Skin Lesions and Their Characteristics

Lentigo Maligna: This pre-invasive lesion has the potential to develop into malignant melanoma. It appears as a pigmented, flat lesion against sun-damaged skin. Surgical excision is the ideal intervention, but cryotherapy and topical immunotherapy are possible alternatives.

Squamous Cell Carcinoma: This common type of skin cancer presents as enlarging scaly or crusted nodules, often associated with ulceration. It may arise in areas of actinic keratoses or Bowen’s disease.

Basal Cell Carcinoma: This skin cancer usually occurs in photo-exposed areas of fair-skinned individuals. It looks like pearly nodules with surface telangiectasia.

Pityriasis Versicolor: This is a common yeast infection of the skin that results in an annular, erythematous scaling rash on the trunk.

Actinic Keratosis: These scaly lesions occur in sun-damaged skin in fair-skinned individuals and are considered to be a pre-cancerous form of SCC.

Understanding Skin Lesions and Their Characteristics

Understanding Multiple Myeloma

Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is characterized by the presence of abnormal plasma cells that produce an excess of monoclonal antibodies, also known as paraproteins. Here are some key diagnostic markers and symptoms of multiple myeloma:

– Bence Jones protein is a reliable diagnostic marker.
– Bone pain is common, usually in the back, but not in the skull.
– White blood cell count is usually normal or low, with a classic leucoerythroblastic anemia.
– Paraprotein may be absent in 20% of cases, but there are light chains in the urine.
– Serum calcium can be normal or raised, and both ESR (usually) and CRP (nearly always) are raised.
– IL6 is a key myeloma growth cytokine. Serum IL6 is raised in active myelomatosis and it primarily controls CRP production. A rise in IL6 is mirrored by a rise in CRP.
– Bone lesions are lytic.

It is important to note that multiple myeloma can present differently in each individual, and a proper diagnosis requires a thorough evaluation by a healthcare professional. If you are experiencing any symptoms or have concerns about multiple myeloma, please consult with your doctor.

Treatment Options for Osteoporosis in Chronic Asthma Patients on Glucocorticoid Therapy

Chronic use of glucocorticoid therapy for asthma can lead to significant osteoporosis. Bisphosphonates are the first-line therapy for improving bone mass in the lumbar spine and hip. While daily preparations were associated with significant gastrointestinal side effects, weekly and monthly options are now available with less propensity for adverse effects. An IV infusion is also a potential delivery option for bisphosphonates. Testosterone replacement is not indicated in this situation, as there is no indication of androgen deficiency. Vitamin D and calcium supplementation alone are inadequate as treatments for osteoporosis. Long-term calcitonin therapy is not recommended due to increased risk of osteosarcoma.

In straightforward cases of death, a medical certificate of cause of death (MCCD) can be completed by the doctor who attended the last illness. Deaths must be registered within 5 days, and if the certifying doctor has not seen the patient within 28 days preceding death, the death must be referred to the coroner. During the Coronavirus pandemic, temporary changes were made to the legislation around completion of MCCD and cremation. Video consultations are acceptable methods of ‘seeing’ a person in the last 28 days of their life but not after death. Doctors are advised to include certain information on all Cremation Forms.

Primary herpes simplex virus infection is indicated by gingivostomatitis, which this man is experiencing.

The herpes simplex virus (HSV) comes in two strains: HSV-1 and HSV-2. It was once believed that HSV-1 caused cold sores and HSV-2 caused genital herpes, but there is now significant overlap between the two. Symptoms of a primary infection may include severe gingivostomatitis, while cold sores and painful genital ulceration are also common. Treatment options include oral aciclovir and chlorhexidine mouthwash for gingivostomatitis, topical aciclovir for cold sores (although the evidence for its effectiveness is limited), and oral aciclovir for genital herpes. Pregnant women with herpes should be treated with suppressive therapy, and those who experience a primary attack during pregnancy after 28 weeks gestation should have an elective caesarean section. The risk of transmission to the baby is low for women with recurrent herpes. Pap smear images can show the cytopathic effect of HSV, including multinucleation, marginated chromatin, and molding of the nuclei.

Visual Field Testing for Glaucoma

Primary open-angle (chronic) glaucoma is a condition that often goes undetected, with up to 50% of cases remaining unnoticed. By the time symptoms arise, up to 90% of optic nerve fibers may have already been irreversibly damaged. However, routine optician checks can help identify abnormal discs, raised intraocular pressure, or reduced visual fields, which are all potential indicators of glaucoma.

Visual field testing is a crucial tool in detecting glaucoma. Perimetry machines objectively document what a patient perceives in their peripheral vision. This is more reliable than simple field testing, such as moving wiggling fingers or the end of a hatpin across each quadrant towards the center of the eye.

Other tests, such as examination of pupillary responses, cover tests, and palpation of the eyes for hardness, are not reliable indicators of glaucoma. Visual acuity testing is also not a reliable indicator, as visual field loss from glaucoma typically spares fixation and visual acuity is preserved until the condition is advanced.

In conclusion, visual field testing is a crucial tool in detecting glaucoma, and routine optician checks can help identify potential indicators of the condition.

Differentiating Rheumatoid Arthritis from Other Joint Conditions: A Case Study

A patient presents with various joint symptoms, and it is important to differentiate between different conditions to provide appropriate treatment. The presence of painless nodules on the elbow and distal interphalangeal joints of the hands are typical of rheumatoid arthritis, an inflammatory condition that can cause irreversible joint damage if not diagnosed and treated promptly. On the other hand, Heberden’s and Bouchard’s nodes, bony swellings at the distal and proximal interphalangeal joints respectively, are caused by osteoarthritis, a degenerative joint disease.

An annular erythematous rash on the trunk is associated with rheumatic fever, which can develop after a streptococcal infection. This condition can cause migratory polyarthritis affecting the wrists, elbows, knees, and ankles. In contrast, an enlarging erythematous bull’s eye lesion on the leg is typical of Lyme disease, which can cause arthritis but usually affects the large joints.

In summary, careful consideration of the specific symptoms and signs can help differentiate between different joint conditions and guide appropriate treatment.

Referring Patients for Joint Replacement Surgery

Referring patients for joint replacement surgery can be a challenging decision. With the increasing demand for this procedure, healthcare professionals must consider various factors before making a referral. These factors include the severity of the patient’s symptoms, their overall health and any comorbidities, their functional abilities and expectations, and the effectiveness of non-surgical treatments.

Orthopaedic assessment tools such as the Oxford hip and knee scores can be helpful in evaluating the impact of osteoarthritis on daily activities. However, they should not be the sole basis for referral decisions. Similarly, x-rays may provide additional information, but they should not be relied upon as the only factor in making a referral decision.

It is important to note that factors such as smoking status, age, and comorbidities should not be used as obstacles to referral. While they may increase postoperative risks and affect long-term outcomes, some patients may still benefit greatly from joint replacement surgery.

In summary, joint replacement surgery should be considered for patients with osteoarthritis who experience significant symptoms that do not respond to non-surgical treatments. Referral should occur before functional limitations and severe pain develop, and the decision should be made collaboratively between the healthcare professional and the patient. Scoring tools and x-rays can be helpful adjuncts, but they should not be the sole basis for referral decisions.

Guillain-Barré Syndrome: A Brief Overview

Guillain-Barré Syndrome is a polyneuropathy that can affect cranial nerves, particularly the facial nerves. It is a lower motor neurone lesion that is often preceded by lumbar or intracapsular pain. While full recovery is possible, some residual weakness is common. In the acute phase, muscle wasting doesn’t occur, but it may develop in the long term. Respiratory muscle involvement can cause reduced peak flow, which may require ventilation. Additionally, sensory disturbance is typically present. Overall, Guillain-Barré Syndrome is a complex condition that requires careful management and monitoring.

Seborrhoeic dermatitis, dry eye syndrome, and acne rosacea are conditions that may be linked to blepharitis. To treat this, patients should clean their eyelids twice a day and apply a warm compress with their eyes closed for 5-10 minutes. There is no known reason for an elevated risk of the other conditions mentioned.

Understanding Blepharitis

Blepharitis is a condition characterized by inflammation of the eyelid margins. It can be caused by dysfunction of the meibomian glands or seborrhoeic dermatitis/staphylococcal infection. Patients with rosacea are more prone to developing blepharitis. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, and any problem affecting these glands can lead to dry eyes and irritation.

Symptoms of blepharitis are usually bilateral and include grittiness and discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Staphylococcal blepharitis may cause swollen eyelids, styes, and chalazions. Secondary conjunctivitis may also occur.

Management of blepharitis involves softening the lid margin using hot compresses twice a day and mechanical removal of debris from the lid margins through lid hygiene. A mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water can be used for cleaning. Artificial tears may also be given for symptom relief in patients with dry eyes or an abnormal tear film.

Safeguarding Children in Healthcare

Safeguarding children has undergone significant changes in recent years, following the Children Act 2004 and the Victoria Climbié Inquiry. As a result, healthcare professionals must navigate a complex landscape of guidance documents, terminology, and organizational changes. The Royal College of General Practitioners offers a useful toolkit for those seeking an introduction to the topic.

According to the General Medical Council, the safety of children and young people must be a healthcare professional’s first concern. If there is reasonable concern that a child is at risk of abuse or neglect, the appropriate person or authority must be informed promptly. If there is no cause for concern, it is still important to discuss and record the decision, as well as any concerns, discussions, and reasons for not sharing information.

While confidentiality is important, it can be breached in limited circumstances, such as safeguarding children at risk. Healthcare professionals must avoid making discreet enquiries, as this can lead to unfounded rumors, breaches of confidentiality, and potentially prejudicing further enquiries. Overall, safeguarding children is a critical responsibility for healthcare professionals, and they must stay informed and vigilant in their efforts to protect vulnerable children.

The 2004 NICE guidelines recommend that the process be carried out with the assistance of a specialist and that benzodiazepine withdrawal should be conducted over an extended period.

Treatment Options for Epilepsy

Epilepsy is a neurological disorder that affects millions of people worldwide. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures. The decision to start AEDs is usually made after a second seizure, but there are certain circumstances where treatment may be initiated after the first seizure. These include the presence of a neurological deficit, structural abnormalities on brain imaging, unequivocal epileptic activity on EEG, or if the patient or their family considers the risk of having another seizure to be unacceptable.

It is important to note that there are specific drug treatments for different types of seizures. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females may be given lamotrigine or levetiracetam. For focal seizures, first-line treatment options include lamotrigine or levetiracetam, with carbamazepine, oxcarbazepine, or zonisamide used as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam used as second-line options. For myoclonic seizures, males are usually given sodium valproate, while females may be prescribed levetiracetam. Finally, for tonic or atonic seizures, males are typically given sodium valproate, while females may be prescribed lamotrigine.

It is important to work closely with a healthcare provider to determine the best treatment plan for each individual with epilepsy. Additionally, it is important to be aware of potential risks associated with certain AEDs, such as the use of sodium valproate during pregnancy, which has been linked to neurodevelopmental delays in children.

Differential Diagnosis for Transient Limb Paralysis with Sleep Paralysis

Transient limb paralysis with sleep paralysis can be a frightening experience for patients. However, it can be caused by a variety of conditions, making it important to consider a differential diagnosis. One possible cause is narcolepsy, which presents with a tetrad of classic symptoms including excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Brainstem transient ischaemic attack (TIA) can also cause vertigo, dizziness, and imbalance, but not episodic limb paralysis. Cervical disc prolapse (CDP) typically produces neck and arm pain or symptoms of spinal cord compression, which are not transient. Depression and anxiety may cause feelings of suffocation during a panic attack, but no other symptoms are described in this patient. Nocturnal seizures, which occur during sleep, may cause unusual conditions upon awakening, but transient limb paralysis is not typically a feature. Considering these potential causes can help clinicians arrive at an accurate diagnosis and provide appropriate treatment.

Occupational Asthma and its Diagnosis

The history of a patient who works as a baker raises concerns about occupational asthma, which is often caused by sensitizing agents found in plant products. It is estimated that 10-15% of adults with new or recurrent asthma have an occupational element to their symptoms. If a patient reports that their symptoms improve when away from the workplace, occupational asthma should be strongly suspected.

To diagnose occupational asthma, the most useful approach is to have the patient perform serial peak expiratory flow rate (PEFR) measurements. The Oxford Handbook of Respiratory Medicine recommends that the patient record a PEFR every two hours from waking to sleep for four weeks, with no changes to their treatment. The patient should document home, work, and holiday periods, and an expert should interpret the results.

If you suspect work-related asthma, it is important to arrange PEFR measurements and refer the patient to a chest physician or occupational physician for assessment and interpretation of the PEFR diary. Early diagnosis and management of occupational asthma can prevent long-term respiratory damage and improve the patient’s quality of life.

Monitoring Lithium Treatment: Guidelines and Recommendations

Before starting lithium treatment, it is important to conduct several tests, including ECG, thyroid function tests, renal function tests, and U&Es. After starting treatment, the plasma level should be checked after 7 days and then every 7 days until the required level is reached. The blood sample should be taken 12 hours after the dose has been taken. Once stable, the level should be checked every 3 months for the first year and 3-6 monthly depending on risk thereafter.

In addition to monitoring lithium levels, it is also important to regularly check thyroid function, calcium, eGFR, and U&Es every 6 months. Normal lithium levels vary between different laboratories but are generally about 0.6 – 1.0 mmol/l.

Lithium toxicity can occur at levels above the normal range and usually consists of gastrointestinal (anorexia, nausea, diarrhea) and central nervous system effects (muscle weakness, drowsiness, ataxia, coarse tremor, muscle twitching). Therefore, serum levels should also be taken during any intercurrent illness as this can increase toxicity.

Overall, monitoring lithium treatment is crucial for ensuring patient safety and optimizing treatment outcomes.

Understanding Angina Symptoms: What to Look Out For

Angina is a type of chest pain that occurs when the heart muscle doesn’t receive enough oxygen-rich blood. Here are some common symptoms associated with angina:

Radiation to the throat and jaw: Chest pain that radiates to the throat and jaw is typical of angina.

Prolonged pain: Anginal pain is typically exertional and quickly relieved by rest or glyceryl trinitrate (GTN spray) within around five minutes. It is not typically prolonged.

Associated dizziness: Pain associated with palpitations or dizziness is less likely to be angina than other attributable causes.

Associated shortness of breath: Shortness of breath can occur in both cardiac and pulmonary causes of chest pain and so is not specific to angina.

Pain associated with taking a breath in: Pain associated with breathing is likely to be associated with pulmonary or musculoskeletal causes of chest pain, rather than angina.

It’s important to note that these symptoms can also be indicative of other health issues, so it’s always best to consult with a healthcare professional if you experience any chest pain or discomfort.

For patients who experience frequent and severe migraines, preventive treatment should be considered if acute treatments are ineffective or not suitable, or if there is a risk of medication-overuse headaches. Propranolol is the first-line prophylactic treatment, but if it is not suitable, alternative treatments such as topiramate or amitriptyline may be considered. Gabapentin should not be used for migraine prophylaxis. Non-pharmacological therapies such as acupuncture, relaxation techniques, or cognitive behavioural therapy can also be used as an alternative or adjunct to pharmacological therapy. Daily riboflavin may also be helpful in reducing migraine frequency and intensity. It is important to advise patients to limit their use of acute medication to a maximum of 2 days per week to avoid medication-overuse headaches. Referral for same-day neurology assessment is not necessary unless there are red-flag features. If the patient doesn’t respond to acupuncture, a neurology referral may be indicated.

Managing Migraines: Guidelines and Treatment Options

Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.

For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.

Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.

For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.

It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.

Clinical Indicators for End-of-Life Care in Various Conditions

The Gold Standards Framework (GSF) Prognostic Indicator Guidance provides specific clinical indicators for various conditions that suggest the patient is approaching the end of life. For motor neurone disease, the indicators include marked rapid decline in physical status, first episode of aspiration pneumonia, increased cognitive difficulties, weight loss, significant complex symptoms and medical complications, low vital capacity, dyskinesia, mobility problems, falls, and communication difficulties. Lack of improvement three months after a stroke is an indicator for someone with severe paralysis. Wheelchair-bound multiple sclerosis patients may have quite a long life. Frail elderly people with co-morbidities may experience significant weight loss, but it needs to be accompanied by deteriorating function or at least two of weakness, slow walking speed, low physical activity, exhaustion, or depression. For patients with heart failure, repeated hospital admissions carry prognostic significance. These indicators can help healthcare professionals provide appropriate end-of-life care for patients with various conditions.

Cushing Syndrome: Symptoms, Diagnosis, and Differential Diagnosis

Cushing syndrome is a rare disorder characterized by hypercortisolaemia, which leads to a variety of symptoms and signs. The most common features include a round, plethoric facial appearance, weight gain (especially truncal obesity, buffalo hump, and supraclavicular fat pads), skin fragility, proximal muscle weakness, mood disturbance, menstrual disturbance, and reduced libido. Hypertension is present in more than 50% of patients, impaired glucose tolerance in 30%, and osteopenia, osteoporosis, and premature vascular disease are common consequences if left untreated.

The annual incidence of Cushing syndrome is approximately two per million, and it is more common in women. The cause of the disease is hypercortisolaemia, and in 68% of cases, it is due to a pituitary adenoma producing adrenocorticotrophic hormone (ACTH). Ectopic ACTH production is the cause in 12% of cases (most commonly small-cell carcinoma of the lung and bronchial carcinoid tumours), adrenal adenoma in 10%, and adrenal carcinoma in 8%.

Diagnosis of Cushing syndrome is made based on the results of the 24-hour urinary free-cortisol assay or the 1 mg (low-dose) overnight dexamethasone suppression test.

Differential diagnosis includes multiple endocrine neoplasia, essential hypertension, phaeochromocytoma, and simple obesity. However, multiple endocrine neoplasia is less likely due to the rarity of the syndrome and lack of other features. Essential hypertension may respond to two agents but cannot explain the other symptoms and signs. Phaeochromocytoma is a rare tumour that secretes catecholamines and presents with headache, sweating, palpitations, tremor, and hypertension. Simple obesity is a differential diagnosis but cannot explain the other features.

Antiemetics in Palliative Care

A variety of antiemetics are used in palliative care to treat nausea and vomiting. However, the underlying cause of the symptoms should be identified to guide which particular treatment is most appropriate. For instance, a patient with cerebral disease and co-existent vertigo may benefit from an antiemetic with antihistamine properties such as cyclizine, which has actions against vertigo, motion sickness, and labyrinthine disorders.

Nausea and vomiting due to drugs or toxins and metabolic causes, such as hypercalcemia, may respond best to haloperidol. Levomepromazine is a broad-spectrum antiemetic usually used as a second-line agent when other first-line antiemetics have not been effective. Metoclopramide is a prokinetic and can be useful in treating symptoms due to gastric stasis. Ondansetron is a 5-HT3 antagonist and acts at the chemoreceptor trigger zone in the brain. It is used as a treatment for emetogenic chemotherapy.

In summary, the appropriate antiemetic for a patient in palliative care depends on the underlying cause of their nausea and vomiting. Healthcare professionals should consider the patient’s individual needs and medical history when selecting an antiemetic.

Common Causes of Short Stature and Delayed Puberty

Short stature and delayed puberty can be caused by a variety of factors. Here are some of the most common causes:

1. Turner Syndrome
Turner syndrome is a genetic disorder that affects females. It occurs in between 1 in 2500 and 1 in 5000 live births. Features include short stature, delayed development of secondary sexual characteristics, and absence of menses. Patients may also have mild intellectual impairment and cardiovascular defects. There is a loss of one X chromosome (chromosome pattern XO), which results in a broad (webbed neck) and widely spaced nipples.

2. Constitutional Delay in Puberty
Constitutional delay in puberty is often familial and is the most common cause of short stature and delayed puberty. In otherwise normal children, linear growth slows until about the age of 3 years, then proceeds normally until expected puberty, and then slows again in the absence of a growth spurt. A full catch-up may not occur.

3. Down’s Syndrome
Short stature occurs in Down’s syndrome, but puberty is not normally delayed. Down’s syndrome would usually have been diagnosed early in life by the presence of typical features, which do not include a webbed neck.

4. Hypothyroidism
Hypothyroidism occurring during prepubertal years, usually due to Hashimoto’s thyroiditis, can cause delayed puberty or, in some cases, precocious puberty. Other features of hypothyroidism should be present. In contrast, treated congenital hyperthyroidism usually results in normal pubertal development.

5. Klinefelter Syndrome
Klinefelter syndrome affects males and is caused by an XXY genotype. The usual presentation is with delayed sexual development or infertility.

In conclusion, short stature and delayed puberty can be caused by a variety of factors, including genetic disorders, hormonal imbalances, and thyroid problems. It is important to identify the underlying cause in order to provide appropriate treatment and support.

Drugs that can cause gynaecomastia

Research has shown that the risk of developing gynaecomastia is almost insignificant when using other drugs as part of the treatment of Zollinger-Ellison syndrome. However, there are other drugs that can cause gynaecomastia, including spironolactone, digoxin, methyldopa, gonadotrophins, and cyproterone acetate.

Zollinger-Ellison syndrome is a condition where a gastrin-secreting pancreatic adenoma is associated with peptic ulcer, and 50-60% of cases are malignant. It is suspected in patients with multiple peptic ulcers that are resistant to drugs and occurs in approximately 0.1% of patients with duodenal ulcer disease.

A case study into male gynaecomastia has shown that spironolactone induced gynaecomastia by blocking androgen production, blocking androgens from binding to their receptors, and increasing both total and free oestrogen levels. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare professional.

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.

Contraceptive Options for Breastfeeding Mothers

New UKMEC criteria (2016) state that breastfeeding mothers can use combined hormonal contraceptives from ≥ 6 weeks (UKMEC 2). However, if the mother is not fully breastfeeding, she may not be adequately protected against unwanted pregnancy. In such cases, condoms could be an appropriate option, but if the mother prefers to use CHC, which is not contraindicated, condoms may not be the most appropriate option.

An intrauterine system is a good option for ongoing contraception and managing periods, but if the patient prefers the combined oral contraceptive pill, which is not contraindicated, it should be offered as her preferred method of contraception. While the progesterone-only pill is an option, it may not provide the regular cycle that the patient desires, and her preferred choice (CHC) is not contraindicated. In summary, breastfeeding mothers have several contraceptive options available to them, and the most appropriate option should be offered based on their individual preferences and medical history.

Medications and their Side Effects

Galactorrhoea is a side effect of selective serotonin reuptake inhibitors (SSRIs), according to the British National Formulary (BNF). On the other hand, gynaecomastia is not listed as a side effect of SSRIs. Tricyclics, however, are known to cause gynaecomastia by stimulating prolactin. Another medication that can cause gynaecomastia is anabolic steroids, which are not catabolic. It is important to be aware of the potential side effects of medications and to consult with a healthcare provider if any concerns arise. Proper monitoring and management can help prevent or alleviate these side effects.

Understanding Capacity to Make Decisions

Capacity to make decisions can vary and may change over time. A person who has the capacity to make one decision may not necessarily have the capacity to make another, and vice versa. To determine if a patient has the capacity to make a particular decision, they must understand the information given to them and be able to retain it long enough to weigh it and come to a decision for themselves. It is not necessary for a psychiatrist or psychogeriatrician to assess capacity, but seeking a specialist view may be helpful if there are doubts. Irrational decisions do not necessarily indicate a lack of capacity. Under the Mental Capacity Act 2005, an individual can appoint an attorney to make decisions on their behalf if they become mentally incapacitated in the future. The attorney can only make decisions when the patient has lost the capacity to make those decisions for themselves.

Current guidelines dictate that cannabis-based products without a license can only be prescribed by doctors who are registered specialists with the General Medical Council. Furthermore, doctors should only prescribe these products for disorders within their area of expertise when there is clear evidence or published guidelines to support it.

The first prescription of cannabis-based medicinal products must be initiated by a specialist medical practitioner in a hospital setting.

There is evidence supporting the efficacy of cannabis-based products, which is why the National Institute for Health and Care Excellence (NICE) supports their prescription.

The THC:CBD spray is available on the NHS in certain situations. It is inappropriate to advise patients to purchase it online as the safety and quality of the product cannot be guaranteed.

While the THC:CBD spray is the appropriate treatment, it should not be initiated in primary care.

Cannabis-Based Medicinal Products: Guidelines and Available Products

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

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

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

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

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

Intra-Articular Corticosteroid Injections for Osteoarthritis Pain

Intra-articular corticosteroid injections can be a helpful addition to treating moderate to severe osteoarthritis pain. If traditional treatments have failed, a corticosteroid injection may be an appropriate option for patients who are not interested in surgical intervention. While the injection provides short-term pain relief, it may also allow patients to engage in other interventions such as physiotherapy, which can provide longer-lasting benefits in terms of both pain and function. However, repeated injections over longer periods may cause joint damage and are generally not recommended.

Other treatment options such as capsaicin, electro-acupuncture, amitriptyline, and glucosamine are not recommended for osteoarthritis pain. Capsaicin is not recommended for shoulder problems, electro-acupuncture is not recommended for any form of osteoarthritis, and amitriptyline is not a licensed or recommended treatment for osteoarthritis. Glucosamine has insufficient data of significant efficacy to justify its cost, but patients can try over-the-counter glucosamine sulfate at a dose of 1500 mg daily and monitor their symptoms before and after three months.

Temporal arteritis doesn’t cause an increase in creatine kinase levels.

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

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

Management of Osteoporosis in Patients with T Score Criteria

Patients who fit the criteria for diagnosis of osteoporosis based on T score should be managed with a generic bisphosphonate as the first line of treatment. This is regardless of whether they have suffered an osteoporotic fracture or not. If a patient doesn’t tolerate a weekly preparation, there are monthly and intermittent IV preparations available. It is important to note that early intervention is key in preventing further bone loss and reducing the risk of fractures. Therefore, prompt management of osteoporosis is crucial in maintaining bone health and preventing complications.