Referral to a rheumatologist is necessary for all individuals who are suspected to have psoriatic arthropathy.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is characterized by joint inflammation that often precedes the development of skin lesions. While it affects both males and females equally, only 10-20% of patients with psoriasis develop this condition. The presentation of psoriatic arthropathy can vary, with the most common types being symmetric polyarthritis and asymmetrical oligoarthritis. Other signs include psoriatic skin lesions, periarticular disease, and nail changes. X-rays may show erosive changes and new bone formation, as well as a pencil-in-cup appearance. Treatment is similar to that of rheumatoid arthritis, but mild cases may only require NSAIDs and newer monoclonal antibodies may be used. Overall, psoriatic arthropathy has a better prognosis than RA.

Verapamil is more likely to worsen heart failure compared to dihydropyridines such as amlodipine.

Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

Hypertension, or high blood pressure, can also affect children. To measure blood pressure in children, it is important to use a cuff size that is approximately 2/3 the length of their upper arm. The 4th Korotkoff sound is used to measure diastolic blood pressure until adolescence, when the 5th Korotkoff sound can be used. Results should be compared to a graph of normal values for their age.

In younger children, secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80% of cases. Other causes of hypertension in children include renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension, which becomes more common as children get older. It is important to identify the underlying cause of hypertension in children in order to provide appropriate treatment and prevent complications.

Lethargy is a common early symptom of multiple sclerosis, an autoimmune condition that affects the myelin in the brain and spinal cord. The patient’s description of symptoms of optic neuritis is also typical of multiple sclerosis. Lyme disease can sometimes mimic multiple sclerosis, but there is no history of a tick bite. Myasthenia gravis, which causes weakness and fatigue, is not likely to cause paresthesia or optic neuritis. Sarcoidosis, a systemic inflammatory disease that often presents with fatigue, is a potential option, but multiple sclerosis is more likely to cause optic neuritis.

Features of Multiple Sclerosis

Multiple sclerosis (MS) is a condition that can present with nonspecific features, such as significant lethargy in around 75% of patients. Diagnosis is based on two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion with reasonable historical evidence of a previous relapse.

MS can affect various parts of the body, leading to different symptoms. Visual symptoms include optic neuritis, optic atrophy, Uhthoff’s phenomenon, and internuclear ophthalmoplegia. Sensory symptoms may include pins and needles, numbness, trigeminal neuralgia, and Lhermitte’s syndrome. Motor symptoms may include spastic weakness, which is most commonly seen in the legs. Cerebellar symptoms may include ataxia and tremor. Other symptoms may include urinary incontinence, sexual dysfunction, and intellectual deterioration.

It is important to note that MS symptoms can vary greatly between individuals and may change over time. Therefore, it is crucial for patients to work closely with their healthcare providers to manage their symptoms and receive appropriate treatment.

Smoking cessation is the process of quitting smoking. In 2008, NICE released guidance on how to manage smoking cessation. The guidance recommends that patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion, and that clinicians should not favour one medication over another. These medications should be prescribed as part of a commitment to stop smoking on or before a particular date, and the prescription should only last until 2 weeks after the target stop date. If unsuccessful, a repeat prescription should not be offered within 6 months unless special circumstances have intervened. NRT can cause adverse effects such as nausea and vomiting, headaches, and flu-like symptoms. NICE recommends offering a combination of nicotine patches and another form of NRT to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

Varenicline is a nicotinic receptor partial agonist that should be started 1 week before the patient’s target date to stop. The recommended course of treatment is 12 weeks, but patients should be monitored regularly and treatment only continued if not smoking. Varenicline has been shown in studies to be more effective than bupropion, but it should be used with caution in patients with a history of depression or self-harm. Nausea is the most common adverse effect, and varenicline is contraindicated in pregnancy and breastfeeding.

Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist that should be started 1 to 2 weeks before the patient’s target date to stop. There is a small risk of seizures, and bupropion is contraindicated in epilepsy, pregnancy, and breastfeeding. Having an eating disorder is a relative contraindication.

In 2010, NICE recommended that all pregnant women should be tested for smoking using carbon monoxide detectors. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services. The first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing, or structured self-help and support from NHS Stop Smoking Services. The evidence for the use of NRT in pregnancy is mixed, but it is often used if the above measures fail. There is no evidence that it affects the child’s birthweight. Pregnant women

Caution and Monitoring for Varenicline Use in Patients with Mental Illness

Patients with a history of mental illness should exercise caution when taking varenicline and be closely monitored during treatment. This medication may worsen underlying psychiatric conditions. Patients should be advised to discontinue use and seek medical attention immediately if they experience suicidal thoughts, depressed mood, or agitation.

Varenicline treatment typically begins one to two weeks before the target stop date. The initial dose is 500 micrograms once daily for three days, followed by 500 micrograms twice daily for four days, and then 1 mg twice daily for 11 weeks. If the 1 mg dose is not well-tolerated, the patient may continue with 500 micrograms twice daily.

It is important to note that there is no disulfiram-type reaction between alcohol and varenicline. However, patients should be aware that bupropion is associated with an increased risk of seizures and requires blood pressure monitoring before and during treatment.

Understanding Chronic Rhinosinusitis

Chronic rhinosinusitis is a common condition that affects approximately 10% of the population. It is characterized by inflammation of the nasal passages and paranasal sinuses that lasts for 12 weeks or more. There are several factors that can predispose individuals to this condition, including atopy, nasal obstruction, recent infections, swimming/diving, and smoking.

Symptoms of chronic rhinosinusitis include facial pain, nasal discharge, nasal obstruction, and post-nasal drip. Treatment options include avoiding allergens, using intranasal corticosteroids, and nasal irrigation with saline solution. However, it is important to be aware of red flag symptoms such as unilateral symptoms, persistent symptoms despite treatment, and epistaxis, which may require further evaluation and management.

In summary, chronic rhinosinusitis is a common inflammatory disorder that can cause significant discomfort and impact quality of life. Understanding the predisposing factors and symptoms, as well as appropriate management strategies, can help individuals effectively manage this condition.

If a patient with scarlet fever has a penicillin allergy and doesn’t require hospitalization, they should be treated with oral azithromycin for 5 days, as per the current NICE CKS guidance. For patients without a penicillin allergy, a 10-day course of oral phenoxymethylpenicillin (penicillin V) or amoxicillin (if there are difficulties swallowing tablets) is recommended. Scarlet fever is a notifiable disease, and healthcare professionals should complete a notification form and send it to Public Health England (PHE) within 3 days if there is a suspicion of the disease.

Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the highest incidence at 4 years. The disease is spread through respiratory droplets or direct contact with nose and throat discharges. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. Scarlet fever is usually a mild illness, but it may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications.

To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be started immediately, rather than waiting for the results. Management involves oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics, and scarlet fever is a notifiable disease. Desquamation occurs later in the course of the illness, particularly around the fingers and toes. The rash is often described as having a rough ‘sandpaper’ texture, and children often have a flushed appearance with circumoral pallor. Invasive complications such as bacteraemia, meningitis, and necrotizing fasciitis are rare but may present acutely with life-threatening illness.

Understanding Eye Conditions: Posterior Vitreous Detachment, Refractive Errors, and Other Symptoms

A posterior vitreous detachment is a condition where the vitreous humor, the gel-like substance in the eye, separates from the retina. Myopia, or short-sightedness, is a risk factor for this condition as well as retinal detachment and tears. Refractive errors such as astigmatism and hypermetropia can also affect vision, causing blurred vision at near and far distances. Miosis, or a constricted pupil, can occur for various reasons including senile miosis, opioid toxicity, and Horner’s syndrome. Ptosis, or drooping of the upper eyelid, can also affect vision and is a feature of Horner’s syndrome, which has a triad of symptoms including miosis, ptosis, and anhidrosis. Understanding these eye conditions and symptoms can help individuals seek appropriate medical attention and treatment.

Understanding Bone Metastases: Common Sites and Impacts

Bone metastases are a significant source of morbidity for cancer patients, causing severe pain, mobility issues, fractures, spinal cord compression, bone marrow problems, and hypercalcemia. The most common sites for bone metastases are the spine, pelvis, ribs, skull, and proximal long bones, with breast, prostate, and lung cancer responsible for over 80% of cases. Once cancer cells invade bone, they stimulate osteoblastic or osteolytic activity, leading to a cycle of bone destruction and tumor growth.

Spinal metastases are particularly problematic, causing pain, instability, and neurological damage. Breast and prostate cancer are the most common sources of skeletal metastases, with median survival rates ranging from 20 months for breast cancer to 53 months for prostate cancer with bone-only disease. Pathologic fractures are common, with the femur being the most frequent site. Pelvic metastases are common in prostate cancer, while rib fractures and vertebral collapses can lead to lung disease. Skull metastases are usually a late event, causing cosmetic issues or neurological damage.

Understanding the common sites and impacts of bone metastases is crucial for effective treatment and management of cancer patients.

Symptoms of Sleep Apnoea

Sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Apart from this, there are other common symptoms that may be experienced by individuals with this condition. These include apparent personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less common symptom. Sleep apnoea may also be associated with other medical conditions such as acromegaly, myxoedema, obesity, and micrognathia/retrognathia.

Understanding Migraine: Symptoms, Triggers, and Diagnostic Criteria

Migraine is a primary headache that affects a significant portion of the population. It is characterized by a severe, throbbing headache that is usually felt on one side of the head. Other symptoms include nausea, sensitivity to light and sound, and a duration of up to 72 hours. During an attack, patients often seek a quiet, dark room to alleviate their symptoms. Some patients may experience an aura before the onset of a migraine attack, which is a visual disturbance that can last up to an hour.

Migraine is more common in women, with a prevalence of 18% compared to 6% in men. There are several triggers that can precipitate a migraine attack, including stress, lack of sleep, certain foods, and hormonal changes. The diagnosis of migraine is based on specific criteria established by the International Headache Society, which includes the frequency and duration of attacks, the location and quality of pain, and the presence of associated symptoms.

There are also variants of migraine, such as hemiplegic migraine, which is characterized by motor weakness as a manifestation of aura. This type of migraine is rare, affecting only around 1 in 1,000 migraine patients, and is more common in adolescent females.

In summary, understanding the symptoms, triggers, and diagnostic criteria of migraine can help patients manage their condition and seek appropriate treatment.

Treatment Recommendations for Childhood Eczema

Topical tacrolimus and pimecrolimus should only be used in children with eczema who have not responded to other treatments. antihistamines are not typically recommended for childhood eczema unless there is a specific issue with itching. However, emollients should be applied generously and can even be covered with a local bandage during the initial stages of treatment. It is important to follow these guidelines to effectively manage childhood eczema and provide relief for the child.

Understanding the Clinical Signs of Complete Heart Block

Complete heart block is a condition where there is a complete failure of conduction through the atrioventricular node, resulting in bradycardia and potential symptoms such as dizziness, fatigue, dyspnea, and chest pain. Here are some clinical signs to look out for when assessing a patient with complete heart block:

Irregular Cannon ‘A’ Waves on Jugular Venous Pressure: Cannon waves are large A waves that occur irregularly when the right atrium contracts against a closed tricuspid valve. In complete heart block, these waves occur randomly due to atrioventricular dissociation.

Low-Volume Pulse: Complete heart block doesn’t necessarily create a low-volume pulse. This is typically found in other conditions such as shock, left ventricular dysfunction, or mitral stenosis.

Irregularly Irregular Pulse: The ‘escape rhythms’ in third-degree heart block usually produce a slow, regular pulse that doesn’t vary with exercise. Unless found in combination with another condition such as atrial fibrillation, the pulse should be regular.

Collapsing Pulse: A collapsing pulse is typically associated with aortic regurgitation and would not be expected with complete heart block alone.

Loud Second Heart Sound: In complete heart block, the intensity of the first and second heart sound varies due to the loss of atrioventricular synchrony. A consistently loud second heart sound may be found in conditions such as pulmonary hypertension.

By understanding these clinical signs, healthcare professionals can better diagnose and manage patients with complete heart block.

Diagnostic Methods for Trichomoniasis in Women

Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis. In women, it can cause symptoms such as vaginal discharge, itching, and pain during sex. To diagnose trichomoniasis, several diagnostic methods are available.

Culture of a vaginal swab is the standard for diagnosis. It is more sensitive and specific than microscopy. Swab specimens may be obtained by the patient, making it useful in resource-poor settings. The GP may also consider testing for other sexually transmitted diseases such as chlamydia and gonorrhoea.

Cervical smear has a low sensitivity for detecting Trichomonas and is not used for this purpose. The ‘whiff test’ (amine odour test) and vaginal pH test are not accurate means of diagnosing trichomoniasis as they may also indicate bacterial vaginosis.

Wet-mount microscopy has historically been used to diagnose trichomoniasis in women. However, it has a low sensitivity in detecting T vaginalis and specimens have to be examined fresh.

In conclusion, culture of a vaginal swab is the most reliable method for diagnosing trichomoniasis in women.

Diabetic Ketoacidosis: A Serious Condition Requiring Hospital Management

Diabetic ketoacidosis is a life-threatening condition that occurs due to absolute insulin deficiency, which is almost exclusively seen in type 1 diabetes. It carries a mortality rate of up to 5% and requires immediate hospital management.

The accumulation of ketones in the body leads to metabolic acidosis, which is compensated for by respiratory mechanisms. Hyperkalaemia is often present at the time of presentation, but it can be resolved quickly with insulin therapy and fluid resuscitation.

It is important to note that starting antibiotics or increasing insulin in a domiciliary setting is not appropriate for managing diabetic ketoacidosis. This condition requires prompt medical attention and close monitoring to prevent complications and improve outcomes.

Post-Exposure Prophylaxis for Viral Infections

Post-exposure prophylaxis (PEP) is a preventive treatment given to individuals who have been exposed to a viral infection. The type of PEP given depends on the virus and the clinical situation. For hepatitis A, either human normal immunoglobulin or the hepatitis A vaccine may be used. For hepatitis B, the PEP given depends on whether the source is known to be positive for HBsAg or not. If the person exposed is a known responder to the HBV vaccine, then a booster dose should be given. If they are a non-responder, they need to have hepatitis B immune globulin and a booster vaccine. For hepatitis C, monthly PCR is recommended, and if seroconversion occurs, interferon +/- ribavirin may be given. For HIV, a combination of oral antiretrovirals should be given as soon as possible for four weeks. The risk of HIV transmission depends on the incident and the current viral load of the patient. For varicella zoster, VZIG is recommended for IgG negative pregnant women or immunosuppressed individuals. The risk of transmission for single needlestick injuries varies depending on the virus, with hepatitis B having a higher risk than hepatitis C and HIV.

Overall, PEP is an important preventive measure for individuals who have been exposed to viral infections. It is crucial to determine the appropriate PEP based on the virus and the clinical situation to ensure the best possible outcome.

Diagnosing Chest Tightness and Palpitations in Primary Care

Symptoms of chest tightness and palpitations are common in primary care, but diagnosing the underlying cause can be challenging. Episodic symptoms often require catching the symptoms during an attack to make an accurate diagnosis. Patients may describe a previous attack, but positive examination findings are often lacking when they are asymptomatic. Therefore, history is crucial, and patients should seek review when experiencing symptoms.

In this case, the patient presented with high blood pressure, tachycardia, and glycosuria during an attack. The episodic nature of the symptoms suggested panic attacks, phaeochromocytoma, or a paroxysmal tachyarrhythmia such as Wolff-Parkinson-White (WPW) syndrome. However, WPW typically causes paroxysmal supraventricular tachycardia and would not cause glycosuria. Panic attacks would not cause glycosuria, and the severity of the hypertension would go against this diagnosis. Phaeochromocytoma unifies the history and clinical features and is the underlying disorder.

Phaeochromocytoma is a rare tumour that produces catecholamines and causes episodes of hypertension, chest tightness, sweating, tremor, and flushing. Glycosuria occurs in approximately 30% of patients during an attack. Diagnosis is made by a 24-hour urine collection for metanephrines, and surgical removal is the treatment of choice.

Implications of Unintended Pregnancy and Contraceptive Efficacy

The risk of unintended pregnancy varies among different contraceptive methods. The Progestogen implant has the lowest failure rate at 0.05% in the first year of use, while the COCP has a failure rate of 9%. However, the implications of an unintended pregnancy for an individual patient must be considered when advising on contraception. In this case, the patient’s FEV1 and BMI suggest that the consequences of an unintended pregnancy would be very serious.

Furthermore, while the COCP may not be a suitable option for this patient due to its high failure rate, her potential risk factors for developing VTE should also be taken into account. Despite having a negative personal and family history, normotension, non-smoking status, and BMI <30 kg/m2, her frequent hospital admissions and indwelling intravenous catheters may increase her risk of developing VTE. Therefore, careful consideration is necessary when selecting a contraceptive method for this patient.

Pyogenic Granuloma: A Common Benign Skin Lesion

Pyogenic granuloma is a benign skin lesion that is relatively common. Despite its name, it is not a true granuloma nor is it pyogenic in nature. It is also known as an eruptive haemangioma. The cause of pyogenic granuloma is unknown, but it is often linked to trauma and is more common in women and young adults. The most common sites for these lesions are the head/neck, upper trunk, and hands. Lesions in the oral mucosa are common during pregnancy.

Pyogenic granulomas initially appear as small red/brown spots that rapidly progress within days to weeks, forming raised, red/brown spherical lesions that may bleed profusely or ulcerate. Lesions associated with pregnancy often resolve spontaneously postpartum, while other lesions usually persist. Removal methods include curettage and cauterisation, cryotherapy, and excision.

In summary, pyogenic granuloma is a common benign skin lesion that can be caused by trauma and is more common in women and young adults. It appears as small red/brown spots that rapidly progress into raised, red/brown spherical lesions that may bleed or ulcerate. Lesions associated with pregnancy often resolve spontaneously, while other lesions usually persist and can be removed through various methods.

Brucellosis: A Zoonotic Infection from Farm Animals

Brucellosis is a zoonotic infection that occurs due to contact with farm animals such as sheep, goats, pigs, cattle, or dogs. It is most commonly seen in farmers, vets, or abattoir workers. Although rare in UK residents, it is prevalent worldwide and caused by Brucella melitensis and Brucella abortus. The infection can be acquired through inhalation, ingestion, or a break in the skin.

The incubation period ranges from 1 week to 3 months, and the symptoms include fever (usually undulant), sweating, weight loss, myalgia, arthralgia, and mild depression. Hepatosplenomegaly may also be present, and the white cell count may be normal or low. Antibody testing confirms the diagnosis, and treatment involves a combination of doxycycline and rifampicin for at least 6 weeks. Shorter courses are associated with a high relapse rate.

The 2014 NICE lipid modification guidelines provide recommendations for familial hyperlipidaemia. Individuals with a total cholesterol concentration above 7.5 mmol/litre and a family history of premature coronary heart disease should be investigated for familial hypercholesterolaemia as described in NICE clinical guideline 71. Those with a total cholesterol concentration exceeding 9.0 mmol/litre or a nonHDL cholesterol concentration above 7.5 mmol/litre should receive specialist assessment, even if they do not have a first-degree family history of premature coronary heart disease.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

When presented with a young female who is obese and experiencing headaches and blurred vision, it is important to consider idiopathic intracranial hypertension as a potential diagnosis, especially if there is evidence of papilloedema but no other neurological abnormalities.

Understanding Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension, also known as pseudotumour cerebri, is a medical condition that is commonly observed in young, overweight females. The condition is characterized by a range of symptoms, including headache, blurred vision, and papilloedema, which is usually present. Other symptoms may include an enlarged blind spot and sixth nerve palsy.

There are several risk factors associated with idiopathic intracranial hypertension, including obesity, female sex, pregnancy, and certain drugs such as the combined oral contraceptive pill, steroids, tetracyclines, vitamin A, and lithium.

Management of idiopathic intracranial hypertension may involve weight loss, diuretics such as acetazolamide, and topiramate, which can also cause weight loss in most patients. Repeated lumbar puncture may also be necessary, and surgery may be required to prevent damage to the optic nerve. This may involve optic nerve sheath decompression and fenestration, or a lumboperitoneal or ventriculoperitoneal shunt to reduce intracranial pressure.

It is important to note that if intracranial hypertension is thought to occur secondary to a known cause, such as medication, it is not considered idiopathic. Understanding the risk factors and symptoms associated with idiopathic intracranial hypertension can help individuals seek appropriate medical attention and management.

For a pregnant woman in the third trimester with a UTI, the recommended antibiotic treatment is amoxicillin for seven days. Nitrofurantoin is the first-line antibiotic, but it should be avoided later in pregnancy due to potential harm to the baby. Cefalexin is also an appropriate second-line option. It is important to obtain a urine sample for testing before starting treatment and to confirm cure with a follow-up test. Hospital admission is not necessary unless there are signs of sepsis or pyelonephritis or pregnancy complications. Empirical therapy should be initiated promptly, and treatment can be adjusted based on sensitivity results if necessary.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.

Risk Factors for Prostate Cancer

Being overweight or obese are both risk factors for developing prostate cancer. Black ethnicity is associated with a higher risk of prostate cancer than Caucasian. A family history of breast cancer or prostate cancer also increases the risk. Additionally, an occupation in farming seems to increase the risk of prostate cancer.

High intake of animal fats and low selenium intake, as well as exposure to radiation and cadmium, may also increase the risk of prostate cancer. However, there isn’t enough evidence to be absolutely sure in the case of cadmium. It’s important to be aware of these risk factors and to discuss any concerns with a healthcare provider.

Understanding Beta Thalassaemia Trait: Symptoms, Diagnosis, and Differences from Other Blood Disorders

Beta thalassaemia trait is a genetic blood disorder that affects the production of beta globin, a protein that makes up part of the haemoglobin molecule. This condition is autosomal-recessive, meaning that it only occurs when both parents carry the gene mutation. Individuals with beta thalassaemia trait have a mild form of microcytic hypochromic anaemia, which can be detected through blood tests that show a normal red cell count and mean cell haemoglobin concentration, but an elevated level of haemoglobin A2.

It is important to distinguish beta thalassaemia trait from other blood disorders, such as acute folic acid deficiency, alpha thalassaemia trait, iron deficiency, and sickle cell anaemia. Acute folic acid deficiency typically occurs after tissue damage or renal failure, while alpha thalassaemia trait is caused by a deficiency in alpha globin production. Iron deficiency can coexist with beta thalassaemia trait, but cannot be diagnosed based on microcytosis alone. Sickle cell anaemia is a separate condition that involves homozygosity for the sickle cell haemoglobin mutation.

Diagnosis of beta thalassaemia trait requires measuring the alpha-beta chain synthesis ratio or performing genetic tests. While beta thalassaemia trait is usually asymptomatic and doesn’t cause problems during pregnancy, it is important to screen both partners to assess the risk of having a child with beta thalassaemia major, a more severe form of the disorder that can lead to life-threatening complications.

Arthroscopic Lavage and Debridement for Osteoarthritis

Patients with osteoarthritis may present with various signs and symptoms, but only a small percentage may benefit from arthroscopic lavage and debridement. This procedure is recommended for patients who have a clear history of mechanical locking of the knee, which is caused by meniscal lesions or loose bodies in the knee. Referral for arthroscopic intervention should only be offered to patients with this specific symptom.

It is important to note that other symptoms of osteoarthritis, such as gelling or giving way, or x-ray evidence of loose bodies, do not warrant referral for arthroscopic lavage and debridement. According to NICE guidelines, this procedure should not be offered for the treatment of any other symptoms of osteoarthritis.

In summary, arthroscopic lavage and debridement is only recommended for patients with a clear history of mechanical locking of the knee. Other symptoms of osteoarthritis do not warrant referral for this procedure.

Tips for Travelling with Insulin

Many patients with diabetes experience hypoglycaemia when travelling to different time zones. To avoid this, it is recommended to reduce the total daily insulin dose by 2-4% per hour of time difference. For example, a trip to Australia may require a reduction of around 30% during the flight and the first few days of adjusting to the time difference.

When travelling with insulin, it is important to carry a membership card from the local diabetes society and a letter from the doctor to make it easier to travel with needles and syringes. Insulin should not be stored in the hold as it may freeze and form crystals. If it must be stored in the hold, it should be placed in an airtight container and packed in the middle of the suitcase. After landing, it should be checked for crystals and thrown away if any are seen.

Airline rules allow staff to store excessive needles and insulin supplies for the duration of the journey. By following these tips, patients with diabetes can travel safely and comfortably with their insulin.

Duration of Nicotine Replacement Therapy and Other Medications for Smoking Cessation

The recommended duration for prescribing nicotine replacement therapy (NRT), varenicline, or bupropion is until two weeks after the target stop date. For NRT, this typically means two weeks of therapy, while varenicline and bupropion may require three to four weeks. It is important to adhere to this timeline to ensure the effectiveness of the medication and to avoid potential side effects from prolonged use. By following this guideline, individuals can increase their chances of successfully quitting smoking and improving their overall health.

For a patient presenting with Bell’s palsy and eye symptoms, it is important to commence on a course of prednisolone and provide eye care advice. Lubricating eye drops should be used frequently during the day, eye ointment used at night, and the affected eye should be taped closed at night using microporous tape. Aciclovir may be considered if Ramsay Hunt syndrome is suspected. Referral to an ophthalmologist is advised if the patient reports eye symptoms. Urgent referral to an appropriate specialist is necessary if the patient has worsening neurologic findings, features suggestive of an upper motor neurone cause, features suggestive of cancer, systemic or severe local infection, or trauma. However, none of these features are present in this patient.

Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It typically affects individuals between the ages of 20 and 40, and is more common in pregnant women. The condition is characterized by a lower motor neuron facial nerve palsy that affects the forehead, while sparing the upper face. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

The management of Bell’s palsy has been a topic of debate, with various treatment options proposed in the past. However, there is now consensus that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, with some experts recommending it for severe cases. Eye care is also crucial to prevent exposure keratopathy, and patients may need to use artificial tears and eye lubricants. If they are unable to close their eye at bedtime, they should tape it closed using microporous tape.

Follow-up is essential for patients who show no improvement after three weeks, as they may require urgent referral to ENT. Those with more long-standing weakness may benefit from a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within three to four months. However, untreated cases can result in permanent moderate to severe weakness in around 15% of patients.

Labial adhesions or fusion is a common occurrence in pre-pubertal females, often caused by a lack of oestrogen. However, it typically resolves on its own and treatment is not usually necessary. Symptoms of contact dermatitis include dry, irritated skin and itching. Imperforate hymen is a congenital disorder that obstructs the vagina. Lichen sclerosus is a skin disorder characterized by itching and white patches on the affected skin. Vulvovaginitis in girls causes discomfort and soreness during urination, and may also result in discharge.

Labial Adhesions: Causes, Symptoms, and Treatment

Labial adhesions refer to the fusion of the labia minora in the middle, which is commonly observed in girls aged between 3 months and 3 years. This condition can be treated conservatively, and spontaneous resolution usually occurs around puberty. It is important to note that labial adhesions are different from an imperforate hymen.

Symptoms of labial adhesions include problems with urination, such as pooling in the vagina. Upon examination, thin semitranslucent adhesions covering the vaginal opening between the labia minora may be seen, which can sometimes cover the vaginal opening completely.

Conservative management is usually appropriate for most cases of labial adhesions. However, if there are associated problems such as recurrent urinary tract infections, oestrogen cream may be tried. If this fails, surgical intervention may be necessary.

In summary, labial adhesions are a common condition in young girls that can cause problems with urination. While conservative management is usually effective, medical intervention may be necessary in some cases.

Maternal Rubella and Fetal Damage

Maternal rubella infection during the first 8-10 weeks of pregnancy can result in fetal damage in as many as 90% of infants, with multiple defects being common. However, the risk of fetal damage decreases to 10-20% by 16 weeks gestation. After 16 weeks, fetal damage due to maternal rubella infection is rare. It is important for pregnant women to ensure they are vaccinated against rubella to prevent potential harm to their developing fetus.

According to NICE guidelines, dipstick testing for leukocyte esterase and nitrite is just as effective as microscopy and culture for diagnosing UTIs in children over the age of 3. If both leukocytes and nitrites are positive, the child should be treated for a UTI with antibiotics. If the child has a high or intermediate risk of serious illness or has had a UTI in the past, a urine sample should be sent for culture. If nitrites are positive but leukocytes are negative, antibiotics should be started and a urine sample should be sent for culture. If leukocytes are positive but nitrites are negative, a urine sample should be sent for microscopy and culture. It is important to only prescribe antibiotics if there is clear clinical evidence of a UTI, such as dysuria. If the dipstick is negative, another cause for the symptoms should be investigated and urine should not be sent for culture.

Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment

Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.

According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.

Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to the hospital. If not admitted, oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days. Children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.

Understanding Different Types of Dementia: Differential Diagnosis for Memory Impairment

Memory impairment is a common symptom in older adults, and it can be caused by various conditions, including dementia. Dementia affects approximately 5% of people over 65 and 20% of individuals over 80. Alzheimer’s disease is the most common cause of dementia, accounting for around 60% of cases. However, other types of dementia should also be considered in the differential diagnosis.

Depression is an important differential diagnosis in an older person presenting with memory impairment. Apathy and disconnection with activities that the patient previously enjoyed are common symptoms of depression. Mild cognitive impairment (MCI) is another condition that can cause memory impairment. However, MCI is characterized by memory impairment with preservation of other cognitive domains and intact activities of daily living.

Lewy-body dementia is a type of dementia that accounts for approximately 20% of cases. It usually presents with parkinsonism, fluctuating cognitive impairment, and visual hallucinations. Vascular dementia (vascular cognitive impairment) is another type of dementia caused by cerebrovascular disease. It is a progressive disease where deteriorations may be sudden or gradual but tend to progress in a stepwise manner.

In this case, the patient’s mini-mental state examination result supports the diagnosis of Alzheimer’s disease. The patient (or their relatives) commonly complains of difficulty with common activities of daily living and short-term memory loss. It is important to consider all possible causes of memory impairment to provide appropriate treatment and support for patients and their families.

As expected, the child’s respiratory rate is less than 30 breaths per minute and heart rate is less than 125 beats per minute. The appropriate treatment for this asthma attack is oral prednisolone and salbutamol via a spacer, with one puff every 30-60 seconds up to a maximum of 10 puffs. It is important to administer steroid therapy to all children experiencing an asthma attack. High flow oxygen and salbutamol nebuliser are not necessary as the child’s SP02 is already at 97%.

The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

The Benefits of Using Protocols in Healthcare

Good protocols are essential in healthcare as they define the exact circumstances in which they should be used. They can be helpful regardless of the grade of the staff using them and do not necessarily lead to dumbing down. In fact, clinicians who actively follow protocols may improve their knowledge and the level of care they provide. It is important to note that not all aspects of care can be recorded or controlled by protocols, but they can still be a valuable tool in enhancing confidence and career development. The course of a condition doesn’t have to be entirely predictable before a protocol can be used. By using protocols, standards, policies, and guidelines, healthcare professionals can provide consistent and effective care to their patients.

Correcting Hypothyroidism with Levothyroxine: Dosage and Risks

One of the main concerns with starting levothyroxine replacement for hypothyroidism is the risk of cardiac arrhythmias or myocardial ischemia, although rare. Therefore, initial low dosing is followed by gradual dose escalation until euthyroid status is achieved. Over-treatment can also lead to osteoporosis. The aim of treatment is to normalise serum TSH and improve thyroid hormone concentrations to the euthyroid state. Levothyroxine alone is the recommended treatment, with an initial dose of 50-100 µg once daily for patients aged 18-49 years, adjusted in steps of 25-50 µg every four weeks according to response. For patients with cardiac disease, severe hypothyroidism, and those over 50 years, the recommended initial dose is 25 µg once daily. Symptom relief may take many months after TSH levels have returned to normal, and persisting symptoms warrant further investigations for non-thyroid causes.

Levothyroxine Dosage and Risks in Correcting Hypothyroidism

The most probable diagnosis for a patient presenting with bilateral sciatica is cauda equina syndrome. This condition may be caused by malignant spread, which is more likely in patients with a history of smoking and advanced age, increasing the risk of prostate cancer. Bilateral claudication, Guillain-Barré syndrome, osteoarthritis, and peripheral neuropathy are less likely diagnoses as they do not present acutely with bilateral sciatica symptoms.

Understanding Cauda Equina Syndrome

Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. This can lead to permanent nerve damage and long-term leg weakness, as well as urinary and bowel incontinence. It is important to consider CES in any patient who presents with new or worsening lower back pain.

The most common cause of CES is a central disc prolapse, typically occurring at L4/5 or L5/S1. Other causes include tumors, infections, trauma, and hematomas. CES may present in a variety of ways, including low back pain, bilateral sciatica, reduced sensation or pins-and-needles in the perianal area, and decreased anal tone. Urinary dysfunction, such as incontinence, reduced awareness of bladder filling, and loss of urge to void, is also a possible symptom.

It is crucial to recognize that there is no one symptom or sign that can diagnose or exclude CES. However, checking anal tone in patients with new-onset back pain is good practice, even though studies show that it has poor sensitivity and specificity for CES. In case of suspected CES, an urgent MRI is necessary. The management of CES involves surgical decompression.

An optimal screening test would possess both high sensitivity and high specificity.

Sensitivity refers to the proportion of individuals with a particular disease who are correctly identified as having the disease by the test. In an ideal screening program, a high sensitivity would ensure that the majority of affected individuals are detected. The positive predictive value, which indicates the proportion of people with the disease among those who test positive, is less important than sensitivity in a screening test. A high positive predictive value doesn’t necessarily mean that most individuals with the disease would test positive, but rather that most of those who test positive have the disease.

Specificity, on the other hand, refers to the proportion of individuals without the disease who are correctly identified as not having the disease by the test. A screening program with high specificity would produce negative test results for those who do not have the disease, reducing the need for further, more invasive tests. It is crucial for a screening program to have few false positive results. The negative predictive value, which indicates the proportion of people without the disease among those who test negative, is not relevant to a screening program’s goals.

Screening for a particular condition should meet certain criteria, known as the Wilson and Jungner criteria. Firstly, the condition being screened for should be a significant public health concern. Secondly, there should be an effective treatment available for those who are diagnosed with the disease. Thirdly, facilities for diagnosis and treatment should be accessible. Fourthly, there should be a recognizable early stage of the disease. Fifthly, the natural progression of the disease should be well understood. Sixthly, there should be a suitable test or examination available. Seventhly, the test or examination should be acceptable to the population being screened. Eighthly, there should be a clear policy on who should be treated. Ninthly, the cost of screening and subsequent treatment should be economically balanced. Finally, screening should be an ongoing process rather than a one-time event.

Appropriate Management for a Patient Dealing with a Major Life Event

When a patient approaches their GP seeking advice and support for a major life event, it is important to provide appropriate management. Starting the patient on night sedatives or an SSRI antidepressant without an assessment for insomnia or depression would not be appropriate at this stage. Referring the patient to a Macmillan Cancer Care Nurse or community mental health services may be required in addition to providing ongoing GP support, but it would not be the initial next step. The initial management should focus on exploring the patient’s needs and offering ongoing GP support and follow-up, upon which later care strategies can be constructed. The GP is uniquely placed to provide medical and supportive care to the patient and possibly their wider family.

Appropriate Study Designs for Type 2 Diabetes Management

Historical controls are not suitable for evaluating the management of type 2 diabetes as targets have become more stringent over time. Additionally, it is not valid to assess an intervention without a comparator. National targets do not consider local factors such as ethnicity, deprivation, and resource provision. Therefore, the most appropriate study design is to compare the intervention’s effect in surgeries versus local controls, matched for other resources, age mix, ethnic mix, and social deprivation level.

Cross-over trials are ideal when there is reasonable evidence that patients will benefit from the treatment, and it would be unethical to withhold it from all patients. These trials are also useful when the treatment effect can be observed quickly. By using appropriate study designs, researchers can accurately evaluate the effectiveness of type 2 diabetes management strategies.

Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

Managing Low Vitamin B12 Levels: Recommendations and Considerations

When a patient presents with a vitamin B12 level at the lower end of the normal range, it is important to determine whether they are deficient or not. This can be complicated by the fact that people within the normal range can still experience symptoms of deficiency. In this case, the patient may have latent pernicious anaemia, dietary deficiency or food malabsorption, or be taking medications that affect gastric acid production.

To determine the cause of the low B12 levels, the serum vitamin B12 test should be repeated after 4-8 weeks. If levels remain unchanged or have fallen further, blood should be taken for intrinsic factor antibodies and a short trial of empirical therapy (oral cyanocobalamin 50 micrograms daily for four weeks) should be given. If the antibody test is positive, lifelong therapy with hydroxocobalamin is recommended. If it is negative, a further vitamin B12 check is recommended after 3-4 months. If this is well within the reference range, food malabsorption as the cause is a strong possibility and long-term low dose cobalamin therapy should be considered.

It is important to provide patients with strict instructions to seek immediate medical attention if symptoms of neuropathy develop. Additionally, failure of the B12 level to rise after oral treatment is an indication for lifelong treatment as for pernicious anaemia. Further investigations (plasma methylmalonic acid or holotranscobalamin) may help confirm biochemical deficiency.

In summary, managing low vitamin B12 levels requires careful consideration of the possible causes and appropriate testing and treatment. Repeat testing, testing for intrinsic factor antibodies, and a trial of oral cyanocobalamin are all important steps in determining the best course of action for each individual patient.

Understanding Patch Testing for Contact Allergic Dermatitis

Patch testing is a diagnostic tool used to identify substances that may be causing delayed hypersensitivity reactions, such as contact allergic dermatitis. This type of reaction occurs when the skin comes into contact with an allergen, resulting in a localized rash or inflammation. During patch testing, diluted chemicals are placed under patches on a small area of the back to produce a reaction. The chemicals included in the patch test kit are the most common offenders in cases of contact allergic dermatitis, including metals, rubber, leather, hair dyes, formaldehyde, lanolin, fragrance, preservatives, and other additives. If a patient has identified a possible allergen, such as shavings from the inside of gloves, it can be included in the test. Patches are removed after 48 hours, and the skin is inspected for reactions. The patient may return after 96 hours to check for late reactions.

Skin-prick testing, intradermal testing, and measurement of specific IgE are used to investigate immediate hypersensitivity reactions. However, direct exposure to gloves is not usually helpful in diagnosing contact allergic dermatitis, as the patient needs to continue wearing them. Additionally, not all cases of hand eczema are allergic in origin and may be caused by constitutional eczema or irritant dermatitis. In these cases, patch testing may be negative or show an irrelevant result. Understanding patch testing and its limitations can help healthcare providers accurately diagnose and treat contact allergic dermatitis.

Diagnosing Death: Common Methods

The diagnosis of death is typically determined by the absence of vital signs, which includes the absence of a pulse, heart sounds, respiratory function, and pupillary light reflex. Brain stem tests are typically only used in cases where organ transplantation may be necessary and the patient is on a ventilator. It is important to note that doctors are typically the ones who diagnose death, not the coroner who provides a verdict on the cause of death. By using these methods, medical professionals can accurately determine when a patient has passed away.

During intercurrent illness such as diarrhoea and vomiting, it is important to suspend the use of metformin as it increases the risk of lactic acidosis. Increasing the dose of ramipril is not recommended as it may increase the risk of electrolyte disturbance while the patient is unwell. Similarly, there is no indication to double the dose of lansoprazole. Suspending ramipril is also not necessary as there is no evidence of acute electrolyte disturbance. However, reducing the dose of paracetamol to 500mg may be considered for patients with a low body weight.

The following table provides a summary of the typical side-effects associated with drugs used to treat diabetes mellitus. Metformin is known to cause gastrointestinal side-effects and lactic acidosis. Sulfonylureas can lead to hypoglycaemic episodes, increased appetite and weight gain, as well as the syndrome of inappropriate ADH secretion and cholestatic liver dysfunction. Glitazones are associated with weight gain, fluid retention, liver dysfunction, and fractures. Finally, gliptins have been linked to pancreatitis.

Importance of Checking Visual Acuity in Ocular Examinations

Regardless of the presenting complaints related to the eyes, the first step in any ocular examination is to check and document the patient’s visual acuity (VA). This can be done using a Snellen chart or any other acceptable form of VA measurement.

Checking VA is crucial as it provides a baseline for future assessments and helps in determining the progression of any ocular condition. It is also important to document VA as it can have medico-legal implications in some cases.

Therefore, before attempting any other form of ocular examination, it is essential to check and document the patient’s VA. This simple step can provide valuable information for the diagnosis and management of ocular conditions.

Anorexia nervosa is a prevalent mental health condition that primarily affects teenage and young-adult females. It is the most common reason for admissions to child and adolescent psychiatric wards. The disorder is characterized by a restriction of energy intake, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Patients with anorexia nervosa also experience an intense fear of gaining weight or becoming fat, even though they are underweight. They may also have a distorted perception of their body weight or shape, which can affect their self-evaluation.

• The BMI should be < 16.5 kg/m² before making the diagnosis:
  • This is not accurate. The DSM-5 criteria for anorexia nervosa include a significantly low body weight relative to the individual’s age, sex, developmental trajectory, and physical health, but it does not specify a precise BMI threshold like <16.5 kg/m².
• If amenorrhoea is present a hormonal disorder needs to be excluded:
  • This is accurate. While amenorrhoea is a common feature of anorexia nervosa, it is important to rule out other potential causes of amenorrhoea, such as hormonal disorders, to ensure an accurate diagnosis.
• It is the most common cause of admissions to child and adolescent psychiatric wards:
  • This is not accurate. While anorexia nervosa is a significant cause of admissions, other conditions such as depression and anxiety disorders are generally more common causes of psychiatric admissions in this age group.
• Around 75-80% of the patients are female:
  • This is accurate in general, but the figure is typically closer to 90%, making it less precise. Anorexia nervosa predominantly affects females, but the exact percentage is often reported higher than 75-80%.
• Has a good prognosis if treated:
  • This is not accurate. Anorexia nervosa has a variable prognosis and can be quite severe with significant mortality and morbidity. While some individuals do recover completely, others may have a chronic course with relapses. Unfortunately, the prognosis for patients with anorexia nervosa remains poor, with up to 10% of patients eventually dying because of the disorder.

The management of anorexia nervosa varies depending on the age of the patient. For adults, NICE recommends individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), or specialist supportive clinical management (SSCM). In children and young people, NICE recommends ‘anorexia focused family therapy’ as the first-line treatment, followed by cognitive behavioural therapy as the second-line treatment.

Treatment Options for Irritable Bowel Syndrome (IBS)

When it comes to treating irritable bowel syndrome (IBS), there are several options available. The National Institute for Health and Care Excellence (NICE) recommends tricyclic antidepressants as a second-line treatment if other medications have not been effective. Treatment should start at a low dose and be reviewed regularly. Acupuncture and aloe vera are not recommended by NICE for the treatment of IBS. It is suggested to limit intake of high-fibre foods and increase intake of fresh fruit, but to limit it to three portions per day. It’s important to consult with a healthcare professional to determine the best treatment plan for individual needs.

Conditions that can present with extensor plantars and absent ankle jerk, along with mixed upper and lower motor neuron signs, include motor neuron disease, subacute combined degeneration of the cord, and syringomyelia. Other possible conditions to consider are diabetic neuropathy and myasthenia gravis.

Absent Ankle Jerks and Extensor Plantars: Causes and Implications

When a patient presents with absent ankle jerks and extensor plantars, it is typically indicative of a lesion that affects both the upper and lower motor neurons. This combination of signs can be caused by a variety of conditions, including subacute combined degeneration of the cord, motor neuron disease, Friedreich’s ataxia, syringomyelia, taboparesis (syphilis), and conus medullaris lesion.

The absence of ankle jerks suggests a lower motor neuron lesion, while the presence of extensor plantars indicates an upper motor neuron lesion. This combination of signs can help clinicians narrow down the potential causes of the patient’s symptoms and develop an appropriate treatment plan.

It is important to note that absent ankle jerks and extensor plantars are not always present in the same patient, and their presence or absence can vary depending on the underlying condition. Therefore, a thorough evaluation and diagnostic workup are necessary to accurately diagnose and treat the patient.