Examination of abdomen 1. Inspection a. From the front i. Symmetry of abdomen b. From the side i.

Hold breath- visible peristalsis ii. Visible pulsation iii. Moves with respiration c. From above i. Scars 1. Site 2. Size 3. Healing (primary intention, secondary intention) ii. Scratch marks iii. Dilated veins (caput medusa) iv. Liver disease stigmata v. Hernia orifice intact? 2. Palpation (all 9 quadrants) a. Superficial- tenderness b. Deep- mass c. Lower border of liver d. Lower pole of spleen e. Kidney ballotable 3. Percussion (all 9 quadrants) a. Tympanic/dull/resonance b. Upper border of liver (liver span) c. Traubs space d. Shifting dullness ascites e. Abdominal thrill 4. Auscultation a. Breath sounds b. Bruit UGIB 1. Investigation a. FBC i. Anemia ii. Leucocytosis b. RP/BUSE i. Electrolyte imbalance ii. Dehydration c. ABG d. Radiological investigation i. Erect plain CXR

1. Ddx of Air under diaphragm a. Perforated viscuspneumatoides cystides intestinalis (gas producing bacteria b. Chilatides sign i. Bowel moves above c. Basal atelectasis d. Tubal inssufflation and per vagina e. Escape air from trachea ii. Differential diagnosis of perforated viscus 1. Perforated gallbladder 2. Perf. Appedicites 3. Perf colon iii. Left lateral decubitus 1. Minimal air under diaphragm 2cc iv. Serum amylase 1. >1000 is acute pancreatitis v. LFT 1. Proteins low- chronic disease 2. Transaminases elevated- hepatocyte destruction 3. Bilirubin- liver/ gallbladder disease 4. ALP- obstruction of CBD 5. GGT- alcoholic vi. Ultrasound 1. Gall bladder thickening 2. CBD dilation 3. gallstone (10% radiopaque) 4. periceolic abcess 2. Tissue perfusion indicators a. CBD- urine output b. CVP Sebaceous cyst 1. Complication a. Infection b. Ulceration c. Calcification d. Serbacoeous whorl e. Sebaceous carcinoma (Arise from cyst) 2. Treatment a. Uncomplicated- no abscess i. Excision of entire sac including underlying of skin ellipse b. Complicated i. I&D 1. 1 mth after i&d review Excision

Ascending cholangitis 1. Definition a. Infection of the biliary tree 2. Signs and symptoms a. Charcot triad i. Fever + chills rigor ii. RUQ pain iii. Jaundice b. Reynods pentad (+ septic shock, mental confusion) 3. Complication of gallstone a. In gallbladder i. Biliary colic ii. Acute cholecystitis iii. Mucocele iv. Empyema b. In biliary system i. Obstructive jaundice ii. Ascending cholangitis iii. Acute pancreatitis c. Outside i. Gallstone ileus 4. investigation a. ERCP i. Diagnostic 1. Gallstone 2. Biopsy- cancer of head of pancreases 3. Brush cytology 4. Sclerosis- primary sclerosing cholangitis ii. Therapeutic 1. Retrieve stone- dornia basket 2. Remove mass 3. Stenting SEMS b. Complication of ERCP i. Perforation of CBD ii. Bleeding 1. Coagulation profile must check prior to procedure 2. Antibiotic cover- pre and post iii. Sepsis iv. Acute pancreatitis v. Stricture- mucosal injury vi. Allergic to dye c. MRCP i. Magnetic ii. Only diagnostic

iii. Not therapeutic d. Management of ascending cholangitis i. conservative 1. IV fluid a. Hydrate patient b. Dilute bilirubin 2. Diuretics a. Flush out bilirubin 3. Antibiotic a. Metorbnidazole b. Ciprofloxacin ii. Surgical 1. Indication a. Fail conservative mx b. Easy dissect in acute d/t fibrouseous i. Fibrous hard to dissect c. 48-72 hours of conservative management iii. Organism 1. E.coli 2. Strp fecalis 3. Klebsiela iv. Differential diagnosis 1. Acute pancreatitis 2. Acute hepatitis 3. R. pyelonephritis 4. Liver abscess 5. Leaking duodenal ulcer