Ward Round Notes

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.

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 par...

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 ...

Definition and demographics heart failure occurs when the heart function fails to perfuse the body adequately under normal physiological conditions. Heart failure can be divided into acute or chronic heart failure, may be caused by reduction of ejection fraction (systolic failure) or failure for the heart to fill (diastolic heart failure or heart failure with preserved ejection fraction), affect the left heart or the right heart, or both sides. It can also be divided into heart failure caused by an intrinsic disease of the heart(high output), or due to increased demands of the body (low output).  There is an increasing prevalence of heart failure patients due to the increase in older individuals and better outcomes for other cardiovascular diseases. The prevalence of heart failure is around 2-3% in the general population, with increasing incidence amongst older people. There is a slightly higher incidence amongst men compared to women, especially in the middle aged populat...

Definition and demographics Acute Kidney Injury (AKI) formerly known as acute renal failure, refers to the deterioration of renal function acutely over hours or days. It is characterised by a rise in plasma urea and creatinine ratios. This may occur without clinical symptoms, however tends to be associated with oliguria (urine output less than 400ml/day or 0.5ml/kg/h). Acute kidney injury is common amongst people admitted to hospital. Causes and risk factors The causes of acute renal failure may be divided into pre-renal, renal and post renal causes.

Demographics: Acute urinary retention is a medical emergency . It is relatively common occurring in 7/1000 men. It is more common in men than women, and incidence is higher in men over 70. Causes: The most common cause of acute urinary retention is benign prostatic hypertrophy. Other causes include: structural changes near the bladder and urethra in men ·       Meatal stenosis ·       Penile constricting bands ·       Phimosis ·       Urethral strictures In women ·       Prolapse ·       Urethral strictures

Definition and demographics:  A subarachnoid haemorrhage refers to the spontaneous arterial bleeding into the subarachnoid space, usually from berry aneurysms in the circle of willis. It is relatively rare, with an average GP seeing one case every 7 years, although it makes up 6% of all strokes. It tends to affect younger patients compared to other types of strokes, with a mean age of 50.  Pathophysiology and aetiology:  Subarachnoid haemorrhages are caused by the rupture of berry aneurysms developing on the circle of willis.  These are most common between the posterior communicating artery and the internal carotid artery, between the anterior communicating artery and the anterior cerebral artery, and at the tri- or bifurcation of the middle cerebral artery. The formation of berry aneurysms is thought to be partly due to genetical pre deposition affecting the tissues of the vessels and additional strains such as hypertension and atherosclerosis.  ...

Definition and demographics Thyrotoxicosis refers to a clinical hyper metabolic syndrome caused by high thyroid hormone levels. Hyperthyroidism is more common in women than men. Graves disease commonly presents between the 2nd and 4th decade, toxic nodular goitre increase with age and is more common in regions where there are iodine deficiency is common.  Causes Graves disease (most common -76%) multi nodular goitre (14%) Solitary thyroid adenoma Rarer causes Subacute thyroiditis (de Quervain's) Post partum thyroiditis Drugs  Very rare causes Radiographic contrast Iodine prophylaxis programme Factitious thyrtoxicosis (where patient takes too much levothyroxine, characterised by raised T4:T3 ratio)  Struma ovarii TSH secreting pituitary adenoma Choriocarcinoma and hydatidiform mole Folicular ± metastases

Demographics Breast cancer is the most common cancer among women and the second largest cause of cancer death. The incidence of breast cancer increases with age and peaks between the ages of 45-55 and plateaus from then onwards. The incidence of breast cancer is increasing due to increased screening.  Aeitiology and pathophysiology:  Breast cancer is caused by accumulation of genetic mutations leading to malignant growth.  Risk factors of breast cancer include:  Previous breast cancer Family history of breast cancer (if more than 2 first degree relatives have breast cancer, the risk to other members is doubled. )  Age Genetical - individuals with 4 relatively common genes are more susceptible to developing breast cancer. This includes BRCA 1, BRCA 2, CHEK2 and FGFR2. In individuals with these genes, lifetime risk of developing cancer may be up to 80% with a 60% risk of developing ovarian cancer.  Hormone replacement therapy with oest...

Myeloproliferative disorders are diseases where one type of myeloid cell is produced excessively. See this link re what is the difference between myeloproliferative disorders and lukaemias? https://www.pathologystudent.com/?p=2153 Primary thrombocythaemia (essential thrombocythaemia) Involves clonal proliferation of the megakaryocyte line of cells leading to a raised platelet level.  Most commonly presents after 50 but may occur at any age. In the younger age groups, it is more common in women than men.  May present as abnormal thrombosis or bleeding, or may be asymptotic (up to 50%) and be found incidentally on routine blood tests. Neurological symptoms from microthrombosis (paraesthesia/burning pain) or signs from arterial /venous thrombosis.  Splenomegaly and/or hepatomegaly may be present in some patients Differentials : other haematological conditions may also caused a raised platelet count, and platelet count may be acutely raised secondary to some condi...

Definition and demographics Occular melanomas are uncontrolled malignant proliferation of melanocytes in the eye. They can be divided into uveal melanomas, which arise in the iris, choroid body or ciliary body, and conjunctival melanomas which arise from the conjunctiva. Uveal melanomas are more common and is the most common type of primary eye malignancy, and second most common type of malignant melanoma.  Ocular melanoma is a rare condition which occurs equally in males and females and the with a peak incidence in people's 60s. It tends to affect fair skinned individuals more.  Aeitiology/pathophysiology Occular melanomas are caused by an accumulation of genetic changes. Sunlight exposure is a risk factor of developing melanoma. Other risk factors include being caucasion/fair skinned, having light coloured irides, melanosis or existing melanocytic naevi of the conjunctiva (moles), congenital ocular melanocytosis, neurofibromatosis and family history.  ...

Demographics:  Colon cancer is a common malignancy, it primarily presents in older patients, however it may occur earlier in two hereditary conditions which leads to colon cancer. Familial adenomatous polyposis (FAP) is a autosomnal dominant condition which causes the formation of multiple polyps in the colon. The condition tends to cause cancer in patients by the age of 40. Hereditary non-polyposis colorectal cancer (HNPCC) also causes colon cancer in younger patients. HNPCC is also associated with endometrial, gastric, renal, uteric and CNS cancers.  Risk factors and causes Crohn's and Ulcerative colitis increases colorectal cancer risk History of small bowel cancer, endometrial cancer, breast cancer or ovarian cancer Family history - family member with cancer before the age of 60 Specific hereditary causes : FAP and HNPCC Low fibre diet and high red meat diet is thought to increase risk Sedentary lifestyle, obesity, smoking, high alcohol intake Diabetes m...

Definition Pleural effusion is a collection of fluid in the pleural space between the visceral pleura surounding the lungs and the parietal pleural attatched to the throacic wall. Demographics Pleural effusions are relatively common, but it is a manifestation of other underlying diseases. The prevalence and incidence of pleural effusions is therefore dependent on it's cause. Pathophysiology/causes Pleural fluid is usually filtered from the parietal pleura into the pleural space, due to hydrostatic pressure from the capillaries, negative pressure in the pleural space and pleural oncotic pressure. The visceral pleura is perfused by the pulmonary system which has a lower pressure, and fluid in the pleural space is therefore drawn back in through the visceral pleura due to the higher oncotic pressure in plasma. Some of this fluid is then drained by the lymphatic system.

Definition: Chronic obstructive pulmonary disease is defined as a condition of restricted airflow which is not fully reversible. It is often a progressive disease caused by abnormal inflammatory responses to obnoxious substances.  Demographics: COPD is a common condition, The prevalence of COPD increases with age, with most patients being diagnosed at around the age of 50.  Aeitiology and pathophysiology:  Airway obstruction in COPD is caused by;  1) increase in mucus secretion, leading to obstruction.  many COPD patients show increased number of goblet cells in their airways, which block airways.  2) inflammation and scarring to the airways, leading to narrowed airways.  Inflammatory cells infiltrate the bronchi and bronchiole walls. The inflammation causes scarring and thickening of walls which cause small airways to narrow. Initially, inflammation is reversible, but this become irreversible with continued smoking. As the dis...

Lung cancer Definition : Uncontrolled invasive (malignant) growth originating from the lungs Presentation:   Depends on the site of the tumour and the type of cancer.  Patients may present with Chest signs and symptoms : (more common in cancers occurring centrally in the bronchial tree, late symptoms in peripheral cancers, may also present on a background of existing lung problems eg. COPD or emphysema)  *Haemoptysis *Cough Wheeze Stridor Pain Hoarse voice clubbing lymphadenopathy localized chest signs superior vena cava obstruction - caused by compression of the superior vena cava

Definition: Inflammation of the middle ear with the collection of fluid, without acute signs of inflammation. Also known as glue ear. Pathophysiology:  The pathophysiology of glue ear is not fully known, however it is thought to be associated with Eustachian tube dysfunction. This is either thought to lead to a sterile accumulation of fluids that predisposes the middle ear to infections, or is thought to cause more acute infections of the middle ear that then leads to chronic effusion. Children with cleft palate also often have glue ear as their tensor veli palatini muscle does not attatch properly to the soft palate such that the Eustachian tube does not open on swallowing or mouth opening.

Definition:  Pneumonia is the inflammation of the terminal bronchioles and alveoli, characterised by consolidation of the affected part by inflammatory cells, exudate and fibrin. Pneumonia is most commonly caused by infection. Community acquired pneumonia is defined as pneumonia presenting in the community or in the first 2 days of hospital admission. Pneumonia occurring after this time is more likely to be hospital acquired and caused by a different set of mircoorganisms.

Definition : A major life threatening metabolic condition occurring in diabetic patients leading to hyperglycaemia , ketoacidosis , dehydration and ketonuria . Pathophysiology:  The lack of insulin primarily leads to hyperglycaemia and ketonaemia:  Insulin insufficiency leads to reduced uptake of glucose into cells and increased blood concentration of glucose.  As glucose are not taken into cells, alternative sources of energy are used.  Most cells break down fatty acids instead of glucose which forms ketones. Ketone levels therefore reflects the glucose deficit in cells.  Lack of insulin also leads to an increase in opposing hormones which lead to increased glycogenolysis, gluconeogenesis and lipolysis. 

Definition: Accumulation of fluid in the pericarial space leading to restriction of the heart's pumping action and reduced cardiac output which may lead to hypoperfusion and failure of other organs. Different to cardiac effusion which is an umbrella term for a fluid collection in the pericardial space with or without haemodynamic compromise.  Pathophysiology A cardiac tamponade is caused by an increase in the pressure in the pericardial sac. The pericardial sac usually has a level of compliance (stretch) and therefore an increase in fluids in this space initially has little effect on the pressure. It is only when the sac has reached the limit of it's stretch that the pressure increases. The compliance of the pericardial sac can also be increased in a chronic effusion and as much of 2000mls of fluid can be present before it causes a tamponade. Compliance can also be reduced by some disease states.