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Clinical Signs and Syndromes in Surgery
© 2011, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2011
Typeset at JPBMP typesetting unit
It had been an extremely pleasant experience going through the pages of Clinical Signs and Syndromes in Surgery.
In an era, where technology is rapidly trying to replace clinical skills, like recording a detailed history, eliciting clinical signs, etc., this work nudges you as a gentle reminder of the unquestionable relevance of clinical examination of a patient. I feel it has been a long-felt need of both undergraduate and postgraduate students, to have a ready-reckoner like this, and its utility is not restricted to students of surgery alone. It is of immense value to students of all disciplines of modern medicine.
In an examination scenario, to be able to group your findings and/or to know the names of various ‘named signs' and syndromes while presenting a case, is definitely a great advantage and would impress an examiner no end. Also, it will have immense utility in viva voce as well, and will make a topper standout from a mediocre. I am convinced that Dr Shivananda Prabhu has worked hard and researched well to collect this wealth of information and I am sure the medical students community will appreciate the value of this collection for years to come.
I congratulate and compliment Dr Shivananda Prabhu for this effort and wish him all the best in all his future academic endeavors.
Maj Gen (Retd) Dr G Rajagopal AVSM
Dean and Professor of Surgery and Oncosurgery
Kasturba Medical College
Mangalore, Karnataka, IndiaPreface
Ever since I was an undergraduate student, eliciting of clinical signs has always fascinated me. I remember watching in awe as seniors demonstrated clinical signs.
This wonderment at such skills reached its peak during discussion of central nervous system (CNS) disorders in the medical wards. Neurological disorders are nothing but a collection of signs, one used to think. Such thoughts brought anxiety with them as one was not sure how to cope.
Those times are long gone, but the fascination with signs remains. Having chosen general surgery as my field, it is only natural that I would now be interested mainly in signs pertaining to surgical conditions. Life of a surgeon is in many ways easier than that of a physician inasmuch as many of surgical conditions produce distinctive symptoms and signs unlike most medical illness. Also, surgical conditions most often than not lead to some anatomical and physiological distortions discernible by clinical examination as clinical signs. Only there have not been many books dedicated to this aspect of clinical examination. There are many excellent books dealing with clinical examination as a whole, but they do not segregate clinical signs from rest of the process of clinical evaluation. Hence, for a student preparing for clinical examination, it becomes a tough task to brush up his knowledge. Hence, the need for a book dealing exclusively with clinical signs. Also, while we do know about a particular sign as an indication of a particular disease often we do not really know the best way to elicit the sign. Easy access to diagnostic imaging has only made the ignorance deeper. This book attempts to address this problem. This should hopefully help not only students preparing for examinations but also practising surgeons.
I have included a brief account of syndromes, as I found these to be the scourge of exam-going students. Examiners revel in catching students off-guard by throwing questions at them about some obscure syndrome or the other. I hope to reduce such a threat by touching upon them. While this book may not have anything new in its content, I am sure the idea of presenting “signs and syndromes” in a concise book is a novel one.
Clinical examination is the most exciting as well as challenging part of a surgical residents' daily routine. Even in today's world where the advancement in the fields of laboratory sciences and diagnostics make the diagnosis of disease conditions less difficult than before, clinical acumen retains its importance. One needs sound clinical judgement to be able to make proper use of diagnostic technology. Hence, students of surgery should endeavor to acquire a level of clinical skills which allows them to narrow down the diagnostic possibilities and order for investigations accordingly.
Often, while examining a patient one relies on certain clinical finding elicited during examination to arrive at a plausible conclusion. Of course a detailed history taken from patient by a sympathetic and astute clinician will go a long way in pointing towards the pathology that the patient has. It is beyond the scope of the book to go into details of history taking. Good history along with well-detected clinical findings, when analyzed together will make the clinical picture clearer. If all the symptoms and clinical observations could be explained by a single pathological entity, then the diagnosis is near certain. Hence, only one diagnosis need be put forth and investigation asked for just to confirm or rule it out. On the other hand if all facets of the case cannot be explained by a single pathological lesion, then differential diagnosis should be thought of and investigations ordered accordingly.
What are these clinical findings which help us reach a definitive conclusion? These are observations made by the clinician during inspection, palpation, auscultation, or percussion. They are objective findings which can be corroborated by any clinician. There is no subjective element in them.
In other words, they are called “clinical signs”.
A clinical sign when properly elicited gives a clue to underlying pathology. Its presence makes the diagnosis more of a probability and less of a guess. When many such observations or signs are put together it is possible to arrive at a conclusive opinion regarding the disease process. It all looks simple and straightforward at first look. But one is well advised to keep the following facts in mind before embarking on the pursuit of this art of eliciting clinical signs.
- Just knowing the theory underlying a clinical sign is not enough. One should be familiar with the exact technique of eliciting the sign. One may not be able to demonstrate a sign, even when it is present if one employs incorrect technique. Even books will help only to a limited extent. There is no substitute for observing an expert clinician eliciting the sign.
- If an attempt at eliciting a sign is likely to cause discomfort to the patient then it is necessary that clinician explains to him the nature of the test and enlists his cooperation, e.g. rebound tenderness. An uncooperative and distressed patient is sure recipe for failure. If one fails to elicit such a sign within one or two attempts it is better to let it go as inconclusive or absent. One should persist in trying to elicit a sign only if it is vital for the diagnosis. There are very few signs of such singular clinical importance.
- If a simple laboratory test can avoid prolonged clinical examination and laborious analysis then choose it, especially in an emergency setting, e.g. chest X-ray with domes of diaphragm to check for free gas under diaphragm will clear the diagnosis immediately and should not be unnecessarily delayed pending detailed examination.
- One should be able to elicit the sign even when the diagnosis is as yet unclear. Anybody can elicit the sign once the diagnosis is established and known, e.g. even a beginner will be able to observe visible gastric peristalsis once endoscopy has revealed the presence of gastric outlet obstruction. But that observation will only serve academic purpose. On the other hand, if visible gastric peristalsis is observed by an astute clinician in the OPD itself, patient will be saved a lot of time and of course money. Such skill at observing the signs is especially useful while one is working in mofussil areas and not a city.
- Remember a particular sign need not be present in all cases of particular pathology. Atypical presentation of a disease condition is quite common and one needs to maintain a high degree of clinical suspicion to be able to diagnose a condition even in the absence of typical signs.
With these few facts in mind let us now acquaint ourselves with clinical signs, system-by-system.