General surgery clinical rounds for the undergraduates

1. Dr.Hisham H.Ahmed
Clinical Rounds
By
Professor of General and Pediatric Surgery

2. 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

3. 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.

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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.

16. 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

17. Dr.Hisham H.Ahmed
Figure 1; Dimpling
Figure 2; Peau d'orange
Figure 3; Paget’s disease of the nipple

18. 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

19. Dr.Hisham H.Ahmed

20. 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

21. 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

22. 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

23. 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?

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. 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

35. 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