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Arriving at a Surgical Diagnosis
Pramod Shrikrishna Bapat
SECTION 1: GENERAL SURGERY
1:
GENERAL PRINCIPLES OF CASE-TAKING
2:
HISTORY-TAKING
DETAILED ANALYSIS OF HISTORY
DATE AND TIME
SOURCE AND RELIABILITY
NAME
AGE
GENDER
RESIDENCE
OCCUPATION
MARITAL STATUS, with number of children produced and their age
DIET
CHIEF COMPLAINT / S
HISTORY OF THE PRESENT ILLNESS
PAST HISTORY
SMOKING / CONSUMPTION OF TOBACCO in any other form?
ALCOHOL?
OTHER ADDICTIONS? Details?
HYPERSENSITIVITY? Details?
HEALTH MAINTENANCE PRACTICES?
FAMILY HISTORY
PERSONAL AND SOCIAL HISTORY
3:
SELECTED COMMON SYMPTOMS IN CLINICAL PRACTICE
4:
GENERAL EXAMINATION
ANALYSIS IN DETAILS
IS THE PATIENT CONSCIOUS (i.e. AWAKE AND ALERT)?
IS THE PATIENT COOPERATIVE?
IS THE PATIENT WELL-ORIENTED IN TIME, PLACE AND PERSON?
POSTURE, GAIT AND GENERAL ACTIVITY?
SIGN OF DISTRESS?
EYES AND FACIAL EXPRESSION?
APPARENT STATE OF HEALTH?
TONGUE?
NECK
SKIN
DORSUM OF THE HANDS
NAILS
PALM
EDEMA
VEINS ON THE DORSUM OF THE FEET in A PATIENT LYING SUPINE in horizontal position
TEMPERATURE
PULSE
RESPIRATION
BP
JVP
HEIGHT
WEIGHT
BMI (Body Mass Index)
BODY PROPORTION
SKULL
HAIR on the scalp, face, axilla, and pubis
SCALP
LIPS
CHEEKS
GUMS AND TEETH
THROAT
NOSE AND PARANASAL SINUSES
EAR
LYMPHADENOPATHY
ODOR OF THE BODY / BREATH
SIGNS OF HYPOVOLEMIA AND HYPERVOLEMIA (Underhydration v/s overhydration)
A NOTE ON NUTRITION
5:
LOCOREGIONAL EXAMINATION
6:
RESPIRATORY SYSTEM EXAMINATION
7:
PELVIC EXAMINATION
VAGINAL EXAMINATION IN A FEMALE PATIENT
EXTERNAL EXAMINATION OF THE VULVA
INTERNAL EXAMINATION OF THE VULVA
INTERNAL EXAMINATION WHEN THE INTROITUS IS SMALL
SPECIFIC GYNECOLOGICAL NORMAL AND ABNORMAL FINDINGS, INTERPRETATION, AND DISCUSSION
RECTAL EXAMINATION
PROCTOSCOPIC EXAMINATION
8:
EXAMINATION OF THE PREGNANT PATIENT
9:
DIAGNOSIS
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
STEP 1: IS THE CONDITION ACUTE, CHRONIC OR ACUTE-ON-CHRONIC?
STEP 2: ANATOMICAL diagnosis?
STEP 3: PATHOLOGICAL diagnosis?
STEP 4: IS THERE HOMEOSTATIC IMBALANCE?
STEP 5: ASSOCIATED DISORDER if any?
MAKE A HYPOTHESIS OF DIAGNOSIS, AND JUSTIFY IT WITH THE HELP OF THE FOLLOWING POINTS
APPLIED PHYSIOLOGY
10:
GUIDELINES ON DOCUMENTATION OF CLINICAL NOTES
11:
SUDDEN LOSS OF CONSCIOUSNESS (SUDDEN UNRESPONSIVENESS) CARDIORESPIRATORY ARREST
A QUICK NEUROLOGICAL AND FOCUSED GENERAL EXAMINATION
12:
SHOCK
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Step 1
Step 2
Step 4
Step 5
Step 6
DIFFERENTIAL DIAGNOSIS
THE OUTCOME OF SHOCK
13:
INFECTIONS / INFESTATIONS
SPECIFIC BACTERIAL INFECTIONS OF SURGICAL IMPORTANCE
ARRIVING AT THE DIAGNOSIS OF ACUTE SPECIFIC BACTERIAL INFECTIONS AFFECTING NON-VISCERAL SOFT TISSUES
Site
Precipitating factor
Predisposing factors
Mode of onset, and progress
Degree of toxemia
DIFFERENTIAL DIAGNOSIS
NOTES ON SELECTED CHRONIC BACTERIAL INFECTIONS
TB
Leprosy
YAWS
FUNGAL INFECTIONS OF SURGICAL IMPORTANCE
PARASITIC INFESTATIONS OF SURGICAL IMPORTANCE
14:
SKELETAL MUSCLES IN THE BODY AMENABLE TO PHYSICAL EXAMINATION: (Applied Anatomy)
15:
SWELLING: Basic concepts, including differential diagnosis of acute swelling and chronic general swelling
ARRIVING AT THE DIAGNOSIS
ARRIVING AT THE DIAGNOSIS OF AN ACUTE SWELLING
ARRIVING AT THE DIAGNOSIS OF A CHRONIC SWELLING
PRINCIPLES AND PITFALLS
HISTOLOGICAL CLASSIFICATION OF GENERAL SOFT TISSUE TUMORS
Combining ‘Anatomical’ and ‘Pathological’ Inferences
DIFFERENTIAL DIAGNOSIS of SELECTED ACUTE INFLAMMATORY SWELLINGS occurring in different regions of the body
DIFFERENTIAL DIAGNOSIS of SELECTED CHRONIC CIRCUMSCRIBED SWELLINGS
Chronic Circumscribed General Swellings Arising from the Skin
Chronic Circumscribed General Swellings Arising from Subcutaneous Tissue
Chronic Circumscribed General Swellings Arising from Deep Fascia / Sheath / Aponeurosis
Chronic Circumscribed General Swellings Arising from Muscle
Chronic Circumscribed Swellings Related to Tendon
16:
CHRONIC LYMPH NODE SWELLING
ARRIVING AT THE DIAGNOSIS
STEPWISE ANALYSIS OF DATA
DIFFERENTIAL DIAGNOSIS of some other disorders (which are not covered in the tables above)
17:
CHRONIC BONE SWELLING
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
General Outline
Easily diagnosed amongst the common conditions
DIFFERENTIAL DIAGNOSIS of scurvy, rickets, post-traumatic conditions, multiple chondromata, osteoma, and some other disorders (which are not covered in the tables above)
18:
CHRONIC VASCULAR SWELLING
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
A PULSATILE SWELLING
A COMPRESSIBLE* SWELLING
AVF
ANEURYSM
DIFFERENTIAL DIAGNOSIS
A note on aneurysm
A note on AV fistula
19:
CHRONIC CIRCUMSCRIBED SWELLING IN THE REGION OF THE HEAD AND FACE: (Excluding swelling of the jaw and oral cavity)
CHRONIC CIRCUMSCRIBED SWELLING IN THE REGION OF THE HEAD (Including SCALP)
CHRONIC SWELLING IN THE REGION OF THE FACE
CHRONIC PERIORBITAL SWELLING
CHRONIC PREAURICULAR SWELLING
CHRONIC PERIAURICULAR SWELLING
CHRONIC AURICULAR SWELLING
INTRA-AURICULAR SWELLING
CHRONIC SWELLING IN THE PAROTID REGION
HISTORY
LOCO-REGIONAL EXAMINATION
ARRIVING AT THE DIAGNOSIS
DIFFERENTIAL DIAGNOSIS of selected parotid swellings
CHRONIC SWELLING IN THE NASOLABIAL FOLD
20:
CHRONIC SWELLING OF THE JAW
ARRIVING AT THE DIAGNOSIS
POST-TRAUMATIC CONDITIONS
CHRONIC OSTEOMYELITIS
OTHER than the above-mentioned
DIFFERENTIAL DIAGNOSIS
21:
CHRONIC CIRCUMSCRIBED SWELLING IN THE NECK
22:
GOITER AND THYROID CANCER
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
DIFFERENTIAL DIAGNOSIS
Short notes on selected clinical conditions
A note on thyroid cancers
23:
A REDUCIBLE (IRREDUCIBLE) SWELLING IN THE GROIN
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Is the swelling irreducible / reducible / pseudoreducible?
Etiology of the hernia?
Associated disorder?
DIFFERENTIAL DIAGNOSIS
24:
A NON-REDUCIBLE SWELLING IN THE GROIN
ARRIVING AT THE DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
25:
SCROTAL SWELLING OR SCROTAL PAIN
SCROTAL SWELLING
HISTORY
Details to be asked in a case of acute painful scrotal swelling
Details to be asked in a case of chronic scrotal swelling
LOCO-REGIONAL EXAMINATION OF AN ACUTE SCROTAL SWELLING
INSPECTION
PALPATION
LOCO-REGIONAL EXAMINATION OF A CHRONIC SCROTAL SWELLING
INSPECTION
PALPATION
SPECIFIC TEST when varicocele is suspected
EXAMINE THE REGIONAL LYMPH NODES
DRE
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
ACUTE SCROTAL SWELLING
CHRONIC SCROTAL SWELLING
Anatomical space / tissue of origin of the swelling?
Pathological nature of the swelling?
DIFFERENTIAL DIAGNOSIS
SCROTAL PAIN
26:
IMPALPABLE TESTICLE EMPTY SCROTUM
CLINICAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
27:
CHRONIC SWELLING IN THE BACK
28:
CHRONIC SWELLING IN THE PERINEUM AND GLUTEAL REGION
29:
SWELLINGS / BULGES RELATED TO VULVA / VAGINA / URETHRA
30:
DISORDERS OF THE FEMALE BREAST
SWELLING IN (THE REGION OF) THE BREAST
HISTORY
LOCOREGIONAL EXAMINATION
INSPECTION
PALPATION
IF THERE IS AN ULCER, examine it in the usual way.
IF THE BREAST IS FOUND TO BE NORMAL, examine the spine for scoliosis.
PITFALLS in interpretation of physical findings:
PRELIMINARY IMPRESSION
RE-EXAMINE (especially palpation) AFTER EMPTYING THE BREAST OF MILK, where applicable.
ARRIVING AT THE DIAGNOSIS of a swelling in the region of the breast
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
DIFFERENTIAL DIAGNOSIS of a chronic swelling in the breast
DIFFERENTIAL DIAGNOSIS of chronic swelling in the skin/subcutaneous tissue overlying the breast
BENIGN SWELLINGS OF THE NIPPLE
EXAMINATION OF A MASTECTOMIZED PATIENT
EXAMIINATION OF THE OPERATED SIDE
Examine the CONTRALATERAL BREAST in usual manner.
EXAMINE THE NECK, CHEST, AND ABDOMEN to rule out metastatic disease.
DISCOMFORT IN THE BREAST/S
CHRONIC PAIN IN THE BREAST (CHRONIC MASTALGIA)
HISTORY
LOCOREGIONAL EXAMINATION
DIFFERENTIAL DIAGNOSIS of chronic mastalgia
WITHDRAWAL OF THE NIPPLE
HISTORY
LOCOREGIONAL EXAMINATION
INSPECTION
PALPATION
ARRIVING AT THE DIAGNOSIS—in a c/o withdrawal of the nipple
Principles and Pitfalls
ANALYSIS OF DATA
DISCHARGE FROM NIPPLE/S
HISTORY
LOCOREGIONAL EXAMINATION
INSPECTION
PALPATION OF THE NIPPLE AND AREOLA
ARRIVING AT THE DIAGNOSIS—in a c/o discharge from the nipple/s.
PRINCIPLES AND PITFALLS
CAUSES OF DISCHARGE FROM THE NIPPLE/S
ARRIVING AT THE DIAGNOSIS BY COMBINING THE ABOVE-MENTIONED VARIABLES
MAMMARY DUCT FISTULA
ECZEMA of the nipple, usually extending onto the areola
CRACKED NIPPLE
PAIN AND HYPERSENSITIVITY IN THE NIPPLE
SMALL SIZE of one or both breasts
BIG SIZE
ASYMMETRY
POLYMAZIA
31:
DISORDERS OF THE MALE BREAST
SWELLING IN (THE REGION OF) THE BREAST
HISTORY
LOCOREGIONAL EXAMINATION
INSPECTION
Methods
PALPATION
IF THERE IS AN ULCER: Examine it in the usual way.
IF THE BREAST IS FOUND TO BE NORMAL: Examine the spine for scoliosis.
In SYSTEMIC EXAMINATION, specifically look for liver disorder and testicular disorder.
ARRIVING AT THE DIAGNOSIS
DIFFERENTIAL DIAGNOSIS of chronic swelling in the male breast
32:
DISORDERS OF THE CHEST WALL
33:
CHRONIC PAIN IN ABDOMEN (CHRONIC ABDOMEN)
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
DIFFERENTIAL DIAGNOSIS
34:
ACUTE PAIN IN ABDOMEN (ACUTE ABDOMEN)
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
GENRAL OUTLINE of analysis to arrive at the diagnosis
STEPWISE ANALYSIS OF DATA
COLICS
DIFFERENTIAL DIAGNOSIS OF COLICS
ACUTE INTESTINAL OBSTRUCTION
Diagnostic points of interest
DIFFERENTIAL DIAGNOSIS OF THE CAUSES OF ACUTE INTESTINAL (MECHANICAL) OBSTRUCTION
BRIEF NOTES ON INTESTINAL OBSTRUCTION
PARTICULAR PROBLEMS with a case of acute intestinal obstruction
ACUTE INFLAMMATION
Differentiating features in general
Diagnostic points of interest
RUQ / epigastrium
LUQ / epigastrium
CONDITIONS COMMON TO BOTH UPPER QUADRANTS—subphrenic abscess, acute pyelonephritis.
RLQ / suprapubic
PARTICULAR PROBLEM
LLQ / suprapubic
PARTICULAR PROBLEM
CONDITIONS COMMON TO BOTH LOWER QUADRANTS
PERITONISM
ACUTE (PARIETAL) PERITONITIS
ACUTE MESENTERIC VASCULAR ISCHEMIA
TORSION
INTERNAL BLEEDING
SPECIFIC GYNECOLOGIC CAUSES of acute abdomen
(ACUTE) PAIN IN ABDOMEN IN A PREGNANT WOMAN
CAUSES OF ACUTE LUMP IN ABDOMEN
Spectrum of disease causing ‘acute abdomen’ of particular importance in TROPICAL COUNTRIES
DIFFERENTIAL DIAGNOSIS
MONITORING AND REVALUATION
RESIDUAL PROBLEM
35:
LUMP IN ABDOMEN
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEP-WISE ANALYSIS OF DATA
PARIETAL SWELLINGS
ABDOMINAL WALL HERNIA
UMBILICAL SWELLINGS other than hernia
‘SUBUMBILICAL’ SWELLINGS
RECTUS SHEATH SWELLINGS
LUMBAR (COLD) ABSCESS
LIVER
SPLEEN
REMARKS
HEPATOSPLENOMEGALY
STOMACH
SMALL INTESTINE
ILEOCECAL REGION
COLON
GREATER OMENTUM
MESENTERY
GALLBLADDER
PANCREAS
EXTRAHEPATIC BILIARY TRACT EXCLUDING THE GALLBLADDER
URINARY BLADDER
UTERUS
UTERINE TUBE
OVARY AND BROAD LIGAMENT
PERITONEAL CAVITY
SUBDIAPHRAGMATIC SPACES
LESSER SAC
KIDNEY
36:
DISTENSION OF ABDOMEN
37:
JAUNDICE
ARRIVING AT A PRELIMINARY CLINICAL IMPRESSION
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
From history and physical examination
‘KEY’ INVESTIGATIONS AND INTERPRETATION OF REPORTS
ACHOLURIC JAUNDICE
ACUTE HEPATITIS
CHRONIC HEPATITIS
CHRONIC CHOLESTATIC JAUNDICE
ACUTE CHOLESTATIC JAUNDICE
ARRIVING AT A DIAGNOSIS OF JAUNDICE DURING PREGNANCY
NOTES ON LIVER, BILIARY AND PANCREATIC DISORDERS WITH REFERENCE TO JAUNDICE
LEVER FAILURE
CIRRHOSIS
PORTAL HYPERTENSION
SPECTRUM OF SYMPTOMATIC GALLSTONE DISEASE
DUCTAL STONES
PERIAMPULLARY CANCER
CHOLANGIOCARCINOMA
BENIGN BILE DUCT STRICTURE
PRIMARY MALIGNANT TUMORS OF THE LIVER
HEPATIC METASTASES
38:
PORTAL HYPERTENSION
39:
DIFFICULTY IN SWALLOWING AND OTHER SYMPTOMS OF ESOPHAGEAL DISORDER
DYSPHAGIA
HISTORY
Step 1
Step 2
Step 3
GENERAL EXAMINATION
EXAMINATION OF THE NECK
EXAMINATION OF THE MOUTH AND PHARYNX
IT IS WORTH ASKING THE PATIENT TO DRINK A MOUTHFUL OF WATER and:
SYSTEMIC EXAMINATION:
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Possible level of obstruction?
Complication?
Associated disease?
DIFFERENTIAL DIAGNOSIS
BELCHING
HISTORY
ODYNOPHAGIA
HISTORY
HEARTBURN
HISTORY
VANISHING HEARTBURN
HISTORY
REGURGITATION
HISTORY
WATERBRASH
PAIN (ESOPHAGEAL ANGINA)
HISTORY
A NOTE ON GERD (GastroEsophageal Reflux Disease)
A NOTE ON NON-REFLUX ESOPHAGITIS
ASPIRATION AND RESPIRATORY SYMPTOMS
GLOBUS
40:
VOMITING OF BLOOD—HEMATEMESIS
41:
ANORECTAL PAIN, BLEEDING PER RECTUM AND OTHER MANIFESTATIONS OF ANORECTAL DISORDER
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
ACUTE MASSIVE BLEEDING PR
‘ACUTE SEVERE ATTACK OF PILES’ (= Acute painful anorectal disorders)
TRIVIAL BLEEDING PR
BLEEDING PR usually during defecation
RECURRENT OBSCURE BLEEDING
BLEEDING OR BLOOD-STAINED/PURULENT/MUCOUS DISCHARGE APART FROM DEFECATION
MISCELLANEOUS / RELATIVELY RARE DISORDERS
AN OVERVIEW OF DIAGNOSIS AND LINE OF INVESTIGATION IN BRIEF IN A CHRONIC ANORECTAL CASE
Look for intestinal obstruction.
Conclusion on detailed history, physical examination and procto/sigmoidoscopy
DIFFERENTIAL DIAGNOSIS
CONSTIPATION
FECAL INCONTINENCE
GUIDELINE STATEMENTS OF DIAGNOSIS OF COMMON ANORECTAL DISORDERS
42:
ULCER
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PitFALLS
Causes of ulcer
Regional ulcers
CLINICAL STAGE AND POSSIBLE CAUSE OF ULCER
DIFFERENTIAL DIAGNOSIS
43:
SINUS / FISTULA
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Diagnosis can be attempted by COMBINING STEPS 2 AND 3
DIFFERENTIAL DIAGNOSIS
44:
(RECURRENT ATTACKS OF) DISCHARGE FROM THE UMBILICUS
45:
PAIN IN THE LIMB
ARRIVING AT A PROVISIONAL CLINICAL IMPRESSION
DIFFERENTIAL DIAGNOSIS
Causes of exercise-induced leg pain and / or weakness
46:
ACUTE ARTERIAL INSUFFICIENCY AND CHRONIC PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD)
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Step 1: Clinical setting
ACUTE (ACUTE-ON-CHRONIC) CASE
CHRONIC CASE USUALLY WITH +ve SIGNS
MACROVASCULAR DISEASE
Step 2
Step 3
Step 4
Step 5
Unusual / rare arterial causes of intermittent pains in the lower limbs
PAOD affecting the proximal vessels of upper limb
Thoracic outlet syndrome
MICROVASCULAR DISEASE
Step 2
Step 3
Differential diagnosis of selected microvascular disorders
INTERMITTENT PAINS PROXIMAL TO FOOT, WITH ALL PERIPHERAL PULSES PALPABLE EVEN AFTER EXERCISE
47:
LIMB GANGRENE
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
DIFFERENTIAL DIAGNOSIS
Clinical points to be considered (in general) for selecting the level of amputation
48:
AMPUTATION STUMP
49:
VARICOSE VEINS AND CHRONIC VENOUS INSUFFICIENCY
50:
LIMB EDEMA
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
CLINICAL SETTING
DIFFERENTIAL DIAGNOSIS
51:
ORAL CAVITY OR OROFACIAL PAIN
OROFACIAL PAIN
HISTORY
EXAMINE the head, face, neck and oral cavity.
ARRIVING AT THE DIAGNOSIS of orofacial pain
GENERAL OUTLINE
Step 1
Step 2 – Etiopathology?
DIFFERENTIAL DIAGNOSIS of selected causes of orofacial pain
COLOR CHANGES in the oral mucosa
WHITE LESION
HISTORY
LOCAL INTRAORAL EXAMINATION
ARRIVING AT THE DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
RED LESION
HISTORY
LOCAL INTRAORAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
RED / WHITE LESION
HISTORY
LOCAL INTRAORAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
PURPLE, VIOLET LESION
AMALGAM TATTOO
MALIGNANT MELANOMA
SUBMUCOUS FIBROSIS
BENIGN ORAL ULCERS
HISTORY
LOCAL INTRAORAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
ORAL SWELLINGS
CHRONIC SWELLING OF THE LIP
CHRONIC SWELLING OF THE JAW – Refer to chapter 20
CHRONIC SWELLING OF THE PALATE
CHRONIC SWELLING IN THE CHEEK
DIFFERENTIAL DIAGNOSIS of selected chronic swellings in the cheek:
CHRONIC SWELLING IN FLOOR OF THE MOUTH
DIFFERENTIAL DIAGNOSIS of selected chronic swellings in the floor of the mouth:
CHRONIC SWELLING OF THE TONGUE
ORAL CANCER
HISTORY
LOCAL INTRAORAL EXAMINATION
EXAMINE THE NECK for metastatic lymphadenopathy.
ORAL MANIFESTATIONS OF SYSTEMIC DISEASE
DISORDERS OF THE LIP
LOCAL EXTRAORAL EXAMINATION
LOCAL INTRAORAL EXAMINATION
DISORDERS OF THE PALATE
LOCAL INTRAORAL EXAMINATION
DISORDERS OF THE TONGUE
HISTORY
LOCAL INTRAORAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
52:
TEMPOROMANDIBULAR JOINT
53:
BACKACHE
SECTION 2: UROGENITAL CASE
54:
UROGENITAL CASE: (For disorders of the scrotum, refer to chapters 25, 26, 85)
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Step 1
Step 2
Step 3
(INCREASED) FREQUENCY OF MICTURITION
POOR FLOW
PAINFUL MICTURITION, i.e. pain while passing urine
Causes of strangury
Urological causes of PAINFUL DEFECATION
RED / BROWN / STALE TEA-COLORED / SMOKY URINE = Hematuria
PURE BLEEDING PER URETHRA INDEPENDENT OF MICTURITION
CLOUDY URINE
TURBID URINE
WHITE-COLORED/MILKY URINE
Causes of HYDATIDURIA
‘NOT PASSING ENOUGH URINE (With regard to frequency / quantity / both)’
INCONTINENCE OF URINE
ENURESIS
BLADDER OUTFLOW OBSTRUCTION
HEMATOSPERMIA
PAIN in lumbar region / upper quadrant of abdomen (2–3 cm below the tip of the 9th costal cartilage)
Essentially painless disorders of the kidney:
Essentially painless disorders of the urinary bladder:
PAIN IN THE PENIS
ACUTE PAIN IN THE PERINEUM
CHRONIC PAIN IN THE PERINEUM
Essentially painless disorders of urethra:
URETHRAL FISTULA
FEVER
PASSAGE OF GAS IN URINE
PASSAGE OF FECAL MATTER / WORMS IN URINE
LOSS OF LIBIDO
IMPOTENCE
ABSENCE OF ORGASM
PREMATURE EJACULATION
INFERTILITY
ANALYSIS AND INTERPRETATION OF URINE EXAMINATION
POINTS OF PRACTICAL IMPORTANCE REGARDING SOME KEY INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS
PRINCIPLES OF MANAGEMENT OF ‘EMERGENCY’ CLINICAL SITUATIONS
STRANGURY
RETENTION OF URINE
OLIGURIA / ANURIA
SECTION 3: NEUROSURGERY
55:
INTRACRANIAL SPACE-OCCUPYING LESION
ARRIVING AT THE DIAGNOSIS
SECTION 4: TRAUMA (ESSENTIALLY SOFT TISSUE)
56:
ACUTE MECHANICAL TRAUMA—GENERAL PRINCIPLES
FIRST AID
NONVISCERAL SOFT TISSUE INJURIES
Skin and subcutaneous tissue
Muscles and tendons
Bursa
Artery
Vein
Lymphatic vessels
Peripheral nerves
Degloving wound
Crush (and devitalized) wound
BONE AND JOINT INJURIES
Bone
Joint
PERTAINING CHILDREN
OUTLINE OF ASSESSMENT AND MANAGEMENT OF A SEVERELY INJURED PATIENT
PRIMARY SURVEY—ABCDE (QUICK INITIAL ASSESSMENT)AND IMMEDIATE LIFE-SAVING MEASURES
SECONDARY SURVEY
DESIRABLE SPECIFIC DETAILS IN THE EMS PERSONNELS's REPORT
HISTORY related to the mode and mechanism of injury
HISTORY to fix the anatomical sites/regions and (pathological) effects of injury particularly those which can be life-threatening or associated with significant morbidity
ROUTINE HISTORY
PHYSICAL HEAD-TO-TOE EXAMINATION and inference therefrom
Head and face
Neck
Chest
Abdomen including pelvis
Limbs
Hand
Spine
Specific points in examination of the wounds
Examine the perineum and rectum
ATTEMPT AT ARRIVING AT A CLINICAL DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Points of medicolegal importance, which must be documented
PITFALLS IN PEDIATRIC TRAUMA
57:
(ACUTE) HEAD INJURY
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEPWISE ANALYSIS OF DATA
Fracture of vault of the skull
Differential diagnosis of fracture of base of the skull
Differential diagnosis of brain injury
Indications for hospitalization
CLINICAL INDICATORS helpful in making decision to operate for relieving cerebral compression
Signs which do not in themselves indicate the need for urgent surgery (exploratory burr hole)
Prognostic factors in brain injury
A NOTE ON CHRONIC SDH
GCS USED IN CHILDREN
58:
FACIAL (MAXILLOFACIAL) TRAUMA
ARRIVING AT THE DIAGNOSIS
59:
SOFT-TISSUE INJURIES OF THE NECK
60:
TRAUMA TO THE CHEST
61:
ESOPHAGEAL INJURY
ESOPHAGEAL PERFORATION
GENERAL REMARKS
SUSPECT
CERVICAL ESOPHAGEAL PERFORATION
THORACIC AND ABDOMINAL ESOPHAGEAL PERFORATION
THORACIC
ABDOMINAL
BOERHAAVE SYNDROME
CORROSIVE INJURY
GENERAL REMARKS
HISTORY
PHYSICAL EXAMINATION
IDENTIFY THE NATURE OF THE INGESTED MATERIAL
PRINCIPLES OF MANAGEMENT
62:
INGESTED FOREIGN BODY
63:
ABDOMINAL TRAUMA: (Including Pelvic Trauma)
ARRIVING AT THE DIAGNOSIS in a case of BLUNT ABDOMINAL TRAUMA
ARRIVING AT THE DIAGNOSIS in a case of PENETRATING ABDOMINAL TRAUMA
INDICATIONS FOR REFERRAL/ADMISSION TO HOSPITAL (for active management or for observation)
KEY INVESTIGATIONS
Monitoring
Indication for local exploration of a stab wound ↓ anesthesia (usually local anesthesia)
GENERAL INDICATIONS FOR LAPAROTOMY
Establishment of priorities
BRIEF NOTES ON DIAGNOSIS OF INDIVIDUAL ORGAN INJURIES
Diaphragm
Spleen
Liver
Stomach
Duodenum
Pancreas
Colon and rectum
Fracture of pelvis
Fracture of acetabulum with or without dislocation of hip
If a patient with abdominal trauma is brought in late (> 18 hours after the trauma)
ABDOMINAL COMPARTMENT SYNDROME FOLLOWING TRAUMA
64:
UROGENITAL TRAUMA
RENAL INJURY
URETERAL INJURY
BLADDER INJURY
MALE URETHRAL INJURY
PENILE INJURY
TESTICULAR INJURY
UROLOGIC TRAUMA IN PREGNANCY
65:
ANORECTAL AND PERINEAL TRAUMA
66:
SPINAL TRAUMA
ARRIVING AT A PROVISIONAL CLINICAL IMPRESSION
67:
HAND INJURY
68:
VASCULAR TRAUMA: (PARTICULARLY IN THE LIMBS AND NECK)
ARRIVING AT THE DIAGNOSIS
PRINCIPLES AND PITFALLS
STEP-WISE ANALYSIS OF DATA
BASIC PRINCIPLES OF MANAGEMENT
69:
BURN INJURY—THERMAL, CHEMICAL, ELECTRICAL
THERMAL BURNS
GENERAL REMARKS
(Specific) CLINICAL EVALUATION
Age of the patient
Cause of the burn?
Details of the event
Pain?
Restlessness?
Site of the burn wound?
Extent of burn?
Depth of burn?
Inhalational injury?
Associated trauma?
Comorbid ailments?
Was the treatment of shock commenced before admission to the hospital?
Does the victim appear able to care for herself/himself?
Clinical systemic monitoring in moderate and major burns essentially during the acute phase (initial 48 hours)
CHEMICAL BURNS
ELECTRICAL BURNS
GENERAL REMARKS
Effects of electrical burns on various systems
Investigations
Monitoring
SECTION 5: PEDIATRIC SURGERY
70:
HISTORY-TAKING IN A CHILD
71:
SURGICAL EXAMINATION OF THE CHILD
72:
RESPIRATORY DISTRESS IN THE NEWBORN
73:
ACUTE ABDOMINAL DISORDERS
74:
COLIC: (Colicky Pain in Abdomen)
75:
NEONATAL INTESTINAL OBSTRUCTION
76:
RECURRENT PAIN IN ABDOMEN
77:
VOMITING IN THE NEONATE
78:
NON-BILE-STAINED VOMITING IN INFANCY
ARRIVING AT THE DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
79:
GASTROINTESTINAL (GI) BLEEDING
80:
JAUNDICE / CHOLELITHIASIS / PORTAL HYPERTENSION
JAUNDICE
CHOLELITHIASIS
PORTAL HYPERTENSION
81:
DISCHARGE FROM THE UMBILICUS
82:
ANORECTAL MALFORMATION
83:
URINARY TRACT INFECTION (UTI) / URINARY STONES
URINARY TRACT INFECTION
URINARY STONES
84:
DISORDERS OF THE LOWER URINARY TRACT
85:
ACUTE SCROTUM
ARRIVING AT THE DIAGNOSIS
86:
DISORDERS OF THE EXTERNAL GENITALIA
FEMALE GENITALIA
MALE GENITALIA
87:
ACUTE PAIN IN THE LIMB: (Acute Limb)
88:
DISORDERS OF THE MOUTH
89:
SPECIFIC REGIONAL SWELLINGS/LESIONS IN THE FACE
90:
SWELLING IN THE NECK
91:
TORTICOLLIS (WRYNECK)
Sternocleidomastoid (SCM) torticollis
92:
DISORDERS OF THE BREAST
93:
A BIG HEAD / HYDROCEPHALUS / ASSESSING A VP SHUNT
HYDROCEPHALUS
ASSESSING A VENTRICULOPERITONEAL SHUNT
94:
SPINAL DYSRAPHISM—SPINA BIFIDA
95:
FOREIGN BODIES
BIBLIOGRAPHY
INDEX
TOC
Index
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