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.

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 par...

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) 

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

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.  ...