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1. DR A. K. Sheriff
General Examination

2. Jaundice.
• Jaundice is detected when serum bilirubin conc is
>50umol/L and the sclerae, mucous membs and skin
become yellow.
TYPES OF JAUNDICE
A. Unconjugated Bilirubin is an insoluble and transported in
plasma bound to albumin; it is therefore not filtered by the
renal glomeruli.
Therefore, the urine is normal in color (acholuric jaundice)
B. Conjugated Bilirubin- bilirubin is conjugated to form
bilirubin diglucuronide in the liver and excreted, giving bile its
green colour.
Therefore, the urine is dark brown in colour.

3. • In the colon, conjugated bilirubin is metabolized by
bacteria flora to stacobilinogen and stercobilin which
are excreted in the stool.
Starcobilinogen is excreted in the urine as urobilinogen, a
colourless, water-soluble compound.
ANATOMICAL CLASSIFICATION OF JAUNDICE
1. Prehepatic Jaundice- occurs due to hemolytic
disorders, accompanying anemia pallor combined with
jaundice producing pale lemon complexion. Stool and
urine are normal in color.
2. Hepatic Jaundice- is as a result of hepatocellular
disease causes hyperbilirubinemia that is both
Unconjugated and conjugated. Urine will be dark and
stools normal in colour.

4. • 3. Post-hepatic Jaundice- it is an obstructive
form of jaundice. In biliary obstruction,
conjugated bilirubin in the bile does not reach
the intestine, so the stool are pale. Conjugated
bilirubin is soluble and filtered by the kidney,
so the urine is dark brown.
Obstructive jaundice may be accomplished by
pruritus (Due to skin deposition of bile salt).
Obstructive jaundice with abdominal pain is
Gallstones. ( Note: Obstructive jaundice +
Abdominal pain which is a right hypochondric
pain + fever or rigor= Charcot triad)

5. Cyanosis
• This is the dusky blue discolouration of the skin and mucus membrane.
• It occurs when the absolute concentration of deoxygenated Hb is > 50g/L
of Hb .
• It corresponds to an arterial O2 saturation of <90% and usually indicates
underlying Cardiac or Pulmonary disease.
• Cyanosis could either be:
Central Cyanosis- seen at the lips, gum and tongue.
Lung Dz- with inadequate oxygen transfer eg luminal obstuction, asthma,
COPD, Pneumonia, PE, Pulmonary Oedema- may be corrected by increasing
inspired O2
Cyanotic Congenital Heart Dz- where there is admixture, eg transposition of
the Great Arteries or Rt to Lt Shunt (eg VSD with Eisenmengers Syndrome.)-is
not reversed by increasing inspired O2
Peripheral Cyanosis- seen in the hands, feet or ears.
It also occurs in causes of central cyanosis.
It occurs in the cold, hypovolaemic shock, Heart failure, peripheral vascular
and venous obstruction.

6. Anaemia
• Anaemia- is described as a low level of Hb.
• It has normal ranges-Men=13.5g/dl and Women =11.5g/dl
• Types of Anaemia:
1. Microcytic (MCV<80fl)
. Chronic blood loss . Thalassaemia
. Iron deficiency . Sideroblastic aneamia
2. Macrocytic (MCV>80fl)
. Megalobastic marrow . Haemolytic disorders
.Vit B12 Def . Liver Dz
. Folate Def .Hypothyroidism
.Excess Alcohol .Aplastic Anaemic
3. Normocytic (MCV=80-96fl)
. Acute blood loss . Connective Ts Disorders
.Anemia of Chronic Dz . Marrow infliltration
.Chronic renal failure
. Chronic Dz

7. CLUBBING
• Clubbing of the fingernail (+/- toenail)is the increase
curvature in all directions and loss if the angle between nail
and the nail fold. The nail fold feels boggy. Majority of pt
have thoracic dz but also gastrointestinal and familial dzs
Thoracic Coz
Tumours : Benings or Malignant
Lung cancers, Tb Chronic lung suppuration (empyema,abscess,
bronchiectasis, Cystic fibrosis)
GI Coz
Inflammatory bowel dz(esplly Crohn’s dz), Cirrhosis, GI
Lymhomas and Malabsorption eg Coeliac dz.
CVS Coz
Cyanotic Congenital Heart Dz, Endocarditis , Aneurysms

8. OEDEMA
• Oedema is the excess fliud in the intestinal space, and in
the peripheral sites which causes tissues to swell.
PATHOPHYSIOLOGY OF OEDEMA.
The movement of fluid bt the intravascular and extravascular
space occurs through the walls of the capillaries.
The efflux of fluid across the capillary wall is governed mainly
by the hydrostatic pressure transmitted by the arterial blood
pressure through the precapillary arteriole and also by the
capillary permeability and the opposing osmotic(Oncotic) pr
through the serum proteins (esplly Albumin)

9. Cont’
• In addition, the oncotic pr of the interstitial fluid may
contribute to the efflux of the intravascular fluid.
• The reabsorption of interstitial fluid is driven primarily by
1. the plasma oncotic pr,
2. the hydrostatic pr in the interstitial space(known as the
tissue pr) and
3. the fall in the hydrostatic pr at the venular end of the
capillary.
These forces (known as the Sterling forces) determine the
movement of fluid and electrolytes between the intravascular
and interstitial compartments.
Therefore, any imbalance of the sterling forces will cause
expansion of the interstitial space.

10. Oedema in Heart Failure
• In heart failure, there is increase in Central venous Pr which
causes increase capillary pr. This reduces reabsorption and
leads to oedema.
• Renal hypoperfusion also stimulates the Renin-angiotensin
system which in turns, causes inappropriate sodium and
water retention and further contributes to oedema.
• When serum albumin falls there is a loss of plasma oncotic
pr. This favours the mvt of fluids into the interstitial space.
The consequent fall in the intravascular vol. causes
activation of the renin-angiotensin system which adds
further fluid retention and oedema.

11. Oedema in Liver Disease
• In Liver Dz complicated by Portal Hypertension,
there is pooling of blood in the splanchnic bed
with increased splanchnic capillary pr.
• The pooling result in a fall in the effective
intravascular volume which in turn, activates the
renin-angiotensin system. These factors all
contribute to the fluid retention that complicates
portal hypertension.
• Ascites complicating portal hypertension usually
only develops when there is hypoalbuminemia
and a fall in oncotic pressure.

12. Causes of Oedema
Unilateral
.Deep vein thrombosis .Trauma
.Soft tissue infection . Lymphatic obstructions
Bilateral
Heart Failure Immobility
Thiamine Deficiency (Wet beriberi)
Drugs like NSAIDS, Nifedipine, Amlodipine
Hypoproteinemia eg Liver cirrhosis, Kwashiorkor
nephrotic syndrome

13. LYMPHATIC SYSTEM
• The lymphatic system comprises the
Lymphatic ducts, lymph nodes, spleen, tonsils, adenoid and thymus
gland.
Note the lymphoid tissue is also present the Peyer’s patches of the
terminal ileum.
A network of lymphatic ducts accompany the blood vessels; these
lymphatic transport lymph from the interstitial tissues to the lymph
nodes.
Lymphatic vessels drain distinct regions of the body into group of
regional lymph nodes
Functions of LYMPHATIC SYSTEM
1. Drains the interstitial space
2. Antigen presentation and lymphocytes activation
3. Antibody producing and phagocytosis
4. Pathway for the absorption of chylomicrons from enterocytes

14. Lymphadenopathy
• Lymphadenopathy is any cause of lymphatic flow.
• In the case of infection may be caused by
proliferation of cells in response to antigen
challenge. Abnormal cells may populate the
nodes.
• Causes
Infections like HIV and TB
Obstruction as in Filarial worms
Cancer as in Breast Ca.