A FEW SPECIAL SYMPTOMS AND

SIGNS IN GENERAL SURGERY

Dr. Sneha M Nair
HS
Dept. of general surgery
 PAIN

Pain v/s Tenderness

pain is the feeling that patient tells you-
(symptom) while tenderness is elicited by the
doctor by giving a stimulus(sign).
 TYPES OF PAIN

SUPERFICIAL SEGMENTAL PSYCHOGENIC/

PAIN DEEP/VISCERAL PAIN
PAIN CENTRAL PAIN
SUPERFICIAL PAIN
• Occurs due to direct irritation of the
peripheral nerve endings in the superficial
tissues.
• It can be due to chemical or mechanical or
thermal or electrical irritation
• Such pain will be sharp and can be pointed out
with a finger tip.
SEGMENTAL PAIN
• Occurs due to irritation of a sensory nerve
trunk or root.
• Pain will be located in a specific dermatome
supplied by the affected nerve trunk or root
DEEP/ VISCERAL PAIN
• This pain occurs due to irritation of deep
structures like deep fascia, muscles, tendons,
bones, joints or viscera.
• Afferent may be somatic or autonomous
nervous system.
• Vague type of pain
PSYCHOGENIC OR CENTRAL PAIN
• Pain arises from the brain, which may be a
functional pain either emotional or hysterical
or due to lesions of thalamus or spinothalamic
tract or due to causalgia.
Points to be noted to determine the cause of pain:
1. Original site of pain- eg. In appendicitis, the
pain initially starts in the umbilical region but
later in the right iliac fossa.
2. Origin and mode of onset- long continued
pain> chronicity eg.: chronic pancreatitis, c/c
peptic ulcer, subacute appendicitis etc., while
recent onset with sudden arrival> acute type
eg.: acute appendicitis, acute pancreatitis,
rupture of aneurysm etc.
Mode of onset: eg. after trauma
3. Severity
4. Nature of pain-
• VAGUE ACHING PAIN- mild continuous pain with no
other specific feature
• BURNING PAIN- burning sensation > peptic ulcer
• THROBBING PAIN > pyogenic absecc
• SCALDING PAIN > felt during micturition in presence of
cystitis or urethritis
• PINS AND NEEDLES SENSATION- In peripheral sensory
nerve injury
• SHOOTING PAIN- sciatica
• STABBING PAIN- sudden, sharp, short lived pain> acute
perforation of peptic ulcer
• CONSTRICTING PAIN- as if something is compressing or
encircling from all directions> angina pectoris
• DISTENSION- feeling of tightness when tension
increases in hollow viscus
• COLIC-occurs when muscular wall of tubular structures
forces out contents from it.eg. ureteric colic, biliary
colic, intestinal colic and appendicular colic
• TWISTING PAIN- volvulus of intestine, tortion of testis/
ovary
• JUST A PAIN- non specific
5. Duration
6. Movement of pain>
• Radiation- extension of pain to other site whilst
pain persist in the original site. Eg. When
duodenal ulcer penetrates posteriorly, pain in
epigastrium remains while it radiates to the back.
• Referred pain- pain is felt at a distance from the
source and there is no pain at the site of disease.
Eg. Irritation or inflammation of diaphragm cause
pain in the shoulder
• Shifting or migrating pain- pain starts at one point
later shifts to other point and pain in the initial
site will disappear. Eg. appendicitis
7. If there is any special time of occurrence of pain- eg.
Hunger pain in duodenal ulcer which occurs mostly at
4pm and early morning 2am to 3am.
8. Periodicity
9. Precipitating or aggravating factors- eg. Pain of a/c
pancreatitis increase on lying down position.
10. Relieving factors- eg. Pain of a/c pancreatitis relives
on sitting and leaning forward position
11. Associated symptoms like pallor, sweating, vomiting
etc.
 NAILS
• Clubbing> tissues at base of nail thickened and angle b/w nail base
and adjacent skin is obliterated.

• Splinter hemorrhages under nails> systemic vasculitis

• Multiple splinter hemorrhages> infective endocarditis
• Koilonychia> spooning of nails as in iron deficiency anemia
• Terrys nail> whitening of nails as in hypoalbuminemia
 VOMITING
• Can be due various reason
• Points to be noted: frequency, time, color,
quantity and smell of vomitus.
VOMITUS POSSIBLE CAUSE
Recent ingested material Acidic: gastric outlet obstruction
Non acidic: achalasia of esophagus/ being or malignant
strictures of esophagus
Yellow colouration Bile content
Green colouration Upper small bowel contents
Faeculant vomitus Lower small bowel contents

Vomitus containing faecus Gastrocolic fistula

Blood in vomitus Fresh blood: gastric ulcer/esophagal varices
Blackish/brownish- coffee ground appearance
 TONGUE
• Tremor of tongue> thyrotoxicosis
• Color
• Moistness> hydration status
• Bald tongue without papillae> vitamin b12
deficiency
• Sides and undersurface should be looked for
ulcers.
 ABNORMAL SUPERFICIAL VEINS/VISIBLE
VEINS
• Radiating veins from the umbilicus in the
abdominal wall > obstruction to the portal
venous system> caput medusae.
• Varicose vein> dilated and tortuous veins in
the lower limb.
• Engorged superficial veins in flanks extending
from axilla to groin> inguino-axillary veins>
obstruction of inferior vena cava.
 PITTING ON PRESSURE
• This indicates subcutaneous edema which can
be generalized edema due to disorders of
heart, kidney, liver, gut or diet or local edema
due to venous or lymphatic obstruction,
allergy, or inflammation, pretibial myxoedema.
 CREPITUS
2 types:
• grating sensation- bone and joint pathologies
• Crackling sensation- presence of air in the
subcutaneous tissue
Grating sensation Cause
Bone crepitus When 2 fractured fragments of bone move against
each other
Joint crepitus Fine crepitations or coarse creps or click as in loose
body or displaced cartilage
Crepitus of bursitis Bursitis
Crepitus of tenosynovitis tenosynovitis

Crackling sensation Cause

Traumatic Rib fracture > subcutaneous emphysema

Infective Gas gangrene

Operative Air trapped during closure of wound
 FAECES
In all bowel disturbance cases stool shpuld be
examined.
• Amount : copious/ scanty,
• liquid/ semi-formed/formed/hard
• Colour : black coloured: haemorrhage
in intestine or iron or bismuth ingestion

Pale coloured: obstructive jaundice

• Odour
Abnormal stools:
• Slimy stools due to excessive mucus> large bowel d/o
• Blood in stool:
1.Malena> when bleeding is from gastric or duodenal origin-
dark and tarry
2.Dark red fragmented clot> small intestine
3.Dark red and jelly like> large intestine
4.Bright red > rectum or anal canal

• Steatorrhea>large, pale, porridge like

• Pipe stem stool> carcinomatous strictures of rectum
• Tooth paste stool> hurschsprung disease
• Meconium> greenish black, scanty, semiliquid, odourless
sticky faeces passed by newborns
THANK YOU