1.

What are the criteria of differentiation between a mass of splenic origin and another of renal origin
on physical examination?

2. Explain the technique of determining the direction of flow in superficial veins on the abdominal wall.

When you find distended veins on the abdomen you should ascertain the direction of flow.
The normal direction of flow is away from the umbilicus , that is the upper abdominal
veins carry blood up ward to the superior vena cava. And the lower abdominal veins flow
downward to the inferior vena cava.

how to ascertain the direction of blood flow you can choice a segment
of vein, then the vein is emptied between two fingers to a distance
of a few centimeters, then allows blood to refill the vein from one direction by removing
one compressing finger.
3. What are the extra hepatic stigmata of liver disease?

* Clubbing
* Palmar erythema
* Spider nevi (angiomata)
* Scratch marks
* Gynaecomastia
* Feminising hair distribution
* Testicular atrophy
* Small irregular shrunken liver
* Anaemia
* Caput medusae (recanalisation of the umbilical vein) (Distended abdominal veins)

4. What are the gastrointestinal causes of clubbing?

Causes of Gastrointestinal causes of clubbing

1. Celiac Disease
2. Crohn's disease
3. Cystic Fibrosis
4. Pancolitis

Gastrointestinal and hepatobiliary:

* Malabsorption
* Crohn's disease and ulcerative colitis
* Cirrhosis, especially in primary biliary cirrhosis.
* Hepatopulmonary syndrome, a complication of cirrhosis.
* Laxative abuse
* Polyposis
* Esophageal CA

5. What are the most common causes of gross distension of the abdomen as from inspection?
 
 Abdominal bulge
generalized abdominal bulge is usually caused by ascites
some causes for ascites:
heart failure
cirrhosis of liver
nephrotic syndrome
TB peritonitis

 The other causes of abdominal bulge:

include the distention of the bowel with trapped gas, such as intestinal obstruction, massive tumor, such as
ovariogenic cystoma, factitious abdominal fullness with air,
pregnancy obesity.
6-What are the differential diagnoses of massive splenomegaly?

Massive splenomegaly is usually defined as a spleen extending well into the left lower quadrant or pelvis or which has crossed
the midline of the abdomen.

The differential diagnosis of massive splenomegaly includes myeloproliferative diseases, Gaucher disease,
lymphoma, thalassemia major, visceral leishmaniasis (kala-azar), and malaria (Table 1). Although many
other diseases such as cirrhosis with portal hypertension, mycobacterial infections, Epstein-Barr virus infection, and
hemolytic anemias can be associated with splenomegaly, they are rarely associated with massive splenic
enlargement.

Myeloproliferative diseases
Chronic myeloid
leukemia
Agnogenic myeloid
metaplasia
Polycythemia vera
Essential thrombocythemia
Gaucher disease
Lymphoma
Hairy cell leukemia
Mantle cell lymphoma
Chronic lymphocytic
leukemia
Prolymphocytic leukemia
Splenic marginal-zone
lymphoma
Follicular lymphoma
Thalassemia major
Visceral leishmaniasis
Malarial splenomegaly

 Infectious Disorders • Allergic, Collagen, Auto-

(Specific Agent)
Histoplasmosis, disseminated
Leishmaniasis/kala-azar
Malaria
 Infected organ, Abscesses
Splenic abscess
 Granulomatous,
Inflammatory Disorders
Sarcoidosis
 Neoplastic Disorders Immune Disorders
Hodgkin's disease Felty's syndrome
Lymphomas • Metabolic, Storage Disorders
Myeloblastic crises/CML patient Amyloidosis, hepatosplenic
Chronic Lymphocytic Leukemia CLL Gaucher's disease
Erythroleukemia/DiGuglielmo's syndrome • Anatomic, Foreign Body,
Leukemia Structural Disorders
Leukemia, chronic Spleen hematoma
Myelogenous leukemia, chronic Splenic subcapsular hematoma
Prolymphocytic leukemia • Arteriosclerotic, Vascular,
 Angioimmunoblastic lymphadenopathy Venous Disorders
Hairy cell leukemia Portal vein thrombosis
Lymphoma, hepatosplenic Splenic vein thrombosis
Lymphoma/malignant, non-Hodgkins • Vegetative, Autonomic,
Primary Myelofibrosis/Myeloid metaplasia Endocrine Disorders
Pulmonary lymphangiomatoid granulomat's Portal hypertension, presinusoidal
Waldenstrom's macroglobulinemia
Spleen sarcoma/primary

7-What is Murphy`s sign and what does it indicate?

Murphy's sign refers to a maneuver during a physical examination as part of the abdominal examination
and a finding elicited in ultrasonography. It is useful for differentiating pain in the right upper quadrant.
Typically, it is positive in cholecystitis, but negative in pyelonephritis, choledocholithiasis, and ascending
cholangitis.

Classically Murphy's sign is tested for during an abdominal examination; it is performed by asking the
patient to breathe out and then gently placing the hand below the costal margin on the right side at the
mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire
(breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm
moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in
moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the
test is considered positive. A positive test also requires no pain on performing the maneuver on the
patient's left hand side. Ultrasound imaging can be used to ensure the hand is properly positioned over the
gallbladder.