GBS is a type of bacteria commonly found in the vagina of many women. While it is generally harmless, it can cause serious infections in newborns, leading to significant health problems and even death.

If GBS is detected during pregnancy, it does not require immediate treatment as it will not reduce the likelihood of transmission to the baby during delivery. However, intravenous benzylpenicillin or clindamycin is necessary during labor to reduce the risk of transmission. This applies to GBS found in vaginal swabs and urine, and appropriate antibiotics are required for GBS urinary tract infections during pregnancy.

There is currently no screening program for GBS in the UK, and vaginal swabs should only be taken when clinically necessary. Women who have had a previous baby infected with GBS are offered intrapartum intravenous benzylpenicillin in future pregnancies.

(Source – RCOG guidelines, GBS in pregnancy).

Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.

When there is excessive menstrual bleeding without any underlying medical condition, it is referred to as dysfunctional uterine bleeding. Endometriosis typically causes pain a few days before menstruation and painful intercourse. The absence of fibroids and polyps is indicated by a normal ultrasound scan, and this condition is more prevalent in older women. Although a clotting disorder must be ruled out, the blood test results suggest that it is improbable.

Understanding Menorrhagia: Causes and Definition

Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

The vignette describes classic symptoms of pericarditis, including a sharp central chest pain that is relieved by sitting up and leaning forward, but worsened by lying flat or taking deep breaths. The patient’s past medical history of systemic lupus also increases the likelihood of pericarditis. On auscultation, scratchy, rubbing S1 and S2 sounds can be heard. The most likely ECG finding in this case is saddle shaped ST elevation, which is a hallmark of pericarditis. Other potential causes of ST elevation include STEMI and left bundle branch block, but these can be ruled out based on the symptoms and examination findings. Narrow peaking T waves are often seen in hyperkalaemia, but this is not the most likely ECG finding in this case.

Understanding Acute Pericarditis

Acute pericarditis is a medical condition characterized by inflammation of the pericardial sac that lasts for less than 4-6 weeks. The condition can be caused by various factors such as viral infections, tuberculosis, uraemia, post-myocardial infarction, autoimmune pericarditis, radiotherapy, connective tissue disease, hypothyroidism, malignancy, and trauma. Symptoms of acute pericarditis include chest pain, non-productive cough, dyspnoea, and flu-like symptoms. Patients may also experience pericardial rub.

To diagnose acute pericarditis, doctors may perform an electrocardiogram (ECG) to check for changes in the heart’s electrical activity. Blood tests may also be conducted to check for inflammatory markers and troponin levels. Patients suspected of having acute pericarditis should undergo transthoracic echocardiography.

Treatment for acute pericarditis depends on the underlying cause. Patients with high-risk features such as fever or elevated troponin levels may need to be hospitalized. However, most patients with pericarditis secondary to viral infection can be managed as outpatients. Strenuous physical activity should be avoided until symptoms resolve and inflammatory markers normalize. A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is typically used as first-line treatment for patients with acute idiopathic or viral pericarditis. The medication is usually tapered off over 1-2 weeks.

Overall, understanding acute pericarditis is important for prompt diagnosis and appropriate management of the condition.

Treatment Options for Ventricular Tachycardia

Ventricular tachycardia is a serious cardiac arrhythmia that requires prompt treatment. The Resuscitation Council tachycardia guideline recommends immediate synchronised electrical cardioversion for unstable patients with ventricular tachycardia who exhibit adverse features such as shock, myocardial ischaemia, syncope, or heart failure. Synchronised cardioversion is preferred over unsynchronised cardioversion as it reduces the risk of causing ventricular fibrillation or cardiac arrest.

In the event that synchronised cardioversion fails to restore sinus rhythm after three attempts, a loading dose of amiodarone 300 mg IV should be given over 10-20 minutes, followed by another attempt of cardioversion. However, in an uncompromised patient with tachycardia and no adverse features, the first-line treatment involves amiodarone 300 mg as a loading dose IV, followed by an infusion of 900 mg over 24 hours.

It is important to note that digoxin and metoprolol are not appropriate treatments for ventricular tachycardia. Digoxin is used in the treatment of atrial fibrillation, while metoprolol is a β blocker that should be avoided in patients with significant hypotension, as it can further compromise the patient’s condition.

There are several medications used to treat heart failure, including ACE inhibitors and beta-blockers, which have been shown to provide a mortality benefit. However, ACE inhibitors can cause hyperkalaemia, so potassium levels should be monitored closely when starting. If ACE inhibitors are not tolerated, angiotensin II receptor antagonists can be used instead. Atenolol is not recommended for use in heart failure, and agents typically used are bisoprolol, carvedilol, or metoprolol. Diuretics like furosemide and bendroflumethiazide provide symptom relief but do not improve mortality. When used together, they have a potent diuretic effect that may be required when patients accumulate fluid despite an adequate furosemide dose. However, this combination provides no long-term mortality benefit. It is important to note that decisions regarding medication management should be made by a specialist.

For patients experiencing recurrent vaginal candidiasis, it is recommended to consider an induction-maintenance regime of oral fluconazole. Over the counter antifungal treatments, such as clotrimazole cream, are typically effective for one-off episodes of thrush. However, in cases of recurrent symptoms, a more comprehensive treatment plan may be necessary. It is important to ensure that the patient is not taking SSRI medications or has hypersensitivity to ‘azole’ antifungal medications before prescribing fluconazole. It should be noted that IM ceftriaxone and oral ciprofloxacin are used to manage Neisseria gonorrhoea, not thrush, and oral metronidazole is used to manage bacterial vaginosis, not thrush.

Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

The appropriate action for a patient presenting with a breast fibroadenoma larger than 3 cm is to refer them for surgical excision. Fibroadenomas are benign masses that develop from the whole lobule and are typically small, firm, and smooth, often referred to as breast mice. While they are usually treated conservatively, surgical excision is necessary if they cause discomfort, as in this case. Checking the mass again in three months, discharge and safety netting, prescribing oral antibiotics, and referring for aspiration are all incorrect management options for a fibroadenoma.

Understanding Breast Fibroadenoma

Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30.

Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended.

In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.

Calcium channel blockers may cause adverse effects such as headaches, flushing, and swelling in the ankles.

Understanding Calcium Channel Blockers

Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.

Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is another calcium channel blocker used to manage 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. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.

On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.

In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.

Prescribing the combined oral contraceptive pill is not recommended for women with a family history of breast cancer associated with a BRCA mutation. However, for those with a family history of breast cancer but no BRCA mutation, the contraceptive pill is considered safe and has no restrictions (UKMEC 1). Therefore, if a patient with this medical history requests the combined oral contraceptive pill, it should be prescribed to her as the preferred contraceptive method.

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

Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy

During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, pre-term labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.

The patient’s symptoms suggest the possibility of a corneal abrasion or dendritic corneal ulcer, with photophobia being a key indicator. However, the feathery pattern observed is more indicative of herpes simplex keratitis. Urgent review by an ophthalmologist is necessary, and caution should be exercised in prescribing topical steroids as they may exacerbate the infection.

Understanding Herpes Simplex Keratitis

Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.

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

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

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

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

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

Treatment Options for COPD Exacerbations: Antibiotics and Corticosteroids

COPD exacerbations are characterized by a sudden worsening of symptoms beyond the patient’s usual stable state. These symptoms include increased breathlessness, cough, sputum production, and changes in sputum color. To treat exacerbations, a combination of antibiotics and corticosteroids is often used.

Oral corticosteroids, such as prednisolone, should be prescribed for five days to patients experiencing a significant increase in breathlessness that interferes with daily activities. Antibiotics are recommended for exacerbations associated with purulent sputum, with first-line agents including amoxicillin, doxycycline, and clarithromycin.

It is important to follow local microbiologist guidance when initiating empirical antibiotic treatment. Flucloxacillin and clindamycin are not useful in treating COPD exacerbations and are recommended for other conditions such as skin infections and bacterial vaginosis, respectively. Nitrofurantoin and trimethoprim are used for urinary tract infections and may be considered as first or second-line agents depending on antibiotic resistance and previous sensitivity.

Management of Fever in a High-Risk Child

When managing a child with fever, it is important to consider their age and any accompanying symptoms. According to the NICE guideline on ‘Fever in under 5s’, children aged <3 months with a temperature of 38°C are at high risk for serious illness. In such cases, it is recommended to refer the child urgently to a paediatric specialist. Encouraging fluids may be useful, but it should not be relied upon to rule out serious underlying illness. Similarly, antipyretics may be given before the child is seen by the paediatric team, but it is important to consult the NICE guideline for appropriate dosages. Blind prescription of oral antibiotics or IM benzylpenicillin is not recommended without a clear source of infection and discussion with the on-call paediatric team. Therefore, it is crucial to refer high-risk children to the paediatric on-call team for further management.

Dietary Recommendations for Chronic Kidney Disease Patients

Chronic kidney disease patients are recommended to follow a specific diet to reduce the strain on their kidneys. This diet includes low levels of protein, phosphate, sodium, and potassium. The reason for this is that these substances are typically excreted by the kidneys, and reducing their intake can help ease the burden on the kidneys. By following this diet, patients can help slow the progression of their kidney disease and improve their overall health. It is important for patients to work with a healthcare professional or registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions.

Syringobulbia is a condition where a fluid-filled cyst/syrinx is present in the spinal cord, extending up to the medulla of the brainstem, causing cranial nerve palsies. It results in dissociated sensory loss and LMN signs at the level of the lesion, with UMN signs below the lesion. Cranial nerve involvement may include facial sensory loss, vertigo, nystagmus, facial, palatal, and laryngeal nerve palsy, and weakness, atrophy, and fasciculation of the tongue. This condition is different from cervical spondylosis, multiple sclerosis, and motor neuron disease, which have distinct clinical features. Syringomyelia is a similar condition, but it progresses slowly over years and affects the cervical area of the cord, leading to early loss of pain and temperature sensation, with preservation of light touch and proprioception. Syringobulbia is characterized by LMN lesions of cranial nerve XII, suggesting the lesion extends above the spinal cord and into the brainstem.

Understanding Pityriasis Versicolor

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

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

The young man in question is likely suffering from borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). This condition is characterized by unstable relationships, alternating between idealization and devaluation of others, recurrent self-harm, unstable self-image and self-esteem, suicidal behavior, difficulty controlling anger, and efforts to avoid abandonment. All of these traits are present in this patient, making BPD the most likely diagnosis.

Narcissistic personality disorder is not a likely diagnosis for this patient, as it is characterized by a grandiose sense of self-importance, lack of empathy, and a sense of entitlement. These traits are not present in this patient, and his periods of devaluing her partner are temporary and not pervasive.

Dependent personality disorder is also an unlikely diagnosis, as this condition is characterized by a pervasive need for others to make decisions for the patient and constant reassurance. While the patient has felt that he cannot live without his partner in the past, his labile mood and alternating view of his partner make this diagnosis less likely.

Paranoid personality disorder is also an unlikely diagnosis, as patients with this condition tend to be reluctant to confide in others and have an unforgiving attitude when insulted or questioned. The patient in question does not exhibit these traits, and his difficulty with trusting friends is likely due to his belief that he is undeserving of them.

Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

Understanding the Causes of Hypercalcaemia

Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. In most cases, two conditions account for 90% of hypercalcaemia cases. The first is primary hyperparathyroidism, which is the most common cause in non-hospitalized patients. The second is malignancy, which is the most common cause in hospitalized patients. Malignancy-related hypercalcaemia may be due to various processes, including PTHrP from the tumor, bone metastases, and myeloma. For this reason, measuring parathyroid hormone levels is crucial when investigating patients with hypercalcaemia.

Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs such as thiazides and calcium-containing antacids, dehydration, Addison’s disease, and Paget’s disease of the bone. It is important to note that hypercalcaemia may occur with prolonged immobilization in patients with Paget’s disease of the bone, although this condition is usually normal.

In summary, hypercalcaemia can be caused by various medical conditions, with primary hyperparathyroidism and malignancy being the most common. Measuring parathyroid hormone levels is essential in investigating patients with hypercalcaemia. Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs, dehydration, Addison’s disease, and Paget’s disease of the bone.

Differential Diagnosis for Abdominal Symptoms: Irritable Bowel Syndrome, Ulcerative Colitis, Colorectal Cancer, Polycystic Ovarian Syndrome, and Ovarian Cancer

Abdominal symptoms can be caused by a variety of conditions, making differential diagnosis crucial. Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder characterized by abdominal pain, bloating, and altered bowel habits. It is more prevalent in women and can be associated with stress. Diagnosis is made by excluding other differential diagnoses, and management includes psychological support and dietary measures, with pharmacological treatment as adjunctive therapy.

Ulcerative colitis (UC) presents with rectal bleeding, frequent stools, and mucus discharge from the rectum. Physical examination may reveal proctitis and left-sided abdominal tenderness. UC is associated with extracolonic manifestations, but this patient’s symptoms are not consistent with a diagnosis of UC.

Colorectal cancer typically presents with rectal bleeding, change in bowel habits, abdominal pain, weight loss, and malaise. However, this patient’s age, clinical history, and normal examination findings make this diagnosis unlikely.

Polycystic ovarian syndrome (PCOS) presents with hyperandrogenism symptoms such as oligomenorrhea, hirsutism, and acne. Abdominal pain, bloating, and change in bowel habits are not features of PCOS.

Ovarian cancer may present with minimal or non-specific symptoms, but persistent abdominal distension and/or pain, early satiety, or lethargy may be present. However, this patient’s young age makes this diagnosis less likely.

The National Institute for Health and Care Excellence recommends that any woman aged over 50 years who presents with new IBS-like symptoms within the past year should have ovarian cancer excluded with a serum CA125 measurement.

The most significant risk factor for psychotic disorders is a person’s family history.

Understanding the Epidemiology of Schizophrenia

Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals with no relatives with schizophrenia have a 1% chance of developing the disorder.

Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.

Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.

When a condition has low genetic penetrance, it may not show many clinical signs or symptoms, and the patient may appear normal, despite having an abnormal genetic profile. This is because the severity of the phenotype is determined by the penetrance of the genotype. If the condition has high penetrance, the phenotype is more likely to be expressed, resulting in more signs and symptoms.

Autosomal Dominant Diseases: Characteristics and Complicating Factors

Autosomal dominant diseases are genetic disorders that are inherited from one parent who carries the abnormal gene. In these diseases, both homozygotes and heterozygotes manifest the disease, and both males and females can be affected. The disease is passed on to 50% of children, and it normally appears in every generation. The risk remains the same for each successive pregnancy.

However, there are complicating factors that can affect the expression of the disease. Non-penetrance is a phenomenon where an individual carries the abnormal gene but does not show any clinical signs or symptoms of the disease. For example, 40% of individuals with otosclerosis do not show any symptoms despite carrying the abnormal gene. Another complicating factor is spontaneous mutation, where a new mutation occurs in one of the gametes. This can result in the disease appearing in a child even if both parents do not carry the abnormal gene. For instance, 80% of individuals with achondroplasia have unaffected parents.

In summary, autosomal dominant diseases have distinct characteristics such as their inheritance pattern and the fact that affected individuals can pass on the disease. However, complicating factors such as non-penetrance and spontaneous mutation can affect the expression of the disease and make it more difficult to predict its occurrence.

The elevated ferritin level can be attributed to the patient’s excessive alcohol consumption, as the typical transferrin saturation rules out iron overload as a potential cause.

Understanding Ferritin Levels in the Body

Ferritin is a protein found inside cells that binds to iron and stores it until it is needed in other parts of the body. When ferritin levels are increased, it is usually defined as being above 300 µg/L in men and postmenopausal women, and above 200 µg/L in premenopausal women. However, it is important to note that ferritin is an acute phase protein, meaning that it can be produced in higher quantities during times of inflammation. This can lead to falsely elevated results, which must be interpreted in the context of the patient’s clinical picture and other blood test results.

There are two main categories of causes for increased ferritin levels: those without iron overload (which account for around 90% of cases) and those with iron overload (which account for around 10% of cases). Causes of increased ferritin levels without iron overload include inflammation, alcohol excess, liver disease, chronic kidney disease, and malignancy. Causes of increased ferritin levels with iron overload include primary iron overload (hereditary hemochromatosis) and secondary iron overload (such as from repeated transfusions). To determine whether iron overload is present, the best test is transferrin saturation, with normal values being less than 45% in females and less than 50% in males.

On the other hand, reduced ferritin levels can indicate a deficiency in iron, which can lead to anemia. When iron and ferritin are bound together, a decrease in ferritin levels can suggest a decrease in iron levels as well. Measuring serum ferritin levels can be helpful in determining whether a low hemoglobin level and microcytosis are truly caused by an iron deficiency state.

Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by antiplatelet antibodies and immune-mediated platelet destruction, leading to a decrease in peripheral platelet count and an increased risk of severe bleeding. The following are the recommended diagnostic and investigative measures for ITP:

Full Blood Count: An urgent first-line investigation with a full blood count is essential to confirm platelet count, which is the hallmark of ITP. Anaemia and/or neutropenia may indicate other diseases. On peripheral blood smear, the morphology of red blood cells and leukocytes is normal, while the morphology of platelets is usually normal, with varying numbers of large platelets.

Surgical Correction: Surgical management is not the first-line intervention for ITP and is reserved for later use in patients with acute ITP, for whom splenectomy usually results in rapid, complete, and life-long clinical remission. Its results in patients with chronic ITP are typically less predictable.

Aspiration for Cytology: Further investigations, such as bone marrow aspiration, could be considered for later use in patients with ITP, such as adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.

Excision Biopsy: Further investigations, such as a biopsy, could be considered further down the line, such as in adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.

None: If a patient presents with purpura/petechiae on the tongue and buccal mucosa, urgent haematological referral is warranted, and not undertaking any further investigations would be inappropriate.

Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)

Bacterial vaginosis is a condition characterized by the excessive growth of mainly bacteria.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

A woman with a moderate or high risk of pre-eclampsia, such as this patient who has a family history of pre-eclampsia and type 1 diabetes mellitus, should take aspirin 75-150mg daily from 12 weeks gestation until delivery to reduce the risk of developing pre-eclampsia.

Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

Differential diagnosis of recurrent positional vertigo

Recurrent positional vertigo is a common complaint that can have various underlying causes. One of the most frequent diagnoses is benign positional paroxysmal vertigo (BPPV), which typically affects middle-aged and older women and is triggered by specific head movements. BPPV is diagnosed based on the patient’s history and confirmed with the Hallpike manoeuvre, which elicits characteristic nystagmus. Treatment options include canalith repositioning manoeuvres and vestibular rehabilitation exercises.

However, other conditions may mimic BPPV or coexist with it, and therefore a thorough differential diagnosis is necessary. Migraine-associated vertigo is a type of vestibular migraine that can cause brief episodes of vertigo without headache, but usually has a longer duration and is not triggered by positional changes. Posterior circulation ischaemia, which affects the brainstem and cerebellum, can also cause vertigo, but typically presents with other neurological symptoms and has a more acute onset. Postural hypotension, which results from a drop in blood pressure upon standing, can cause dizziness and syncope, but is not usually related to head movements. Labyrinthitis, an inflammation of the inner ear, can cause vertigo and hearing loss, but is not typically triggered by positional changes.

Therefore, a careful history and physical examination, including a neurological assessment, are essential to differentiate between these conditions and guide appropriate management. In some cases, further testing such as imaging or vestibular function tests may be necessary to confirm the diagnosis.

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

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

Common Medications and Their Side Effects

Furosemide: A loop diuretic that carries the risk of ototoxicity, especially in patients with renal impairment or given a rapid intravenous infusion. Hearing loss and tinnitus are potential side effects.

Ciprofloxacin: A broad-spectrum quinolone antibiotic that is not commonly associated with ototoxicity, but has an increased risk of Clostridium difficile infection. Rupture of the Achilles tendon is a known side effect.

Amlodipine: A calcium channel blocker used to treat hypertension. Common side effects include flushing, headaches, and ankle swelling due to vasodilation.

Indapamide: A thiazide-like diuretic that is not associated with ototoxicity. Possible side effects include electrolyte imbalances, dry mouth, and gastrointestinal disturbance.

Paracetamol: Not associated with ototoxicity and has few side effects listed in the British National Formulary. Non-steroidal anti-inflammatory drugs, which have similar indications for use, can cause ototoxicity.

Understanding the Side Effects of Common Medications

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.