Recognizing  acute cholecystitis  on  US:

-The presence of gallstones, possibly impacted in the neck of the  gallbladder or cystic duct)  (Fig.  21-5)
-Thickening  of the gallbladder  wall  (>3  mm) (see  Fig.  21-5,  A)
-Pericholecystic fluid (fluid around the  gallbladder) (see  Fig.  21-5,  B)
- A positive sonographic Murphy sign  (A positive Murphy sign in this case is pain  that is  elicited  by compression of  the gallbladder with the US probe).

•In  the  presence  of  gallstones  and  gallbladder wall  thickening, US  has  a  positive  predictive  value  for  acute cholecystitis  as high  as 94%.

#Surgery

Some examiners need to tell them what is the most important US finding ,Thinking of GB wall.

Comparison between amebic and pyogenic liver abscess.

#Surgery

They are among DDx of hepatic hydatid cyst .

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.

حومش يعجبه نسوي بالطريقة الثانية.

Associated Anomalies with undescended testis:

-Epididymal anomalies and patent processus vaginalis upto 90%.

-Renal Anomalies in10% cases (Renal hypoplasia, agenesis,horseshoe kidney, PUJ obstruction)

-Hypospadias.

#Surgery

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).

#Surgery

The right supraclavicular node is called Scalene node.

#Surgery

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.

#Surgery

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.

#Surgery

Amount of secretions of gut.

#Medicine

Stomas.

#Surgery

Stoma examination.

#Surgery

•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.

#Surgery

Remember:

-Hasselbach's triangle is also called triangle of Halshted, inguinal triangle.

#Surgery