Bedside notes

Dr sunet weight loss, appetite and fever. Different way to check axillary lymph. Pain radiating example is gall stone pain radiated to the tip of scapula from right hypocondrium, referred because of sharing same nerve root between viscera and somatic and migrating example is acute appendicitis pain from periumbilicus to right iliac fossa because same embryonic origin. Others are lymph nodes, cns examination, current treatment and basic science. 22/09/10 Dr Ghassan Summary about the history taking and clinical examination. History SYMPTOMS while c. examination SIGNS. Diseases according to age and sex Age Female (breast lump) Male 20 Fibroadenoma 30 Fibroadenosis 40 Breast cancer Gall stone is more common in female while in male the peptic ulcer is more common if pt came with upper abdominal pain. Examine the pain site and its related lymph nodes. Urine bag oliguria less than 400ml/day 1cc/hr/day of normal urine output Cervical superior lymph nodes deep cervical chain posterior lymph nodes Axillary central, humeral, subscapular, pectoral and parastenal lymph nodes Inguinal horizontal (umbilicus, genitalia, buttock and back)and vertical chain from lower limb 24/09/10 Dr Sunet - Renal stone - Gall stone and acute pancreatitis - Prepyloric ulcer - Acute appendicitis Questions: 1. Pain (referred, radiating and migrating) 2. Colicky pain on off, 1 min in, 10 min gone and intestinal obstruction 3. Strangury: slow and painful discharge of urine due to urethra and bladder spasm 4. Nocturia: excessive urination at night 5. Dysuria: painful/difficulty during micturition 6. Hematuria: blood in the urine 7. Frequency: urination at short interval w/o increase in daily volume intake or urine output due to reduce bladder capacity

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27/09/10 Clinic with Dr Ghassan 1. Hemorrhoids - 4 stage of it I with bleeding, II bleeding and prolapsed but return back itself, III bleeding and prolapsed and need to be push to return it back, IV bleeding, prolapsed and strangulated 2. Inguinal hernia - Cause divided to 2: I because of straining, lifting heavy things, to forceful coughing, II due to abdominal muscle weakness congenital, surgery, pregnancy 3. Thyroid problem - It may enlarge during pregnancy but it will be diffuse. But it also can be nodular in multiple pregnancies. - It may also diffusely enlarge if eating cabbage, in IDA and - Symptoms include palpitation, swelling on neck, increase appetite, loss weight, prefer cold weather - Signs are tachycardia, sweating and warm hand, and enlargement of thyroid, lid retraction, lid lag and exophthalmos. - Thyroid may move during swallowing

CASES
22/09/10 Appendicitis a. Inflammation to the vermiform appendix b. Clinical features: pain migrated from periumbilicus to right iliac fossa region, ass with nausea/vomiting and low grade fever, Rovsings sign and rebound tenderness c. Cx: appendix abscess and mass, perforation and peritonitis 24/09/10 Prepyloric ulcer a. Peptic ulcer: type I(gastric),II(gastric and duodenal aka prepyloric) and atypical ulcer b. Gastric ulcer: CF epigastric pain exaggerated by foods, causing weight loss and anorexia c. Prepyloric ulcer: CF ep relieved by food and pain may also be felt at the central back, more cyclical and ass with nausea d. Atypical ulcer mostly due to hypergastrinemia and ectopic gastric secretion e. Cx: GIT bleeding, IDA, perforation and obstruction because of scarring f. Drugs: antacids, antihistamine, PPI 28/09/10 1. Motorbike accident inquiry of small bowel injury 2. Bowel obstruction due to past colorectal surgery 06/10/09 1. Jaundice Serum bilirubin level is more than 40mmol

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Etiology: a. Pre hepatic more destruction of RBC b. Hepatic unconjugated and conjugated bilirubin c. Post hepatic intraluminal, intramural and extrinsic compression 2. Gall stone aka cholelithiasis a. Risk factor female, fat, fertile, forty and fair b. Types of stone mix, cholesterol and pigment c. Clinical features biliary colic (intermittent epigastric and RUQ pain, nausea and vomiting), acute cholecystitis (RUQ, right flank and back pain, fever and anorexia) and chronic cholecystitis 3. Stone in CBD aka choledocolithiasis a. Types primary and secondary stone b. Clinical features obstructive jaundice (yellowish coloration of skin and sclera, tea colored urine, pale stool, itchiness, epigastric pain, fever, nausea and anorexia), ascending cholangitis (obstructive jaundice, fever and RUQ pain) and acute pancreatitis 4. Acute pancreatitis (>55 years old) a. Etiology trauma, neoplastic (tumor of head of pancreas), infection (mumps and CMV), and others (drug related, gall stone, alcohol and hyperlipidemia) b. Clinical features fever, epigastric pain radiated to back, severe nausea and vomiting, hypotension, tachycardia and dehydration

My EOP notes
1. Perforated peptic ulcer a. Symptoms sudden onset epigastric/generalized abdominal pain, hematemesis, melena, altered consciousness b. Signs signs of shock (tachycardia, low pulse volume, low BP, pallor), abdomen less move with respiration, rigid abdomen, tenderness on palpation on upper abdomen/generalized, shifting dullness, absent bowel sound c. Differential diagnosis ruptured abdominal aortic aneurysm, acute pancreatitis, acute cholecystitis, trauma and stomach ca?, esophageal varices d. Investigation FBC, RF, DPL, CT scan and serum amylase, CXR, AXR, e. Management stabilized pt (O2, IV fluid, analgesia, NBM, NG tube, parenteral nutrition), investigation, manage f. Surgical option suture, excision and suture and gastectomy, peritoneal toilet g. Complication of surgical abscess, bleeding, stricture, small stomach syndrome, nutritional problem, surgical infection, recurrent ulcer and 2. Stomach ca - Spread of tumor: direct (pancreas, liver), lymphatic (Virchows LN, troissier sign), blood borne to liver and transperitoneal umbilicus and ovaries 3. Description on stoma bag

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4. 5. 6. 7.

Transparent/not Site Content (fluid/feces) Sprouting Typeeg: end loop etc Complication: infection, healthy/gangrene etc Breast carcinoma Vitiligo: white depigmentation of skin, associated with diabetes, hashimoto disease, Addisons disease, syphilis etc Lower git bleeding: common cause is diverticular disease at right colon and angiodysplasia at left and sigmoid colon.rectal bleeding???????? Spleen injury - Abdominal aorta celiac trunk spleenic artery

OSCE 1. Per rectal examination - Explain: insert finger in anus - Permission, clean hand and wear glove - Inspection - Lubricate finger - Insert, squeeze, feel post and ant - Look at finger - Swap lubricant from patient perianal region - Finding: rectal tumor, BPH, tenderness - Contraindication: fissure in ano and abscess 2. Fluid and electrolytes - Crystalloid: NS, 5% dextrose, dextrose saline and Hartmann/Ringers lactate (Na, K, Cl, Ca and lactate) - Colloid (blood, albumin and gelatin) - Gelatin will stay in intravascular compartment to pulling fluid from extravascular compartment 3. Surgical hemostasis - Direct pressure - Packing - Surgical option: artery forceps, electrocautery and clamping 4. Blood transfusion - Indication: traumatic accident with blood loss, severe burn, blood loss during major surgery, post operative anemia, loss to much blood because peptic ulcer bleeding - Preparation: donor, hospital etc and recipient? - Donor: fit, healthy - Hospital etc: anticoagulant added to blood and screening test (ABO typing, Rh, HIV, Hep B, Treponema pallidum)

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- Complication: acute hemolysis and transmitted infection 5. Skin lesion - Epidermis (include melanocyte), dermis and subcutaneous tissues - Basal cell carcinoma: ulcers at face, roll edge, causes are expose to UV, irridation and genetic, treatment are excision, cryosurgery and radiation - Squamous cell carcinoma: similar to above, except angry looking ulcer with bleeding and everted edge. Easily metastases than BCC - Maglinant melanoma: tumor of melanocytes. Based on A B C D criteria, asymmetry border color and discharge. Types are superficial spreading, nodular maglinant, lentigo maglina and acral lentigonous. Treatment are excision, chemotherapy and radiation - Cyst: epidermoid (scrotal), dermoid (midline) and trichilemmal (female scalp)

Surgery posting Y3