Professional Documents
Culture Documents
Clinical Sureery
2012
WhiteKnightLove
Index
1. How to take a history.
2. Examination of a swelling....
..................1
............6
3. Ulcer sheet.
4. Scrotal cases....
5. Hernia sheet.
.........13
gland.
7. Salivary glands.
8. Breast
9. Varicose veins.
.....34
....16
....25
6. Thyroid
....46
.........53
.......61
disease
11. Lymphadenopathy...
l2.Abdominal case.
13. Jaundice sheet.
l0.Peripheral arterial
WhiteKnightLove
.......69
.......80
...........93
.....112
Age:
lnfancy
- Child
-2 years old.
2 - 12 years old.
- Adolescence 12 - 20 years old.
- Adulthood 20 - 40 years old.
40 - 60 years old.
- Middle age
-
- Old
age
> 60 years.
* Occupation : Varicose
age
WhiteKnightLove
).
years.
llll Eornplaint
4
Mention duration.
sl,tut
Onset
/
/
Duration
Progressive.
Regressive.
S Stationary.
V Variable.
Eg. The condition started 5 years, age, by insidious onset and slowly
progressive course! for which the patient
WhiteKnightLove
..........
Ilistorv of Pain :
a.
4-
Ilistorv of swe
Site.
b. Relation to constitutional
stitching or throbbing).
manifestations.
c. Other
d. Effect
c. Radiation.
d. Precipitating factors.
e. Relieving factors.
pressu re manifestations
5- History of traurna :
Physical (direct or indirect) or psychic (as in goiter).
6- Constitutional rnanifestations :
Acute inflammations
Chronic inflammations
dealing with-
4
6
4
Previous treatment.
& postoperative
complications.
WhiteKnightLove
tV| Farnilg
Historg
Ceneral Examination
l- General Appearance
? Mental state : alert, confused or drowsy.
? Posture.
? Body built (over or under weight).
? Faces (e.g. toxic in infection, cachetic ... etc).
2- Vital signs
7
?
t
Temp : 36.5
- 37.2oC
R.R. z 14 - 18 / min.
B.P. : 120 / 80.
17 Pulse : 60
- 90 / min.
3.Ifead
1. Skull and scalp masses.
Eye'
*Jaundice.
* Signs of thyrotoxicosis.
4. Nose : Epistaxis (bleeding tendency).
cyanosis.
WhiteKnightLove
cyanosis, coated
4- Neck
2 vessels
2 glands
* Carotid pulsations.
* Neck veins (congested pulsating or normal).
* Thyroid gland.
* Lymph glands (upper and lower deep cervical).
wall
a. Bony tenderness.
b. Gynecomastia.
c. Dilated veins.
6- Abdorninal Exarnination
* Palpable
L.
2.Para
- aortic LN.
3. Ascites ( percussion ).
or renal swellings ).
7- Upper Lirnb
1.
Hand
WhiteKnightLove
3. Epitrochlear
8- I'ower lirnb
1. Inguinal lymph nodes.
2. Oedema
tlllnspectiontTSt
I. Solitory or muhiple
\
Some swellings are multiple from the start as multiple
neurofibromatosis, multiple lipomatosis & lymphoma.
---+
---+
goitre.
3. Size:
o Measure
> 10 cm
4. Shope:
WhiteKnightLove
-- huge.
O An aneurysm is pulsating.
7. Skin overlying :
O Redness -+ Inflammation.
g
g
Dilated veins
---r
Venous compression.
Pigmentation.
t II
I Palpation
o Confirmation
O
of inspection.
TECRM-D
Tenderness
: PrGss
&
l00kforthe
[aficils
facial enuession.
edge.
-+ Well
difined.
* Solid
WhiteKnightLove
z(
Jts
One finger is
If the swelling is freely mobile fix it firmly between the thumb &
firinq
watolbq.
l.
O Place the index & the thumb of one hand on each side of the swelling.
O The dip the index of the other hand into the middle of the swelling.
O If it is fluctuant -> index & the thumb of l't hand will move apart
by the fluid shift.
(b) Cross fluctuation
test :
WhiteKnightLove
O For swellings which have 2 poles like vaginal hydrocele of the testis-
To avoid Pain.
s Deep swellings.
>. Frx the swelling between the index and thumb of one hand.
>. Press the center of the swelling by the lip of little or index finger of
the other hand.
a.If
cystic swelling.
:
o Fixed in all directions :
O Mobile in one direction :
or ganglion.
R : Relation to surroundings
l- Skin :
ffi
WhiteKnightLove
2-
Muscle
nnuscle
y If more prominent :
muscular swelling.
y If disappeared :
N.B. : If the swelling was moving across the muscle & not along hefore
contraction & after contraction it becomes fixed to the muscle
Muscular swelling.
If deep :
A Try to pinch the muscle away from the swelling
while the muscle is relaxed.
Consistency, mobilify.
l0
WhiteKnightLove
Head
&
neck.
&
breast.
a) Pulsadons (expansile
or transrnitted) :
artery:
aneurysm.
i.{)
b) knpulse on cor4flr :
i. Expansile impulse
ll
WhiteKnightLove
in
all
directions.
d)
Thrilt :
A If systolic
true aneurysm.
A. V fistula.
e) Crepitus :
A A crakling
Transillurninafion :
I
E)
Pitdn$ on pressure
WhiteKnightLove
tllllPercussion
Resonant.' Gaseous swellings (e.g hernia containing bowel loops).
tlvf AusElrltatirrn
* For bruit, venous hum, rub, gurgle, intestinal sounds ... etc.
Ulcer Sheet
IIISTORY : Look general
sheet.
LOCAL EXAMINATION
lnspection
x
Single or multiple :
" Site
Rodent )
Face
Trophic ,
Traumatic )
Venous
* Size
ulcer ,
Shin of tibia
xShape: *Rounded
*
Sole of foot
*Oval
* Serpeginous
13
WhiteKnightLove
ro*ffi..a '-'dt*
Edge:
uffiiT#i.
a-7-7
uhdmed
(hMEhssl
Ilealthy granulation
o**!I;}lr* ",8\-,ft-
Unhealthy granulation
<t -
- Purulent discharge.
- + Pain.
- Painless.
Palpation
214,4,4
& L.N.
14
WhiteKnightLove
4. Base:
O It
@ Hold the ulcer base between the thumb & index fingers, move it side
to side in 2 different directions & then comment on
ulcers)
malignant ulcer.
5.
&
fixed
---
e. Matted together
Malignant ulcer.
---+
T.B. ulcer
l5
WhiteKnightLove
I- Sorotum:
OA
gumma
(syphilisf of testis.
O A postsrior
sinus
may be to
T.B epididymitis.
tr- Tunioa:
O By pinching test to detect a small lax2ry hydrocele.
Pinch the skin of the scrotum,
Itr- Testis
O Size.
O Masses
O Testicular sensation.
What are tne Gauses 0f IosI testicular sensation p
* Malignancy.
* 3ry syphilis ( Gumma
).
l6
WhiteKnightLove
N-
epid'dgmis :
O Can be felt overlying the posterior border of the testis laterally
O Normally there is a space between the testis & the epididymis
known as (Genital sinus).
o Abnormalities include :
a) Tenderness in acute epididymitis.
b) Solid mass at the tail
---+
---+
---+
cysts.
advanced T.B.
V- Spematio wrd.:
:s.Roll the contents of the cord in between the index and thumb at
the neck of scrotum.
rs.
Abnormalities include
17
WhiteKnightLove
mass.
Irrspection (7S):
1) Solitary or
Scrotal neck test : (Considered inspection)Hold the neck of scrotum by your index and middle
: Scrotal
3) Size : Variable.
4) Shape : Piriform, or oval or rounded.
5) Surface : Smooth.
6) Skin overlying : Normal.
7) Special Gharacter : Trans-illumination positive.
l8
WhiteKnightLove
: Inguinoscrotal.
Palpation 3 TECRM-D
Fo{lori,
tlw
fo,tlurirg
ddfem,noes
of your left hands & press on the lower pole by the thumh & index
of the other hand in 2 perpendicular directions. You will
5)NoMorR.
6) Draining lymph nodes are iliac & para-aortic.
as above.
r9
WhiteKnightLove
II- Varicocele :
Try
Inspecdon:
1) Solitary or multiple : Usually solitary with left scrotum hanging
downwards & Large varicoceles are also visible.
2) Site : inguinoscrotal swelling giving a tfuill oa oorrgL
3) Size : Variable.
4) Shape : oblong.
5) Surface : Smooth.
6) Skin overlying : Normal.
7) Special Gharacter : giving a thrill on cough
PatiPr.t
&
e.rnpties wlrlbtl:u.;
i. b,rrg dor.,ru
Palpation:
1) Temperature & tenderness : as before.
of lvorms".
3) Ask the patient to lie flat in bed & elevate the scrotun OR to bow
2. Examine
as above.
to exclude 2ryvaricocele.
20
WhiteKnightLove
ru
Because
I feel dilated,
elongated
tRY
A) ttre varicocele empties while the patient is lying down & the
scrotum is elevated or by bow test.
Second,arA uarieoeele
O this rare condition is due to obstruction of the venous flow in
the spermatic vein by an abdominal tumour, usually
hypernephroma.
CtINICAI FEATURES
Secondary varicocele differs from the primary type:
2. lt
o,t"
21
WhiteKnightLove
I-
Dptid,id,ymal egsts
ETIOLOGY
A
A
..
tubules).
t Paradidymis.
* Appendix of the epididymis.
PATHOLOGY
CLINICAL PICTURE
CiO :
otE :
* Site :
* Size.' variable.
* Shape & Surface
of
grapes.
x Special character
septae
: Brilliantly translucent
with numerous
x Consistencv: Cystic.
D.D
1. Spermatocele.
22
WhiteKnightLove
3. Vaginal hydrocele
TREATMENT
If-
Spermatoeele
ETIOLOGY
CLINICAL PICTURE
c/o:
v
v
It
third
1.
TTT
V
V
testis.
: As epididymal
OIE
cyst but
It is dimly translucent
2.
It
is unilocular.
Small spermatocele
: Can be ignored.
Large spermatocele :
* Excision
WhiteKnightLove
ETIOTOGY
CTINICAL PICTURE
C/O :
otE :
* Site :
Size: Small.
Surface:
Smooth.
* Special choracter :
becomes fixed.
* Consistencv
D.D :
H
Tense
* Translucent.
cystic.
24
WhiteKnightLove
Hernia
Personal histo{y z As general sheet *
a. Occupation
b. Special habits
Chronic smoking
hernia.
chronic cough.
site of hernias ).
Present history:
1. Analysis of the complaint ( Onset course, duration ).
order.
3. Pain = If complicated.
4. Other swellings : Other hernius.
5. Previous investigations and treatment.
6. History suggestive of the cause
V Chronic cough.
V Chronic constipation.
V Straining at micturation.
V Lifting heavy objects.
V Weak mesenchyme like varicosities, piles, varicocele.
V Previous operations in incisional hernia.
7. History suggestive of complications
@
Irreducibility.
manifestations of
intestinal obstruction.
25
WhiteKnightLove
: As general sheet.
Farnily history: As general sheet * varicose veins, piles, varicocele
Past history
(weak mesenchyme).
Eeneral Exarnination
l- General appearanc,e
'
2-Vitatl sifns.
'
Usually Normal
3- Head.
4- Neck.
Usually Normal
Usually Normal
5- Ghest.
Chronic
6- Abdomen.
bronchitis.
Emphysema.
-
Bronchial
asthma.
I I -
Divercation of recti.
I I -
Swellings,Ascites,other
I I
hernias.
Malgaigne'sbulgings.
26
WhiteKnightLove
7- Upper Umb
8- Lower Limb
Usually Normal
Varicose veins.
Flat foot.
Position
Inspeclion (ZS) :
1) Solitary or multiple : Usually solitary (may be bilateral).
Palpation 3 TECRM-D
Fo{lotl, tlrr- gra,rpralsoJ.ervr.e wttt" t}ue fo{louing dftt?r,rps
1) Temperature & tenderness : as before & then let the patient lie flat.
WhiteKnightLove
it if reduction
is
Intestine
0mentum
Consistency
Soft
Doughy
Gurgling on reduction
0ccurs
No
May he resonant
Dull
Ease
of reduction
Percussion
5) No R.
IWy
swelling is hernia
beeanrse
it is red,ucible &
giaes
28
WhiteKnightLove
l!
or oblique
hernia.
29
WhiteKnightLove
E
l4J
If impulse
B If impulse
-EL
l4l
is
felt at the
is felt at the
tip:
indirect hernia.
c. Can stretch the external ring ) OIH can reach the scrotum.
3) If OIH, is it congenital or acquired ?
a. The congenital OIH reaches down the scrotum from the start.
b. The testis is inseparate from the hernial sac and its contents.
30
WhiteKnightLove
Irnportant Notes
l.
Malg;ailine's bulging :
EA Are looked for above the inguinal ligament when the patient raises
his head slowly.
E0 It
Ef,x
Yz
31
WhiteKnightLove
Irrspection (ZS) =
1) Solitary or multiple : Usually solitary.
2) Site
O More common
3) Size : Variable.
4) Shape : usually hemispherical.
5) Surface : Smooth or lobular due to.
@ Multiple defects in linea alba.
Palpation 3 TECRM-D
LPt ilrr- pofiP
tln u.be/
"e
fo{tor"tng ddfercrtoes
32
WhiteKnightLove
it if reduction is
darets Prcsenoe
# adhesioas
betreen
is sharp or
not.
The main difference hetween epigastric hernia & fatty hernia of linea alba is
that fatty hernia of linea alba D0ES N0T give expansile impulse on cough.
33
WhiteKnightLove
Thyroid Gland
Historg
PERSONAT IIISTORY : As general + stressing on
O Residence : For endemic goiters.
O Age : malignancy more common in elderly.
COMPLAINT
PRESENT TIISTORY
a) Palpitation.
b) Nervousness, anxiety, insomnia & tremors.
appetite.
d) Exophthalmos.
e) Swelling in the neck if it was nol the main complaint
as
in cases of
toxic goiter.
c) Dysphagiu
4- Dontt forget to osk about diaruhea.
Apathy.
* Tendency to sleep.
etc.
34
WhiteKnightLove
c.
Fr4lMItY HISTORY
Eeneral Exarninatirrrr
A. ln SMNG ) Normal
Don't forget to examine the scalp for metastases of
B. ln toxic
FTG
II) Ihe
lor:
c) Clubbing
d) Pulse
of fingers.
- hummer
character).
Multiple extrasystoles.
A.F.
e) B.P. : Systolic B.P. is high but the diastolic is usually low or normal or
not much raised (due to peripheral V.D).
35
WhiteKnightLove
a) Exophthalmos
v Types
lor:
spasm of
inflammatory fluids.
Definition : It
Grades:
1. Moderate.
2. Severe :
* Ophthalmic vein compression leading to
lid edema,conjunctival injection & ecchymosis
3. Progressive (malignant):
* Papilledema, corneal ulceration & optic nerve neuropathy
36
WhiteKnightLove
Normal
Diagnosis:
DErrnuirue wl-rrrhen o<ophrhnlnaos
False
exophthalmos
i.llormallytne utrlcl
cyc lid Gouers
l/6
True
of the
exophthalmos
attne Iim[us.
exophthalmos
as
g In true exophthalmos
,r
iii."frazefs" method
O Examine the patient from the side with the eyes lightly closed to
ascertain if the sulcus between the orbital margins and the covered
globe is shallower than normal.
37
WhiteKnightLove
iu. fiulerIGSI:
O Normally a simple ruler can touch the superior and inferior bony
g In true exophthalmos,
u.
O The distance between the lateral orbital margin and the apex of cornea
is measured in millimeters and is normally 15-17 mm.
."-:,.'''
Joffroy's sign
1. Rosenbach's sign :
O Tremors on closing eye lids.
2. Stellwagl's sigln :
O Staring Iook with infrequent blinking.
3. Von Graef's
sigfn
4. Dalrymple's sign :
O A rim of sclera is seen between the cornea & the upper eye lid.
38
WhiteKnightLove
to
5. Joffroy's sign
6. Moebius'
s.iHn:
v) Ihen
loo[ [or :
Local Exarninatirrn
* Position.' Semi-sitting with the neck extended during inspection and
-,
--+
Retrosternal extension.
Recurrent goitre.
39
WhiteKnightLove
Palpadon 3 TECRM-D
o
Sfad examination standing behind the patient & then continue from
infront.
Fo.llni, tlre garprolsohp,rnp wttl" tl,s fo{lolrltry ddfeter,oes
palpate the gland as a whole & let the patient swallow, Then
El Palpate each lobe at a time, tilting the head to the same side.
a) Make sure that the swellingis single, Iocated in the lower part olthe
front of the neck & moves with deglutition.
It
is
Consistencv
so we can't do
40
WhiteKnightLove
fluctuation test.
B) Belation to srrrroundings :
(a) Skin
---+
tugging sign.
N.B
Tilt the neck to the same side and try to pinch the muscle
away from the goiter while the patient is swallowing.
In early malignancy, you will feel that the sternomastoid is tugging
away from your hand.
---+
displaced only
4l
WhiteKnightLove
Berry's sign
l.
Shifted or not
front
Then put your hand at the lower border of the gland during descent.
I
ro
3. Kocher's test
42
WhiteKnightLove
4) Draining L.Ns
Percussion :
O Direct over manubrium or the sternoclavicular joint.
Arrscultafion :
O Systolic murmur may be heard over the upper pole in primary toxic goitre
while the patient is holding his breath due to hypervascularity.
43
WhiteKnightLove
Refrosternal Goiter
A retrosternal goitre is an anatomical entity and not a pathological one.
A retrosternal goitre may be simple, toxic or neoplastic.
it can be forced
tissue
in
the
uscles)
CLINICAL PICTORE:
Sqrnptoms :
1. Mediastinal syndrome : commonest presentation :
3 Dvspnea
2. Toxic
44
WhiteKnightLove
Sioros :
ll I lnsmction:
a. The lower border of the cervical goitre is not seen.
innominate vein.
c. Edema of the face best noticed in the eve
d. Special tests
lids.
"i=
& dyspnea.
joint.
Itrrr,estiqo,tions :
1. X-Ray chest : Soft tissue swelling occupies the mediastinum
&
N.B.:
&
Gan
[e deliueled [y
45
WhiteKnightLove
Saliuary Glands
PERSONAL HISTORY : As general sheet * stressing on
* Mumps ) common in childhood.
* Sialectasis ) in young age.
1. Age.'
* Malignancy
2. Residence
in old age.
eOMPtr4lINT :
* Swelling infront and below the ear.
* or swelling at the side of face.
PRESENT TiISTORY
1. Analysis
* In sialadenitis
* Stones during eating or in relation to sour juice like lemon.
* Benign tumours are painless.
4. Other swellings :
* Like LN metastases in malignancy.
* Lachrymal gland may be enlargement in Sjogren's disease.
5. Constitutional manifestations t FAHMR
6. Ask about dryness of mouth and the conjunctiva.
46
WhiteKnightLove
il.B:
a.
b.
)
c.
acute sialadenitis.
f intra-oral
bilateral
sialectasis.
d.
without complications
e.
pleomorphic adenoma.
malignancy.
As general sheet.
Eeneral Exarnination
(1) General look : Usually normal
except
if
* Malignancy ) cachexia.
* Acute sialadenitis ) toxic flushed facies.
47
WhiteKnightLove
Inspecfion (ZS)
3) Size : Variable.
---+
Recurrent parotid
mass.
Palpation:
TECRM-D
6) Relation to surroundings
(a) Skio t
O Pinching or sliding test (to ensure absence of skin fixation).
48
WhiteKnightLove
nerve palsy.
3.
Asl<
4. Ask the patient to show his teeth & see whether there is
deviation of the angle of mouth or not.
(e) IUandible :
O Try to move the swelling over the mandibular ramus from
side to side make sure that the swelling is not fixed.
cervical L.Ns
49
WhiteKnightLove
1) Inspect the opening of the duct inside the oral cavity for
stones, inflammation, 0r pus coming from the duct.
Qaroti[
fuct
mofar tootL
Sarotil [uct
Su6man[i6u[ar
gfanf:
L]1.
50
WhiteKnightLove
fernufum
tissue
S.C
Abscess
* Lipoma.
Sebaceous cyst
* Haematoma.
b. Parotid LN :
V
V
c. Parotid gland :
V Inflammations ) acute and chronic
V Tumours ) benign and malignant.
V S;ogren's disease.
V Endemic parotitis.
d. From the masseter :
Fibrosarcoma.
5l
WhiteKnightLove
sialadenitis.
Lipoma
Haematoma
b. Submandibular LN .'
c. Submandibular gland
Inflammations
'A
Tumours
Adamantinoma.
Sarcoma or osteoclastoma.
Osteomyleitis.
52
WhiteKnightLove
The Breast
PERSONAt HISTORY
As general sheet
* stressing
on
- Menstrual history.
COMPLAINT
PRESENT TIISTORY
Mastitis
Sarcoma.
UL
Chest
Abdomen
Bone
Bone aches
PAST HISTORY
: As general sheet +
53
WhiteKnightLove
Eeneral Exarninatirrrr
1. General appearance : Cachexia in advanced cancer
* Resp. Rate: dyspnea if lung metastases.
2. Vital signs '
* Temp : - | in acute mastitis.
- Low grade in malignancy.
3. Head
* Skull metastasis.
* Jaundice from liver metastasis.
* Lips for
mammary LN).
4. Neck:
"
compressing S.V.C.
5. Chest :
*
Pleural eftusion.
6. Abdomen
* Hepatomegally ) metastasis.
* Umbilical nodules (sister Mary Joseph sign).
* Malignant ascites.
* P/V
Krukunberg tumour.
7. Upper Limb
Dilated veins.
B. Lower Limb :
* Pathological fracture.
54
WhiteKnightLove
LN
Local Exarninatirrn
Exposure .' Upper half of the body is completely naked to the umbilicus
(the back and shoulder being covered with blanket).
INSPECTION
Breast
Areola
Nipple
Mass ( if visible)
l- Breas t, c)*p::':rrr
Breasts concerning
: normal or distorted.
* Skin manifeststions :
x
See
text notes.
Mobilitv:
[!!
55
WhiteKnightLove
2-
Areola :
* Colour : (pink in virgin, brown ui't". pregnancy).
* Surface : puckering) eczema or ulceration.
* Swellings or nodules.
3-Nipple:7D
* Direction : (downward, forwards & lateral), Iook for deviation.
x
4-Mass:
7S
PATPATION: For the breast, the mass & the axillary L.N.
1. Breast
WhiteKnightLove
2. Mass
Thc ftey
(a) skin t
* Pinching or sliding test (to ensure absence of skin fixation).
(b) Muscles:
1) Pectoralis major:
* If mobility is lost
alz
57
WhiteKnightLove
If
(d) Nipple :
x Hold nipple by one hand and move the mass away
"flfi.f'kry
b*pfi
nofes
One hand in the axilla with the palm directed forward on the deep
surface of pectoralis major.
V White the palm of other hand ( Or the thumb of the same hand)
presses at the anterior oxillarv fold.
58
WhiteKnightLove
2- Central group
3- Apical group
\_.,1
-
\_
s9
WhiteKnightLove
6. Supra-clavicular group
* Felt above the mid clavicular point from behind.
60
WhiteKnightLove
Uaricose Ueins
Historg
PERSONAT IIISTORY
: As general sheet
Stressing on
COMPLAINT
.
o
Or complications (CVI).
PRESENT IIISTORY
1.
Early cases:
eczema.
b) Lipo dermatosclerosis.
c)
Venous ulcer.
d)
pressare.
61
WhiteKnightLove
4. Swellings :
* Saphena varix (soft, compressible swelling at the groin)
* A-V fistula.
5. Previous investigations and treatment.
6. Possible etiology
PAST IIISTORY
: As general sheet
stressing on
FAMILY TIISTORY
Eeneral Exarnination
1- General appearance
2- Vital signs
o
o
o
:
4- Neck :
3- Head
Usually normal.
f if thrombophlebitis.
5- Abdomen
a. Visceroptosis.
b. Masses, scars of previous operation.
WhiteKnightLove
f.
P/R
6- Upper Limb
Piles.
: Usually free.
Local exarnination
A The patient should be examined while STANDING
and
H Affecting
veins.
Retrcurar
sl
H Large in diameter:
5-15 mm.
2. Reticular varicosities
varlrose vein
Deep Veirl
2. What
of veins ?
lnspection:
63
WhiteKnightLove
2ry
V.V.
favour of 2ryV.V.
@ Presence of veins crossing the inguinal ligament (with reversed flowl
denotes 2'Y V.Y.
Palpation:
@ Palpation of a thrill over the veins denotes the existence of an A-V fistula.
a.GhewieltGSt:
O If
&
64
WhiteKnightLove
on
?alpafion :
O Palpation of a thrill
Aim:
a. Detection of sapheno-femoral incompetence.
b. Detection of incompetence of communicating veins.
Method :
a. The patient
c.
Results :
below upward
above downwards.
means
lo
second,s.
fill
65
WhiteKnightLove
If
O Ast
30o.
SFJ
fill
66
WhiteKnightLove
of
incompetent perforator.
b. Itlanual Localization of Blotp-Ouls f Two Finglers Test ) :
O Patient stands.
@ The 2 index are pressed at a point on great saphenous vein
a segment.
O lf this segment remains empty, it has no underlying blowout but if it fills, an underlying blow-out exists.
lg|
(b,
c. Fegan's ltlettod :
O Mark the varicosities with a skin pen while the patient stands.
O Ask him to lie down & raise the affected limb & rest the
heel against the examiner's upper chest.
O They are felt as circular openings with sharp edges & are marked.
67
WhiteKnightLove
test:
Method :
SFJ & the patient is asked to walk quickly in situ for five minutes.
Result :
O If V.V disappear i
O If V.V become
more engorged
llot done
as
it is sulbig@.
Method :
&
Result:
test:
Perthe's
test will show venous engorgement even if the deep system is patent.
Therefore, apply the tourniquet just helow the incompetent
perforator & test the veins below.
68
WhiteKnightLove
.
.
disease.
COMPLAINT
'
PRESENT TIISTORY
ef Pain
Glaudicafion
adps,
[flin:
Character.
- Site.
factors.
- Claudication time.
- Claudication distance.
- Aggravating factors.
- Relieving
- Period of rest.
* nest lrlin:
Character.
- Aggravating factors.
-
- Site.
- Relieving factors.
hair.
- Dry scaly skin.
- Tapering digits.
- Brittle nails.
- Loss of
- Muscle wasting.
- Ulceration.
Gl Goldness
69
WhiteKnightLove
Dl Golour changles :
* Pallor, cyanosis.
* Gangfgne
or tight shoes).
- Site and extent.
El Funclional changes :
-
H0t0l diStuftances
* Hypo or hyperaesthsia.
'
'SGluat
3- Swelling
4- Trauma
For aneurysms.
5- Constitutiona! manifestations
Heart
PAST IIISTORY
* Similar attacks.
* DM, hypertension, heart disease.
FAMITY HISTORY
'
* Similar condition.
* Atherosclerosis, Diabetes.
70
WhiteKnightLove
Eeneral Exarninatirrn
1. General Appearance & facies
* Temperature : J if infection.
* B.P.' higher in arms than in thighs in aortic coartication.
x
l?.1? .'
3, Head
* Pallor.
* Cyanosis.
4. Neck
7l
WhiteKnightLove
stenosis.
Local Exarnination
Both Limbs
P0Siti0n: Lying supine or semi-sitting.
A-
INSPEETION
hair.
- Brittle nails.
skin.
* No : Single or multiple.
* Site: foot, big toe.
Floor: Granulation
tissue.
e
e
The colour of blood is at first red but it later becomes blue due
72
WhiteKnightLove
(septic or aseptic)
&
. Line of seporotioru
B- PALPATION :
I- Ternperature chan$es :
Uncover the limbs for 5 minutes and compare by the back of your
fingers the ischaemic part to the unaffected part of the same limb
and to the same part of the other limb.
Ischaemic limb is usually colder and the level of temperature
change indicates the level of arterial obstruction.
a
Infection.
Sympathectomy.
Covered with blankets.
Atheroscterosis.
N.B
73
WhiteKnightLove
till
: Active &
passive movements.
V- Sens<rry chan$es :
C- SPECIAL TESTS :
1. Test for the capillary circulation
H If > 30 seconds I
H If there is failure
2. Buerger's angle
Advanced ischemia.
of blanching
Established gangrene.
H If < 20o:
advanced ischaemia.
74
WhiteKnightLove
"some prefer
H Normally
the veins
ischaemia
H If > 2 minutes :
advanced ischaemia.
Guttering of veins
is lying horizontal
&
collapse when the foot is raised above the level of the heart.
limb elevation.
D- RUSCULTATION :
H Over femoral artery for a bruit which indicates
H Continuous machinery murmur in A-V fistula.
stenosis.
r.
Gommon carotid
z. Suhclavian artery
urutid tulemleltransverse
process of C6 ).
3. Superficial tempor?l
* Above the root of the nose and above the middle of the eye brow.
E. Facial artery:
* Along anterior border of masseter muscle against tlrc nmus
tl,o h'arrdilb
75
WhiteKnightLove
af
IJpper lirnb :
l.
Axillary artery
2. Brachial artery
a-
sh& hamutsalong
the
3. Ulnar artery:
* Lateral to the tendon of flexor carpi ulnaris against louu
I/9
of ulna.
4. Radial artery
louu 1B of radtus
Abdornerr :
1- Aorta
* At midline starting from the xiphoid and ends 1.5 inches below
and to the left of the umbilicus against tJo
2- Gommon iliac
6t& of lt nlat
).
76
WhiteKnightLove
3- External iliac
tle lEuiot
polio ranus.
Lower Lirnb :
1. Gommon femoral
slightly
externally rotated).
2. Superficial femoral
* Along upper
213
3. Poplit?l
shilt of{"mrt
O Flex the knee 90' place the thumbs just above the knee and
the rest of the fingers over the upper part of popliteal fossa
to feel the pulse against to*r?t urd of tJa fururt
popttul
fossa-
77
WhiteKnightLove
of
endoftilia.
4. Posterior tibial
ulmnPfis.
78
WhiteKnightLove
nalldus ot
5. Anterior tihial
5. Dorsalis Pedis :
*Lateraltotheextensorhallucislongustendonagainst
79
WhiteKnightLove
I.ymphadenopathy
PERSONAT IIISTORY
ffi
: General sheet
EQ
COMPLAINT
PRESENT NISTORY
durution
4, Fever
Abdominal: Jaundice.
80
WhiteKnightLove
PRST TIISTORY
Y Similar conditions.
Y Previous operations ( L.N. biopsy ).
FAMILY HISTORY : T.B. may affects members
Eeneral Exarnination
l. General agrpearanee
2. Vital s0grrs ;
* Temperature : I T.B, Hodgkin's disease & IMN.
* Pulse : usually normal.
* Blood pressure : usually normal.
* Respiratory rate : usually normal.
4. Neek
3. Head,
a. Skull metastases.
sydrome).
b. Trachea : central or not.
Epistaxis.
8l
WhiteKnightLove
6.
5. Chest
a. Sternal and
b.
rib tenderness.
Abd,onten,
a. Hepato-splenomegaly.
b. Malignant ascites.
c.
(T.B. or metastasis).
c. Despine sign
e.
Back: vertebral
metastases.
f. Par-aortic LN enlargement.
7. Upper Limb
B.
Lawer Limb
a- Oedema.
a- Oedema.
b- Dilated veins.
b- Dilated veins.
c- Ischaemic manifestations.
d- Rashes (infectious
d- Rashes.
E- Inguinal L.N.
mononucleosis).
e-
Local Exarnination
O If the patient has Localized lvmphadenopathv. the local examination
is done for the affected group, the other groups are examined by
general examination.
If
l't involved
82
WhiteKnightLove
INSPDCTION i 7 S
&
Skin overlying:
* Inflammatory signs.
* Sinus
T.B.
Surroundings :
* Muscles ) superficial or deep.
* Veins ) distal oedema and dilated veins.
* Artery ) ischaemic changes or arterial displacement.
[onsistcncy:
) NHL or calcif,rcation.
2) Firm ) T.8., chronic lymphadenitis.
3) Cystic ) cold abscess.
l)
Hard
Edge:
Well defined
1) Separale
)
4) Rosette shape )
3) Amalgamated
\
\
TB.
Hodgkin's lymphoma.
0ther swellings.
Relation to the surrounding structures.
IDon't
Y Cervical LN )
Y Axillary LN )
Inguinal LN
(,,reo,s :
till umbilicus.
83
WhiteKnightLove
PERCUSSION
far
med,io,stfuio,l LN :
How
l- Geruical llodes :
A- Vertical group :l. Suneilicial grou[
2.llec[ Ulou[:
L Mo/,iangro{lp
* Prelaryngeal LN.
* Pretracheal LN.
* Suprasternal LN.
iL Loturalgroup : Is lnidpl" alflu t+pw E louw groups bg tI"
L+p?, bader
@ Upper deep cervical [N
"f
d.grotd oortllagu
lugulo digastilc node [elongs t0 tnis g10u[ a lies [elow t[e [ostctio] [elly 0f
digastilc am inflont 0IInG intemal iugularuein.
O lower
deep mrvical
84
WhiteKnightLove
B- Circular liroup :
@ Submental
LN.
@ Submandibular
LN.
: Look breast.
B. The deep
inguinal LN
* Are arranged vertically along the upper part of the femoral vein.
* Are difficult to be felt.
85
WhiteKnightLove
A. The para-aortic LN
B. The
iliac LN :
pulses.
U- The epitrochlear
Lll
Irnportant Notes
1. The main causes of generalized lymphadenopathy are
* Lymphoma.
* Infectious mononucleosis.
o. Blood picture :
* For leukaemia, lymphoma and infectious mononucleosis.
c.
Tuberculin test
Good
86
WhiteKnightLove
COMPLIEATIONS
2.
]l.B
:@
& appetite-
WhiteKnightLove
B- Blood-borne tylre:
PATHOLOGY :
1. This type is more common in elderly people.
2. The organisms reach lymph nodes via blood stream and
affect many groups of nodes in the body.
88
WhiteKnightLove
so
CLINIEAL PIETURE :
@ Multiple groups of enlarged lymph nodes which are
* Not tender. * Not matted together.
* Rubbery in consistency. * Discrete.
e
e
Hodgkin's diseose ( HD )
PATNOLOGY :
1. It usually starts in cervical lymph nodes.
2. The affected nodes are :
* Enlarged. * Discrete. * Rubbery. * Have a pink colour.
3. Microscopically : the diagnostic feature is finding the
characteristic Dorothy-Reed Sternberg cells.
Iftese ale gianl cells mat naue an euen num[c] 0f nuclei wnich are
auangeil in a mirrolimagc mannel.
4. There ure four known histological types of Hodgkin's disease.
A. Lymphocyte predominance
$
s
B. Nodular sclerosis
A ttris
C. Mixed cellularity.
D, Lymphocyte depletion I The prognosis is the urotst.
STAGING : The Ann Arbor staging system is in common use
Stage I : * Single involved lymph node group ( I ).
* Or a single extralymphatic site ( IE ).
Stage II : * Two or more involved lymph node groups limited to
one side of the diaphragm.
* Or a solitary extralymphatic site with one or more lymph
node areas on the same side of the diaphragm ( IIE ).
*
Stage III : Involvement of lymph node groups on both sides of the
diaphragm with or without splenic involvement ( IIIS ).
89
WhiteKnightLove
c/o
otE
2.
INVESTIGATIONS
(a)Splenectomy.
(b)Biopsy of both liver lobes.
(c) Biopsy of all intra-abdominal lymph node groups, which are marked
by metal clips to help future localization by the radiotherapist.
90
WhiteKnightLove
WhiteKnightLove
Burkitl's lymphomo
92
WhiteKnightLove
ebdominal Case
PERSONAL HISTORY
a.
Age.' * Haemolytic
As general sheet
* stressing
on
anaemias in children.
habi*.'
c. Speciul
COMPLAINT
2. Pain ( dyspepsia,
).
3. Complications :
a
a
a
a
PRESENT HISTORY
3- Pain : in splenomegaly.
@
@ Character :
Heaviness
@ Precipitating
@ Reliving
WhiteKnightLove
4- Swellings : In splenomegaly
@ Other swellings like generalized lymphadenopathy and
hepatic swellings suggestive of lymphoma or leukemia.
5- Constitutional manifestations
liver tumour.
@ Pel-Ebstin fever in Lymphomas.
Oeophageal:
Dysphagia
Haematemsis \
* No of attacks.
* Amount of each.
* At what level ?
* to fluids or solids 2
* course : Intermittent
* Colour.
or
Progressive.
Eastric
Dyspepsia
Vomiting
94
WhiteKnightLove
Liver
- Bleeding tendency.
- Gynecomastia.
- Palmar erythema and spider navei.
- Drowsiness, insomnia, flapping tremors and foetar hepaticus.
Spleen : )
*Thrombocytopenia : Bleeding
tendency.
* Recturn.
lntestinal
Defecation (constipation
. Frequency
. Amount
. Colour, odour, contents
PAST TIISTORY
I .
| .
I o
Amounttmucus
Associated or following haematemesis.
Type of treatment
FAMILY TIISTORY
* Hemolytic anaemia.
* Bilharziasis in endemic areas.
95
WhiteKnightLove
Eeneral Exarninatirrn
2- Vital signs
l-Gieneral@
* BP : Usually normal
- Cachexia in lymphoma.
4- Neck
3- Ilead
* Skull metastasis.
* Jaundice.
* Epistaxis.
*Pallor, jaundice, cyanosis.
* Spider navei.
* Congested neck veins in corpulmonal.
* Feotor hepaticus.
* Glossitis, stomatitis.
* Endemic parotitis.
* Spider navei.
96
WhiteKnightLove
6- Alrdorrren
5- Ghest
1. Gynecomastia.
Local Examination
4. Spider navei.
7-
ffpper Lirnlr
8- Lourer Lirnb
pallor.
2. Flapping tremors.
3. Palmar erythema.
1.
4.
Clubbing of nails,
| 1.
| 2.
Axillary LN enlArgement.
5. Water-hummer pulse.
malignancy ).
d. P/R &
97
WhiteKnightLove
Local Exarnination
*t Position
xt Exposure : From
INSPECTION
1) Abdominal Contour
Scaphoid abdomen.
A Flat abdomen.
Distended abdomen.
2) Abdominal
look
Male: abdomino-thoracic.
haemorrhage.
intra-abdominal pressure.
4) Epigastric pulsations :
*If B cor-pulmonale ) Rt. Side heart failure.
5) Divercation of Recti
*With chronic f intra-abdominal pressure.
6) Umbilicus
c. Impulse
on cough.
98
WhiteKnightLove
7) Supra-pubic hair
,l
8) Hernial orifices
9) The back
a
1O) Any
for
PALPATION
A. SUPERFICIAL PALPATION
ERrlles :
ffi ttre abdomen is palpated symmetrically region by region ( 9 regions ).
[E Superficial palpation is done
by the FLAT of hand resting
over the relaxed abdomen.
EE Start from the diagonal
WhiteKnightLove
2.
To
elicit:
.
.
.
3.
n,dclarriculaa
Abdomin,,,l reqions
$nQ
,t
\u
s
o
B. DEEP PALPATION
ERrrles:
1- Using warm hands.
2- Ask the patient to flex his knees (slightly 45").
l- LiVgf :
* Rt. Lobe
100
WhiteKnightLove
* Lt. lobe
t.
Clossie method,:
* Starting from Rt. Iliac fossa moving up to palpate the lower
border of the Rt. Iobe.
, Bimunuul Exannino,tion :
* Where the liver edge can be made more prominent by putting
the Lt. hand under the lower ribs and lifting them forwards.
ascites) :
* We put the tips of fingers on the abdomen over the liver and
by a quick push, the abdominal wall is depressed to displace
the fluid and hit the organ.
4. Hooking method, :
* Hook the Rt. costal margin while the patient is semisitting
taking a deep breath.
l[ enlarged comment on : t l0r liver and $rleen
-f
emleraturc, f endGrness.
.[nettt0f
-[[ge "snal[
o] Ioundeil".
-Gonsistency,
suilacG [smooth
01
i]reuulail.
l0l
WhiteKnightLove
ll- Spleen:
Spleen (normally not palpable) is present under the left
costal margins parallel to long axis of ribs (9, 10, 11) behind
It usually
Lt.
iliac fossa).
(Clossie m,ethod.:
* Starting from the right iliac fossa moving towards the umbilicus
reaching lower pole of the spleen.
102
WhiteKnightLove
{D
o-Dr
Dipping method,:
( in tense ascites)
* We put the tips of fingers on the abdomen over the spleen and
by a quick push, the abdominal wall is depressed to displace
the fluid and hit the organ.
4. Hooking method, :
* Hook the Lt. costal margin while the patient is semisitting
taking a deep breath.
5.
lll- Kldry
beh,ind, :
103
WhiteKnightLove
[y
stlilc
tnG
[ostelior hand.
Splenomegaly
1) Has a sharp
1)
Reniforn in shape
a notch on it.
It
104
WhiteKnightLove
if
distended )
it
it
3. lts surface is smooth and its edges are rounded & wel! defined
nol
liver dullness.
6. Gan moue
a) A line drawn from Rt. ASIS to the umbilicus and cross the
midline by one inch you can feel the mesenteric LN on that line.
105
WhiteKnightLove
PERCUSSION:
l-Liver
a.
i.o*er horder a
LIGHT PERCUSION
b. cUpper border
HEAW PERCUSSION
ll-Spleen :
i Normal splenic dullness extends
* Anteriorly to midaxillary line.
WhiteKnightLove
]l.B : Boundaries o[
ftaub's fl]Gfl
tL ) + 9HIFTING DULLNESS
b. cFor minimat ascites (. lil ) I KNEE ELBow PosITIoN
107
WhiteKnightLove
Padilel sign
* Put a
ellow [osition.
* S[a[e the a[domen
c.
) [s[lash is heatd.
Etr The patient places his hand firmly on the center of the
abdomen to avoid fat thrill.
@ The abdominal
AUSCULTATION
m
m
ffi
ffi
e
Bowel sounds.
Friction rub of perisplenitis over the spleen or perihepatitis over the liver.
Scratch sign for liver enlargement.
ru
cases of
108
WhiteKnightLove
Oral Qrrestions
0:
l-
Detection of aetiology :
1. Hepatitis markers : HBsAg, HCV-Ab ( better PCR
2.
Stool
).
3. Serological
& CFT .
tests :
1. Abdominal U.S.
*
2.
hypertension
3. Detection of oesophageal varices : Upper GIT endoscopy.
calillailes
109
WhiteKnightLove
0n tne uailGes I
G[c]ty
CBC.
,l
RBCs
R.adioisotope scan using radioactive chromium tagged
t"Ir, to show the
)
(.tC. or platelets labeled with indium (
degree
ffi
10th
thoracic spine'
Rt.midctavicularlinepassingthroughthexiphoid
process.
ll0
WhiteKnightLove
7th
EE
..
j--'
t
ll.B.:'f,enal anglc : Angle [etween tnc ]ast fi[ and lateral [order of
sacrus[inalis muscle.
.10in:
't
!
,
)
,}
111
WhiteKnightLove
Jaundice Sheet
PERSONAT IIISTORY : As generul sheet * stressing on
A4ie :
age.
in any age.
Sex:
* Calcular obstructive jaundice ) in females.
* Malignant obstructive jaundice ) in males.
COMPLAINT :
(a) Yellow colour of sclera, skin
&
mucus membrane.
PRESENT TIISTORY
(a) Calcular:
Sudden onset, intermittent course, short duration.
(b) Cancer pancreas :
fi2
WhiteKnightLove
(2) Pain.
a. Site.' Rt. hypochondrium and epigastrium.
Character
c.
* Calcular : biliarycolics.
Radiation
d. Aggravating
e-
Relieving factors
* Calcular ; antispasmodics.
'
(3) Swellings.
'
'
'
'
ll3
WhiteKnightLove
* Anaemia.
* Normal colour urine, deep dark stools.
c) Hepato-cellular jaundice :
* Bleeding tendency.
\
* Dark urine and normal colored stools.
* Past history
* Farnily history
Eeneral Exarninatirrrr
l- General aopearance.
\ Posture : Leaning forward |
in advanced cancer head
of I
pancreas.
\ Cachexia : In cancer.
\
Body
built:
I
I
2- Uital siEns
| Pulse :
I
lTemp:Characot'sfever
I R.P. : f if charaot's fever.
Obese female in
gall stones.
n4
WhiteKnightLove
4- Neck.
3- Head.
@ Skull Metastasis.
@ Jaundice.
O Pallor (haemolytic
jaundice).
Cervical LN (Virchow's) in
@ Foetor hepaticus.
malignant obstructive
@ Spider navei.
jaundice
Xanthelasma.
6- Abdomen
5- Ghest
:s Gynecomastia.
:s Itching marks,
>. Back: For metastasis in
malignant jaundice.
7- Upper Umb
\9 Itching
marks.
V Echymosis (bleeding
tendency).
t9 Hand manifestations
liver cell failure.
of
I I
| |
I I V Thrombophlebitis migrans in
I I
cancer pancreas.
lls
WhiteKnightLove
Local Exarnination
INSPECTION : As abdominal
sheet
sheet)
1- Liver.
2-
Spleen.
PERCUSSION
&
AOSCUTTATION
lrnportant nrrtesi
(1) tlaemolytic jaundice is usually very light (Lemon yellow):
jaundice.
116
WhiteKnightLove
CAUSES OF O.' :
1. Causes in the lumen of the bile ducts :
a. Calculi.
b. Parasites as ascaris, fasciola or daughter cysts.
2. Causes in the wall of the bile ducts which include
o. Congenital biliary atresia.
b. Inflummatory stricture :
* Sclerosing cholangitis.
* Secondary to an impacted stone which has been
present for a long time.
c. Traumatic stricture: Usually iatrogenic following :
* Cholecystectomy,
* Choledocholithotomy. * BRCP.
d. Malignant stricture ( cholangiacarcinoma ).
3. Causes outside the bile ducts :
b. A
O.'
biliary radicles
Hydro-hepatosis.
2. 2rg ir{"}:iDt- ) Ascprdirg ol,o{angilis ( cho{angblppatfiis ).
3. In severe cases liver cells stop to secrete bile white bile ducts
will continue to secrete pale yellow mucous ( white bile ).
This indicates severe liver damage.
4.2'v biliary cirrhosis in Iong standing cases.
C-
117
WhiteKnightLove
INVESTIGATIONS
Laboratorlr
$ LFTs : * t
s
$ cBc.
K.
Prothrombin time.
S CA 19.9 ) Elevated in cancer head pancreas.
Badiological
l. U.SaDdomen:
2.
3.
4.
[.B.G.P
: IliagnosUcarelieucsiaundioe.
5.
0.
TREATMENT OF O.I:
Initial rnanagernent
l. Hospitalization.
2. Liver support ( high glucose intake ).
3. Vit K injection to correct the coagulation abnormalities
4. Antibiotics ( 3'd generation cephalosporins ) to prevent ascending
cholangitis.
5. Prevention of hepato- renal failure:
a. Mannitol I.V (osmotic diuretic).
b. Oral bile salts to diminish liability of endotoxaemia.
c. Adequate hydration by I.V. fluids.
I- Ealcular O-J :
a) ERCP, sphinterotomy & stone extraction by dormia basket
or balloon catheter followed by cholecystectomy either open
or better laparoscopic.
ll8
WhiteKnightLove
+ Liver transplantation.
O
O
Courvoisier's Lqw
ln a natient witn 0J, iI the gall
c.
2.
ll9
WhiteKnightLove