Methods to elicit MURPHY’S SIGN:

1)Patient in upright/sitting  position, the right hand of the examiner curls  up under the  right  costal  margin (or extended fingers  with moderate pressure) of the patient at the tip of the ninth rib and patient is requested to  take  a deep breath. If the gallbladder is inflamed, the  patient will experience  pain (winces with  pain and catch  the breath) as the gallbladder descends and contacts the palpating  hand.

2)The extended and abducted  left thumb is placed  in right subcostal region without pressing deep; the patient is requested to take a deep  breath.This is  elicited  in lying down supine position. Called Moynihan’s modification of eliciting Murphy’s sign.

3)Identify the right Midclavicular line then descend to the right costal margin and put your one or two fingers there, as that site is the anatomical position of GB fundus.

4)From linea semilunaris and ascend to right costal margin. This isn't good in obese patients.

5)A line from left ASIS to the umblicus and other from the umblicus to the right costal margin tip of 9th costal cartilage. It's called Grey Turner line.

6)From the RIF and ascend upward, this facilitates the detection if there is also hydropes of GB. د. رمزي

7)Sonographic Murphy’s sign  is eliciting same sign using sonographic transducer. It is more sensitive and more accurate.

The sign is described by John murphy, a professor of surgery chicago USA.

•Murphy's Triad:
-It is associated with acute appendicitis, a medical emergency which presents with:
1-Lower right abdominal pain
2-Nausea and vomiting
3-Fever.

•Murphy's sign:
-It is useful for differentiating pain in the right upper quadrant.
-Typically, it is positive in acute cholecystitis, but negative in choledocholithiasis, pyelonephritis, and ascending cholangitis.

•Murphy's test
-It is a costovertebral angle (CVA) tenderness that results from touching the region inside of the costovertebral angle.

•Murphy's drip:
-It is a rectal infusion apparatus to administer the medical procedure of proctoclysis, also known as rectoclysis.

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The right supraclavicular node is called Scalene node.

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Remember:

Development of the Thyroid Gland:
-The thyroid gland begins to develop during the third week as an entodermal thickening in the midline of the floor of the pharynx between the tuberculum impar and the copula.

-By the seventh week, it reaches its final position in relation to the larynx and trachea.

-The thyroid gland develops from a median down growth of a column of cells from the pharyngeal floor between the first and second pharyngeal pouches (subsequently marked by the foramen caecum of the tongue).

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What is the bone that has not articulation with any bone?

-The hyoid bone is a mobile single bone found in the midline of the neck below the mandible and abides the larynx.
-It does not articulate with any other bones.

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Prominent Veins over Breast are seen in:

-Rapidly growing sarcoma
-Cystosarcoma phyllodes
-Huge breast absces.

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Remember:

-Oral contraceptive pills are not a risk factor now in cancer breast!

-It's only progesterone only (mini pills) pills that have the risk of cancer breast.

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In sebaceous cyst:

-Presence of bluish black spot, called punctum indicating the site of blockage at the opening of the duct, which is diagnostic.

-The punctum is adherent to the cyst.
-On squeezing the cyst putty-like or cheesy sebaceous material with an unpleasant smell may come out through the punctum.

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Remember:

-Varicocele is common in tall, thin young men.

-Varicocele causes increased temperature in the scrotum which depresses the spermatogenesis and so causes infertility (correctable infertility).
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Grading of varicocele:

I–small;
II–moderate;
III-large;
IV - severely tortuous.

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Sites of Pilonidal Sinus:

1-Natal cleft(commonest)
2-Axilla
3-Umbilicus
4-Between fingers
5-Genitalia
6-Amputation stump.

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Varicocele Classification:

Subclinical:
Not palpable or visible.

Grade I: Palpable during Valsalva maneuver.
Grade II: Palpable at rest ,but not visible
Grade III: Visibleand palpable at rest.

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What is Bow sign?

-On lying down it gets reduced slowly and spontaneously (except in renal cell carcinoma) in primary varicocele.

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Retrosternal goiter:

-Common in short neck individuals and males with strong pretracheal muscles

Types:

1.Substernal—part of nodule palpable in lower neck
2.Plunging—on increased intrathoracic pressure gland forced into neck
3.Intrathoracic goiter.

Classes:
1-Primary: rare, congenital.
2-Secondary: more common, acquired as in a large MNG.

#Surgery

-The only effective treatment of Retrosternal goiter is surgery.

-The antithyroid drugs in pre-operative preparation or treatment are contraindicated, Why?

-Because they will lead to ↓in thyroid hormones levels which lead to feedback activation of TSH that causes increased thyroid growth and size with more obstruction at neck without effect on hormone levels!!

So they use BB as Propranolol.
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INDICATIONS OF CBD EXPLORATION:

1. History of charcot’s triad
2. USG proven stones in CBD
3. Dilated CBD (>1cm)
4. OTCshows filling deffect
5. Palpable stones in CB.

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When would you find appendicitis and jaundice?

-In portal pyemia. "rare complication".

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Remember:

-Celsius, Fahrenheit and Kelvin are the three common temperature scales.

-F° denotes for Fahrenheit , this is considered an American"US" system.

-C° means Celsius, it's used by UK "British system "and rest of the world.

Celsius is invented in 1742 by the Swedish astronomer Anders Celsius.

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