Ward Round Notes

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.