Hypertrophic pyloric stenosis of infancy

•A condition of unknown aetiology, in which the pylorus is thickened and elongated leading to gastric outlet obstruction with resultant projectile vomitting and metabolic derangments.

•It occur 3 in every 1000 born child, it is 4 times more common in males, and more common in the first born child, some cases show familial tendency.

•The condition most commonly present 4 weeks after birth, but it can range from as early as 2 weeks, to as late as 7 weeks, but this is rare.

•Non bilious vomitting that soon becomes projectile after 2 or 3 days is the main feature, other features include striking weight loss, dehydration, hyponatremia with a hypokalemic hypochloremic metabolic alkalosis.

•Visible peristalsis after a meal is also found, the Hypertrophic pylorus can also be palpated (olive sign) in the epigastrium or right upper quadrant.

•Investigation of choice is ultrasound (White line is elongated pylorus, black line is thickened pylorus).

#Surgery

Effects and complications of gallstones:

● Biliary colic
● Acute cholecystitis
● Chronic cholecystitis
● Empyema of the gallbladder
● Mucocoele
● Perforation
● Biliary obstruction
● Acute cholangitis
● Acute pancreatitis
● Intestinal obstruction (gallstone ileus)

Differential diagnosis of acute cholecystitis:
Common:
● Appendicitis
● Perforated peptic ulcer
● Acute pancreatitis
Rare:
● Acute pyelonephritis
● Myocardial infarction
● Pneumonia – right lower lob.


#Surgery

Symptoms of appendicitis

● Periumbilical colic
● Pain shifting to the right iliac fossa
● Anorexia
● Nausea

Signs to elicit in appendicitis:

● Pointing sign
● Rovsing’s sign
● Psoas sign
● Obturator sign

Clinical signs in appendicitis
● Pyrexia
● Localised tenderness in the right iliac fossa
● Muscle guarding
● Rebound tenderness

The patient is then asked to point to where the pain began and where it moved (the pointing sign).

#Surgery

Sleeping pulse rate:
Pulse rate counted early morning around 4 am, before the patient wakes up, without disturbing the sleep.

#Surgery

Sign of Moulding:

1-Sebaceous cyst
2-Dermoid cyst
3-Colonic mass with faecal matter.

#Surgery

Fluctuation:
-It's the transmission of an impulse in two directions at right angles to each other, and it implies presence of fluid in the swelling.

#Surgery

-Ascitic fluid less than 500 cc cannot be detected clinically.

-Minimal Ascites (500-1000cc).
-Moderated Ascites (1000-2000cc).
-Severe Ascitis (>2000 cc)

•Moderate amount: Shifting dullness.
•Tense: transmitted thrill.
•Minimal: knee - elbow.

#Surgery

Swellings that move with deglutition?

1-Thyroid
2-Thyroglossal cyst
3-Subhyoid bursitis
4-Nodes attached to larynx and trachea
5-Laryngocele.

Swellings which are brilliantly transilluminant:

1-Ranula
2-Cystic hygromaand lymph cyst
3-Hydrocele
4-Meningocele
5-Epididymal cyst (Chinese-lantern pattern)
6Hydrocele of the canal of Nuck.

#Surgery

Reducible swellings:

1-Hernia
2-Meningocele
3-Varicocele
4-Saphena varix.

#Surgery

Cold Abscess:

-It is a soft fluctuant swelling without signs of inflammation, which is mistaken for a cyst.
-This is lined by granulation tissue and caseous material.
-It is due to tuberculous infection and contains tubercle bacilli.
-It is not hot.
-Brawny induration, edema and tenderness are absent.

#Surgery

Acute Abdomen definition:
-Any sudden spontaneous nontraumatic disorder affecting the abdomen for which urgent operation may be necessary and undue delay in diagnosis may adversely affect the outcome.

#Surgery

A serum amylase level four times above the normal is indicative of acute pancreatitis.

#Surgery

Bacteremia:
-Circulating bacteria in the blood without producing disease.

Pyemia:
-Circulating infective emboli composed of masses of organisms, vegetations and infected clots in the bloodstream.

Septicemia:
-Circulation of bacteria in blood producing disease.

#Medicine
#Surgery

In Breast Carcinoma:

-Skin tethering and fixity:
The skin tethering is due to early involvement of ligaments of Cooper.

-Manifested as puckering of the skin:
The underlying lump can be moved independently of the skin to some extent.

-Skin fixity:
-It is because of invasion of carcinoma along the ligaments of Cooper to the skin.The lump and the skin cannot be moved separately.

-Retraction (Recent) of nipple:
Extension of growth along the lactiferous duct and subsequent fibrosis.

-Peau d’ Orange appearance:
It is due to blockage of the lymphatics draining the skin—cutaneous lymphedema. The hair follicles are more firmly fixed to the subcutaneous tissue than the rest of the skin. The hair follicles appear to be retracted and the between areas swell giving the orange peel appearance.

-Multifocal:
Tumor foci in the same quadrant are called multifocal.

-Multicentric:
Tumor foci in different quadrants are called multicentric.

#Surgery

Constipation:
- A bowel frequency of less than one every 3 days. (Fewer than two per week).

Obstipation:
-(Absolute constipation): Absence of passage of both stool and flatus.

#Surgery

Cough Impulse:
-Expansile impulse seen or felt over a swelling when the patient coughs, cries or strains.

#Surgery

Crepitus:
-Grating or crackling sensation imparted to the examining fingers.
-May be present when the joint contain loose bodies.

#Surgery

Flail chest:
-Three or more ribs fractured in 2 or more places.
-Bilateral costochondral separation will result in flail sternum.

Goiter:
- Any enlargement of thyroid gland is called goiter.

Grading of goiter: WHO (1990) Perez Classification
Grade 0 No goiter
Grade Ia Not visible, but palpable
Grade Ib Visible with neck extended and palpable
Grade II Visible with neck in normal position and palpable
Grade III Large gland evident from a distance.

#Surgery

Hydronephrosis:
-Aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction.