Understanding Serotonin Syndrome

Serotonin syndrome is a condition that is often overlooked in primary care. It occurs when there is an excessive amount of serotonergic activity in the body, which can be caused by the initiation of medication affecting serotonin activity or an interaction between medicines that affect serotonin activity. Patients who take medications such as codeine, triptans, and St. John’s wort are at a higher risk of developing serotonin syndrome when co-prescribed with an SSRI.

If a patient presents with symptoms of serotonin syndrome, it is important to withdraw the offending medicine, such as Citalopram. However, it is also important to consider other factors that may have contributed to the onset of symptoms, such as the use of a triptan for a migraine. Prescribing pizotifen or referring the patient for counseling may not alleviate their symptoms.

It is important to note that some authorities caution against the use of propranolol, as it can result in hypotension and mask the response to treatment by slowing the pulse. By understanding the risk factors and symptoms of serotonin syndrome, healthcare providers can better diagnose and treat this condition.

Treatment Options for Raynaud’s Phenomenon

Raynaud’s phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow, leading to reduced blood flow and pain. The most commonly used drug for treatment is nifedipine, which causes vasodilatation and reduces the number and severity of attacks. However, patients may experience side-effects such as hypotension, flushing, headache, and tachycardia.

For those who cannot tolerate nifedipine, other agents such as nicardipine, amlodipine, or diltiazem can be tried. Limited evidence suggests that angiotensin receptor-blockers, fluoxetine, and topical nitrates may also provide some benefit. However, there is no evidence to support the use of antiplatelet agents.

In secondary Raynaud’s phenomenon, management of the underlying cause may help alleviate symptoms. Treatment options are similar to primary Raynaud’s phenomenon, with the addition of the prostacyclin analogue iloprost, which has shown to be effective in systemic sclerosis.

Overall, treatment options for Raynaud’s phenomenon aim to improve blood flow and reduce the frequency and severity of attacks. It is important to work with a healthcare provider to find the most effective treatment plan for each individual.

ESA113 Medical Report for Employment and Support Allowance

When a person applies for Employment and Support Allowance (ESA), the Department for Work and Pensions (DWP) may request additional information from the patient’s doctor through an ESA113 medical report. This report is used to determine if the patient is unwell enough to receive ESA benefits.

It is important to note that the doctor is not required to interview or examine the patient in order to complete the report. Instead, they can provide a computer printout of the patient’s medical history, but any unanswered sections on the form must still be completed.

To assist doctors in completing the ESA113 report, the DWP has provided helpful guidance. This ensures that the report is accurate and provides the necessary information to determine the patient’s eligibility for ESA benefits.

When a pregnant woman reports reduced fetal movements, it is important to investigate the cause as it can indicate a risk of stillbirth and fetal growth restriction. The first step in this investigation should be to use a handheld Doppler to confirm the presence of a fetal heartbeat.

If a fetal heartbeat is detected with the handheld Doppler and the pregnancy is over 28 weeks gestation, a CTG should be used to monitor the fetal heart rate for at least 20 minutes to assess for any fetal compromise.

The guidelines recommend assessing fetal movements based on the subjective perception of the mother. If a mother reports reduced fetal movements, there is no need for further counting of fetal movements.

If no fetal heartbeat is detected with the handheld Doppler, an immediate ultrasound should be offered. If there is still concern about reduced fetal movements despite a normal CTG, an urgent ultrasound can be used to assess abdominal circumference or estimated fetal weight and amniotic fluid volume measurement, rather than ultrasound with Doppler.

Understanding Reduced Fetal Movements

Reduced fetal movements can indicate fetal distress and are a cause for concern as they can lead to stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency. Fetal movements usually start between 18-20 weeks gestation and increase until 32 weeks gestation, after which the frequency of movement tends to plateau. Multiparous women may experience fetal movements sooner, from 16-18 weeks gestation. Fetal movements should not reduce towards the end of pregnancy.

There is no established definition for what constitutes reduced fetal movements, but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment. Reduced fetal movements are a fairly common presentation, affecting up to 15% of pregnancies. Risk factors for reduced fetal movements include posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size.

Investigations for reduced fetal movements are dependent on gestation at onset. If past 28 weeks gestation, handheld Doppler should be used to confirm fetal heartbeat. If no fetal heartbeat is detectable, immediate ultrasound should be offered. If fetal heartbeat is present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm the presence of fetal heartbeat. If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

While reduced fetal movements can be a cause for concern, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Therefore, it is important for expectant mothers to be aware of their baby’s movements and seek medical attention if they notice a decrease in fetal movements.

If the patient is using contact lenses, there is a possibility that she has a corneal ulcer. This is a serious eye condition that requires urgent attention from an ophthalmologist. Therefore, the other options are not appropriate. Removing the contact lenses could aggravate the situation, and asking her to visit an optician would only delay the diagnosis.

Understanding the Causes of Red Eye

Red eye is a common condition that can be caused by various factors. It is important to identify the underlying cause of red eye to determine the appropriate treatment. Some causes of red eye require urgent referral to an ophthalmologist. Here are some key distinguishing features of different causes of red eye:

Acute angle closure glaucoma is characterized by severe pain, decreased visual acuity, and a semi-dilated pupil. The patient may also see haloes and have a hazy cornea.

Anterior uveitis has an acute onset and is accompanied by pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.

Scleritis is characterized by severe pain and tenderness, which may be worse on movement. It may be associated with an underlying autoimmune disease such as rheumatoid arthritis.

Conjunctivitis may be bacterial or viral. Bacterial conjunctivitis is characterized by purulent discharge, while viral conjunctivitis has a clear discharge.

Subconjunctival haemorrhage may be caused by trauma or coughing bouts.

Endophthalmitis typically occurs after intraocular surgery and is characterized by a red eye, pain, and visual loss.

By understanding the different causes of red eye and their distinguishing features, healthcare professionals can provide appropriate treatment and referral when necessary.

Understanding the Risk Factors for Colonic Adenocarcinoma in Ulcerative Colitis Patients

Colonic adenocarcinoma is a serious complication that can develop in 3-5% of patients with ulcerative colitis (UC). The cancer tends to be multicentric and atypical in appearance, and it can rapidly metastasize. To prevent this, it is important to understand the risk factors associated with the onset of the disease in childhood.

One of the main risk factors for colon cancer in colitis is the early age of onset, which is before the age of 15 years. Other risk factors include extensive disease (pancolitis), duration (more than ten years), and unremitting disease. Colonoscopic surveillance is recommended for all patients, starting about ten years after the onset of symptoms.

It is important to note that annual relapses are not a risk factor for colonic carcinoma since there is remittance in between episodes. Chronic active inflammation and unremitting disease are the main risk factors.

Left-sided colitis is also a risk factor, but extensive disease and pancolitis carry a higher risk of developing colon cancer. Poor compliance with therapy is not a risk factor in itself, but unremitting disease is a risk factor for colon cancer in UC.

Finally, patients with proctitis alone do not need colonoscopy surveillance, as they are not at increased risk of developing colon cancer compared to the general population. Understanding these risk factors can help prevent the onset of colonic adenocarcinoma in UC patients.

Contraception Options for Patients with Past Breast Cancer

Patients with a past history of breast cancer should be advised to use barrier contraception or the intrauterine device (IUD) only. Hormonal containing contraception, including progestogens, are UKMEC 3 in these patients. This means that the benefits of using hormonal contraception may outweigh the risks, but caution should be taken and alternative options should be considered.

The IUD and implant are also UKMEC 3 in patients with past breast cancer, while the IUD and progesterone-only pill are also considered UKMEC 3. It is important for patients to discuss their options with their healthcare provider and weigh the potential benefits and risks of each method before making a decision. By considering all options and taking precautions, patients with past breast cancer can still have access to effective contraception while minimizing potential risks.

Possible Ectopic Pregnancy: A Gynaecological Emergency

If you have a history of pelvic inflammatory disease (PID), previous terminations, and a positive pregnancy test, you should be aware of the risk of an ectopic pregnancy. This condition occurs when the fertilized egg implants outside the uterus, usually in the fallopian tube. It is a medical emergency that requires immediate admission to a hospital. If left untreated, it can lead to severe complications, such as internal bleeding and infertility.

Urinary retention may be caused by tricyclic antidepressants, particularly Amitriptyline, due to its anticholinergic effects. This can result in symptoms such as tachycardia, dry mouth, mydriasis, and urinary retention. However, SSRIs like fluoxetine and SNRIs like venlafaxine are not typically associated with these side effects, with dry mouth and urinary retention being rare occurrences. Unlike Amitriptyline, Diazepam, a benzodiazepine, doesn’t have anticholinergic effects.

Tricyclic antidepressants (TCAs) are not commonly used for depression anymore due to their side-effects and potential for toxicity in overdose. However, they are still widely used for the treatment of neuropathic pain, where smaller doses are typically required. The common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of QT interval. When choosing a TCA, low-dose amitriptyline is commonly used for the management of neuropathic pain and the prevention of headaches. Lofepramine is preferred due to its lower incidence of toxicity in overdose, while amitriptyline and dosulepin are considered the most dangerous in overdose. The sedative effects of TCAs vary, with amitriptyline, clomipramine, dosulepin, and trazodone being more sedative, while imipramine and nortriptyline are less sedative. Trazodone is technically a ‘tricyclic-related antidepressant’.

NICE Guidelines for Drug Treatment of Lower Urinary Tract Symptoms

NICE recommends drug treatment for bothersome lower urinary tract symptoms (LUTS) if conservative measures fail. For moderate to severe LUTS, an alpha-blocker like tamsulosin should be offered. Patients should be reviewed after four to six weeks until stable. If LUTS is accompanied by an enlarged prostate or a high PSA level, a 5-alpha reductase inhibitor like finasteride should be prescribed. Anticholinergic drugs like oxybutynin can be used to manage storage symptoms. For patients with moderate to severe LUTS and an enlarged prostate or high PSA level, both an alpha-blocker and a 5-alpha reductase inhibitor can be started. In the case of a patient with moderate LUTS, a prostate less than 30 g, and a PSA level less than 1.4, starting an alpha-blocker like tamsulosin and reviewing the patient in four to six weeks is the most appropriate approach.

Macular Degeneration: A Common Cause of Distorted Vision in Elderly Patients

An elderly patient complaining of wavy distorted vision should raise suspicion of macular degeneration, a common age-related eye condition. There are two types of macular degeneration: dry and wet. Unfortunately, there is no treatment for the dry type, but patients can be advised on good lighting and the use of magnifying glasses to aid their vision. However, patients should be aware that there is a 10% chance of the dry type converting into the more aggressive wet type.

The wet type of macular degeneration can be treated with anti-vascular endothelial growth factor (anti-VEGF) injections, which are given directly into the eye. This treatment aims to stabilize the condition and prevent further loss of central vision. While it is not a cure, a large minority of patients may experience some improvement in their vision. Therefore, it is crucial to refer patients with suspected macular degeneration to an ophthalmologist urgently, as delays may impact the prognosis.

Physical Signs and Symptoms of Depression in Elderly Patients

Depression in elderly patients can manifest in various physical signs and symptoms. Early morning waking and decreased appetite are common symptoms, often accompanied by short-term memory loss. While memory loss is also seen in dementia, it improves with treatment of depression. Other physical signs include weight loss, constipation, loss of libido, impotence in men, fatigue, and body aches and pains. Retardation or agitation of behavior may also occur. These symptoms may be precipitated by life events and should be addressed promptly to improve the patient’s quality of life.

It is recommended to try eliminating egg as the symptoms indicate a non-IgE-mediated food allergy.

Food allergies in children and young people can be categorized as either IgE-mediated or non-IgE-mediated. It is important to note that food intolerance is not caused by immune system dysfunction and is not covered by the 2011 NICE guidelines. Symptoms of IgE-mediated allergies include skin reactions such as pruritus, erythema, urticaria, and angioedema, as well as gastrointestinal and respiratory symptoms. Non-IgE-mediated allergies may present with symptoms such as gastro-oesophageal reflux disease, loose or frequent stools, and abdominal pain. If the history suggests an IgE-mediated allergy, skin prick tests or blood tests for specific IgE antibodies to suspected foods and co-allergens should be offered. If the history suggests a non-IgE-mediated allergy, the suspected allergen should be eliminated for 2-6 weeks and then reintroduced, with consultation from a dietitian for nutritional adequacies, timings, and follow-up.

Understanding Coeliac Disease Testing: Differentiating Between IgA tTGAs, IgA Gliadin Antibodies, IgA EMAs, HLA Genetic Testing, and IgG tTGAs

Coeliac disease is a condition that affects the small intestine and is caused by an intolerance to gluten. While small-bowel biopsy is the most reliable way to diagnose coeliac disease, IgA tissue transglutaminase antibodies (tTGAs) are the preferred initial investigation. This test is highly specific and sensitive for untreated coeliac disease, but should not be performed on children younger than two years as it may give a false negative result.

It is important to note that around 0.4% of the population has selective IgA deficiency, which can lead to a false-negative result. In such cases, the laboratory should measure IgA levels. Some laboratories may do this routinely when measuring tTGAs.

IgA gliadin antibodies are not commonly used to diagnose coeliac disease. Instead, IgA EMAs are autoantibodies against tissue transglutaminase type 2 (tTGA2) and are highly specific and sensitive for untreated coeliac disease. However, IgA EMAs should be measured if IgA tTG is only weakly positive.

HLA genetic testing is not recommended for diagnosing coeliac disease in primary care. Coeliac disease is strongly associated with the genes HLA-DQ2 and HLA-DQ8, but testing for these genes is not necessary for diagnosis.

Finally, IgG tTGAs should only be considered in people who are IgA deficient to avoid the risk of a false-negative IgA tTGA result.

In summary, understanding the differences between these tests is crucial in accurately diagnosing coeliac disease and providing appropriate treatment.

Timing and Options for Emergency Contraception

When it comes to emergency contraception, timing is crucial. If ovulation can be estimated, an IUD can be inserted up to five days after the expected date of ovulation. On the other hand, levonorgestrel can be taken beyond the recommended 72-hour window, but its effectiveness may be reduced. It can also be repeated within the same menstrual cycle. In cases where condoms are the only form of contraception, additional levonorgestrel may be prescribed. However, it’s important to note that pharmacists will not sell levonorgestrel to males. By understanding the timing and options for emergency contraception, individuals can make informed decisions about their reproductive health.

Managing Microscopic Haematuria

Persistent microscopic haematuria should be considered clinically relevant if present on at least two out of three samples tested at weekly intervals. A dipstick showing ‘trace’ blood should be considered negative. Blood 1+ or more is significant. If a patient is aged 60 and over and has unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test, referral to a Urologist as an urgent suspected cancer is advised according to NICE guidelines on the recognition and referral of suspected cancer.

It is important to note that certain medications, such as clopidogrel, aspirin, and warfarin, should not be attributed to microscopic haematuria. Additionally, if the sample is painless, it must have 1+ of blood or more on at least 2 out of 3 occasions to be considered abnormal.

If a patient is on pioglitazone, which carries a small but significant increased risk of bladder cancer, it would be prudent to stop the medication at least until the microscopic haematuria has been investigated.

In summary, managing microscopic haematuria involves careful consideration of the frequency and amount of blood present in the sample, as well as referral to a specialist for further investigation in certain cases.

If parents take their child to the A&E department instead of a GP on a regular basis, it could be an indication of child abuse. This is because they may assume that seeing a different doctor each time will decrease the likelihood of any suspicions being raised.

Recognizing Child Abuse: Signs and Symptoms

Child abuse is a serious issue that can have long-lasting effects on a child’s physical and emotional well-being. It is important to recognize the signs and symptoms of child abuse in order to protect vulnerable children. One way that abuse may come to light is through a child’s own disclosure. However, there are other factors that may indicate abuse, such as inconsistencies in a child’s story or repeated visits to emergency departments. Children who appear frightened or withdrawn may also be experiencing abuse, exhibiting a state of frozen watchfulness.

Physical signs of abuse can also be indicative of maltreatment. Bruising, fractures (especially in the metaphyseal area or posterior ribs), and burns or scalds are all possible signs of abuse. Additionally, a child who is failing to thrive or who has contracted a sexually transmitted infection may be experiencing abuse. It is important to be aware of these signs and to report any concerns to the appropriate authorities. By recognizing and addressing child abuse, we can help protect vulnerable children and promote their safety and well-being.

Individuals with insulin-dependent diabetes who are driving must monitor their blood glucose levels every 2 hours, according to DVLA guidelines. This man falls under this category and must adhere to this requirement. It would not be advisable to suggest that he only check his blood glucose when experiencing symptoms, as this could lead to impaired cognitive function and potentially cause an accident while driving before he has a chance to check his levels.

DVLA Regulations for Drivers with Diabetes Mellitus

The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

Effects of Cholesterol-Lowering Medications on Glucose Control

The mechanism by which nicotinic acid affects glucose levels is not fully understood, but it may increase blood glucose in some patients by stimulating hepatic glucose output or blocking glucose uptake by skeletal muscle. However, for most patients with diabetes, nicotinic acid has minimal effect. A meta-analysis in 2011 suggested an increased risk of inducing diabetes in patients treated with intensive statin therapy, but this did not examine whether statins worsened glucose control in established diabetics. Cholestyramine may interact with oral hypoglycemics, but it doesn’t typically worsen diabetic control and may even improve it. Fenofibrate and ezetimibe have not been shown to worsen diabetic control. Overall, the effects of cholesterol-lowering medications on glucose control vary and should be monitored closely in patients with diabetes.

Managing Nephropathy Progression

Tight control of blood pressure and glucose levels is crucial in managing the progression of nephropathy. The recommended target for systolic blood pressure is 130 or less, while the HbA1c target should be less than 53 mmol/mol. Although BMI, diastolic blood pressure, and cholesterol are relevant factors, they are less significant compared to blood pressure and glucose control.

Among all antihypertensives, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest evidence for reducing nephropathy progression. Therefore, it is important to prioritize these medications in the management of nephropathy. Proper management of blood pressure and glucose levels, along with the use of ACE inhibitors and ARBs, can significantly slow down the progression of nephropathy.

Conversion disorder is a condition that often results in the loss of motor or sensory function and is believed to be triggered by stress.

Unexplained Symptoms in Psychiatry

In psychiatry, there are several terms used to describe patients who present with physical or psychological symptoms for which no organic cause can be found. Somatisation disorder is characterized by the presence of multiple physical symptoms that persist for at least two years, and the patient refuses to accept reassurance or negative test results. Illness anxiety disorder, also known as hypochondriasis, involves a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results. Conversion disorder typically involves the loss of motor or sensory function, and the patient doesn’t consciously feign the symptoms or seek material gain. Dissociative disorder involves the process of separating off certain memories from normal consciousness, and may present with psychiatric symptoms such as amnesia, fugue, or stupor. Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms, while malingering refers to the fraudulent simulation or exaggeration of symptoms for financial or other gain. These terms help clinicians to better understand and diagnose patients with unexplained symptoms.

Investigating Hypogonadism: Appropriate Tests and Procedures

Hypogonadism is a condition that can be caused by primary or secondary factors. To determine the presence and type of hypogonadism, appropriate investigations should be conducted. In cases of primary hypogonadism, gonadotrophin levels are elevated while testosterone levels are low. Secondary hypogonadism, on the other hand, is characterized by low to normal gonadotrophin levels and low testosterone levels.

While investigating hypogonadism, it is important to conduct the appropriate tests and procedures. An MRI scan of the brain is not always necessary, but it may be appropriate in cases of hypopituitarism or hyperprolactinaemia to investigate a pituitary tumour. Depression screening may be appropriate as depression often co-exists with physical illness, but objective evidence of hypogonadism should not be ignored. Semen analysis is not necessary unless investigating infertility, as oligospermia is a consequence of hypogonadism. The Short Synacthen test is used to investigate adrenocortical insufficiency and is not relevant to investigating hypogonadism.

In summary, appropriate investigations for hypogonadism include determining whether it is primary or secondary through gonadotrophin and testosterone level testing. Other tests and procedures may be appropriate depending on the individual case, but should be carefully considered.

Enquiring about Suicide Risk Factors in Depressed Patients

When speaking with patients who are experiencing depression, it is important to always ask about suicide. Even if depression is not explicitly mentioned, it is helpful to identify any potential risk factors for suicide in the patient’s history. One example of a risk factor listed in this case is the patient’s low socio-economic status. Other risk factors include advancing age, male gender, recent major life events, unemployment, living alone, previous suicide attempts, and concurrent mental disorders.

To identify high-risk patients, clinicians may use formal assessments such as the PATHOS self-harm assessment. This tool is used after an overdose attempt to identify patients who are at a higher risk for suicide. By enquiring about suicide risk factors and using appropriate assessments, clinicians can better identify and support patients who may be at risk for self-harm.

Common Head and Neck Symptoms and Referral Guidelines

The following are common head and neck symptoms and the appropriate referral guidelines:

1. Discrete slow-growing lump in the right parotid gland: Any unexplained lump in the head or neck requires a 2-week rule referral. A discrete, persistent, unilateral lump in the parotid gland requires an urgent referral, imaging, and further investigation to determine the nature of the mass.

2. Solitary, painful ulcer on the oral mucosa, of 1-week duration: This is most likely to be an aphthous ulcer. An unexplained oral ulceration lasting more than three weeks, or an unexplained neck lump, would warrant a 2-week wait referral.

3. A 7-day history of hoarseness and sore throat: Patients over the age of 45 with persistent unexplained hoarseness should be referred using the cancer pathway. After seven days, this is most likely to be an upper respiratory tract infection.

4. Diffuse multinodular thyroid swelling: For suspected thyroid cancer, the single referral criterion is an ‘unexplained thyroid lump’. The most likely diagnosis in this patient is a multinodular goitre.

5. Nasal obstruction and bilateral grey swellings visible by nasal speculum: Bilateral nasal swellings of this description are almost certainly polyps. These can initially be managed in primary care. Unilateral polyps should be referred to the ear, nose and throat clinic.

Head and Neck Symptoms and Referral Guidelines

Interpreting Elevated CK Levels in a Post-MI Patient on Statin Therapy

When a patient complains of symptoms while on statin therapy, it is reasonable to check their CK levels. An elevated level suggests statin-induced myopathy, and the statin should be discontinued. However, if the patient doesn’t complain of further chest pain suggestive of another MI, CK is no longer routinely measured as a cardiac marker. Heavy exercise should also be avoided, and CK levels usually return to baseline within 72 hours post-MI. While undiagnosed hypothyroidism can cause a rise in CK, it is less likely than statin-induced myopathy, and other clinical features of hypothyroidism are not mentioned in the scenario.

Parkinson’s disease is a progressive neurodegenerative disorder that occurs due to the degeneration of dopaminergic neurons in the substantia nigra. This leads to a classic triad of symptoms, including bradykinesia, tremor, and rigidity, which are typically asymmetrical. The disease is more common in men and is usually diagnosed around the age of 65. Bradykinesia is characterized by a poverty of movement, shuffling steps, and difficulty initiating movement. Tremors are most noticeable at rest and typically occur in the thumb and index finger. Rigidity can be either lead pipe or cogwheel, and other features include mask-like facies, flexed posture, and drooling of saliva. Psychiatric features such as depression, dementia, and sleep disturbances may also occur. Diagnosis is usually clinical, but if there is difficulty differentiating between essential tremor and Parkinson’s disease, 123I‑FP‑CIT single photon emission computed tomography (SPECT) may be considered.

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.

Meniscal Tear: Causes and Symptoms

A meniscal tear is a common knee injury that usually occurs due to twisting injuries. The symptoms of a meniscal tear include pain that worsens when the knee is straightened, a feeling that the knee may give way, tenderness along the joint line, and knee locking in cases of displaced tears. A positive Thessaly’s test, which involves weight-bearing at 20 degrees of knee flexion while the patient is supported by a doctor, indicates pain on twisting the knee.

Screening for Depression: Two Questions Recommended by NICE

The National Institute for Health and Care Excellence (NICE) recommends two questions for screening depression: Have you often been bothered by having little interest or pleasure in doing things? and Have you been feeling down, depressed or hopeless? These questions relate to the past month and have a sensitivity of 96% and a specificity of 57%. While useful for screening, they are not sufficient for diagnosis.

Screening for depression is particularly important for those with a history of depression, significant physical illness, or other mental health problems like dementia. Depression and dementia can have similar symptoms, making screening crucial. Other high-risk groups include women in the puerperium, alcoholics and drug abusers, socially isolated individuals (especially the elderly), people in stressful situations, and those with unexplained symptoms.

If a patient answers yes to the screening questions, further questions about worthlessness, concentration, and thoughts of death should follow. Early detection and treatment of depression can improve outcomes and quality of life for patients.

Understanding Sydenham’s Chorea: A Common Cause of Acute Chorea Worldwide

Sydenham’s chorea, also known as St Vitus’ dance, is a neurological manifestation of rheumatic fever and remains the most common cause of acute chorea worldwide. While it was commonly seen in the 1930s, it occurs less frequently in the UK today. This condition can occur with or without symptoms of rheumatic fever and is usually self-limiting. Improvement occurs over about two weeks, but total recovery can take up to nine months, and may recur in some patients.

In this scenario, the short time course of the chorea and the girl’s age are useful diagnostically. It is important to note that psychological changes may precede or accompany the choreiform movements, as demonstrated by the girl’s emotional lability.

It is important to consider other potential causes of chorea, such as cerebral tumour, cerebrovascular accident, Guillain–Barré syndrome, and Huntington’s chorea. However, in this case, these conditions are unlikely as they do not fit with the girl’s symptoms and age.