Dr.Hisham H.Ahmed

Clinical Rounds

By

Professor of General and Pediatric Surgery

Dr.Hisham H.Ahmed

To approach any case you have to;

1. Take History …82%

2. Do Examination…9%

Then ask yourself

3. what is the possible diagnosis (Dx)

4. Differential diagnosis (DDx)

5. Investigations…9%

6. Treatment lines

7. Prognosis

Dr.Hisham H.Ahmed

I- History Taking; you have to introduce yourself to the patient ( your name & your role in the team)

Personal history

Complaint

Present history

System review

Past history

Family history

Social history

Occupational history

(a) Personal history;

-name

-age

-sex

-occupation

-residence

-marital status

-special habits

-date of admission (if admitted)

(b) Complaint and its duration;

You have to ask the patient an open Q i.e.

Give the patient the chance to express his complaint without interruption

Saied is a 45 y/o farmer

from Benha, married and

has 3 children the last

one is 6 y/o and he is

smoker.

Dr.Hisham H.Ahmed

(c) Present history (Analysis of the complaint)

1. Onset, Course, Duration

2. Modifying factors - What make symptoms worse?

- What make it better?

3- Related symptoms i.e. (symptoms arising from the swelling)

- pain

- cosmetic appearance

- dyspnea

- dysphagia

- fainting attacks

- hoarseness of voice

- Horner’s syndrome

4- Associated symptoms i.e.( symptoms arising from other systems)

- Eye symptoms i.e. double vision, eye protrusion

- Tachycardia

- Loss weight in spite of good appetite

- Dyspnea at rest….etc.

5- How it affects his/her life

6- Relevant medical history

- Operation

- Current medication

- Radioiodine therapy

- Investigations

- Medical advice

Dr.Hisham H.Ahmed

(d) System review;

i- CNS

ii- CVS

iii- Resp. System

iv- GIT

v- GUS

vi- Musclo-skeletal

Don’t forget in women ask about menstrual and obstetric details

(e) Past history; Ask about current (active) and inactive medical

conditions

i- Hospital admission

ii- Operations GA or LA

iii- Drugs - Oral hypoglycaemic & Insulin

- Oral contraceptive pills (OCP)

- Oral anti-coagulant & Heparin

- Other drugs antiepileptic, antiheart failure

iv- Diseases

- D.M

- T.B

- Hypertension

- IHD

- Myocardial infarction

- stroke

- Renal impairment

- jaundice

v- Allergy Atopy & Drugs

vi- Accident

Dr.Hisham H.Ahmed

(f) Social history; 1- Special habits smoking, alcohol. etc.

2- Help by other family members

(g) Family history; 1- Similar disease

2- Death of 1st degree relative during surgery

(h) Occupational history; 1- Current job

2- All previous jobs

II- Examination ; you have to ask the patient for his permission before touching him

1- General examination; the relevant systems to be examined include

the cardiorespiratory system and the lower limbs

- Pulse rate, rhythm, water hummer pulse

- Look for signs of heart failure

- Inspect the shins for pretibial myxedema

- Test for proximal myopathy

- Test for reflexes

2- Local examination;

TIPS

Push the seat away from the wall

Render the water to the patient by yourself

Exposure down to both clavicles

Seat at a distance of 50 cm and nearly at the same level

with the organ to be examined.

Dr.Hisham H.Ahmed

Inspection - Trachea -Eyes

Palpation. - Esophagus - Hands

Percussion - RLN

Auscultation

Inspection; from front

- At rest…site, size, surface, shape, skin over

- On swallowing

- On protrusion of the tongue

Palpation; From front (3T)

- Temperature, Tenderness and Trachea

Then From behind

- repeat the swallowing and protrusion test

- palpate 2 lobes and isthmus

- palpate upper pole for thrill and lower pole for

retrosternal extension

- palpate the carotid pulse

- palpate the cervical L.Ns using up and down technique

N.B; - To do the swallowing test ask the patient to take a sip of water, hold it

in the mouth and swallow when you indicate

- To do protrusion test you have to support the lower jaw

Dr.Hisham H.Ahmed

Percussion; from front

Percuss over the sternum from the notch downwards listening for a change in the

percussion note if there is retrosternal extension

Auscultation; from front

Listen over the thyroid for systolic bruit

Gently palpate the trachea for deviation by placing one finger over the trachea.

It should lie equidistant between the heads of the clavicle.

Ask the patient if she/he has had any problems swallowing.

Ask the patient if she/he has noticed any change of voice

Ask the patient to repeat a sentence that you read in order to listen to the

hoarse voice.

Dr.Hisham H.Ahmed

This includes examination of the hands and eyes

1- Hands

Increased sweating

Palmar erythema

Thyroid acropachy

Fine tremors

Pulse tachycardia, water hummer pulse

2- Eyes; 4 groups

1- Lid retraction

i.e. Dalrymple’s sign

2- Lid lag i.e. Von Grafe’s sign

3- Infrequent blinking i.e.Stellwag’s sign

1- Sclera is seen below the inferior limbus

2- Sclera is seen all around the cornea

3- Nafziger test for proptosis

4- Lack of convergence (Mobius’ sign)

5- Lack of forehead wrinkling (Joffroy’s sign)

6- Corneal ulceration

Ask the patient to look up and out to test for the

integrity of the superior rectus and inferior oblique

Edema of the conjunctiva with or

without redness

Dr.Hisham H.Ahmed

Assessment sheet

Elements being assessed

Done well 2

Done adequately 1

Not done zero

1- Introduction to the patient

2- Adequate

exposure

3- Observing neck

from front

4- Observing swallowing and protrusion of the tongue

5- Palpating neck

from behind

6- Checking for cervical L.Ns

7- Percussion and

Auscultation from front

8- Thyroid status

9- Thanking the

patient and washing hand

Dr.Hisham H.Ahmed

More than a ¼ of general surgical outpatient referrals are females with breast symptoms, only a small proportion of whom will have breast cancer. Breast cancer has by far the best prognosis of the common solid organ malignancies with up to 80% 10 years survival rate. Normally the female breast develops shortly before the menarche. The breasts increase in size in the second half of each menstrual cycle, following ovulation. In pregnancy the size and texture of the breasts change profoundly in preparation for lactation. At this time and during lactation, clinical assessment is much more difficult.

History of breast disease;

As any other history but you have to focus on

Age; is a simple but very important piece of diagnostic information.

Young women very rarely have cancer, but over the age of 70 most

breast lumps turn out to be malignant.

Previous pregnancies; the age at 1st pregnancy, how many children,

were the children breast fed and for how long.

Parity and breast feeding reduce the incidence of breast cancer

Menstrual pattern; the age of 1st menarche, the age at menopause, the

regularity, duration and quality of bleeding

Breast symptoms which alter with the menstrual cycle

are highly likely to be associated with benign disease.

Medication; OCP, HRT

Mental attitude; remember that patients are often fearful of the

consequences of breast lumps and hide their symptoms with an

impressive degree of self-delusion.

Dr.Hisham H.Ahmed

Examination; “ask for a chaperone” First you have to introduce yourself to the patient, identify your

role in the surgical team and ask for her permission.

Exposure must be undressed to the waist (never to expose the patient

in front of other patients even female)

Position for inspection ≥ 45, for palpation of the breast ≤ 45, palpation

of the axilla done while the patient is sitting upright.

Examination inspection, palpation, percussion and auscultation.

Breast Supracla

vicular

fossae

Axilla Arms

Dr.Hisham H.Ahmed

1. Inspection : patient in semi-sitting position

√ Arms beside; look at the breast in an inverted U shaped manner

1. Breast Symmetry (contour and level)

Size

2. Nipple Destruction, Depression, Deviation

Displaced, Discoloration, Discharge

Duplication

3. Areola fissures , eczema

4. Skin scars, edema, dilated veins, DPP

5. Visible lump

6. Supraclavicular fossae

7. Arms

√ Raise arms (hands behind neck)

Nipples ……… level, distortion

Breasts ….tethering

Back of the breast

Axilla …. Swellings, scars, effect of radiation.

√ Press hands against the waist

To observe if there is distortion and tethering

2. Palpation;

While patient in semi-sitting position ( for the breast)

-Ask the patient to point to the mass if not visible

-Start by the normal side

-If large breast either hold the breast by your left hand or

ask the patient to roll on the contralateral side

Dr.Hisham H.Ahmed

- 4 quadrants of the breast by flat of fingers against the chest wall

- Back of the breast

- Nipple and areola ….between 2 fingers

- Mass ………….. by pulps fingers of both hands

- Breast tail …….between thumb and fingers

N.B; if you find a mass complete your palpation first, then comment on the

mass in the regular way

Dr.Hisham H.Ahmed

While patient in upright position ( for the axilla & supraclavicular L.N)

For palpation of the supraclavicular L.Ns you have to stand either in front or

behind the patient and ask her to shrug her shoulders.

3. Percussion of the spine

4. Auscultation of the chest

To complete your examination let the examiner knows that you have

to palpate the abdomen for hepatomegaly and ascites.

Dr.Hisham H.Ahmed

What are the types of nipple discharge?

1. Blood…..duct papilloma or carcinoma

2. Black…...obstructed duct

3. Pus……….mastitis ( acute or chronic)

4. Green or watery……fibroadenosis

5. Milk……..lactation or galactorrhoea

6. Ductactasia any type except blood

Types of nipple retraction

Congenital Pathological - Since childhood

- Areola is normal size

- Can be pulled out

- Recent onset

- Areola is small in size

- Can’t be pulled out

Dr.Hisham H.Ahmed

Figure 1; Dimpling

Figure 2; Peau d'orange

Figure 3; Paget’s disease of the nipple

Dr.Hisham H.Ahmed

We have 3 principal nerves of the upper limb (UL)

Ulnar nerve Median nerve Radial nerve C7,8,T1 Medial cord

C5678T1 Medial and lateral cord

C5-T1 Posterior cord

Motor supply Forearm

Ulnar ½ of the FDP,FCU

Intrinsic hand muscles All intrinsic muscles of the hand except 4 muscles; LOAF are supplied by the

median nerve.

Motor supply Forearm

Flexors of the forearm; pronator teres, FCR, palmaris longus, FDS.

Anterior interosseus nerve supplies FPL and ½ of the FDP.

Intrinsic hand muscles LOAF;

- Lateral 2 lumbricals - Opponens pollicis - Abductor pollicis brevis

- Flexor pollicis brevis

Motor supply Triceps , brachialis

(small part), brachioradialis.

Extensors of the forearm; by the posterior interosseus nerve - ED - EDM - ECU - ABPL - EPL - EPB - EIN

Sensory supply Medial one and ½ fingers and medial third of the palm of the hand

Partial claw hand

Finger spreading test Card test Froment’s test Sensory distribution

Sensory supply Lateral 3 and ½

fingers and lateral 2/3 of the palm of the hand.

The palmar cutaneous branch supplies the lateral palmar skin

Ape hand

Abductor pollicis brevis test

Tinel’s test Phalen’s test

Sensory supply Radial 1 ½ fingers

dorsally by the superficial branch.

Skin on the back of the forearm by the posterior cutaneous nerve of the forearm.

Wrist drop

Wrist extension test

Dr.Hisham H.Ahmed

Dr.Hisham H.Ahmed

As before;

1. Greet the patient and introduce your self

2. Expose both hands, forearms and elbows

3. Don’t shake hand with the patient

Map;

Don’t forget:

I would like to examine the neck i.e. cervical rib

I would like to examine other peripheral nerves.

Inspect; Skin

Soft tissue

Bone & Joint

Sensory Motor

Four quick tests of the motor and sensory innervation of the hand

Autonomous Motor innervation;

Median nerve……abduct the thumb

Radial nerve……extend the wrist at the level of the MCP joint

Ulnar nerve……abduct the fingers

Autonomous sensory innervation;

Median nerve……index finger

Radial nerve……..lateral aspect of the base of the thumb

Ulnar nerve……….little finger

Dr.Hisham H.Ahmed

Ulnar nerve injury (C7,8 T1)

Inspect;

Scar of injury

Claw hand ( ring & little finger)

Wasting of the hypothenar muscles

Guttering of the dorsum of the hand obvious on the 1st web space.

Sensory;

Loss of sensation on the little finger (middle & distal phalanges)

N.B; compare both sides

Motor;

Palmar interossei card test

Dorsal interossei finger spreading test

Adductor polices froment’s test N.B; compare both sides

How to identify level of injury?

1. Scar site

2. Flexion of both PIP.J and DIP.J indicate lower lesion but if PIP.J only

indicate proximal lesion (Ulnar Paradox)

3. Wasted medial forearm proximal lesion

4. Inability to flex ring & little finger proximal lesion

5. Loss of sensations at the ulnar side of the dorsum of the hand

proximal lesion.

DDX;

Partial claw hand Complete claw hand 1. Ulnar nerve injury 2. Volkmann’s ischemic contracture 3. Dupuytren’s contracture 4. Post-burn skin contracture 5. Congenital contracture of the PIP.J of the little

finger.

1. Combined ulnar & median nerve injury 2. Volkmann’s ischemic contracture 3. Advanced rheumatoid arthritis 4. Lesions of the medial cord of the B.P 5. Lesions of the spinal cord e.g. poliomyelitis

Dr.Hisham H.Ahmed

Radial nerve injury C5,T1(spiral groove)

Saturday night paralysis

Inspect;

Wrist drop & finger drop ( ask the patient to keep his hands out in front of

him, palms downwards)

No wasting of the hand muscles.

Sensory;

Loss of sensation over the 1st dorsal interosseus space ( between the thumb

and the index finger)

Loss of sensation over the dorsal aspect of the forearm.

Motor;

Loss of extension at the level of the MCP.J and wrist.

N.B:

Triceps weakness only in higher lesion (axilla)

Posterior interosseus lesion only finger drop & no sensory loss

IPJ extension is preserved in radial n. injury as lumbricals & interossei are

supplied by the ulnar and median ns.

Median nerve injury C5,6,7,8 T1

Inspect;

Thenar muscle wasting

Sensory;

Loss of sensation over the distal phalanges of the index and middle fingers

Motor;

Test of abductor polices brevis & Opponens polices

Dr.Hisham H.Ahmed

Tests;

Tinel’s test Tapping

Phalen’s test Maximum flexion for one minute will induce pain

Qs;

What is the finger that receives sensory fibers from all 3 nerves

of the hand?

Middle finger

How to assess the motor power of the 3 nerves of the hand?

“OK” sign

What are the causes of ulnar nerve lesions?

How do you treat ulnar nerve palsies?

What are the causes of radial n. lesions?

What are the causes of carpal tunnel syndrome?

Dr.Hisham H.Ahmed

This is essentially an examination of the patient’s abdomen; it is also called

the gastrointestinal examination (GI). It is a complex examination which also

includes examination of other parts of the body including the hands, face and

neck.

The abdominal examination aims to pick up on any gastrointestinal pathology

that may be causing a patient’s symptoms e.g. abdominal pain or altered

bowel habit.

This examination is performed on every patient that is admitted to hospital

and regularly in clinics and general practice.

Like most major examination stations this follows the usual procedure of;

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

5. PR

It is an essential skill to master and is often examined in our clinical

exams.

Look Feel Listen

Dr.Hisham H.Ahmed

Examination Tips

1. Introduce yourself, clarify your role and take the patient’s consent.

2. Exposure from the nipple to the knees, keep the underwear on, but you have to lift it

to see the scrotum and genitalia.

3. Patient is to lie flat on a firm couch or bed, be sure that he feels comfortable with a

pillow underneath his head.

N.B; you may need to ask the patient to flex his legs to relax the abdomen.

Examination Map;

A- General abdominal examination Hand clubbing, koilonychia, leukonychia, palmar erythema, Dupuytren’s contracture,

flappy tremors.

Eyes jaundice in the sclera, pallor in the conjunctiva

Mouth angular stomatitis, glossitis, foetor hepaticus, pallor

Neck palpate for supraclavicular L.Ns (Virchow’s node)

Shoulder spider nevi

Breast gynaecomastia

Lower limb pitting edema

B- Local abdominal examination

From the end of the bed for asymmetry or distension.

From bedside while sitting or kneeling for the movement with respiration,

peristalsis, epigastric pulsation (hold breath).

From up while standing for distension, mass, scars, dilated veins, umbilicus

Ask the patient to raise his head and to cough for divarication of recti and

impulse in the hernia orifices respectively.

N.B; The umbilicus have to be assessed for;

Position i.e. normally midway between xiphisternum and SP

Shape i.e. normally tucked in

abnormalities

1. Hernia .i.e. PUH, IUH (bulged out)

2. Caput medusae

3. Discharge .i.e. bloody, urine, stool

4. Polyp

5. Granuloma

6. Hemangiomas

7. Cysts i.e. dermoid or inclusion

Dr.Hisham H.Ahmed

Superficial tenderness, superficial masses

Deep tenderness, deep masses

Organs liver, spleen, kidneys

9 areas of the abdomen

Tips;

Kneel down next to the patient right side

Ask if he has any pain anywhere .i.e. tender area is the last to be felt

Look at the patient’s face the whole time

Palpate the 9 areas with four fingers of your right hand held together & movement at the MCPJ

If you are right handed, start in the left iliac fossa and move round in anti-clockwise direction to

finish in the right iliac fossa.

Dr.Hisham H.Ahmed

1. Liver; Rt lobe begin from the RIF by resting the radial border of

your fingers on the abdomen parallel to the right costal margin

and ask the patient to breathe in. The hand is stable during

inspiration and move one inch during expiration.

Lt Lobe the same but begin from just above the umbilicus

with the index finger is horizontal.

2. Spleen; begin to feel from the RIF towards the Lt costal margin passing below the umbilicus in a J shaped manner. If the spleen

is not palpable you can make it more prominent by lifting the

lower ribs forwards with your left hand while asking the

patient to turn to the right side.

3. Kidneys; bimanual palpation ( Rt hand in the lumbar region and the Lt hand in the loin) pressing firmly during inspiration, if

there is palpable mass elicit posterior ballotment.

N.B;

If the liver or spleen is palpable you have to comment on the span from the

costal margin (i.e. finger breadth), border, surface, consistency &

tenderness.

If you find an abdominal mass during superficial or deep palpation

comment… (I feel a mass, I will comment on it later) then continue your

palpation in circular manner then return back to this area even before

palpating organs.

RIF= Right Iliac Fossa

Dr.Hisham H.Ahmed

For the liver and spleen

For any masses

For ascites from the umbilicus to the flanks (if +ve do shifting dullness)

Tips of percussion;

1- Middle finger of the Lt. hand press firmly, percuss with the middle finger of the

Rt. hand over the middle phalanx.

2- Percussion over the chest is heavy (mainly heard) but over the abdomen is light

(mainly felt).

3- Percussion is done from resonant to dull areas.

4- For the liver we do Tidal percussion starting from the 2nd intercostal space MCL

to determine the upper border , the lower border obtained by either palpation

or regular percussion. The distance between the 2 borders is called liver span

and it’s normally about 6-12 cm in the MCL.

5- For the spleen we percuss over the Traube’s area then over the lower border.

6- For ascites from the umbilicus to the flanks.

- If resonant no ascites

- If dull do the other side then do shifting dullness

- Tense ascites fluid thrill

1- Over the liver Bruit

2- Over the Aorta & iliac vessels Bruit

3- Over the Lt. iliac fossa intestinal sounds

4- Epigastrium venous hum

Don’t forget;

PR

Back

Scrotum

Femoral pulse

MCL= Mid-Clavicular Line

Dr.Hisham H.Ahmed

Qs;

What is Traube’s area?

Surface Markings;

1. Draw two vertical lines one

passing through the 6th rib in the

midclavicular line and the next

passing through the 9th rib in

midaxillary lines.

2. Now draw a smooth curving

line with convexity upwards from

the sixth rib in midclavicular line

to 9th rib in midaxillary line.

3. Draw another straight line

passing through the costal

margin from 6th rib to 9th rib.

All these boundaries enclose a

near semilunar space called

Traubes space.

Anatomical boundaries are:

1. Right : Lateral margin of left lobe of liver.

2. Left: Spleen.

3. Superior: Resonance of lung.

4. Inferior: Costal margin.

Contents;

1. Fundus of stomach (Hence percussion of Traubes area normally gives Tympanitic resonance).

2. Costo-phrenic recess of left pleura devoid of lungs.

Causes of obliteration of Traubes space:

1. Full stomach.

2. Left sided Pleural effusion.

3. Splenomegaly.

4. Enlargement of left lobe of liver due to any etiology.

5. Dextrocardia.

6. Proliferative growth in fundus of stomach.

Dr.Hisham H.Ahmed

How can you differentiate between spleen and kidney?

Spleen kidney

1. Not ballotable 2. can’t get above it 3. percussion….dull 4. moves diagonally with respiration 5. can’t put hand between it & CM 6. notch may be palpable

1. ballotable 2. can get above it 3. resonant 4. moves vertically with respiration 5. can put hand between it & CM 6. NO notch

CM= Costal Margin

What are the physical signs of enlarged liver?

1. Descends from below the Rt costal margin

2. Moves down with respiration

3. I can’t get above the swelling

4. Dull on percussion and dullness continue with the normal hepatic dullness

What are the causes of hepatomegaly and splenomegaly?

What is loin? It’s the space between 12th rib & iliac crest

What is renal angle? It’s the angle between the 12th rib & erector spinae muscle

What is ballottement?

A palpatory technique for detecting or examining a floating object in the body, as: - The use of a finger to push sharply against the uterus and detect the presence or

position of a fetus by its return impact. - Palpation of the abdominal wall while a kidney is being pushed sharply from the

backside, used as a test for determining the presence of a floating kidney.

What is clubbing?

Normal nail/nail fold angle is 130-170

In clubbing > 180 due to hypertrophy of the tissue beneath the nail

bed obliteration of the window

In pseudoclubbing the same but without hypertrophy of the tissue.

Dr.Hisham H.Ahmed

What is palmar erythema?

Palmar erythema is a reddening of the skin on the palmar aspect of the hands,

usually over the hypothenar eminence. It may also involve the thenar eminence and

fingers. It can also be found on the soles of the feet, when it is termed plantar

erythema.

What is caput medusa?

Also known as palm tree sign, is the appearance of distended and engorged

paraumbilical veins, which are seen radiating from the umbilicus across the

abdomen to join systemic veins. The name caput medusae (Latin for "head of

Medusa") originates from the apparent similarity to Medusa's head, which had

venomous snakes in place of hair.

Dr.Hisham H.Ahmed

Ask the patient some questions about his/her jaundice to find out whether

the cause of jaundice is;

Pre-hepatic

Hepatic

Post-hepatic

Remember that in the exam, post-hepatic is the most likely cause and is the easiest to be

diagnosed from the history.

1. Have you noticed any change in the color of your urine?

2. Have you noticed any change in the color of your stool?

3. Have you noticed yourself feeling itchy?

If the patient has noticed pale stools and dark urine then explore possible

cause.

4. Weight loss, change in bowel habit, loss of appetite and back pain

1ry and 2ry intra-abdominal malignancies.

5. Younger age, previous biliary colic or episodic right upper quadrant pain

Gallstones.

Continue to ask about;

6. Foreign travel hepatitis A

7. Blood transfusion hepatitis B & C

8. Sore throat ESBV

9. Alcohol intake, OCP, Phenothiazine.

Dr.Hisham H.Ahmed

Expose the patient as previously mentioned and begin by;

General examination ( look for signs of chronic liver disease)

Hand clubbing, koilonychia, leukonychia, palmar erythema, Dupuytren’s contracture,

flappy tremors.

Eyes jaundice in the sclera, pallor in the conjunctiva

Mouth angular stomatitis, glossitis, foetor hepaticus, pallor, jaundice in the soft

palate, and central cyanosis on the undersurface of the tongue.

Neck palpate for supraclavicular L.Ns (Virchow’s node)

Shoulder spider nevi

Breast gynaecomastia

Lower limb pitting edema

Local examination 1. Inspection

The abdomen may be distended with ascites

There may be dilated veins around the umbilicus (Caput medusae)

Scratch marks

2. Palpation

Palpate carefully in the right upper quadrant for any

tenderness or masses

Courvoisier’s law .i.e. jaundice + palpable gallbladder in the

right upper quadrant, the cause is unlikely to be malignant.

3. Percussion….as before

4. Auscultation ….as before

Complete your examination as before, say that you would like to;

PR

Back

Scrotum

Femoral pulse

Dr.Hisham H.Ahmed

Causes of jaundice and effects on liver function tests (LFT)

Pre-hepatic Hepatic Post-hepatic

Major causes

Haemolysis Hereditary e.g.

Gilbert’s syndrome

Hepatitis Decompensated

‘CLD’ Drugs

Gall stones Ca. head of

pancreas Lymph

nodes

Bili type unconjugated conjugated conjugated

Bili level ++ +++/++++ ++

ALT +/++ ++/+++ +/++

ALP -/+ +/++ ++/+++

Bili=bilirubin

ALT=alanine aminotransferase

AST=aspartate aminotransferase

ALP=alkaline phosphatase

CLD=chronic liver disease

What is the normal level of bilirubin, and the level before jaundice

can be detected clinically?

Normal level is < 17 mmol/L

It has to reach at least 3 times before the sclera is discolored i.e. > 50

mmol/L

Very high levels are usually associated with hepatic jaundice.

How should jaundiced patient be investigated?

You have to start by the cheapest investigations first then go through according to the demands.

Blood tests

1. Urine analysis raised bilirubin

2. CBC anaemia suspecting GI malignancies, or associated infection

3. Renal function tests (RFT) any evidence of hepatorenal syndrome

4. LFT ALT, AST, ALP, Bilirubin, Albumin

5. Clotting BT, CT, PT, PC, PTT, INR

Dr.Hisham H.Ahmed

Radiological investigations

1. US

Liver cirrhosis

Gall stones

Dilated CBD > 8mm is abnormal

Pancreatic mass

Lymphadenopathy

2. CT

3. ERCP

4. MRCP

What are the causes of post-operative jaundice?

1. Pre-hepatic jaundice due to hemolysis 2ry to blood transfusion

2. Hepatic jaundice 2ry to the use of halogenated anesthetics, sepsis, or

intra- or post-operative hypotension

3. Post-hepatic jaundice due to biliary injury such as Lap.Chole

Lap.Chole= Laparoscopic Cholecystectomy

Good luck

Dr.Hisham H Ahmed.M.D, PhD, MRCS.Eng

Prof. of General and Pediatric Surgery

Benha University

2017