect to the left, which is caused by a lesion in the right optic tract. On the other hand, homonymous quadrantanopias can be categorized into PITS (Parietal-Inferior, Temporal-Superior) and can be caused by lesions in the inferior or superior optic radiations in the temporal or parietal lobes.

When it comes to congruous and incongruous defects, the former refers to complete or symmetrical visual field loss, while the latter indicates incomplete or asymmetric visual field loss. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by optic radiation or occipital cortex lesions. In cases where there is macula sparing, it is indicative of a lesion in the occipital cortex.

Bitemporal hemianopia, on the other hand, is caused by a lesion in the optic chiasm. The type of defect can indicate the location of the compression, with an upper quadrant defect being more common in inferior chiasmal compression, such as a pituitary tumor, and a lower quadrant defect being more common in superior chiasmal compression, such as a craniopharyngioma.

Understanding visual field defects is crucial in diagnosing and treating various neurological conditions. By identifying the type and location of the defect, healthcare professionals can provide appropriate interventions to improve the patient’s quality of life.

Pertussis Guidance for Healthcare Workers

According to the latest guidance from Public Health England (PHE), healthcare workers (HCWs) suspected of having pertussis should be excluded from work until 48 hours of appropriate antibiotic treatment is completed or for 21 days from onset if not treated. This is a change from earlier advice to exclude for 5 days. Hospitalized patients with pertussis should be placed in respiratory isolation until 48 hours of treatment is completed or for 21 days from onset if not treated. HCWs looking after patients with pertussis should wear appropriate personal protective equipment (PPE).

It is important for GPs to understand and implement key national guidelines that influence healthcare provision for respiratory problems, as stated in the RCGP Curriculum Statement 3.19. Public Health England has published comprehensive guidelines on the symptoms, diagnosis, management, surveillance, and epidemiology of pertussis, including updated sub-documents. Staying up to date with the latest guidance is crucial for providing safe and effective care to patients and protecting the health of healthcare workers.

Before considering a cochlear implant as a management strategy for hearing loss in adults, a failed trial of hearing aids for at least 3 months is generally required, regardless of the cause, age at the time of hearing loss, duration, or severity of the condition. In the case of this patient, the duration of his hearing aid use is the most significant factor suggesting the appropriateness of a cochlear implant.

A cochlear implant is an electronic device that can be given to individuals with severe-to-profound hearing loss. The suitability for a cochlear implant is determined by audiological assessment and/or difficulty developing basic auditory skills in children, and a trial of appropriate hearing aids for at least 3 months in adults. The causes of severe-to-profound hearing loss can be genetic, congenital, idiopathic, infectious, viral-induced sudden hearing loss, ototoxicity, otosclerosis, Ménière disease, or trauma. Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any underlying pathological process contributing to the loss of hearing.

Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. Patients are discharged for the postoperative physical recovery of the implantation site and generally return to outpatient clinic 3-5 weeks post-op for device stimulation. Contraindications to consideration for cochlear implant include lesions of cranial nerve VIII or in the brain stem causing deafness, chronic infective otitis media, mastoid cavity or tympanic membrane perforation, and cochlear aplasia.

The device has both internal and external components. Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The electrodes do the work that would be performed by the inner ear hair cells in a ‘normal’ ear. The brain can then process these signals to comprehend sound.

Rechargeable batteries can be used to power the apparatus and life span depends upon usage and the individual device. Hearing link describes cochlear implants as ‘…the world’s most successful medical prostheses in that less than 0.2% of recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.’ It is important for patients to demonstrate an understanding of what to expect from cochlear implantation, including comprehension of the likely limitations of the device. Patients should also demonstrate an interest in using the