ILLUSTRATIVE CASES

26-year-old woman with right iliac fossa pain of six-week duration with associated highgrade fever and vomiting. Pelvic ultrasound scan showed a cystic mass in the right adrenal with dilated loops of bowel indicative of an inflammatory process. Clinical diagnosis Right tubo-ovarian mass Histological section showed granulomas with ova of Schistosoma

 20yr old lady who was amenorrhoeic for five months and had abdominal pain of eight day duration and bleeding per vaginum of one week duration. Clinical diagnosis Hydatidiform mole Histological section shows malignant cytotrophoblastic and syncytiotrophoblastic cells with surrounding necrosis and haemorrhage. Histological diagnosis Choriocarcinoma

 33yr old woman with right breast lump for 2month. Clinical diagnosis Fibroadenoma Histological sections showed fibrocystic changes with a focal area of atypical epithelial hyperplasia. Histological diagnosis Fibrocystic changes with atypical epithelial hyperplasia

GENERAL PHYSICAL FINDINGS Loss of consciousness[coma] Depression Anxiety Fluffiness of the hair Respiratory distress Dehydration Pallor Jaundice Cyanosis Fever Peripheral lympadenopathy Finger clubbing Asterixis Pedal oedema

LOSS OF CONSCIOUSNESS[COMA] Head injury Epilepsy Cerebrovascular accident Infections such as meningitis, encepahilitis Space occupying lesions such as cererbral tumors Metabolic and toxic conditions such as diabetic ketoacidosis Hyperosmolar non-ketotic acidosis Hypoglycaemia Renal failure Hepatic failure Overdose of sedative drugs Alcohol intoxication Hypothermia rge

ANXIETY Anxiety neurosis Thyrotoxicosis Hyperthyroidism Depression Insomnia Irritability Nightmares Increased sympathetic discha

DEPRESSION

Psychosis Psychomotor retardation Terminal or chronic illness Malignancies FLUFFINESS OF FLUFFINESS OF THE HAIR Malnutrition Protein losing enteropathy Nephritic syndrome Chronic liver disease like chronic hepatitis, liver cirrhosis, Primary liver cell carcinoma Malabsorption syndrome Familial

RESPIRATORY DISTRESS Use of accessory muscles such as sub coastal, intercostals, scalene; flaring of the alae nasi, mouth breathing, increased respiratory rate. Congestive cardiac failure Pulmonary embolism Tuberculosis Bronchial carcinoma Metabolic derangements Pulmonary fibrosis

DEHYDRATION Fluid loss as in vomiting Diarrhoea, burns, shock Haemorrhage Diabetes insipidus Diabetes mellitus Hot weather Hyperventilation Drugs e.g. diuretics Thyrotoxicosis/hyperthyroidi sm

PALLOR Paleness of the skin and mucous membrane Severe anaemia Chronic renal failure Haemorrhage Malaria Congestive cardiac failure Hypopituitarism Malignancies Syncope Chronic diseases like TB Infective endocarditis Osteomyelitis Rheumatoid arthritis Lead poisoning

JAUNDICE Yellowish discoloration of the sclera, skin and mucous membrane due to increased bilirubin in the blood greater than 2.5g/dl PREHEPATIC Haemolytic anaemia G6PD deficiency Malaria Erythroblastosis foetalis Dubin-Johnson syndrome Gilbert syndrome Hepatic Viral hepatitis A, B, C, D, E Bacterial hepatitides IV haemolysis Transfusion reactions Alcoholic hepatitis PLCC, Liver cirrhosis

Post hepatic Cholelitiasis Choledocholithiasis Biliary atresia Peri-ampullary carcinoma Carcinoma of the head of pancreas Drugs: carbamazepine, erythromycin, halothane, paracetamol Others: congenital: Rotor syndrome, Criggler-Najar syndrome

CYANOSIS Bluish discoloration of the skin and mucous membrane due to an increased amount of the deoxygenated haemoglobin greater than 5g/dl

PERIPHERAL Exposure to cold Venous obstruction Arterial thrombosis Cardiac failure

CENTRAL Heart failure Pulmonary oedema Fallots tetralogy Tricuspid atresia Tricuspid stenos is Transposition of the great vessels Pneumonias COPD Severe asthma ARDS

FEVER

Infections Bacterial e.g. TB Viral e.g. HIV infection Fungal e.g. histoplasma Protozoa e.g malaria Septicaemia Malignancies lymphoma, leukaemias Connective tissue disease-SLE, rheumatoid arthritis Sarcoidosis Drug reactions Thyrotoxicosis Liver cirrhosis

PERIPHERAL LYMPADENOPATHY/ ENLARGED NODES Infections Bacterial treponema, mycobacterium Fungal histoplasma Protozoan toxoplasmosis Neoplasms lymphomas, solid tissue tumors Connective tissue diseases rheumatoid arthritis, SLE Sarcodosis Amyloidosis Reticulosis Generalised sepsis Plaque

FINGER CLUBBING Heart diseases-infective endocarditis; congenital heart diseases such as cyanotic heart diseases e.g. tetralogy of Fallot, congestive cardiac failure, endomyocardial fibrosis, atrial myxomas

Lung diseases: chronic suppurative diseases[lung empyema, bronchietasis], bronchial carcinoma, emphysema, lung abscess, asbestosis, pulmonary TB, chronic fibrosing alveolitis, silicosis
Abdominal diseases: crohn disease, polyposis coli, ulcerative colitis. Steatorrhae, Liver diseases: cirrhosis. Primary hepatoma Others: sickle cell anaemia, AV fistula, familial

ASTERIXIS
Congestive cardiac failure Chronic renal failure Hepatic encephalopathy Liver failure Respiratory failure Overdose of hypnotic drugs Lithium poisoning

PEDAL OEDEMA Right heart failure Nephritic syndrome Liver cirrhosis Malnutrition Hypoproteinaemia Lymphatic obstruction due to inflammation, neoplasia, postirradiaton, postsurgery Protein losing enteropathy Malabsoprtion syndrome Renal failure Hyperaldosteronism Constrictive pericarditis