For a patient with poorly controlled hypertension who is already taking an ACE inhibitor and a thiazide diuretic, the recommended next step would be to add a calcium channel blocker. This is because adding another ACE inhibitor would not be appropriate, and beta-blockers may be contraindicated if the patient has asthma. Loop diuretics are not typically used as a treatment for hypertension.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Understanding 5-HT3 Antagonists

5-HT3 antagonists are a type of medication used to treat nausea, particularly in patients undergoing chemotherapy. These drugs work by targeting the chemoreceptor trigger zone in the medulla oblongata, which is responsible for triggering nausea and vomiting. Examples of 5-HT3 antagonists include ondansetron and palonosetron, with the latter being a second-generation drug that has the advantage of having a reduced effect on the QT interval.

While 5-HT3 antagonists are generally well-tolerated, they can have some adverse effects. One of the most significant concerns is the potential for a prolonged QT interval, which can increase the risk of arrhythmias and other cardiac complications. Additionally, constipation is a common side effect of these medications. Overall, 5-HT3 antagonists are an important tool in the management of chemotherapy-induced nausea, but their use should be carefully monitored to minimize the risk of adverse effects.

Understanding Cannabis Intoxication: Symptoms and Diagnosis

Cannabis intoxication refers to the problematic behavioural or psychological changes that occur after recent use of cannabis. These changes may include impaired motor coordination, euphoria, anxiety, a sensation of slowed time, impaired judgment, or social withdrawal. To diagnose cannabis intoxication, at least two physical signs must be present. However, sweating is not considered a recognized sign of cannabis intoxication, as it is more commonly associated with cannabis withdrawal. It is important for doctors to rule out any underlying medical conditions or mental disorders that may be causing the patient’s symptoms. This article provides an overview of the symptoms and diagnosis of cannabis intoxication.

Differential Diagnosis for Respiratory Symptoms in Infants

Respiratory symptoms in infants can be caused by a variety of conditions, and it is important to consider the differential diagnosis to provide appropriate treatment. Here are some common conditions and their typical symptoms:

Bronchiolitis: This acute infection of the lower respiratory tract is most common in infants between two and six months old. Symptoms include difficulty feeding, low-grade fever, coryza, cough, dyspnoea, wheezing, and respiratory distress.

Croup: This inflammation of the upper airways is usually caused by a respiratory virus and affects children from three months to three years old. Symptoms include a barking cough, stridor, and wheeze.

Asthma: This condition is rarely diagnosed in infants due to the lack of a clear diagnostic test. Symptoms overlap with common childhood illnesses and include coughing, wheezing, and difficulty breathing.

Heart failure: This should be considered in infants with feeding and breathing difficulties, but typically presents with symptoms since birth.

Pneumonia: This is another possible diagnosis for respiratory symptoms in infants, but examination findings such as reduced air entry and dull percussion note would support this diagnosis.

In summary, a thorough evaluation of symptoms and examination findings is necessary to determine the appropriate diagnosis and treatment for respiratory symptoms in infants.

Drug-induced Postural Hypotension

Drug-induced postural hypotension is a condition that can occur as a side effect of antihypertensive therapy, especially with the use of alpha-blockers. In this case, the patient’s recent introduction to doxazosin is a clue to the cause of their symptoms. Postural hypotension is characterized by a sudden drop in blood pressure when standing up, leading to dizziness, lightheadedness, and even fainting. It is important to monitor patients closely when starting new medications and adjust dosages as needed to prevent this potentially dangerous condition.

Sildenafil use is not recommended for patients who have had a recent myocardial infarction or unstable angina, as stated in both the BNF and NICE guidelines. As the patient in this question had a myocardial infarction just 4 months ago, prescribing sildenafil is contraindicated. Therefore, the answer to this question is do not prescribe.

Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

Arterial Ulceration in Smokers: Symptoms and Treatment Options

Arterial ulceration is a common problem among smokers, which is characterized by intense leg pain and sleep interference. The absence of foot pulses bilaterally indicates peripheral vascular disease, and it is important to assess for ischaemic heart disease and carotid disease as well. Angioplasty or bypass surgery may be appropriate for improving the peripheral blood supply in a limited number of cases only, while peripheral vasodilators are rarely effective. However, other options such as varicose veins, vasculitis, injury, or bites should be ruled out before making a diagnosis. In this article, we will discuss the symptoms and treatment options for arterial ulceration in smokers.

Dermatitis and Work-Related Exposure

Dermatitis is a skin condition that can be caused by work-related exposure to chemicals or biological irritants. According to the Health and Safety Executive (HSE), dermatitis is reportable when associated with exposure to any chemical or biological irritant or sensitizing agent. This includes chemicals with warnings such as may cause sensitization by skin contact or irritating to the skin. Common causes of dermatitis include epoxy resins, latex, rubber chemicals, soaps and cleaners, metalworking fluids, cement, wet work, enzymes, and wood. Corrosive and irritating chemicals can also lead to dermatitis.

Various industries are associated with dermatitis, including construction work, health service work, rubber making, printing, paint spraying, agriculture, horticulture, electroplating, cleaning, catering, hairdressing, and floristry. However, dermatitis can also be caused by exposure to common agents found outside the workplace. If there is good evidence that the condition has been caused solely by such exposure rather than by exposure to an agent at work, it is not reportable.

It is important to note that arranging patch testing, referral, and prescribing are considerations for the patient’s own doctor and not their employer. While most questions in the AKT exam relate to a doctor’s duties to their patients, it is essential to have a basic understanding of employment law and health and safety regulations to ensure the safety and well-being of employees in the workplace.

Treatment Recommendations for Heart Failure Patients

Angiotensin converting enzyme inhibitors and beta blockers are recommended for patients with heart failure due to left ventricular systolic dysfunction, regardless of their NYHA functional class. The ACE inhibitors should be considered first, followed by beta blockers once the patient’s condition is stable, unless contraindicated. However, the updated NICE guidance suggests using clinical judgment to decide which drug to start first. Combination treatment with an ACE-inhibitor and beta blocker is the preferred first-line treatment for these patients. Beta blockers have been shown to improve survival in heart failure patients, and three drugs are licensed for this use in the UK. Patients who are newly diagnosed with impaired left ventricular systolic function and are already taking a beta blocker should be considered for a switch to one shown to be beneficial in heart failure.

Polymyalgia Rheumatica: A Condition Common in the Elderly

Polymyalgia rheumatica is a condition that typically affects individuals over the age of 50, with the highest incidence in those over 70 years old. One of the core features of PMR is age greater than 50. The most common symptoms of PMR include bilateral shoulder and/or pelvic girdle aching that lasts for more than two weeks, morning stiffness lasting for more than 45 minutes, and raised erythrocyte sedimentation rate (ESR) and C reactive protein (CRP). It is important to note that these symptoms can also be present in other conditions, so a proper diagnosis is necessary.

Managing Haemoptysis in Terminal Lung Cancer Patients

Haemoptysis is a common symptom experienced by 20-30% of patients with lung cancer, with 3% experiencing massive haemoptysis as a terminal event. The management of haemoptysis in terminal lung cancer patients depends on the volume of blood loss, its cause, and prognosis.

For massive haemoptysis, intramuscular or intravenous morphine and midazolam are indicated, and the use of dark-coloured towels can mask blood. For smaller, self-limiting haemorrhage, tranexamic acid 1 g three times a day can often be effective.

In this scenario, there is no information to suggest a cause other than tumour progression, so tranexamic acid is the correct answer. It would be reasonable to try tranexamic acid first before considering radiotherapy.

In the secondary care setting, protamine is given intravenously as a reversal agent to heparin, should this be required. However, it is not usually used in the community.

Overall, managing haemoptysis in terminal lung cancer patients requires careful consideration of the individual’s situation and needs.

Managing Hepatitis B in Pregnancy: Vaccination and Testing for Newborns

Hepatitis B is a viral infection that can be transmitted from mother to child during childbirth. To prevent transmission, it is important to manage hepatitis B in pregnancy. Here are some important points to keep in mind:

– The baby should receive their first hepatitis B vaccination within 24 hours of birth. This is crucial to prevent transmission, as there is a 90% chance of the infant contracting hepatitis B without immunisation at birth.
– Subsequently, the baby should receive a further vaccination against hepatitis B at 4 weeks of age, followed by routine immunisations which include hepatitis B at 8, 12 and 16 weeks, and then a 6th and final hepatitis B vaccination at one year of age.
– Vaccination can occur at 8, 12 and 16 weeks of age, as per the routine immunisation schedule, but babies born to hepatitis B infected mothers require additional hepatitis B vaccinations.
– The baby should be tested for hepatitis B at 12 months old, at which point they should also have bloods taken to test for hepatitis B infection.
– The mother should not receive the hepatitis B vaccination at 28 weeks’ gestation, as this is not appropriate advice.
– The mother should not take antiviral therapy while pregnant and should not avoid breastfeeding her infant to reduce the risk of vertical transmission, as this is not necessary for hepatitis B.

In summary, managing hepatitis B in pregnancy involves vaccinating the newborn and testing for hepatitis B at 12 months old. With proper management, transmission of hepatitis B from mother to child can be prevented.

The most appropriate course of action for gestational diabetes is to commence insulin immediately if the fasting glucose level is equal to or greater than 7 mmol/L at the time of diagnosis. While lifestyle changes and co-prescribing metformin should also be discussed, starting insulin is the priority. This is in line with NICE guidelines, which recommend immediate insulin initiation (with or without metformin) and lifestyle advice for glucose levels between 6 and 6.9 mmol/L, especially if there are complications such as macrosomia or hydramnios.

Re-checking the glucose level in two weeks is not appropriate as uncontrolled hyperglycaemia can be dangerous for both the mother and the unborn child.

Starting exenatide is not recommended during pregnancy as there is insufficient data on its safety. Studies in mice have shown adverse effects on fetal and neonatal growth and skeletal development.

Starting metformin alone is not sufficient if the fasting glucose level is greater than 7 mmol/L. However, metformin can be prescribed in combination with insulin.

A trial of lifestyle changes alone is not appropriate if the fasting glucose level is already above 7 mmol/L. If the level is below 7 mmol/L, lifestyle changes can be tried for 1-2 weeks, and if glucose targets are not met, metformin can be offered.

Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

Postpartum Thyroiditis

The likely diagnosis for the patient is postpartum thyroiditis, which typically occurs within three months of delivery and is followed by a hypothyroid phase at three to six months. In one third of cases, there is spontaneous recovery, while the remaining two-thirds may experience a single-phase pattern or the reverse. Management of this condition involves symptomatic treatment using beta blockers to alleviate tremors or anxiety, and observation for the development of persistent hypo- or hyperthyroidism.

Graves’ disease is a less likely diagnosis due to the proximity to delivery and the absence of other signs such as Graves’ ophthalmopathy, goitre, and bruit. Hashitoxicosis is a possibility but less likely than Graves’. While carbimazole and propylthiouracil (PTU) are thyroid peroxidase inhibitors used in thyrotoxicosis, postpartum thyroiditis is usually transient, and symptomatic treatment with beta blockers is typically sufficient. Radioactive iodine is used in cases of thyrotoxicosis that have not responded to PTU or carbimazole. Lugol’s iodine is part of the treatment for a thyrotoxic storm, which is not the diagnosis in this case.

Patients with rheumatoid arthritis may have an increased risk of developing accelerated atherosclerosis, which is believed to be linked to the inflammatory process. The QRisk2 calculator, used to predict the 10-year risk of developing cardiovascular disease, includes rheumatoid arthritis as a risk factor. However, a blood pressure reading of 130/80 mmHg and a BMI of 24 kg/m2 are within the normal range and not a cause for concern. Additionally, the HbA1c level of 41 mmol/mol is normal and doesn’t indicate an increased risk of diabetes. While a family history of myocardial infarction is significant, it is only considered a risk factor if the relative was diagnosed before the age of 60, not at 65.

Eye Infections and Obstructions: Understanding the Differences

Dacryocystitis is an inflammation of the nasolacrimal sac caused by an infection resulting from an obstruction in the nasolacrimal duct. This obstruction leads to the stagnation of tears and can cause systemic illness in infants. If left untreated, the infection can spread and cause orbital cellulitis.

A chalazion, also known as a meibomian cyst, occurs when the small oil glands around the eyelashes become blocked due to inflammation. This blockage leads to the formation of a small, tender swelling within the eyelid. Chalazions can occur on either the inferior or superior eyelids.

An external hordeolum, commonly known as a stye, is a localized infection or inflammation of the eyelash follicle. This type of infection is usually caused by a staphylococcal infection.

While nasolacrimal duct obstruction can contribute to the development of dacryocystitis in infants, it should not cause inflammation and illness on its own. It is important to note that congenital nasolacrimal duct obstruction is common in infants and typically resolves within 12 months.

Ophthalmia neonatorum caused by Neisseria gonorrhoeae typically occurs within the first five days of birth and is characterized by bilateral purulent discharge. When caused by chlamydial infection, the conjunctivitis may occur after three days but can arise as late as two weeks after birth.

Urgent Admission for a Patient with Acute Glomerulonephritis

Explanation:

A patient presenting with nephritic syndrome, including haematuria, oliguria, hypertension, and oedema, is likely suffering from acute glomerulonephritis, possibly post-streptococcal. This condition can lead to acute kidney injury and requires urgent investigation. Therefore, routine referral to paediatric nephrologists or urologists is not appropriate in this case. Instead, the patient needs to be admitted to the hospital for urgent investigation and management. While follow-up with paediatric nephrologists may be necessary, the acute presentation with hypertension and oedema requires immediate attention. A two-week rule referral for suspected malignancy is not indicated in this case.

Harmful Levels of Paracetamol

When it comes to harmful levels of paracetamol, patients are divided into two groups: those who have taken an acute overdose and those who have taken a staggered overdose, which includes patients who may have taken therapeutic excess over a period of time. Surprisingly, even modest amounts of paracetamol can be harmful, especially for frail elderly patients.

According to the British National Formulary, a staggered overdose involves ingesting a potentially toxic dose of paracetamol over more than one hour, with the possible intention of causing self-harm. Therapeutic excess is the inadvertent ingestion of a potentially toxic dose of paracetamol during its clinical use. In these cases, patients who have taken more than 150 mg/kg of paracetamol in any 24-hour period are at risk of toxicity and should be commenced on acetylcysteine immediately, unless it is more than 24 hours since the last ingestion, the patient is asymptomatic, the plasma-paracetamol concentration is undetectable, and liver function tests, serum creatinine and INR are normal.

It’s important to note that there is no set number of tablets that can cause toxicity as it depends on the patient’s weight. Rarely, toxicity can occur with paracetamol doses between 75-150 mg/kg in any 24-hour period, and clinical judgement of the individual case is necessary to determine whether to treat those who have ingested this amount of paracetamol. For small adults, this may be within the licensed dose, but ingestion of a licensed dose of paracetamol is not considered an overdose. The doctor may not be informed until after the event, so familiarity with the timescales is also important.

If a patient experiences palpitations, the first step in investigating the issue should be to conduct a Holter monitor test after conducting initial blood tests and an ECG. Palpitations are often indicative of an arrhythmia, such as atrial fibrillation, and it is important to conduct further investigations to rule out this possibility.

Holter monitoring is the recommended first-line investigation to capture any episodes of arrhythmia. Since the patient experiences these episodes daily, a 24-hour monitoring period is appropriate. However, a troponin test is not necessary as there is no chest pain, and an echocardiogram is not warranted as there are no indications of heart failure.

If the Holter monitoring results are normal and the patient continues to experience symptoms, an external loop recorder may be considered.

Investigating Palpitations: Identifying Possible Causes and Capturing Episodic Arrhythmias

Palpitations are a common symptom that can be caused by various factors such as arrhythmias, stress, and increased awareness of normal heartbeats. To investigate the underlying cause of palpitations, first-line investigations include a 12-lead ECG, thyroid function tests, urea and electrolytes, and a full blood count. However, these investigations may not capture episodic arrhythmias, which are often missed during a short ECG recording.

To capture episodic arrhythmias, the most common investigation is Holter monitoring. This portable battery-operated device continuously records ECG from 2-3 leads for 24 hours or longer if symptoms are less than daily. Patients are asked to keep a diary to record any symptomatic palpitations, which can later be compared to the rhythm strip at the time of the symptoms. At the end of the monitoring, a report is generated summarizing heart rate, arrhythmias, and changes in ECG waveform.

If no abnormality is found on the Holter monitor and symptoms persist, other options include an external loop recorder or an implantable loop recorder. These investigations can help identify the underlying cause of palpitations and guide appropriate management.

Ocular Manifestations of Infectious Diseases

Choroidal tubercles, toxocariasis, Kaposi’s sarcoma, syphilis, and toxoplasmosis are all infectious diseases that can manifest in the eye. Choroidal tubercles are a common presentation of intraocular tuberculosis, while toxocariasis is caused by roundworm larvae migration and can lead to ocular larva migrans. Kaposi’s sarcoma presents as highly vascular lesions on the eyelids, conjunctiva, caruncle, and lacrimal sac. Syphilis can cause optic neuritis, uveitis, and interstitial keratitis, while toxoplasmosis can lead to chorioretinitis and vitreous inflammation. It is important to consider these infectious diseases in patients presenting with ocular symptoms and to evaluate for systemic involvement.

Understanding Hydroceles: Causes and Diagnosis

A hydrocele is a painless swelling that occurs in the scrotum due to a collection of fluid within the tunica vaginalis. It is often confined to one side and the underlying testicle may not be palpable. Transillumination with a light source can help diagnose a hydrocele.

Hydroceles can be primary or secondary. Primary hydroceles tend to occur in children and the elderly and appear gradually. Secondary hydroceles, on the other hand, are associated with testicular pathology and tend to appear rapidly. Possible underlying causes of a secondary hydrocele include testicular tumour, infection (epididymo-orchitis), torsion, and trauma.

A clinical diagnosis is often sufficient, but an ultrasound scan may be requested in cases of secondary hydrocele or when there is suspicion of an underlying pathology. For instance, a new onset, rapidly growing hydrocele in a man in his thirties may warrant an ultrasound scan to rule out a testicular tumour.

If the history and examination do not suggest an infective/inflammatory process, torsion, or trauma as an underlying cause, immediate referral to the hospital is not necessary. The use of anti-inflammatory and antibiotics is also not indicated in such cases. Understanding the causes and diagnosis of hydroceles can help in their appropriate management.

Hypertension Management in Type 2 Diabetes

This patient with type 2 diabetes has poorly controlled hypertension, but is currently tolerating his medication well. The recommended antihypertensive for diabetes is an ACE inhibitor, which can be combined with a calcium channel blocker like amlodipine. Beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is used for hypertension during pregnancy, while moxonidine is used when other medications have failed. If blood pressure control is still inadequate, a thiazide diuretic can be added to the current regimen of ramipril and amlodipine. Proper management of hypertension is crucial in diabetic patients to prevent complications and improve overall health.

Patients with rheumatoid arthritis are at a higher risk of developing IHD.

Complications of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects the joints, causing inflammation and pain. However, it can also lead to a variety of extra-articular complications. These complications can affect different parts of the body, including the respiratory system, eyes, bones, heart, and mental health.

Respiratory complications of RA include pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, and pleurisy. Ocular complications can include keratoconjunctivitis sicca, episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, and chloroquine retinopathy. RA can also lead to osteoporosis, ischaemic heart disease, and an increased risk of infections. Depression is also a common complication of RA.

Less common complications of RA include Felty’s syndrome, which is characterized by RA, splenomegaly, and a low white cell count, and amyloidosis, which is a rare condition where abnormal proteins build up in organs and tissues.

In summary, RA can lead to a variety of complications that affect different parts of the body. It is important for patients with RA to be aware of these potential complications and to work closely with their healthcare providers to manage their condition and prevent or treat any complications that may arise.

Diagnostic Markers for Paget’s Disease of Bone

Paget’s disease of bone is a condition characterized by cellular remodelling and deformity of one or more bones. To aid in its diagnosis, several diagnostic markers are used, including alkaline phosphatase (ALP), calcium, parathyroid hormone, phosphate, and uric acid.

ALP is a useful marker for Paget’s disease as bone-specific ALP levels are elevated due to increased osteoblastic activity and bone formation. However, the adequacy of total ALP levels depends on the patient having normal liver function and a normal level of liver ALP. Serial measuring of ALP is also used to monitor the effects of treatment and disease activity.

Calcium levels should be normal in patients with Paget’s disease, but hypercalcaemia or hypercalciuria may develop in patients who are immobile. Parathyroid hormone levels are usually normal in Paget’s disease, but hyperparathyroidism causes osteitis fibrosa cystica with low bone mineral density, bone pain, skeletal deformities, and fractures. Phosphate levels are usually normal.

Hyperuricaemia can occur in Paget’s disease and is more common in men than women. It is due to the increased turnover of nucleic acids as a result of high bone turnover, and attacks of gout may be precipitated.

In conclusion, the measurement of ALP and other diagnostic markers can aid in the diagnosis and monitoring of Paget’s disease of bone.

If a person aged 40 or over has appetite loss and is a smoker, an urgent chest X-ray should be offered within two weeks, according to the updated 2015 NICE guidelines. This is because appetite loss is now considered a potential symptom of lung cancer. While counseling, smoking cessation, and a career change may be helpful, investigating the possibility of lung cancer is the most urgent action required. It is important to address each issue separately, as trying to tackle all three at once could be overwhelming for the patient.

Referral Guidelines for Lung Cancer

Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.

For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.

In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.

Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.

Chronic Subdural Haematoma in the Elderly

The patient’s history of a previous fall and subsequent development of confusion and neurological symptoms suggest a possible diagnosis of chronic subdural haematoma. The best investigation for this condition is a CT scan, which is the preferred choice over a skull x-ray that may only reveal a fracture.

Chronic subdural haematoma is a common condition in the elderly, and it occurs when blood accumulates between the brain and the outermost layer of the brain’s protective covering. This condition can cause a range of symptoms, including confusion, headaches, and difficulty with balance and coordination. If left untreated, chronic subdural haematoma can lead to serious complications, such as seizures, coma, and even death.

Managing Statin Intolerance in Patients with Ischaemic Heart Disease and Type 2 Diabetes Mellitus

This patient has both ischaemic heart disease and type 2 diabetes mellitus, making him a candidate for statin therapy due to his elevated cholesterol levels. However, he has experienced myalgia and raised liver function tests while taking atorvastatin at its maximum dose, indicating statin intolerance. NICE guidance recommends reducing the dose or trying an alternative statin in such cases. Fibrate and ezetimibe are not recommended for patients with type 2 diabetes. Referral to a specialist may be necessary if statins are not tolerated at all.

To minimize the risk of side effects, starting at a low dose and gradually titrating up can be helpful. Rosuvastatin and pravastatin may have a lower incidence of myalgia compared to other statins. If another statin is prescribed, cautious monitoring of liver function tests is necessary. Patients with a history of statin-related hepatitis or rhabdomyolysis should generally avoid statins in the future if possible.

Women who have taken ulipristal acetate should wait for 5 days before beginning regular hormonal contraception. It is crucial to note that the effectiveness of EllaOne decreases if progestogen is used within 5 days after taking it. Therefore, it is essential to start hormonal contraceptives 5 days after taking EllaOne. Starting the combined oral contraceptive pill at the same time or less than 5 days after taking EllaOne would be incorrect. It is a misconception that EllaOne is only effective if the combined oral contraceptive pill has already been started. Taking EllaOne 14 days after the start of the last menstrual period is also incorrect. The copper coil could be inserted as an effective form of contraception 5 days after the expected date of ovulation, but EllaOne must be taken within 5 days of unprotected sexual intercourse.

Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

Side Effects of Commonly Used Medications

Nephrotic syndrome is a condition characterized by proteinuria, oedema, hyperlipidaemia, and hypoalbuminaemia. It can be caused by various primary and secondary glomerular diseases, as well as certain drugs. Some drugs that can cause nephrotic syndrome include non-steroidal anti-inflammatory drugs, captopril, lithium, gold, diamorphine, interferon alfa, penicillamine, and probenecid.

Gold, specifically sodium aurothiomalate, is used to treat active progressive rheumatoid arthritis. However, it can cause immune complex nephritis, leading to unexplained proteinuria above 300 mg/l, and blood dyscrasias and gastrointestinal bleeding.

Chloroquine is associated with several side effects, such as visual disturbances, skin reactions, nausea and vomiting, hepatitis, and abdominal pain. However, nephrotic syndrome and renal impairment are not known complications.

Methotrexate can cause various blood dyscrasias and liver toxicity, but nephropathy is a rare complication.

Paracetamol, when used in its oral form, has rare side effects. However, overdose can lead to liver damage, but kidney damage is infrequent.

Prednisolone is associated with numerous side effects, including anxiety, abnormal behavior, cataracts, cognitive impairment, Cushing syndrome, hypertension, increased risk of infection, and weight gain. Renal complications are not commonly associated with prednisolone use.

In summary, while these medications can be effective in treating certain conditions, it is important to be aware of their potential side effects and to monitor for any adverse reactions.

An ultrasound scan should be conducted on patients with superficial thrombophlebitis of the long saphenous vein to rule out the possibility of an underlying DVT.

Superficial thrombophlebitis is inflammation associated with thrombosis of a superficial vein, usually the long saphenous vein of the leg. Around 20% of patients will have an underlying deep vein thrombosis at presentation and 3-4% will progress to a DVT if untreated. Treatment options include NSAIDs, topical heparinoids, compression stockings, and low-molecular weight heparin. The use of low-molecular weight heparin has been shown to reduce extension and transformation to DVT. Patients with superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT and can be considered for prophylactic doses of LMWH for up to 30 days. Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks.