Choosing the Next Step in Asthma Treatment: Addition of Inhaled Corticosteroids

According to the Scottish Intercollegiate Guidelines Network (SIGN)/British Thoracic Society (BTS) guidance, patients with asthma who have had an attack in the last two years, use inhaled β2 agonists three times or more a week, are symptomatic three times or more a week, or wake up one night a week should move to the next step of treatment. The preferred next step is the addition of inhaled corticosteroids, which should be titrated to the smallest effective dose while maintaining symptom control.

While an oral leukotriene-receptor antagonist is suggested as an alternative next step if the patient cannot take inhaled corticosteroids, it is not as effective as inhaled corticosteroids. Oral corticosteroids are not recommended as they have many side effects and are not necessary in this scenario.

An inhaled long-acting β2 agonist would be appropriate for the third step of treatment, but this patient should move to the second step, which involves inhaled corticosteroids and continuing as required salbutamol. Simply increasing the salbutamol dose would be inappropriate and not in line with guidance. This patient requires both preventer and reliever therapy to effectively manage her asthma.

The recommended first line treatment for threadworm is mebendazole. In this case, as the patient is showing symptoms of threadworm, it is important to treat all members of the household with a single dose of mebendazole and provide hygiene advice. While a ‘Scotch tape test’ can be used to confirm the presence of eggs or worms, treatment is often based on symptoms. It is not appropriate to only treat the daughter and provide hygiene advice, as other members of the household may also be infected. Additionally, prescribing 7 days of mebendazole for the daughter alone is incorrect, as a single dose is recommended and a second dose should be taken 14 days later. Piperazine is only recommended for children under 2 years old, so it is not appropriate to prescribe 14 days of piperazine for the daughter in this case.

Threadworm Infestation in Children

Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.

The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.

Prior to initiating tamoxifen treatment, women should be informed about the elevated risk of VTE, which is one of the most significant side effects of the medication. Additionally, tamoxifen has been linked to an increased risk of endometrial cancer.

Venous Thromboembolism: Common Risk Factors

Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While there are many factors that can increase the risk of VTE, some are more common than others. These include malignancy, pregnancy, and the period following an operation. Other general risk factors include advancing age, obesity, family history of VTE, immobility, hospitalization, anaesthesia, and the use of central venous catheters. Underlying conditions such as heart failure, thrombophilia, and antiphospholipid syndrome can also increase the risk of VTE. Additionally, certain medications like the combined oral contraceptive pill, hormone replacement therapy, raloxifene, tamoxifen, and antipsychotics have been shown to be risk factors.

It is important to note that while these factors can increase the risk of VTE, around 40% of patients diagnosed with a PE have no major risk factors.

Crohn’s disease and ulcerative colitis are the two main types of inflammatory bowel disease with many similarities in symptoms and management options. However, there are key differences such as non-bloody diarrhea and upper gastrointestinal symptoms being more common in Crohn’s disease, while bloody diarrhea and abdominal pain in the left lower quadrant are more common in ulcerative colitis. Complications and pathology also differ between the two diseases.

Carbimazole: Side Effects and Mechanism of Action

Carbimazole is a medication used to treat hyperthyroidism by inhibiting the production of thyroid hormones. However, it can also cause several side effects that patients should be aware of.

The most serious side effect is bone marrow suppression, which can lead to neutropenia and agranulocytosis. Patients should report any symptoms of infection immediately, as routine monitoring of white cell count is not useful. Cholestatic jaundice and drug-induced hepatitis are also possible side effects, but usually reversible upon discontinuation of the drug. Hypoprothrombinaemia, a rare side effect, can increase the risk of bleeding in patients on anticoagulant therapy.

Carbimazole works by inhibiting the enzyme thyroperoxidase, which is responsible for the synthesis of thyroid hormones. However, its onset of clinical effects is slow because it takes time to deplete the large store of pre-formed thyroid hormones in the thyroid gland.

In addition to its anti-thyroid effect, carbimazole also has a modest immunosuppressive activity, reduces the serum level of thyroid-stimulating hormone antibody, and can cause a reduction in clotting factor prothrombin. However, these effects are not thought to contribute significantly to its efficacy.

Overall, patients taking carbimazole should be aware of its potential side effects and report any symptoms to their healthcare provider promptly.

Management of Bradycardia in Peri-Arrest Rhythms

The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.

Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.

If enzyme-inducing drugs are taken at the same time as the combined oral contraceptive pill, its effectiveness is decreased. Out of the given choices, only St John’s wort is an enzyme inducer, while the rest are enzyme inhibitors.

Counselling for Women Considering the Combined Oral Contraceptive Pill

Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on the potential harms and benefits of the pill. The COC is highly effective if taken correctly, with a success rate of over 99%. However, there is a small risk of blood clots, heart attacks, and strokes, as well as an increased risk of breast and cervical cancer.

In addition to discussing the potential risks and benefits, women should also receive advice on how to take the pill. If the COC is started within the first 5 days of the menstrual cycle, there is no need for additional contraception. However, if it is started at any other point in the cycle, alternative contraception should be used for the first 7 days. Women should take the pill at the same time every day and should be aware that intercourse during the pill-free period is only safe if the next pack is started on time.

There have been recent changes to the guidelines for taking the COC. While it was previously recommended to take the pill for 21 days and then stop for 7 days to mimic menstruation, it is now recommended to discuss tailored regimes with women. This is because there is no medical benefit to having a withdrawal bleed, and options include never having a pill-free interval or taking three 21-day packs back-to-back before having a 4 or 7 day break.

Women should also be informed of situations where the efficacy of the pill may be reduced, such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, or taking liver enzyme-inducing drugs. It is also important to discuss sexually transmitted infections and precautions that should be taken with enzyme-inducing antibiotics such as rifampicin.

Overall, counselling for women considering the COC should cover a range of topics to ensure that they are fully informed and able to make an informed decision about their contraceptive options.

Roseola infantum is a condition characterized by the occurrence of a fever, which is later followed by the appearance of a rash.

Understanding Roseola Infantum

Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

Common Causes of Knee Pain in Adolescents and Young Adults

Knee pain is a common complaint among adolescents and young adults. There are several possible causes of knee pain, including osteochondritis dissecans, chondromalacia patellae, Osgood-Schlatter disease, osteoarthritis, and patellar dislocation.

Osteochondritis dissecans occurs when the articular cartilage separates from the joint surface, typically in the knee joint. This condition is common in teenagers and young adults and can cause vague, achy joint pain that worsens with activity. Other symptoms may include swelling, locking, catching, and giving way. Diagnosis is confirmed with an X-ray and magnetic resonance imaging can help with management and prognosis.

Chondromalacia patellae is characterized by abnormal softening of the cartilage on the underside of the patella. This condition is a common cause of chronic knee pain in teenagers and young adults. Symptoms include anterior knee pain that worsens after sitting for a prolonged period or walking down stairs. Diagnosis is made through examination and a positive shrug test.

Osgood-Schlatter disease is a cause of knee pain in young adolescents, particularly sporty boys. It is caused by overuse of the quadriceps, which strains the patellar ligament attachment to the tibia. Symptoms include pain inferior to the patella that worsens with activity and improves with rest. Diagnosis is usually clinical and treatment involves simple analgesics and ice packs.

Osteoarthritis is a disease of older age caused by degeneration of the articular cartilage. It is often seen in weight-bearing areas such as the knee and hip, but is unlikely in young adults.

Patellar dislocation is most common in teenage girls and often occurs during sports. Symptoms include sudden pain and an inability to weight bear on the affected side. Examination reveals a dislocated patella, often laterally, and an associated osteochondral fracture may be seen on an X-ray.

In March 2018, NICE released new guidelines for identifying and managing Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. According to DSM-V, ADHD is characterized by persistent features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. Children up to the age of 16 must exhibit six of these features, while those aged 17 or over must exhibit five. ADHD has a UK prevalence of 2.4%, with a higher incidence in boys than girls, and there may be a genetic component.

NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should be implemented to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, typically to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants, as well as how their condition affects their lives.

Drug therapy should be considered a last resort and is only available to those aged 5 years or older. Parents of children with mild/moderate symptoms can benefit from attending education and training programmes. For those who do not respond or have severe symptoms, pharmacotherapy may be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. It is a CNS stimulant that primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side effects include abdominal pain, nausea, and dyspepsia. Weight and height should be monitored every six months in children. If there is an inadequate response, lisdexamfetamine should be considered, followed by dexamfetamine if necessary. In adults, methylphenidate or lisdexamfetamine are the first-line options, with switching between drugs if no benefit is seen after a trial of the other. All of these drugs are potentially cardiotoxic, so a baseline ECG should be performed before starting treatment, and referral to a cardiologist should be made if there is any significant past medical history or family history, or any doubt or ambiguity.

As with most psychiatric conditions, a thorough history and clinical examination are essential, particularly given the overlap of ADHD with many other psychiatric and

Nodal osteoarthritis is the usual cause of osteoarthritis in the hands, resulting from genetic factors. This type of arthritis leads to the development of Heberden’s nodes, which is swelling in the distal interphalangeal joints, and Bouchard’s nodes, which is swelling in the proximal interphalangeal joints. These nodes do not require any treatment. Pyogenic granuloma is a lesion that appears as a bright red or blood-crusted area, often following trauma, and is more common in children. A ganglion is a cystic lesion that occurs in the joint or synovial sheath of a tendon, most commonly in the wrist. A sebaceous cyst is a mobile, round cyst with a central punctum.

Clinical Diagnosis of Osteoarthritis

Osteoarthritis can be diagnosed clinically without the need for investigations, according to NICE guidelines. This means that a doctor can diagnose the condition based on the patient’s symptoms and physical examination alone. The guidelines state that if a patient is over 45 years old and experiences pain during exercise, but does not have morning stiffness or morning stiffness lasting more than 30 minutes, they can be diagnosed with osteoarthritis.

This approach to diagnosis is based on the fact that osteoarthritis is a degenerative condition that affects the joints, causing pain and stiffness. The symptoms tend to develop gradually over time, and are often worse after periods of inactivity or overuse. By focusing on the patient’s symptoms and history, doctors can make an accurate diagnosis and start treatment as soon as possible.

Overall, the clinical diagnosis of osteoarthritis is a simple and effective way to identify the condition in patients who meet the criteria. It allows for prompt treatment and management of symptoms, which can improve the patient’s quality of life and prevent further joint damage.

Understanding Gonorrhoea: Causes, Symptoms, Microbiology, and Management

Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. The incubation period of gonorrhoea is typically 2-5 days. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. Rectal and pharyngeal infections are usually asymptomatic.

Immunisation against gonorrhoea is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins. Local complications may develop, including urethral strictures, epididymitis, and salpingitis, which can lead to infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.

Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If ceftriaxone is refused, oral cefixime 400mg + oral azithromycin 2g should be used. Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis. Later complications include septic arthritis, endocarditis, and perihepatitis.

Management of Bradycardia in Peri-Arrest Rhythms

The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.

Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.

The patient experienced a fall caused by a mechanical issue, with a potentially harmful mechanism of injury.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Peripheral neuropathy is a well-known side effect of isoniazid, while paraesthesia is not a common side effect of amlodipine according to the BNF. Therefore, it is more likely that isoniazid is the cause in this case. Rifampicin is associated with orange bodily fluids, rash, hepatotoxicity, and drug interactions, while isoniazid is known to cause peripheral neuropathy, psychosis, and hepatotoxicity.

Side-Effects and Mechanism of Action of Tuberculosis Drugs

Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

Exposed bowel in babies with gastroschisis leads to a considerable loss of fluid and heat, which can pose a serious risk to their lives. Unlike exomphalos, gastroschisis is not associated with cardiac and renal issues. Additionally, there is no correlation between gastroschisis and microcephaly or macrocephaly.

Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.

When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.

Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.

Assessing Ankle Injuries: Indications for X-rays

When evaluating a patient with ankle pain, the Ottawa Rules can be used to determine if an X-ray is necessary. These rules have a high sensitivity for excluding fractures and can be applied to patients between the ages of three and 55. Bony tenderness at the navicular meets the criteria for an X-ray. However, bruising of the toes or non-tender swelling over the lateral malleolus do not necessarily require an X-ray. Inability to weight bear for four steps or tenderness at the base of the fifth metatarsal may indicate the need for an X-ray. Treatment for uncomplicated fractured toes involves neighbour strapping.

Medication Recommendations for a Patient with Diabetes and High Blood Pressure

Based on the patient’s HbA1c level, it is recommended to start first-line treatment with metformin. If the patient experiences poor tolerance or side-effects from metformin, gliclazide may be considered as a second-line option. Pioglitazone may also be used in conjunction with metformin if HbA1c is poorly controlled on monotherapy. However, the patient’s blood pressure is adequately controlled, so an additional antihypertensive is not necessary. Lastly, the patient’s LDL cholesterol level suggests adequate control, and therefore, there is no need to increase the dosage of atorvastatin.

The positive Chvostek and Trousseau signs, along with a history of tetany and convulsions, suggest that the patient is suffering from hypocalcaemia. This condition can lead to cataracts, which may explain the patient’s vision problems. It is unlikely that the cataracts are related to age, as the patient is still young. Hypercalcaemia is not a common cause of cataracts, and the patient is not taking steroids, which can also cause cataracts. Additionally, the patient’s normal HbA1c indicates that she does not have diabetes mellitus.

Understanding Cataracts: Causes, Symptoms, and Management

A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

A loop ileostomy is the appropriate procedure for defunctioning the colon to protect an anastomosis. This involves taking a loop of ileum, making a horizontal incision, and bringing it up to the skin. It is commonly used after rectal cancer surgery and can be reversed at a later time.

An end colostomy is performed when an anastomosis is not possible or desirable, and the colon needs to be diverted or resected. The distal part of the colon is brought up to the skin in this procedure.

An end ileostomy is typically done after the complete removal of the colon or when an ileocolic anastomosis is not planned. While it can be used to defunction the colon, it is more challenging to reverse.

A gastrostomy is used for gastric decompression or feeding.

A loop jejunostomy is used as a high-output stoma and may be performed after an emergency laparotomy with planned early closure.

Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be spouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.