Post-Treatment Surveillance Strategies for Colorectal Cancer: The Role of CEA Monitoring, Colonoscopy, and CT Scans

Carcinoembryonic antigen (CEA) is a protein that is elevated in the serum of patients with colorectal cancer. While not suitable for screening, CEA levels can be used to monitor disease burden and predict prognosis in patients with established disease. Additionally, elevated preoperative CEA levels should return to baseline after complete resection, and failure to do so may indicate residual disease. Serial CEA testing can also aid in the early detection of recurrences, which can increase the likelihood of a complete resection.

The National Institute for Health and Care Excellence recommends regular serum CEA tests (at least every six months in the first three years) and a minimum of two CT scans of the chest, abdomen, and pelvis in the first three years after treatment. Surveillance colonoscopy should be performed one year after initial treatment, and if normal, another colonoscopy should be performed at five years. The timing of colonoscopy after adenoma should be determined by the risk status of the adenoma.

While periodic colonoscopy is beneficial for detecting metachronous cancers and preventing further cancers via removal of adenomatous polyps, trials have failed to show a survival benefit from annual or shorter intervals compared to less frequent intervals (three or five years) for detecting anastomotic recurrences. Routine fecal occult blood testing is not recommended in post-treatment surveillance guidelines.

In summary, post-treatment surveillance strategies for colorectal cancer should include serial CEA monitoring, CT scans, and colonoscopy at recommended intervals. These strategies can aid in the early detection of recurrences and improve the likelihood of a complete resection.

Understanding Alcohol Use: Categories and Definitions

Alcohol use can have varying degrees of impact on a person’s health and well-being. To better understand these impacts, different categories and definitions have been established.

Harmful use refers to a pattern of alcohol consumption that is already causing harm to a person’s health, but doesn’t necessarily involve dependence. This can include acute or chronic damage, such as depression or cirrhosis. Brief interventions may be effective in addressing harmful use.

Dependence syndrome, on the other hand, involves a compulsion to drink, inability to control drinking, tolerance, withdrawal symptoms, neglect of normal activities, and persistent drinking despite evidence of harm.

Acute intoxication is a transient condition resulting from the administration of alcohol, causing disturbances in consciousness, cognition, perception, affect, or behavior. It is only diagnosed when intoxication occurs without more persistent alcohol-related problems.

Binge drinking is defined as drinking more than double the lower risk guidelines for alcohol in one session, and is considered a more risky type of hazardous drinking.

Hazardous drinking is the regular consumption of a certain amount of ethanol per day, as determined by population studies and the associated risk of harm. It is not a diagnostic term in ICD-10, but is often used to describe drinking that may lead to harm.

Understanding these categories and definitions can help individuals and healthcare professionals identify and address problematic alcohol use.

Managing Nephropathy Progression

Tight control of blood pressure and glucose levels is crucial in managing the progression of nephropathy. The recommended target for systolic blood pressure is 130 or less, while the HbA1c target should be less than 53 mmol/mol. Although BMI, diastolic blood pressure, and cholesterol are relevant factors, they are less significant compared to blood pressure and glucose control.

Among all antihypertensives, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest evidence for reducing nephropathy progression. Therefore, it is important to prioritize these medications in the management of nephropathy. Proper management of blood pressure and glucose levels, along with the use of ACE inhibitors and ARBs, can significantly slow down the progression of nephropathy.

The bony protrusion observed in the left ear canal is known as an exostosis or a bone prominence. Although spending a lot of time in water may increase the risk of otitis externa, the patient doesn’t exhibit the typical signs of inflamed canals or debris. Cholesteatoma, which is characterized by a foul-smelling discharge and an abnormality in the attic, is also ruled out as it is not evident on examination. Wax or foreign body are not considered as they were not found during the examination.

Surfer’s Ear: A Condition Caused by Repeated Exposure to Cold Water

Surfer’s ear, also known as exostosis, is a condition that occurs as a result of repeated exposure to cold water. This condition is commonly seen in surfers, divers, and kayakers, and is more prevalent in countries such as New Zealand and the USA. However, cases have also been reported in some areas of the United Kingdom, such as Cornwall. Patients with surfer’s ear may experience recurrent ear infections, reduced hearing, and water plugging.

Surfer’s ear is a progressive condition, and it is essential to take preventative measures to avoid repeated exposure. Wearing hoods, ear plugs, or swim caps can help to protect the ears from cold water. In severe cases, surgery may be necessary to remove the bony growths that have developed in the ear canal. By taking the necessary precautions, individuals can reduce their risk of developing surfer’s ear and prevent further complications.

Confidentiality of Deceased Person’s Information

When dealing with the records of a deceased person, it is important to respect their wishes regarding the disclosure of information. If the deceased person had explicitly stated that certain information should remain confidential, or if the record contains sensitive information that the deceased person expected to remain private, then it must be kept confidential.

However, if the mother of the deceased person requests that certain information be kept confidential, then the rest of the records can be released. It is up to the record holder to make a judgement call on whether the information could be harmful to the applicant or if it would identify a third party. In any case, it is crucial to handle the information with care and respect the wishes of the deceased person and their family.

Understanding Hydrocoele

A hydrocoele is a condition where there is a buildup of fluid in the tunica vaginalis. It can either be primary, which usually occurs in middle age, or secondary, which can happen in younger individuals and may be caused by an underlying malignancy, chronic epididymo-orchitis, or a hernia. The main symptom is a cystic-feeling swelling in the scrotum, which makes it difficult to feel the testis separately. However, the swelling can be felt above and transilluminates.

Ultrasound is not typically used to diagnose a simple hydrocoele, but it may be helpful in ruling out other conditions such as testicular tumors.

Understanding Alcohol Withdrawal Symptoms

Alcohol withdrawal symptoms can manifest in different ways depending on the severity of the addiction. DTs or delirium tremens usually occur 2-4 days after stopping drinking and are characterized by severe agitation, confusion, and hallucinations. On the other hand, tremulousness or withdrawal convulsions can occur during a drinking spree or within a few hours of cessation. Alcoholic hallucinosis, which is characterized by auditory hallucinations, can occur over days or weeks. However, it is less severe than DTs.

Admission to a medical facility for appropriate sedation, nursing support, and thiamine replacement is necessary to manage the symptoms and prevent complications. Understanding the different alcohol withdrawal symptoms can help you identify when someone needs medical attention and provide the necessary support.

Understanding Achondroplasia: Causes, Inheritance, and Prognosis

Achondroplasia is a common type of short-limb dwarfism that results from a mutation in a growth-factor receptor gene on chromosome 4. This genetic condition is inherited as an autosomal dominant trait, meaning that affected individuals have a 50% chance of passing on the gene to their offspring. However, over 80% of cases arise from new mutations, which means that many affected children are born to non-affected parents.

Antenatal ultrasound can detect achondroplasia during pregnancy, allowing parents to make informed decisions about their child’s care. While the prognosis for affected children is generally good, they may experience complications such as hydrocephalus and spinal stenosis.

It’s important to note that unaffected children have the same risk of inheriting the gene as the general population. By understanding the causes, inheritance, and prognosis of achondroplasia, individuals and families can better navigate this genetic condition.

Understanding Alcohol Withdrawal Seizures

Alcohol withdrawal seizures are a common occurrence in individuals who abruptly stop drinking. These seizures typically occur within 6-48 hours of the last drink and are often the first sign of alcohol withdrawal. They are major motor seizures that can last for a few minutes and are characterized by tonic-clonic movements. However, if the seizure lasts for more than 20 minutes, it may indicate an alternative cause and should be investigated further.

It is important to note that alcohol withdrawal seizures usually occur in patients who have no previous history of seizures or epileptiform disorders. Electroencephalograms are usually normal, and only about 30-40% of patients progress to delirium tremens. If a patient has a past history of epilepsy or experiences a partial/focal seizure, it may indicate another cause and should be investigated further.

Additionally, a prolonged post-ictal phase is very unusual in alcohol withdrawal seizures and should prompt consideration of another cause. Overall, understanding the characteristics and potential causes of alcohol withdrawal seizures can aid in proper diagnosis and treatment.

Possible Diagnoses for Abdominal Pain and Shock with Neurological Symptoms

Abdominal pain and shock with neurological symptoms can be indicative of several medical conditions. One possible diagnosis is a ruptured aortic aneurysm, which may cause a pulsatile mass in the abdomen and involve the spinal arteries. Acute pancreatitis may also cause abdominal pain and shock, but it would not typically produce neurological symptoms. Biliary colic, on the other hand, may cause pain in the epigastrium or right upper quadrant that radiates to the back, but it usually resolves within 24 hours. Acute myocardial infarction (MI) is another emergency presentation that may produce abdominal pain and shock, but it would also involve chest or jaw pain/heaviness and ECG changes. Finally, a perforated duodenal ulcer may cause abdominal pain and shock, but it would also involve marked tenderness and rigidity. Therefore, a ruptured aortic aneurysm is the most likely diagnosis in this case.

Severity Categorisation in Depression Assessment Tools

The severity of depression is an important aspect to consider when assessing and treating patients. There are several depression assessment tools that categorise severity differently. The Patient Health Questionnaire 9 (PHQ-9) categorises severity as minimal, mild, moderate, moderately severe and severe. The Hospital Anxiety and Depression Scale (HADS-D) categorises depression as normal, mild, moderate and severe. Lastly, the Beck Depression Inventory II categorises severity as minimal, mild, moderate and severe. It is important for healthcare professionals to understand the severity categorisation of each tool to accurately assess and treat patients with depression.

Temporal arteritis is a type of large vessel vasculitis that often occurs in patients over the age of 60 and is commonly associated with polymyalgia rheumatica. This condition is characterized by changes in the affected artery that skip certain sections while damaging others. Symptoms of temporal arteritis include headache, jaw claudication, and visual disturbances, with anterior ischemic optic neuropathy being the most common ocular complication. A tender, palpable temporal artery is also often present, and around 50% of patients may experience symptoms of PMR, such as muscle aches and morning stiffness.

To diagnose temporal arteritis, doctors will typically look for elevated inflammatory markers, such as an ESR greater than 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to confirm the diagnosis, with skip lesions often being present. Treatment for temporal arteritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is typically used, while IV methylprednisolone is usually given if there is evolving visual loss. Patients with visual symptoms should be seen by an ophthalmologist on the same day, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.

Interpreting Diabetic Retinopathy Findings: What Requires Urgent Referral?

Diabetic retinopathy is a common complication of diabetes that can lead to vision loss if left untreated. As part of routine eye exams, healthcare professionals may identify various findings in the retina that indicate the presence and severity of diabetic retinopathy. However, not all findings require urgent referral to an ophthalmologist. Here are some examples:

– New vessels on the disc: These are a sign of proliferative retinopathy and require urgent referral as they can cause bleeding and threaten vision.
– Dot-and-blot haemorrhages: These are a feature of background retinopathy and do not require urgent referral unless they are within one-disc diameter of the fovea. Annual monitoring is recommended.
– Cataract: While cataracts are more common in people with diabetes, routine referral is sufficient if vision is significantly affected.
– Hard exudates > one-disc diameter from the fovea: These are also a feature of background retinopathy and do not require urgent referral.
– Two soft exudates in the temporal field: These cotton-wool spots are not a reason for referral, but referral for review within four weeks is indicated if other signs of pre-proliferative disease are present.

Understanding which findings require urgent referral can help healthcare professionals provide appropriate care for people with diabetic retinopathy and prevent vision loss.

Giant Cell Temporal Arteritis: Urgent Management Required

This patient’s history strongly suggests giant cell temporal arteritis (GCA), a medical emergency that requires urgent management. While ophthalmologists may be involved in the management of GCA, their involvement is only necessary if the condition is affecting the patient’s vision. In this scenario, the patient’s vision is not affected.

The recommended course of action is to start the patient on 40-60mg of prednisolone per day (for patients without visual symptoms) and refer them urgently to a physician, typically a Rheumatologist. It is important to note that national guidance should be followed, rather than local variations, when assessing patients in an exam setting. Shared care is recommended, and patients may require treatment for several years.

In addition to steroids, aspirin and PPIs are recommended. However, long-term treatment with oral steroids can increase the risk of osteoporosis, which should be assessed. For more information on national guidance and associated information, CKS provides a comprehensive summary of GCA management.

Caloric and Fat Content of Selected Foods

When it comes to watching our calorie and fat intake, it’s important to be mindful of the foods we consume. Here’s a breakdown of the caloric and fat content of some common foods:

Cheddar Cheese 100g
This amount of cheddar cheese contains a whopping 413 kcal and 34g of fat, making it the highest in both categories compared to the other foods listed.

Banana 100g
A 100g banana contains 95 kcal and is a great source of potassium and fiber.

Cornflakes 30g
A 30g serving of cornflakes with 125 ml of semi-skimmed milk contains 173 kcal and 2.5g of fat.

Orange Juice Unsweetened 140ml
140 ml of unsweetened orange juice contains roughly 50 kcal. While it’s important to be mindful of sugar intake, consuming a small glass of fruit juice each day can count towards our recommended daily intake of fruits and vegetables.

Plain Scone 48g
A plain scone weighing 48g contains around 173 kcal and 7g of fat. It’s important to enjoy treats in moderation and balance them with healthier options.

Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain is typically sharp and stabbing, and it occurs around one eye. Patients may experience redness, lacrimation, lid swelling, nasal stuffiness, and miosis and ptosis in some cases.

To manage cluster headaches, acute treatment options include 100% oxygen or subcutaneous triptan. Prophylaxis involves using verapamil as the drug of choice, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.

Since desogestrel has a 12-hour window, the patient can take the pill now without requiring any additional steps.

The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.

If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.

Common Genitourinary Conditions and Diagnostic Methods

Chronic prostatitis is a condition that often results in pain in the perineal area. Gonorrhoea, on the other hand, can be diagnosed through a nucleic acid amplification test (NAAT) using urine samples in men or through a positive culture of urethral discharge. Urinary tract infections (UTIs) can be detected through a midstream urine culture. Meanwhile, balanitis xerotica et obliterans is a chronic condition characterized by atrophic white patches on the foreskin and glans penis. These conditions can be diagnosed through various diagnostic methods, which are essential in determining the appropriate treatment plan.

Possible Causes of Unexplained Weight Loss in Older Adults

Unexplained weight loss in older adults is a symptom of malignancy and should be investigated promptly. The most prevalent cancer among men in the UK is prostate cancer, which frequently presents with no specific symptoms. Other symptoms of prostate cancer include lower urinary tract symptoms, anorexia, haematuria, erectile dysfunction, lethargy, and low back pain. Lung cancer and colorectal cancer can also cause weight loss, but they are less common among men than prostate cancer. Lung cancer may present with fatigue, shortness of breath, cough, chest pain, haemoptysis, or recurrent chest infections, and may be associated with finger clubbing or lymphadenopathy. Colorectal cancer may cause a change in bowel habit, rectal bleeding, fatigue, and abdominal pain, and may be accompanied by an abdominal or rectal mass. Frailty is another possible cause of unintentional weight loss, but it is usually associated with other indicators, such as slow gait speed, loss of grip strength, exhaustion, and low levels of physical activity. Type I diabetes mellitus can also cause weight loss, but it is more commonly diagnosed in young people, while Type II diabetes is more likely to occur in older age and is associated with weight gain rather than weight loss.

Antipsychotic medication can lead to sexual dysfunction due to their ability to block dopamine and increase prolactin levels. This can result in a decrease in libido. Additionally, some antipsychotics can block alpha1-adrenoreceptors, leading to erectile dysfunction and difficulty with ejaculation.

Commonly prescribed antipsychotics such as risperidone and haloperidol are known to cause sexual dysfunction. Treatment options include reducing the dosage or switching to a different antipsychotic medication. (Source: BNF)

Antipsychotics are a type of medication used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. However, they are known to cause extrapyramidal side-effects such as Parkinsonism, acute dystonia, akathisia, and tardive dyskinesia. These side-effects can be managed with procyclidine. Other side-effects of typical antipsychotics include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients due to an increased risk of stroke and venous thromboembolism.

First Line Treatments for Parkinson’s Disease

Parkinson’s disease (PD) is a neurological disorder that affects movement and can cause tremors, stiffness, and difficulty with coordination. When it comes to treating PD, there are several options available, but not all of them are suitable as first-line treatments.

Anticholinergics, for example, should be avoided as a first-line treatment due to their association with an increased frequency of neuropsychiatric and cognitive adverse effects. This is especially important to consider for PD patients with cognitive impairment or clinically significant psychiatric illness.

On the other hand, there are other options that can be used as first-line treatments, such as levodopa, dopamine agonists, and monoamine oxidase B inhibitors. However, ergot-derived dopamine agonists like cabergoline and pergolide should not be used as first-line treatments due to the risk of cardiac fibrosis with long-term use and the need for additional monitoring.

In summary, it’s important to carefully consider the potential risks and benefits of different treatment options for PD, and to choose the most appropriate first-line treatment based on the individual patient’s needs and medical history.

If a patient with undiagnosed bilateral renal artery stenosis starts taking an ACE inhibitor, they may experience significant renal impairment. Therefore, it is important to consider the possibility of bilateral renal artery stenosis in patients with risk factors for atherosclerotic vascular disease, especially if they develop hypertension later in life and experience a sudden drop in renal function after starting an ACE inhibitor. This acute decline in renal function is not consistent with chronic kidney conditions like diabetic or hypertensive nephropathy. Glomerulonephritis or pre-renal acute kidney injury from dehydration are unlikely based on the information provided.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Correcting Misconceptions About Child Health: Understanding When to Seek Medical Advice

As a parent or caregiver, it can be difficult to know when to seek medical advice for a child’s health concerns. However, it is important to correct some common misconceptions to ensure that children receive appropriate care.

Firstly, if a parent or caregiver feels that a child has become less well, they should seek further advice. Additionally, if they are distressed or concerned about their ability to care for the child, seeking advice is recommended.

Contrary to popular belief, a strong normal cry is not a cause for concern. However, a weak, high-pitched, or continuous cry is a red flag. Similarly, a non-blanching rash should cause concern, as it may indicate meningococcal septicaemia.

Parents should seek further advice if a fever is still present after five days, not two. A temperature rise up to 39°C in the absence of other worrying signs is not a reason for concern in a child of this age. However, if a child has a febrile fit, parents should seek immediate advice.

By understanding these misconceptions and knowing when to seek medical advice, parents and caregivers can ensure that children receive appropriate care for their health concerns.

Treatment Options for Mild Depression

When it comes to treating mild depression, antidepressants are not typically the first choice. Instead, cognitive behavioural therapy has the strongest evidence for effectiveness, although it may not be readily available in all areas. In some cases, psychodynamic therapy may be helpful, particularly if the root cause of distress is related to difficulties in interpersonal relationships. While selective serotonin reuptake inhibitors have been shown to be effective for severe depression, their efficacy for mild-to-moderate depression is less clear. St John’s wort is not recommended due to uncertainty around appropriate dosing, variations in preparation, and potential interactions with other medications.

Molluscum contagiosum doesn’t require school exclusion or antiviral treatment as it is a self-limiting condition. Unlike Chickenpox, the lesions do not crust over. Antibiotics are not effective against this viral infection. It may take several months for the lesions to disappear, making unnecessary and impractical to consider other options.

Understanding Molluscum Contagiosum

Molluscum contagiosum is a viral skin infection that is commonly found in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, the lesions are commonly found on the trunk and flexures, while in adults, they can appear on the genitalia, pubis, thighs, and lower abdomen.

While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be necessary to alleviate itching or if the lesions are considered unsightly. Treatment options include simple trauma or cryotherapy, depending on the age of the child and the parents’ wishes. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.

Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent the spread of the infection and alleviate symptoms if necessary.

Treatment for Microalbuminuria

In cases of confirmed microalbuminuria, even if the patient is normotensive, it is recommended by NICE guidance to start an ACE inhibitor. The dose should be gradually increased until the full dose is reached. If the patient experiences poor tolerance, an Angiotensin receptor blocker can be used as an alternative. It is important to maintain blood pressure below 130/80 mmHg (140/80 if there is no kidney involvement).

NICE doesn’t recommend diabetic foods for individuals with diabetes. Instead, it is important to prioritize a healthy and balanced diet that includes high-fibre, low-glycaemic-index sources of carbohydrates (such as fruits, vegetables, whole grains, and pulses), low-fat dairy products, and oily fish. It is also advised to limit the consumption of foods that contain saturated and trans fatty acids. Additionally, the use of foods marketed specifically for individuals with diabetes should be discouraged.

NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

Individuals with a family history of glaucoma should undergo annual screening from the age of 40. As this patient is over 40 and has a mother with glaucoma, this is the most appropriate health screening to initiate.

Routine chest X-ray screening for lung cancer is not recommended for asymptomatic individuals, and as this patient is a non-smoker with no symptoms, it is not the most appropriate option.

Faecal immunochemical screening for bowel cancer is typically initiated at age 60 unless there are concerning symptoms or a family history. As this patient has neither, this is not the most appropriate screening to commence.

While PSA screening for prostate cancer is controversial, the patient’s father’s diagnosis at age 75 would not significantly increase his risk. It could be discussed with the patient and initiated at age 50, but it is not necessary at this time.

Although blood tests to check HbA1c could be considered, the patient has no symptoms, no family history of diabetes, and is at a healthy weight. Therefore, this is not the most important health screening to initiate.

Glaucoma is a condition where the optic nerve is damaged due to increased intraocular pressure (IOP). Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris doesn’t cover the trabecular meshwork, which is responsible for draining aqueous humour from the eye. POAG is more common in older individuals, with up to 10% of those over 80 years of age affected. Genetics, Afro-Caribbean ethnicity, myopia, hypertension, diabetes mellitus, and corticosteroid use are all risk factors for POAG. POAG may present with peripheral visual field loss, decreased visual acuity, and optic disc cupping, which can be detected during routine optometry appointments.

Fundoscopy signs of POAG include optic disc cupping, optic disc pallor, bayonetting of vessels, and cup notching. Optic disc cupping occurs when the cup-to-disc ratio is greater than 0.7, indicating a loss of disc substance. Optic disc pallor indicates optic atrophy, while bayonetting of vessels occurs when vessels have breaks as they disappear into the deep cup and reappear at the base. Cup notching usually occurs inferiorly where vessels enter the disc, and disc haemorrhages may also be present.

The diagnosis of POAG is made through a series of investigations, including automated perimetry to assess visual field, slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline, applanation tonometry to measure IOP, central corneal thickness measurement, and gonioscopy to assess peripheral anterior chamber configuration and depth. The risk of future visual impairment is assessed using risk factors such as IOP, central corneal thickness (CCT), family history, and life expectancy. If POAG is suspected, referral to an ophthalmologist is necessary for further evaluation and management.

Management of Subthreshold Depressive Symptoms

This patient is currently experiencing subthreshold depressive symptoms that have lasted for less than two weeks. The cause of her symptoms is likely due to a stressful period at work, which is expected to end soon. Fortunately, she has a strong support network. According to NICE guidance on Depression in adults (CG90), medication is not recommended at this stage. Instead, CBT should be considered for persistent subthreshold depressive symptoms. St John’s wort is not recommended due to its interaction with the oral contraceptive pill and lack of evidence of effective dose and variation between preparations. NICE has suggested that short term dynamic psychotherapy be evaluated in a formal research setting. After a thorough assessment, the patient should be advised on sleep hygiene and reducing alcohol intake. She should also receive written information about depression and be scheduled for a follow-up appointment within two weeks at most.

Following a miscarriage or abortion, the COC can be initiated without delay and provides immediate protection against pregnancy for women.

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on various aspects. This includes the potential benefits and harms of the COC, such as its high effectiveness rate of over 99% when taken correctly, but also the small risk of blood clots, heart attacks, strokes, and increased risk of breast and cervical cancer. Additionally, advice on taking the pill should be provided, such as starting it within the first 5 days of the cycle to avoid the need for additional contraception, taking it at the same time every day, and considering tailored regimens that eliminate the pill-free interval. It is also important to discuss situations where efficacy may be reduced, such as vomiting or taking liver enzyme-inducing drugs. Finally, counselling should include information on STIs and the use of concurrent antibiotics, which may no longer require extra precautions except for enzyme-inducing antibiotics like rifampicin.

Overall, women should receive comprehensive counselling on the COC to make informed decisions about their reproductive health. This includes discussing the potential benefits and harms, advice on taking the pill, and situations where efficacy may be reduced. By providing this information, women can make informed decisions about their contraceptive options and reduce the risk of unintended pregnancies.