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Some Important Notes On Clinical Surgery Collected by : Dr.Soran M.Gharih Cause of mass in the right iliac fossa: 1.Appendicitis 2. tuberculosis 3.carcinoma of caecum 4. crohn's disease 5.iliac lymphadenopathy 6. iliac artery aneurysm 7. psoas abscess 8. chondrosarcoma of the ilium 9. tumor in an undescended testis 10. actinomycosis 11. ruptured epigastric artery For left iliac fossa delete the first three causes and insert diverticulitis and carcinoma of colon. Common causes of enlargement of kidney: 1. hydronephrosis 2. pyonephrosis 3.perinephric abscess 4. malignant disease (hypernephroma and nephroblastoma) 5. solitary cysts 6. polycyic disease 7. hpertrophy Some causes of pathological lymhadenopathy: Generalized: • viral: EBV, CMV,HIV • bacterial: brucellosis, syphilis • protozoal: toxoplasmosis • neoplastic: lymohoma, acute or chronic lymphocytic leukemia CLL , ALL • others: RA, SLE, sarcoidosis Localized: . infective: acute or chronic including viral bacterial, and other agents •neoplastic :secondary metastatic, primary hematological including Hodgkin's and non Hodgkin's lymphoma Differential diagnosis of the swollen limb: 1-non-vascular or lymphatic * General disease state:cardiac failure , liver failure, hypoproteinemia , hypothyroidism (myxedema), allergic diseases including,angioedema, and idiopathic cyclic edema.immobility and lower limb dependency. *Local disease processes: ruptured Baker's cyst, Myositis ossificans, bony or soft tissue tumors, arthritis hemiarthrosis, calf muscle hernatoma, achiles tendon rupture *Retroperitoneal fibrosis: *Gigantistm Drugs:corticosteroids , estrogen , progestagen , MAOI , phenylbutazone, methyldopa ,hydralazine, nifedipine *Trauma *Obesity 2-venous: *Deep venous thrombosis: *Post thrombotic syndrome *Varicose veins :not simple primary varicose vein *KlippeI Trenauray syndrome *External venous compression: pelvic or abdominal tumors gravid uterus, retroperitoneal fibrosis 3-arteriaI: *ischemic reperfusion following lower limb revascularization for acute and chronic ischemia *arteriovenous malformation *aneurysm : popliteal, femoral, false aneurysm following trauma Causes of superficial thrombophlebitis 1.varicose veins 2.occult carcinoma: bronchus,pancreas. stomach, lymphoma 3.thromboangitis obliterans (Buerger's disease) 4.polycythemia 5.polyarteritis 6.iatrogenic : intravenous injection and injuries 7.idiopathic Common causes of hair loss: 1.local • male balding • alopecia aerate •skin infections 2. general: *hypothyroidism *cytotoxic drugs *hypopituitarism *iron deficiency *severe illness. Causes of ptosis: 1.inflammation 2.tumors 3.excessive eyelid skin 4.muscle weakness (myopathy and myasthenia) 5. third nerve palsy Causes of swelling of the chest wall 1. bony hard: • secondary carcinoma • chondroma • osteoma • exostosis • meyloma 2. fluctuant: • tuberculous abscess of rib or LN • empyema necessitas • infectcd hematoma 3. pulsatile • eroding aortic aneurysm Causes of swelling of salivary gland: 1. acute infection: • viral (mumps) • bacterial (staphylococcus) 2.duct obstruction 3.sialectasis (chronic _infection) 4.tumor 5. sarcoidosis (Mlkulickz's syndrome) 6.Sjogren'syndrome Causes of swelling of the jaw: 1.infections •dental abscess • acute osteomyelitis • actinomycosis 2. cysts • denogenerus cyst • cystic tumors 3. neoplasma benign: • fibrous dysplasia • giant cell granuloma • odutogenic tumorsadaniantinoma malignant: *osteogenic sarcoma *malignant lymphorna (Burkitt's tumor) *secondary tumors Causes of cervical lymphadenopathy: 1. infection • non specific • glandular fever •tuberculosis •syphilis • toxoplasmosis • cat scratch fever 2.metastatic tumor *from head, neck, chest an abdomen 3.primary reticulosis *lymphoma • lymphomasarcoma • reticulosarcoma 4.sarcoidosis Causes of solitary nodule in the thyroid: I. dominant nodule in multinodular goiter 2. hemorrhage into nodule 3. adenoma 4. carcinoma(papillary or follicular) 5. enlargement of the whole of one lobe (usually Hashimoto's disease) Causes of massive enlargement of the breast: 1.benign hypertrophy (usually bilateral) 2. giant fibroadenoma 3.phylloides tumor 4.sarcoma 5.colloid carcinoma 6. filarial elephantiasis The differences between eczema and paget's disease of the nipple eczema Paget's disease bilateral unilateral Commonly occurs at lactation Occurs at menopause itches Does not itch vesicles No vesicles Nipple intact Nipple may be destroyed No lumps May be an underlying lump The varieties of mastitis: 1. Neonatal (caused by maternal hormones) 2. milk engorgement during lactation 3. diffuse infection during lactation 4. mumps Breast changes of pregnancy I. fullness and pricking sensation 2. enlargement 3. distended subcutaneous veins 4. increased nipple and areolar pigmentation 5. circumareolar pigmentation 6. hypertrophy of subareolar sebaçeous glands(montgomery's tubercies) 7. a clear expressible secretion (colostrums) The causes of a solid single mass in one side of the scrotum 1. tumor 2. orchitis 3. ematocele 4. gumma 5. epididymoorchitis (when the epididymis large and the testis is small) The differential diagnosis of inguinal hernia: 1. femoral hernia 2. vaginal hydrocele 3. hydrocele of the cord or the canal of Nuck 4. undescended testis 5. lipoma of the cord The differential diagnosis of femoral hernia: I. inguinal hernia 2. enlarged lymph gland 3. saphenovarix 4. ectopic testis 5. psoas abscess 6. psoas bursa 7. lipoma The differential diagnosis of a lump in the groin I. inguinal hernia 2. femoral hernia 3. enlarged lymph gland 4. saphenovarix 5. ectopic testis 6. femoral aneurysm 7. hydrocele of the cord or hydrocele of the canal of Nuck 8. lipoma of the cord 9. psoas bursa 10. psoas abscess Causes of discharge from the umbilicus 1. congenital *intestinal Fistula • patent urachus • umbilical adenoma 2. acquired 1. umbilical granuloma 2. dermatitis 3. ompholith (umbilical concretion) 4.fistula (intestinal) 5. secondary carcinoma 6. endometriosis The common conditions that present with acute upper abdominal pain 1.esophagitis 2. boerhaave s syndrome 3.acute gastritis 4.perforated peptic ulcer 5.acute cholecystitis 6. gall stone and biliary colic 7.acute pancreatitis The common conditions that present with chronic upper abdominal pain 1. chronic peptic ulceration 2. carcinoma of the stomach 3.chronic cholecystitis 4.chronic pancreatitis 5.liver metastasis 6.splenomegaly Causes of acute central abdominal pain 1.meckle's diverticulitis 2. acute gastroenteritis 3.inflammatory bowel disease 4.yersisnia ileitis 5. typhoid 6. tuberculosis 7. urinary tract infection The causes of chronic central abdominal pain 1. crohn's disease 2. tuberculosis 3. radiation bowel damage 4 tumors of the small bowel 5. recurrent adhesive obstruction 6. ischemia of the small bowel 7. endometriosis . The causes of the generalized abdominal pain 1. irritable bowel syndrome 2. recurrent adhesive obstruction 3. mesenteric ischemia 4. carcinomatosis 5.chronic constipation 6.radiation damage 7.retroperitoneal damage 8.retroperitoneal tumors 9.endometriosis 10.pelviureteric junction obstruction 11.lumbar spine pain 12.retroperitoneal fibrosis. 13.psychsomatic The causes of acute and chronic lower abdominal pain 1. appendicitis 2. crohn’s disease 3. carcinoma of the caecum and right colon 4. diverticular disease 5. carcinoma of the left colon and rectum 6. bladder outflow obstruction 7.interstitial and irradiation cystitis 8. pelvic inflammatory disease The cardinal symptoms of intestinal obstruction 1.pain 2.vomiting 3.distension 4.absolute constipation The sources of intraabdominal hemorrhage 1.ruptured abdominal aortic aneurysm 2. ruptured spleen 3. ruptured ectopic pregnancy 4.ruptured ovarian cyst 5.hemorrhage from liver adenoma 6.ruptured visceral aneurysm (splenic, hepatic and mesenteric) 7. torn mesentery 8.retroperitoneal hemorrhage (over anticoagulation) The causes of hematemesis and melena 1. chronic peptic ulceration 2. acute gastric erosions (aspirin, phenylbutazone, steroids, trauma especially burns) 3. carcinaoma of the stomach 4. esophageal varices 5. purpura 6. hemophilia Causes of enlargement of kidney: 1. distension of the pelvicaliceal system 2. space occupying lesions: • single (cyst, abscess, and tumor) •multiple (polvcystic disease) 3. compensatory hypertrophy Causes of abdominal distesion 1.fetus 2. flatus 3. faeces 4. fat 5. fluid (ascites, encysted) 6. large solid tumors: • fibroids • enlarged liver • enlarged spleen • polycystic kidneys • retroperitoneal sarcomata Conditions which present with rectal bleeding 1. • blood mixed with stool : carcinoma of colon • blood streaked on stool: carcinoma of rectum • blood after defecation :hemorrhoids • blood and mucus : colitis . blood alone diverticular disease • melaena : peptic ulceration 2. bleeding with pain: fissure, or carcinoma of colon , proctitis caused by schistosomiasi Diagnosis of anal conditions which present with anal pain 1. pain alone: • fissure (pain after defecation) • proctalgia fugax (pain spontaneously at night) • anoreetal abscess 2.pain and bleeding fissure 3. pain and a lump: •perianal hematoma • anorectal abscess 4. pain, lump and beeding: •prolapsed hemorrhoids •carcinoma of the anal canal • prolapsed rectal polyp or carcinoma •ptolapsed rectum Anal conditions which present with lump 1. a lump with no other symptoms: • anal warts •skin tags. 2. a lump and pain: • perianal hematoma 3. a lump, pain and bleeding: • prolapsed hemorrhoids • carcinoma Of anal canal • prolapsed rectal polyp or carcinoma • prolapsed rectum The causes of pruritis ani 1. mucous discharge from the anus caused by • hemorrhoids • polyps •skin tags • condylomata • fissure •. fistula • carcinoma of anus 2. vaginal discharge caused by •trichomonas vaginitis •monilia vaginitis •cervicitis • gonorrhea 3. skin diseases caused by • tinea cruris • fungal infections • infection in diabetics 4. parasites • threadworm 5. fecal soiling •poor hygiene • incontinence • diarrhea 6. psychoneurosis Causes of pericoccygeal swelling 1. pilonidal sinus 2. postanal dermoid cyst 3. chondroma 4. sacroccygeal teratoma Causes of fecal incontinence 1. diarrhea 2. fecal impaction 3. nerve damage 4. sphincter muscle damage 5. dementia In This series : Preparing the following practical books : 1- Clinical Orthopedic. 2- Clinical Gynecology . 3- Clinical ENT . 4- Clinical psychiatry . 5- Clinical Neurology ( History taking & Physical Examination In neurology) 6- 52 Cases in Clinical pediatric . 7- History taking and physical examination in surgery . 8- The most important subject for 4,5, 6th stages that you have to know before the exam . 9- OSCE exam for 6th stage . 10- ECG Interpretation. 11- Common abdominal signs and symptoms . 12- Theory exam Of previous years for 6 th stage 13- History taking and physical examination in Medicine 14- Collection Of Physiology exam of previous years for second stage medical students. Preparing the following practical books for newly graduated doctors (Rotator) : About how to learn the routine of treating patient in All department in hospital : 1-Medical emergency & Case Management in CCU. 2-Surgical emergency . 3- Pediatric emergency & Case Management in premature Unit . 4- Obstetrical & Gynecological emergency. 5-Assessing and Management of patients in Primary health care & the most important medications used daily 6-ECG Interpretation.