Preliminary Pages

1Arriving at a SURGICAL DIAGNOSIS2

3Arriving at a SURGICAL DIAGNOSIS

Pramod Shrikrishna Bapat Consultant General Surgeon Shree Harneshwar Clinic Talegaon (Dabhade), Pune, Maharashtra, India Formerly Registrar Rajawadi Hospital, Mumbai, Maharashtra, India Lecturer Lokamanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India Professor of General Surgery People's College of Medical Sciences, Bhopal, Madhya Pradesh, India Consultant General Surgeon Colonial War Memorial Hospital, Suva, Fiji Islands

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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.

Arriving at a Surgical Diagnosis

First Edition: 2013

9789350258101

Printed at

5Dedicated to

Infinite patience of my daughter Anuprita and wife Vaishali for tolerating me, always

7Preface

‘Clinical diagnosis is an art’—I DISAGREE. Clinical diagnosis is a science. ‘Art’ is a faculty, which can be mastered only by few having an inborn aptitude in a particular field of art. Clinical medicine cannot afford to be an art! Every clinician must be a master with the greatest level of competence in arriving at the clinical diagnosis; and the mastery will be achieved with a scientific approach.

What was the need for yet another book on ‘clinical surgery’? Well, most of the existing books explain clinical methods, and then describe ‘differential diagnoses’. There is hardly any book which explains how to analyze clinical data systematically and arrive at a clinical diagnosis by using logical thinking in stepwise manner. Operative surgery books describe procedures in stepwise manner. Why not have a clinical surgery book which explains the method of arriving at the diagnosis in the same manner?

In the present era of technological advent, clinicians seem to be requesting a battery of investigations even in straightforward cases. Such a practice tends to blunt the thinking aptitude very fast, and decay the clinical approach. Unfortunately, junior students in surgical training seem to be adopting this approach from the beginning of their apprenticeship. Hence, I thought of writing this book, which will guide them to make a clinical diagnosis with confidence, without having to rely on too many unnecessary investigations.

The contents, including the steps in arriving at the diagnosis in each chapter, are generally ordered in the same sequence unless special circumstances dictate otherwise. However, systems and organs naturally possess a remarkable degree of individuality with respect to anatomy, physiology and pathology; and it follows that the techniques for history-taking and examining one anatomical region / system may have to be varied when it comes to look at another. In spite of this fact, I have tried to derive a common sequence as best as possible.

I do not claim originality in all the facts presented in this book; most of these have been derived from various authentic books existing on the subject. However, some of the facts have been derived from the knowledge imparted to me by my teachers, and observations from my own clinical experience.

I am conscious of deficiencies as a single author, but I hope that this fact has helped in maintaining coherence and continuity of the methods and subject. Nevertheless, there is a possibility for inadequacies and errors to have occurred. I invite the readers to share their critical reviews and positive ideas for improvement of future editions of this book.

Pramod Shrikrishna Bapat

E-mail: bapat.asd@gmail.com

9Layout of the Book

By and large, titles given to the chapters are none other than the chief complaints with which patients present. This book focuses on history-taking in a readymade questionnaire format, and systematic step-by-step analysis of the clinical data to arrive at the diagnosis. Each chapter on individual problem is written in a standard format:

Definition/s.
General remarks.
History-taking.
Physical examination.
Arriving at the diagnosis
- Principles and pitfalls
- Stepwise analysis of clinical data.
Differential diagnosis.
Residual problem, if any.

Clinical tests are described in a uniform format all throughout the book:

Title of the test.
Aim.
Principle.
Precaution to be observed, if any, while performing the test.
Prerequisite.
Procedure (clinical method).
Observation and inference.
Causes of false +ve and false –ve results.
Controversy, if any.
Therapeutic application, if any.

Justification of the diagnosis is discussed in ‘to-the-point’ form:

Basic point.
Differentiating points.
Supporting points.

In addition, variations in clinical presentation and important relevant short notes on various conditions are also described.

11How to Use This Book

THIS IS NOT A TEXTBOOK. This is a manual. I have converted the information and knowledge from a large number of textbooks in a practically executable format in this book. To make the best use of this book, get started in the following way:

Read chapters 1 and 9 at the outset.
Then spend some time familiarizing with the format of the book by going through a few chapters between 15 and 49.
Read chapters 2 to 8 for basic clinical methods.
Read chapters 11, 12 and 13 as they are important in themselves particularly with respect to ‘emergency’ cases.
While ‘taking a clinical case’:
1. After knowing the patient's chief complaint, open the appropriate chapter and start asking history which is given in a readymade questionnaire format. Finding the appropriate chapter will be easy as titles given to the chapters are none other than the chief complaints with which patients present.
2. Examine the patient.
3. Analyze the clinical data as explained in the chapter, and I am confident you will arrive at the diagnosis smoothly.
4. Cross-check your diagnosis by going through the section on ‘differential diagnosis’.

Arriving at the clinical diagnosis will never be a difficult problem henceforth. After reading this book, you will soon develop interest in taking even challenging cases and attempt to make clinical diagnosis.

I wish you success in your future clinical journey in the field of Surgery.

13Acknowledgments

I am greatly indebted to the following consultants who helped me in some or the other way during different stages of preparation of this book. YR Kher, Former Professor and Head of the Department (Retired), TN Municipal Medical College and Nair Hospital, Mumbai, Maharashtra; Col. YG Tambay, Senior Consultant Plastic and Reconstructive Surgeon (Retired), Indian Armed Forces; (Late) Manohar J Joshi, Former Honorary Professor, BJ Medical College and Sassoon Hospital, Pune, Maharashtra; NC Joshi, Senior Consultant Pediatrician, Mumbai, Maharashtra; Mahendra Bendre, Professor, DY Patil Medical College, Mumbai, Maharashtra; AK Banerjee, Consultant General Surgeon, Raikot, Ludhiana, Punjab; Ashwin Apte, Consultant Pediatric Surgeon, Bhopal, Madhya Pradesh; Ajay Jain, Consultant Pediatric Surgeon, Bhopal, Madhya Pradesh; Mrudul Shahi, Consultant Neurosurgeon, Bhopal, Madhya Pradesh; Neelesh Risbud, Consultant Obstetrician and Gynecologist, Pune, Maharashtra; Ajit Oak, Consultant Pediatrician, Dombivlee, Thane, Maharashtra; Ashutosh Mangalgiri, Professor of Anatomy, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh; Shreekant and Mrs Jyotee Jategaonkar, Consultant General Physicians, Talegaon (Dabhade), Pune, Maharashtra; Santosh Sabnis, Consultant Radiologist, Talegaon (Dabhade), Pune, Maharashtra; Rajendra Bhojwani, Consultant Radiologist, Gwalior, Madhya Pradesh; T Laxminarayana, Senior Consultant Radiologist, Hyderabad, Andhra Pradesh; Rajendra Zope, Consultant Pathologist, Talegaon (Dabhade), Pune, Maharashtra; Pankaj Goel, Professor and Head of the Department, Community Dentistry, People's Dental Academy, Bhopal, Madhya Pradesh.

I am also grateful to my teachers: SV Nadkarni, Former Head of the Department and Dean (Retired), LTM Medical College and General Hospital, Mumbai, Maharashtra; (Late) TT Changlani, Former Head of the Department, LTM Medical College and General Hospital, Mumbai, Maharashtra; VG Mehendale, Honorary Professor and Head of the Department (Retired), Rajawadi Hospital, Senior Consultant General Surgeon, and Urologist, Mumbai, Maharashtra; MV Bhatt, Former Honorary Professor (Retired), LTM Medical College and General Hospital, Mumbai, Maharashtra; P Anantharam, Former Honorary Professor (Retired), LTM Medical College and General Hospital, Mumbai, Maharashtra; Paresh Varty, Consultant General and GI Surgeon, Mumbai, Maharashtra; SN Shenoy, Senior Consultant GI, Laparoscopic and General Surgeon, Mumbai, Maharashtra.

I am thankful to Charles Collins, Consultant Anesthesiologist, Colonial War Memorial (CWM) Hospital, Suva, Fiji, for taking the photographs of the patient in Fig. 35-6, an unusually big and challenging case to manage from all aspects.

I am also thankful to M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing my book which has been written in unorthodox style, and also for allowing me to use photographs from their titles mentioned: 1. ‘Jaypee Gold Standard Mini Atlas Series Surgical Diseases’. 1st edition, 2007. 2. ‘SRB's Manual of Surgery’. 3rd edition, 2009. 3. ‘Jaypee Gold Standard Mini Atlas Series Dermatology’. 1st edition, 2008. 4. ‘Step by Step Imaging of Bone and Joints. 1st edition, 2008. 5. ‘Textbook of Ophthalmology’ 5th edition, 2008.

I would like to thank the patients with a sense of gratitude for offering their photographs for propagation of clinical teaching and learning in general; this book being a part of the process.

I would also like to thank all the technocrats related to the world of electronics and computers, without whose efforts typing, editing, typesetting and publishing books like this would not have become easy.

19Abbreviations →

:Lead to / leading to

⇒

: Imply / implies / implying

↑ed

: Increased

↓ed

: Decreased

↓

:Under

: May be either present or absent

: For

AAA

: Abdominal aortic aneurysm

ABPI

: Ankle brachial pressure index

ADH

: Antidiuretic hormone

:Atrial fibrillation

AFB

: Acid fast bacilli

AIN

: Acute interstitial nephritis

ALI

: Acute limb ischemia

: Above knee

AKT

: Anti-Koch's treatment

ANIML

: Acute nonspecific ileocecal mesenteric lymphadenitis

ARDS

: Acute respiratory distress syndrome (Older terminologies: Adult respiratory distress syndrome, shock lung)

ARF

: Acute renal failure

ATN

: Acute tubular necrosis

ATT

: Antituberculous treatment

: Arteriovenous

AVF

: Arteriovenous fistula

AVM

: Arteriovenous malformation

BCC

: Basal cell carcinoma

BEP

: Benign enlargement of prostate

: Below knee

BNC

: Bladder neck contracture

BNH

: Bladder neck hypertrophy

BOO

: Bladder outflow obstruction

BPE

: Benign prostatic enlargement

BPH

:Benign prostatic hyperplasia/hypertrophy

BTF

: Blood transfusion

C & D

: Cleaning and dressing

C/F

: Clinical feature

C/M

: Clinical manifestation

C/o

:Case of

CAPD

: Continuous ambulatory peritoneal dialysis

: Carcinoma

CBD

: Common bile duct

CDH

: Congenital diaphragmatic hernia

CHF

:Congestive heart failure

CHPS

: Congenital hypertrophic pyloric stenosis

CML

: Chronic myeloid leukemia

COAD

: Chronic obstructive airway disease

: Cardiopulmonary

CRF

: Chronic renal failure

CRPS

: Complex regional pain syndrome

: Connective tissue

CTD

: Connective tissue disorder

CVA

: Cerebrovascular accident

CVD

: Cerebrovascular disease

CVI

: Chronic venous insufficiency

CVU

: Chronic venous ulcer / ulceration

CW Doppler

: Continuous wave Doppler

: 1st part of duodenum

: 2nd part of duodenum

DAI

: Diffuse axonal injury

D & C

: Dilatation and curettage

: Diabetes insipidus

: Duodeno jejunal

DL scopy

: Direct laryngoscopy

: Diabetes mellitus

DPL

:Diagnostic peritoneal lavage

DSD

: Detrusor-sphincter dyssynergia

: Duodenal ulcer

: Epstein-Barr

ECF

: Extracellular fluid

ECFV

: Extracellular fluid volume

EMS

: Emergency medical services

ERCP

: Endoscopic retrograde cholangiopancreatography

: Endotracheal

EUA

: Examination under anesthesia

F/b

:Followed by

: Female(s)

FAP

: Familial adenomatous polyposis

FAST

: Focused assessment with sonography in trauma

FBC

: Full blood count

FDP

: Flexor digitorum profundus

FDS

: Flexor digitorum superficialis

FFD

: Fixed flexion deformity

FPL

: Flexor pollicis longus

:General anesthesia

GCS

: Glasgow coma scale

: Gastroenteritis

: Gastrointestinal

GIT

: Gastrointestinal tract

: Glomerulonephritis

: Gastric ulcer

H/o

: History of

HCC

: Hepatocellular carcinoma

HRT

: Hormone replacement therapy

HS purpura

: Henoch-Shonlein purpura

: Hypertension

I & D

: Incision and drainage

IBD

: Inflammatory bowel disease

IBS

: Irritable bowel syndrome

: Ileo-cecal

ICH

: Intracerebral hematoma

ICU

: Intensive care unit

IDL

:Indirect laryngoscopy

IHD

: Ischemic heart disease

IJV

: Internal jugular vein

: Inferolateral

: Inferomedial

IMA

: Inferior mesenteric artery

: Interphalangeal

: Intelligence quotient

IUD

: Intrauterine contraceptive device

IVP

: Intravenous pyelography

IVU

:Intravenous urography

K-B analysis

: Kleihauer-Betke analysis

K/c/o

:Known case of

: Local analgesia

LLQ

: Left lower quadrant

LOC

: Level of consciousness

: Lumbar puncture

LUQ

: Left upper quadrant

LSV

: Long saphenous vein

LUT

: Lower urinary tract

LVF

: Left ventricular failure

: Male(s)

: Metacarpophalangeal

MRC

: Medical Research Council

: Myocardial infarction

MNG

: Multinodular goiter

MVA

: Motor vehicle accident

MVT

: Mesenteric vein thrombosis

M-W tear

: Mallory-Weiss tear

NAD

: No abnormality detected

NEC

: Necrotizing enterocolitis

:Nasogastric

NTG

: Nitroglycerine

: Osteoarthrosis

OPD

: Outpatient department

OPG

: Orthopantomogram

PCN

: Percutaneous nephrostomy

PCNL

: Percutaneous nephrolithotomy

: Peritoneal dialysis

: Pulmonary embolism

PFT

: Pulmonary function test

PHT

:Portal hypertension

PID

: Pelvic inflammatory disease

PIH

: Pregnancy-induced hypertension

: Per rectum

21PSA

: Prostate-specific antigen

PTA

: Post-traumatic amnesia

PTC

: Percutaneous transhepatic cholangiography

PTD

: Percutaneous transhepatic drainage

PTS

: Post-thrombotic syndrome

: Pelviureteric

PUJ

:Pelviureteric junction

PUO

: Pyrexia of unknown origin

QOL

: Quality of life

: Rheumatoid arthritis

RCC

: Renal cell carcinoma

RGP

: Retrograde pyelography

RGU

: Retrograde ureterography

RHD

: Rheumatic heart disease

RLQ

: Right lower quadrant

RTA

: Road traffic accident, renal tubular acidosis

RTI

: Respiratory tract infection

RUQ

: Right upper quadrant

S/o

:Suggestive of

: Spinal anesthesia

SAB

: Subarachnoid bleed

SAH

: Subarachnoid hemorrahge

SBE

: Subacute bacterial endocarditis

SCC

: Squamous cell carcinoma

SCM

: Sternocleidomastoid (muscle)

SDH

: Subdural hematoma

: Saphenofemoral

SFJ

:Saphenopopliteal junction

: Sacroiliac

SIADH

: Syndrome of inappropriate ADH secretion

: Superolateral

: Superomedial

SMA

: Superior mesenteric artery

SOL

: Spaceoccupying lesion

: Saphenopopliteal

SPJ

: Saphenopopliteal junction

SPC

: Suprapubic catheter/catheterization

SSV

:Short saphenous vein

STN

: Solitary thyroid nodule

SVC

: Superior vena cava

Syn.

: Synonym

TAO

: Thromboarteritis obliterans

: Tuberculosis

TBSA

: Total body surface area

TCC

: Transitional cell carcinoma

: Thromboembolism

TEF

: Tracheoesophageal fistula

: Temporomandibular

: Tubo-ovarian

TOS

: Thoracic outlet syndrome

TURP

: Transurethral resection of prostate

UOQ

: Upper outer quadrant

URTI

: Upper tespiratory tract infection

: Ultrasound

UTI

: Urinary tract infection

UUT

: Upper urinary tract

: Ventricular fibrillation

VOD

: Veno-occlusive disease

VP shunt

: Ventriculo-peritoneal shunt

VSD

: Ventricular septal defect

: Venous thrombosis / ventricular tachycardia

VTE

: Venous thromboembolism

: Vesicoureteric

VVF

: Vesicovaginal fistula

Chapter Notes