In acute appendicitis, there is no 
great increase  in body temperature.
-It relatively reaches 38 -38.5 C°.
-If greater think of complication or 
other diagnosis.

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How to differentiate between acute appendicitis and renal colic?

-Acute appendicitis : the patient loathy to move, ask him to cough he  develops pain.

-Renal colic: rolling on the bed , coughing doesn’t elicit pain.

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When would you find appendicitis and diarrhea?

-In retroilial appendix.

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How to differentiate between sub-hepatic acute appendicitis and acute cholycycstis?

-By tow things
1-Type of the patient:
-In acute appendicitis : the patient is young , thin.
-In acute cholycystitis: female , fatty , fertile, fory, fair.

2-Hyperesthesia:
-In appendicitis: hyperesthesia in the tringle of sherrene.
-In cholycytisits : hyperesthesia in the on the back( boas's sign).

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When would you find appendicitis and jaundice?

-In portal pyemia.

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How to differentiate between acute appendicitis and mesenteric lymph  adenitis ?

-In mesenteric lymph adenitis the patient has shifting tenderness ( the patient hasPain localize tothe RIF, When he terns to the other side the pain  shift with the direction of the movement) also the patient may have tonsillitis.

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How to differentiate between acute appendicitis and gastroenteritis?

-If abdominal  pain precedes  vomiting it indicates acute appendicitis, but if vomiting precedes abdominal  pain  it indicates gastroenteritis.

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-Analgesics is contraindicated if acute appendicitis is suspected to avoid masking of diagnosis.

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Differential Diagnosis for Epigastric Abdominal Pain:

1- Gastroenteritis:-

History and physical:-
Nausea, extensive vomiting, diarrhea, myalgia, fever, mild abdominal tenderness

2-Acute gastritis:-

History and physical:-
Burning/gnawing epigastric pain, NSAID use, mild abdominal tenderness

3-Acute cholecystitis:-

History and physical:-
Right upper quadrant/epigastric pain radiating to around the right back, nausea, vomiting, fever, Murphy’s sign

4-Peptic ulcer disease (PUD)

History and physical:-
Intermittent burning epigastric pain that is better (duodenal ulcer) or worse (gastric ulcer) with food intake, nausea, Helicobacter pylori infection, NSAID use, steroids

5-Perforated ulcer :-

History and physical:-
Initial epigastric pain, followed by diffuse tenderness, abdominal rigidity, rebound tenderness

6-Pancreatitis:-

History and physical:-
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, alcohol abuse

7-Appendicitis:-

History and physical:-
Periumbilical pain migrating toward the right lower quadrant (McBurney’s point), associated with nausea, vomiting, anorexia, fever, Rovsing’s sign, psoas sign

8-Small bowel obstruction :-

History and physical:-
Adhesions, hernia, neoplasms, dilated loops of bowel with air fluid levels, absence of distal colonic gas on plain radiograph

9-Mesenteric ischemia :-

History and physical:-
“Severe abdominal pain out of proportion to physical exam,” nausea, most often cardiac embolus to superior mesenteric artery from atrial fibrillation, bloody diarrhea in severe cases

10-Ruptured AAA :-

History and physical:-
Severe abdominal/back/left flank pain, pulsatile abdominal mass, hypotension, elderly male smoker

11-Referred pain from myocardial infarction:-

History and physical:-
Atypical presentation more common in women and diabetics, cardiovascular disease, obesity, hypercholesterolemia.

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-In males, first decide whether the lump is a hernia or a true scrotal lump by seeing if you can ‘get above it’, namely feel its upper edge with a normal spermatic cord above.
-If you can, it is a scrotal swelling and not a hernia.
-If the lump has no upper edge because it passes into the inguinal canal, it is a hernia.

#Hernia
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-Combination of indirect and direct inguinal hernias is called pantaloon hernia.

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When the case is inguinal hernia and you asked why this not femoral hernia ?

-It is inguinal because:
1) The hernia is above inguinal ligament.
2) The neck of the hernia is above & medial to pubic tubercle.
3) Because the hernia descends into the scrotum (if so).

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•Why is indirect inguinal hernia more common in right side ?

Due to delayed descend of right testis , slower closure of a patent processus vaginalis on the right side compared to the left.

It's almost about one month difference.

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•What's the difference between osteoporosis and osteomalasia ?

-In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.

-In osteomalacia, the ratio of bone mineral to bone matrix is low.

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Examination of an Incision 

By inspection:

Site, side, length, direction, the healing by primary or secondary intention,  relation to deep structures  any signs of complication of incision as hematoma, discharge, swelling, redness..etc

-If there's dressing, comment on:
Site, side, dry or wet, clear in colour or red, yellow...

-Do not forget to say to the examiner:
"I shoud to expose the dressing".


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Until proven otherwise.

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Difference between small and large bowels obstruction on X-ray.

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Management of urinary tract stones.

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Types of wounds.

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-Gall stone may obstruct the ileum leading to what called- Gall stone ileus.
Or
-Leads to gastric outlet obstruction  is called- Bouverte's syndrome.

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Triple asessment of the breast:

1-History and examination
2-US and Mammography
3-Trucut  biopsy.

Good exposure in breast examination  is from umbilicus upward,Why?
-Because the lymph from the level of umbilicus upward comes to axilla.

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