Some Important Notes

On Clinical Surgery

Collected by :

Dr.SoranM.Gharih

Cause of mass in the right iliac fossa:

1.Appendicitis

2. tuberculosis

3.carcinoma of caecum

4. crohn's disease

5.iliaclymphadenopathy

6. iliac artery aneurysm

7. psoas abscess

8. chondrosarcoma of the ilium

9. tumor in an undescended testis

10. actinomycosis

11. rupturedepigastric 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,Myositisossificans, 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

*Varicoseveins :not simple primary varicose vein

*KlippeITrenauray 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.thromboangitisobliterans (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

• empyemanecessitas

• 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

• acuteosteomyelitis

• actinomycosis

2. cysts

• denogenerus cyst

• cystic tumors

3. neoplasma

benign:

• fibrous dysplasia

• giant cell granuloma

• odutogenictumorsadaniantinoma

malignant:

*osteogenic sarcoma

*malignant lymphorna (Burkitt's tumor)

*secondary tumors

Causes ofcervical lymphadenopathy:

1. infection

• non specific

• glandular fever

•tuberculosis

•syphilis

• toxoplasmosis

• cat scratch fever

2.metastatic tumor

*from head, neck, chest an abdomen

3.primaryreticulosis

*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. giantfibroadenoma

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 subareolarsebaçeous glands(montgomery'stubercies)

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. vaginalhydrocele

3. hydrocele of the cord or the canal of Nuck

4. undescendedtestis

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 ofNuck

8. lipoma of the cord

9. psoas bursa

10. psoas abscess

Causes of discharge from the umbilicus

1. congenital

*intestinal Fistula

• patenturachus

• umbilical adenoma

2. acquired

1. umbilicalgranuloma

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.acutecholecystitis

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.chroniccholecystitis

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'sdisease

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 theleft 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. esophagealvarices

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

. bloodalone 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)

• proctalgiafugax (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 pruritisani

1. mucous discharge from the anus caused by

• hemorrhoids

• polyps

•skin tags

• condylomata

• fissure

•. fistula

• carcinoma of anus

2. vaginal discharge caused by

•trichomonasvaginitis

•moniliavaginitis

•cervicitis

• gonorrhea

3. skin diseases caused by

•tineacruris

•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. postanaldermoid cyst

3. chondroma

4. sacroccygealteratoma

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)

6-25 Cases inClinical 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.