Spot Dx

Spot Diagnosis — Dr. Ahmed Khan

Name the clinical test? Diagnosis? Aetiology? — Cystic hygroma

Most common post triangle Tumor = cystic hygroma
Clinical test: transillumination
If infected, won’t transilluminate

Differential diagnosis? — Submandibular swelling

FB skin swelling – near the mandibular angle

Bilateral submandibular lymph node is submandibular gland:

Painful and malignant
If solid → lymph node
Cystic → Sublingual
What causes it to swell
The most anterior part of gland is palpable in the floor of gland
In parotid — Pleomorphic Tumor — usually more benign → superficial parotidectomy

Differential diagnosis? — Thyroid isthmus nodule

Thyroid isthmus nodule
Slowly, self, protruding on the tongue in swallowing. Normal thyroid. Tongue protrudes test
If both are negative most likely dermoid
Ttt: excision

Differential diagnosis? — Pendulous neck swelling

Pendulous

Causes:

Hypothyroidism
Weight loss
Hirsutism
Menorrhagia
Dry cold skin
D- constipated
By symptoms + signs and daily TSH = tx

Eye signs — Normal vs Lid retraction vs Exophthalmos

Diagram of the upper lid relations of the eyeball: Normal / Lid retraction / Exophthalmos

Diagnosis & Other eye signs? — Toxic goiter

Toxic goiter
In primary hyperthyroidism — mostly eye manifestation
In secondary — none
Eye: ecchymosis conjunctivitis, lid lag or retraction, exophthalmos

Differential diagnosis? — Left neck (posterior triangle) cervical lymph nodes

Left neck
Post triangle
Cervical lymph nodes
Pharyngeal pouches
Dermoid cysts in kids
Hx: fever, weight loss, hunger = TB
Exd: acid hiselosis then penetrating then matting
Ttt: ATD + excision biopsy
When it exceeds through fascia and skin → forms a collar-stud abscess and later a chronic sinus

Location? — Carotid body tumor

Blineath the sternodeidomastoid
Deep to SCM, upper anterior triangle

Carotid body Tumor

OK:
- Firm
- Pulsatile
(1) $∵ A D = B D = 1$ — Transmitted
Moves: horizontally / not vertically

Diagnosis?

If small and asymptomatic = leave it
If large compressing the vessels and might cause TIA = vascular surgery
US, Duplex, CT angiography

Differential diagnosis? — Parotid swelling

Glateral = mumps
Unilateral = parotid abscess
Early: firm, solid swelling
Late = fluctuation
Ask for US = how many ml of pus, size of the cavity
Effusion how to confirm? Intraoral examination of the duct/papila of the gland
Ask the pt to maintain oral hygiene

Immunocompromised or pt kept NPO for long time = ascending infection

Differential diagnosis? — Basal cell carcinoma

Basal cell carcinoma / rodendant cell

Roped edge
In the nose
Most common malignancy, rarely Meta but barrow adjacent structures
Tis: wide excision
Other (dix, sac, melanoma

Differential diagnosis? — Ganglion cyst

Ganglion cyst

How to confirm? Along the tendons
Sometimes communicate w joints
Ttt: aspirate w big needle as thick fluid
If recurrence or complicated we might excise it

Differential diagnosis? — Lipoma

Any soft tissue tumor, lipoma
By consistency
Ask for US
Confirmed by FNA
Ttt: excision

Differential diagnosis? — Neurofibromatosis

Neurofromatosis

Reassure the pt + give symptomatic ttt
As they are attached to the nerve, pt comes with pain + compression + cafe o late spots
Van Recklinghausen disease

Differential diagnosis? — Squamous cell carcinoma

Squamous cell carcinoma

Sun exposed area
Reverted edge
Less common than bcc but more aggressive
Mets through lymphatic, if did = very poor prognosis
Ttt: surgical excision + might give radiation

Differential diagnosis? — Hemangioma

Hemangioma

Involuting type, superficial, go by 7 yr, reassure + leave it
If complicated we treat + ILS (intralesional steroids. Photocoagulation

Differential diagnosis? — Gangrene (black spots)

How to confirm the Dx?
Black spots + pain + fever + systemic symptoms
He: any signs of hemorrhage or petechial hemorrhage (low platelet), OM, trauma
Investigations: fasting sugar, cbc, …
How to confirm? Exclude others by cbc, , and biopsy will show gangrenous cells

Differential diagnosis? — Incisional hernia

The swelling appeared after abdominal surgery
Incisions hernia
If you reduce it you will feel the defect
Investigations: defected abdominal wall
Tilt repair + mesh, if 3–4 cm we might suture only, unless pt is not fit for the surgery

Differential diagnosis? — Umbilical / periumbilical hernia

A partially reducible swelling
Complications
If from the center of umbilicus = umbilical
If around > periumbilical
Defect is smaller, more likely to have complications
This is most likely omentum only, confirm by palpation

Differential diagnosis? — Incisional / Epigastric hernia

Incisional hernia / Epigastric hernia
What kind of surgery was done?
Epigastric hernia — any hernia between xiphoid crescent + umbilicus, Detect in lines alba

Differential diagnosis? — Inguinoscrotal swelling

How to confirm Dx?
Inguinoscrotal swelling
Indirect hernia due to patent vaginas processes
Decreased in pit lying down
- hydrocele
TC herniotomy

Name the clinical test

Aetiology: Child / Adult
In adults it is inflammatory, in kids no, more benign

A groin swelling — Name the test?

Ring occlusion test, at the midinguinal point occlude the internal deep ring
Include their occlusion

Adults – mostly direct
Kids indirect
If butes Medial to my finger – direct

DIAGNOSIS & INDICATIONS? — Ileostomy

Bleostomy
Bulging + right side
Why bulge? Digestive enzymes irritate the skin
More likely to have electrolyte imbalance than colostomy
Sympatory (toop) or permanent (end)

DIAGNOSIS & INDICATIONS? — Loop colostomy

Loop colostomy
Complications: bleeding, edema, ischemia / necrosis, retraction, prolapse, parasitomal hernia, stenosis, and skin irritation.

Bleostomy as bulged

Name the procedure on left & its indications? — Hartmann

hartmann
Temporary but not a help, and! Exception
Reansistomose later

Laparotomy for acute abdomen — Causes? Treatment?

How to confirm? believe strangulation and check if color go back, or if bleeds/peristalsis = viable
Return or resection + anastomosis fix A Same operation or stoma + later anastomose

Laparotomy for acute abdomen

Small bowel echemia

Laparotomy for liver mass — Hydatid cyst

Terminal epithelium which grow to daughter cyst + laminated fibroses Wall — CT superior, US

Mydaloid cyst of liver
Vague pain
If bursts out = anaphylactic
If calcified + away from portal v we can leave it
Causative organism: Echromococcus granulosa
Tic lap cystectomy and if big we replace the part w omentum, + albendazole

15-year girl — abdominal pain, vomiting & abdominal mass

Microbiaceae (swallowed hair)
Pt w psychiatric problem, hairs caused obstruction. Titred was it + refer to psychiatry

Diagnosis and management? — Perforated PU

Perforated PU, anterior wall
If in post, go breeding
Laparotomy
Closed by graham patch (smentum)

Stitch gently or it will cut away + Guillotine effect 3-4 layers

Calot’s triangle — Why important?

Calot’s triangle
Anatomy needs to be preserved (delineated?) during cholecystectomy to prevent bile duct injury
Contains the cystic artery + cystic duct + lymph node of Lund

Abdominal pain — Laparoscopic appendectomy

Laparoscopic appendicitomy

Differential diagnosis? — Jaundice

Jaundice
Mostly obstructive jaundice as surgical
GGT + ALP
US + dilated CBC
Tilt depends on the cause

Differential diagnosis? — Erysipelas

Etiology
Non-necrotic
Aeribiotic + raise
Etiopyelas

Differential diagnosis? — Furuncle

Euroride
Tilt I D + abs

Inspection — Differential diagnosis? (red + inflamed swelling)

Red + inflamed = abscess + complicated hernia

Differential diagnosis? — Management (necrotizing infection)

Neo face
Involving the subcutaneous
Old age, immunocompromised
If involved the whole circumference $\geq$ risk of compartment syndrome so fasciotomy
Flt: urgent debridement + abx
Former = common in dm

Pain at IV site — Differential diagnosis?

Superficial thrombophlebitis, VTE
Ricks: hyperosmolar fluid, trauma, endothelial injury, placing it for too long = inflammation + extravasation of fluid
Cord like in palpation
Tlt: remove the carruza + place it somewhere else
Ddx: cellulitis - acute abscess, any inflammatory diseases, dermatological conditions

Post operative immobilized — Pain and swelling — Differential diagnosis?

Hammam test
Confirmed = Doyle’s
DVT — usually unilateral
Tlt: anticoagulation therapy. If not completely dissolve we put ivc filter to prevent PE
Best is prevention by pharma (tmsh) + non pharma (stocking - intermittent pneumatic compression device)

Inspection — Differential diagnosis? (varicose veins)

Vancose vein, if late < medial ulcer
Occupation, females, long standing jobs, congenital, familial
Initial stage: telangiectasia — less than 1mm —, spider nives — 3,4 mm —, huncial varicose
Duplex to see the flow, US
Incompetent sepharofemoral junction
Tlt: if initial = compression stocking - MIP laser ablation, Endovenous foam sclerotherapy
If toe big < surgery to ligate the junction = perforators