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3921. MRSA in primary care: Scenario: Management of MRSA in primary care

in the community but may be indicated if the person has (such as a wound or invasive device, or is resident in a care home) – discuss the need for suppression therapy with the local infection-control team. Suppression treatment typically consists of an antibacterial solution for body and hair in addition to nasal treatment. After completion of decolonization treatment, further screening or treatment is generally not required unless advised by the Infection Control team. Further information on decolonisation (...) to skin contact with other people (for example athletic activities) until their wound is healed. To wear disposable gloves when changing dressings and dispose of these and used dressings safely — gloves must never be re-used. To wash their hands with soap and water regularly, especially before and after touching any dressings or wounds, even if gloves are worn — carers should wash their hands after any physical contact with an infected or colonised person. To maintain good general hygiene with regular

2020 NICE Clinical Knowledge Summaries

3922. Miscarriage: Scenario: Follow up after a miscarriage

). Discuss any questions she has about her miscarriage, including: The of miscarriage. When to resume sexual intercourse. Advise avoidance of sexual intercourse until miscarriage symptoms have completely settled. Trying for another baby. Explain that menstruation can be expected to resume within 4–8 weeks of the miscarriage, and ovulation will occur before this. For women who wish to become pregnant, advise that they can do so as soon as they feel psychologically and physically ready, and offer pre (...) after a miscarriage. The following leaflet produced by the miscarriage association may be helpful: Ensure that all rhesus-negative women who have had a surgical procedure to manage miscarriage have received anti-D immunoglobulin. Be aware that anti-D immunoglobulin should not be given to women who: Receive solely medical management for a miscarriage. Have had a threatened miscarriage. Have had a complete miscarriage. Provide additional patient information on miscarriage. For example: The Royal

2018 NICE Clinical Knowledge Summaries

3923. Itch - widespread: What should I ask and look for on examination?

— consistently localized itch suggests a localized cause rather than systemic disease. Relieving factors — itch that is relieved with emollients or topical antipruritics is rarely associated with a serious cause. Associated symptoms (for example rash, fever, weight loss). Drug history (to exclude medications that can cause itching, for example opioids, statins, angiotensin-converting enzyme [ACE] inhibitors). Diet — to identify features suggesting iron deficiency. Itching in other people who have been (...) contacts — may indicate scabies. Alcohol misuse — may indicate liver disease. Emotional stress and mental health history — may indicate a psychogenic cause. Review all systems to identify symptoms associated with . This may help focus the physical examination and laboratory tests. A full physical examination may be useful if there are no localizing clues from the history. Always examine: The skin, for Lesions, rash, signs of infestation, or excoriation. Dermographism (skin becomes raised and red when

2019 NICE Clinical Knowledge Summaries

3924. Bipolar disorder: When should I suspect bipolar disorder?

lead to increased performance at work or socially. Feelings of well-being, or physical and mental efficiency. Increased sociability, talkativeness, and over-familiarity. Diagnosis of a hypomanic episode requires symptoms to last for at least 4 days. A mixed episode is suggested by a mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms. Depression is suggested by feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy (...) opinion within the BMJ Best Practice guideline Bipolar disorder in adults [ ] which states that: Hyperthyroidism may mimic manic or hypomanic states. Hypothyroidism can produce mental depression. Serum vitamin D should be performed to exclude other possible causes of mood symptoms. Toxicology screen should be performed to exclude other possible causes of mood symptoms — symptoms observed in manic, mixed, or hypomanic episodes may occur as part of an intoxication or withdrawal phenomenon from a drug

2020 NICE Clinical Knowledge Summaries

3925. Bipolar disorder: What else might it be?

. Auditory hallucinations may be in the second person rather than the third person. For more information, see the CKS topic on . Mood disorder due to underlying medical condition such as stroke, thyroid disease, or multiple sclerosis — suspect based on other signs and symptoms of these conditions. For more information, see the CKS topics on , , and . Substance misuse — stimulant effects of drugs such as cocaine, ecstasy, or amphetamines may mimic some features of bipolar disorder. Suspect (...) if there is known drug use and if symptoms subside within 7 days. Organic brain disease caused by, for example, progressive frontal lobe dementia, cerebrovascular disease, multiple sclerosis, AIDS, epilepsy, systemic lupus erythematosus, encephalitis, or a space-occupying lesion. Iatrogenic causes, for example, use of antidepressants, corticosteroids, levodopa, pramipexole, and prescribed stimulants (such as methylphenidate). Metabolic disorders, for example, hyperthyroidism, Cushing's disease, Addison's

2018 NICE Clinical Knowledge Summaries

3926. Bipolar disorder: Valproate

Syndrome. The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends that valproate should not be prescribed to female children, female adolescents, women of childbearing potential, or pregnant women to treat bipolar disorder unless the illness is very severe and there is no effective alternative option. Females of childbearing potential taking valproate should be enrolled in a pregnancy prevention plan. Valproate is a teratogen and can cause physical birth defects and developmental (...) of bipolar disorder. Both semisodium and sodium valproate are metabolized to valproic acid, which is responsible for their pharmacological activity. [ ] What are the contraindications and cautions? Do not prescribe valproate to people with: Active liver disease. Personal or family history of severe, drug-related, hepatic dysfunction. Acute porphyria. Mitochondrial disorders caused by mutations in the nuclear gene encoding the mitochondrial enzyme polymerase γ (POLG), for example Alpers-Huttenlocher

2018 NICE Clinical Knowledge Summaries

3927. Bipolar disorder: Scenario: Women of childbearing age

or planning a pregnancy to a specialist perinatal mental health service if available, or to the community mental health service for an assessment and discussion of drug treatment. Note: NICE recommends that if women or young girls of childbearing potential are already taking valproate they should be advised to gradually stop the medicine because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy . The dose of valproate should be reduced gradually (...) over at least 4 weeks to minimise the risk of relapse. Do not alter or stop drug treatment without seeking specialist advice. Explain to the woman that she may be advised to: Remain on her current drug treatment throughout conception, pregnancy, and birth. Switch to another drug treatment. Stop or reduce the dose of her medication. Explain that the strategy which is chosen will depend on her wishes, and on the advice of the medical team who need to balance the risks of under-treatment (relapse

2018 NICE Clinical Knowledge Summaries

3928. Bipolar disorder: Scenario: Routine bipolar disorder review

is a stimulant). Avoiding alcohol and drug misuse. When carrying out a physical health review: Ask about symptoms that could be due to adverse effects of medication. See the section on for more information. Ensure that there are arrangements in place for monitoring of , , and (if applicable). Ask about alcohol intake and substance misuse, and encourage people who smoke to stop. Note that smoking enhances the metabolism of olanzapine and clozapine. For more information, see the CKS topics on , and . Ask about (...) [ ]. Frequency of routine review NICE recommends annual physical health, mental health, and treatment review for people with bipolar disorder [ ], or more frequently if the person or their carer express any concerns. The recommendation for more frequent review if the person has sleep disturbance or following stressful life events is pragmatic, based on what CKS considers to be good medical practice, on the basis that both may trigger an acute episode, and sleep disturbance may be an early symptom

2018 NICE Clinical Knowledge Summaries

3929. Bipolar disorder: Scenario: Primary care management

behavioural therapy) may be offered. For more information, see the CKS topic on . Secondary care will usually: Monitor the person's physical health, mental health, and the effects of antipsychotic drug treatment for at least the first 12 months, or until the person's condition has stabilized. Encourage the person to make a lasting power of attorney, so that a trusted person or an advocate can express the person's point of view as expressed in the advanced statement or statement of wishes and feelings (...) offered appropriate psychological interventions that have either been developed specifically for bipolar disorder, or in-line with those recommended for the management of depression. For further information, see the CKS topic on . Monitoring the person's mood, and if necessary, following crisis plans developed in secondary care and liaising with secondary care specialists. For more information, see the section on . Reviewing the person's physical health, mental health, and medication at least annually

2018 NICE Clinical Knowledge Summaries

3930. Bipolar disorder: Antipsychotics

(for example erythromycin), and tricyclic antidepressants, may have a synergistic effect on the QT interval. Avoid co-prescribing drugs that prolong the QT interval. These drugs are contraindicated with haloperidol, sertindole, or pimozide therapy. Diuretics may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics. Azole antifungals Azole antifungals may increase levels of some antipsychotics, for example: Aripiprazole levels are predicted (...) requiring a change in the dose of their antipsychotic or a change of drug should be referred to specialist mental health services, or that specialist advice should be sought. When discontinuing antipsychotics, the dose should be reduced gradually over at least 4 weeks if the person is continuing with other antimanic drugs. If the person is not continuing with other antimanic drugs or if there is a history of manic relapse, a withdrawal period of up to 3 months should be considered. [ ] How should I

2018 NICE Clinical Knowledge Summaries

3931. Benign paroxysmal positional vertigo

without treatment. An explanation that treatment may help the person's symptoms resolve more quickly should be offered. If the person prefers treatment, a particle repositioning manoeuvre, such as the Epley manoeuvre should be offered and Brandt-Daroff exercises considered. Symptomatic drug treatment is not usually helpful for people with BPPV. The person should be advised to return for follow up in 4 weeks if symptoms have not resolved in case BPPV has been incorrectly diagnosed. Admission (...) to hospital should be arranged if there is severe nausea and vomiting and an inability to tolerate oral fluids. Referral should be arranged to a medically qualified balance specialist (such as an ear, nose, and throat specialist, audiovestibular specialist physician, or care of the elderly physician with a special interest — depending on local protocol) if any of the following apply: The expertise to provide a canalith repositioning procedure (for example the Epley manoeuvre) is not available in primary

2018 NICE Clinical Knowledge Summaries

3932. Back pain - low (without radiculopathy): Scenario: Management

. If pain or functional impairment persists: Offer referral for a group exercise programme (if not this is not ongoing), taking into account the person's specific needs, preferences and capabilities. Consider in conjunction, offering referral for cognitive behavioural therapy, and/or physiotherapy (including spinal manipulation, mobilisation, or massage). A combined physical and psychological programme is particularly recommended for people with persistent low back pain, when they have significant (...) to improve quickly generally need less intensive support, while people at higher risk of a poor outcome may require more complex and intensive support. For all people with non-specific low back pain: Offer , tailored to the person's needs and capabilities, including information on the nature of low back pain, and encouragement to continue with normal activities. Offer analgesia to manage pain: Offer a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen first-line

2018 NICE Clinical Knowledge Summaries

3933. Back pain - low (without radiculopathy): Diazepam

driving. If you have a positive roadside drug test for benzodiazepines, the police may ask you to provide a blood sample to measure the amount of benzodiazepine in your body. Even if you are found to have more than the specified amount of benzodiazepine in your body, as long as your driving is not impaired, and you are taking your medicine on the advice of a doctor or pharmacist, you will be able to raise a statutory 'medical defence' and the police may not prosecute you. It may be helpful to keep (...) evidence that you are taking a benzodiazepine in accordance with medical advice with you while you are driving. Suitable evidence may include: your medication box with the pharmacy label on, or the other half of your prescription with the list of medicines prescribed by your doctor. Other adverse effects include: Headache, vertigo, tremor, slurred speech, decreased libido, erectile dysfunction, gynaecomastia, and obstructive sleep apnoea syndrome. Paradoxical effects such as talkativeness, excitement

2018 NICE Clinical Knowledge Summaries

3934. Autism in children: Scenario: How should I manage a child with confirmed autism spectrum disorder in primary care?

to Public Health England (PHE), a substantial proportion of people with a learning disability, autism, or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn. The (Stopping Over-Medication of People with a Learning Disability, Autism or Both) project was launched in 2016 by NHS England, the Royal College of Nursing (RCN), the Royal College of Psychiatrists, the Royal College of GPs (RCGP), the Royal Pharmaceutical Society (RPS (...) birth to 19 years. How should I manage a child or young person with confirmed autism spectrum disorder? Following confirmation of the diagnosis of autism spectrum disorder (ASD) in secondary care , the deci sion to routinely review children or young people with ASD in primary care (to ensure that they, and their family, are coping well and receiving appropriate medical, educational, and social support) should be made on a case by case basis using clinical judgement. Review in primary care may

2018 NICE Clinical Knowledge Summaries

3935. Autism in adults: Scenario: Managing confirmed autism

; chelation; exclusion diets (such as gluten- or casein-free and ketogenic diets); vitamins, minerals and dietary supplements (such as vitamin B6 or iron supplementation); drugs specifically designed to improve cognitive functioning (for example, cholinesterase inhibitors); oxytocin; secretin; testosterone regulation; and hyperbaric oxygen therapy. Antidepressants for the routine management of core symptoms of ASD in adults. Drugs specifically designed to improve cognitive functioning (for example (...) an understanding of the: Nature, development, and course of ASD. Impact on personal, social, educational, and occupational functioning. Impact of the social and physical environment. All health and social care professionals providing care and support for adults with ASD should have a broad understanding of the: Nature, development, and course of ASD. Impact on personal, social, educational, and occupational functioning. Impact of and interaction with the social and physical environment. Impact

2020 NICE Clinical Knowledge Summaries

3936. Breast cancer - managing Family History: Scenario: Breast cancer - managing family history

of breast cancer when: A person has concerns about their family history of breast cancer. A person has breast symptoms. It is clinically relevant, for example: In women over 35 years of age using an oral contraceptive pill. In women being considered for long-term hormone replacement therapy (HRT). Document a family tree including the person and their first-degree relatives (mother, father, daughter, son, sister, and brother) and second-degree relatives (grandparents, grandchildren, aunt, uncle, niece (...) Health England (PHE, ) can be used by healthcare professionals to explain to women how to be aware of changes in their breasts. Give lifestyle advice regarding breast cancer risk. Advise on reduction of alcohol intake, maintenance of a healthy weight, increasing physical exercise, and smoking cessation (where appropriate). Advise women that the following may reduce the risk of breast cancer: having a first child at a younger age, having a large family, and breastfeeding. Give women appropriate

2018 NICE Clinical Knowledge Summaries

3937. Breast cancer - managing Family History

the disease. The risk increases with the number of relatives affected and the age at diagnosis of the relative (the younger the age of diagnosis the greater the risk), and is modified by other breast cancer risk factors, including age at menopause, parity, oral contraception, hormone replacement therapy (HRT), and breastfeeding. People without a personal history of breast cancer can be managed in primary care if they have only one first-degree relative (mother, father, daughter, son, sister, or brother (...) (for example BRCA1 or BRCA2) has been identified in the family, direct referral to a specialist genetics service should be offered. Appropriate information and support should be provided to the person, including: Information on breast cancer risk, breast awareness, and the NHS Breast Screening Programme. Lifestyle advice regarding breast cancer risk, including advice on alcohol, weight, physical exercise, and smoking cessation (where appropriate). Advice on hormonal contraception and HRT. © .

2018 NICE Clinical Knowledge Summaries

3938. Bowel screening: Scenario: Bowel screening

in stools, changes in bowel habit and abdominal pain) — advice the person to seek urgent medical review if symptoms develop even if they have taken part in screening recently. Negative screening results should not be used to guide investigation of a person presenting with symptoms of bowel cancer. There are major differences in the use of faecal occult blood testing in investigation of symptomatic disease compared to use as a screening test including different threshold levels for abnormal results (...) physical activity (at least moderate intensity for a minimum of 30 minutes five days a week). Basis for recommendation The recommendations on the contribution of primary care to the bowel screening programme are based on clinical guidance The UK NSC recommendation on bowel cancer screening in adults [ ], Diagnosis and management of colorectal cancer. A national clinical guideline [ ], Scottish Bowel Screening Programme - a guide for professionals [ ], Engaging primary care in bowel screening. GP good

2019 NICE Clinical Knowledge Summaries

3939. Blackouts: Scenario: Management

the person is waiting for assessment, advise them: To seek urgent medical attention (by dialling 999 if necessary) if they have another event. How they should modify their activity (such as avoiding physical exertion if appropriate). If there are clinical features suggestive of epilepsy as an f or blackout, refer the person for neurological assessment by an epilepsy specialist within 2 weeks. Advise the person with suspected epilepsy: To avoid potentially dangerous work or leisure activities while (...) . For people in whom orthostatic hypotension is confirmed: Consider likely causes, review any drug therapy, and eliminate any potentially causative drugs where possible. Explain the mechanisms causing the blackouts. Written is available from the Newcastle upon Tyne Hospitals Falls and Syncope service. Advise the person of simple lifestyle changes that can lessen symptoms of orthostatic hypotension, including: First sitting when going from a supine to a standing position. Eating frequent, small meals

2019 NICE Clinical Knowledge Summaries

3940. Ankylosing spondylitis: Scenario: Confirmed ankylosing spondylitis

on ( ). Information about employment and the ability to work. Advise the person that they may be more prone to fractures and that they should seek medical advice following a fall or physical trauma, especially if they have increased pain. Basis for recommendation This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline Spondyloarthritis in over 16s: diagnosis and management [ ; ]. The NICE guideline development group advocated information provision to improve (...) : An explanation of and . of ankylosing spondylitis. Likely symptoms and their management. Extra-articular symptoms (for example uveitis). Flare episodes — consider a flare management plan tailored to the person's needs, preferences, and circumstances including access to care (for example specialist rheumatology nurse), self care (for example exercise, stretching), pain and fatigue management, potential medication changes, and managing the impact on work and daily life. Treatment options (pharmacological

2019 NICE Clinical Knowledge Summaries


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