1.

Thyroid
History
C/c: anterior neck swelling
Hx
Onset
Duration: long – benign, MNG & colloid G; short – malignant
Recent increase in size (hemorrhage [pain] or malignant transformation)
Associated pain, radiation
Dyspnea: tracheomalasia (MNG); 2ry thyrotoxicosis effect on CVS; RLN palsy
(bilateral)-Ca; retrosternal extension
Local effects
• Dyspnea, dysphagia, hoarseness of voice
• Pain – thyroiditis, granulomatous, autoimmune, Riedel’s thyroiditis
Toxic sx:
• CNS: predominantly 10 TT(GD); Irritability, tremor, excitability, heat
intolerance, cold preference, diplopia/blurring of vision
• CVS: usually 2ry MNG; Palpitation, dyspnea on exertion, pericardial chest
pain
• Wt loss with inc apetite, Increased stool freq, dysmenorrhea
(oligomenorrhea), proximal limb muscle weakness
Hypo:
• Lethargy, deposition of fat, deep husky voice, intolerance to cold

Mx features:
• SOB, cough- lung mx (follicular ca) 1st
• Bone pain or mass (flat): skull, ribs, sternum, vertebral column (follicular ca)
2nd
• Ascites, jaundice – liver mx (follicular ca) 3rd
• Hoarseness of voice – RLN palsy (unilateral) – anaplastic Ca
• neck swelling (papillary ca)
Family hx (medullary ca)
Chest irradiation
Drugs – PAS & Sulfonamides (goiterogens)
Physical examination Indications for surgery
General appearance
Toxicity
Anxiousness
Malignancy
Restlessness
Obstructive Symp
nervousness
Cosmetics
Wasting
Clothing, style on bed
Vital sign
PR: rhythm, volume, character
RR:
 T
BP
Eyes
Lid lag
Lid retraction
Exophtalmus
• Upper sclera visible (dalrymple’s sign)
• Absence of wrinkling of the forehead when pt is asked to look upwards (Joffroy’s
sign)
Ophtalmoplegia
• Loss of convergernce of eyeball muscle (paresis) (Moebius sign)
Chemosis

Tongue
Dry or wet
Tremor
Neck
Inspection: pt sitting with neck slightly hyper extended & inspect from the front
Location (unilateral, midline, bilateral)
Size, shape, surface, border
Swallowing (ligament of Berry, pretracheal fascia; restricted – Ca, RSG, large
goiter, previous surgery),
Tongue protrusion to r/o TG cyst,
Skin: redness, scar (recurrence), dilated veins
Palpation: done from behind (Lahey’s method)
Temp local rise – toxic G
Size, shape, surface, consistency, border (esp the lower)
Surface(smooth – GD, adenoma, pubertal goiter; irregular –Ca; nodular –
MNG),
Consistency (soft – GD, colloid G; firm – adenoma, MNG; hard – Ca),
Intrinsic mobility
Tracheal deviation,
Cervical/supraclavicular LN – papillary ca
Berry’s sign: pulse of CCA in posterior triangle; CA (anaplastic) – BS +ve (if
pulsation is absent)
Kocher’s sign: gentle compression on lateral lobe produces stridor - +ve:
tracheomalacia, carcinoma infiltration
Pizzilo’s method: pt clasp his/her hand and press against his/her occiput
with head extended: to better visualize the thyroid in obese or short necked
ppl
Pembertons’ sign: engorgement of neck veins when hands are raised above
the head: retrosternal goiter
Percussion: Upper chest for retrosternal mass extension
Auscultation:
 site – upper pole(STA – superficial, direct branch of ECA)
Bruit + trill – toxic G, follicular ca (better app with the bell)
Chest – mx
CVS
HR, rhythm, murmur
Abd- hepatomegaly, ascities
MSS
Tremor, sweating, pretibial swelling,
CNS
Anxiety, restlessness, DTR
DDx
Simple NTG/colloid: euthyroid, soft nodule
MNG: euthyroid or toxic(2ry)
Solitary nodule: adenoma, cyst, Ca, part of MNG
Follicular adenoma
Malignant tumor: P-Ca – LLN involvement; F-Ca – scalp 2ry; A-Ca - +ve berry sign, stridor,
most rapidly growing
Graves’ disease: diffuse, soft, swelling,
Hashimoto thyroiditis
Reidel thyroiditis
Subacute thyroiditis: initial hyper
Investigation
U/S
FNAC biopsy
TFT(T3, T4, TSH & TRH)
Flexible laryngoscopy (vocal cord mobility)
Thyroid abs
CBC
LFT, abd u/s
CXR
CT
Bone scan
Isotope scan(hot, warm & cold nodules)
Rx
Early hyperplastic goiter – thyroxine – TSH suppression
Thyrotoxicosis
Carbimazole
PTU
B-blocker: Propranolol
Iodides
Radio iodine
Diffuse ˃45 – RI, ˂45 –surgery, drugs
NTG – surgery
Toxic nodule – RI
 Recurrent after surgery- RI
Failure of drugs & surgery - RI
Surgery
pre-op euthyroid pt using
• Carbimazole: 30-40 → 6-8wks
• iodide: 10-14 days before surgery
• B-blocker(propranolol): cont post- op
Subtotal thyroidectomy
• Indication
• Neoplastic
• Toxic adenoma
• Pressure symptoms(dyspnea, dysphagia)
• Cosmetic, pts wish
Near total thyroidectomy
• 1-2gm remnant (parathyroid gland)
Total thyroidectomy
• Ca: multifocal papillary(excellent prognosis), anaplastic, medullary
Esthmusectomy
Lobectomy
Additional measures
Thyroxine: to ↓ TSH, to replace thyroid hormone
RI: for metabolism
Thyroglobuline: follow up
Post-op complications
Hemorrhage
Respiratory obstruction (tension haematoma, tracheomalacia)
RLN paralysis (unilateral: whispering voice bilateral: stridor>respiratory failure)
Hypothyroidism
Hypoparathyroidism (most are transient- ischemia)
Thyrotoxic crisis (storm)
Wound infection
Scar hypertrophy & Keloid
Stich granuloma
2. Breast
C/c: Unilateral or bilateral breast swelling with or without pain
Hx:
Onset/ how noticed
Progression
Local symp
Pain : cyclic Or progressive
Skin ulceration, discoloration or discharge
Nipple retraction or ulceration
Nipple discharge
• Unilateral or bilateral
• Color (serous=fibroadenosis; greenish=fibroadenosis, duct ectasia,; pus=
abscess; bloody= ductal papilloma or carcinoma; milky=galactocele; pate=duct
ectasia)
• Amount
• Mechanism (spontaneous, squeezed)
• Pain associated
Hx of trauma to the breast
Hx of antibiotic use for breast abscess
Fever, Malaise, Chills and rigors
Risk factor for breast ca
Age
Age at menarch and menopause
Parity, breast feeding
HRT
Alcohol
Hx of breast ca in the same pt or in the family
Chest irradiation
Diet (high animal fat and meat)
Metastatic manifestations
Wt loss, dec apetite
Axillary swelling, ipsilateral arm swelling
Cough, hemoptysis, dyspnea
Jaundice, abd swelling
Back pain or swelling in bony areas
CNS mx: headache, vomiting & blurring of vision
Physical examination
G/A(Exposure, 90° sitting)
V/S
HEENT: pallor, icterus
Breast
Inspection: hand by side of the body, hands raise above the head, bending forward
Edema of the arm
Skin Axillary LN levels (surgical)

• Level I: Lateral to pec minor

• Level II: Deep to pec minor
• Level III: Medial to pec minor
 • Dimpling
• Peau d’orange
• Lump (Size, Location, Symmetry)
• Erythema
• Ulceration
Nipple
• Discoloration
• Retraction (circumferential: malignancy slit-like: duct ectasia, periductal
mastitis)
• Discharge
• Deviation
• Destruction
Palpation(start from the normal appearing breast)
Local rise in temp & tenderness
Lump
• Location - quadrant
• Consistency
• Size
• Shape
• Surface- hard, irregular = Ca; soft = necrosis, mastitis Ca
• Border
• Mobility
• Fixation to
o Skin: pinch the skin above the mass
o Pec major: Hands on hip & press- if can’t be moved after contraction
o Chest wall: if not mobile when pec major is relaxed
o Seratous ant: pressing the hand against the wall. When the tumor is
situated in the outer and inferior quadrant
Nipple
• Eversion
• Retraction
• Lump beneath
• Tenderness
• Squeezing
Axillary LN
Supraclavicular LN
Chest: signs of pleural effusion
Abd: liver enlarged, nodular; ascites; PR (deposition in the rectouterine pouch)
MSS: areas of tenderness and swelling (spine, long bones, skull)
Neurologic examination
DDx
Breast Ca
Ductal papilloma
Fibrocystic change +/- of chronic abscess
Fat necrosis
Sarcoma
Phylloids tumor
Fibro-adenoma
Pure-adenoma
Lipoma
Investigation
CBC, urine analyisis, LFT (alkaline phosphatase)
Mammography: less sensitive in youngsters(U/S is indicated); in elderly even(35+) sensitive to
non-palpable mass, 90-95% accurate; pattern = loss of architecture, calcification
Ill-defined edge
Micro-calcification
Shrinking of skin
Single dilated duct
Nodularity
Indication
• Coarse nodularity
• Fibroadenoma
• Over 40yrs
Advantage
• Non invasive
• No radiation
Disadvantage
• 3% false +ve
• Need FNAC to confirm
U/s
Age less than 35
Greater than 95% accuracy
Of +ve intra-op frozen section is arranged
FNAC (Lump, axillary LN(confirmatory))
Biopsy (core needle, excisional)
CXR
Bone x-ray
Abd U/S
Management
Depends on staging
Post op complications
Arm swelling
Recurrence
Lymphangiosarcoma
Psychological stress
Ca frequency
Upper outer (most of the breast tissue is located here) = 60%
Areola = 12%
Upper inner = 12%
Lower outer = 10%
Lower inner = 6%
 3. Esophageal Ca
History
C/c: difficulty of swallowing
Hx
Onset
Progression - solid→ semisolid → liquid → saliva =>Ca;
- Liquid → solid; liquid=solids =>achalasia
Intermittent (motility disorders), progressive (CA)
Halitosis
Regurgitation – pronounced in achalasia at recumbent position
Nausea/ vomiting: pattern, amount, content, time
Squeezing type of chest pain pronounced during emotional stress and/or cold meals
and drinks- DES, nutcracker esophagus
Efforts to facilitate swallowing
Site of discomfort or associated pain
Frequent Consumption of hot and spicy foods (porridge)
Alcohol, cigarette
longstanding heart burn RF
corrosive ingestion
carnivorous diet
Appetite & weight loss (significant if 10% in 3mo)
Voice change (hoarseness)
Choking episode (trachoesophageal fistula, aspiration)
Hematemesis, melena (esophagoaortic fistula)
Cough, dyspnea (pleural effusion), hemoptysis (lung mx) Advanced Sxs
Swelling around the neck (Cervical & SC lymphadenopathy)
Ascites (mx to liver [jaundice], or hypoalbuminemia)
Chronic back pain (celiac node enlargement)
Bone pain (mx to bone)
Chronic illnesses (DM, Htn, Asthma, cardiac disease)
Physical examination
General appearance
Choking
Sick looking
Wasting Every time one ingests food: fistula
V/S When full: aspiration
HEENT: pallor, jaundice, dehydration, halithosis
LGS: supraclavicular and cervical LAP SOB & Stridor
CVS Bilateral RLN paralysis
RS: mx (pleural effusion) Infiltration of airway
Abdomen: hepatomegaly, ascites Lung mx
MSS: Edema (hypoalbuminemia) Pleural effusion
DDx
Esophageal Ca
Leiomyoma of esophagus
 Achalasia
Gastric Ca
Pharyngeal pouch
Scleroderma
Corrosive ingestion
Chronic esophagitis
Para-esophageal hernia
Thymoma
Plummer Vinson syndrome(PVS)
Investigation
CBC (anemia), LFT, RFT
Barium swallowing (proximal dilatation, shouldering, irregular lumen)
Upper GI Endoscopy (Esophagescopy)
Edndoscopic U/S (least invasive, better diagnostic)
Manometer (if we are inclining to motility disorders)
Serum electrolyte (esp potassium-saliva)
Serum albumin
CXR
Abd U/S (liver secondaries, ascites, LN mx)
CT (staging)
Bronchoscopy: compression, tracheo- esophageal fistula
Management
Achalasia
Pharmacotherapy
Botulinum toxin
Esophageal dilation
Operative myotomy (Heller’s cardiomyotomy)
Esophageal Ca
Surgery
• Palliative
• Dilatation
• Stenting
• Local laser ablation
• Definitive:
• Esophagectomy
o Transhiatal
o Ivor lewis
o Mc. Kweon
• Chemotherapy: 5-fluorouracil
• Radiotherapy
Terminal complications
• Cachexia
• Dehydration
• Pneumonia
• Mediastinitis
• Erosion to aorta
• Hemothorax, pneumothorax
 4. Cholelithiasis
History
C/c: RUQ pain
HPI
Pain: location (RUQ/epigastric), type, onset, duration, relief, radiation(back,
shoulder), association with food specially fatty meal (1-2 hrs later)
Diaphoresis, nausea and Vomiting: fat intolerance, content
Flatulence, Diarrhea, Constipation
RF for cholelithiasis
• Female sex, age >40, family hx
• Obesity, rapid wt loss (fasting), pregnancy
• Medicine (OCP, ceftriaxone, octerotide), surgery (ileal resection)
• DM, spinal injury, total parental nutrition, dec physical activity
DDX for cholelithiasis (chronic)
• PUD (gastritis): dyspepsia, heart burn, melena, hematemesis, relation with
antiacids, NSAID, smoking, alcohol
• Renal calculi: flank pain, frequency, urgency, urine discoloration
• Chronic Hepatitis: blood transfusion, alcoholism
• Chronic pancreatitis
• IBD
• Diverticular disease
Complications of Cholelithiasis
• Acute Cholecystitis: fever, rigor, chills, nausea, vomiting (tenderness,
guarding, murphy’s sign)
o Ddx: perforated PUD, acute pancreatitis, rt sided
pneumonia, pyelonephritis, acute hepatitis
• Chronic cholecystitis: recurrent episodes of RUQ pain, N, V, bloating,
belching& flatus
• Cholidocholithiasis: jaundiced, prutitis, urine and stool color change
• Cholangitis: jaundice, fever, altered mental status
• Pancreatitis:
• Gallstone illeus: abd pain, vomiting, distension, constipation
Traditional(herbal) medication
Physical examination
General appearance
Skin & eye color
Scratch marks
V/s
HEENT
Eye: pallor, icterus
Parotid enalrgment
Lymhoglandular - Virchow’s, gynecomastia
Chest :
 CVS
GIT
Abdomen:
• Rt. subcostal: pain, guarding
• Murphy’s sign
• Boas sign
• stigmata of CLD: ascites, liver span, capute medusa
GUS: CVAT
Integumentary: telangectasia
MSS: dupetryens contracture, thenar atrophy
CNS
Investigation
CBC (leucocytosis> cholangitis, cholecystitis; anaemia>malignancy, platelet count)
LFT (↑ conjugated bilirubin and alkaline phosphatase in OJ)
Serum Amylase (Acute pancreatitis)
Urine analysis: uro-bilirubine
Plain abdominal x-ray
U/S
CT (if mass is seen on U/S)
PTC
ERCP

Management
Conservative
Analgesia
Anti-spasmodic
Low fat intake
Medication: bile acid, chemodeoxycholic acid
Surgery
Emergency cholecystectomy
• Acute cholecystitis ˂ 48hrs
o NG tube, IV fluid, analgesia, antibiotics,
• Cholecystectomy in 2-3days
Elective cholecystectomy
• After conservative mgt: in chronic cholecystitis(acute on chronic)
• Pre-op
o Antibiotics
o Medication
o Cholangiography
• Operation
o Cholecystectomy (open/laparascopic)
 5. OJ
Hx
Jaundice: onset, progression, intermittent (CBD stone)/persistent (malignancy)
RUQ or epigastric pain (if painless-malignancy)- onset, duration, quality, radiation
Nausea, vomiting
Fever (cholangitis): intermittent/continuous, duration, chills/rigors
Pale stool, dark urine, pruritus
High carrot ingestion, or rifampine use
Night blindness, bone pain, brusing, weakness, steatorrhea (due to conjugated
hyperbilirubinemia or chronic malabsorption of fat-soluble vitamins)
Appetite and wt loss, abd discomfort (malignancy)
DM, alcohol, smoking- RF for pancreatic head tumor
Biliary surgery (biliary stricture)
Medical
Contact with other jaundiced pts
History of injections or blood transfusion
Exposure to drugs
Contact with river water (shistosomiasis)
Physical
G/s
V/s: fever (cholangitis)
HEENT: icteric sclera, pale conjunctiva, dehydrated
LGS:
Chest:
CVS
ABD: RUQ tenderness, stigmata of liver disease, ascites, distended gallbladder, DRE
Integumentary: scratch marks
MSS: edema (hypoproteinemia due to decreased fat absorption)
Investigation
CBC, e-
HBsAg
LFT (bilirubine, ALT/AST), PT, PTT (b/c defect in the fat soluble vit. Esp vit k)
RFT (hepatorenal syndrome)
U/S liver, CBD, ascites
CT if mass is seen in U/S
ERCP,MRCP,PTC
DDx
Non-surgical
Drugs
Alcohol
Viral hepatitis
1ry biliary cirrhosis
Surgical
Choledocholelithiasis
 CBD Ca
Peri-ampulary Ca
CBD stricture
LAP of portahepatis
Liver HC
Chronic pancreatitis
Management
Of complications (PreOP)
Oral fluids or IV crystalloids (dehydration)
Blood transfusion (anemia)
Broad spectrum antibiotics (ceftriaxone + metronidazole)
Vit K 10 mg IM 5-10 days. If no improvement fresh frozen plasma or whole blood.
High protein diet (hypoproteinemia) high carbohydrate diet (low glycogen reserve)
Normal saline, diuretics (renal failure 20 due hepatorenal syndrome)

Operation (stone in CBD) Common causes of biliary infection

Ideal setup: optimize the pt> ERCP
Enterobactericae (68%)
(sphinterotomy and stone removal)>laparascopic
cholesystectomy • Ecoli
Our setup: CBD exploration (cholecystectomy + • Klebsella
cholidocolitotomy)> remove stone> insert t-tube> • Enterobacter
suture the CBD over the t-tube> drain the sub
hepatic space> do cholangiography 8-10 days later Enterococci (14%)
(retained stones, patency of the duct)> remove Anaerobes (10%)
the t-tube 1st and the drainage tube 2-3 days later.
Clostridium (7%)
If retained stone (seen on t-tube cholangiography)
Irrigate (mechanical flushing with heparinized
saline)
Contact dissolution agents (work only for pure cholesterol stones)
Send the pt home for 4-6 wks>t-tube tract will be well forme>remove t-tube and
insert choledoscope and remove stone
Shock lithotripsy
ERCP (sphincterotomy and removal of stone)
Laparascopic cholidocholitotomy
Open cholidocolithotomy (Only one done in our setup)
Complications (of OJ)
Ascending cholangitis
Pancreatitis
Biliary Cirrhosis Whipple’s procedure
Hypoprotenemia and Malnutrition
Bleeding diathesis • Gastro-jejunostomy
Infection and sepsis • Hepatico-jejunostomy
• Pancreatico-jejunostomy
 Dehydration
Hepato-Renal syndrome
Impaired wound healing
Impaired drug metabolism
Electrolyte disturbances
Reccurent stone
Complications (of Mgt)
(ERCP)pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding,Stricture
(PTC)Bacteremia, Hemorrhage, Contrast reaction, Pneumothorax, Intrahepaticarterioportal
fistula, Bile leakage
(pancreaticoduodenectomy)Anastomotic leaks, pancreatic fistula, intra-abdominal
abscesses, postoperative malabsorption and steatorrhea anddelayed gastric emptying
Indication for CBD exploration
Palpable CBD stones
Stone CBD
Dilated CBD
Jaundice (even hx)
Abnormal LFT, in particular, the alkaline phosphatase is raised
6. Gastric outlet obstruction
History
C/c epigastric pain & vomiting
HPI
Pain: onset, type, radiation, progression, association with meal, wakes from
sleep,
Vomiting: mechanism(induce or spontaneous), prior nausea, content (blood,
coffee ground, bilious, ingested matter) [in GOO non bilous]
Appetite: hunger, sense of early fullness
hematemesis
Tarry stool, melena,
Weight loss, abd distension, bloating
Rf for PUD, Gastric ca
• NSAID, smoking, alcohol, khat, stress
• Carnivores diet, fruit and vegetable def, gastric surgery
Mx
• Jaundice, ascites
• Cough, chest pain, sob
• Bone pain
• Swelling in other sites (supraclavicular, umbilical)
Previous TB infection, contact with a smear positive TB pt
Previous hx of caustic ingestion
Hx of HTN, DM, medication
Physical examination Indications for surgery in PUD
General appearance
• Bleeding
Dehydration, pallor, icteric, sunken eye,
• Perforation
consciousness, skin turgor, mucus
• GOO
membrane, arrhythmia, LAP (Virchow, sis
• Transformation into malignancy
merry joseph)
Abdomen
Epigastric tenderness, palpable mass, succusion splash, visible gastric
peristalsis, hepatomegaly
PR
Inspection, melena, blummer shelf (rectovesical deposits-transperitoneal
spread), tenderness
DDx
Pyloric stenosis (PUD)
Gastric Ca
Leiomyoma (GIST) - bleed
Lymphoma
Tb lymphadenitis
Chronic pancreatitis
Crohn’s disease
Caustic ingestion
Investigation
CBC, ESR, HB%
Electrolyte,
Barium meal
Gastroduodnoscope (biopsy)
Occult blood
LFT, urine alnalysis
H pylori test
CT &U/s (secondary to liver, acites, celiac node enlargment)
Serum amylase, lipase
Management
GOO
IV isotonic saline + K supplementation
If anemic- blood
Vagotomy + GJ (PUD)
Total gasterectomy with esophagojejunostomy , or billroth 2 (Gastric ca)
Conservative mgt of PUD
Decrease acid:
• H2-blocker: cimetidine 200mg
• PPI: omeprazole 20mg
Anticholinergic are contraindicated
Avoid provoking agent: drugs, alcohol, smoking, food, coffee
7. Bladder outlet obstruction
C/c: difficulty of micturition
HPI:
Onset, duration, progression
Complaints: hesitation, poor flow, intermittent stream, dribbling, sensation of
incomplete emptying
Frequency, urgency, urge incontinence, enuresis, nocturia, dysuria
Supra-pubic pain (acute retention, urinary infection, bladder stone & prostatic ca)
Hematuria: initial, mid-stream, terminal or full stream
Flank dragging sensation (hydronephrosis, pyelonephritis [fever])
Carnivores diet, dietary fat (prostatic ca RF)
Bone pain, back pain, jaundice, cough, hemoptysis (prostatic ca mx)
Cigarette smoking, occupational exposure (textile, dye, leather, exterminator, painter),
river water exposure (shistosomia) – Bladder CA
Weakness, fatigue, weight loss, appetite loss (malignancy)
Gonococcal urethritis, repeated catheterization, urethral trauma (urethral stricture)
Hx of TURP (bladder neck stenosis)
Hx of DM, HTN, stroke, parkinsonism, vertebral trauma (neurogenic bladder)
PE:
General appearance
Sick looking, apprehension
V/S
HEENT: icteris, paleness, dehydration
CHEST: mx
ABD: liver, ascites
GUS:
Kidney
Urinary bladder
Genitalia
Scrotum
Pelvis
DRE (Smooth, rubbery, median sulcus palpable, rectal mucosa mobile, nontender - BPH)
(Nodular, hard, median sulcus obliteration, rectal mucosa immobile, nontender – Ca)
DDx
BPH
Irritative symptoms
Obstructive symptoms
hematuria
Stricture
Trauma: catheterization, direct trauma, pelvic surgery(BPH)
Inflammation: discharge
Neoplasia
Prostatic Ca
BPH ssx
 Bone pain
Wt. loss, weakness, appetite
Bowel habit
Pain
Bladder neck contraction
Neurogenic bladder
Investigation
CBC (anemia- renal failure, extensive marrow invasion), LFT (inc alk phosphatase)
Urine
Qualitative: color, smell, PH(6.5-8), SG(1.05-1.30)
Quantitative: amount, capacity (250-500ml, M˃F)
Substances: protein, sugar
Sedimentation: SG = 1.40 pyuria
Collection: clean couch, avoid latency, mid-stream specimen
Centrifuge at 1000evo/sec/2min or 2000evo/sec/1min, prevent cell lysis
Cell in urine: WBC, RBC, bacteria, fungal spore, casts, cytology(benign or
malignant cells)
Protein casts – renal paranchymal
Crystal: calcium, oxalate, phosphate
Chemical testes
PSA
Blood:
BUN: depend on diet & catabolism
Creatinine – highly sensitive
Creatinine clearance = UV/P/24hr
U/s: highly sensitive & specific; solid as small as 2mm, cysts; most widely used in
urology; transrectal ultrasonography: r/o out P. Ca; done when level of PSA rises;
flow- echocardiography, Doppler u/s; air-undetected
Plain radiography - KUB: level, side, shadow, soft tissue, skeleton (scoliosis, gibbus, S.
bifida), surface
Contrast study:
IVU/IVP + post micturition film:
• Preparation for IUV: laxatives, moderate fluid restriction
• Position, abnormality, uretericposition, bladder, site of obstruction(wine
glass appearance),
Retrograde pyelography: catheterize urethra, always following IVP revealed
obstruction to assess length of obstruction
Anterograde pyelography: injection into pelvic ureter, in pt with renal failure,
allergic pts
Urodynamic flow studies
Flow rate: greater than 200ml at 10ml/sec – obstruction; at 15ml/sec – normal
Pressure: high pressure low flow rate – obstruction; low pressure low flow rate -
detros abnormality
Cystourethrocope
 CI in urethral stricture
Look at: trigon, ureteral opening, diverticulosis, trabeculation, inflammation,
urethral lumen, urothelium
??Biopsy
Angiography
CT, MRI, chest and lumbar xray (sclerotic lesion)
Radioisotope scan: function of individual renal unit
Management
BPH: indication for prostatectomy
Acute retention: exclude other causes – drugs, constriction, recent operation
Chronic retention: RV greater than 200ml, uremia, hydro ureter or nephrosis
Complication: stone, infn, diverticulosis
Hemorrhage
Sever symptoms (affecting quality of life) IPSS (20-35)
Methods:
Medical
• alpha adrenergic blocking agents (inhibit contraction of sm in the
prostate)- Doxazosin, Terazosin, tamsulosin
• 5alpha reducates inhibitors (inh conversion of testosterone to DHT):
Surgical
• TURP
• Transvesical
• Retropubic
• Perineal(abandoned)
Complication:
Local:
hemorrhage,
perforation,
sepsis,
urethral stricture,
bladder neck contraction,
incontinence (damage to the external sphincter)
retrograde ejaculation
General: CVS – CHF. MI, DVT, water intoxication in TURP, death
Pain in urinary tract
Upper
Dullaching – colicky
Referred to Ipsilateral groin, scrotum, labium, upper inner thigh
Lower
Suprapubic discomfort
Referred to tip of penis(trigon irritation)
Worsen by bladder filling
Stranguria – severe pain wrenching discomfort at the end of micturition =
indicates severe infn of bladder.
 8. COLONIC CA
HISTORY

• age: more common above 50

• sex :Rt sided colonic ca is more common in females &Lt sided colonic ca is more common in
males
• rectal bleeding (melena [rt], hematochezia [lt]), fatigue, weakness
• abdominal mass or pain(with characterization),back pain, pelvic pain
• bowel habit change (alternating consitipation and diarhea)
• tenesmus (straining during defication), sense of incomplete defecation, heamatochezia (blood in
the stool), =rectal ca
• urinary complaints (pneumaturia, fecaluria, recurrent UTI) – CT, cystoscopy
• abdominal distension, vomiting, nausea
• fever, chills
• jaundice, ascites,
• smoking, alcohol, pelvic radiation, IBD (RF for colonic Ca)
• family history of colonic ca (RF for colonic Ca)
• dietary factors: red meat ,fat (predisposing); high fiber diet and aspirin (protective)
• raw milk consumption, contact with a smear +ve case, previous TB hx (TB)

PHYSICAL EXAMINATION

• Usually normal except in advanced disease.

• general appearance: chronically sick looking, acutly sick looking if there is obstruction
• vital signs:BP low &HR high if there is excessive bleeding, temp high if there is secondary
infection or pericolic abcess
• signs of anemia: pallor in conjuctiva and or/palm
• icteric sclera
• abdominal mass due to the tumor it self,hepatomegally,ascites
• abdominal tenderness
• PR: mass,blood,fixation
• fecal matter coming out of vagina or urethra(in case of fistula)
• edema (hypoalbuminaemia)

INVESTIGATIONS

• Hb,WBC,ESR
• stool exam: occult blood
• LFT,RFT,ECG
• BGL
• US
• CT
• Barium enema
• Colonoscopy(gold standard)
• flexible sigmoidoscopy
• CXR,CEA

COMPLICATIONS

• Intestinal obstruction
• Pericolic abscess
• Fecal fistula
• Internal fistula
• Generalized peritonitis

DDX

• Colorectal ca
• Inflammatory bowel disease
• Diverticulosis
• Intestinal TB
• Irritable bowel syndrome
• Other dynamic and adynamic causes of bowel obstruction (volvulus ,band ,adhesion ,intussusception
,ileus ,etc…)
• AVM(arterio venous malformation)
• Ischemic bowel disease
• Hemorrhoids