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Sri Aurobindo University - General Surgery Ward Completion Test

All 6 Questions Answered (5 marks each)

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Q1. General Physical Examination of a Patient Presenting with Jaundice

Definition

General Physical Examination - Systematic Approach

• Wash hands, introduce yourself
• Position patient: semi-recumbent, good lighting
• Note general appearance: well/ill, nutritional status, body habitus

• Tenderness in right hypochondrium - hepatitis, cholecystitis
• Hepatomegaly - texture: smooth (hepatitis/congestion), nodular (malignancy/cirrhosis)
• Splenomegaly - portal hypertension, haemolytic anaemia
• Palpable gallbladder (Courvoisier's sign: painless, palpable gallbladder + jaundice) - malignant obstruction (carcinoma head of pancreas)
• Abdominal masses - metastases, pancreatic carcinoma

• Liver dullness - note span
• Shifting dullness - ascites

• Absent bowel sounds - peritonitis
• Venous hum at umbilicus - portal hypertension

• Dark urine + pale stools = obstructive (cholestatic) jaundice
• Normal stool colour = pre-hepatic (haemolytic) jaundice

Surgical Relevance of Jaundice

1. Coagulopathy - impaired vitamin K absorption (fat-soluble) → measure prothrombin time, give IV/IM Vitamin K
2. Hepatorenal syndrome - renal failure risk post-op; maintain IV fluids, mannitol infusion intraoperatively, urinary catheter with output >40 mL/hr
3. Wound infection - bile is infected in >95% of obstructed cases; give prophylactic antibiotics
4. Poor wound healing - especially in malignant jaundice; use non-absorbable sutures for wound closure
5. Hypoalbuminaemia - impaired liver synthesis; correct before surgery

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Q2. Clinical Examination of a Breast Lump

Step 1 - History

Step 2 - Inspection (Patient seated, arms by side, then hands on hips, then arms raised)

Step 3 - Palpation

1. Site - quadrant (UOQ most common for breast cancer)
2. Size - in cm (three dimensions)
3. Shape - regular / irregular
4. Surface - smooth / nodular
5. Margin/Edge - well-defined (benign) vs. ill-defined (malignant)
6. Consistency - soft / firm / hard / fluctuant
7. Tenderness - tender (abscess, fibroadenosis) / non-tender (cancer)
8. Temperature - warm (inflammatory / malignant)
9. Mobility - freely mobile (fibroadenoma = "breast mouse") vs. fixed to skin or underlying muscle
10. Skin fixity - pinch skin over lump; dimpling = tethered
11. Muscle fixity - ask patient to press hands on hips (tenses pectoralis major); if lump less mobile = attached to pectoralis

• Discharge on gentle squeezing
• Blood-stained = suspect malignancy / papilloma
• Retraction - recent vs. long-standing

Step 4 - Lymph Node Assessment

• Anterior (pectoral) group - along lateral chest wall
• Posterior (subscapular) group - along posterior axillary fold
• Medial (central) group - against chest wall
• Lateral group - along humerus
• Apical group - apex of axilla

• Supraclavicular fossa - supraclavicular nodes (N3 disease in breast cancer)
• Internal mammary nodes - cannot be palpated clinically
• Infraclavicular nodes

Step 5 - Systemic Examination (for metastases)

• Spine/bony tenderness - bone metastases
• Hepatomegaly - liver metastases
• Chest - pleural effusion (lung metastases)

Clinical Differentiation of Breast Lumps

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Q3. Examination of a Swelling in the Neck

Step 1 - History

Step 2 - Inspection

• Position: patient seated, neck exposed, good light
• Number, site, size (visible?)
• Shape and contour of neck
• Movement with swallowing (thyroid/thyroglossal) - ask patient to swallow water while observing
• Movement on tongue protrusion (thyroglossal cyst - moves upward)
• Skin over swelling - colour, sinuses, scars
• Pulsatile (carotid aneurysm)
• Overlying dilated veins

Step 3 - Palpation

• Feel swelling from behind
• Site - anterior triangle / posterior triangle / midline
• Size - measure in cm
• Shape - regular / irregular
• Surface - smooth / lobulated / nodular
• Edge - defined / ill-defined
• Consistency - soft / firm / hard / fluctuant / rubbery
• Tenderness - inflammatory vs. neoplastic
• Temperature - warm = inflammatory / thyroid storm
• Transillumination - brilliant transillumination = cystic hygroma / thin-walled cyst; absent in solid swellings
• Fluctuation - present in cysts/abscesses
• Mobility - fixity to skin or deep structures
• Pulsatility - transmitted vs. expansile pulsation
• Movement with swallowing - thyroid swellings move up
• Movement with tongue protrusion - thyroglossal cyst
• Compressibility - cystic hygroma is compressible (empty into lymph channels)
• Reducibility - pharyngeal pouch partially reducible

Step 4 - Percussion

• Retrosternal extension of goitre: stony dullness on sternum

Step 5 - Auscultation

• Bruit over thyroid (thyrotoxicosis - increased vascularity)
• Bruit over carotid body tumour

Step 6 - Lymph Node Examination

Differentiating Cystic vs. Solid Neck Swellings

• Midline + moves with tongue protrusion = Thyroglossal cyst (Sistrunk's operation)
• Anterior triangle, young adult, smooth, fluctuant = Branchial cyst
• Brilliantly transilluminable, multilocular, infant = Cystic hygroma
• Hard, non-tender, matted nodes = Malignant (metastatic / lymphoma)
• Moves with swallowing + goitre symptoms = Thyroid swelling

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Q4. Clinical Examination of an Inguinoscrotal Swelling

Step 1 - History

• Duration, onset (sudden vs. gradual)
• Reducibility (disappears on lying down)
• Cough impulse
• Pain / discomfort
• Bowel symptoms (obstruction in hernia)
• Urinary symptoms (hydrocele + testicular pathology)
• Previous hernia repair

Step 2 - Inspection (Patient standing, adequate exposure from umbilicus to knees)

• Site - groin, scrotum, or both
• Size and shape of swelling
• Skin - colour (erythema in strangulation / Fournier's gangrene), oedema
• Asymmetry of scrotum
• Position of testis - can you see testis separately from swelling?
• Ask patient to cough - observe cough impulse
• Ask patient to reduce hernia

Step 3 - Palpation

• Cannot get above = inguinal/femoral hernia (extends into inguinal canal)
• Can get above = scrotal swelling (hydrocele, epididymal cyst, etc.)

• Site, size, shape, surface, edge
• Consistency - soft, fluctuant
• Transillumination - positive = hydrocele / epididymal cyst; negative = hernia (unless omentocele has some)
• Reducibility - can be pushed back into inguinal canal
• Cough impulse - felt at deep ring
• Testis palpable separately or not
• Cord - thickening

• Reduce hernia, occlude deep ring (1.5 cm above midpoint of inguinal ligament)
• Ask patient to cough
• If hernia controlled = indirect inguinal hernia (deep ring)
• If hernia not controlled = direct inguinal hernia (Hesselbach's triangle)

• Below and lateral to pubic tubercle (inguinal hernia is above and medial)
• More common in women
• High risk of strangulation (narrow neck)

Step 4 - Differentiating Hernia from Hydrocele

Step 5 - Examine the Other Side

• Bilateral examination of inguinal regions
• Examine abdomen for masses causing secondary hernia

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Q5. Clinical Examination of a Patient with Varicose Veins

Step 1 - History

• Duration, progression
• Aching, heaviness, throbbing in limb - worse with standing, relieved by elevation
• Swelling of ankle (worse evenings)
• Skin changes - pigmentation, eczema, ulceration
• Thrombophlebitis - tender, inflamed vein
• Bleeding from varicosity
• Deep vein thrombosis history (post-thrombotic syndrome)
• Occupation (prolonged standing), pregnancies, family history

Step 2 - Inspection (Patient standing in good light, full exposure of both legs)

• Distribution and extent of varicosities - GSV (great saphenous vein) territory (medial) vs. SSV (small saphenous vein) territory (posterolateral calf)
• Skin changes at gaiter area (lower 1/3 of leg):
  • Hyperpigmentation (haemosiderin deposition from RBC breakdown)
  • Lipodermatosclerosis (skin becomes hard, indurated, fibrotic)
  • Varicose eczema (itchy, weeping skin)
  • Atrophie blanche (pale, avascular scarring)
  • Venous ulcer - typically at medial malleolus; shallow, irregular edges, sloping margins
• Ankle oedema
• Scar from previous surgery/sclerotherapy
• Perforator distribution (medial aspect)

Step 3 - Palpation

• Temperature - warm overlying varicosities (inflammation)
• Tenderness - thrombophlebitis along varicosity
• Consistency - soft, compressible veins (empty on elevation)
• Fascial defects - thickenings along medial calf where perforators emerge
• Saphena varix - bluish swelling in groin at saphenofemoral junction (SFJ) - has cough impulse, disappears on lying down

Step 4 - Clinical Tests

• Patient lies down, leg elevated to drain veins
• Tourniquet applied at upper thigh (occludes SFJ)
• Patient stands - veins fill slowly from below = reflux at perforators below tourniquet
• Release tourniquet - sudden filling = SFJ incompetence (GSV reflux)
• Repeat at different levels to identify incompetent perforators

• One finger on varicosity distally, tap varicosity proximally
• Transmitted impulse felt = continuous column of blood (confirms varicosity)
• Indicates incompetence in the system

• Felt as expansile impulse in groin = SFJ incompetence

• Tourniquet around upper thigh
• Ask patient to walk on tiptoes (10 times)
• Veins empty = deep veins patent (superficial blood drained through perforators)
• Veins remain full / pain = deep vein obstruction (post-thrombotic) - CONTRAINDICATION to stripping

• Finger placed over saphenous opening in saphenous fascia
• Cough - expansile impulse = SFJ incompetence

Step 5 - Systemic Examination

• Abdominal exam - pelvic/abdominal masses causing extrinsic venous compression
• DVT assessment - Homan's sign (not reliable), calf swelling, tenderness
• ABPI (Ankle Brachial Pressure Index) - must be checked before compression bandaging; normal >0.8

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Q6. Examination of a Case of Chronic Ulcer in the Leg

Step 1 - History

• Duration (months to years = chronic)
• Mode of onset (trauma, spontaneous)
• Progression - healing, enlarging, or static
• Pain - venous ulcer often painless/mildly painful; ischaemic ulcer very painful (rest pain)
• Previous ulcers / recurrence
• Varicose veins, DVT history (venous)
• Diabetes, hypertension, smoking (arterial)
• Neuropathy (diabetic neuropathy, neurotic ulcer)
• Tropical travel (tropical ulcer)
• Systemic illness - rheumatoid arthritis, sickle cell, vasculitis

Step 2 - Local Examination of the Ulcer

• Medial malleolus / gaiter area = venous ulcer
• Pressure points (heel, toe tips, metatarsal heads) = neuropathic / pressure ulcer
• Dorsum of foot / lateral malleolus = arterial (ischaemic) ulcer
• Anywhere = malignant ulcer (Marjolin's ulcer at scar sites)

• Measure in two dimensions (length x width)
• Regular vs. irregular

• Healthy pink granulation tissue = healing
• Pale granulation = ischaemic / poor healing
• Slough (yellow) = infected / venous
• Eschar (black) = necrotic / arterial
• Bone visible = osteomyelitis

• Probe depth - superficial / deep / down to tendon/bone

• Serous = clean, healing
• Purulent = infected
• Serosanguineous = venous / healing
• Watery = lymphorrhea

• Pigmentation, lipodermatosclerosis, eczema (venous)
• Shiny, hairless, atrophic (arterial/ischaemic)
• Callus formation around edge (neuropathic)
• Satellite ulcers
• Lymphoedema

Step 3 - Assessment of Vascularity

• Skin colour - pallor (arterial), cyanosis, rubor on dependency
• Hair loss on dorsum of foot/leg - ischaemia
• Shiny, atrophic skin - arterial disease
• Nail changes - thick, ridged nails = chronic ischaemia

• Temperature - cold limb = arterial insufficiency (compare bilaterally)
• Capillary refill time - normal <2 sec; prolonged = arterial disease
• Peripheral pulses:
  • Femoral artery (femoral triangle)
  • Popliteal artery (behind knee, patient prone)
  • Posterior tibial artery (behind medial malleolus)
  • Dorsalis pedis artery (dorsum of foot, lateral to EHL)
  • Note: presence, rate, character, volume
• Buerger's angle - angle of limb elevation at which foot turns pale; <20 degrees = severe ischaemia

• Elevate leg to 45 degrees for 1-2 minutes - colour of foot
  • Pallor on elevation = ischaemia
• Then hang leg dependent (Buerger's reactive hyperaemia)
  • Sunset red/dusky colour on dependency = ischaemia (venous guttering then reactive hyperaemia)

• Femoral bruit = femoral artery stenosis
• Popliteal bruit = popliteal aneurysm (rare)

Step 4 - ABPI (Ankle-Brachial Pressure Index)

• Doppler probe + sphygmomanometer
• ABPI = Ankle systolic pressure / Brachial systolic pressure
• Normal: 0.9-1.2
• Mild ischaemia: 0.7-0.9
• Claudication: 0.5-0.7
• Rest pain: 0.3-0.5
• Critical ischaemia: <0.3
• Important: >1.2 = calcified vessels (diabetic, elderly) - falsely elevated

Step 5 - Systemic Examination

• Blood pressure (hypertension - arterial disease)
• Heart - AF (embolic), cardiac failure
• Carotid bruits (generalized atherosclerosis)
• Abdomen - aortic aneurysm
• Nervous system - peripheral neuropathy (light touch, proprioception, vibration - diabetic foot)
• Blood glucose assessment (bedside/HbA1c)

Differentiation of Common Chronic Leg Ulcers

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Obstructed Hernia in Surgery

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Definition

"An obstructed hernia means the hernia is associated with intestinal obstruction due to occlusion of the lumen of the bowel. It must be remembered that there is no interference with the blood supply to the intestine in this hernia."

• S. Das: A Manual on Clinical Surgery

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The 5 Clinical Types of Hernia (Progression)

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Pathophysiology of Obstruction

1. Lumen is compressed at the narrow neck of the sac
2. Proximal bowel dilates as peristalsis tries to overcome obstruction
3. Gas accumulates - overgrowth of aerobic and anaerobic organisms produces gas (90% nitrogen + hydrogen sulphide)
4. Fluid accumulates - digestive juices (~3+ litres/day) pool in lumen; absorption by obstructed gut is retarded
5. Dehydration and electrolyte imbalance result from:
   • Reduced oral intake
   • Defective intestinal absorption
   • Vomiting losses
   • Sequestration in bowel lumen
   • Transudation into peritoneal cavity
6. If not relieved → bowel dilates further → peristalsis weakens → flaccidity and paralysis
7. Increased intraluminal pressure → venous congestion → progression to strangulation

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Common Sites for Obstruction

"Strangulation occurs more frequently in femoral or umbilical herniae than in inguinal herniae."

• Pye's Surgical Handicraft, 22nd Ed.

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Clinical Features

Symptoms

• Irreducible swelling that was previously reducible
• Colicky central abdominal pain (small bowel obstruction pattern)
• Vomiting - early and bilious (high obstruction) or faeculent (prolonged obstruction)
• Absolute constipation (no flatus or faeces) - late sign
• Abdominal distension - develops progressively
• NO fever or toxaemia (differentiates from strangulation initially)

Signs

• Swelling is tense, firm, and irreducible
• NOT markedly tender (in contrast to strangulation, which is extremely tender)
• No cough impulse (neck is occluded)
• Skin is normal (not red or oedematous - if present, suspect strangulation)
• No bowel sounds audible over hernia (bowel is distended and paralytic)

• Distension - central (small bowel)
• Increased/tinkling bowel sounds early; absent late
• Visible peristalsis in thin patients
• No peritonism (no guarding or rigidity - these suggest strangulation/perforation)

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Differentiation: Obstructed vs. Strangulated Hernia

"It is a dangerous venture to diagnose obstructed hernia when strangulation may be the real state of affair, and thus valuable time will be wasted until it becomes too late to save the patient's life."

• S. Das: A Manual on Clinical Surgery

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Special Varieties Relevant to Obstruction

Richter's Hernia

• Only the antimesenteric border (partial circumference) of bowel herniates - does NOT occlude the full lumen
• Therefore, intestinal obstruction may be absent despite necrosis
• Very dangerous because the diagnosis is easily missed
• Most common at femoral ring (36-88%), then inguinal canal
• Signs of obstruction are equivocal despite advancing necrosis
• Laparoscopy trocar sites are a modern cause

Maydl's Hernia (Hernia-en-W)

• Two loops of bowel in sac with an intervening loop inside the abdomen
• The intra-abdominal loop may strangulate first while the hernial contents appear viable
• Danger: reducing the sac contents may leave gangrenous bowel inside the abdomen

Littre's Hernia

• Contains a Meckel's diverticulum in the sac
• Can strangulate without full bowel obstruction

Sliding Hernia (Hernia-en-Glissade)

• Retroperitoneal structure (caecum on right, sigmoid on left, bladder on either side) forms part of the wall of the sac
• Cannot be fully reduced without risking injury
• Risk of obstruction if the bowel itself slides down and kinks

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Investigations

• Dilated loops of small bowel
• Multiple air-fluid levels (ladder pattern)
• Absence of bowel gas distally
• Bowel shadow visible in the region of the hernia

• Confirms hernia, demonstrates obstruction
• Shows transition point
• Can identify strangulation (fat stranding, thickened bowel wall, pneumatosis)
• Rules out other causes of obstruction (adhesions, malignancy) that may distend a coincidental hernia

• FBC - leucocytosis (if progressing to strangulation)
• Urea and electrolytes - dehydration
• Lactate - elevated in strangulation/ischaemia
• Group and save

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Management

Resuscitation (Pre-operative)

1. IV access - large-bore cannula
2. IV fluids - normal saline / Hartmann's to correct dehydration and electrolyte imbalance
3. Nasogastric tube - decompress proximal gut, reduce vomiting
4. Urinary catheter - monitor urine output
5. Analgesia - IV opioids (does NOT mask peritonism to the degree previously thought)
6. Antibiotics - broad-spectrum IV (e.g., co-amoxiclav + metronidazole) pre-operatively
7. Bloods and ECG - pre-operative workup

Taxis (Gentle Manual Reduction) - Rarely Appropriate

• Gentle, sustained pressure to reduce hernia
• Only if the hernia is soft, non-tender, and obstruction is of short duration
• CONTRAINDICATED if any suspicion of strangulation (tender, erythematous, toxic patient)
• Danger of "reduction en masse" - hernia contents return to abdomen still strangulated within the sac

Operative Management - Urgent Surgery

1. Expose the hernia through appropriate incision
2. Open the sac carefully
3. Assess viability of bowel - colour, lustre, peristalsis, mesenteric pulsation
4. Enlarge the neck of the sac if needed to reduce contents:
   • Inguinal hernia: divide the neck; inferior epigastric vessels can be ligated and divided safely
   • Femoral hernia: split the inguinal ligament anteriorly (or divide lacunar ligament medially - Lockwood's approach; beware abnormal obturator artery - "Crown of Death")
5. If bowel is viable: reduce into abdomen, repair hernia
6. If bowel is non-viable (gangrenous):
   • Resect the non-viable segment
   • Primary anastomosis (if patient is stable and bowel ends are healthy)
   • Assess the entire GI tract - rule out other causes of obstruction
   • Diagnostic laparoscopy is a useful adjunct
7. Repair the hernia after bowel management

Bowel Viability Assessment

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Prognosis and Complications

• Untreated obstructed hernia progresses to strangulation - with rising mortality
• Mortality of elective hernia repair: <0.1%
• Mortality of emergency repair (obstruction): 1-3%
• Mortality of strangulated hernia with bowel resection: 5-10% (higher in elderly/comorbid)

• Wound infection (especially if bowel opened)
• Anastomotic leak
• Recurrence of hernia
• Short bowel syndrome (if extensive resection needed)

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Obstructed Hernia vs. Other Causes of Intestinal Obstruction

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Ward Leaving Test - Surgery (Written)

MBBS 2022 D Batch | All 6 Questions Answered

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Q1. Clinical Features and Examination Findings of a Reducible Hernia (5 marks)

Definition

Clinical Features (Symptoms)

• Swelling in the groin/scrotum/umbilical region that appears on standing, straining, or coughing
• Swelling disappears on lying down - the hallmark of reducibility
• Dragging, aching discomfort in the groin - worsens towards end of day
• Gurgling sensation during reduction (if bowel is in sac = enterocele)
• No pain at rest - pain only during straining or prolonged standing
• History of swelling first noticed when lifting heavy objects, coughing, or straining at stool

Examination Findings

• Visible swelling in groin/scrotum/umbilical area
• Swelling increases on coughing or Valsalva manoeuvre
• Swelling disappears on lying down (patient reduces it spontaneously)
• Skin over swelling - normal colour, no oedema

• Index finger on deep inguinal ring (1/2 inch above mid-inguinal point)
• Middle finger on superficial inguinal ring
• Ring finger on saphenous opening (4 cm below and lateral to pubic tubercle)
• Ask patient to cough:
  • Impulse on index finger = Indirect inguinal hernia
  • Impulse on middle finger = Direct inguinal hernia
  • Impulse on ring finger = Femoral hernia

Key Distinguishing Points of a Reducible Hernia

• Can get above the swelling? No = inguinal/femoral hernia; Yes = scrotal swelling
• NOT tender, NOT tense
• Cough impulse present
• Transillumination negative (vs. hydrocele which is brilliantly positive)

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Q2. History of Present Illness (HOPI) in a Patient with Thyroid Swelling (5 marks)

Introductory Note

HOPI - Detailed Points

• Duration - how long has the swelling been present? (Long duration with slow growth = benign goitre; rapid growth = malignancy or thyroiditis)
• Onset - gradual or sudden
• Rate of growth - slow (simple/multinodular goitre), rapid (anaplastic carcinoma, thyroiditis)
• Change in size - increased, decreased, or fluctuating
• Pain or tenderness - painful = thyroiditis, haemorrhage into cyst; painless = most goitres and carcinomas
• Single or multiple lumps in the neck

• Dysphagia - difficulty swallowing (oesophageal compression by large goitre)
• Dyspnoea / Stridor - breathlessness, noisy breathing (tracheal compression - important surgical emergency)
• Change in voice / Hoarseness - recurrent laryngeal nerve involvement (suggests malignancy)
• Choking sensation when lying flat or turning head
• Pemberton's sign - ask if raising both arms above the head causes dizziness, facial flushing (retrosternal goitre compresses SVC)

• Heat intolerance, excessive sweating
• Palpitations, rapid heart rate
• Weight loss despite good appetite (increased metabolism)
• Tremors of hands
• Nervousness, anxiety, irritability, restlessness
• Diarrhoea, frequent bowel movements
• Menstrual irregularity (oligomenorrhoea) in women
• Eye symptoms - prominence of eyes (exophthalmos), grittiness, diplopia (Graves' disease)

• Cold intolerance
• Weight gain, lethargy, fatigue
• Constipation
• Dry skin, hair loss, brittle nails
• Hoarse voice (myxoedematous)
• Menorrhagia
• Depression, memory loss

• Hard, fixed lump that is rapidly growing
• Hoarseness of voice (RLN palsy)
• Dysphagia (oesophageal invasion)
• Cervical lymph node enlargement
• Bone pain (metastatic differentiated thyroid cancer)
• History of prior neck irradiation in childhood (papillary carcinoma risk)
• Family history of thyroid cancer or MEN syndrome (medullary carcinoma - MEN 2)

• Previous thyroid surgery or radioiodine treatment
• Previous neck irradiation
• Medications - amiodarone (causes thyroid dysfunction), lithium, contrast agents

• Goitre in family (endemic goitre - iodine deficiency)
• Family history of thyroid cancer

• Residence in iodine-deficient area (endemic goitre)
• Diet - consumption of goitrogens (cassava, cabbage, turnip)

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Q3. Clinical Examination of Varicose Veins and Special Tests (5 marks)

History

• Aching, heaviness, throbbing in leg (worse on prolonged standing, relieved by elevation)
• Visible dilated veins
• Ankle swelling (worse evenings)
• Skin changes - itching, pigmentation, eczema, ulceration
• Thrombophlebitis episodes
• DVT history (post-thrombotic syndrome)
• Pregnancies, occupation (standing), family history

Examination

• Visible tortuous dilated subcutaneous veins
• Distribution: GSV territory (medial aspect, thigh and calf) or SSV territory (posterolateral calf)
• Skin changes at gaiter area (lower 1/3 leg):
  • Haemosiderin pigmentation (brown discolouration)
  • Lipodermatosclerosis (hard, indurated skin)
  • Varicose eczema (itchy, weeping)
  • Atrophie blanche (white avascular scarring)
  • Venous ulcer - medial malleolus, shallow, sloping edges
• Ankle oedema
• Saphena varix - bluish swelling in groin (SFJ)

• Temperature along varicosities (warm = thrombophlebitis)
• Tenderness along veins (thrombophlebitis)
• Fascial defects over medial calf (incompetent perforators)
• Saphena varix: soft, compressible, disappears on lying

Special Tests

• Patient lies, leg elevated to drain veins
• Tourniquet applied at upper thigh (controls SFJ)
• Patient stands:
  • Veins fill slowly from below = perforator incompetence below tourniquet
  • Release tourniquet: sudden filling = SFJ incompetence (GSV)
• Repeat at different levels to locate all incompetent perforators

• One finger on lower varicosity; tap vein proximally
• Impulse transmitted = continuous column of blood = varicosity confirmed
• Indicates valvular incompetence in that segment

• Tourniquet around upper thigh
• Patient walks on tiptoes 10 times
• Veins empty = deep veins patent (OK to perform stripping)
• Veins remain full or pain increases = deep vein obstruction (post-thrombotic syndrome) - CONTRAINDICATION to stripping

• Finger placed at saphenofemoral junction (groin)
• Patient coughs - expansile impulse felt = SFJ incompetence

• Must be done before compression therapy
• Normal: >0.9; <0.8 = arterial disease - compression contraindicated

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Q4. Causes of Right Iliac Fossa Lump and One Distinguishing Feature of Each (5 marks)

Anatomical Structures in RIF

Causes and Distinguishing Features

Important Point

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Q5. Clinical Examination of a Breast Lump (5 marks)

Step 1 - History

Step 2 - Inspection

Step 3 - Palpation

1. Site - which quadrant (UOQ most common for cancer)
2. Size - in cm (three dimensions)
3. Shape - regular (benign) vs. irregular (malignant)
4. Surface - smooth vs. nodular
5. Edge/Margin - well-defined (benign) vs. ill-defined (malignant)
6. Consistency - soft / rubbery (fibroadenoma) / fluctuant (cyst) / hard (carcinoma)
7. Tenderness - tender (cyst/fibroadenosis) vs. non-tender (carcinoma)
8. Temperature - warm (inflammatory/malignant)
9. Mobility/Skin fixity - pinch skin; dimpling = skin tethering (malignant)
10. Muscle fixity - ask patient to press hands on hips (tenses pectoralis major); if lump becomes less mobile = attached to pectoralis (T4 disease)

Step 4 - Lymph Node Examination (Axilla)

• Anterior (pectoral) group - along lateral chest wall
• Posterior (subscapular) group - along posterior axillary fold
• Central group - against chest wall
• Lateral group - along humerus
• Apical group - apex of axilla

Step 5 - Systemic Examination (for metastases)

• Spine / rib tenderness (bone metastases)
• Hepatomegaly (liver metastases)
• Pleural effusion (lung metastases)

Clinical Differentiation

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Q6. Steps of Examination of a Swelling in General (Inspection, Palpation, etc.) (5 marks)

History First

• Duration, onset (sudden/gradual)
• Rate of growth - slow (benign/cyst/lipoma) vs. rapid (malignant/abscess)
• Pain - painful (inflammatory/abscess) vs. painless (benign/malignant)
• Any preceding trauma
• Associated symptoms (fever, weight loss, discharge)

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Step 1 - INSPECTION

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Step 2 - PALPATION

• Soft = lipoma, abscess (fluctuant)
• Firm = fibroma, lymph node
• Hard = carcinoma, calcified lesion, bone
• Rubbery = lymphoma
• Fluctuant = cyst, abscess (test in two planes at right angles)

• Two fingers of one hand on sides of swelling; press with finger of other hand
• Fluid transmitted in both directions = fluctuation positive (cyst/abscess)

• Torch in dark room pressed on one side of swelling
• Bright glow through swelling = cyst with clear fluid (hydrocele, epididymal cyst, hygroma)
• No glow = solid tumour, abscess (opaque fluid)

• Swelling reducible on gentle pressure = hernia, reducible hydrocoele

• Swelling reduces on pressure but refills on release = cystic hygroma (empties into lymph channels)

• Expansile pulsation in all directions = aneurysm (arterial)
• Transmitted pulsation (tapped from one side) = non-vascular swelling overlying vessel

• Can the swelling be moved freely? - mobile = not attached
• Skin fixity: pinch skin over swelling; if skin cannot be pinched = tethered (malignant)
• Deep fixity: ask patient to contract underlying muscle; if swelling moves less = attached to deep structure

• Does it move with swallowing? (thyroid/thyroglossal)
• Does it move with tongue protrusion? (thyroglossal cyst)
• Does it move with adjacent joint movement?

• Always examine draining lymph nodes - enlarged, tender (infection), hard and matted (malignancy)

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Step 3 - PERCUSSION

• Resonant = gas-containing swelling (bowel in hernia)
• Dull = solid tumour, fluid-filled (if large)
• Stony dull = solid mass, bone
• Shifting dullness - large abdominal cysts

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Step 4 - AUSCULTATION

• Bowel sounds over hernia = bowel content
• Bruit over swelling = arteriovenous malformation, vascular tumour, aneurysm
• Venous hum = AV fistula
• Crepitus on movement = air in tissue (gas gangrene, surgical emphysema) or bone crepitus

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Step 5 - SPECIAL TESTS (as applicable)

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Summary Table: Differentiating Common Swellings

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Acute Appendicitis - Clinical Features and Examination

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Anatomy Relevant to Clinical Presentation

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Pathophysiology (Basis of Clinical Features)

1. Luminal obstruction (faecolith 65%, appendicolith, lymphoid hyperplasia, foreign body) → mucus accumulates → bacterial proliferation
2. Visceral distension → stimulates T10 visceral sensory nerves → periumbilical colicky pain (lasts 4-6 hours)
3. Intraluminal pressure exceeds capillary pressure → ischaemia → transmural inflammation
4. Inflammation extends to parietal peritoneum → somatic pain localises to RIF (the "shift" of pain)
5. If untreated → necrosis → perforation → faecal peritonitis (generalised pain, toxaemia)

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Clinical Features (Symptoms)

1. Pain - The Cardinal Symptom

• Stage 1 - Visceral pain: Dull, colicky, periumbilical or central abdominal pain; onset gradual; lasts 4-6 hours; patient cannot localise it precisely
• Stage 2 - Somatic pain: Pain shifts and localises to the RIF (McBurney's point area); becomes constant, sharp, and worsened by movement, coughing, or bumps in the road
• Coughing and sudden movement exacerbate the RIF pain

"The classic visceral-somatic sequence of pain is present in only about half of those patients subsequently proven to have acute appendicitis."

• Bailey & Love's Short Practice of Surgery, 28th Ed.

2. Anorexia

• Nearly universal - if patient has a good appetite, appendicitis is unlikely
• Precedes or accompanies the onset of pain

3. Nausea and Vomiting

• Nausea almost always present
• Vomiting occurs in ~75% - usually 1-2 episodes only (unlike gastroenteritis where vomiting is profuse and prolonged)
• Vomiting follows pain onset (if vomiting precedes pain, think gastroenteritis)

4. Fever

• Low-grade pyrexia: 37.2-37.7°C
• Corresponding mild tachycardia: 80-90 bpm
• During first 6 hours: little or no temperature change
• High fever (>38.5°C) suggests perforation, peritonitis, or alternative diagnosis (mesenteric adenitis in children)

5. Altered Bowel Habit

• Constipation is common (due to ileus from peritoneal irritation)
• Diarrhoea may occur with pelvic appendicitis (inflamed appendix irritates rectum)

6. Urinary Symptoms

• Frequency, dysuria, or pyuria - with pelvic or retrocaecal appendix irritating the ureter/bladder

7. Sequence of Symptoms (Murphy's Triad)

1. Anorexia (first)
2. Pain (central, then shifting to RIF)
3. Vomiting (last)

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Examination Findings

General Examination

• Patient looks unwell, lying still (peritoneal irritation causes pain with movement)
• Prefers to lie with right hip slightly flexed (reduces tension on psoas - retrocaecal appendix)
• Flushed face, coated tongue, foetor oris
• Low-grade fever (37.2-37.7°C)
• Mild tachycardia (80-90 bpm)
• Dehydration (dry tongue, decreased skin turgor) if prolonged vomiting

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Abdominal Examination

INSPECTION

• Reduced respiratory movement of the lower abdomen (splinting due to peritoneal irritation)
• Abdominal distension - if peritonitis/perforation
• Pointing sign - ask patient to point where pain started and where it moved; localisation to RIF is diagnostic

PALPATION (begin in left iliac fossa, move anticlockwise to RIF - avoid the tender area first)

• Maximum tenderness at junction of lateral 1/3 and medial 2/3 of line from RASIS to umbilicus
• Most specific point for appendix base
• Note: appendix tip is highly variable, so maximal tenderness may be elsewhere

• Involuntary contraction of right iliac fossa muscles
• Indicates localised peritoneal irritation
• Progresses from voluntary guarding → involuntary rigidity as inflammation worsens
• "Board-like" rigidity = perforation with generalised peritonitis

• Press firmly over suspected area, then suddenly release pressure
• Pain on release > pain on pressure = peritoneal irritation positive
• Can also be elicited by percussion (gentler test)
• Positive in localised or generalised peritonitis

• Deep palpation of the left iliac fossa causes pain in the right iliac fossa
• Mechanism: pressure on left colon shifts bowel gas rightward, distending the caecum and stretching the inflamed appendix
• Positive Rovsing's sign supports appendicitis

• Patient lies on left side; examiner hyperextends the right hip (or asks patient to flex right hip against resistance)
• Pain in RIF = positive
• Indicates retrocaecal appendix in contact with the iliopsoas muscle

• Patient supine; examiner flexes right hip and knee to 90°, then internally rotates the hip
• Pain in RIF/hypogastrium = positive
• Indicates pelvic appendix in contact with the obturator internus muscle

• Worsening of RIF pain on coughing
• Simple, non-invasive indicator of peritoneal irritation

• Distress or pain in epigastrium or anterior chest when McBurney's point is continuously pressed

PERCUSSION

• Percussion tenderness over RIF - gentler method to detect peritoneal irritation than rebound testing
• Loss of liver dullness = free air (perforation)
• Generalised dullness = ascites (late peritonitis)

AUSCULTATION

• Diminished or absent bowel sounds - paralytic ileus (peritonitis)
• Hyperactive bowel sounds - early obstruction

RECTAL EXAMINATION (Digital PR)

• Mandatory in all patients with acute lower abdominal pain
• Tenderness on right side of rectum = pelvic appendicitis
• Boggy, tender mass = pelvic abscess / appendicular mass
• Note: cervical motion tenderness (CMT) is positive in 28% of female patients with appendicitis - NOT specific for pelvic pathology

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Special Signs Summary Table

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Variations in Clinical Presentation

Retrocaecal Appendicitis

• Anterior abdominal signs minimal (appendix not touching parietal peritoneum)
• Psoas sign positive - flank/back pain
• Diagnosis often delayed
• Pain in right loin / flank

Pelvic Appendicitis

• Suprapubic pain, tenesmus, diarrhoea, urinary symptoms
• Obturator sign positive
• Tenderness only on PR examination (not on anterior abdominal palpation)
• Easily confused with ovarian/tubal pathology in women

Appendicitis in the Elderly

• Localisation to RIF is unusual
• Signs often minimal and atypical
• Perforation rate much higher (delayed presentation)
• Higher mortality

Appendicitis in Pregnancy

• Appendix displaced upward and laterally (though in <25% in 3rd trimester is it truly out of RIF)
• Pain and tenderness higher in the right side
• Physiological leucocytosis and elevated ESR can confuse the picture
• Perforation rates higher due to diagnostic delay

Appendicitis in Children

• Temperature >38.5°C suggests mesenteric adenitis rather than appendicitis
• Presentation more often at perforation stage
• Diarrhoea and vomiting may be more prominent

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Alvarado Score (MANTRELS Score) - Clinical Scoring

• 1-4: Appendicitis unlikely - observe / discharge
• 5-6: Possible appendicitis - admit, observe
• 7-8: Probable appendicitis - consider surgery
• 9-10: Almost certain appendicitis - operate

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Investigations

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Differential Diagnosis

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Complications of Acute Appendicitis

1. Perforation - most common complication (higher in extremes of age)
2. Appendicular mass - omentum walls off perforated appendix; palpable RIF mass 3-5 days after onset
3. Appendicular abscess - fluctuant, tender mass; needs drainage
4. Peritonitis - generalised (board-like rigidity, septic shock)
5. Portal pyaemia - septic emboli to liver via portal vein (rare, very serious)
6. Pylephlebitis - septic thrombophlebitis of portal vein (jaundice, high fever, liver abscesses)

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Cholelithiasis (Gallstones)

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Definition

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Types of Gallstones

1. Cholesterol Stones (80% in Western countries)

• Contain 50-99% cholesterol plus calcium salts, bile acids, bile pigments, phospholipids
• Usually pale yellow, solitary or multiple, faceted
• Radiolucent on X-ray (10-15% may calcify and become radio-opaque)
• Form due to bile supersaturation with cholesterol

2. Black Pigment Stones (10-20%)

• Contain insoluble bilirubin polymer + calcium phosphate + calcium bicarbonate
• <30% cholesterol
• Radiopaque (calcified), small, multiple, irregular
• Associated with: chronic haemolysis (hereditary spherocytosis, sickle cell, thalassemia), cirrhosis, increasing age
• Form in sterile bile

3. Brown Pigment Stones

• Contain calcium bilirubinate + calcium palmitate + cholesterol
• Soft, greasy, earthy brown
• Form in bile ducts (not gallbladder primarily)
• Associated with: bile stasis + bacterial infection (β-glucuronidase deconjugates bilirubin)
• Associated with: biliary parasites (Clonorchis sinensis, Ascaris lumbricoides), stents/foreign bodies

4. Mixed Stones

• Mixture of cholesterol, pigment, and calcium salts
• Multiple, faceted, laminated

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Composition Summary

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Pathogenesis

For Cholesterol Stone Formation - Three Key Factors:

• Cholesterol is water-insoluble and is secreted in phospholipid vesicles
• When cholesterol : bile acids : phospholipids ratio is disturbed - unstable unilamellar vesicles form
• Cholesterol crystals precipitate from these vesicles
• Triggers: obesity, high-calorie diet, OCP, clofibrate, HMG-CoA reductase overactivity, ileal disease (depletes bile acid pool)

• Abnormal emptying allows aggregation of cholesterol crystals
• Gallbladder stasis = crystal aggregation → stone formation
• Removing stones without removing the gallbladder → inevitable recurrence

• Mucoproteins (pronucleating factors) in bile accelerate crystal formation
• Anti-nucleating factors (apolipoproteins AI and AII) reduced

For Pigment Stone Formation:

• Unconjugated bilirubin (from haemolysis or bacterial β-glucuronidase) precipitates as calcium bilirubinate
• Infection (E. coli, Bacteroides) produces β-glucuronidase → bilirubin deconjugation → precipitation

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Risk Factors - "The 5 Fs" (for Cholesterol Stones)

• Oral contraceptive pills / hormone replacement therapy
• Rapid weight loss (bariatric surgery, fasting)
• Ileal disease or resection (Crohn's disease) - depletes bile acid pool
• Diabetes mellitus (impaired gallbladder motility)
• Drugs: clofibrate, octreotide, ceftriaxone
• Genetic factors: ABCG5/G8 transporter polymorphism (found in 21% of gallstone patients)
• Total parenteral nutrition (gallbladder stasis)

• Chronic haemolytic anaemias (sickle cell, spherocytosis, thalassemia)
• Biliary infection / parasites
• Cirrhosis
• Crohn's disease / ileal resection

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Clinical Presentation

1. Silent / Asymptomatic Gallstones (>80%)

• Detected incidentally on imaging
• ~2% per year develop symptoms in first 5 years; risk decreases to 0.5%/year after 10-15 years
• Over 20 years, only 18% develop biliary pain
• Prophylactic cholecystectomy NOT usually indicated in silent gallstones

2. Biliary Colic

• Site: Right upper quadrant (RUQ) or epigastric pain; may radiate to right shoulder tip (diaphragmatic irritation via phrenic nerve) or back (interscapular)
• Character: Despite the term "colic," it is more often dull, constant, and severe - not truly colicky (does not completely come and go in waves)
• Duration: Lasts minutes to several hours (typically 1-4 hours); usually resolves when stone slips back into gallbladder body
• Onset: Classically post-fatty meal or at night (wakes the patient)
• Associated symptoms: Nausea, vomiting, belching
• Relieved by: Spontaneous stone slippage; antispasmodics
• Dyspeptic symptoms (questionable relation): Flatulence, bloating, food intolerance to fatty foods, altered bowel frequency

3. Acute Cholecystitis

• Pain: RUQ pain, constant and severe, persists >6 hours (unlike biliary colic which resolves)
• Preceded by fatty meal
• Nausea, vomiting, fever (38-38.5°C), tachycardia
• Anorexia
• Jaundice in ~10% (compression or stone in CBD)

4. Chronic Cholecystitis

• Repeated episodes of biliary colic → gallbladder wall thickening, fibrosis, contraction
• Dull, progressive RUQ pain or back/right shoulder pain
• Dyspepsia, fat intolerance
• Eventually: contracted, non-functioning gallbladder

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Examination Findings

General

• Obese, middle-aged woman (classically)
• Fever and tachycardia - in acute cholecystitis (absent in biliary colic)
• Jaundice - if CBD stone or Mirizzi syndrome

Abdominal Examination

• Tenderness in RUQ
• No peritonism in uncomplicated biliary colic
• Reduced respiratory movement of RUQ in acute cholecystitis

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Complications of Gallstones

In the Gallbladder:

1. Biliary colic - stone obstructs cystic duct transiently
2. Acute cholecystitis - sustained cystic duct obstruction + inflammation
3. Chronic cholecystitis - repeated episodes; fibrotic contracted gallbladder
4. Empyema of gallbladder - pus in gallbladder; high fever, toxaemia; surgical emergency
5. Mucocele of gallbladder - complete cystic duct obstruction; bile reabsorbed; mucus accumulates; palpable, non-tender mass
6. Perforation - localised peritonitis or generalised peritonitis; rarely pericholecystic abscess
7. Emphysematous cholecystitis - gas-forming organisms (Clostridium, E. coli, Klebsiella); elderly diabetic men; high mortality
8. Carcinoma of gallbladder - long-standing gallstones associated with gallbladder carcinoma

In the Bile Ducts (CBD):

1. Choledocholithiasis - stone passes into CBD → obstructive jaundice, cholangitis, pancreatitis
2. Acute cholangitis (Charcot's triad) - fever + RUQ pain + jaundice; life-threatening if untreated
3. Reynold's pentad (severe cholangitis) - Charcot's triad + hypotension + confusion
4. Mirizzi syndrome - stone in gallbladder neck/cystic duct compresses CBD extrinsically → jaundice
5. Acute pancreatitis - stone in common channel at ampulla of Vater

Intestinal:

1. Gallstone ileus - large stone erodes gallbladder wall → cholecystoduodenal fistula → stone enters gut → mechanical small bowel obstruction (usually at terminal ileum); X-ray: Rigler's triad (pneumobilia + dilated bowel + aberrant gallstone)

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Investigations

Blood Tests

Imaging

• Sensitivity >95% for gallstones >2 mm
• Findings: Echogenic foci with posterior acoustic shadowing (stones)
• Gallbladder wall thickening >3 mm (acute cholecystitis)
• Pericholecystic fluid
• Sonographic Murphy's sign
• Gallbladder distension
• CBD dilatation (>6 mm = abnormal; suggests CBD stone)
• Preferred initial study: cheap, no radiation, widely available

• Only 10-15% of gallstones are radio-opaque (calcium-containing)
• May show: porcelain gallbladder (calcified GB wall), gallstone ileus (Rigler's triad)
• Generally unhelpful for routine diagnosis

• Poor for gallstone detection (stones often isodense to bile)
• Good for: complications (perforation, abscess, pancreatitis, pericholecystic fluid)
• "Tensile gallbladder fundus sign" - sensitivity 75%, specificity >90% for acute cholecystitis

• Gold standard for CBD stones (non-invasive)
• Shows biliary tree anatomy; detects stones, strictures
• No radiation; no contrast injection required
• Preferred over ERCP for diagnosis (ERCP reserved for therapy)

• Diagnostic AND therapeutic for CBD stones
• Allows sphincterotomy and stone extraction
• Risk of pancreatitis (~3-5%)

• For equivocal cases of acute cholecystitis
• Failure of gallbladder to opacify at 60 minutes = cystic duct obstruction = acute cholecystitis
• CCK-stimulated HIDA: gallbladder ejection fraction <35-40% = biliary dyskinesia

• Highly sensitive for small CBD stones (<5 mm)
• Used when MRCP inconclusive

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Management

1. Asymptomatic Gallstones (Silent)

• Conservative management (watchful waiting)
• Annual risk of developing symptoms is only ~2% in first 5 years
• Prophylactic cholecystectomy NOT routinely indicated
• Exceptions (consider prophylactic cholecystectomy):
  • Porcelain gallbladder (associated with cancer risk - controversial)
  • Very large stones (>3 cm) - higher cancer risk
  • Congenital haemolytic anaemias (sickle cell) - before they develop acute cholecystitis
  • Patients in remote areas
  • Immunocompromised patients
  • Gallbladder polyp >1 cm (not stones per se)

2. Symptomatic Gallstones (Biliary Colic / Chronic Cholecystitis)

• Definitive treatment: Laparoscopic cholecystectomy (gold standard)
  • Introduced by Philippe Mouret in France in 1987
  • Has largely replaced open cholecystectomy
  • Benefits: smaller scars, shorter hospital stay (1-2 days), earlier return to work
  • Conversion rate to open: ~5%
  • Removing stones without removing gallbladder = inevitable recurrence (gallbladder is the source of abnormal bile)

• Nil by mouth
• IV fluids
• NSAIDs (diclofenac IM/IV - reduces cystic duct spasm effectively)
• Opioid analgesia (morphine, pethidine)
• Antispasmodics (hyoscine)

3. Acute Cholecystitis

• IV fluids, analgesia (NSAIDs/opioids), NBM
• IV antibiotics - broad spectrum (co-amoxiclav ± metronidazole; or piperacillin-tazobactam)
• Laparoscopic cholecystectomy: within 72 hours of symptom onset (early surgery preferred over delayed "interval" surgery - reduces hospital stay, cost, total complications)
• If unfit for surgery: percutaneous cholecystostomy (ultrasound-guided drainage)

4. CBD Stones (Choledocholithiasis)

• ERCP + sphincterotomy + stone extraction - followed by laparoscopic cholecystectomy
• Or: laparoscopic CBD exploration at time of cholecystectomy (single-stage)

5. Non-surgical Options (rarely used now)

• Ursodeoxycholic acid (UDCA) - dissolves small (<5 mm), radiolucent, cholesterol stones in functioning gallbladder; requires 12-24 months; high recurrence rate after stopping; rarely used
• Extracorporeal Shock Wave Lithotripsy (ESWL) - fragments stones; combined with UDCA; largely abandoned due to high recurrence

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Differential Diagnosis of RUQ Pain / Biliary Colic

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Key Surgical Mnemonics

Fat, Female, Forty, Fertile (+Fair)

RUQ Pain + Fever + Jaundice

Charcot's triad + Hypotension + Mental confusion

Pneumobilia + Dilated small bowel + Aberrant gallstone shadow

"A palpable, non-tender gallbladder + jaundice = malignant CBD obstruction (NOT gallstones)" (Gallstone disease causes fibrosis of the gallbladder wall → it cannot distend)

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