Managing Incidental Findings of Hypercalcaemia

It is crucial to consider the differential diagnosis when an incidental finding of hypercalcaemia is discovered. Immediate hospital review is necessary for severe hypercalcaemia (>3.40mmol/L) or those with symptoms. Further investigations may be required for mild hypercalcaemia, depending on the clinical context, such as chest x-ray, serum and urine protein electrophoresis, and serum cortisol.

NICE recommends referring patients suspected of having primary hyperparathyroidism to endocrinology. They will exclude other causes of hypercalcaemia and assess whether a parathyroidectomy is appropriate. Calcimimetic drug treatments and bisphosphonate therapy are potential treatments, but these would be considered in secondary care initially. A normal dietary intake of calcium is usually advised.

It is recommended to refrain from swimming until a perforated tympanic membrane has fully healed, which typically takes longer than a week. Using a swimming cap may not offer adequate protection. Antibiotics should only be prescribed if there is an infection present, and oral antibiotics are preferred over drops.

Perforated Tympanic Membrane: Causes and Management

A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.

In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.

If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.

Monitoring Liver Function in Statin Therapy

Before starting statin therapy, it is important to measure liver function. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can still be used.

Once statin therapy is initiated, liver function tests should be repeated within the first three months of treatment and then at 12 months. Additionally, liver function tests should be measured if a dose increase is made or if signs or symptoms of liver toxicity occur.

It is crucial to monitor liver function in patients receiving statin therapy to ensure their safety and prevent potential liver damage. By following these guidelines, healthcare providers can ensure that patients receive the appropriate treatment while minimizing the risk of liver toxicity.

A returning traveler experiencing retro-orbital headache, fever, facial flushing, rash, and thrombocytopenia is likely suffering from dengue fever. This disease is commonly found in South America and Southeast Asia and is characterized by sudden onset fever and joint pain, as well as low platelet counts and bleeding in severe cases. Chagas disease, which is also found in this region, typically presents with mild symptoms and elevated eosinophil levels. Viral hepatitis and malaria are less probable causes of a petechial rash.

Understanding Dengue Fever

Dengue fever is a viral infection that can lead to viral haemorrhagic fever, which includes diseases like yellow fever, Lassa fever, and Ebola. The dengue virus is an RNA virus that belongs to the Flavivirus genus and is transmitted by the Aedes aegypti mosquito. The incubation period for dengue fever is seven days.

Patients with dengue fever can be classified into three categories: those without warning signs, those with warning signs, and those with severe dengue (dengue haemorrhagic fever). Symptoms of dengue fever include fever, headache (often retro-orbital), myalgia, bone pain, arthralgia (also known as ‘break-bone fever’), pleuritic pain, facial flushing, maculopapular rash, and haemorrhagic manifestations such as a positive tourniquet test, petechiae, purpura/ecchymosis, and epistaxis. Warning signs include abdominal pain, hepatomegaly, persistent vomiting, and clinical fluid accumulation (ascites, pleural effusion). Severe dengue (dengue haemorrhagic fever) is a form of disseminated intravascular coagulation (DIC) that results in thrombocytopenia and spontaneous bleeding. Around 20-30% of these patients go on to develop dengue shock syndrome (DSS).

Typically, blood tests are used to diagnose dengue fever, which may show leukopenia, thrombocytopenia, and raised aminotransferases. Diagnostic tests such as serology, nucleic acid amplification tests for viral RNA, and NS1 antigen tests may also be used. Treatment for dengue fever is entirely symptomatic, including fluid resuscitation and blood transfusions. Currently, there are no antivirals available for the treatment of dengue fever.

To investigate for threadworms when the diagnosis is unclear, the recommended method is the adhesive tape test. While lab confirmation is not typically necessary for diagnosis, the adhesive tape test can be used to confirm the presence of threadworm eggs. This involves applying clear adhesive tape to the perianal skin first thing in the morning, before washing or using the toilet, and sending the sample to the lab for microscopy. It may be necessary to repeat the test if initial results are inconclusive. Serology is not a reliable method for diagnosing threadworms, and skin scrape and skin swab tests are not commonly used in the UK.

Threadworms: A Common Infestation Among Children in the UK

Infestation with threadworms, also known as pinworms, is a prevalent condition among children in the UK. The infestation occurs when individuals swallow eggs present in their environment. Although around 90% of cases are asymptomatic, some possible features 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 recommended management for threadworm infestation is a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is used as a first-line treatment for children over six months old, with a single dose given unless the infestation persists. By following these guidelines, individuals can effectively manage and prevent the spread of threadworms.

The most common symptoms of oral allergy syndrome are itching and tingling of the lips, tongue, and mouth. This condition occurs when the body reacts to proteins in certain foods as if they were pollen due to cross-reacting allergens. While the reaction is localized, it can cause an itchy mouth or throat and sometimes hives. However, there is no evidence of anaphylaxis as there is no wheezing or hypotension.

While contact dermatitis is a possibility, it typically presents with a rash rather than swelling of the lips and an itchy mouth. The presence of hay fever also makes a diagnosis of oral allergy syndrome more likely. Eczema, on the other hand, presents as dry and red skin rather than swelling and itching of the lips.

Lastly, hand, foot, and mouth is a viral infection that causes a sore throat and high temperature. It can also cause ulcers in the mouth and blisters on the hands and feet.

Understanding Oral Allergy Syndrome

Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.

It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.

OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.

In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.

Management of Persistent Hoarse Voice

A persistent hoarse voice for over three weeks is a ‘red flag’ presentation and should prompt urgent action to investigate for a suspected cancer, such as laryngeal or lung cancer. Risk factors such as smoking history and alcohol history are important to consider but would not alter your management plan.

NICE guidance on this changed slightly with the release of NG12. NICE advises that you should consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness.

It is important to note that a normal basic examination is not sufficient to rule out a sinister underlying cause. Hoarseness can also be caused by pulmonary pathology, and if you have any suspicions that this may be the case, you should arrange an urgent chest x-ray.

In summary, a persistent hoarse voice should be taken seriously and investigated promptly to rule out any potential underlying cancer or pulmonary pathology.

Management of Iron Deficiency Anemia

Explanation:
When managing a patient with iron deficiency anemia, it is important to consider the underlying cause and appropriate treatment options. In this case, as the patient is tolerating ferrous sulfate well but has not seen an increase in hemoglobin levels, malabsorption such as coeliac disease should be suspected. The preferred initial investigation for coeliac disease is the IgA anti-tissue transglutaminase antibodies (tTGAs) test.

Changing the preparation of iron is not necessary as the patient has tolerated ferrous sulfate well. Doubling the dose of ferrous sulfate is also not recommended as the patient has already been treated with an adequate dose. A blood transfusion is not indicated unless the patient is acutely unwell and meets certain criteria.

Treatment with iron, folic acid, and vitamin B12 is not necessary as the patient’s folic acid and vitamin B12 levels are normal. The low mean corpuscular volume (MCV) and ferritin levels indicate that the primary cause of anemia is iron deficiency. Therefore, the appropriate management would be to investigate for malabsorption and continue treatment with iron supplementation.

DVLA guidance following multiple TIAs: driving prohibited for a period of 3 months.

The DVLA has guidelines for individuals with neurological disorders who wish to drive cars or motorcycles. However, the rules for drivers of heavy goods vehicles are much stricter. For individuals with epilepsy or seizures, they must not drive and must inform the DVLA. If an individual has had a first unprovoked or isolated seizure, they must take six months off driving if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met, the time off driving is increased to 12 months. Individuals with established epilepsy or those with multiple unprovoked seizures may qualify for a driving license if they have been free from any seizure for 12 months. If there have been no seizures for five years (with medication if necessary), a ’til 70 license is usually restored. Individuals should not drive while anti-epilepsy medication is being withdrawn and for six months after the last dose.

For individuals with syncope, a simple faint has no restriction on driving. A single episode that is explained and treated requires four weeks off driving. A single unexplained episode requires six months off driving, while two or more episodes require 12 months off. For individuals with other conditions such as stroke or TIA, they must take one month off driving. They may not need to inform the DVLA if there is no residual neurological deficit. If an individual has had multiple TIAs over a short period of time, they must take three months off driving and inform the DVLA. For individuals who have had a craniotomy, such as for meningioma, they must take one year off driving. If an individual has had a pituitary tumor, a craniotomy requires six months off driving, while trans-sphenoidal surgery allows driving when there is no debarring residual impairment likely to affect safe driving. Individuals with narcolepsy/cataplexy must cease driving on diagnosis but can restart once there is satisfactory control of symptoms. For individuals with chronic neurological disorders such as multiple sclerosis or motor neuron disease, they should inform the DVLA and complete the PK1 form (application for driving license holders’ state of health). If the tumor is a benign meningioma and there is no seizure history, the license can be reconsidered six months after surgery if the individual remains seizure-free.

Calculating the Number Needed to Treat (NNT) for Vertigo Treatment

To determine the effectiveness of a vertigo treatment, we can calculate the Number Needed to Treat (NNT). This is done by first calculating the Absolute Risk Reduction (ARR), which is the difference between the Control Event Rate (CER) and the Experimental Event Rate (EER). For example, if 55 out of 100 control patients failed to have a resolution of vertigo, and 30 out of 100 treatment patients failed to improve, the ARR would be 0.55 – 0.30 = 0.25. To find the NNT, we simply take the reciprocal of the ARR, which in this case would be 1/0.25 = 4. This means that for every 4 patients treated with the vertigo treatment, one patient will have a resolution of their vertigo.

Scleritis is a serious condition that requires urgent ophthalmology attention within 24 hours to prevent complications such as perforation of the globe, glaucoma, cataracts, raised intraocular pressure, retinal detachment, and uveitis. It is important to note that scleritis can lead to raised intraocular pressure, not decreased, and entropion is not a complication of scleritis. Episcleritis, a less severe inflammatory condition of the episclera, can be managed within primary care and doesn’t affect vision.

Understanding Scleritis: Causes, Symptoms, and Treatment

Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.

Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Other common symptoms include watering and photophobia, which is sensitivity to light. In some cases, scleritis can also lead to a gradual decrease in vision.

Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease.

Best Antibiotic Choice for Children

When it comes to choosing an antibiotic for children, it’s important to consider their age and potential side effects. In this circumstance, Amoxicillin would be the best choice due to its effectiveness and safety profile. Quinolones and tetracyclines should be avoided in childhood, while co-trimoxazole has limited indications and nitrofurantoin would not be effective. It’s crucial to consult with a healthcare professional before administering any medication to children.

For individuals with type 2 diabetes, NICE suggests the following target for blood pressure:

Blood Pressure Management in Diabetes Mellitus

Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that tighter blood pressure control did not significantly improve outcomes for patients with diabetes, except for a slightly reduced rate of stroke. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. However, autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. It is important to note that the routine use of beta-blockers in uncomplicated hypertension should be avoided, especially when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.

Anticholinergic Overdose and Treatment

This patient is exhibiting symptoms of anticholinergic overdose, including drowsiness, irritability, large pupils, pyrexia, and tachycardia. Tricyclics, commonly used as antidepressants, can be lethal in overdose. Close monitoring is necessary as ventricular arrhythmias and seizures may occur. Treatment for seizures involves phenytoin, while lidocaine can be used for ventricular arrhythmias. Bicarbonate can correct metabolic acidosis.

Paracetamol overdose typically presents with few symptoms or signs initially, but can lead to fulminant hepatic failure later on. Opiates cause small pupils and depressed respirations, while benzodiazepines typically only cause marked drowsiness. Ecstasy often causes excitability, tachycardia, and hypertension, but can also lead to severe hyponatremia when associated with excessive water consumption, resulting in drowsiness and obtundation.

In summary, anticholinergic overdose requires close monitoring and prompt treatment to prevent potentially lethal complications.

Contraindications and Considerations for MMR Vaccine

Anaphylaxis to the MMR vaccine is rare, with less than 15 cases per million. The few contraindications to the vaccine include pregnancy, immunosuppression, gelatin or neomycin allergy with previous known anaphylaxis, and anaphylaxis to a previous dose of MMR. Egg allergy is not a contraindication, but some regions suggest immunizing in the secondary care setting. Breastfeeding and milk allergy are also not contraindications. Patients with pre-existing neurological conditions can receive the vaccine, but it is advised to postpone immunization if the condition is poorly controlled or progressive.

According to the Green Book, minor illnesses without fever or systemic upset are not valid reasons to postpone immunization. However, if an individual is acutely unwell, immunization should be postponed until they have fully recovered to avoid confusing the differential diagnosis of any acute illness by wrongly attributing any signs or symptoms to the adverse effects of the vaccine. It is important to note that patients who have received the MMR vaccine in the past can receive another dose, and the risk of allergy reduces with each successive immunization. At least two doses should provide satisfactory cover, but further immunization may not be required.

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

NSAIDs and Peptic Ulceration: Risks and Symptoms

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause of gastric and duodenal ulceration, second only to Helicobacter pylori. The inhibition of cyclooxygenase (COX) by NSAIDs reduces the production of gastric mucosal prostaglandins, leading to decreased cytoprotection. This can result in peptic ulceration, with at least one-third to one-half of ulcer perforations being associated with NSAIDs.

Patients at high risk of NSAID-induced peptic ulceration include the elderly, those with a history of peptic ulcer disease, and those with serious co-morbidities such as cardiovascular disease, diabetes, renal or hepatic impairment. The risk varies between individual NSAIDs and is also dose-related.

Symptoms of acute complications of NSAID-induced peptic ulceration can include peritonitis, which requires urgent surgical referral. Acute pancreatitis may present with similar symptoms, but tenderness may be less and there may be a history of Gallbladder disease or alcohol abuse. Gastritis typically doesn’t involve altered bowel sounds or signs of peritoneal irritation, while cholecystitis and appendicitis present with tenderness in the right upper quadrant and right iliac fossa, respectively.

In summary, NSAIDs can pose a significant risk for peptic ulceration, particularly in high-risk patients. It is important to be aware of the symptoms of acute complications and to promptly refer patients for appropriate management.

Understanding Eye Conditions

Dry eye syndrome is a common condition that occurs when the eyes do not produce enough tears or the tears evaporate too quickly. This can lead to inflammation and discomfort. Posterior capsular opacification is another condition that can occur after cataract surgery, causing clouding of vision. It is often treated with YAG laser capsulotomy. Posterior synechiae is a condition where the iris sticks to the lens of the eye, usually caused by trauma or inflammation. Bacterial conjunctivitis may cause purulent discharge, but this is not a symptom of dry eye syndrome unless there is a secondary infection. Small lacrimal puncta can lead to poor tear drainage and epiphora, but this is not the same as dry eye syndrome. Understanding these different eye conditions can help with proper diagnosis and treatment.

The FSRH has updated its guidance on missed contraceptive pills. If a woman misses two or more pills, she should continue taking the rest of the pack as usual and use an additional form of contraception for the next seven days. Condoms should be used or sexual activity avoided until seven consecutive active pills have been taken. This advice may be overly cautious in the second and third weeks, but it serves as a backup in case more pills are missed. If the woman has a new partner, it is recommended to consider STI screening after a suitable period. For more information, refer to the FSRH guidelines.

The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

Regular review of pain management is crucial in palliative care patients, especially if rescue analgesia is needed frequently. Each patient should be assessed individually, taking into account factors such as pain relief efficacy, adverse effects, and patient preference. For opioid-naïve patients, a safe starting dose of morphine is between 20-30 mg daily, while patients switching from a regular weak opioid can start with 40-60 mg daily. The dose can be given as an immediate-release preparation every four hours or as a modified-release preparation every 12 hours, with additional rescue doses for breakthrough pain. Dose adjustments should be made based on the number of rescue doses required and the patient’s response to them, with increases not exceeding one-third to one-half of the total daily dose every 24 hours. Adjuvant analgesics can also be considered during dose titration. Oxycodone can be used as an alternative to morphine for patients who cannot tolerate it, with a conversion rate of 6.6mg orally to 10 mg of oral morphine. Subcutaneous infusion may be necessary if swallowing is an issue. The equivalent dose of morphine is about half the daily oral requirement, and for diamorphine, one third. A ceiling of morphine immediate-release 30 mg every four hours (or modified-release 100 mg every 12 hours) is usually sufficient for most patients, although higher doses may be necessary in some cases.

Urinary incontinence is a common condition that affects approximately 4-5% of the population, with elderly females being more susceptible. There are several risk factors that can contribute to the development of urinary incontinence, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. The condition can be classified into different types, such as overactive bladder, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of urinary incontinence involves completing bladder diaries for at least three days, performing a vaginal examination to exclude pelvic organ prolapse, and conducting urine dipstick and culture tests. Urodynamic studies may also be necessary. Management of urinary incontinence depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures may be necessary. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be offered to women who decline surgical procedures.

In summary, urinary incontinence is a common condition that can be caused by various risk factors. It can be classified into different types, and management depends on the predominant type of incontinence. Initial investigation involves completing bladder diaries, performing a vaginal examination, and conducting urine tests. Treatment options include bladder retraining, bladder stabilizing drugs, pelvic floor muscle training, surgical procedures, and duloxetine.

According to Cancer Research UK, there are certain factors that are not associated with an increased risk of bowel cancer. These include fish consumption, low B12 levels, milk consumption, and selenium consumption. However, it is important to note that alcohol consumption, even at moderate levels, is associated with an increased risk of bowel cancer. Therefore, it is recommended to limit alcohol intake to reduce the risk of developing this type of cancer. By being aware of these factors, individuals can make informed choices about their diet and lifestyle to help reduce their risk of bowel cancer.

Management of Memory Loss in the Elderly

MRCGP candidates are expected to have an understanding of the management of conditions commonly associated with old age, including memory loss. However, the correct course of management for memory loss would be to undertake a full assessment in the first instance. The abbreviated mental test is only a screening test and should not be used alone to form a diagnosis. If a significant problem is found, it is usual to refer to memory assessment services, which may be provided by a memory assessment clinic or community mental health teams. This should be the single point of referral for all people with a possible diagnosis of dementia. GPs would not normally initiate prescribing in this manner, although they may be involved in a shared care arrangement with specialist initiation and supervision of medication.

Before considering a cochlear implant, both children and adults must undergo an assessment by a multidisciplinary team. As part of this assessment, they should have tried using an acoustic hearing aid for at least three months. Cochlear implantation is recommended for individuals with severe to profound deafness who do not receive sufficient benefit from hearing aids.

Mark should try to avoid noisy environments, including his current workplace, to prevent further damage to his hearing. However, it is not advisable for him to immediately stop working. Instead, he should discuss his situation with his occupational health team to explore options for working in a quieter environment.

While education on sign language and lip reading may be helpful, it is important to note that adults who become deaf are unlikely to become proficient in sign language.

It is incorrect to tell Mark that nothing more can be done. He may be eligible for a trial of hearing aids and referral for a cochlear implant if necessary.

A cochlear implant is an electronic device that can be given to individuals with severe-to-profound hearing loss. The suitability for a cochlear implant is determined by audiological assessment and/or difficulty developing basic auditory skills in children, and a trial of appropriate hearing aids for at least 3 months in adults. The causes of severe-to-profound hearing loss can be genetic, congenital, idiopathic, infectious, viral-induced sudden hearing loss, ototoxicity, otosclerosis, Ménière disease, or trauma. Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any underlying pathological process contributing to the loss of hearing.

Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. Patients are discharged for the postoperative physical recovery of the implantation site and generally return to outpatient clinic 3-5 weeks post-op for device stimulation. Contraindications to consideration for cochlear implant include lesions of cranial nerve VIII or in the brain stem causing deafness, chronic infective otitis media, mastoid cavity or tympanic membrane perforation, and cochlear aplasia.

The device has both internal and external components. Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The electrodes do the work that would be performed by the inner ear hair cells in a ‘normal’ ear. The brain can then process these signals to comprehend sound.

Rechargeable batteries can be used to power the apparatus and life span depends upon usage and the individual device. Hearing link describes cochlear implants as ‘…the world’s most successful medical prostheses in that less than 0.2% of recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.’ It is important for patients to demonstrate an understanding of what to expect from cochlear implantation, including comprehension of the likely limitations of the device. Patients should also demonstrate an interest in using the

Referral Criteria for Breast Cancer Screening

Breast cancer is a serious health concern that affects many individuals worldwide. To ensure early detection and prompt treatment, it is important to identify individuals who are at a higher risk of developing breast cancer. The following referral criteria have been established to identify individuals who should be referred to secondary care for breast cancer screening:

– One first degree female relative diagnosed with breast cancer under the age of 40 years
– One first degree male relative diagnosed with breast cancer at any age
– One first degree relative with bilateral breast cancer where the first primary was diagnosed under the age of 50 years
– Two first degree relatives, or one first degree and one second degree relative, diagnosed with breast cancer at any age
– One first degree or second degree relative diagnosed with breast cancer at any age and one first degree or second degree relative diagnosed with ovarian cancer at any age (one of these should be a first degree relative)
– Three first degree or second degree relatives diagnosed with breast cancer at any age.

By identifying individuals who meet these criteria, healthcare providers can ensure that they receive appropriate screening and monitoring for breast cancer. Early detection and treatment can significantly improve outcomes and reduce the risk of complications associated with breast cancer.

According to a study published in JAMA, the use of antidepressants has been found to be effective in treating fibromyalgia. The meta-analysis, conducted in 2009, supports the use of these medications for managing the symptoms of the condition.

Fibromyalgia is a condition that causes widespread pain throughout the body, along with tender points at specific anatomical sites. It is more common in women and typically presents between the ages of 30 and 50. Other symptoms include lethargy, cognitive impairment (known as fibro fog), sleep disturbance, headaches, and dizziness. Diagnosis is made through clinical evaluation and the presence of tender points. Management of fibromyalgia is challenging and requires an individualized, multidisciplinary approach. Aerobic exercise is the most effective treatment, along with cognitive behavioral therapy and medication such as pregabalin, duloxetine, and amitriptyline. However, there is a lack of evidence and guidelines to guide treatment.

Emergency Contraception for Patients on Liver Enzyme-Inducing Drugs

When a patient is on liver enzyme-inducing drugs or has had a copper intrauterine device (IUD) inserted in the last 28 days, the copper IUD is recommended as first-line emergency contraception. However, if the patient declines this option, a higher dose of levonorgestrel (3mg) is recommended as second-line. Common drugs that induce liver enzymes include antiretrovirals, carbamazepine, phenytoin, rifampicin, and St John’s wort. It is important to note that ulipristal is not suitable for women on liver enzyme-inducing drugs, according to NICE guidelines. It is crucial for healthcare providers to be aware of these recommendations and provide appropriate emergency contraception options for patients on liver enzyme-inducing drugs.

Carer’s Credit: A National Insurance Record Boost for Carers

Carer’s credit is a program that provides credits to carers who may have gaps in their national insurance record due to caring for their loved ones. This program ensures that carers will not be affected in claiming their state pension later in life. To be eligible for the carer’s credit, the carer must be at least 16 years old, under the State Pension age, and must be looking after one or more people for at least 20 hours a week. The person being cared for must receive one of the following: Disability Living Allowance care component at the middle or highest rate, Attendance Allowance, Constant Attendance Allowance, Personal Independence Payment – daily living component, at the standard or enhanced rate, or Armed Forces Independence Payment. The carer’s credit program is a helpful way to support carers who dedicate their time and effort to care for their loved ones.

Reference:
Carer’s Credit – https://www.gov.uk/carers-credit/overview. Department of Work and Pensions
Carer’s Credit – http://www.macmillan.org.uk/information-and-support/organising/benefits-and-financial-support/looking-after-someone-with-cancer/carers-credit.html. Macmillan Cancer Support

If a patient has unilateral ear discharge and a facial nerve palsy on the left side, it is more likely to be a case of malignant otitis externa. This is a serious condition where the infection has spread to the temporal bone and can affect the facial nerve. The pain associated with this condition is severe and persistent, often waking the patient at night. Malignant otitis externa can be life-threatening in severe cases, and immediate referral to an ENT specialist for intravenous antibiotics and imaging is necessary.

Malignant Otitis Externa: A Rare but Serious Infection

Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.

Key features in the patient’s history include diabetes or immunosuppression, severe and persistent ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and facial nerve dysfunction.

Diagnosis is typically done through a CT scan, and non-resolving otitis externa with worsening pain should be referred urgently to an ENT specialist. Treatment involves intravenous antibiotics that cover pseudomonal infections.

In summary, malignant otitis externa is a rare but serious infection that requires prompt diagnosis and treatment. Patients with diabetes or immunosuppression should be particularly vigilant for symptoms and seek medical attention if they experience persistent ear pain or other related symptoms.

Tips for Answering Tricky Questions in the AKT Exam

When faced with a tricky question in the AKT exam, it can be easy to feel overwhelmed and unsure of how to proceed. However, there are strategies you can use to help narrow down your options and improve your chances of selecting the correct answer.

One approach is to look for key information in the question stem, such as the presence of certain risk factors or the sudden onset of symptoms. By considering which answer option is most likely given this information, you can eliminate some of the less plausible choices.

It’s important to remember that you won’t know the answer to every question in the exam, and that’s okay. By using these strategies and taking a methodical approach, you can increase your hit rate and feel more confident in your overall performance.

To see an example of this approach in action, check out the Endgames scenario on sudden unilateral painless loss of vision in the BMJ article linked above. With practice and preparation, you can tackle even the trickiest questions on the AKT exam.