Differential Diagnosis of Abdominal Lump In Right Hypochondrium

Swellings in the Abdominal Wall

Cold Abscess

1. Fluctuant swelling with no signs of inflammation
2. Swelling becomes prominent when the abdominal muscles contract
3. Irregularity in the affected rib or deformity of the spine

Intra-abdominal Swellings

Hepatic

1. It moves with respiration but is not mobile sideways
2. The swelling is continuous with the liver dullness without a band of colonic resonance

Gall Bladder

1. Oval smooth swelling, the size of an egg
2. Moves with respiration, can be moved sideways but cannot be pushed down into the loin (like kidney swelling) Read more

What Is Spider Nevi?

It is also known as Arterial spider, Spider telangiectasis, Spider angioma

Definition:

An arterial spider is a central arteriole, from which numerous small vessels radiate resembling a spider’s legs.

Sites:

Arterial spiders are found in the territory of the superior vena cava. They are commonly seen on the face, neck, forearm and shoulder.

Appearance:

They range in size from 3 to 15 mm in diameter. They are pulsatile and blanch on pressure. When the skin is stretched or compressed they fill from the centre to the periphery. Read more

Examination Of Abdomen-Inspection

Examination of the abdomen begins with inspection. The shape of the abdomen in most normal persons with normal musculature is  boat-shaped i.e. the abdominal wall sinks slightly within the bony margins of the abdominal surface.

In a very muscular person, the lateral margin of the rectus muscle is visible in the center. Usually the medial edges of both the recti are contiguous. However they may be separated as a congenital defect, after pregnancy or with obesity and ascites. This is called divarication of recti.

Scaphoid or sunken abdomen is seen with starvation and malignancy especially of stomach and esophagus. Read more

How To Examine A Patient of Abdominal Complaints

In a patient with an abdominal disorder, the following points must be asked whilst taking the history and noted on examination.

History

History is of paramount importance in clinical examination. It enables you to narrow your examination to a region and also guides you about the likelihood of particular disorder. Following points should be asked in patient of abdominal complaints. These points cover whole abdomen in general and can be individualized depending upon the complaint. Read more

Jugular Venous Pulse – JVP

Normal Jugular Venous Pulse (JVP):

The normal JVP consists of three positive pulse waves a, cand v and two negative pulse waves x and y.

The ‘A’ Wave: The ‘a’ wave is produced by retrograde transmission of the pressure pulse produced by right atrial contraction. In normal subjects the ‘a’ wave is often the largest positive wave visible, coinciding with the fourth heart sound.

1. ‘a’ wave is absent in atrial fibrillation

2. ‘a’ wave is diminished in

• Tachycardia
• Prolonged PR interval Read more

Hypotension -Types and Causes

Hypotension is diminished blood pressure. This could be acute or chronic.

Acute Recumbent Hypotension

Causes

1. Cardiovascular: Acute myocardial infarction, pulmonary embolism, dissecting aneurysm, ventricular tachycardia, cardiac rupture.
2. Intravascular volume contraction: Hemorrhage, vomiting, diarrhea, burns, intestinal obstruction, periotonitis, etc.
3. Anaphylaxis
4. Gram negative septicemia

Clinical Features

1. Due to shock: Tachycardia, vomiting, fainting
2. Due to causative disease
3. In vasovagal attacks, hypotension with brady-cardia
4. In postural hypotension, fall of BP occurs on suddenly assuming erect posture from supine posture.

Treatment

1. Of the cause
2. Posture: The patient should be in lying position with legs raised.
3. For vasovagal attacks: Atropine 0.6 mg IV
4. For anaphylaxis: Hydrocortisone hemisuccinate 100mg IV, repeated as required
5. For postural hypotension: This is best treated by advising the patients to assume the erect posture slowly and to wear elastic stockings and abdominal binder.
6. Vasoconstrictors: Dopamine, nor-epinephrine and ephedrine have been tried.
7. Salt: Adequate amount of salt (NaC1) in diet helps to expand the plasma volume.
8. Fludrocortisone Acetate: (0.1 – 0.2 mg) causes fluid retention and avoids postural fall of BP. Read more

Normal Pulse and Its Variants

The normal pulse has a small anacrotic wave on the upstroke which is not felt. This is followed by a big tidal or percussion wave which is felt by the palpating finger. On the following downstroke there is a notch (dicrotic notch) followed by a wave (dicrotic wave) both of which are not normally palpable.

The normal pulse appears at regular intervals and has a rate between 60-100 per min. There may be a mild variation in the rate between the two phases of respiration which is called sinus arrhythmia. Read more

Causes of Hypothermia

Hypothermia

Hypothermia is decreased body temperature.

Causes

1. Endocrine: Myxedema, Simmond’s cachexia, hypoglycemia
2. Toxic: Alcoholic intoxication, barbiturate poisoning, ketoacidosis
3. Exposure to cold
4. Autonomic dysfunction

Fever – Definition, Types, Causes and Effects

The body temperature refers to the temperature of the viscera and tissues of the body. It is kept within the normal level by maintaining a balance between the heat gain and heat loss, which is regulated by the hypothalamus.

The body temperature is best recorded with a mercury thermometer which should be kept in position for about a minute. Usually temperature is recorded in the axilla. However, if there is a lot of perspiration, oral temperature should be taken. In cholera, rectal temperature is recorded which may be high, whereas the skin temperature may be subnormal.

The normal body temperature varies from 36 degree Celsius – 37.5 degree Celsius. There is normally a diurnal variation of 1 degree Celsius, the lowest temperature being between 2-4 am and highest in the afternoon.

Fever or pyrexia is an increase of more than 1 degree Celsius or any rise above the maximal normal temperature.

Types of Fever

1. Continuous fever: The temperature remains above normal throughout the day and does not fluctuate more than 1 degree Celsius in 24 hours e.g. lobar pneumonia, typhoid, urinary tract infection, infective endocarditis, brucellosis, typhus, etc.
2. Remittent fever: The temperature remains above normal throughout the day and fluctuates more than 2 degree Celsius in 24 hours e.g. typhoid, infective endocarditis, etc. This type of fever is most common in practice.
3. Intermittent fever: The temperature is present only for some hours in a day and remains to normal for the remaining hours. When the spike occurs daily, it is quotidian, when every alternate day, it tertian and when every third day, it is quartan. Intermittent fever is seen in malaria, kala-azar, pyemia, septicemia etc.
4. Hectic or septic: The temperature variation between peak and nadir is very large and exceeds 5 degree Celsius e.g. septicemia.
5. Pel Ebstein type: There is a regular alternation of recurrent bouts of fever and afebrile periods. The temperature may take 3 days to rise, remains high for 3 days and remits in 3 days, followed by apyrexia for 9 days.
6. Low grade fever: Temperature is present daily especially in the evening for several days but does not exceed 37.8 degree Celsius at any time. Usually it does not indicate disease, but it is commonly present with tuberculosis.

Causes of Fever

1. Infection: Bacterial, viral, rickettsial, fungal parasitic, etc.
2. Neoplasms: Fever may be present with any neoplasm but commonly with hypernephroma. Lymphoproliferative malignancies, carcinoma of pancreas, lung and bone and hepatoma.
3. Vascular: Acute myocardial infarction, pulmonary embolism. Pontine hemorrhage, etc.
4. Traumatic: Crush injury
5. Immunological:

• Collagen disease, SLE, rheumatoid arthritis.
• Drug fever
• Serum sickness

6. Endocrine: Thyrotoxicosis, Addison’s disease.

7. Metabolic: Gout, porphyria, acidosis, dehydration

8. Hematological: Acute hemolytic crisis

9. Physical agents: Heat stroke, radiation sickness.

10. Miscellaneous: Factitious fever, habitual hyperpyrexia, cyclic neutropenia

Special Types of Fever

1. Fever with rigors: This occurs in:

• Malaria
• Kala azar
• Filariasis
• Urinary tract infection
• Cholangitis
• Septicemia
• Infective endocarditis

2. Fever with herpes labialis: Elevated body temperature may activate the herpes simplex virus and cause small vesicles around the angle of the mouth (herpes labialis). It occurs with:

• Pneumonia
• Malaria
• Meningitis
• Streptococcal infection

3. Fever with rash: This is seen in:

• Chicken pox
• Small pox
• Measles
• Rubella
• Typhus
• Allergy

4. Fever with membrane in the throat: occurs in:

• Diphtheria
• Infectious mononucleosis
• Agranulocytosis
• Moniliasis
• Vincent’s angima

5. Fever with delirium: This is common in:

• Encephalitis
• Typhoid state
• Meningitis
• Pneumonia (especially in alcoholics and elderly people with senility)

6 Hyperpyrexia
Hyperpyrexia is said to occur when body temperature is more than 105 degree Fahrenheit.

1. Tetanus
2. Malaria
3. Septicemia
4. Heat Stroke
5. Encephalitis
6. Pontine hemorrhage

Benefits of Fever

In some human disease, fever is beneficial, e.g. widespread cancer, neurosyphilis, chronic arthritis, etc. Fever was often induced in these diseases by injection of milk protein or BCG vaccine.

It has been suggested that fever is associated with release of endogenous pyrogens, which activate the T cells and thus enhance the host defense mechanism.

Harmful Effects

1. Hypercatabolism-nitrogen wastage and weight loss.
2. Fluid and electrolyte imbalance-due to sweating.
3. Convulsions and brain damage
4. Circulatory overload, arrhythmia, etc.

What is Pes Cavus and What Causes It

Pes Cavus: Pes cavus is the increased antero-posterior curvature of the arch of the foot.

Causes:

1. Idiopathic
2. Spinocerebellar atrophy: Friedreich’s ataxia, peroneal muscular atrophy
3. Spinal cord disease: Poliomyelitis, spina bifida
4. Cerebral palsy

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