DR A. K.

Sheriff

General Examination
 Jaundice.
• Jaundice is detected when serum bilirubin conc is >50umol/L
and the sclerae, mucous membs and skin become yellow.

TYPES OF JAUNDICE
A. Unconjugated Bilirubin is an insoluble and transported in
plasma bound to albumin; it is therefore not filtered by the renal
glomeruli.
Therefore, the urine is normal in color (acholuric jaundice)

B. Conjugated Bilirubin- bilirubin is conjugated to form bilirubin

diglucuronide in the liver and excreted, giving bile its green
colour.
Therefore, the urine is dark brown in colour.
• In the colon, conjugated bilirubin is metabolized by
bacteria flora to stacobilinogen and stercobilin which
are excreted in the stool.
Starcobilinogen is excreted in the urine as urobilinogen, a
colourless, water-soluble compound.
ANATOMICAL CLASSIFICATION OF JAUNDICE
1. Prehepatic Jaundice- occurs due to hemolytic disorders,
accompanying anemia pallor combined with jaundice
producing pale lemon complexion. Stool and urine are
normal in color.
2. Hepatic Jaundice- is as a result of hepatocellular disease
causes hyperbilirubinemia that is both Unconjugated and
conjugated. Urine will be dark and stools normal in colour.
• 3. Post-hepatic Jaundice- it is an obstructive
form of jaundice. In biliary obstruction,
conjugated bilirubin in the bile does not reach
the intestine, so the stool are pale. Conjugated
bilirubin is soluble and filtered by the kidney, so
the urine is dark brown.
Obstructive jaundice may be accomplished by
pruritus (Due to skin deposition of bile salt).
Obstructive jaundice with abdominal pain is
Gallstones. ( Note: Obstructive jaundice +
Abdominal pain which is a right hypochondric pain
+ fever or rigor= Charcot triad)
 Cyanosis
• This is the dusky blue discolouration of the skin and mucus membrane.
• It occurs when the absolute concentration of deoxygenated Hb is > 50g/L of
Hb .
• It corresponds to an arterial O2 saturation of <90% and usually indicates
underlying Cardiac or Pulmonary disease.
• Cyanosis could either be:
Central Cyanosis- seen at the lips, gum and tongue.
Lung Dz- with inadequate oxygen transfer eg luminal obstuction, asthma, COPD,
Pneumonia, PE, Pulmonary Oedema- may be corrected by increasing inspired O2
Cyanotic Congenital Heart Dz- where there is admixture, eg transposition of the
Great Arteries or Rt to Lt Shunt (eg VSD with Eisenmengers Syndrome.)-is not
reversed by increasing inspired O2
Peripheral Cyanosis- seen in the hands, feet or ears.
It also occurs in causes of central cyanosis.
It occurs in the cold, hypovolaemic shock, Heart failure, peripheral vascular and
venous obstruction.
 Anaemia
• Anaemia- is described as a low level of Hb.
• It has normal ranges-Men=13.5g/dl and Women =11.5g/dl
• Types of Anaemia:
1. Microcytic (MCV<80fl)
. Chronic blood loss . Thalassaemia
. Iron deficiency . Sideroblastic aneamia
2. Macrocytic (MCV>80fl)
. Megalobastic marrow . Haemolytic disorders
.Vit B12 Def . Liver Dz
. Folate Def .Hypothyroidism
.Excess Alcohol .Aplastic Anaemic
3. Normocytic (MCV=80-96fl)
. Acute blood loss . Connective Ts Disorders
.Anemia of Chronic Dz . Marrow infliltration
.Chronic renal failure
. Chronic Dz
 CLUBBING
• Clubbing of the fingernail (+/- toenail)is the increase curvature in
all directions and loss if the angle between nail and the nail fold.
The nail fold feels boggy. Majority of pt have thoracic dz but also
gastrointestinal and familial dzs
Thoracic Coz
Tumours : Benings or Malignant
Lung cancers, Tb Chronic lung suppuration (empyema,abscess,
bronchiectasis, Cystic fibrosis)
GI Coz
Inflammatory bowel dz(esplly Crohn’s dz), Cirrhosis, GI Lymhomas
and Malabsorption eg Coeliac dz.
CVS Coz
Cyanotic Congenital Heart Dz, Endocarditis , Aneurysms
 OEDEMA
• Oedema is the excess fliud in the intestinal space, and in the
peripheral sites which causes tissues to swell.

PATHOPHYSIOLOGY OF OEDEMA.
The movement of fluid bt the intravascular and extravascular
space occurs through the walls of the capillaries.

The efflux of fluid across the capillary wall is governed mainly by

the hydrostatic pressure transmitted by the arterial blood
pressure through the precapillary arteriole and also by the
capillary permeability and the opposing osmotic(Oncotic) pr
through the serum proteins (esplly Albumin)
 Cont’
• In addition, the oncotic pr of the interstitial fluid may contribute
to the efflux of the intravascular fluid.
• The reabsorption of interstitial fluid is driven primarily by
1. the plasma oncotic pr,
2. the hydrostatic pr in the interstitial space(known as the tissue
pr) and
3. the fall in the hydrostatic pr at the venular end of the capillary.
These forces (known as the Sterling forces) determine the
movement of fluid and electrolytes between the intravascular and
interstitial compartments.
Therefore, any imbalance of the sterling forces will cause expansion
of the interstitial space.
 Oedema in Heart Failure
• In heart failure, there is increase in Central venous Pr
which causes increase capillary pr. This reduces
reabsorption and leads to oedema.
• Renal hypoperfusion also stimulates the Renin-angiotensin
system which in turns, causes inappropriate sodium and
water retention and further contributes to oedema.
• When serum albumin falls there is a loss of plasma oncotic
pr. This favours the mvt of fluids into the interstitial space.
The consequent fall in the intravascular vol. causes
activation of the renin-angiotensin system which adds
further fluid retention and oedema.
 Oedema in Liver Disease
• In Liver Dz complicated by Portal Hypertension, there
is pooling of blood in the splanchnic bed with
increased splanchnic capillary pr.
• The pooling result in a fall in the effective intravascular
volume which in turn, activates the renin-angiotensin
system. These factors all contribute to the fluid
retention that complicates portal hypertension.
• Ascites complicating portal hypertension usually only
develops when there is hypoalbuminemia and a fall in
oncotic pressure.
 Causes of Oedema
Unilateral
.Deep vein thrombosis .Trauma
.Soft tissue infection . Lymphatic obstructions

Bilateral
Heart Failure Immobility
Thiamine Deficiency (Wet beriberi)
Drugs like NSAIDS, Nifedipine, Amlodipine
Hypoproteinemia eg Liver cirrhosis, Kwashiorkor nephrotic
syndrome
 LYMPHATIC SYSTEM
• The lymphatic system comprises the
Lymphatic ducts, lymph nodes, spleen, tonsils, adenoid and thymus gland.
Note the lymphoid tissue is also present the Peyer’s patches of the
terminal ileum.
A network of lymphatic ducts accompany the blood vessels; these
lymphatic transport lymph from the interstitial tissues to the lymph
nodes.
Lymphatic vessels drain distinct regions of the body into group of regional
lymph nodes
Functions of LYMPHATIC SYSTEM
1. Drains the interstitial space
2. Antigen presentation and lymphocytes activation
3. Antibody producing and phagocytosis
4. Pathway for the absorption of chylomicrons from enterocytes
 Lymphadenopathy
• Lymphadenopathy is any cause of lymphatic flow.
• In the case of infection may be caused by
proliferation of cells in response to antigen
challenge. Abnormal cells may populate the nodes.
• Causes
Infections like HIV and TB
Obstruction as in Filarial worms
Cancer as in Breast Ca.