Ward Round Notes

Technical issues - projection, AP film, patient rotated or inadequate inspiration.  Masses - Thyroid, Lymphoma, teratoma, neurogenic tumour.  Achalasia  Scoliosis Paravetebral abscess from tuberculosis Thoracic aortic aneurysm Ellis H, Calne R, Watson C, Lecture Notes General Surgery, 11th ed. Oxford, Blackwell Publishing 2006 Radiology Masterclass, Mediastinal abnormalities [online] available at: http://radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page9.html [accessed:02/11/2014] Van Sambeek R, Anterior mediastinal masses, [online] available at: http://eradiology.bidmc.harvard.edu/LearningLab/respiratory/sambeek.pdf, [accessed: 02/11/2014] Image: http://en.wikipedia.org/wiki/Achalasia#mediaviewer/File:Achalasia2010.jpg [accessed: 02/11/14] 

Fluid compartments:   The body is made of about 60% water, which is divided between the intracellular and extracellular space. Fluid is distributed in these spaces by osmotic forces determined by ion distribution between the intracellular and extraceullular space. Approximately 2/3rds (40% total body weight) of the body’s fluids is distributed in the intracellular space and 1/3rd (20%)in the extracellular space.

Resuscitation Reduction Restriction Rehabilitation Eg. A 28 y/o man arrives in ED after a motorbike accident with a fractured tibia and fibula. 1) resuscitate according to ATLS guidelines. Examine limb for neurovascular deficit once patient resuscitated. X rays with 2 views. 2) Reduction - may be closed reduction by manually pulling distal fragment to line up bone under sedation or anaesthesia, or open reduction where pins and plates are put in. Depends on type of fracture etc. Open fractures are managed differently to closed fractures. 3) Restriction - eg. using plaster of paris, External fixation, internal fixation with plates/pins etc. again dependent on injury. 4) Rehab - Encouraging mobilisation, physiotherapy, occupational therapy to help adapt environment etc. References: Gosling A, Stansby G, Surgical Talk- Surgery for Finals , London, Imperial College Press, 2004

Fresh PR bleed: Diverticulitis Benign and malignant tumour Haemarrhoids anal fissure Ulcerative colitis Angiodysplasia Trauma Coagulopathy massive upper GI bleed Non PR bleeding - mensturation, haematuria.  Malaena: Gastric ulcer Peptic ulcer Mallory weiss tear Gastritis Benign and malignant tumour Oesophageal varicies Merkel's diverticulum Dark stools without blood - iron tablets References: Ellis H, Calne R, Watson C, Lecture notes - General Surgery,  11th Ed., Oxford, Blackwell Publishing, 2006 SurgWiki, Haematemasis and Malaena, [online] available from: http://www.surgwiki.com/wiki/Haematemesis_and_melaena [accessed:20/10/2014]

Grade 1 - heard by specialist in optimum conditions Grade 2 - heard by non specialist in optimum conditions Grade 3 - Easily heard no thrill Grade 4 - loud murmur with thrill Grade 5 - very loud heard over wide area with thrill Grade 6 - Murmur heard without stephoscope Douglas G, Nicol F, Robertson C, Macleod's clinical examination 12th ed . Edinburgh, churchill livingstone, 2009. 

Persistent hyperkalaemia (above 7mmol/L) Acidosis - pH less than 7.2 or base excess over 10 refractory pulmonary oedema Uraemic encephalopathy Uraemic pericarditis High catabolic state with progressive renal failure Reference Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR, Oxford handbook of clinical medicine, 8th ed. Oxford, Oxford university press, 2010. 

Lung cancer is one of the most common malignancies worldwide, but has one of the poorest outcomes as 2/3rds of patients present late with the disease. Given this it is important to be vigilant of the possibility of lung cancer in patients. Patients with lung cancer may present with r espiratory symptoms , with worsening chronic disease such as COPD, with symptoms suggestive of malignancy without symptoms specific to the respiratory system, and occasionally with other symptoms which are neither respiratory or point to a malignancy. NICE guidelines suggests that an urgent chest x ray (within 1 week) should be considered for the following symptoms: Haemoptysis Persistent (+3 weeks) cough Persistent shortness of breath Persistent chest signs Persistent hoarseness Persistent weight loss Persistent clubbing Persistent cervical lymphadenopathy Persistent chest or shoulder pain (think of pancoast tumours) Persistent signs or symptoms suggesting metastases such as bone pain, sk

patients with diabetes are at increased risks of developing peripheral arterial disease and peripheral neuropathy, which commonly affects the feet causing secondary problems such as ulceration or joint deformities. Diabetic neuropathy is thought to affect 16-26% of patients with diabetes, 2.2% of diabetics will present with foot ulcers annually, increasing to 7.2% in patients with neuropathy. the incidence of amputations is around 0.5-5 per 1000 of people with diabetes. Risk factors Risk factors for developing peripheral neuropathy includes increased age, increased periods of poor glycaemic control, increasing time since hyperglycaemia first occured, smoking, hypertension and ischaemic heart disease. Risk factors for peripheral ischaemia includes smoking, hypertension and hypercholestrolaemia.

Ulcerative colitis Definition: Ulcerative colitis (UC) is a relapsing and remitting inflammatory condition of the large bowel, with unknown aeitiology. Ulcerative colitis is moderately common with a prevalence of 100-200 per 100 000. It is 3 times more common than crohns, and is more common amongst Caucasians, and tends to affect women more than men. It has a bimodal distribution, most commonly affecting people between the ages of 15-30 with a smaller peak between 55-65. Risk factors: ·       Ulcerative colitis is thought to be autoimmune ·       Family history of parent, children or sibling with ulcerative colitis increases the risk of an individual developing it. ·       Smoking is protective in ulcerative colitis, and UC is 3 times more common in non smokers.

Some causes of peripheral neuropathies (click to enlarge)

Parkinson’s disease Degenerative disease of the substantia nigra characterized by a triad of resting tremor, rigidity and bradykinesia and akinesia.   Demographics Parkinson’s disease is the most common akinetic condition, it has a prevalence of around 170 per 100000 population. It tends to affect men more than woman with the average age of onset at 60. pathophysiology In parkinson’s disease there is degeneration of cells within the pars compacta of the substantia nigra of the basal ganglia. There are also abnormal lewy bodies in the surviving cells. These cells transmit dopamine to the striatum, so there is a loss of dopamine in this area. Other areas of the brain which are not dopaminergic are also affected in Parkinson’s disease. Aeitiology Causes of parkinsons disease is unclear. There may be a familial link in some cases, and certain chemicals such as MPTP found in contaminated heroin has been shown to produce similar symptoms. Presentation Symptoms of parkins

Disease of the motor system can roughly be divided into upper motor neurone problems - due to disease between the neurones in the cerebral cortex and the anterior horn, lower motor neurone problems - due to disease of nerves from the anterior horn to the muscle, cerebellar disease , and disease of the basal ganglia . This may present with different symptoms summarised below. Motor pathways (note: different motor fibres decussate at different levels - this is a hugely simplified picture) 

1. Kocher’s incision/ Right subcostal -  Cholecystectomy 2. Transverse 3. Lanz (at McBurney’s point) 4. Mcburney’s incision - appendicectomy 5. Full midline laparotomy - most major abdominal surgery, trauma, aortic surgery. 5a. Upper midline – gastric surgery, duodenal surgery, cholecystectomy. 5b. Lower midline – colon surgery, gynaecological surgery. 6. Paramedian 7. Pfannensteil/suprapubic – gynaecological surgery, Caesarean sections 8. Loin/oblique – nephrectomy 9. Laparoscopic ports – laparoscopic procedures eg. Cholecystectomy, appendectomy, gynaecological surgery and urological surgery. 10. Inguinal/hockey stick – Inguinal hernia, renal transplant. (not shown, usually on RIF) References:  http://chestofbooks.com/health/anatomy/Human-Body-Construction/Abdominal-Incisions.html#.UtV5xGRdWyU http://www.surgical-tutor.org.uk/default-home.htm?system/abdomen/incisions.htm~right http://www.fastbleep.com/medical-not

  Inflammatory arthritis Mechanical arthropathy   Swollen knee Includes: Rheumatoid arthritis, seronegative spondyloarthropathy (psoriatic arthritis, enteropathic arthritis, ankylosing spondylitis, reactive arthritis)  Osteoarthritis with herbeden's node (bony swelling)   Includes: Osteoarthritis, mechanical back pain.   Pain comes and goes and tends not to relate to movement Pain worsens with increased movement Diurnal stiffness occurring in the mornings and at night Stiffness after resting joint for prolonged period of time. Morning stiffness often lasts for a prolonged period (>30minutes) Morning stiffness can be ‘worked off’ after 20-30 minutes. Associated with heat, redness and 'boggy' swelling of the joint. Although redness may not be marked. +ve metacarpal/metatarsal squeeze  pain along joint line, no swelling. Acute/suba

Both phalen's test and tinel signs are ways of eliciting symptoms from patients with suspected carpal tunnel syndrome. In phalen's test, the wrist is flexed for 30-60 seconds, and results in tingling/numbness of the thumb, index and middle finger if positive. Sensitivity and specificity of the test is variable. Tinel's sign in carpal tunnel syndrome can be elicited by extending the wrist slightly and tapping on the radial side of the palmar surface of the wrist. It is positive if it results in a tingling sensation of the first 3 fingers.

Immediate ECG changes (stage1)  Widespread, saddle shaped ST elevation (except AvR and lead 1)  PR interval depression (except AvR and lead 1)  Reciprocal changes in lead 1 and AvR.  Sinus tachycardia due to pain or effusion.  (taken from: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/V5-pericarditis.jpg)  1-3 weeks (stage 2)  Flattened T waves, no ST elevation or PR interval depression.  3- several weeks (stage 3)  Inverted T waves several weeks + (stage 4) ECG returns to normal *not all patients go through the later stages of ECG changes. http://lifeinthefastlane.com/ecg-library/basics/pericarditis/ (this is a brilliant site!) http://emedicine.medscape.com/article/156951-overview

Diabetes is characterised by chronic hyperglycaemia caused by increased insulin resistance or reduced insulin release.  Aeitiology:  Diabetes may be primary or secondary. The main types of diabetes include type 1 diabetes, type 2 diabetes, secondary diabetes, and gestational diabetes. This post mainly discusses type 1 and type 2 diabetes. The main differences between type 1 and type 2 diabetes are summarised below:  Type 1 diabetes Type 2 diabetes Caused by the autoimmune destruction of B cells in the islet of Langerhans. Caused by increased peripheral insulin resistance and reduced insulin secretion. Tends to present before puberty, but may present at any age. Tends to occur in patients above 40 but increasingly affects younger individuals. Polygenetic, associated with inheritance of HLA types: HLA-DR3 and HLA-DR4. Associated with other autoimmune conditions. Polygenetic with high twi

"Pulsus paradoxus" refers to an abnormal decrease of over 10mmHg in pulse pressure and subsequently pulse volume on inspiration. It is caused by a decrease in intrathoracic pressure.  On inspiration the intrathoracic pressure decreases The pressure intrathoracically is lower than the pressure extrathoracically which leads to an increased venous return to the right ventricles The right ventricles bulges into the left side reducing left ventricular volume.  Reduced intrathoracic pressure also leads to dialation of the pulmonary vessels Blood from the right ventricle pools in the lungs leading to reduced blood returning to the left ventricles Reduced blood in the left ventricles leads to a reduced stroke volume according to starling's law.  Reduced thoracic pressure on the aorta also contributes to the reduced pulse pressure Reduction of pulse pressure leads to a weaker or absent pulse volume being felt whist a contraction is heard on auscultation.  Pulsus

Non pigmented skin cancers (click to enlarge)

Differentials of pigmented lesions  (click to enlarge) - search on dermnetnz.org for more pictures! (also right click and open in new tab to see it in full size)  *correction - lentigo maligna melanoma is an invasive melanoma whereas lentigo maligna itself is a melanoma in situ. This tends to occur on the face in more elderly patients.

Anatomy of the skin

AVPU Alert Verbal Pain Unconcious Glasgow coma score Eye 4 – spontaneous eye opening 3 – opens to verbal command 2 – opens to pain 1 – no eye opening Verbal 5 – obeys commands 4- confused speech 3 – inappropriate words 2 – Incomprehensible sounds 1 – no response Motor 6 – Obeys commands 5 – localizes to pain 4 – flexion or withdrawal to pain 3 – abnormal flexion 2 – extension 1 – no response

Ottawa rules are used to decide whether an injury needs an xray to rule out fractures or not.   Ankle rules: x rays are needed if: unable to weight bear after injury and at examination (take more than 4 steps) tenderness of the posterior surface of the distal 6cm of the posterior lateral or medial malleolus. Tenderness over base of 5th metatarsal bone tenderness of the navicular or calcaneum.  

1. subcostal recession 2. Intercostal recession 3. Sternal recession 4. use of accessory muscles 5. Tracheal tug 6. nasal flaring 7. head bobbing Other signs of respiratory effort: Stridor, grunting, Silent chest Tachypnoea Cyanosis Tripod Seesaw respiration

Some respiratory diseases seen in children (click to enlarge)

Causes of stridor and management of acute stridor (click to enlarge):

A basic guide to drawing pedigree trees: Basic symbols  

Type Mediators Timing Examples Type I Hypersensitivity Allergy Exogenous antigen binding to IgE bound to Mast cells leading to degranulation Within minutes to an hour, rarely delayed onset (10-12 hours) Asthma Anaphylaxis Hayfever Type II Hypersensitivity Cytotoxic Caused by endogenous antigens which bind to cells. Antibodies IgM and IgG bind to these cells causing apoptosis Minutes to hours Autoimmune haemolytic anaemia, thrombocytopenia, Goodpasture’s syndrome Type III Hypersensitivity Immune complex (autoimmune) Caused by endogenous or exogenous antigens bound to IgG forming immune complexes which causes activation of the complement system and neutrophils causing systemic or organ specific damage. 3-8 hours SLE, Aspergillosis, Rheumatoid arthritis, Type IV Hypersensitivity