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Hypokalaemia in adults- treatment

Management of hypokalaemia
 in Primary care-No current national guideline on management of hypokalaemia Focus here is on management in general practice using oral potassium supplement Sando-K® Reference range 
( may vary between organizations )
see box above Hypokalaemia is usually well tolerated in otherwise healthy people but can be life threatening if severe Hypokalaemia increases the risk of morbidity and mortality in patients with CV disease Treatment is with potassium supplementation usually oral or IV

Identify and treat the underlying cause before starting / considering Potassium replacement. 


Tremor is an involuntary , rhythmic , oscillatory movement of a body part. Tremor results from contractions of agonist and antagonist muscles 
entrained by a signal pattern originating from an oscillator in the CNS 
( International Parkinson and Movement Disorder Society )

Background- Most common movement disorder Generally affects the upper extremities but can also affect the head ,

Pancreatic cancer

Pancreatic cancer refers primarily to adenocarcinomas – specifically 
ductal adenocarcinoma which account for > 85 % of all 
pancreatic neoplasm. Pancreatic adenocarcinoma- most common and arises in exocrine glands of the pancreas. Pancreatic neuroendocrine tumour -Less common ( < 5 % and occurs in the endocrine tissue of pancreas )

Epidemiology-Pancreatic cancer is not rare and the incidence of pancreatic adenocarcinoma
( hence mentioned as pancreatic cancer Pan-Ca here ) is rising in the developed world Seventh leading cause of global cancer deaths in industrialized countries 11 th most common cancer in the world
458,918 new cases in 2018 and causing 432 ,242 deaths ( GLOBOSCAN 2018 )
367,000 new cases in 2015 and 359,000 deaths in same year Slightly more common in men Most common presentation is from 65-75 yrs age with painless obstructive jaundice and weight loss ( seldom diagnosed before 55 yrs age ) Highest incidence in Europe and N America and lowest in Europe and S Central Asia

Why important- Extremely poor prognosis –

Motor Neurone Disease

Motor neuron diseases are a heterogeneous group of disorders characterized pathologically by death of motor neuron cells 
( Thomas T.Warner , Practical Guide to Neurogenetics , 2009 )

Subtypes –MND classification is based on those affecting primarily the UMNs , those affecting the LMNs and those affecting both

Amyotrophic lateral sclerosis or Lou Gehrig’s disease- Involvement of upper ,

ADA-EASD-guideline on management of Type 2 Diabetes

consensus report by the American Diabetes Association (ADA) and the European. Association for the Study of Diabetes (EASD).

with proven
 CVD benefit (1) SGLT2i with 
proven CVD 
benefit (1) 
if eGFR 
adequate (2) If HbA1c above target If further intensification is required or patient is now unable to tolerate GLP-1 RA and / or SGLT2i choose agents demonstrating CV safety Consider adding the other class
( GLP-1 RA or SGLT2i ) with proven CV benefit DPP-4i if not on GLP-1 RA Basal insulin (4) TZD (5) SU (6)

HF OR CKD PREDOMINATES-PREFERABLY SGLT2i with evidence of reducing HF and / or CKD progression in CVDTs if eGFR adequate If SGLTi not tolerated or contraindicated or if eGFR less than adequate (2) add GLP-1 RA with proven CVD benefit (1) If HbA1c above target Avoid TZD in setting of HF

Consider agents demonstrating CV safety
 Consider adding the other class with proven CVD benefit (1) DPP-4i ( not saxagliptin ) in the setting of HF ( if not on GLP-1 RA ) Basal insulin (4) SU(6)

Proven CVD benefit means it has label indication of reducing CVD benefits.

Diabetes-Referral guide

Manage in primary care –Impaired GTT  Impaired fasting glucose New diagnosis type 2 diabetes Minor self-treated hypoglycaemia Transient hyperglycaemia Well controlled diabetes ( diet or treated ) Stable micro-macro vascular complications

Referral to secondary care – Routine All with type 1 diabetes – managed in secondary care Age < 25 yrs Patient not achieving target HbA1c despite optimum management in general practice or
Worsening glycaemic control Erratic glycemic control Assessment for insulin initiation or intensification / change GLP-1 –

Diabetes-Alphabet Strategy

Alphabet strategy for diabetes care

Advice-Smoking cessation physical activity diet weight control – aim for 5-10 % loss / year if over weight. Structured education- especially- 
 self-management beliefs knowledge skills driving occupation Regular follow up with Care Planning Annual Review is essential

 20 % with early severe complications will be persistent Diabetes Clinic non-attenders Ramadan advice Advice DiabetesUK membership.

Bell’s Palsy

Bells palsy-A rapid onset , isolated , unilateral , lower motor neurone facial weakness 
of unknown cause ( idiopathic )

Named after Scottish anatomist Sir Charles Bell – described 1st in 1829 Most common acute mononeuropathy ( accounts for 60 % of all cases of sudden onset facial paralysis ) Relatively uncommon- affects 20-40 per 100,000 people per year 
( ie in UK about 12,400- 24,800 people / year ) Equal sex distribution No side preference ( ie can happen equally either side ) Treatment is controversial ( about 70 % recover spontaneously untreated ) No seasonal or geographical predisposition Affects more -
○ peak incidence 2nd and 4th decade of life
○ diabetics
○ immunocompromised
○ obese
○ hypertensives
○ pregnant (↑ ed risk 3rd trimester )

cause –Cause is unknown Pathophysiology –

Routine immunisation schedule

Immunisation information for health care professionals.

2 months ( 8 weeks )– Diphtheria, tetanus, pertussis
(whooping cough), polio,
Haemophilus influenzae type b (Hib)
and hepatitis B
DTaP/IPV/Hib/HepB Infanrix hexa Thigh
Pneumococcal (13 serotypes) Pneumococcal
conjugate vaccine (PCV) Prevenar 13 Thigh
Meningococcal group B (MenB) MenB Bexsero Left thigh
Rotavirus gastroenteritis Rotavirus Rotarix By mouth

3 months ( 12 weeks ) – 

Movement disorders

Movement disorders –Neurological syndromes in which there is either an excess of movement or paucity of voluntary and automatic movements unrelated to weakness or spasticity 

( Epidemiology and Classification of Movement Disorders Njideka U . Okubadejo Professor and Consultant Neurologist College of Medicine , University of Lagos & Lagos University Teaching Hospital , Nigeria )

Common neurological disorders Generalisation of prevalence is difficult- broad spectrum of conditions Most common hypokinetic disorder is Parkinsonism / Parkinsons disease
PD prevalence 1 % in people aged 65-85 yrs
↑ es to 4.3 % above 85 Essential tremor is the most common tremor
4 % in people aged over 40 yrs
↑ es to 14 % in people over 65 yrs Tics in school going children &