Clinical

'It is more blessed to give than to receive.
Clinical Sureery
By ltr : HanY Rafik
2012
WhiteKnightLove
Freely you have received; freely give.
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
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.......69
.......80
...........93
.....112
How to Take a History
tll Personal historu

* Nume: - Medical registration
*
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.
* Sex.' Breast cancer in female.

* Residence : Filariasis in Imbaba, Mansoura, SharkiarBilharziasis in
country sides.
* Occupation : Varicose
veins ( in prolonged standing ), cancer bladder
( aniline dye workers ).
* Marital status.' ( Married or single, No of children,

age of last one ).
Menstrual history : (Age of menarche, regular or irregular)
age
of menopause, method of contraception ).
* Special habits.' ( Smoking, Alcohol, Drug addiction
WhiteKnightLove
).
9(n *tn,tp,Ll, fon*annl, hi"rn rr/t

...
...... Years old,from
working as a
years ago, and has ...... moruied ..
children, last one is
... cigurettes per dayfor ...........
.. years old, he's smoking
A male patient named
years.
llll Eornplaint
4
Only one complaint (the most distressing).

By the patient's own wards (no medical terms).
Mention duration.
Ihe main G/0 in surgery ale swcllings, [ain, deformity 01ulcel
IIIII Preserrt Historg

'l/au
sl,tut
ld lrrl4ill, tl,p,fnlln nt rE ilpm,s
l- Analysis of the cornplaint :

Course
Onset
V Sudden : (after trauma).

V Acute: infection.
V Insidious: gradual.
V Accidentally discovered
2-
/
/
Duration
Progressive.
V Short (in malignancy).
Regressive.
S Stationary.
V Variable.
Long (in chronic

diseases).
Ilistory of the disease in chronolo*ical order :
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
a. Relation to pain or trauma.
Site.
b. Character (coliclcy, dull ache,
b. Relation to constitutional
stitching or throbbing).
manifestations.
c. Other
d. Effect
c. Radiation.
d. Precipitating factors.
e. Relieving factors.
swellings (e.g metastasis).

on surroundings, e.g.
pressu re manifestations
5- History of traurna :
Physical (direct or indirect) or psychic (as in goiter).
6- Constitutional rnanifestations :
Acute inflammations
Chronic inflammations
Fever, headache, malaise, rigors.
weight loss, anorexia, Ioss of appetite,
low grade fever, night sweat.
7- Previous investi$ations and treatrnent

8- Systerns revieur: ( CNS, Cardiological, Musculoskeletal,
Endocrine manifestations ).
9- Cornplications of the pathology or systern you are
dealing with-
llVI Past Historg

/A Similar conditions.
4
6
4
Previous treatment.
Medical disorders : DM,
BP, T.B., Bilharziasis ... etc.
Previous operations, type of anaesthesia
& postoperative
complications.
History of blood transfusion or drug allergy.
WhiteKnightLove
tV| Farnilg
Historg
4 Similar conditions in the same family.

4 Consanguinity.
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.
* Rhythm & equality on both sides.

* Volume.
* Character like water hummer pulse.

* State of vessel wall cord like in atherosclerosis.
3.Ifead
1. Skull and scalp masses.
2. Eye brows ( loss of outer 1/3)

3.
Eye'
*Jaundice.
* Signs of thyrotoxicosis.
4. Nose : Epistaxis (bleeding tendency).
5. Lips : Pallor, jaundice,
cyanosis.
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6. Tongue : tremor, central
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).
I tube : Trachea (central or deviated).

5- Chest
1. Chest
wall
a. Bony tenderness.
b. Gynecomastia.
c. Dilated veins.
2.Lrung & heart : Complete chest and heart examination.
6- Abdorninal Exarnination
* Palpable
L.
Liver & Spleen.
2.Para
- aortic LN.
3. Ascites ( percussion ).
4. dilated veins ( inspection ).

5. Scrotum ( for masses ).
6. Back ( for vertebral tenderness
or renal swellings ).
7.PtR& PA/ ( masses, piles, polyps, ulcers ).
7- Upper Lirnb
1.
Hand
* Warm or cold (sweaty or not).

* Palmar erythema.
* Clubbing or spooning of nails.
* Pallor.
* Tremors : Fine or flappy.
2. Water hummer pulse.
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3. Epitrochlear
& Axillary LNs.
8- I'ower lirnb
1. Inguinal lymph nodes.
2. Oedema
& pretibial myxoedema.
3. Pulses ( dorsalis pedis ).

4. Dilated veins.
I.ocal Examination of a Swelling
tlllnspectiontTSt
I. Solitory or muhiple
\
Some swellings are multiple from the start as multiple
neurofibromatosis, multiple lipomatosis & lymphoma.
o For example parotid swelling
with cervical lymphadenopathy may
indicate malignant parotid mass

2. Site:
swelling in the lower part of the front of the neck
swelling in the parotid region
---+
---+
goitre.
parotid gtand swelling.
3. Size:
o Measure
the swelling in 2 perpendicurar directions.
A <2 cm ---) small is size.
2-5 cm --+ moderate in size.
O 5-10 cm --+ Iarge.
> 10 cm
4. Shope:
O A thyroid swelling is butterfly in shape.

5. Surloce : (Smooth, nodular, lobular ....etc
)
5. Speciol cholocler:
O Hernia gives expansile impulse on cough.
O Goitre moves with deglutition.
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-- huge.
O An aneurysm is pulsating.
7. Skin overlying :
O Redness -+ Inflammation.
g Ulceration or fungation ---+ Malignant lesion.

O Scar of previous operations ---+ Recurrent swelling.
g
g
Dilated veins
---r
Venous compression.
Pigmentation.
t II
I Palpation
o Confirmation
O
of inspection.
TECRM-D
T: Tenderness, temperature & transillumination if cystic.

Temperature : By the Dac[ of hand and Gomla]G with neal alca 0[
n0tmal tem[e]atulc.
Tenderness
: PrGss
all [oints oue]thc suuelling
&
l00kforthe
[aficils
facial enuession.
E: Edge & confirmation of inspection
Put your hand on the swelling to confirm inspection.
O Well defined or ill delined
edge.
Start from the normal side towards the swelling.
I If you get a point of separation between the surroundings
-+ Well
difined.
C : Consistenc! ! Cystic or solid.

x Cystic
* Solid
Lax or tense cystic.

Soft like ear lobule, fleshy like relaxed biceps, firm like tip of
nose "cartilage" or hard like forehead "bone".
WhiteKnightLove
% n tt* tn, dptent, co,n si,sfmaV:
(I) Fluetuation test
z(
For swellings > 2cm and lax).
Fluctuotion is lhe sensolion perceived due lo displocement of fluid or gos inside o

cystic swelling from side to side.
The fingers of the 2 hands are applied as far as the surface

of the swelling allows.
Jts
One finger is
The other is Orcssit
If the swelling is freely mobile fix it firmly between the thumb &
firinq
watolbq.
fingers OR by an assistant's hand.

lt.B:
l.
Fluctuation should be done in 2 perpendicular directions
As muscles are normally fluctuant in one direction (across).

2. A false sensation of fluctuation ( pseudo fluctuation ) may he obtained
in very soft swelling e.g. lipoma.
Uarianls of Fluctuation lesl:

(a) Modified fluctuation test
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 :
O To test weather 2 adjacent cystic swelling are communicating or

not as psoas abscess.
(c) Bipolar fluctuation test : look scrotum
WhiteKnightLove
O For swellings which have 2 poles like vaginal hydrocele of the testis-
(II) Paget's test :

Indications:
$ Small swellings <2cm
No place for fingers'
$ Tense swellings ) No place for fluctuation'

$ Tender swellings
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
the center is yielding > the periphery
cystic swelling.
M : Mobility : Mobile or fixed to the surroundings
:
o Fixed in all directions :
O Mobile in one direction :
O Mobile in all directions
Skin and subcutaneous swellings'

BonY or attached to bone.
Muscular swelling, neuroma' aneurysm
or ganglion.
R : Relation to surroundings
l- Skin :
ffi
gy pinching test or stiding (gliding) test'
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2-
Muscle
A) ls rhr swrllir.rq suprnficinl on deep ro rhe

on anisinq hovr rke nnusclr irse[f ?
* Contract
nnuscle
the muscle against resistance and notice
any change in size of the swelling.
y If more prominent :
swelling is superficial to the muscle or it is a
muscular swelling.
y If disappeared :
deep to the muscle.
B) ls rl-rr swellinq arrncl-rrd ro rkE MUsc[E oR Nor

If superficial :
V Test mobility of the swelling when the muscle is relaxed and

wh
en contracting against resistance.
y If the swelling is freely mobile before and during

contraction ) The swelling is NOT attached to the muscle
y If there is limitation of movement during contraction ) The
swelling is attached to the muscle.
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.
D : Draining anatomical lymph nodes i If palpable tookfor:
Consistency, mobilify.
@ Relation to over lying structures and underlying tissues.

@ Relation to each others (separate, matted, amalgamated.. etc).
l0
WhiteKnightLove
%lr.Vd. : %tr,/one.rr,t, cu(pa,s :

Examine cervical L.Ns. for swellings of:
Head
&
neck.
Examine axillary L.Ns. for swellings of

@ Upper limb
&
breast.
O Front of the trunk above the umbilicus.

@ Back till the iliac crest
Examine inguinal L.Ns. for swellings of :
Front of the trunk below the umbilicus.
O Lower limbs & genitalia

O Gluteal region, perineum & lower l.l3 of anal canal.
lmportant notes 0n some of the specia[ characters of swellings
a) Pulsadons (expansile
or transrnitted) :
Swelling communicating with an
artery:
aneurysm.
'ts Very vascular swelling like sarcoma.

'0 In close contact with an artery ( like pseudo pancreatic cyst ).
Apply 2 fingers (1 from each hand) liqhtly to the surface of the swelling &
determine whether the pulsations are expansile or transmitted.
i.{)
Placc inilex & rniddle lingers on lhe s*'clling.
(B; Transrnitterl pulsatious(C) Expansilc pulsation
b) knpulse on cor4flr :
i. Expansile impulse
ll
WhiteKnightLove
Expansile impulse means increase in srzg & tension of the swelling
in
all
directions.
!r iudicnres rknr rke swrLtlnq is connpruruicnrixq wirh n body

caviry
likr l-renr.ria, EMpyEMA necessirRNs oR ueniruqocete.

ii. Transmitted impulse
: Just a thrust in one direction.
c) ErnptyinE rln pressure :

i. Compressible swelling
Disappears partially or completely on pressure then it will return
to its normal size on releasing pressure e.g. saphena varix,

haemangioma.
ii. Reducible swelling:
Disappears or decreases in size when compressed in a certain
direction and reappears only on straining e.g. hernia.
d)
Thrilt :
A If systolic
and localized to the swelling that disappear on
occlusion of the feeding artery
true aneurysm.
A If continuous and along the vessels :
A. V fistula.
e) Crepitus :
A A crakling
sensation that is felt on pressing or manipulating the
swelling e.g osteoarthritis, fracture, surgical emphysema ... etc.
Transillurninafion :
I
E)
For cystic swellings in dark room e.g. hydrocele, cystic hygroma.
Pitdn$ on pressure
A Soft pitting e.g in early oedema.

A Soft pitting in red area: underlying pus.
A Non pitting: Late oedema.
t2
WhiteKnightLove
tllllPercussion
Resonant.' Gaseous swellings (e.g hernia containing bowel loops).
Dull : Solid or cystic swellings.
tlvf AusElrltatirrn
* For bruit, venous hum, rub, gurgle, intestinal sounds ... etc.
Ulcer Sheet
IIISTORY : Look general
sheet.
GENERAL EXAMINATION FOR
Distant metastasis in malignant ulcers.

Tuberculosis,syphilis.
Hemolytic anemia ( Splenomegaly, jaundice.. etc).
Full neurological examination (for neurotrophic ulcers).
LOCAL EXAMINATION
lnspection
x
: 45, edge, floor & margin.
Single or multiple :
" Site
Rodent )
Face
Trophic ,
Traumatic )
Venous
* Size
ulcer ,
Shin of tibia
Over medial malleolus
Variable (cm x cm)
xShape: *Rounded
*
Sole of foot
*Oval
* Serpeginous
Margins : Condition of the skin surrounding the ulcer (Red, pigmented,

dilated veins, scar ... etc).
13
WhiteKnightLove
ro*ffi..a '-'dt*
Edge:
* Undermined in T.B ulcer.

* Punched out in syphilitic ulcer.
* Sloping in venous ulcer.
* Rolled in & beaded in rodent ulcer.
* Raised everted in malignant ulcer.
uffiiT#i.
a-7-7
uhdmed
(hMEhssl
RErd " '17'?

^__.,/>_
Floor : * Healthy or unhealthy granulation ,ir.ll.*''"**'

* White callus in neurotrophic ulcers.
* Necrotic tissue in malignant ulcer.
Ilealthy granulation
o**!I;}lr* ",8\-,ft-
Unhealthy granulation
- Pink or bright red.
- Congested or pale grayish.
- Finely granular surface.
- Coarse, granular, raised.
- Doesn't bleed easily on touch
- Bleeds easily on touch.
<t -
Minimal serous discharge.
- Purulent discharge.
- + Pain.
- Painless.
Palpation
214,4,4
O Temperature & tenderness
O Solitary or multiple, site, size & shape.

@ Edge, base, floor & margin.
@ Artery, Yein, nerve
1. Start by palpation
& L.N.
if the surrounding skin for temperature & tenderness
like any swelling.

2. Then palpate the edge of the ulcer :
O Soft --+ Healing ulcer.

O Firm ---+ Chronic non healing ulcer.
O Hard -+ Malignant ulcer.
3. Then palpate the granulation tissue in the
floor of the ulcer
@ Whether it bleeds easily on touch or not
14
WhiteKnightLove
4. Base:
O It
is felt rather than seen.
@ Hold the ulcer base between the thumb & index fingers, move it side
to side in 2 different directions & then comment on
a. Soft or indurated (soft in healing ulcers, indurated in chronic
ulcers)
b. Mobile orftxed (mobile in benign ulcers & fixed in malignant ulcers).

N.B : Induration in inflammatory and benign ulcers doesn't extend
beyond the margin, while induration extends beyond the margin in
malignant ulcer.
5.
Draining Lvmph nodes * Artery + Vein + Nerve :
Pulsations should be felt to exclude ischemic ulcers.
@ Veins of the L.L. should be examined to exclude venous ulcer.

@ Sensations should be examined to exclude neuropathic ulcer.
O Draing L.Ns. should be examined
c. Firm & mobile ---+ Infected ulcer.

d. Hard
&
fixed
---
e. Matted together
Malignant ulcer.
---+
T.B. ulcer
l5
WhiteKnightLove
lngaino{crotal Cases & Hernia

Irr any ingirrino-scrotal case the patient is exposed frorn
rrrnbilicus to mid-thighIrr any in$rrino-scrotal case you should exarnine :
I- Sorotum:
OA
of the scrotum may be due to
sinus at the anterior surtate
gumma
(syphilisf of testis.
O A postsrior
sinus
may be to
T.B epididymitis.
O Dilated veins (varicocele) or sebaceous cysts.

O If there is empty compartment (maldescended) testis.
tr- Tunioa:
O By pinching test to detect a small lax2ry hydrocele.
Pinch the skin of the scrotum,
if you can feel the sl<in as a
separate layer & the tunica as another separate layer.

This means that there is a small lax hydrocele.
Bipolar fluctuation test
Itr- Testis
to detect large vaginal hydrocele
z Cotrrparu bdtl" tBstinles
O Number & site (maldescended 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
---+
c) Solid mass at the head
T.B. epididymitis lymphatic born.
---+
T.B. epididymitis blood born.
d) Cystic mass at the head --+ spermatocele or epididymal

e) The whole epididymis is firm & irregular
---+
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
a) Dilated veins : varicoceele

b) Matted: Filariasis.
c) Nodules (Beading of the vas) : T.B.

d) Localized firm ovoid swelling anteriorly -> bilharzial
e) Cyst: Encysted hydrocele of the cord.
Brnnlnotisrtshot ld. be bilatBml
VI- Dmirtirq LN.
)s.Para-aortic & iliac L.N. for testis & epididymis.
:s.Inguinal L.N. for scrotum.
17
WhiteKnightLove
mass.
I- l'Y Vaginal hydrocele :

Fo{lo,tr t}re geretolsoJ.p.mB
Irrspection (7S):
1) Solitary or
multiple : Usually solitary.
2) Site : purely scrotal (by scrotal neck test).
Scrotal neck test : (Considered inspection)Hold the neck of scrotum by your index and middle
fingers behind and the thumb infront and ask yourself is

the swelling
a. Completely above your fingers -- Inguinal.

b. Completely below your fingers
: Scrotal
c. Felt partly above and partly below your fingers
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
g?rrrlrolsohc,rne wtth t},a
fo,tlurirg
ddfem,noes
1) Temperature & tenderness : as before.
2) Confirmation of inspection : as before.
3) Edge : well defined.

4) Consistency : bipolar fluctuation test.
Hold & fix the upper pole of the hydrocele with the thumb & index
of your left hands & press on the lower pole by the thumh & index
of the other hand in 2 perpendicular directions. You will
fluctuation in the upper pole.
5)NoMorR.
6) Draining lymph nodes are iliac & para-aortic.
Dort fotget W omqlptp.tl..e ful[ sorotal r.lr,aminotlur'

1. When you examined the hydrocele : You have already examined
the tunica.
2. Testis & epididymis are very difficult to be palpated because the

hydrocele fluid overlaps them.
3. Examine the cord & scrotum
as above.
r9
WhiteKnightLove
II- Varicocele :
Try
fo,tlot tlre gurrl,urlsoh^erne
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.
6) Skin overlying : Normal.
7) Special Gharacter : giving a thrill on cough
PatiPr.t
&
e.rnpties wlrlbtl:u.;
i. b,rrg dor.,ru
Palpation:
2) Gonfirmation of inspection : as before & you will feel the

dilated, elongated, tortuous veins like a "bag
of lvorms".
3) Ask the patient to lie flat in bed & elevate the scrotun OR to bow
The I "Y varieoeele wilt empty

4) No C, No R, No M.
Doat fi,tg* tD outrlrrlprEtte firll sorotal exr.minatiotr

L. Examine the tunica by pinching test for 2ry vaginal hydrocele.
2. Examine
the testis as above.
3. Examine the scrotum
as above.
4. Examine the epididymis as above.
N.B I * Examine the abdomen
to exclude 2ryvaricocele.
20
WhiteKnightLove
Q) WHY YOUR SWDLLING rS VARICOCELE
ru
Because
I feel dilated,
elongated
& tortuous veins like a "bag of worms".
Q) WHY YOUR VARICOCELE IS
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:
1. It occurs after the age of40 years.
2. lt
affects both sides equally.
3. It develops rapidly and enlarges in a few weeks.

4.ltdoes mt &.oPP*,
o,t"
b,r,g dounot f,tJlo soroturn is doxotp/.
21
WhiteKnightLove
Epididymal cysts and spermatccele
I-
Dptid,id,ymal egsts
ETIOLOGY
A
A
..
Epididymal cysts are of obscure etiology.

They are degeneratiye cysts of the vestigial embroyonal
remnants (Remnant of ntesorteplwic
tubules).
t Paradidymis.
* Appendix of the epididymis.
PATHOLOGY
They are multi-locular
& filled with crystal clear fluid.
CLINICAL PICTURE
CiO :
Painless swelling of the scrotum.
otE :
* Site :
Purely scrotal lying just above and behind the testis.
* Size.' variable.
* Shape & Surface
Multi-locular & feel like a tiny bunch
of
grapes.
x Special character
septae
: Brilliantly translucent
with numerous
& tessellated givingthe Chinese lantern appearance.
Edse: Well defined.
x Consistencv: Cystic.
D.D
1. Spermatocele.
2. Encysted hydrocele of the cord.
A The main difference from encysted hydrocele of the cord

is that there is NO gap between it
& the testis.
22
WhiteKnightLove
3. Vaginal hydrocele
A 1ltre main difference from a vaginal hydrocele is that the

testis is palpable.
TREATMENT
Most epididymal cysts deserve no treatment.
A Excision if causing discomfort but the patient must be warned

that excision may interfere with the export of sperms from the
testes on the affected side.
If-
Spermatoeele
ETIOLOGY
V ft is a retention cyst derived

PATNOLOGY
from the tubules of the vasa efferentia.
V ft is unilocular and contains spermatozoa which make the

fluid resembles barley water in appearance.
CLINICAL PICTURE
c/o:
v
v
The patient complains of a painless small scrotal swelling, Dzl
It
is sometimes very large
third
1.
TTT
V
V
testis.
: As epididymal
OIE
& the patient thinks that he has a
cyst but
It is dimly translucent
2.
It
is unilocular.
Small spermatocele
: Can be ignored.
Large spermatocele :
* Excision
if causing discomfort but the patient must be
warned that excision may interfere with the export of

sperms from the testes on the affected side.
23
WhiteKnightLove
A) Encysted hydrocele of the cord
ETIOTOGY
H Due to persistence of the intermediate part of the processus vaginalis.

H Although congenital, it usually appears in childhood because
fluid takes time to accumulate.
CTINICAL PICTURE
C/O :
Painless swelling in the scrotal part of the spermatic cord.
otE :
* Site :
Scrotal part of the spermatic cord.
Size: Small.
x Shupe : Oval in shape
Surface:
with its long axis is along the axis of the cord.
Smooth.
* Special choracter :
H It can be moved from side to side but not from above

downwards.
H With gentle traction
on the testis, it is pulled downwards and
becomes fixed.
* Edge t Well defined.
* Consistencv
D.D :
H
Tense
* Translucent.
cystic.
Epididymal cysts & spermatocele.
The main difference from epididymal cysts & spermatocele is
that there is GAP between it & the testis.
TREATMENT : Excision through an inguinal incision.

ll.B: llydrocGlc 0f me Ganal oI lluclr is similart0 Gncysteril
hydrocele 0f tltc c0rd
t mat occuls in females and thG Gyst lics
in relation t0 tne ruund ligament 0I the ulerus.
24
WhiteKnightLove
Hernia
Personal histo{y z As general sheet *
a. Occupation
* Jobs with straining or carrying heavy objects
b. Special habits
Chronic smoking
Cornplaint : Swelling ( in an anatomical
hernia.
chronic cough.
site of hernias ).
Present history:
1. Analysis of the complaint ( Onset course, duration ).
order.
2. History of the disease in chronic
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.
O ODstruction.' (colics, distention, vomiting, constipation).

@
Strangulation.' Tense, Tender
manifestations of
intestinal obstruction.
25
WhiteKnightLove
Sliding bladder.' Double micturation, desire to micturate on

pressing upon the hernia, irreducibte.
: 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.
Hernias are common in

obese persons.
'
Facies : Denoting C.O.P.D
Usually Normal
( Puffy eye lids, congested

face
with cyanotic tinge ).
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.
Scars of previous operations.
PIR: For prostatic

enlargement.
Malgaigne'sbulgings.
26
WhiteKnightLove
7- Upper Umb
8- Lower Limb
Usually Normal
Varicose veins.
Flat foot.
Local Exarnination of Eroin Hernia

E><posure :
Position
From the umbilicus to mid-thigh
* Standing up during inspection.

* Lying supine during the most of palpation.
Fo{lo{^, thw g?rraralsol..p,rrtp
Inspeclion (ZS) :
1) Solitary or multiple : Usually solitary (may be bilateral).
2) Site : by scrotal neck test.
O OIH is inguinal or inguinoscrotal.

O DIH is inguinal.
3) Size : Variable.
4) Shape : oval or oblong in OIH, hemispherical in DIH.

6) Skin overlying : Normal (redness indicates strangulation & scar of
previous operation indicates recurrent hernia)
7) Special Character : Giving expansile impulse on cough.
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.

21
WhiteKnightLove
4) Gonsistency & Mobility
Try to reduce the hernia, or let the patient to reduce
difficult & Notice the direction of reduction
it if reduction
is
llpwards, borlr^,ards E latprafu ilr OI++

Banlr,tards in DI++
hrcfi^r;hle d ollmplinntet ot femoml hrein;rWhen you reduce the contents, try to differentiate between the
contents, either it is intestine or omentum
Intestine
0mentum
Consistency
Soft
Doughy
Gurgling on reduction
0ccurs
No
First part more difficult
Last part more difficult
May he resonant
Dull
Ease
of reduction
Percussion
5) No R.
IWy
swelling is hernia
beeanrse
it is red,ucible &
giaes
exprcnwile imgtulse on cough,
Asb gourself 3 qrrcstiorts in a groin jrp*nia?

1) Relation of the origin of hernia to the
pubic tubercle
If ahove and medial = inguinal

b. If below and lateral = femoral
a.
28
WhiteKnightLove
l!
2)lf inguinal, is it direct
or oblique
(l lrrterr-t tirrg test :

B Let the patient lies down.
B Reduce the hernia.
E Occlude the internal ring by the thumb of opposite hand (internal ring is
Yzinch above the mid point of inguinal ligament).
Then ask the patient TO STAND UP and cough
O If hernia descends : direct hernia.

O If hernia descends after release of thumb : indirect
hernia.
b. rtprnal. rtng test :
E Let the patient lies down & reduce the hernia.

E Introduce the little finger into the inguinal through external ring and ask
the patient to cough.
29
WhiteKnightLove
E
l4J
If impulse
B If impulse
-EL
l4l
is
felt at the
is felt at the
tip:
indirect hernia.
side: direct hernia.
This test is not done because
a. Not a verlr sensitive test.

b. Painful.
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.
N.B': Urhat ,sziunor,J. 3 fi"gerc test i

b. The patient lies down then the hernia is reduced,
)s. 3
fingers are put as follows
* One on the internal ring ( indirect hernia ),

* One on the external ring ( direct )
* And the third over the saphenous opening ( femoral hernia
).
The patient is asked to cough and you will see which finger receives the
impulse first.
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
is commonly seen in old patients
with week musculature.
It indicates that the patient will develop direct hernia.
2-The internal rin$:

* Is situated
Yz
inch ( one finger ) above the midpoint of the inguinal
ligament ( measured from ASIS to the pubic tubercle which can be

reached by following the adductor longus tendon ).
3. Tfre external ring

* Is situatedYz inch above and medial to the pubic tubercle.
31
WhiteKnightLove
Darau mlrilical tlernia

fo{lo{n t}.e- gurProlso,l p,rrrp
Irrspection (ZS) =
1) Solitary or multiple : Usually solitary.
2) Site
O More common
above the umbilicus because linea alba is thinner
and wider above umbilicus than below.
3) Size : Variable.
4) Shape : usually hemispherical.
5) Surface : Smooth or lobular due to.
@ Multiple defects in linea alba.
O Adhesions between the omentum &
the fundus of the sac.
6) Skin overlying : Normal (redness indicates strangulation & scar of

previous operation indicates recurrent hernia)
7) Special Gharacter : Giving expansile impulse on cough.
Palpation 3 TECRM-D
LPt ilrr- pofiP
tln u.be/
Fo{toil tllu- gr*rprolsohprnp wtt}" tl
"e
fo{tor"tng ddfercrtoes

4) Consistency & Mobility
Try to reduce the hernia, or Iet the patient to reduce

diff icult.
32
WhiteKnightLove
it if reduction is
When you reduce the contents, try to differentiate hetween the
contents, either it is intestine or omentum.
?Ull is usuall4 po*;alla ine&rtlo
darets Prcsenoe
# adhesioas
betreen
tlu- oru,nfum9 tl"Efirndrrs of tts sag or beJr;erzntlro eontp,nts ilseH,

5) No R.
a) Don't forget to examine if there is divarication of the recti.
b) Don't forget to feel the defect if the hernia was reducible.
A Whether the defect
is sharp or
not.
A To measure its width by finders.
Epigastric flernia &

Fatty lrernia of the linea allra
l-
DattE hernia of the linea ulbo- :

H
The hernia starts as a protrusion of the extraperitoneal fat
through a defect in the supraumbilical part of the linea alba.
2- True epigastrie hernia :

H As the protrusion enlarges
the extraperitoneal fat pulls a small peritoneal
sac through the defect which may contain intestine or omentum.

ll.B : The
ilefect in the linea al[a is lrnown as fo]amine 0I tgres
thruugh which [alamedian uessels and ne]res pass.
N.B. : Examination of epigastric hernia or incisional hernia is typical of

PU H.
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
O Neck swelling usually in SMNG.
O Symptoms of thyrotoxicosis usually in toxic goitre.
PRESENT TIISTORY
1- Analysis of C/O : onset, course, duration.
2- Ask about all symptoms of hyperthyroidism
a) Palpitation.
b) Nervousness, anxiety, insomnia & tremors.
c) Loss of weight in spite of good
appetite.
d) Exophthalmos.
e) Swelling in the neck if it was nol the main complaint
as
in cases of
toxic goiter.
3- Ask about symptoms of malignant goitre (pressure symptoms)

a) Dyspnea.
b) Hoarseness of voice.
c) Dysphagiu
4- Dontt forget to osk about diaruhea.
5- Ask about symptoms of hypothyroidism:

*
Apathy.
* Tendency to sleep.
* Intolerance to cold ...
etc.
6- Previous investigations and treatment.
34
WhiteKnightLove
PAST ITISTORY : As general sheet *

b. Drug intake.
c.
Past history of neck irradiation (precancerous).
Fr4lMItY HISTORY
O Medullary carcinoma (familial MEN syndrome).
O Endemic goitre (environmental conditions).
Eeneral Exarninatirrrr
A. ln SMNG ) Normal
Don't forget to examine the scalp for metastases of
B. ln toxic
FTG
goiter: There are some findings
Stafl by lhe D0dy bUilt: under weight in toxic goitre.
II) Ihe
0o to tne fianfl & looli
lor:
a) Tremors (done when
eyes are closed).
b) Palms : Moist & warm in toxic goitre.
c) Clubbing
d) Pulse
of fingers.
Rste : Tachycardia with a sleeping pulse more than 90 beats/min
Pulse rate is always increased to 100-120 beats/min.
In severs cases it may reach 140-160

>* Character : Big pulse volume (water
- hummer
character).
Rhvthm : All types of arrhythmia except heart block & V.F.
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).
Wide pulse pressure.
35
WhiteKnightLove
III)Then 0o to tne eye & looli
a) Exophthalmos
v Types
lor:
i- Alrytarent (tnild = false) exophrtalrnos :

* It consists of widening of the palpebral fissure due to
Muller's
spasm of
muscle without any butging of the eyes.
* Present with both diffuse & nodular toxic goiters
iii- Trtte exophthalrnos : In Graves'disease only

True Exophthalmos ( proptosis ) is also an autoimmune disease due to
antigen-antibody inflammatory process in the retrobulbar tissue
leading to infiltration with inflammatory round cells & accumulation of
inflammatory fluids.
Definition : It
is actual protrusion of the eyeballs
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
ls nppneENr oR rnur by:
exophthalmos
i.llormallytne utrlcl
cyc lid Gouers
l/6
True
of the
exophthalmos
Gotneawhilc lhe loure]

eye lirl toucnes thc cornca
False & True
attne Iim[us.
exophthalmos
ii."llaffiigef s" metho il :

O The examiner stands behind the patient, with the head tilted backwards
& holding the head by both hands.

O Observe the eyeballs by looking from above, taking the supra & infra
orbital ridges
as
your plane of vision.
g In true exophthalmos
the eye balls protrude beyond this plane.
,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
orbital margins without touching the cornea.
g In true exophthalmos,
u.
the cornea bulges beyond this plane.
Meas[le Ine dcg]ee of []omosis:
O The distance between the lateral orbital margin and the apex of cornea
is measured in millimeters and is normally 15-17 mm.
O Measurement can be made by simple ruler, or exophthalmometer
."-:,.'''
Joffroy's sign
b) Certain eye signs
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
O Lagging of the upper eye lid when the patient is asked

look gradually down without moving the head.
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
O Lack of corrugation of the;[orehead when looking up without moving

the head.
6. Moebius'
s.iHn:
O Lack of convergence when looking to near object (due to muscular

paresis).
IV)
Ihen go to lfte le0 & loolr lor: preti[ial myxdema
v) Ihen
examine tlle nefl0u|0-endothelial system &
loo[ [or :
* Just palpable spleen & generalized lymphadenopathy.

VI)
finatly 0o to tne heart & Ioolt lot
Accentuation of heart sounds.
O Functional soft systolic murmur maximum over pulmonary & aortic

aYEA.
Local Exarninatirrn
* Position.' Semi-sitting with the neck extended during inspection and
slightly flexed during palpation.

* Exposure : From the top of the head to the mid chest.
Fo{lor., tlrr- g?rranlsoJ,ernp
Inspecfon (ZS) : frorn infront of the pafient

1) Solitary or
multiple : Usually solitary.
2) Site : lower part of the front of the neck.

3) Size : Variable.
4) Shape : butterfly in Graves' & irregular or butterfly in nodular goitre.
5) Surface : Smooth in Graves' & nodular in nodular goitre.
6) Skin overlying : Usually normal.
O Look for dilated veins on the chest

O Scar of previous operation
-,
--+
Retrosternal extension.
Recurrent goitre.
39
WhiteKnightLove
7) Special Gharacter : Moves up & down with deglutition.

Don't forget to protrude the tongue as it may be a thyroglossal cyst
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
l) Temperature & tenderness (& thrill in Graves').

2) Coffirmation of inspeetion, E, C, M :
H Put the2 thumbs
at the nape & use the fingers of both hands to
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.
b) During deglutition feel the lower edge of the swelling to exclude

retrosternal extension.
c) Feel the surface : Smooth in Graves' & nodular in nodular goitre.

d)
It
is
Consistencv
firm or fleshy in nodular goitre & soft in Graves'.
difficult to fix the swelling,
so we can't do
40
WhiteKnightLove
fluctuation test.
B) Belation to srrrroundings :
(a) Skin
O Pinching or sliding test (to ensure absence of skin fixation).

(b) Sternomastoid muscle
I. Superficial or deep to the muscle :

I
The swelling gets smaller on contraction of the muscles by flexion the

head against resistance.
2. Fixed to the muscle or not :

O Tilt the neck to the same side and try to pingh the muscle awaylrom
the swelling.
O If you can't pinch it --r The gland is attached to the muscle.

O If you can pinch the muscle
---+
The gland is not attached to the
muscle & to be sure let him swallow to exclude sternomastoid
tugging sign.
N.B
Sternomastoid tugging is an early sign of malignancy.
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.
(c) Garotid artery
O Normally pulsations can be felt at the anterior border of sternomastoid

at the level of the cricoid cartilage against the carotid tubercle
(transverse process C6 vertebra).
o If it is not felt -, it is either displaced or infiltrated.

O Try to feel it along the posterior border or try to feel the superficial
temporal artery -+ If felt
---+
displaced only
4l
WhiteKnightLove
Berry's sign
Absent pulsations on one side in presence of

malignancy due to infiltration of carotid sheath.
(d) Trachea: Go to the
l.
Shifted or not
front
O Determine tracheal displacement by insinuating the index tip in

the sides of trachea in the suprasternal notch.
O Normally : there are2 equal distances as the trachea is central.
A wider distance denotes pushed trachea to the other side.
Tracheal displacement can also be elicited by tracing the
tracheal rings from the larynx downwards.
2. The goitre is fixed to the trachea or not:

i. Rocking movement:
O Fix the trachea by hyperextending the neck.
O Normally the thyroid gland swelling can be moved vertically
along the trachea
N.B : Loss of rocking movement is an early sign of malignancy.
ii. Ask the patient to swallow
The gland will move upwards.
Then put your hand at the lower border of the gland during descent.
I
ro
lF the gland is fixed to the trachea, the lower border of the
gland will try to descend against the power of your hand
3. Kocher's test
O To elicit tracheal obstruction by goiter.
O Slight compression on the lateral thyroid lobes produces stridor.

It indicates tracheomalachia or retrosternal extension
42
WhiteKnightLove
4) Draining L.Ns
O Upper & lower deep cervical.

O Pre-tracheal & pre-laryngeal.
Percussion :
O Direct over manubrium or the sternoclavicular joint.
O Dullness in cases of retrosternal extension.
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.
N.B- : Lahey's rnethod for thyroid exrnaninatiion :
m Done from infront the patient.

ru Push the thyroid gland to one side (while tilling the head to this side)
and palpates the lobe of this side, then repeat for the other lobe.
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.
There are B antutomieal oarieties

lll Su[sternal goitre: rts lower border
t2t PlunginU
U0itte: The goiter
can be felt during deglutition.
is totally intrathoracic but
it can be forced
up to the neck by increase intrathoracic pressure

l3I
lntmil0lacic: Very rare due to enlarged ectopic thyroid
tissue
in
the
thorax and it gets its blood supply from the mediastinal

vessels.
N.B : Factors helping downwards extension of an enlarged normally

placed thyroid gland
1. Pretracheal muscles preventing forward extension of the gland
(common in males due to short neck and strong pretracheal

m
uscles)
2. Negative intrathoracic pressure.
CLINICAL PICTORE:
Sqrnptoms :
1. Mediastinal syndrome : commonest presentation :
3 Dvspnea
which is worse at night aggravated by lying
down so the patient prefers to spend the night on a chair.
Dvsphagiu : less common than dyspnea.
2. Toxic
& malignant goiters
present with their appropriate symptoms
in addition to the mediastinal syndrome.
44
WhiteKnightLove
Sioros :
ll I lnsmction:
a. The lower border of the cervical goitre is not seen.
b. Dilated veins infront of the manubrium sterni due compression on the
innominate vein.
c. Edema of the face best noticed in the eve
d. Special tests
lids.
"i=
Tilting the head to one side causes face flushing
& dyspnea.
Raising the arms up until they touch the ears
& keep them for a while
causes face flushing
& dyspnea (Pemberton's sipn).

[2] PalUati0n : During deglutition the lower border of the cervical goitre can be
felt in substernal type.

[3] PgfCUSSiOn : * Dullness over the manubrium sterni or sterno-clavicular
joint.
Itrrr,estiqo,tions :
1. X-Ray chest : Soft tissue swelling occupies the mediastinum
&
deviates the column of air in the trachea.
2. Thyroid scan : reveals the nature of the space occupying lesion.

3. C.T scan chest : reveals the exact level of extension.
TREATMENT : Always o[Glaliuc t lhyroideclomy accolding t0 its Eathology I .

fhe retrosternal [oflion
finger mo[ilization
N.B.:
&
Gan
[e deliueled [y
stc]notomy is tarely needed.
How to prepare a cose of Toxic retrosternal Goitre
Antithyroid drugs are contraindicated; so : B-blocker (lnderal)
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.
Patients from rural areas have endemic parotitis.
eOMPtr4lINT :
* Swelling infront and below the ear.
* or swelling at the side of face.
PRESENT TiISTORY
1. Analysis
of CIO = Onset, course, duration.
2. History in chronological order.

3. Pain
* 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.
7. Complications z * Facial palsy.

46
WhiteKnightLove
il.B:
a.
Ghange in size of the swelling in relation to meals or

sour juice
b.
chronic calcular sialadenitis.
Acute exacerbation and constitutional manifestations
)
c.
acute sialadenitis.
0ccupation which requires chronic
f intra-oral
pressure (glass hlowing, trumpet players
bilateral
sialectasis.
d.
Painless unilateral parotid swelling slowly growing
without complications
e.
pleomorphic adenoma.
Rapidly growing swelling with facial palsy, pain

referred to the ear
malignancy.
PAST IIISTORY & FAMITY IIISTORY
As general sheet.
(1) General look : Usually normal
except
if
* Malignancy ) cachexia.
* Acute sialadenitis ) toxic flushed facies.
(2) Vital sings : Pulse, Temp.,
B.P, Resp. rate.
(3) Head : Local examination.

(a) Neck : Upper deep cervical LN enlargement for metastases.
(5) Chest : For lung metastases in malignancy.
(6) Abdomen : HSM is a common association with bilateral
endemic parotitis (residence of rural areas).
(7) Upper & lower limbs I ( rheumatoid arthritis may be associated

with salivary gland enlargement) Sjogren's disease.
47
WhiteKnightLove
Local Exarnination of Parotid

Fo{lou t}u- gurrlrolsoJ,srrre
Inspecfion (ZS)
1) Solitary or multiple : Usually solitary.

2) Site : Parotid region (the region overlapping the mandible & the
upper part of sternomastoid muscle).
3) Size : Variable.
4) Shape : Variable (oval, irregular).

5) Surface : Smooth (in benign lesions or nodular in
malignant lesions).
6) Skin overlying : Usually normal.
O Redness -+ Acute parotitis.
O Scar of previous operation
---+
Recurrent parotid
mass.
7) Special character : Parotid swelling raises the ear lobule.
Palpation:
TECRM-D
Fo{lon tha get plmlsohst rz wttl" tho foiluriryg dftrpr,oes

3) Edge : well defined or ill defined.
4) Gonsistency : fluctuation test.
5) Mobility : as before.
6) Relation to surroundings
(a) Skio t
O Pinching or sliding test (to ensure absence of skin fixation).
48
WhiteKnightLove
(b) Masseter rmrscle :

I.
Superficial or deep to the muscle :
O The swelling gets more prorninent on contraction of the

muscle by asking the patient to clench his teeth
2. Fixed to the muscle or not :

O Ask the patient to clench his teeth and try to move the
parotid over it to ensure non infiltration.
(c) Superftcial ternporal artery:

* Examine its pulsations infront of the ear tragus ogainst the
zvgomatic arch.
*A malignant parotid swelling may obliterate the superficial

temporal pulse.
(d) Facial nerrre z Testfor manifestations offacial
nerve palsy.
1. Asl< the patient to raise his eye brows (frontalis muscle).

2. Asl< the patient to close his eye lids firmly (orbicularis occuli).
3.
Asl<
the patient to blow his cheek (buccinator).
4. Ask the patient to show his teeth & see whether there is
deviation of the angle of mouth or not.
5. Ash the patient to whistle (orbicularis oris).
(e) IUandible :
O Try to move the swelling over the mandibular ramus from
side to side make sure that the swelling is not fixed.
7) Draining lymph nodes are preauricular, upper & lower
cervical L.Ns
49
WhiteKnightLove
N.B : Don't forget to
1) Inspect the opening of the duct inside the oral cavity for
stones, inflammation, 0r pus coming from the duct.
Qaroti[
fuct
Operu in tfic vestiSule of moutfr o2rpoite

tfre tqrper
mofar tootL
2) Examine the pharynx to detect dumbbell tumours (arising
from deep lobe) that push the tonsil medially.

3) Try to palpate the parotid duct.
Sarotil [uct
* The parotid duct can be rolled against the anterior

border of the masseter in the middle Ll3 of a line
drawn between the tragus of the ear and a point
midway between the angle of mouth and the ala nasi.
Su6man[i6u[ar
gfanf:
l. Gan'[ [e lolled ouG]thc mandi[ula] ramrs rnlike su[mandi[ular
L]1.
felt by bimanual examination unlike

the submandibular L.N. which can't be felt from inside
2. The gland can be
the oral cavity.
50
WhiteKnightLove
3.Iry to mlmte Jacial ailely along anterior [order of masseter muscle

agatnsl tfie nmas of tfie manilihle.
4. Su6man[i6u[ar
fuct ) f foor of moutfr on tfrc si[es of tongut
fernufum
D-D of swelli4is in the parotid regiion :

a. From skin &
tissue
S.C
Abscess
* Lipoma.
Sebaceous cyst
* Haematoma.
b. Parotid LN :
V
V
Acute and chronic lymphadenit

Lymphoma.
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.
V Hypertrophy of the muscle.

e. From the mandible :
V Tempro-mandibular arthritis.
V Adamantinoma.
V Sarcoma or osteoclastoma.
V Osteomyleitis.
5l
WhiteKnightLove
sialadenitis.
D-D of swellings of the subrnandibular regiion :

a. From skin & S.C tissue :
* Abscess. * Sebaceous cyst
*
Lipoma
Haematoma
b. Submandibular LN .'
Acute and chronic lymphadenitis.

Lymphoma.
c. Submandibular gland
Inflammations
'A
Tumours
acute and chronic sialadenitis.
benign and malignant
d. From the mandible
/A Dental or dentigerous cyst.
Adamantinoma.
Sarcoma or osteoclastoma.
Osteomyleitis.
52
WhiteKnightLove
The Breast
PERSONAt HISTORY
As general sheet
* stressing
on
- Menstrual history.
- Contraceptive pill using.

- Marital status.
COMPLAINT
Painful or painless lump in the breast.
PRESENT TIISTORY
1. Analysis of C/O : (onset, course, duration).
2. History of the disease in chronological order.

3. Pain : (analysis as usual)
Mastitis
Sarcoma.
4. Trauma : ( relation to the onset of the disease).
5. Fever : lactational mastitis or mastitis carcinomatosa.

6. Symptoms suggestive of metastases
UL
oedema, pain, weakness, axillary swellings.
Chest
I)vspnea & haemoptysis.
Abdomen
Bone
jaundice, ascites, hepatomegatly.
Bone aches
& pathological fractures

8. Other swellings : Axillary metastases or bony swellings.
PAST HISTORY
: As general sheet +
(a) Past history of any breast problems.
(b) Past history of any gynecological problem.
FAMILY TIISTORY : Similar
condition in the near relatives.
53
WhiteKnightLove
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
cyanosis (mediastinal syndrome from internal
mammary LN).
4. Neck:
"
* Congested neck veins from mediastinal syndrome
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
Oedema (axillary metastases).
Dilated veins.
Axillary swelling (LNs).
B. Lower Limb :
* Pathological fracture.
Oedema from liver metastases & hypoproteinemia.
9. Back : fender s[ine fiom ue]tcDlal mctastasis.
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).
Position : (2 positions) : * Semi-sitting with the back supported

(during inspection).
* Lying down with the arm abducted
(during palpation).
INSPECTION
Breast
Areola
Nipple
Mass ( if visible)
l- Breas t, c)*p::':rrr
Breasts concerning
* Site : elevated or at a lower level.

* Size.'shrunken or enlarged.
x Shape
: normal or distorted.
* Skin manifeststions :
x
See
text notes.
Mobilitv:
[!!
Lst< the patient to bend forward and note the degree
of protrusion of the breasts or change in the level.
55
WhiteKnightLove
E ast the patient to raise her arms up, so that any

deformity, lumps, or dimpling becomes obvious.
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
Depression: Retraction : congenital or recent.
Discharge : Type and colour (unilateral or bilateral).
* Dermatitis: Fissure, erosion... etc.

x Discoloration.
* Destruction : As in Paget's disease.
4-Mass:
7S
5. Axilla : For visible enlarged lymph nodes or related UL. Edema.
PATPATION: For the breast, the mass & the axillary L.N.
1. Breast
Palpate both breasts, starting with the normal one.

Palpate quadrant by quadrant.
Palpate by flat of the hand (palmer aspect of the fingers) and
with your finger tips for fibroadenosis.

56
WhiteKnightLove
2. Mass
: Confirmation of inspection + TECRM - D
The cystic consistency of breast musses can be detected only by

Pagetts test because most masses are deeply situated and
fluctuotion is not effective as the breast tissue is itselffluctuunt
Thc ftey
[0int in [rcast mass Gxamination is tne lclation t0 su]lorndings
(a) skin t
* Pinching or sliding test (to ensure absence of skin fixation).
(b) Muscles:
1) Pectoralis major:
* Fixity to the pectoralis major muscle and fascia can be

determined by comparing the range of movements of the
swelling before and after contraction of the muscle by asking
the patient to press hardly by her hands against her waist.
* If mobility is lost
alz
Mass is attached to the muscle
57
WhiteKnightLove
If
only limitation of movements and not complete loss

.1,
Mass is attached only to pectoralfascia above the muscle.
2) Serratus ant. (in lower lateral quadrant tumours).
* Fixity to the serratus anterior muscle can be determined

by moving the swelling before and after contraction
of the muscle, by asking the patient to press hard
against the shoulders of examining doctor.
(c) Breat fissue :

* By holding the breast with one hand and trying to move
the mass with the other hand within the breast fat.
(d) Nipple :
x Hold nipple by one hand and move the mass away
by the other hand.
"flfi.f'kry
b*pfi
nofes
1- Anterior (pectoral) group
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
V Direct the palm toward
the chest wall
{7 The L.Ns are rolled asainst the chest wall.
3- Apical group
V Let the patient raises her hand.

{? Put the fingers high up in the axilla.
Ttre other hand fingers press the infraclavicular fossa.
\_.,1
-
\_
4- Lateral (humeral) group
The fingers of the 2 hands directed laterally against the surgical

neck of humerus, while the thumb of both hand are over the deltoid
muscle.
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WhiteKnightLove
5- Posterior (subscapular) group
V Stand behind the patient.

V Palm of the hand in the axilla is directed baclrward to toward
subscapularis muscle.
V ttre other hand may support the scapula from behind.

V Ttre L.Ns are rolled against the posterior axillarv fold
6. Supra-clavicular group
* Felt above the mid clavicular point from behind.
60
WhiteKnightLove
Uaricose Ueins
Historg
PERSONAT IIISTORY
: As general sheet
Stressing on
* Occupation : which necessitate prolonged standing.

* Marital status.' Varicose veins may develop during pregnancy or
after delivery from prolonged recumbency.
COMPLAINT
.
o
Cosmetic disfigurement of the limb.
Or complications (CVI).
PRESENT IIISTORY
1.
Analysis of the G/O : onset course, duration.

3. Symptoms of Chronic Venous lnsufficiency (CVl)
Early cases:
a) Postural discomfort & dull aching pain of the limb :
H Usually at the end of the day or on prolonged standing.

El Relieved by leg elevation.
b) L.L edema:
Usually at the end of the day or on prolonged standing.
c) Night muscular cramps.
lale & seuere cascs
a) Pigmentation, dermatitis,.itching &
eczema.
b) Lipo dermatosclerosis.
c)
Venous ulcer.
d)
Venous claudication during walking due to very high venous
pressare.
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WhiteKnightLove
4. Swellings :
* Saphena varix (soft, compressible swelling at the groin)
* A-V fistula.
6. Possible etiology
a. History suggestive of hernia, flat foot, varicocele, piles : (lry

varicose veins due to congenital mesenchymal weakness).
b. History of repeated pregnancy ) May be 1ry or Zry varicosities.
PAST IIISTORY
: As general sheet
stressing on
(a) Prolonged recumbency in bed, fever ( D.V.T ).
(b) Contraceptive pills, abortion, purpural sepsis ( D.V.T ).

(c) Pelvic or abdominal operations.
FAMILY TIISTORY
H Similar conditions (congenital
weak mesenchyme in 1o V.V).
1- General appearance
2- Vital signs
o
o
o
:
4- Neck :
3- Head
Usually normal.
Pulse : Branham's bradycardia sign if A-V fistula.
Blood pressure : hyperdynamic circulation in A-V fistula.

Temperature :
f if thrombophlebitis.
Cyanosis if associated H.F. due A-V fistula.

Congested neck veins in H.F due A-V fistula..
5- Abdomen
a. Visceroptosis.
b. Masses, scars of previous operation.
c. Dilated veins in flanks.

d. Abdominal hernias.
e. Scrotum ) varicocele.
WhiteKnightLove
f.
P/R
6- Upper Limb
Piles.
: Usually free.
Local exarnination
A The patient should be examined while STANDING
and
should be exposed up to the um-bilieus.
A Varicose veins appear as dilated, elongated tortuous

A MORPHOLOGIEAL PICTURE OF V.V :
1. Large vein varicosities
H Affecting
veins.
Retrcurar
sl
the LSV or SSV themselves or one of
their main tributa.ries.
H Large in diameter:
5-15 mm.
2. Reticular varicosities
H Lying immediately beneath the skin.

H 1-5 mm in diameter.
3. Spider varicosities "telangiectasia"
A one shoutd answer following questions.
varlrose vein
Deep Veirl
1. Are the varicosities primary or secondary ?
2. What
is the saphenous system affected
3. The competency of the sapheno-femoral junction ?

4. The competency of the perforators ?
5. The condition of the deep system
of veins ?
6. The presence of complications?
l) Are the varicosities prirnary rrr secondary

Ilistory : Of DVT, previous
leg injury, fracture or abdominal surgery.
lnspection:
Varicose veins may be arranged haphazardly incase of
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WhiteKnightLove
2ry
V.V.
@ Presence of complications as oedema, eczema, or ulceration is in
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.
2) What is the saphenous systern affected ?

tnspection : By the site & anatomical distribution of the varicosities.
?ercussion f Tap tesl ) :
a.GhewieltGSt:
O With the patient
erect, place the fingers of the left hand at the
saphenous opening (or any vein above knee).
@ Percuss the main bunch of varicosities once with the right

middle finger.
O If
an upward wave of blood is perceived at the saphenous
opening, this indicates that these varicosities belong to the LSS.

b.Schulanz's Test:
The saphenous vein is percussed by the index of one hand
&
palpated distally by the fingers of the other hand.

@ Only if the valves are incompetent, the wave is transmitted distally.
@ Other opinion is that the impulse is transmitted along the vessel wall
& not the blood column.

3) The cornpetency of the sapheno-fernoral iunction ?
lnspection 3 Saphcna-uarix may be presGlrt.
@ Ttris is saccular dilatation of upper end of great saphenous vein
opposite incompetent sapheno-femoral valve.
O It forms bluish rounded or ovoid subcutaneous mass in upper part of

femoral triangle "4 cm below & lateral to pubic tubercle".
64
WhiteKnightLove
O rt is soft, cystic, compressible with expansible impulse and thrill
on
cough (D.D. femoral hernia and other swellings of femoral triangte)
?alpafion :
O Palpation of a thrill
over sapheno-femoral junction on cough denotes
an incompetent sapheno-femoral junction.
Special fests fTrendlenburg!'s testl :
Aim:
a. Detection of sapheno-femoral incompetence.
b. Detection of incompetence of communicating veins.
Method :
a. The patient
lies supine and raises his leg empty the veins.
b. A venous tourniquet is applied just below the SFJ.
c.
The patient is then asked stand up.
Results :
a. If No varicosities appear while the tourniquet is still in place )

Incompetent SFJ & competent perforators & when the tourniquet
is released
l00yo the veins will
OIt will fill from
fill rapidly from
below upward
above downwards.
b. If the veins fill rapidly while the tourniquet is still in place )
means
incompetent perforators ( in this case ONLY the multiple tourniquet

test is done to identify the site of the incompetent perforators).
The tou,rniquet is then rele,,sed. qfter

a- rf the sapheno-femoral valve is normal
lo
second,s.
the veins will
fill
slowly "minimum 10 seconds" from below upward (normal

venous fillinq).
65
WhiteKnightLove
If
the sapheno-femoral valve is incompetent
rapidly from below upward
the veins will
will fill from above downwards.
Special tests fltlorrisey couth impulse tesll :
@ The patient lies flat & elevate the limb for
O Ast
30o.
the patient to cough forcibly.
O If there is retrograde filling Incompetent
SFJ
4) The cornpetency of the perforators ?

a. Irlultiple tourniquef test :
Method .' Application of three tourniquets
O One just below the knee.

O The second at the junction of the lower third of the thigh
with the upper two thirds.
fill
The third tourniquet is just below the SFJ.
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WhiteKnightLove
The patient is then asked. to stund u,p
& the tourniquets
are released, one bg one from below ugnoard,.

Result:
O Rapid filling beyond any segment
indicates the site
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
& then moved in opposing directions to empty
a segment.
O lf this segment remains empty, it has no underlying blowout but if it fills, an underlying blow-out exists.
Whole vein is tested segment by segment from above down.
Ttris simple test is an alternative to multiple tourniquet test.
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.
Palpate the line of the marked varicosities carefully for gaps
in the deep fascia through which the perforating veins pass.
O They are felt as circular openings with sharp edges & are marked.
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WhiteKnightLove
5) The patency of the deep systern of veins ?

a. Uodified Perfhe's
test:
Method :
O While the patient
is standitrB, o tourniquet is applied
just below the
SFJ & the patient is asked to walk quickly in situ for five minutes.
Result :
O If V.V disappear i
deep system is patent
& competent (lry V.V. or
2'v V.Y. with canalized deep veins).
O If V.V become
more engorged
deep system is occluded or
incompetent (2ry V.V with uncanalized deep veins).

b. Perthe's Test :
llot done
as
it is sulbig@.
Method :
O Patient lies down,
his leg is raised
O Elastic bandage is applied from
&
massaged to empty the V.V.
toes to groin, to occlude superficial veins.
@ The patient then walks in situ for 10 min.
Result:
O If no pain I deep system is patent.

O If pain occurs ) deep system is occluded.
Jl.B. : Hoffman's modification of ltlodified ?erthe's
test:
If the patient is having incompetent perforators, modified
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.
6) tl{r" preserrce of cornplications
? rnore with 2'vV.V
a) Recurrent supedicial thrombophlebitis.

b) CVI with its complications.
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WhiteKnightLove
Peripheral erterial Disease

PERSONTIL IIISTORY : As general sheet * stressing on.
Marital status : Impotence with Leriche synfrome.
.
.
Special habits : Smoking in atherosclerosis and Burger's
disease.
OccuPation : Raynaud's phenomenon.
COMPLAINT
'
* Pain on walking or rest pain.
* Skin trophic changes or gangrene.
PRESENT TIISTORY
1- Analysis of CIO (onset, course, duration).
2- History of the disease in chronic order.
?rcss O Sez*tou Colryur f
ef Pain
Glaudicafion
adps,
[flin:
Character.
- Site.
- Severity (boyd's classification).
factors.
- Claudication time.
- Claudication distance.
- Aggravating factors.
- Relieving
- Period of rest.
* nest lrlin:
Character.
- Aggravating factors.
-
- Site.
- Relieving factors.
Bl Skin trophic chantfes :
hair.
- Dry scaly skin.
- Tapering digits.
- Brittle nails.
- Loss of
- Interdigital fungal infection.
- Muscle wasting.
- Ulceration.
Gl Goldness
Of the affected part (Temprature changes).
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WhiteKnightLove
Dl Golour changles :
* Pallor, cyanosis.
* Gangfgne
- Onset, course, duration.

- Relation to trauma (e.g. careless cutting of nails
or tight shoes).
- Site and extent.
El Funclional changes :
-
H0t0l diStuftances
* Weakness and wasting of the limb.
'SenSOry diStUftanGGS: * Paraesthesia (tingling and numbness).
* Hypo or hyperaesthsia.
'
'SGluat
3- Swelling
4- Trauma
distuftanGcs: * Impotence in Leriche syndrome.
For aneurysms.
: May be a precipitating factor for gangrene or ulceration.
5- Constitutiona! manifestations
: Septic gangrene & infection.

7- Possible aetiology : symptoms of other organs ischaemia; (for
atherosclerosis).
: Angina, infarction, chest pain.

Bruin : TIA (transient ischemic attacks)
Renal : Pain, haematuria, hypertension.
Heart
Intestine : Post prandial intestinal angina (colics), bloody diarrhea.
PAST IIISTORY
* Similar attacks.
* DM, hypertension, heart disease.
FAMITY HISTORY
'
* Similar condition.
* Atherosclerosis, Diabetes.
70
WhiteKnightLove
Eeneral Exarninatirrn
1. General Appearance & facies
* Agony: in rest pain.
* Toxic: Septic gangrene.

2. Vital signs
* Temperature : J if infection.
* B.P.' higher in arms than in thighs in aortic coartication.
x
Pube.' Irregular in heart troubles.
l?.1? .'
in congestive heart failure.
3, Head
* Pallor.
* Cyanosis.
4. Neck
H Congested neck veins : H.F.

H Cervical Rib.
H Scar of cervical sympathectomy.
H Auscultation over Common Carotid for a bruit which indicates
5. Chest & heart :
* Complete cardiac examination for coronary atherosclerosis
6. Abdominal
1) Epigastric pulsation of aortic aneurysm.
2) Scar of lumbar sympathectomy.

3)
Bruit for renal artery stenosis over the renal angle.
Body pulses are the most important aspect in general examination
7l
WhiteKnightLove
stenosis.
Local Exarnination
Both Limbs
P0Siti0n: Lying supine or semi-sitting.
Exmsure: Both upper and lower limbs.

2 by inspection, 2 hy palpation & 2-3 special tests
A-
INSPEETION
(1) Skin trophic changes

- Loss of
hair.
- Dry thin scaly
- Brittle nails.
skin.
- Interdigital fungal infection.
- Tapering digits due to loss of subcutaneous'fat.
- Calf muscle wasting.

- Ulceration.
* No : Single or multiple.
* Site: foot, big toe.
* Size and shape: Variable.

* Edge.' Punched out.
* Margin: Blackish or inflamed (ischaemic).
x
Floor: Granulation
tissue.
* Base: Firm, mobile.
(2) Colour changes
e
e
Pallor is due to decreased blood flow into the skin.

Cvanosis and rubor are due to stagnation of blood in the markedly dilated
capillaries under the effect of accumulated vasodilator metabolites.
The colour of blood is at first red but it later becomes blue due
extraction of oxygen by the tissues.
Rubor "rubber colour" is reversible as it increases with dependency &

disappears (foot becomes pale) with elevation.
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WhiteKnightLove
Fitced black colour of drV ganglene in severe cases.
. Extent: Big toe, fore foot, below knee ... etc..
. Type: Dry or moist
(septic or aseptic)
. Line of demarcation .' Band of hyperaemia
&
anaesthesia between living and dead
tissues (evident in dry gangrene).
. Line of seporotioru
: Dead tissues start to fatl off by non septic
ulceration, proximal to line of demarcation.
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
Ischaemic limb may be hot if :
Infection.
Sympathectomy.
Covered with blankets.
II- Arterial pulsadons :

UOlUme:
- weak pulse denotes arterial stenosis.
- Absent pulse denotes arterial obstruction.
Ihicfiening 0I a]telial wall

GOm[feSSiDle maSS:
Atheroscterosis.
With expansile pulsations, systolic thrill +
diminished distal pulse ) aneurysm.
N.B
The disappearing pulse
If distal pulsation (lil<e dorsalis pedis) is felt in an ischaemic limh.
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WhiteKnightLove
Let the patient to practice physical exercise (walking in situ)
till
claudication. The previously felt pulse will disappear due to pooling of

blood into the muscles
III- Function (rnotor power)
: Active &
passive movements.
IV-Palpate the veins :
For thrombophlebitis or V.V. in Burger's disease.
V- Sens<rry chan$es :
Touch, pain (compare both sides).
C- SPECIAL TESTS :
1. Test for the capillary circulation
H If one presses over the tip of the toe, it becomes pale.

H Once the pressure is released, the colour returns.
H Normal capillary refill is < 2 seconds.
H In an ischaemic limb the return of colour is slow and is
called sluggish capillary circulation.
H If > 30 seconds I
H If there is failure
2. Buerger's angle
Advanced ischemia.
of blanching
Established gangrene.
H The patient lies supine and the limb is gradually elevated.

H The angle at which blanching of the toes occurs is called Buerger's angle.
H The smaller the angle at which blanching occurs, the more
severe the ischaemia is.
H If < 20o:
advanced ischaemia.
3. Harvey's venous refilling time & Guttering of veins
H With the patient
supine, the limb is elevated to right angle until
all veins empty.
H It is then brought down to the horizontal position

to lower the limb below the level of the bed".
74
WhiteKnightLove
"some prefer
H Normally
the veins
fill in 10-15 seconds, in chronic
ischaemia
venous refilling is delayed to above 30 seconds.
H If > 2 minutes :
advanced ischaemia.
Guttering of veins
H Veins of a normal foot are full when the patient
is lying horizontal
&
collapse when the foot is raised above the level of the heart.
H With severe chronic ischaemia, guttering of veins occurs with 1015o
limb elevation.
D- RUSCULTATION :
H Over femoral artery for a bruit which indicates
H Continuous machinery murmur in A-V fistula.
stenosis.
How to palpate different bodg pulses

Head and neck:
r.
Gommon carotid
* At the anterior border of sternomastoid at the level of the cricoid

cartilage against the
z. Suhclavian artery
urutid tulemleltransverse
process of C6 ).
* Above the middle of the clavicle against the first ril.
3. Superficial tempor?l
* Anterior to ear tragus against tlrc zggaaafu ard"
L. Supra-orhital and supratrochlear
* 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
* Felt against medial side of tqPu f /g oftlro lranuus.
2. Brachial artery
a-
Upper half : Against medial side of
sh& hamutsalong
the
medial border of biceps.
b- Lower half : Felt in cubital fossa medial to the bicipital

aponeurosis agahst
louu 1/9 of tAe furnsus.
3. Ulnar artery:
* Lateral to the tendon of flexor carpi ulnaris against louu
I/9
of ulna.
4. Radial artery
* Between radial styloid and tendon of flexor carpi radialis

against the
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
w*tebnc( Only in thin patients
2- Gommon iliac
6t& of lt nlat
).
* Along the upper Ll3 of a line from lower end of aorta to

mid inguinal point against tie supuiot Polb nanu:s.
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WhiteKnightLove
3- External iliac
* Along the lower 2/3 ofthe previous line against
tle lEuiot
polio ranus.
Lower Lirnb :
1. Gommon femoral
* Below mid inguinal point

against tlrc hcad of fent\ip
slightly
flexed, abducted and
externally rotated).
2. Superficial femoral
* Along upper
213
of a line from the mid inguinal point to the
adductor tubercle against
3. Poplit?l
shilt of{"mrt
[af Upper half
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
th) Ittiddle half:

O Turn the patient into prone position, hold the lower leg by
one hand
& flex the knee to feel the pulse in the orrtre
popttul
fossa-
77
WhiteKnightLove
of
fc) Lower half :
O Flex the knee 90'place the thumbs on tibial tubersoity &

the rest of the fingers over the lower part of popliteal fossa
to feel the pulse against ryPu
N.B : The cross leg test
endoftilia.
When a person sits with legs crossed, oscillatory movements of the
foot occur synchronously if the pulse of the popliteal artery is present.
4. Posterior tibial
* Just behind the medial malleolus against the mcdial
ulmnPfis.
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WhiteKnightLove
nalldus ot
5. Anterior tihial
* Midway between the2malleoli against tlre lou,u part oft'itA'
5. Dorsalis Pedis :
*Lateraltotheextensorhallucislongustendonagainst
tla naYaurlu bot'e'
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WhiteKnightLove
I.ymphadenopathy
PERSONAT IIISTORY
ffi
: General sheet
Age : T.B. more common in adults, lymphoma common in

elderly.
Residence : Filarial district.
EQ
Special habits : Alcoholism I pain in lymphoma.
COMPLAINT
: Swellings in the anatomical sites of L.N.
PRESENT NISTORY
1. Analysis of CIO Onset, course,

=
durution

3. Pain
* May precedes the appearance of L.N with
infla mmatory conditions.
4, Fever
* May occurs late in lymphoma and metastases.

* T.B. ( night fever
).
* Hodgkin's ( Pel-ebestein fever :2 weeks fever

)
alternating with 2 weeks free.
* lnfectious mononucleosis.
5. Complications & effect on general condition.

x Cervical: Dyspnea, dysphagia or hoarseness of voice.
* Mediastinsl: Dyspnea, dysphagia, cough or haemoptysis.
* Axillarv: Ischemia or edema of U.L.
x
fnguinal : Ischemia or edema of L.L.
Abdominal: Jaundice.
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WhiteKnightLove
PRST TIISTORY
Y Similar conditions.
Y Previous operations ( L.N. biopsy ).
FAMILY HISTORY : T.B. may affects members
of the same family.
l. General agrpearanee
* Facies : Toxic in acute conditions.

* Body built : under weight in T.B. and lymphomas.
* Cachexia : in lymphoma and malignancy.
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.
a. Congested veins (mediastinal
b. Jaundice, pallor, cyanosis.

c. Bleeding gums
sydrome).
b. Trachea : central or not.
Epistaxis.
c. Carotid pulse : not felt from
enlarged cervical LN.
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WhiteKnightLove
6.
5. Chest
a. Sternal and
b.
rib tenderness.
Abd,onten,
a. Hepato-splenomegaly.
(bone marrow affection)
b. Malignant ascites.
Lung: for consolidation.
c.
(T.B. or metastasis).
d. P/R: nodulas in doglous pouch.
c. Despine sign
e.
Back: vertebral
metastases.
Scrotum : for testicular tumou
f. Par-aortic LN enlargement.
7. Upper Limb
B.
Lawer Limb
a- Oedema.
a- Oedema.
b- Dilated veins.
b- Dilated veins.
c- Ischaemic manifestations.
c- Pulses (dorsalis pedis).
d- Rashes (infectious
d- Rashes.
E- Inguinal L.N.
mononucleosis).
e-
Axillary and epitrochlear LN.
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
the patient has generalized lvmphadenopathv, the
l't involved
group, or the largest or most symptomatising is examined by local

examination, while the other groups are examined by general
examination.
@
While examining the L.N, the areas drained by it shoutd be

exposed.
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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.
PALPATION : Confirmation of inspection + TECRM.
[onsistcncy:
) NHL or calcif,rcation.
2) Firm ) T.8., chronic lymphadenitis.
3) Cystic ) cold abscess.
l)
Hard
Edge:
Well defined
scattered or discrete LN.
D IA defined ) matted or amalgamated.
fielation to each others :
1) Separale
chronic lymphadenitis, metastases.
2) Matted or rosory beads
)
4) Rosette shape )
3) Amalgamated
\
\
TB.
Non Hodgkin's Lymphoma.
Hodgkin's lymphoma.
0ther swellings.
Relation to the surrounding structures.
IDon't
forqet to examine the draininq
Y Cervical LN )
Y Axillary LN )
Inguinal LN
(,,reo,s :
mouth, tongue, cheek, thyroid, sinuses.

breast, U.L., upper trunk
till umbilicus.
LL, sole of foot, external genitalia, anus.
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WhiteKnightLove
PERCUSSION
Esternum and vertebrae for tenderness in leukaemia.

T1USCULTATION
IDespi"ne's sigro
far
med,io,stfuio,l LN :
UBronchial breathing is osculated below the level of T4 at the back of

the patient.
How
to Palpate llifferent Eroups of L-N
l- Geruical llodes :
A- Vertical group :l. Suneilicial grou[
O External & anterior jugular LN. :

* Along the external & anterior jugular vein respectively.
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
Along the internal jugular vein.
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
tN & supraclavicular [N.
lugulo omohyoid node [elongs t0 tnis g10u[.
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WhiteKnightLove
B- Circular liroup :
@ Submental
LN.
@ Submandibular
LN.
O Parotid & pre-auricular LN.

O Post-auricular LN.
O Occipital LN.
X : ls the iugulo-digaslric LN.
lI- exillary lymph nodes

\
: Look breast.
III- Inguinal lymph nodes
A. The superficial inguinal LN : Are arranged like letter "T"

* The transverse limb lies below and parallel to the inguinal
ligament, while the vertical limb Iies along the upper part ofthe
long saphenous vein.
B. The deep
inguinal LN
* Are arranged vertically along the upper part of the femoral vein.
* Are difficult to be felt.
lU- ebdominal lymph nodes :
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WhiteKnightLove
A. The para-aortic LN
* Are deeply palpated in the midline of the

abdomen just above the umbilicus.
B. The
iliac LN :
* Can be deeply palpated in the iliac
fossa along the external iliac
pulses.
U- The epitrochlear
Lll
* Can be felt if enlarged on the medial border of the biceps just

above the elbow.
Irnportant Notes
1. The main causes of generalized lymphadenopathy are
* Lymphoma.
* Infectious mononucleosis.
* Blood borne T.B.

* Leukaemia.
2. The main causes of localized lymphadenopathy are

* Acute and chronic non specific infections.
* Chronic specific like fibrocaseous T.B.

* Metastases.
3. The commonest investigations for lymphadenopathy are
o. Blood picture :
* For leukaemia, lymphoma and infectious mononucleosis.
b. Chest X-Ray.' For T.B. and metastasis.
c.
Tuberculin test
Good
-ye test for T.B.
d. L.N. biopsy.' Most accurate.

e. Abdominal U.S :
* For splenomegaly and para-aortic nodes.
Sternal puncture : For bone marrow involvement.
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WhiteKnightLove
Tuberc ulous lymphodenitis

ETIOLOGY : There are two main pathological types :
6 The lymph borne type.
e The blood borne type.
A- Lyrnph-borne ( ftbr<rcaserrus ) type

This lype is common in young patients.
SITES
upper deep ceruical.
1. The common est
O The organisms reach them from the tonsils.
2. Mediastinal and the axillary groups are also affected.

3. Abdominal nodes are commonly affected from ingested milk
PATHOLOGY
The organisms reach the nodes by afferent lymphatics, thus ltrst

reaching the capsule and causing tuberculous periadenitis)
\
causes matting of the nodes.
The cortex will then be affected and finally the medulla.
COMPLIEATIONS
1. Caseation and cold
2.
]l.B
abscess formation which may burrow

through the deep fascia or an overlying muscle so that it
becomes bilocular and then called "collar stub abscess".
Secondary infection of the abscess.
cold alscess is aclually ncithe] cold n01an aDsoess,

@ lt is not cold because Glinicallu it is ulam, [ut is in tact Golilcl
than a [Uogenic a[scess.
o It is not an a[scess [ecause me Gontents ale not [us [ut
Gaseafing matclial.
:@
3. Sinus formation with a thin, cyanotic or bluish margin,

undermined edges and a thin serous discharge.
4. Spread to the other groups of lymph nodes may occur.
CLINICAL PICTURE : 1. Affected nodes are enlarged :
H Usually not tender nor warm.
H They are firm or elastic in consistency.
H fttaltpdtogerhpr.
H May be fluctuant due to breaking down.
An im[ortant diagnostic sign is feeling 0I [eadcd cords [etuleen
differcnt g10u[s 0[ n0des.I[ese Gofls ]e[rcsent thickened tu[erculous
lymRhatics.
2. Night sweat, nightfever, loss of weight
& appetite-
CLINIC,IL PICTURE OF COLD ABSCESS :

1. Soft, fluctuant swelling connected to the underlying caseating nodes.
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WhiteKnightLove
2. A cold abscess is slightly warm and slightly tender.

3. The overlying skin is at first normal, then it becomes dusky ( not
firy red and not oedematous as in an ordinary pyogenic abscess ).
4. The skin ultimately thins out before rupture, which ends in a sinus.
INVESTIGATIONS :
1. Chest X-ray.
2. Tuberculin test i Serves as a good negative indicator.

from the nodes : Will establish the diasnosis.
Central zone of eosinophilic necrosis containing T.B bacilli.
Midzone of Langhans giant cells & epitheloid cells.
Peripheral zone of small round cells.
4. Aspiration of a cold abscess or smears from a sinus
are examined by : * Culture on Lowenstein Jensen media.
* Ziehl-Nelson's stain. * Guinea pig inoculation.
TREATMENT :
I- Tubcrculous lynrphadenilis bef;ore casealion :
(l) At least two antituberculous drugs are prescribed for at least 9
months. A combination of rifampicin and INH is very efficient.
(2) Surgical excision is indicated for a single group of L.Ns showing
no response to medical treatment after a period of 6 months.
II- Cold abscess :
(1) Antiuberculous drugs.
(2) Aspiration and iniection of streptomycin solution.
The rules of aspiration of a cold abscess should be followed to
avoid sinus formation :
l. The nBedle is insGnGd in a healtlry [a]t 0f the slfin.
2. The sirr o[ puNC]uRE should br in A NoN deprr.rdrrrrr pARr.
3.The needle should also [ass in a ualuula]manlle].
4. lr.riecrioN of srREprovycir,r ar rhE end of nspinarion.
(3)Incision is indicated with 2ry infection transforming the
cold abscess into an acute pyogenic abscess.
lll- Trcalmcnl ol a tuberculous sinus :
(1) Antituberculous drugs.
(2) Dressing with streptomycin powder every three days.
(3) Excision with the underlying nodes, if resistant.
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.
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WhiteKnightLove
so
3. The organisms enter the nodes through the arterial supply in

4.
the hilum and so the main affection is central in the medulla

and periadenitis does not occur, and thus, there is no matting.
There is no caseation nor cold abscess formation.
CLINIEAL PIETURE :
@ Multiple groups of enlarged lymph nodes which are
* Not tender. * Not matted together.
* Rubbery in consistency. * Discrete.
e
e
No cold abscess or sinus is ever seen clinically in this type.

Muy be mistaken for Hodgkin's disease, hence the name
lymphadenoid type of tuberculosis.
INV : L.N biopsy TTT : Antituberculous drugs.
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
Giant cells are rare, but there are abundant lymphocytes

and histiocytes.
This type carries tl^e best prcgr,o61s.
B. Nodular sclerosis
A ttris
is the eomrnoaest tktD{ogbalwdotg.

Is characterized by the presence of broad fibrous bands
that disrupt the lymph node architecture.
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 ).
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WhiteKnightLove
* Or a solitary extralymphatic site with one or more lymph

node areas on the opposite side of the diaphragm ( IIIE ).
*
Stage IV : Diffuse or disseminated involvement of one or more
extralymphatic organs including liver, lung, bone marrow.
8 AA stuges are subdivided into either :
(A) No systemic symptoms.
(B) One or more of the three systemic symptoms :
* Fever. * Night sweats. * Weight loss of more than lUoh in six months.
CLINICAL PIETURE :
@ No age is exempt, yet the disease shows two age peaks, the first
is between 15 to 35 years, and the other is above 50 years.
c/o
1. The usual presentation is by painless progressive enlargement of

the cervical lymph nodes.
2. With progress of the disease other
node groups in the neck,

axillae, groin, mediastinum, and abdomen are affected.
bllows an orderlv anatomical
N.B : prosression of L.N e
3. Some patients exhibit systemic manifestations in the form of :
* Fever. * Night sweats.
* Weight loss. * Pruritus, anaemia, and jaundice.
4. Sometimes a characteristic intermittent fever which lasts for a few days
followed by a remission for few weeks occurs ( Pel-Ebstein fever ).
5. Immediate pain may occur in diseased areas after drinking
alcoholic beverages.
otE
1. These enlarged nodes are :

* Non-tender. * Rubbery in consistency.
* Discrete.
2.
Splenomegaly and hepatomegaly may also be present.
INVESTIGATIONS
1. Full blood picture : Usually shows no abnormality, but sometimes

* Anaemia. * Oesinophilia or lymphopenia. * High ESR.
2. Serum LDH is raised.
3. Alkaline phosphatase : Raised with bone or liver involvement.
4. Lymph node biopsy is the cornerstone of diagnosis :
S liltlorlr* do4 ryrtt'otLLNs are the preferred site of biopsy.
5. MRI & CT scan I detection of intra-thoracic & intra-abdominal L.Ns.
6. Staging Iaparotomy = The operation includes :
(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.
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WhiteKnightLove
(d)Bone marrow biopsy from the iliac crest.

(e) In females the ovaries and Fallopian tubes are fixed in the
middle line behind the uterus to guard them against
irradiation when treatins the iliac nodes.
lrrr nddirioN ro rkE benrrfir of sraqirrrq, nruova[ of rke spleer.r
obviarrs rhe r.rerd fon irs innndinrioru Rrud, krruce, spAREs rl-rr lrfr
kidnry nr.rd lur.rq rhe hnznnds of nndinriorrr i
The operation of staging laparotomy is dropping because of twofacts:
(a)The high accuracy of CT scan & availability of MRI.
(b)The risk of overwhelming post-splenectomy infection.
TREATMENT :
1. Stage IA, IB/ and IIA ) Treated by radiotherapy :
* Mantle technique : For Z.Ns above diaphragm.
x Inverted Y technique : For Z.Ns below diaphragm.
2. Stage IIB , radiotherapy and 6 cycles of combination chemotherapy.
III and M 12 cycles of chemotherapy & Radiothera
Ihe ffi0PP chemotncraru rcgimen was tne one in commofl usG:
+ Orcoviru (vincnisrirrrr ).
+ MusriruE.
* Pnrdnisolrs.
* Pnocqnbazinr.
llow tfie ABUII legimen is the one in Golnm0n usG :
* Adninruycir,r. * B[roruycin. * Vinblnsrir.r * Dncnnbnzine
Non-Hodgkin's Lymphomo (NHL)

ELASSINICATION :
1. B cell lymphoma ( 80-85% ) is further classi/ied into :
(a) Small cell lymphoma.
(b) Large cell lymphoma.
(c) Mixed small and large cell lymphoma.
(d) Immunoblastic lymphoma.
2. T cell lymphoma.
3. Lymphoblustic lymphoma.
4. Histiocytic lymphoma.
CLINICAL PICTURE :
1. The usual presentation is by painless progressive
enlargement of the ceruical lymph nodes.
Progression of lymph node enlargement, however, does not

follow an orderly anatomical pattern as in Hodgkin's disease.
2. NHL is more likely to present in extranodal sites than H.D.

(a) Gastric lymphoma) manifestations similar to carcinoma.
(b) Intestinal lymphomas ) I.O, bleeding, or perforation.
3. Mycosis fungoides is a variant of NHL in which skin
eruption is the first of the disease manifestations.
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WhiteKnightLove
STAGING & INV : As llodgkin's disease.

TREATMENT : 1. Radiotherapy and combination chemotherapy.
Inc G[0P Ghemotnelaly rGgimcn is tnc one in Gomflon usG :

* Cyctophospknnnide. * Adninrraycilt * OrrrcoMn- * Ppedrisonr.
2. Gastrectomy for gastric lymphoma.
3. Intestinal resection for intestinal lymphoma.
Burkitl's lymphomo
ETIOLOGY : The exact etiology is not known.

@ Thought to be related to infection with the Ebstein Barr ( EB ) virus.
O Malaria I paving the way for the EB virus to induce the disease.
CHNICNL PTCTURE :
\ The disease affects children below the age of 12 years living in
the eastern part of Africa, with a male predominance.
\ The qsual presentation is that of a child who has a pqiuless
progressively enlarginq i aw sw elling.
\ This swelling distorts the face, may displace the eye, and
partially occludes the mouth.
It
also affects the kidneys, ovaries, long bones & CNS.
\
TTT : chemotherapy using a combination of cyclophosphamide and
cytosine arabinoside.
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ebdominal Case
PERSONAL HISTORY
a.
Age.' * Haemolytic
As general sheet
* stressing
on
anaemias in children.
* Bilharzial splenomegaly in adults.

b. Residence and occupation
habi*.'
c. Speciul
COMPLAINT
: Farmers for bilharziasis.
Alcoholic cirrhosis, drug addiction hepatitis.
1. Abdominal swellings ( hepatomegaly or splenomegaly
2. Pain ( dyspepsia,
).
heaviness in left side of abdomen ).
3. Complications :
a
a
a
a
Vomiting of blood ( haematemses ).

Bleeding per rectum.
Black tarry stools ( melena ).

Ascites ( abdominal distention ).
PRESENT HISTORY
1- Analysis of the complaint ( onset, course, duration ).
2- History of the disease in chronological order.
3- Pain : in splenomegaly.
@
Site.' Left hypochondrium.
@ Character :
) weight of huge spleen.

Stitching ) perisplenitis.
Dullache ) stretch of the capsule.
Heaviness
Radiation : Lt. shoulder in case of perisplenitis only.
@ Precipitating
@ Reliving
factors .' Exercise, heavy meals.
factors .' Rest, small meals.

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WhiteKnightLove
4- Swellings : In splenomegaly
@ Other swellings like generalized lymphadenopathy and
hepatic swellings suggestive of lymphoma or leukemia.
5- Constitutional manifestations
@ Low grads fever in : liver cirrhosis, chronic hepatitis,
liver tumour.
@ Pel-Ebstin fever in Lymphomas.

7- Abdominal symptomatology
Oeophageal:
Dysphagia
Haematemsis \
* No of attacks.
* Amount of each.
* At what level ?
* to fluids or solids 2
* course : Intermittent
* Colour.
or
Progressive.
Eastric
* associated loss of conscious.

* Type of treatment.
Dyspepsia
Vomiting
* Onset, course, duration. * Frequency, amount.

* Colour, odour, contents.
* Relation to meals.
* Relation to posture
Relation to meals.
* What precipitate, what's relieve.
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WhiteKnightLove
Liver
* Liver cell failure
- Jaundice (colour of stools and urine).

-
LL oedema and ascites.
- Bleeding tendency.
- Gynecomastia.
- Palmar erythema and spider navei.
- Drowsiness, insomnia, flapping tremors and foetar hepaticus.
Spleen : )
Hypersplenism : *Anaemia: easy fatigability.

*Leucopenia : repeated attacks of
infections.
*Thrombocytopenia : Bleeding
tendency.
* Recturn.
lntestinal
Defecation (constipation
/ diarrhea) | Bleeding per rectum or melena
. Frequency
. Amount
. Colour, odour, contents
PAST TIISTORY
I .
| .
I o
Amounttmucus
Associated or following haematemesis.
Type of treatment
* Bilharziasis, type of treatment received, from how long

* Typhoid, malaria, hepatitis, blood transfusion.
FAMILY TIISTORY
* Hemolytic anaemia.
* Bilharziasis in endemic areas.
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WhiteKnightLove
Eeneral Exarninatirrn
2- Vital signs
l-Gieneral@
* Temp : * low grade fever?

* Pulse : Water hummer pulse?
* Facies : Toxic or (earthy look).

* Body built :
- Under weight Bilharziasis.
* BP : Usually normal
- Cachexia in lymphoma.
* RR: Dyspnea in biharzial cor-
* Orientation : Drowsy in liver cell
Pulmonal or tense ascites
4- Neck
3- Ilead
* Skull metastasis.
* Jaundice.
* Epistaxis.
*Pallor, jaundice, cyanosis.
* Spider navei.
* Congested neck veins in corpulmonal.
* Enlarged cervical nodes
* Feotor hepaticus.
* Glossitis, stomatitis.
( leukaemia and lymphomas).
* Endemic parotitis.
* Spider navei.
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WhiteKnightLove
6- Alrdorrren
5- Ghest
1. Gynecomastia.
* Bilharzial cor- pulmonale.

2. Bony tenderness.
Local Examination
3. Dilated veins crossing chest wall.
4. Spider navei.
7-
ffpper Lirnlr
8- Lourer Lirnb
pallor.
2. Flapping tremors.
3. Palmar erythema.
1.
4.
Clubbing of nails,
| 1.
Inguinal L.N enlargement.
| 2.
Oedema in liver cell failure.
3. Dorsalis pedis pulse.
Axillary LN enlArgement.
5. Water-hummer pulse.
IDon't torget to Exarnine

a.
Back: For masses or bony tenderness, vertebral deformity.
b. Scrotum: * ry epidiymal mass, cord masses.
* Testicular atrophy in liver failure or tumours.

* Hydrocele with tense ascites.
c. Left supraclavicular region (
for Virchow's LN in abdominal
malignancy ).
d. P/R &
P/V: - Bilharzial rectal polyps.

- 2ry piles in portal hypertension.
- Nodules in Douglas pouch or Kruknberg tumours.
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WhiteKnightLove
Local Exarnination
*t Position
: Patient should be flat on his back with knees flexed

to relaxes the abdominal muscles.
xt Exposure : From
nipples to mid thighs.
INSPECTION
1) Abdominal Contour
Scaphoid abdomen.
A Flat abdomen.
Distended abdomen.
2) Abdominal
look
mobility with respiration by tangential
,ll Female: thoraco-abdominal.
Male: abdomino-thoracic.
t, Lost: in peritonitis and internal
haemorrhage.
3) Subcogtal anqle (9O - 11O")

*Obtuse angle if chronic
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
a. Site.'midway between xiphisternum and symphysis

pubis.
b. Shape.' Inverted due to its attachment to umbilical ligaments.
c. Impulse
on cough.
d. Discharge, nodule, pigmentation.

e. Dilated veins (Caput Medusae).
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WhiteKnightLove
7) Supra-pubic hair
A Male : Triangular towards the umbilicus.
,l
Female : Transverse upper border.
8) Hernial orifices
9) The back
a
1O) Any
for
Swellings, Ulcers or Pigmentations.
other abnormalities like
A Dilated veins in IVC
obstruction or portal HTN or thrombosis
ln portal hypertension : the veins are central & the

direction of flow is away from the umbilicus.
ln IVG obitruction : the veins are peripherat & the

direction of flow is from below upwards.
Scars of previous operations.
.tl Localized swelling.

Site : intra-abdominal or not.
Special signs : lmpulse on cough or visible pulsations over iL
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
quadrant to that of the

complaint e.g if complaint in
Lt. Hypochondrium start

palpation from Rt. Iliac fossa.
99
WhiteKnightLove
ffi Proceed in an rrsrr shaped manner.

:
Oloiecti;res
1.
To get patientts confidence.
2.
To
elicit:
.
.
.
3.
Tenderness and rebound tenderness.
Temperature of the abdominal wall.

Muscle guarding and rigidity.
To examinefor superficial abdomirual swellings.
n,dclarriculaa
Abdomin,,,l reqions
$nQ
,t
(1,3) Rt., Lt. Hypochondrium.
(4,6) Rt., Lt. Lumbar region.

(7,9) RL, Lt. Iliac fossa.
(2) Epigastric Region.
\u
(5) Umbilical Region.
(8) Hypogastric Region.
s
o
B. DEEP PALPATION
ERrrles:
1- Using warm hands.
2- Ask the patient to flex his knees (slightly 45").
3- Ask the patient to open his mouth and breathe deeply.

4- Do deep palpation using flexor surface of your fingers or tip
ofyours fingers.
l- LiVgf :
Lower border only"
* Rt. Lobe
Normally not palpable because it's parallel to Rt. Costal

margin and soft ( except in the first 3 years of life may be
felt
finger below the costal margin ).
100
WhiteKnightLove
* Lt. lobe
Normally midway between xiphisternum and umbilicus

( but not palpable being soft ).
MefJrods of fiver palpation:
t.
Clossie method,:
* Starting from Rt. Iliac fossa moving up to palpate the lower
border of the Rt. Iobe.
* Starting from umbilicus moving upwards towards the

xiphisternum to palpate the Lt. 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.
3. Dipping methad : ( in tense
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
Gnla]gement [y patient own Iingerc 0] Gm.
-[[ge "snal[
o] Ioundeil".
-Gonsistency,
suilacG [smooth
01
i]reuulail.
*Relation to respiratory movements.

*Pulsating or not.
N.B : In the spleen do not forget to comment on the NOTCH
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
the midaxillary line.
To be palpable, the spleen should enlarge 2-3 times its

normal size.
It usually
enlarges towards Rt. iliac fossa due to the
attachment of phrenico colic ligament except in chronic

blood diseases and lymphoma or intra-abdominal adhesions
it may enlarges in any direction
(e.g down towards the
Lt.
iliac fossa).
Methods of palpation of the spleen:

I.
(Clossie m,ethod.:
* Starting from the right iliac fossa moving towards the umbilicus
reaching lower pole of the spleen.
2. Bim,anual Dxumination in the B;t. lateral positiot, :

* Let the patient lies on his right side, take a deep breath and
withhold it.
* The spleen can be made more prominent by lifting the lower

ribs forwards by the left hand.
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.
Palpution of the spleen from
lll- Kldry
beh,ind, :
Y Normally kidneys are not palpable,
except the lower pole of the
right kidney in thin individuals during inspiration.
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WhiteKnightLove
How to palpate the kidney?

Bimqnu,ul examirtqtion :
* Pressing firmly into the lumbar region (at anterior abdominal
wall) during inspiration by one hand while lifting the kidney
forwards with the other hand in the loin.
Ballottement is also elicilcd during this [imanual Grramination
[y
rushing the kidney swelling lonrards [y the [oste]ior hand in the

loin,
$e kidney will strifie me ante]ior nanil and lall [ack again t0
stlilc
tnG
[ostelior hand.
ll.B.: llifferences [etwecn cnlalgcd s[leen anil cnlargc[ lcftkidney:
Left kidney swellings
Splenomegaly
1) Has a sharp
anterior border with
1)
Reniforn in shape
a notch on it.
2) You can't insinuate your hand
2) You can insinuate your hand between
between it and the left costal margin.
and the left costal margin.
you can insinuate but you can't
reach its upper border ).

3)
It
is dullness is continuous with
3) Its dullness is obliterated by a band of
the normal splenic fullness.
resonance (air in splenic flexure) over
4) Gives *ve anterior ballottement.
4) Give *ve posterior ballottement.
5) Left renal angle is free
5) Fullness of the left renal angle.
lV- Gall hladdI
( Fundus can be felt
1- At the tip of 9th Rt. costal cartilage.
104
WhiteKnightLove
if
distended )
it
it
2- A line drawn from Lt. ASIS to the umbilicus and extend up

will meet the Rt. costal margin at this point.
3- At meeting of Rt. linea semilunaris with Rt. costal margin.

N,B : Physical signs of distended gallbladder :
1.lt is a pyriform swelling occupying the right hypochondrium.

2.
lt moues u[ and down with ]esliration.
3. lts surface is smooth and its edges are rounded & wel! defined
except superiorly where it disappears beneath the right costal

margin.
4. It d0cs
nol
lill lenal anglG & it il0es not lall0t
5. On percussion it is dull & the dullness is continuous with the
liver dullness.
6. Gan moue
lrom side t0 sidc [ut not u[ and down.
* lf G.B. is not palpable you can elicit Murphy's sign
If continuous gentle pressure
is exerted over right hypochondrium while
the patient takes a deep breath, there will be a "catclt" of breath

suddenly withfacial expression of pain before the end of inspiration.
V-Mesenteric and para-aortic lymph hodes
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.
b) Para aortic LN are felt midway between umbilicus and

xiphisternum.
VI- Colon (commonly sigmoid color)
At the Lt. iliac fossa by rolling by both hands for

palpation of tender spastic colon or any paracolic masses,
( bilharzial pericolic mass ).
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WhiteKnightLove
PERCUSSION:
l-Liver
a.
i.o*er horder a
LIGHT PERCUSION
$ Percuss the lower border if NOT defined by palpation

in Rt. midclavicular line for Rt. Iobe
S And middle line for left lobe.
b. cUpper border
HEAW PERCUSSION
Percuss the upper border starting from the Rt. 2nd
intercostal space opposite ( angle of Louis ).
When you reach the dullness of upper border, ( normally at the

5th intercostal space Rt. midclavicular line ) ask the patient to
take a deep breath and hold it then percuss again,
. If it becomes resonant ) previous dullness was the liver.

. If it remains dull ) previous dullness due to supra
diaphragmatic causes other than liver.
If it remains resonont below the Sth spoce :

* Shrunken liver, if the lower border is not felt by palpation.
* Ptosed liver, if the lower border is felt by palpation.
ll-Spleen :
i Normal splenic dullness extends
* Anteriorly to midaxillary line.
* Posteriorly to 4cm from the midline at T10.

x
Above to the 9th rib.
* Below to the 1lth rib.
In huge spleen percussion start from Rt. iliac fossa towards

Ieft hypochondrium.
A If not palpable percuss Traube's area:

106
WhiteKnightLove
]l.B : Boundaries o[
ftaub's fl]Gfl
O Lt. 5tr intercostal space in midclavicular line.
Lt. 8th rib in midclavicular line.
O Lt. 1lth rib in midaxillary line.

O Lt. 9th rib in midaxillary line.
N.B: Other causes of dullness in Traube's ureo :

* Full stomach.
* Enlarged Lt. lobe of liver,
* Lt. pleural or lung disease.
lll'KidnY : while the patienr is semi-sirfing

A Normally the renal angle is resonant.
A If renal swelling ) dull
lV-Ascites :
tL ) + 9HIFTING DULLNESS
b. cFor minimat ascites (. lil ) I KNEE ELBow PosITIoN
a. cFor moderate ascites ( >
Etr Percuss around the umbilicus at knee elbow position.
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WhiteKnightLove
Padilel sign
* Put a
slethoscopc at tne um[ilicus wftile me [atienl is in tnc knee
ellow [osition.
* S[a[e the a[domen
c.
) [s[lash is heatd.
Tor tense ascites , TRANSMITTED FL(IID TIIRILL
Etr The patient places his hand firmly on the center of the
abdomen to avoid fat thrill.
@ The abdominal
wall on one side is flickered and the thrill is
felt by the other hand on the other side.
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.
Murmurs of abdominal aneurysms.

Bruit over lumbar region in renal artery stenosis.
EA Venous hum in portal hypertension specially over the xiphisternum

(Kenawi's sign ).
ru
Bruit over the liver in
cases of
HCC (Maamoon sign).
108
WhiteKnightLove
Oral Qrrestions
0:
l-
W[at are the essentia! inuestigations re[uiled [or a Gase oI HSM
Detection of aetiology :
1. Hepatitis markers : HBsAg, HCV-Ab ( better PCR
2.
Stool
).
& urine analysis for bilharzial ova "hatching test".
3. Serological
& CFT .
tests for bilharziasis : ELISA
4. Barium enema & sigmoidoscopy + biopsy ( bilharzial polypi ).

5. Liver biopsy : Sure method to confirm diagnosis but invasive.
lI- Liver function
tests :
1. Serum albumin : 3.5-5 gm o/o.
2. Prothombin time : ll-14 seconds.

3. Serum bilirubin :0.2-l mgo/o.
4. Serum ALT, AST & alkaline phosphatase.
lll- lnvestigations for portal hypertension
1. Abdominal U.S.
xTo detect HSM & liver ciruhosis.
*
2.
To detect the presence of ascites.
ortal venous d uplex.
To measure the size of portal vein in cases of portal
hypertension
3. Detection of oesophageal varices : Upper GIT endoscopy.
N.B: Grades of oesophageal varices.

Gmde I : Ililated ucins with inlact I not elGUatG[
Gmde
ll: tleuated toiluous
I mucosa all oue].
ueins wim nomal mucosa in [etween.
Glado lll : tleuated tortuous ueins with n0 nolmal mucosa in [etween.

Gmde lU: lrosions, ulcerations & dilalcd
calillailes
led $gts = im[ending ruptulG I.
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WhiteKnightLove
0n tne uailGes I
G[c]ty
lV- Detection of lrYrrersPlenism :

1.
CBC.
,l
RBCs
R.adioisotope scan using radioactive chromium tagged
t"Ir, to show the
)
(.tC. or platelets labeled with indium (
degree
& the rate of destruction by the spleen'
Bone marrow ( sternal or iliac crest ) puncture : Active'
m It is lies parallel to the left 9, 10, 11 ribs,

m The anterior end doesn't cross the left mid axillary line.
ffi
Its posterior end lies about 1.5 inches from
10th
thoracic spine'
ffi The superior border :

*Represented by a line drawn from the 5th left intercostal
space in the midclavicular line to the 5th
right rib in the
Rt.midctavicularlinepassingthroughthexiphoid
process.
ffi The right border :

* Represented by a line drawn from the 5th rib to the
and L1th rib in the Rt. midaxillary line'
ll0
WhiteKnightLove
7th
EE
The inferior border
* Represented by a line drawn from the Rt. l1th rib in the

Rt. midaxillary line to the tip of Rt. 9th costal cartilage
and then to the left 5th intercostals space.
..
j--'
t
ll.B.:'f,enal anglc : Angle [etween tnc ]ast fi[ and lateral [order of
sacrus[inalis muscle.
.10in:
lrea [etween last ]i[ and iliac G]est
't
!
,
)
,}
111
WhiteKnightLove
Jaundice Sheet
PERSONAT IIISTORY : As generul sheet * stressing on
A4ie :
* Calcular obstructive jaundice ) in middle
age.
* Malignant obstructive jaundice ) in old age.

* Haemolytic jaundice ) in young age.
* Hepatocellular jaundice
in any age.
Sex:
* Calcular obstructive jaundice ) in females.
* Malignant obstructive jaundice ) in males.
COMPLAINT :
(a) Yellow colour of sclera, skin
&
mucus membrane.
(b) Colour changes of urine and stools.
(c) Severe itching.
PRESENT TIISTORY
(1) Analysis of CIO ! Onset, course, duration.

0tstructiue iaundice
(a) Calcular:
Sudden onset, intermittent course, short duration.
(b) Cancer pancreas :
Insidious onset, progressive course, short duration.

(c) Peri-ampullary curcinoma :
Insidious onset, intermittent course (due to necrosis of
tumour allowing for transient relieve of jaundice),

relatively long duration.
fi2
WhiteKnightLove
(2) Pain.
a. Site.' Rt. hypochondrium and epigastrium.
Character
c.
* Calcular : biliarycolics.
Radiation
* Malignant: LATE boring pain.

* Calcular : Rt. shoulder.
* Malignant : to the back.
d. Aggravating
factors.' * Calcular : fatty meals.

* Malignant : lying flat.
e-
Relieving factors
* Calcular ; antispasmodics.
'
" Malignant : leaning forward.
(3) Swellings.
'
'
'
'
Hepatomegaly : In obstructive and haemolytic jaundice.

Splenomegaly : In haemolytic and hepatocellular jaundice.
GaI[Bladdpr sweJling : In malignant jaundice.

Other swellings suggestive of Metastasis (e.g. virchow's gland).
(4) Previous operatiofl
post-cholecystectomy obstructive jaundice.
(5) Constitutional manifestations
Charcot intermittent fever in calcular obstruction.
(7) Previous investigations, drug intake and treatment.
ll3
WhiteKnightLove
(8) Symptoms suggestive of the cause and complications

of jaundice.
a) Obstructive jaundice :
* Fatty dyspepsia & biliary colics in calcular jaundice.

* Pruritis and bleeding tendency.
* Dark colour urine, pale bulky stools.
b) Haemolytic jaundice :
* Anaemia.
* Normal colour urine, deep dark stools.
c) Hepato-cellular jaundice :
* Bleeding tendency.
\
* Dark urine and normal colored stools.
* Past history
* As general sheet + history of hepatitis, blood transfusion, I.V.

drug intake.
* Pretsiou;s operqtions on the bili,arg sgstetn.
* Farnily history
* Of similar condition ( haemolytic jaundice ).
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
Bradycardia in obst. Jaundice
BP : Hypotension in obst. Jaundice.
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
:s. Lung metastasis.
malignant jaundice.
& lower Umb
7- Upper Umb
\9 Itching
marks.
I I V Oedema (liver affection).
V Echymosis (bleeding
tendency).
t9 Hand manifestations
liver cell failure.
of
I I
| |
V Ulcers over the shin of tibia in

sickle cell anaemia.
I I V Thrombophlebitis migrans in
I I
cancer pancreas.
lls
WhiteKnightLove
Local Exarnination
INSPECTION : As abdominal
sheet
V It.t irg marks

V S"u.s of previous operations.
PALPATION
(A) Superficial palpation
Tenderness over Rt. hypochondrium in calcular
obstructive jaundice (+ve Murphy's sign).
(B) Deep palpation : (Look abdominal
sheet)
1- Liver.
2-
Spleen.
3- Gall Bladder. ( Courvoisier's law)

4- Epigastric Mass : In cancer head of pancreas.
5- Para-Aortic L.N.
PERCUSSION
&
AOSCUTTATION
.'.as abdominat sheet.
lrnportant nrrtesi
(1) tlaemolytic jaundice is usually very light (Lemon yellow):
calcular obstructive and hepatocellular jaundice are usually

( orange-yellow ).
(2) Matignant obstructive jaundice is usually (olive-green).

(3) Xanthelasma is a yellowish plaque commonly seen at the inner
canthus in patients with prolonged obstructive jaundice or
patients with hypercholesterolaemia.

(4) Generalised lymphadenopathy may denote the presence of
enlarged L.N. in porta hepatic as a cause for obstructive
jaundice.
116
WhiteKnightLove
Importanl Ouestions in O.l

DEFINITION
Jaundice is yellowish coloration of the body tissues and fluids

(except the brain, CSF, tears, saliva and milk) which results
from accumulation of bilirubin in blood.
It becomes manifest when serum bilirubin exceeds 2.5 mg / dl.
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 :
a. Carcinoma of the head of pancreas obstructing the lower

part of the common bile duct
mass of metastatic lymph nodes at the porta hepatis
obstructing the hepatic ducts.
b. A
SEQUETAE & COMI'LICATTONS OF

A- Changes in the liver :
1. Dilatation of intrahepatic
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.
B-Effects on the coagiulation factors :
@ Bile salts fail to reach the intestine ) failure of absorption

of fat soluble vitamins esp. Vit K ) Hypoprothrombinemia.
C-
Hepato-renal failure "renal shut doryrl":

O Absence of bile salts in the intestine leads to bacterial translocation.
O This gram -ve endotoxemia causes renal cortical necrosis & acute
renal failure.
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WhiteKnightLove
INVESTIGATIONS
Laboratorlr
$ LFTs : * t
Total & direct bilirubin, ALP & 6GT.

* ALT & AST are high if there is cholangitis.
Kidney function tests : * Serum creatinine, BUN &
s
$ cBc.
K.
Prothrombin time.
S CA 19.9 ) Elevated in cancer head pancreas.
Badiological
l. U.SaDdomen:
Reveals IHBR dilatation.

@ If CBD is not dilated ) High obstruction ( Klatskin tumour ).
@ If CBD is dilated I Low obstruction.
O Reveals gall stones.
2.
3.
4.
[.B.G.P
: IliagnosUcarelieucsiaundioe.
@ Stone extraction via dormia basket & sphincterotomy in

calcular O.J.
@ Stent insertion in the CBD in malignant O.J.
Percutaneous ttanshe[atic Gholangiog]a[hy t PIG I :
O For external biliary drainage in cases of malignant O.J if E.R.C.P fails
but it is not recommended by all surgeons due to its complications.
Sniml G.T scan aldomen : ln malignant 0J.
El Replaced coeliac & superior mesenteric angiography for
assessment of vascular invasion & operability.
mnGP in cases 0[ ttaumatic st]ictulc & sclerosing G[olangitis.
lllllA scan Ior congenital [iliary atlesia.
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.
Detinitive rnanagernent of individual carrses
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
b) Open cholecystectomy, CBD exploration & choledocholithotomy

& then
[E C@
: * IfCBD diameter> 1.5 cm.
* Presence of intrahepatic stones.
ffi Clocrrre of tls CED otr* aT-tthe: * If CBD diameter < 1.5cm.
lI- Eancer head pancreas [. periarnpullarg carcinolrla :
a) Operable ) Pancreatico- duedenectomy (Whipple's operation)
b) lnoperable ) Triple bypass or cholecysto- jejunostomy.
lll- Choledochal cgst:

ol IyReS l-lU: Excision with Roux en Y hepaticojejunostomy.
bl IIfeSU-Ull: a. Localized -+ Partial hepatectomy.
b. Generalized
+ Liver transplantation.
lV : Sclerosing cholangitis : Liver transplantation.

V: Eongenial biliarg atresia :
O
O
Porto-enterostomy ( Kasai operation ).

Liver transplantation : Better or if Kasai operation
fails.
VI = Traurnatic strictrrre :
O
Roux en Y choledochojejunostomy or
hepaticoj ej unostomy or
even left duct approach.
Courvoisier's Lqw
ln a natient witn 0J, iI the gall
iladdcl is Dal[aile, mosl 1t10[aHy it is not

calculalo[structiue iaundice as the gall iladder is [ilrosed and
shrunlen fiom [reuious choleoystitis.
lr is usuaLty paLpnble iru obsrnucrivr jaundicr dur ro cnrrrcen o[
krnd of pANCREAs As ir is hra[rl-ry nrud disrrrrrsiblr.
Exceptions to Courvoisier's low (4oolo) :

l. Palpable gall bladder with culcular obstructive jaundice :
a. Metabolic stone with a healthy distensible gall bladder.
b. A stone in the CBD causing jaundice and another one in
c.
2.
the cystic duct causing a mucocele of the gall bladder.

A stone of Hartman's pouch, obstructing both CBD and
cystic duct.
Malignant O.J without palpable gall bladder :

a. Associated cancer head with calcular cholecystitis.
b. Previous cholecystectomy.
c. Cancer head with metastasis at porta hepatis causing
obstruction of the bile duct above the level of the gall
bladder which thus cannot be distended.
d. Klatskin tumour.
ll9
WhiteKnightLove

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'It is more blessed to give than to receive.

By ltr : HanY Rafik

Freely you have received; freely give.

'It is more blessed to give than to receive.

How to Take a History

tll Personal historu

* Sex.' Breast cancer in female.

veins ( in prolonged standing ), cancer bladder

( aniline dye workers ).

* Marital status.' ( Married or single, No of children,

Menstrual history : (Age of menarche, regular or irregular)

of menopause, method of contraception ).

* Special habits.' ( Smoking, Alcohol, Drug addiction

Freely you have received; freely give.

9(n *tn,tp,Ll, fon*annl, hi"rn rr/t

A male patient named

Only one complaint (the most distressing).

Ihe main G/0 in surgery ale swcllings, [ain, deformity 01ulcel

IIIII Preserrt Historg

ld lrrl4ill, tl,p,fnlln nt rE ilpm,s

l- Analysis of the cornplaint :

V Sudden : (after trauma).

V Short (in malignancy).

Long (in chronic

Ilistory of the disease in chronolo*ical order :

'It is more blessed to give than to receive.

a. Relation to pain or trauma.

b. Character (coliclcy, dull ache,

swellings (e.g metastasis).

Fever, headache, malaise, rigors.

weight loss, anorexia, Ioss of appetite,

low grade fever, night sweat.

7- Previous investi$ations and treatrnent

9- Cornplications of the pathology or systern you are

llVI Past Historg

Medical disorders : DM,

BP, T.B., Bilharziasis ... etc.

Previous operations, type of anaesthesia

History of blood transfusion or drug allergy.

Freely you have received; freely give.

4 Similar conditions in the same family.

* Rhythm & equality on both sides.

* Character like water hummer pulse.

2. Eye brows ( loss of outer 1/3)

5. Lips : Pallor, jaundice,

'It is more blessed to give than to receive.

6. Tongue : tremor, central

I tube : Trachea (central or deviated).

2.Lrung & heart : Complete chest and heart examination.

Liver & Spleen.

4. dilated veins ( inspection ).

7.PtR& PA/ ( masses, piles, polyps, ulcers ).

* Warm or cold (sweaty or not).

2. Water hummer pulse.

Freely you have received; freely give.

& Axillary LNs.

& pretibial myxoedema.

3. Pulses ( dorsalis pedis ).

I.ocal Examination of a Swelling

o For example parotid swelling

with cervical lymphadenopathy may

indicate malignant parotid mass

swelling in the lower part of the front of the neck

swelling in the parotid region

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