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4001. Erectile dysfunction

should include: A detailed history, including present and past erection quality, lifestyle (including alcohol intake, smoking status, and illicit drug use), and previous treatments tried. A focused physical examination to identify any genitourinary, endocrine, vascular, or neurological causes of erectile dysfunction. Appropriate investigations, including glucose-lipid profile and total testosterone, to identify any reversible/modifiable risk factors. Erectile dysfunction usually responds well (...) satisfactory sexual performance. It is a complicated disorder with several possible organic and/or psychogenic causes. It can also be drug induced. Organic causes may be vasculogenic (for example cardiovascular disease [CVD], hypertension, hyperlipidaemia, diabetes mellitus); neurogenic (for example multiple sclerosis, Parkinson’s disease); anatomical (for example Peyronie’s disease, hypospadias, prostate cancer), or hormonal (for example hypogonadism, hyper-and hypothyroidism, Cushing’s disease

2018 NICE Clinical Knowledge Summaries

4002. Diabetes - type 2: Scenario: Management of children and young people with type 2 diabetes

/carers to: Have the following immunizations recommended by the Department of Health (if applicable): Annual immunization against influenza (if over the age of 6 months). See the CKS topic on for more information. Immunization against pneumococcal infection (for children and young people with diabetes who need insulin or oral hypoglycaemic drugs). See the CKS topic on for more information. Always wear or carry some form of diabetes identification, for example: A MedicAlert® bracelet, necklace (...) people that live far away from the hospital. A continuing programme of education. This should: Include the following core elements: HbA1c monitoring and targets. The effects of diet, physical activity, body weight, and intercurrent illness on blood glucose control. The aims of metformin treatment and possible adverse effects. The complications of type 2 diabetes and how to prevent them. Be tailored to the child/young person and/or their family/carers, taking account of issues such as: Emotional

2019 NICE Clinical Knowledge Summaries

4003. Endometriosis: Scenario: Management of endometriosis

-pharmacological management. Advise that the available evidence does not support the use of traditional Chinese medicine or other Chinese herbal medicines or supplements for treating endometriosis. Assess her individual information and support needs, taking into account her circumstances, symptoms, priorities, desire for fertility, aspects of daily living, work and study, cultural background as well as her physical, psychosexual, and emotional needs. Assess for of endometriosis. Assess the impact (...) evidence available. Despite a lack of evidence, the Committee concluded that a short trial (for example 3 months) of paracetamol or a non-steroidal anti-inflammatory drug (NSAID) alone or in combination is appropriate for the first-line management of endometriosis-related pain. The Committee discussed whether the addition of an opioid analgesic could be considered if pain was not adequately controlled after a trial period of these medications. However, given the chronic nature of endometriosis-related

2016 NICE Clinical Knowledge Summaries

4004. Endometriosis

suspicion remains or symptoms persist, referral for further assessment and investigation should be considered. Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis. However, other less invasive methods (including ultrasound) may be useful in assisting diagnosis. Management of women with suspected or confirmed endometriosis involves: Managing endometriosis-related pain with simple analgesics (paracetamol and/or a non-steroidal anti-inflammatory drug (...) ) and/or hormonal treatment (combined oral contraceptive pill or a progestogen), as appropriate. Assessing the woman's individual information and support needs, taking into account her circumstances, symptoms, priorities, desire for fertility, aspects of daily living, work and study, cultural background as well as her physical, psychosexual, and emotional needs. Assessing for, and managing, complications of endometriosis, such as fertility problems or depression. Reviewing the woman. Referral to secondary care

2016 NICE Clinical Knowledge Summaries

4005. Shoulder pain: Scenario: Frozen shoulder

for the efficacy of conservative and surgical treatments for frozen shoulder [ ; ]. A step-up approach in terms of treatment invasiveness should be considered. Management should depend on the degree of symptoms and functional impairment, and involve shared-decision making [ ; ]. Analgesia BESS/BOA recommend analgesia for the pain of frozen shoulder. Pain relief is particularly important in the initial painful stage [ ] and may be useful in helping compliance with physical therapy [ ]. NSAIDs have been shown (...) flare of pain' and hyperglycaemia in people with diabetes [ ] [ ]. Advice for the person to rest for 24 hours following the injection, and seek medical advice if there is severe pain, especially if associated with fever, is recommended by the Drug and Therapeutics Bulletin review. A New Zealand guideline advises monitoring blood glucose in people with diabetes after corticosteroid injection as this may be elevated for 24–48 hours [ ]. Feedback from expert reviewers suggests that it may be preferable

2018 NICE Clinical Knowledge Summaries

4006. Self-harm: Scenario: Long-term management following an act of self-harm

and support to facilitate any goals (such as education, employment, and occupation) outlined in the person's care plan. Managing any mental health or other problems that have been identified, if appropriate (possibly as part of a shared-care arrangement). For further information, see the CKS topics on , , , , , , , , and . Monitoring the person's the physical health, including the physical consequences of self-harm as well as other healthcare needs. Preventing access to any means of self-harm, where (...) possible. For people at risk of self-poisoning, ensure that any drugs prescribed for them or other members of their household are least dangerous in overdose (such as selective serotonin reuptake inhibitors for treatment of depression), and consider prescribing few tablets at one time. Offering written and verbal information to the person and their family, carers, or significant others, about local and national sources of support, groups, and voluntary organizations. For further information see

2019 NICE Clinical Knowledge Summaries

4007. Self-harm: Scenario: Acute management of a person at risk of self-harm

of recreational drugs and/or alcohol, physical health problems, personal skills, strengths, assets, coping strategies, and the need for psychological intervention. Factors that increase the person's risk, such as: Features of depression. For further information, see the CKS topic on . Feelings of hopelessness. Features that suggest suicidal intent. Consider history and frequency of any past self-harm, medical seriousness, use of violent methods, evidence of planning such as suicide note or changes (...) to will, and precautions taken to prevent rescue. Other clinical, demographic, and psychological features associated with risk, including male sex; physical health problems; low socioeconomic status; high-risk employment (such as farmers or healthcare professionals); unemployment; bereavement; changes in relationships; social isolation; neglectful, abusive, or violent relationships; and access to the means to self-harm (such as a supply of their own or other people in their household's medications, or a firearm

2019 NICE Clinical Knowledge Summaries

4008. Self-harm: Scenario: Acute management following an act of self-harm

and frequency of any past self-harm, medical seriousness, use of violent methods, evidence of planning, such as suicide note or changes to will, and precautions taken to prevent rescue. Feelings of hopelessness. The presence of any associated mental health disorders, or misuse of recreational drugs and/or alcohol. For further information, see the CKS topics on , , , , and . Other clinical, demographic and psychological features associated with risk, including male sex, physical health problems, low (...) applies. When and how the can be used in the urgent assessment of people who have self-harmed to treat the physical consequences of self-harm, if their behaviour has been caused by a mental health condition. That they have a duty to protect confidentiality wherever possible, but medical information may be disclosed without consent if a person lacks capacity and it is in their best interests. For additional information, see the BMA's . Capacity and confidentiality issues in young people aged 16–17

2020 NICE Clinical Knowledge Summaries

4009. Pyelonephritis - acute

the bladder – the most common causative pathogen is Escherichia coli, which is responsible for 60-80% of uncomplicated infections. Complications of acute pyelonephritis include: Sepsis. Parenchyma renal scarring. Recurrent urinary tract infections. Renal abscess formation. Preterm labour in pregnancy. Emphysematous pyelonephritis. Acute pyelonephritis should be diagnosed by taking a detailed medical history and conducting a physical examination. Acute pyelonephritis should be suspected in people (...) for severe infections) for 7-10 days should be prescribed. The culture and sensitivity results should be reviewed when they become available, and the antibiotic changed if indicated. If the bacteria are resistant and symptoms are not already improving, a narrow-spectrum antibiotic should be used wherever possible. Advice should be given about: Possible adverse effects of the antibiotic, particularly diarrhoea and nausea. When to seek medical help — for example, if symptoms worsen at any time, do

2018 NICE Clinical Knowledge Summaries

4010. Pulmonary embolism: When should I suspect pulmonary embolism?

[ ]. History, examination, and investigations NICE recommends that if a person presents with signs or symptoms of PE, an assessment of their general medical history, a physical examination, and a chest X-ray should be carried out to exclude other causes [ ; ]. Electrocardiogram (ECG) and chest X-ray findings associated with PE This information is based on expert opinion in the ESC guideline [ ], a review article on DVT and PE [ ], and the Oxford textbook of medicine [ ]. © . (...) . Pleural rub. Hypotension (systolic blood pressure less than 90 mmHg) and cardiogenic shock (rare signs indicating central PE and/or a severely reduced haemodynamic reserve). The presence of , such as pregnancy, previous DVT or PE, active cancer, or recent surgery, makes the diagnosis of PE more likely. Be aware that PE may be completely asymptomatic and be discovered incidentally when assessing for another condition. If PE is suspected: Carry out an assessment of their general medical history

2018 NICE Clinical Knowledge Summaries

4011. Pulmonary embolism: Scenario: Confirmed pulmonary embolism

on PE. Detailed information on anticoagulant treatment, including adverse effects, drug interactions, advice during surgery and dental treatment, managing dosing errors, and where to obtain an alert care, are available in the CKS topic on . For people with : Review the medical history and baseline blood test results including full blood count, renal and hepatic function, prothrombin time (PT) and activated partial thromboplastin time (APTT), and offer a physical examination for people who (...) if these occur. The effects of other medications, foods, and alcohol on oral anticoagulation treatment. Monitoring their anticoagulant treatment. How anticoagulants may affect their dental treatment. Taking anticoagulants if they are planning pregnancy or become pregnant. How anticoagulants may affect activities, such as sports and travel. When and how to seek medical help. Verbal and written information on PE. The British Lung Foundation website ( ) has patient information on . There is also a printable

2019 NICE Clinical Knowledge Summaries

4012. Pulmonary embolism

or hormone replacement therapy, known thrombophilias, long-distance travel, obesity, and increasing age (older than 60 years of age). If PE is left untreated, the prognosis is poor and risk of death is high. Following treatment, some people develop complications, such as chronic thromboembolic pulmonary hypertension, which is associated with considerable morbidity and mortality. PE should be suspected in people with one or more of the following (especially if there are risk factors for PE): Dyspnoea (...) , chest pain, cough, haemoptysis, features of DVT (including leg pain and swelling [usually unilateral], lower abdominal pain, redness, increased temperature, and venous distension), dizziness, and syncope. Tachypnoea or tachycardia, hypoxia, pyrexia, elevated jugular venous pressure, gallop rhythm, pleural rub, hypotension, and shock. If PE is suspected, a history, physical examination, and investigations should be carried out to exclude other causes of symptoms, such as acute coronary syndrome

2019 NICE Clinical Knowledge Summaries

4013. Psychosis and schizophrenia: Scenario: The routine schizophrenia or psychosis review

a previous ECG abnormality, or if they have an additional risk factor for QT prolongation (for example taking another medication that can increase the QT interval such as erythromycin, co-trimoxazole, or pregabalin). These drugs have been associated with QTc prolongation. A QT interval of >450 milliseconds may be cause for concern, while a QT interval > 500 milliseconds should prompt the seeking of specialist advice. Send a copy of the results of the annual physical health review to the person's care (...) health review of someone with psychosis or schizophrenia? Arrange review in primary care at least annually to assess the mental and physical health needs of the person. The secondary care team should maintain responsibility for monitoring the person's physical health and the effects of any antipsychotic medication for the first 12 months of treatment, or until the person's condition has stabilised (whichever is the longest). After this, the responsibility for monitoring may be transferred to primary

2019 NICE Clinical Knowledge Summaries

4014. Psychosis and schizophrenia: Scenario: Primary care management

in at-risk mental states should carry out the assessment. Do not start antipsychotic drug treatment while awaiting specialist assessment unless under advice from a consultant psychiatrist. For information on management strategies that may be implemented in secondary care, see the section on . The secondary care team should maintain responsibility for monitoring the person's physical health and the effects of any antipsychotic medication for at least the first 12 months of treatment, or for longer until (...) with secondary care specialists. Reviewing the person's physical health, mental health, and medication at least annually and more often if the person, carer or healthcare professional has any concerns. For more information, see the section on for people with a psychotic disorder. Asking the person about the support they receive from family and carers, and considering referral to the community mental health service for family intervention to manage any conflict or difficulties that could trigger a relapse

2019 NICE Clinical Knowledge Summaries

4015. Restless legs syndrome: How do I know my patient has it?

been previously present. When symptoms are very severe, the worsening in the evening or night may not be noticeable but must have been previously present. Features that are not necessary for the diagnosis, but are helpful to support the diagnosis of RLS when there is uncertainty, are: Presence of positive family history of RLS (seen in more than 50% of cases). Positive response to dopaminergic therapy. Sleep disturbance with periodic limb movements in sleep (seen in 85% of cases). A physical (...) the legs and any accompanying unpleasant sensations: Begin or worsen during periods of rest or inactivity such as lying down or sitting. Are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues. During rest or inactivity only occur, or are worse, in the evening or night than during the day. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioural condition (for example

2020 NICE Clinical Knowledge Summaries

4016. Renal or ureteric colic - acute: How should I assess a person with suspected renal or ureteric colic?

it as being more intense than the pain of childbirth. The person may complain of dysuria, urinary frequency, and straining (due to the stone irritating the detrusor muscle when it reaches the vesico-ureteric junction). Review the person's medical, drug, and family history as well as their dietary habits to identify for stone formation. The person may have a history of previous episodes. Examine the person. Perform a full and thorough abdominal examination to help exclude , such as ruptured aortic aneurysm (...) support the diagnosis of renal or ureteric colic. However, specificity and positive predictive values are poor, and the absence of haematuria does not exclude a diagnosis but should prompt consideration for of pain. Check for nitrite and leucocyte esterase — the presence of nitrite (with or without leucocyte esterase) in the urine suggests a urinary tract infection. See the CKS topics on and for more information. If there is suspicion for urinary stones based on the history, physical examination

2020 NICE Clinical Knowledge Summaries

4017. Pyelonephritis - acute: What else might it be?

conditions — however, typically there is no tenderness in the costovertebral region. Musculoskeletal disorders — suspect when costovertebral pain is a conspicuous feature. Lower lobe pneumonia — symptoms include cough and pleuritic chest pain. Physical examination may show decreased breath sounds, rales, or rhonchi. Lower urinary tract infection — for more information, see the CKS topics on and . Pelvic inflammatory disease — for more information, see the CKS topic on . Pelvic pain syndrome — recurrent (...) symptoms, including dysuria, pain on intercourse, and pelvic pain, occur with negative cultures. Shingles — for more information, see the CKS topic on . Basis for recommendation These recommendations are based on the British Medical Journal (BMJ) best practice guide Acute pyelonephritis [ ], and expert opinion in a narrative review Pyelonephritis can lead to life-threatening complications [ ]. © .

2018 NICE Clinical Knowledge Summaries

4018. Pyelonephritis - acute: How should I diagnose acute pyelonephritis?

Pyelonephritis - acute: How should I diagnose acute pyelonephritis? Diagnosis | Diagnosis | Pyelonephritis - acute | CKS | NICE Search CKS… Menu Diagnosis Pyelonephritis - acute: How should I diagnose acute pyelonephritis? Last revised in March 2019 How should I diagnose acute pyelonephritis? Acute pyelonephritis is diagnosed by taking a detailed medical history and a physical examination. Suspect acute pyelonephritis in people with signs or symptoms of a urinary tract infection (for example (...) , dysuria, frequency, urgency) accompanied by any of pyelonephritis (including fever, nausea, vomiting, or flank pain). For information on the signs and symptoms of UTI, see the CKS topics on , and . In all people suspected of having acute pyelonephritis, arrange collection of a mid-steam urine (MSU) or catheter specimen of urine (CSU), to determine the infecting micro-organism. Obtain a urine sample for culture before starting empirical drug treatment. See the section on in the CKS topic on for more

2018 NICE Clinical Knowledge Summaries

4019. Shoulder pain: Scenario: Rotator cuff disorders

glucose in people with diabetes after corticosteroid injection, as this may be elevated for 24–48 hours [ ]. Feedback from expert reviewers suggests that it may be preferable to defer steroid injections until diabetes is well controlled, and that the risk of infection should be carefully considered in a person with diabetes. Advice for the person to rest for 24 hours following the injection, and seek medical advice if there is severe pain, especially if associated with fever, is recommended by a Drug (...) '. For further information see the CKS topic on If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine. Consider any contraindications and which drug has a more favourable balance of benefits and risks for the person. If there is no early benefit from an oral NSAID, discontinue its use. For prescribing information on NSAIDs, information on minimising associated risks and when to consider gastroprotection, see the CKS topic on . For prescribing information on codeine, see

2018 NICE Clinical Knowledge Summaries

4020. Psychosis and schizophrenia

are cardinal features of psychotic disorders, the most common of which is schizophrenia, but may also be caused acutely by certain medicines, substance misuse, and by some medical conditions such as sepsis. With treatment, psychotic symptoms as a feature of a psychotic disorder may resolve fully, recur intermittently with periods of remission between, or persist. Complications of psychotic disorders include: An increased risk of premature death due higher rates of suicide, cardiovascular disease, and type (...) without delay refer to the early intervention in psychosis service (if available) or a specialist mental health service. A consultant psychiatrist or a trained specialist with experience in at-risk mental states should carry out an assessment. An antipsychotic drug should not be given to the person while awaiting specialist assessment, unless under advice from a consultant psychiatrist. For people who are at risk of developing a psychotic disorder, specialist mental health services will usually offer

2020 NICE Clinical Knowledge Summaries

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