Long Cases

Compiled by AELAF
 1. Thyroid
 History
 C/c: anterior neck swelling
 Hx
 Onset
 Duration: long – benign, MNG & colloid G; short – malignant
 Recent increase in size (hemorrhage [pain] or malignant transformation)
 Associated pain, radiation
 Dyspnea: tracheomalasia (MNG); 2ry thyrotoxicosis effect on CVS; RLN palsy
(bilateral)-Ca; retrosternal extension
 Local effects
 Dyspnea, dysphagia, hoarseness of voice
 Pain – thyroiditis, granulomatous, autoimmune, Riedel’s thyroiditis
 Toxic sx:
 CNS: predominantly 10 TT(GD); Irritability, tremor, excitability, heat
intolerance, cold preference, diplopia/blurring of vision
 CVS: usually 2ry MNG; Palpitation, dyspnea on exertion, pericardial chest
pain
 Wt loss with inc apetite, Increased stool freq, dysmenorrhea
(oligomenorrhea), proximal limb muscle weakness
 Hypo:
 Lethargy, deposition of fat, deep husky voice, intolerance to cold

 Mx features:
 SOB, cough- lung mx (follicular ca) 1st
 Bone pain or mass (flat): skull, ribs, sternum, vertebral column (follicular ca)
2nd
 Ascites, jaundice – liver mx (follicular ca) 3rd
 Hoarseness of voice – RLN palsy (unilateral) – anaplastic Ca
 neck swelling (papillary ca)
 Family hx (medullary ca)
 Chest irradiation
 Drugs – PAS & Sulfonamides (goiterogens)
 Physical examination Indications for surgery
 General appearance
 Toxicity
 Anxiousness
 Malignancy
 Restlessness
 Obstructive Symp
 nervousness
 Cosmetics
 Wasting
 Clothing, style on bed
 Vital sign
 PR: rhythm, volume, character
 RR:

Compiled by AELAF
  T
 BP
 Eyes
 Lid lag
 Lid retraction
 Exophtalmus
 Upper sclera visible (dalrymple’s sign)
 Absence of wrinkling of the forehead when pt is asked to look upwards (Joffroy’s
sign)
 Ophtalmoplegia
 Loss of convergernce of eyeball muscle (paresis) (Moebius sign)
 Chemosis

 Tongue
 Dry or wet
 Tremor
 Neck
 Inspection: pt sitting with neck slightly hyper extended & inspect from the front
 Location (unilateral, midline, bilateral)
 Size, shape, surface, border
 Swallowing (ligament of Berry, pretracheal fascia; restricted – Ca, RSG, large
goiter, previous surgery),
 Tongue protrusion to r/o TG cyst,
 Skin: redness, scar (recurrence), dilated veins
 Palpation: done from behind (Lahey’s method)
 Temp local rise – toxic G
 Size, shape, surface, consistency, border (esp the lower)
 Surface(smooth – GD, adenoma, pubertal goiter; irregular –Ca; nodular –
MNG),
 Consistency (soft – GD, colloid G; firm – adenoma, MNG; hard – Ca),
 Intrinsic mobility
 Tracheal deviation,
 Cervical/supraclavicular LN – papillary ca
 Berry’s sign: pulse of CCA in posterior triangle; CA (anaplastic) – BS +ve (if
pulsation is absent)
 Kocher’s sign: gentle compression on lateral lobe produces stridor - +ve:
tracheomalacia, carcinoma infiltration
 Pizzilo’s method: pt clasp his/her hand and press against his/her occiput
with head extended: to better visualize the thyroid in obese or short necked
ppl
 Pembertons’ sign: engorgement of neck veins when hands are raised above
the head: retrosternal goiter
 Percussion: Upper chest for retrosternal mass extension
 Auscultation:

Compiled by AELAF
  site – upper pole(STA – superficial, direct branch of ECA)
 Bruit + trill – toxic G, follicular ca (better app with the bell)
 Chest – mx
 CVS
 HR, rhythm, murmur
 Abd- hepatomegaly, ascities
 MSS
 Tremor, sweating, pretibial swelling,
 CNS
 Anxiety, restlessness, DTR
 DDx
 Simple NTG/colloid: euthyroid, soft nodule
 MNG: euthyroid or toxic(2ry)
 Solitary nodule: adenoma, cyst, Ca, part of MNG
 Follicular adenoma
 Malignant tumor: P-Ca – LLN involvement; F-Ca – scalp 2ry; A-Ca - +ve berry sign, stridor,
most rapidly growing
 Graves’ disease: diffuse, soft, swelling,
 Hashimoto thyroiditis
 Reidel thyroiditis
 Subacute thyroiditis: initial hyper
 Investigation
 U/S
 FNAC biopsy
 TFT(T3, T4, TSH & TRH)
 Flexible laryngoscopy (vocal cord mobility)
 Thyroid abs
 CBC
 LFT, abd u/s
 CXR
 CT
 Bone scan
 Isotope scan(hot, warm & cold nodules)
 Rx
 Early hyperplastic goiter – thyroxine – TSH suppression
 Thyrotoxicosis
 Carbimazole
 PTU
 B-blocker: Propranolol
 Iodides
 Radio iodine
 Diffuse ˃45 – RI, ˂45 –surgery, drugs
 NTG – surgery
 Toxic nodule – RI

Compiled by AELAF
  Recurrent after surgery- RI
 Failure of drugs & surgery - RI
 Surgery
 pre-op euthyroid pt using
 Carbimazole: 30-40 → 6-8wks
 iodide: 10-14 days before surgery
 B-blocker(propranolol): cont post- op
 Subtotal thyroidectomy
 Indication
 Neoplastic
 Toxic adenoma
 Pressure symptoms(dyspnea, dysphagia)
 Cosmetic, pts wish
 Near total thyroidectomy
 1-2gm remnant (parathyroid gland)
 Total thyroidectomy
 Ca: multifocal papillary(excellent prognosis), anaplastic, medullary
 Esthmusectomy
 Lobectomy
 Additional measures
 Thyroxine: to ↓ TSH, to replace thyroid hormone
 RI: for metabolism
 Thyroglobuline: follow up
 Post-op complications
 Hemorrhage
 Respiratory obstruction (tension haematoma, tracheomalacia)
 RLN paralysis (unilateral: whispering voice bilateral: stridor>respiratory failure)
 Hypothyroidism
 Hypoparathyroidism (most are transient- ischemia)
 Thyrotoxic crisis (storm)
 Wound infection
 Scar hypertrophy & Keloid
 Stich granuloma

Compiled by AELAF
 2. Breast
 C/c: Unilateral or bilateral breast swelling with or without pain
 Hx:
 Onset/ how noticed
 Progression
 Local symp
 Pain : cyclic Or progressive
 Skin ulceration, discoloration or discharge
 Nipple retraction or ulceration
 Nipple discharge
 Unilateral or bilateral
 Color (serous=fibroadenosis; greenish=fibroadenosis, duct ectasia,; pus=
abscess; bloody= ductal papilloma or carcinoma; milky=galactocele; pate=duct
ectasia)
 Amount
 Mechanism (spontaneous, squeezed)
 Pain associated
 Hx of trauma to the breast
 Hx of antibiotic use for breast abscess
 Fever, Malaise, Chills and rigors
 Risk factor for breast ca
 Age
 Age at menarch and menopause
 Parity, breast feeding
 HRT
 Alcohol
 Hx of breast ca in the same pt or in the family
 Chest irradiation
 Diet (high animal fat and meat)
 Metastatic manifestations
 Wt loss, dec apetite
 Axillary swelling, ipsilateral arm swelling
 Cough, hemoptysis, dyspnea
 Jaundice, abd swelling
 Back pain or swelling in bony areas
 CNS mx: headache, vomiting & blurring of vision
 Physical examination
 G/A (Exposure, 90° sitting)
 V/S
 HEENT: pallor, icterus
 Breast
Inspection: hand by side of the body, hands raise above the head, bending forward
 Edema of the arm

Compiled by AELAF
  Skin Axillary LN levels (surgical)
 Dimpling
 Peau d’orange  Level I: Lateral to pec minor
 Lump (Size, Location, Symmetry)  Level II: Deep to pec minor
 Erythema  Level III: Medial to pec minor
 Ulceration
 Nipple
 Discoloration
 Retraction (circumferential: malignancy slit-like: duct ectasia, periductal
mastitis)
 Discharge
 Deviation
 Destruction
Palpation (start from the normal appearing breast)
 Local rise in temp & tenderness
 Lump
 Location - quadrant
 Consistency
 Size
 Shape
 Surface - hard, irregular = Ca; soft = necrosis, mastitis Ca
 Border
 Mobility
 Fixation to
o Skin: pinch the skin above the mass
o Pec major: Hands on hip & press- if can’t be moved after contraction
o Chest wall: if not mobile when pec major is relaxed
o Seratous ant: pressing the hand against the wall. When the tumor is
situated in the outer and inferior quadrant
 Nipple
 Eversion
 Retraction
 Lump beneath
 Tenderness
 Squeezing
 Axillary LN
 Supraclavicular LN
 Chest: signs of pleural effusion
 Abd: liver enlarged, nodular; ascites; PR (deposition in the rectouterine pouch)
 MSS: areas of tenderness and swelling (spine, long bones, skull)
 Neurologic examination
 DDx
 Breast Ca

Compiled by AELAF
  Ductal papilloma
 Fibrocystic change +/- of chronic abscess
 Fat necrosis
 Sarcoma
 Phylloids tumor
 Fibro-adenoma
 Pure-adenoma
 Lipoma
 Investigation
 CBC, urine analyisis, LFT (alkaline phosphatase)
 Mammography: less sensitive in youngsters(U/S is indicated); in elderly even(35+) sensitive to
non-palpable mass, 90-95% accurate; pattern = loss of architecture, calcification
 Ill-defined edge
 Micro-calcification
 Shrinking of skin
 Single dilated duct
 Nodularity
 Indication
 Coarse nodularity
 Fibroadenoma
 Over 40yrs
 Advantage
 Non invasive
 No radiation
 Disadvantage
 3% false +ve
 Need FNAC to confirm
 U/s
 Age less than 35
 Greater than 95% accuracy
 Of +ve intra-op frozen section is arranged
 FNAC (Lump, axillary LN(confirmatory))
 Biopsy (core needle, excisional)
 CXR
 Bone x-ray
 Abd U/S
 Management
 Depends on staging
 Post op complications
 Arm swelling
 Recurrence
 Lymphangiosarcoma
 Psychological stress
 Ca frequency

Compiled by AELAF
  Upper outer (most of the breast tissue is located here) = 60%
 Areola = 12%
 Upper inner = 12%
 Lower outer = 10%
 Lower inner = 6%

Compiled by AELAF
 3. Esophageal Ca
 History
 C/c: difficulty of swallowing
 Hx
 Onset
 Progression - solid→ semisolid → liquid → saliva => Ca;
- Liquid → solid; liquid=solids => achalasia
 Intermittent (motility disorders), progressive (CA)
 Halitosis
 Regurgitation – pronounced in achalasia at recumbent position
 Nausea/ vomiting: pattern, amount, content, time
 Squeezing type of chest pain pronounced during emotional stress and/or cold meals
and drinks- DES, nutcracker esophagus
 Efforts to facilitate swallowing
 Site of discomfort or associated pain
 Frequent Consumption of hot and spicy foods (porridge)
 Alcohol, cigarette
 longstanding heart burn RF
 corrosive ingestion
 carnivorous diet
 Appetite & weight loss (significant if 10% in 3mo)
 Voice change (hoarseness)
 Choking episode (trachoesophageal fistula, aspiration)
 Hematemesis, melena (esophagoaortic fistula)
 Cough, dyspnea (pleural effusion), hemoptysis (lung mx) Advanced Sxs
 Swelling around the neck (Cervical & SC lymphadenopathy)
 Ascites (mx to liver [jaundice], or hypoalbuminemia)
 Chronic back pain (celiac node enlargement)
 Bone pain (mx to bone)
 Chronic illnesses (DM, Htn, Asthma, cardiac disease)
 Physical examination
 General appearance
Choking
 Sick looking
 Wasting  Every time one ingests food: fistula
 V/S  When full: aspiration
 HEENT: pallor, jaundice, dehydration, halithosis
 LGS: supraclavicular and cervical LAP SOB & Stridor
 CVS  Bilateral RLN paralysis
 RS: mx (pleural effusion)  Infiltration of airway
 Abdomen: hepatomegaly, ascites  Lung mx
 MSS: Edema (hypoalbuminemia)  Pleural effusion
 DDx
 Esophageal Ca
 Leiomyoma of esophagus

Compiled by AELAF
  Achalasia
 Gastric Ca
 Pharyngeal pouch
 Scleroderma
 Corrosive ingestion
 Chronic esophagitis
 Para-esophageal hernia
 Thymoma
 Plummer Vinson syndrome(PVS)
 Investigation
 CBC (anemia), LFT, RFT
 Barium swallowing (proximal dilatation, shouldering, irregular lumen)
 Upper GI Endoscopy (Esophagescopy)
 Edndoscopic U/S (least invasive, better diagnostic)
 Manometer (if we are inclining to motility disorders)
 Serum electrolyte (esp potassium-saliva)
 Serum albumin
 CXR
 Abd U/S (liver secondaries, ascites, LN mx)
 CT (staging)
 Bronchoscopy: compression, tracheo- esophageal fistula
 Management
 Achalasia
 Pharmacotherapy
 Botulinum toxin
 Esophageal dilation
 Operative myotomy (Heller’s cardiomyotomy)
 Esophageal Ca
 Surgery
 Palliative
 Dilatation
 Stenting
 Local laser ablation
 Definitive:
 Esophagectomy
o Transhiatal
o Ivor lewis
o Mc. Kweon
 Chemotherapy: 5-fluorouracil
 Radiotherapy
 Terminal complications
 Cachexia
 Dehydration
 Pneumonia

Compiled by AELAF
  Mediastinitis
 Erosion to aorta
 Hemothorax, pneumothorax

Compiled by AELAF
 4. Cholelithiasis
 History
 C/c: RUQ pain
 HPI
 Pain: location (RUQ/epigastric), type, onset, duration, relief, radiation(back,
shoulder), association with food specially fatty meal (1-2 hrs later)
 Diaphoresis, nausea and Vomiting: fat intolerance, content
 Flatulence, Diarrhea, Constipation
 RF for cholelithiasis
 Female sex, age >40, family hx
 Obesity, rapid wt loss (fasting), pregnancy
 Medicine (OCP, ceftriaxone, octerotide), surgery (ileal resection)
 DM, spinal injury, total parental nutrition, dec physical activity
 DDX for cholelithiasis (chronic)
 PUD (gastritis): dyspepsia, heart burn, melena, hematemesis, relation with
antiacids, NSAID, smoking, alcohol
 Renal calculi: flank pain, frequency, urgency, urine discoloration
 Chronic Hepatitis: blood transfusion, alcoholism
 Chronic pancreatitis
 IBD
 Diverticular disease
 Complications of Cholelithiasis
 Acute Cholecystitis: fever, rigor, chills, nausea, vomiting (tenderness,
guarding, murphy’s sign)
o Ddx: perforated PUD, acute pancreatitis, rt sided
pneumonia, pyelonephritis, acute hepatitis
 Chronic cholecystitis: recurrent episodes of RUQ pain, N, V, bloating, belching
& flatus
 Cholidocholithiasis: jaundiced, prutitis, urine and stool color change
 Cholangitis: jaundice, fever, altered mental status
 Pancreatitis:
 Gallstone illeus: abd pain, vomiting, distension, constipation
 Traditional(herbal) medication
 Physical examination
 General appearance
 Skin & eye color
 Scratch marks
 V/s
 HEENT
 Eye: pallor, icterus
 Parotid enalrgment
 Lymhoglandular - Virchow’s, gynecomastia
 Chest :

Compiled by AELAF
  CVS
 GIT
 Abdomen:
 Rt. subcostal: pain, guarding
 Murphy’s sign
 Boas sign
 stigmata of CLD: ascites, liver span, capute medusa
 GUS: CVAT
 Integumentary: telangectasia
 MSS: dupetryens contracture, thenar atrophy
 CNS
 Investigation
 CBC (leucocytosis> cholangitis, cholecystitis; anaemia>malignancy, platelet count)
 LFT (↑ conjugated bilirubin and alkaline phosphatase in OJ)
 Serum Amylase (Acute pancreatitis)
 Urine analysis: uro-bilirubine
 Plain abdominal x-ray
 U/S
 CT (if mass is seen on U/S)
 PTC
 ERCP

 Management
 Conservative
 Analgesia
 Anti-spasmodic
 Low fat intake
 Medication: bile acid, chemodeoxycholic acid
 Surgery
 Emergency cholecystectomy
 Acute cholecystitis ˂ 48hrs
o NG tube, IV fluid, analgesia, antibiotics,
 Cholecystectomy in 2-3days
 Elective cholecystectomy
 After conservative mgt: in chronic cholecystitis(acute on chronic)
 Pre-op
o Antibiotics
o Medication
o Cholangiography
 Operation
o Cholecystectomy (open/laparascopic)

Compiled by AELAF
 5. OJ
 Hx
 Jaundice: onset, progression, intermittent (CBD stone)/persistent (malignancy)
 RUQ or epigastric pain (if painless-malignancy)- onset, duration, quality, radiation
 Nausea, vomiting
 Fever (cholangitis): intermittent/continuous, duration, chills/rigors
 Pale stool, dark urine, pruritus
 High carrot ingestion, or rifampine use
 Night blindness, bone pain, brusing, weakness, steatorrhea (due to conjugated
hyperbilirubinemia or chronic malabsorption of fat-soluble vitamins)
 Appetite and wt loss, abd discomfort (malignancy)
 DM, alcohol, smoking- RF for pancreatic head tumor
 Biliary surgery (biliary stricture)
 Medical
 Contact with other jaundiced pts
 History of injections or blood transfusion
 Exposure to drugs
 Contact with river water (shistosomiasis)
 Physical
 G/s
 V/s: fever (cholangitis)
 HEENT: icteric sclera, pale conjunctiva, dehydrated
 LGS:
 Chest:
 CVS
 ABD: RUQ tenderness, stigmata of liver disease, ascites, distended gallbladder, DRE
 Integumentary: scratch marks
 MSS: edema (hypoproteinemia due to decreased fat absorption)
 Investigation
 CBC, e-
 HBsAg
 LFT (bilirubin, ALT/AST), PT, PTT (b/c defect in the fat soluble vit. Esp vit k)
 RFT (hepatorenal syndrome)
 U/S liver, CBD, ascites
 CT if mass is seen in U/S
 ERCP,MRCP,PTC
 DDx
 Non-surgical
 Drugs
 Alcohol
 Viral hepatitis
 1ry biliary cirrhosis
 Surgical
 Choledocholelithiasis

Compiled by AELAF
  CBD Ca
 Peri-ampulary Ca
 CBD stricture
 LAP of portahepatis
 Liver HC
 Chronic pancreatitis
 Complications (of OJ)
 Ascending cholangitis
 Pancreatitis
 Hypoprotenemia and Malnutrition
 Bleeding diathesis
 Infection and sepsis
 Dehydration
 Hepato-Renal syndrome
 Impaired wound healing
 Impaired drug metabolism
 Electrolyte disturbances
 Recurrent stone
 Biliary Cirrhosis

 Management
 Of complications (PreOP)
 Oral fluids or IV crystalloids (dehydration)
 Blood transfusion (anemia)
 Broad spectrum antibiotics (ceftriaxone + metronidazole)
 Vit K 10 mg IM 5-10 days. If no improvement fresh frozen plasma or whole blood.
 High protein diet (hypoproteinemia) high carbohydrate diet (low glycogen reserve)
 Normal saline, diuretics (renal failure 20 due hepatorenal syndrome)

 Operation (stone in CBD) Common causes of biliary infection

 Ideal setup: optimize the pt> ERCP
Enterobactericae (68%)
(sphinterotomy and stone removal)>laparascopic
cholesystectomy  Ecoli
 Our setup: CBD exploration (cholecystectomy +  Klebsella
cholidocolitotomy)> remove stone> insert t-tube>  Enterobacter
suture the CBD over the t-tube> drain the sub
hepatic space> do cholangiography 8-10 days later Enterococci (14%)
(retained stones, patency of the duct)> remove Anaerobes (10%)
the t-tube 1st and the drainage tube 2-3 days later.
Clostridium (7%)

Compiled by AELAF
  If retained stone (seen on t-tube cholangiography)
 Irrigate (mechanical flushing with heparinized saline)
 Contact dissolution agents (work only for pure cholesterol stones)
 Send the pt home for 4-6 wks>t-tube tract will be well formed>remove t-tube and
insert choledoscope and remove stone
 Shock lithotripsy
 ERCP (sphincterotomy and removal of stone)
 Laparascopic cholidocholitotomy
 Open cholidocolithotomy (Only one done in our setup)

Whipple’s procedure
 Complications (of Mgt)
 (ERCP) pancreatitis, cholangitis,  Gastro-jejunostomy
perforation of duodenum or bile duct,  Hepatico-jejunostomy
bleeding, Stricture  Pancreatico-jejunostomy
 (PTC) Bacteremia, Hemorrhage, Contrast
reaction, Pneumothorax,
Intrahepaticarterioportal fistula, Bile leakage
 (pancreaticoduodenectomy) Anastomotic leaks, pancreatic fistula, intra-abdominal
abscesses, postoperative malabsorption and steatorrhea anddelayed gastric emptying
 Indication for CBD exploration
 Palpable CBD stones
 Stone CBD
 Dilated CBD
 Jaundice (even hx)
 Abnormal LFT, in particular, the alkaline phosphatase is raised

Compiled by AELAF
 6. Gastric outlet obstruction
 History
 C/c epigastric pain & vomiting
 HPI
 Pain: onset, type, radiation, progression, association with meal, wakes from
sleep,
 Vomiting: mechanism(induce or spontaneous), prior nausea, content (blood,
coffee ground, bilious, ingested matter) [in GOO non bilous]
 Appetite: hunger, sense of early fullness
 hematemesis
 Tarry stool, melena,
 Weight loss, abd distension, bloating
 Rf for PUD, Gastric ca
 NSAID, smoking, alcohol, khat, stress
 Carnivores diet, fruit and vegetable def, gastric surgery
 Mx
 Jaundice, ascites
 Cough, chest pain, sob
 Bone pain
 Swelling in other sites (supraclavicular, umbilical)
 Previous TB infection, contact with a smear positive TB pt
 Previous hx of caustic ingestion
 Hx of HTN, DM, medication
 Physical examination Indications for surgery in PUD
 General appearance
 Bleeding
 Dehydration, pallor, icteric, sunken eye,
 Perforation
consciousness, skin turgor, mucus
 GOO
membrane, arrhythmia, LAP (Virchow, sis
 Transformation into malignancy
merry joseph)
 Abdomen
 Epigastric tenderness, palpable mass, succusion splash, visible gastric
peristalsis, hepatomegaly
 PR
 Inspection, melena, blummer shelf (rectovesical deposits-transperitoneal
spread), tenderness
 DDx
 Pyloric stenosis (PUD)
 Gastric Ca
 Leiomyoma (GIST) - bleed
 Lymphoma
 Tb lymphadenitis
 Chronic pancreatitis
 Crohn’s disease
 Caustic ingestion

Compiled by AELAF
  Investigation
 CBC, ESR, HB%
 Electrolyte,
 Barium meal
 Gastroduodnoscope (biopsy)
 Occult blood
 LFT, urine alnalysis
 H pylori test
 CT &U/s (secondary to liver, acites, celiac node enlargment)
 Serum amylase, lipase
 Management
 GOO
 IV isotonic saline + K supplementation
 If anemic- blood
 Vagotomy + GJ (PUD)
 Total gasterectomy with esophagojejunostomy , or billroth 2 (Gastric ca)
 Conservative mgt of PUD
 Decrease acid:
 H2-blocker: cimetidine 200mg
 PPI: omeprazole 20mg
 Anticholinergic are contraindicated
 Avoid provoking agent: drugs, alcohol, smoking, food, coffee

Compiled by AELAF
 7. Bladder outlet obstruction
 C/c: difficulty of micturition
 HPI:
 Onset, duration, progression
 Complaints: hesitation, poor flow, intermittent stream, dribbling, sensation of
incomplete emptying
 Frequency, urgency, urge incontinence, enuresis, nocturia, dysuria
 Supra-pubic pain (acute retention, urinary infection, bladder stone & prostatic ca)
 Hematuria: initial, mid-stream, terminal or full stream
 Flank dragging sensation (hydronephrosis, pyelonephritis [fever])
 Carnivores diet, dietary fat (prostatic ca RF)
 Bone pain, back pain, jaundice, cough, hemoptysis (prostatic ca mx)
 Cigarette smoking, occupational exposure (textile, dye, leather, exterminator, painter),
river water exposure (shistosomia) – Bladder CA
 Weakness, fatigue, weight loss, appetite loss (malignancy)
 Gonococcal urethritis, repeated catheterization, urethral trauma (urethral stricture)
 Hx of TURP (bladder neck stenosis)
 Hx of DM, HTN, stroke, parkinsonism, vertebral trauma (neurogenic bladder)
 PE:
 General appearance
 Sick looking, apprehension
 V/S
 HEENT: icteris, paleness, dehydration
 CHEST: mx
 ABD: liver, ascites
 GUS:
 Kidney
 Urinary bladder
 Genitalia
 Scrotum
 Pelvis
 DRE (Smooth, rubbery, median sulcus palpable, rectal mucosa mobile, nontender - BPH)
(Nodular, hard, median sulcus obliteration, rectal mucosa immobile, nontender – Ca)
 DDx
 BPH
 Irritative symptoms
 Obstructive symptoms
 hematuria
 Stricture
 Trauma: catheterization, direct trauma, pelvic surgery(BPH)
 Inflammation: discharge
 Neoplasia
 Prostatic Ca
 BPH ssx

Compiled by AELAF
  Bone pain
 Wt. loss, weakness, appetite
 Bowel habit
 Pain
 Bladder neck contraction
 Neurogenic bladder
 Investigation
 CBC (anemia- renal failure, extensive marrow invasion), LFT (inc alk phosphatase)
 Urine
 Qualitative: color, smell, PH(6.5-8), SG(1.05-1.30)
 Quantitative: amount, capacity (250-500ml, M˃F)
 Substances: protein, sugar
 Sedimentation: SG = 1.40 pyuria
 Collection: clean couch, avoid latency, mid-stream specimen
 Centrifuge at 1000evo/sec/2min or 2000evo/sec/1min, prevent cell lysis
 Cell in urine: WBC, RBC, bacteria, fungal spore, casts, cytology(benign or
malignant cells)
 Protein casts – renal paranchymal
 Crystal: calcium, oxalate, phosphate
 Chemical testes
 PSA
 Blood:
 BUN: depend on diet & catabolism
 Creatinine – highly sensitive
 Creatinine clearance = UV/P/24hr
 U/s: highly sensitive & specific; solid as small as 2mm, cysts; most widely used in
urology; transrectal ultrasonography: r/o out P. Ca; done when level of PSA rises;
 flow- echocardiography, Doppler u/s; air-undetected
 Plain radiography - KUB: level, side, shadow, soft tissue, skeleton (scoliosis, gibbus, S.
bifida), surface
 Contrast study:
 IVU/IVP + post micturition film:
 Preparation for IUV: laxatives, moderate fluid restriction
 Position, abnormality, uretericposition, bladder, site of obstruction(wine
glass appearance),
 Retrograde pyelography: catheterize urethra, always following IVP revealed
obstruction to assess length of obstruction
 Anterograde pyelography: injection into pelvic ureter, in pt with renal failure,
allergic pts
 Urodynamic flow studies
 Flow rate: greater than 200ml at 10ml/sec – obstruction; at 15ml/sec – normal
 Pressure: high pressure low flow rate – obstruction; low pressure low flow rate -
detros abnormality
 Cystourethrocope

Compiled by AELAF
  CI in urethral stricture
 Look at: trigon, ureteral opening, diverticulosis, trabeculation, inflammation,
urethral lumen, urothelium
 ??Biopsy
 Angiography
 CT, MRI, chest and lumbar xray (sclerotic lesion)
 Radioisotope scan: function of individual renal unit
 Management
 BPH: indication for prostatectomy
 Acute retention: exclude other causes – drugs, constriction, recent operation
 Chronic retention: RV greater than 200ml, uremia, hydro ureter or nephrosis
 Complication: stone, infn, diverticulosis
 Hemorrhage
 Sever symptoms (affecting quality of life) IPSS (20-35)
 Methods:
 Medical
 alpha adrenergic blocking agents (inhibit contraction of sm in the
prostate) - Doxazosin, Terazosin, tamsulosin
 5alpha reducates inhibitors (inh conversion of testosterone to DHT):
 Surgical
 TURP
 Transvesical
 Retropubic
 Perineal(abandoned)
 Complication:
 Local:
 hemorrhage,
 perforation,
 sepsis,
 urethral stricture,
 bladder neck contraction,
 incontinence (damage to the external sphincter)
 retrograde ejaculation
 General: CVS – CHF. MI, DVT, water intoxication in TURP, death
 Pain in urinary tract
 Upper
 Dullaching – colicky
 Referred to Ipsilateral groin, scrotum, labium, upper inner thigh
 Lower
 Suprapubic discomfort
 Referred to tip of penis(trigon irritation)
 Worsen by bladder filling
 Stranguria – severe pain wrenching discomfort at the end of micturition =
indicates severe infn of bladder.

Compiled by AELAF
 8. COLONIC CA
HISTORY

 age: more common above 50

 sex :Rt sided colonic ca is more common in females &Lt sided colonic ca is more common in
males
 rectal bleeding (melena [rt], hematochezia [lt]), fatigue, weakness
 abdominal mass or pain(with characterization),back pain, pelvic pain
 bowel habit change (alternating consitipation and diarhea)
 tenesmus (straining during defication), sense of incomplete defecation, heamatochezia (blood in
the stool), =rectal ca
 urinary complaints (pneumaturia, fecaluria, recurrent UTI) – CT, cystoscopy
 abdominal distension, vomiting, nausea
 fever, chills
 jaundice, ascites,
 smoking, alcohol, pelvic radiation, IBD (RF for colonic Ca)
 family history of colonic ca (RF for colonic Ca)
 dietary factors: red meat ,fat (predisposing); high fiber diet and aspirin (protective)
 raw milk consumption, contact with a smear +ve case, previous TB hx (TB)

PHYSICAL EXAMINATION

 Usually normal except in advanced disease.

 general appearance: chronically sick looking, acutly sick looking if there is obstruction
 vital signs:BP low &HR high if there is excessive bleeding, temp high if there is secondary
infection or pericolic abcess
 signs of anemia: pallor in conjuctiva and or/palm
 icteric sclera
 abdominal mass due to the tumor it self,hepatomegally,ascites
 abdominal tenderness
 PR: mass,blood,fixation
 fecal matter coming out of vagina or urethra(in case of fistula)
 edema (hypoalbuminaemia)

INVESTIGATIONS

 Hb,WBC,ESR
 stool exam: occult blood
 LFT,RFT,ECG
 BGL
 US
 CT

Compiled by AELAF
  Barium enema
 Colonoscopy(gold standard)
 flexible sigmoidoscopy
 CXR,CEA

COMPLICATIONS

 Intestinal obstruction
 Pericolic abscess
 Fecal fistula
 Internal fistula
 Generalized peritonitis

DDX

 Colorectal ca
 Inflammatory bowel disease
 Diverticulosis
 Intestinal TB
 Irritable bowel syndrome
 Other dynamic and adynamic causes of bowel obstruction (volvulus ,band ,adhesion ,intussusception
,ileus ,etc…)
 AVM(arterio venous malformation)
 Ischemic bowel disease
 Hemorrhoids

Compiled by AELAF