Management of Burn Injuries

Burn injuries can cause thermal damage and inflammation, which can be reduced by cooling the affected area with water at 15oC. However, ice-cold water should be avoided as it can cause vasospasm and further ischaemia. Sensation and capillary refill should be assessed at initial presentation, as full thickness burns are insensitive. Silver sulfadiazine has not been proven to prevent infection. Epidermal burns are characterized by erythema, while larger or awkwardly positioned blisters should be aspirated under aseptic technique to prevent bursting and infection. De-roofing blisters should not be routinely done.

NICE Guidance for Suspected Pancreatic, Gallbladder, and Liver Cancer

There is a growing concern about malignancy when a patient experiences weight loss, jaundice, and an abdominal mass. To address this issue, the latest NICE guidance recommends several actions.

Firstly, for patients aged 40 and over with jaundice, healthcare professionals should refer them using a suspected cancer pathway referral for an appointment within two weeks to assess for pancreatic cancer. Secondly, for patients with an upper abdominal mass consistent with an enlarged Gallbladder, healthcare professionals should consider an urgent direct access ultrasound scan to assess for Gallbladder cancer within two weeks. Lastly, for patients with an upper abdominal mass consistent with an enlarged liver, healthcare professionals should consider an urgent direct access ultrasound scan to assess for liver cancer within two weeks.

By following these guidelines, healthcare professionals can quickly identify and address potential cancer diagnoses, improving patient outcomes and quality of life.

Verapamil exhibits the strongest negative inotropic effect among calcium channel blockers.

Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

Management of Unilateral Otitis Media in Primary Care

This child doesn’t exhibit any life-threatening symptoms or signs of serious illness. Based on the NICE ‘traffic light’ system, there are no ‘red’ or ‘amber’ indicators. The most probable diagnosis is unilateral otitis media, which can be safely managed in primary care. Parents should be advised to administer Calpol and/or Nurofen for pain relief and encourage oral fluids. The average duration of acute otitis media is four days.

Immediate antibiotics are only necessary for children with bilateral acute otitis media under the age of two, otorrhoea, systemic illness, symptoms and signs of serious illness and/or complications, or high risk of complications due to pre-existing comorbidity. Despite national guidelines, a large primary care study has shown that antibiotic prescribing remains high. Antibiotic prescriptions for otitis media have increased from 77% in 1995 to 85% in 2011. Therefore, it is crucial to educate patients on the natural duration of common infections and the potential harm of inappropriate antibiotic use.

Distinguishing Different Skin Lesions: Dermatofibroma, Malignant Melanoma, Seborrhoeic Keratosis, Cutaneous Metastasis, and Actinic Keratosis

When it comes to skin lesions, it’s important to distinguish between different types to determine the appropriate treatment. One such lesion is a dermatofibroma, which is a benign growth that often appears on the limbs of women. A key feature of a dermatofibroma is the dimpling that occurs when the skin is pinched, due to the fibrous tissue underneath.

On the other hand, malignant melanoma is less likely to be the cause of a skin lesion if it has regular pigmentation, hasn’t changed in several months, and has dimpling – all features of a dermatofibroma. Seborrhoeic keratosis, another type of skin lesion, has a rough, stuck-on appearance that doesn’t match the description of a dermatofibroma.

A cutaneous metastasis, which is a skin lesion that results from cancer spreading from another part of the body, typically presents as a rapidly growing nodule. This is different from a dermatofibroma, which is relatively static. Similarly, an actinic keratosis, a flat lesion with a fine scale, is unlikely to be the diagnosis for a nodular lesion like a dermatofibroma.

In summary, understanding the characteristics of different skin lesions can help in accurately identifying and treating them.

The usual management for Vitamin B12 deficiency involves intramuscular B12 replacement, with a loading regime followed by injections every 2-3 months. In the case of a woman with macrocytic anaemia and low serum B12 levels, the presence of intrinsic factor antibodies (IFAB) suggests pernicious anaemia, which requires lifelong hydroxocobalamin injections at 2-3 monthly intervals. While most patients with B12 deficiency are treated with IM replacement, NICE guidelines during the COVID pandemic recommend oral cyanocobalamin where possible, but this is not appropriate for this patient. Ferrous sulphate is a suitable treatment for iron deficiency anaemia. A haematology referral may be necessary if initial treatment is unsuccessful.

Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.

Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.

Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.

Symptoms of alcohol withdrawal can occur within 6-12 hours, including seizures.

Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. This is due to the fact that chronic alcohol consumption enhances GABA-mediated inhibition in the central nervous system (CNS), similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. When alcohol consumption is stopped, the opposite occurs, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission.

Symptoms of alcohol withdrawal typically start within 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at around 36 hours, while delirium tremens, which is characterized by coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, is most likely to occur at around 48-72 hours.

Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

Antimicrobial treatment is often unnecessary for most cases of infective conjunctivitis, regardless of whether it is caused by a virus or bacteria. It can be challenging to differentiate between the two, although bacterial conjunctivitis may present with purulent discharge instead of watery discharge. Patients can alleviate symptoms with self-care measures such as cold compresses and ocular lubricants. If symptoms persist after seven days, patients should seek further medical attention. In severe cases of suspected bacterial conjunctivitis, chloramphenicol ointment can be purchased over the counter, while fusidic acid may be used as a second-line antimicrobial. Herpetic conjunctivitis, which causes a painful red eye with vesicular eyelid lesions, can be treated with aciclovir. Swabs are not useful in diagnosing conjunctivitis.

Infective conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes that are accompanied by a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

In most cases, infective conjunctivitis is a self-limiting condition that resolves on its own within one to two weeks. However, patients are often offered topical antibiotic therapy, such as Chloramphenicol or topical fusidic acid. Chloramphenicol drops are given every two to three hours initially, while chloramphenicol ointment is given four times a day initially. Topical fusidic acid is an alternative and should be used for pregnant women. For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. It is important to advise patients not to share towels and to avoid wearing contact lenses during an episode of conjunctivitis. School exclusion is not necessary.

Spirometry Procedure for Health Care Providers

To perform spirometry, a clean, disposable, one-way mouthpiece should be attached to the spirometer. The patient should be instructed to take a deep breath until their lungs feel full and then hold their breath long enough to seal their lips tightly around the mouthpiece. The patient should then blast the air out as forcibly and fast as possible until there is no more air left to expel, while the operator verbally encourages them to keep blowing and maintain a good mouth seal.

It is important to watch the patient to ensure a good mouth seal is achieved and to check that an adequate trace has been achieved. The procedure can be repeated at least twice until three acceptable and repeatable blows are obtained, with a maximum of 8 efforts. Finally, there should be three readings, of which the best two are within 150 mL or 5% of each other. By following these steps, health care providers can accurately measure a patient’s lung function using spirometry.

Hand foot and mouth disease is the correct answer. The patient’s history reveals a mild illness with symptoms such as systemic upset, sore throat, and fever, followed by the appearance of oral ulcers and lesions on the hands and feet. It is worth noting that the lesions may also be present in the groin or buttocks area. The rash is characterized by scattered erythematous macules and papules, usually with a central greyish vesicle measuring around 25 mm.

Hand, Foot and Mouth Disease: A Contagious Condition in Children

Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

Types of Alopecia and Their Causes

Alopecia, or hair loss, can be categorized into two types: scarring and non-scarring. Scarring alopecia occurs when the hair follicle is destroyed, while non-scarring alopecia is characterized by the preservation of the hair follicle.

Scarring alopecia can be caused by various factors such as trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis. On the other hand, non-scarring alopecia can be attributed to male-pattern baldness, certain drugs like cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune disorders like alopecia areata, telogen effluvium, hair loss following a stressful period like surgery, and trichotillomania.

It is important to identify the type of alopecia and its underlying cause in order to determine the appropriate treatment. In some cases, scarring may develop in untreated tinea capitis if a kerion develops. Understanding the different types and causes of alopecia can help individuals take necessary steps to prevent or manage hair loss.

Felodipine is more likely to cause ankle swelling than verapamil compared to dihydropyridines like amlodipine. Calcium channel blockers are commonly used as a first-line treatment for hypertension in patients over 55 years old, but a common side effect is peripheral edema. Dihydropyridines, such as amlodipine, work by selectively targeting vascular smooth muscle receptors, causing vasodilation and increased capillary pressure, which can lead to ankle edema. On the other hand, non-dihydropyridines like verapamil are more selective for myocardial calcium receptors, resulting in reduced cardiac contraction and heart rate.

Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

This woman has exhibited a concerning symptom of experiencing loose stools for over 6 weeks, which is a red flag indicator. Given her age of over 60 years, it is important to discuss the potential of an underlying cancer and refer her to secondary care for further testing within 2 weeks to rule out the possibility of bowel cancer.

Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.

An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.

The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.

Understanding Vulvovaginitis

Vulvovaginitis is a common condition that can have various causes, including lichen sclerosus, VIN, and other dermatological conditions. However, in young women, an inflammatory vulval dermatitis is often the culprit, triggered by factors such as soaps, frequent washing, perfumes, sanitary towels, douching, or candidiasis.

The initial treatment for this condition typically involves a combination of topical steroid and antifungal preparations. While STI screening and specialist referrals are not usually necessary, it’s important to offer a chaperone during same-sex examinations and consider them mandatory for opposite-sex examinations.

It’s worth noting that lack of estrogen is not typically a cause of vulvovaginitis, and vulval biopsy is not usually indicated based on the information available. By understanding the causes and appropriate treatments for vulvovaginitis, healthcare providers can help their patients manage this common condition effectively.

Types of Diabetes

There are two major types of diabetes: type 1 and type 2. Type 1 diabetes is characterized by a deficiency of insulin and typically affects children. Patients with type 1 diabetes are thin, lose weight, and are treated with insulin. On the other hand, type 2 diabetes affects an older age group and is associated with weight gain (obesity). It is usually treated with diet and/or drugs. Although not inherited in any mendelian fashion, type 2 diabetes has a familial occurrence due to the body type of the family. Iatrogenic diabetes is caused by medical treatments, while mitochondrial diabetes is a very rare form of diabetes resulting from damage to mitochondrial DNA. Finally, secondary diabetes occurs as a consequence of another disease.

It is important to differentiate between the types of diabetes as this guides treatment. Patients with type 1 diabetes require insulin, while those with type 2 diabetes may initially be treated with diet and/or drugs but may eventually require insulin. Understanding the cause of diabetes is also important in determining the appropriate treatment.

Long-term steroid use often leads to psychiatric issues.

Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

Hepatitis E and D: A Comparison

Hepatitis E is a self-limiting illness that follows a similar course to hepatitis A. However, fulminant disease can occur in a small percentage of cases. This type of hepatitis is most commonly found in developing countries and is transmitted through contaminated drinking water. While person-to-person contact transmission is rare, maternal-neonatal transmission can occur, with pregnant women being at the highest risk of developing fulminant hepatitis. Management of hepatitis E is supportive, and there are no chronic cases except in immunocompromised individuals.

On the other hand, hepatitis D requires co-infection with hepatitis B to cause inflammation. Co-infection with hepatitis D increases the likelihood of hepatitis B progressing to chronic disease and cirrhosis. Hepatitis D is most commonly found in Mediterranean countries, parts of Eastern Europe, the Middle East, Africa, and South America.

Management of Endometriosis-Related Pain and Pelvic Inflammatory Disease

When it comes to managing endometriosis-related pain, a trial of paracetamol or an NSAID (alone or in combination) is recommended as first-line treatment. If this proves ineffective, other forms of pain management, including neuropathic pain treatment, should be considered. Hormonal treatment, such as COCP and POP, is also a sensible first-line option for women with suspected or confirmed endometriosis.

For pelvic inflammatory disease (PID), metronidazole + ofloxacin is often used as first-line treatment. However, there is no indication of this from the patient’s history. Referral to gynaecology would not add much at this stage, as they would likely offer the same options. Additionally, the patient is not keen on any surgical intervention at this point, which would include laparoscopy.

It’s important to note that GnRH agonists are not routinely started in primary care. They are sometimes started by gynaecology as an adjunct to surgery for deep endometriosis. Overall, a tailored approach to management is necessary for both endometriosis-related pain and PID, taking into account the individual patient’s needs and preferences.

Complications of Hyperuricaemia

Hyperuricaemia, or high levels of uric acid in the blood, can lead to various complications. One of these is renal disease, which can manifest as acute or chronic urate nephropathy. Another complication is the formation of urinary stones, which is seen in 10-25% of people with gout. The incidence of urinary stones is strongly correlated with plasma urate level, with a 50% increase in those with levels higher than 780 µmol/L. It is important to manage hyperuricaemia to prevent these complications from occurring.

Assessment and Severity of Acute Asthma

The British Thoracic Society provides clear guidance on the assessment and management of acute asthma. It is important to familiarize oneself with this document, as questions about the assessment and severity of acute asthma are common in exams.

Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of the patient’s best or predicted rate, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or the inability to complete sentences in one breath. The goal of oxygen therapy is to maintain SpO2 levels between 94-98%.

It is important to note that there is no fixed numerical peak flow rate for all patients to determine the severity of their asthma. It depends on their personal best reading or predicted peak flow reading. If their actual peak flow is 33-50% of this figure, it is a marker of an acute severe attack.

For example, a peak flow rate of 400 L/min in a patient with a personal best of 500 L/min equates to 80% of their best and would not be considered a marker of an acute severe attack. However, a pulse of 115 would be considered a marker of acute severe asthma because the threshold is 110/min or greater.

If any of these features of an acute severe asthma attack persist after initial treatment, the patient should be admitted.

When using Ellaone, it is recommended to wait for 5 days before starting the combined contraceptive pill and to use barrier contraception for 7 days. This is because taking progestogen within 5 days of using Ulipristal may reduce its effectiveness as an emergency contraceptive. Waiting for this period and avoiding further unprotected sexual intercourse ensures that Ellaone is as effective as possible in preventing pregnancy. When starting the combined contraceptive pill, patch, or ring, or the progesterone-only implant or injection, barrier contraception should be used for 7 days. For Qlaira contraceptive pill, barrier contraceptives should be used for 9 days, and for the progesterone-only pill, for 2 days after starting the method.

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.

The HbA1c target for individuals with type 2 diabetes mellitus who are taking a single drug not linked to hypoglycemia, such as metformin, is 48 mmol/mol. However, if they are taking multiple medications or a single medication that is associated with hypoglycemia, the target may differ.

NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

For primary prevention of cardiovascular disease, the recommended treatment is atorvastatin 20 mg, while for secondary prevention, atorvastatin 80 mg is recommended. Simvastatin used to be the first-line option, but atorvastatin is now preferred due to its higher intensity and lower risk of myopathy at high doses. Before starting statin treatment, it is important to check liver function tests, which in this case were normal. According to the BNF, atorvastatin 20 mg is appropriate for patients with chronic kidney disease. It is not recommended to use ezetimibe or fenofibrate as first-line options for managing cholesterol.

Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

According to the latest NICE Guidelines for suspected cancer (June 2015), individuals aged 60 and above with persistent bone pain, particularly back pain, or unexplained fracture should be offered a FBC, calcium and plasma viscosity or ESR to assess for myeloma. Additionally, those with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma should be offered very urgent protein electrophoresis and a Bence Jones protein urine test within 48 hours. In cases where the plasma viscosity or ESR and presentation are consistent with possible myeloma, very urgent protein electrophoresis and a Bence Jones protein urine test should be considered. If the results of protein electrophoresis or a Bence Jones protein urine test suggest myeloma, referral should be made within 2 weeks. These guidelines have been updated in 2015.

Understanding Multiple Myeloma: Features and Investigations

Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is most commonly found in patients aged 60-70 years. The disease is characterized by a range of symptoms, which can be remembered using the mnemonic CRABBI. These include hypercalcemia, renal damage, anemia, bleeding, bone lesions, and increased susceptibility to infection. Other features of multiple myeloma include amyloidosis, carpal tunnel syndrome, neuropathy, and hyperviscosity.

To diagnose multiple myeloma, a range of investigations are required. Blood tests can reveal anemia, renal failure, and hypercalcemia. Protein electrophoresis can detect raised levels of monoclonal IgA/IgG proteins in the serum, while bone marrow aspiration can confirm the diagnosis if the number of plasma cells is significantly raised. Imaging studies, such as whole-body MRI or X-rays, can be used to detect osteolytic lesions.

The diagnostic criteria for multiple myeloma require one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of the disease. Major criteria include the presence of plasmacytoma, 30% plasma cells in a bone marrow sample, or elevated levels of M protein in the blood or urine. Minor criteria include 10% to 30% plasma cells in a bone marrow sample, minor elevations in the level of M protein in the blood or urine, osteolytic lesions, or low levels of antibodies in the blood. Understanding the features and investigations of multiple myeloma is crucial for early detection and effective treatment.

Death Certification Processes and Referral to the Coroner

The mode of death in a patient must be known before issuing a death certificate. If it is unknown, the case must be referred to the coroner. For instance, if a patient dies after acute onset chest pain, it is impossible to determine if they died of a myocardial infarction, pulmonary embolus, a thoracic aortic dissection, or another pathology.

The Coronavirus Act 2020 introduced temporary changes to death certification processes and cremation forms in England, Wales, and Northern Ireland. However, these changes expired in March 2022. The key changes included the requirement for a certifying doctor to have attended the deceased in their last illness and either seen them in the 28 days prior to death or after death. Video consultations were acceptable methods of ‘seeing’ a person in the last 28 days of their life but not after death.

If a medical practitioner has not attended the deceased in their last illness or not seen them in the 28 days prior to death or after death, they must refer the case to the coroner for discussion to establish if the coroner is content for them to issue a death certificate. Medical practitioners are advised to include the name of the person verifying death if they did not view the deceased themselves, whether a Part 100A has been issued by the coroner, and the names of other practitioners attending and their role on all cremation forms.

The effectiveness of the progesterone only pill can be achieved within 48 hours of starting it, regardless of the time in the menstrual cycle it is initiated.

Counselling for Women Considering the Progestogen-Only Pill

Women who are considering taking the progestogen-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. It is important to note that the POP should be taken at the same time every day, without a pill-free break, unlike the combined oral contraceptive (COC).

When starting the POP, immediate protection is provided if commenced up to and including day 5 of the cycle. If started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a COC, immediate protection is provided if continued directly from the end of a pill packet.

In case of missed pills, if the delay is less than 3 hours, the pill should be taken as usual. If the delay is more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours.

It is important to note that antibiotics have no effect on the POP, unless the antibiotic alters the P450 enzyme system. Liver enzyme inducers may reduce the effectiveness of the POP. In case of diarrhoea and vomiting, the POP should be continued, but it should be assumed that pills have been missed.

Finally, it is important to discuss sexually transmitted infections (STIs) with healthcare providers when considering the POP. By providing comprehensive counselling, women can make informed decisions about whether the POP is the right contraceptive choice for them.

Coughing is a common symptom that can be caused by various factors. Asthma, recurrent infections, and prolonged infections are very common causes of coughing. Cigarette smoking, habit or psychogenic cough, and idiopathic reasons are also common causes. Uncommon causes include aspiration, gastro-oesophageal reflux, incoordinate swallowing, intrabronchial foreign body, suppurative lung disease, and mediastinal or pulmonary tumors. Very rare causes include suppurative lung disease. Other less common causes of coughing include cystic fibrosis, post-infective conditions, tuberculosis, ciliary abnormalities, congenital abnormalities of the respiratory tract, and immunodeficiency.

Calculation of Propranolol Dose

When calculating the dose of propranolol, it is important to consider the patient’s weight and the daily dose required. For example, if the patient weighs 12 kg and requires a daily dose of 0.5 mg/kg, the total daily dose would be 6 mg TDS.

To determine the amount of propranolol needed, it is important to know the concentration of the medication. In this case, the concentration is 5 mg/5 ml, which can be simplified to 1 mg/1 ml. Therefore, the total daily dose of 6 mg would be equivalent to 6 ml TDS.

It is important to accurately calculate the dose of propranolol to ensure the patient receives the appropriate amount of medication for their condition. By considering the patient’s weight and the medication concentration, healthcare professionals can determine the correct dosage for their patients.

Understanding and Treating Blepharitis

Blepharitis is a chronic condition that can be caused by staphylococcal infection, seborrhoeic dermatitis, meibomian gland dysfunction, or a combination of these factors. It is characterized by inflammation of the eyelid margins and can be managed with self-care measures. Good eyelid hygiene is crucial in treating blepharitis, and patients should be advised to clean their eyelids twice a day using dilute baby shampoo.

While topical or oral antibiotics may be prescribed in certain cases, they should be reserved for second-line use when eyelid hygiene alone is ineffective. Contact dermatitis and acute conjunctivitis are not the same as blepharitis, and treatment with artificial tears is not always necessary.

In some cases, chronic blepharitis may be a symptom of rosacea and can be treated with oral tetracycline. It is important for patients to understand the causes and treatment options for blepharitis in order to effectively manage their symptoms.

This individual’s diagnosis of Addison’s disease is confirmed by a failed short synacthen test, which measures the adrenal glands’ response to synthetic adrenocorticotrophic hormone (ACTH) analogue.

Autoimmune disease is the leading cause of Addison’s disease in developed countries, while tuberculosis (TB) is the most prevalent cause globally. However, given the patient’s Welsh heritage and lack of TB risk factors, TB is less probable in this scenario. Metastatic disease, amyloidosis, and Waterhouse Friderichsen syndrome are all less frequent causes of Addison’s disease.

Addison’s disease is the most common cause of primary hypoadrenalism in the UK, with autoimmune destruction of the adrenal glands being the main culprit, accounting for 80% of cases. This results in reduced production of cortisol and aldosterone. Symptoms of Addison’s disease include lethargy, weakness, anorexia, nausea and vomiting, weight loss, and salt-craving. Hyperpigmentation, especially in palmar creases, vitiligo, loss of pubic hair in women, hypotension, hypoglycemia, and hyponatremia and hyperkalemia may also be observed. In severe cases, a crisis may occur, leading to collapse, shock, and pyrexia.

Other primary causes of hypoadrenalism include tuberculosis, metastases (such as bronchial carcinoma), meningococcal septicaemia (Waterhouse-Friderichsen syndrome), HIV, and antiphospholipid syndrome. Secondary causes include pituitary disorders, such as tumours, irradiation, and infiltration. Exogenous glucocorticoid therapy can also lead to hypoadrenalism.

It is important to note that primary Addison’s disease is associated with hyperpigmentation, while secondary adrenal insufficiency is not.