Patients name
Age and sex
Address
Family History Personal History ( DM,H/O RA , H/O TB)
A.Introduction
Hi, I am Dr. Tanvir Rahaman
Could I have a look at the place please.
Do you mind If I talk to my examiners while I examine you.
Ok, Fine.
Now tell me,
1. How long are you having it?
2. How did it start?
3. Is it enlarging? How fast?
4. Is it tender at all?
5. Is it associated with (fever, malaise, cough, chest pain, Bone Pain)?
6. Are you Diabetic/ Having any H/O TB/RA?
7. Are you loosing your weight?
8. Does any body of your family have it?
9. Does it cause any Problem ( Breathlessness/Painful deglutition/ Discharge) for you?
10. Does it even go back?
Points | General Findings | Branchial Cyst | Pharyngeal Pouch | Cystic Hygroma | Lymphadeno Pathy | Lymphoma | lipoma | |
Age | Appears at birth evident(15-25) years | 40-60 years | Mid-old | Appears at birth Regress by age of 4 | Child –young- Lymphadeno Reactive Young- TB Adult- Mets ( Lip, Tongue m/m larynx) | |||
C/C | Disfigurement Painless swelling | TIA | Halitosis H/O Sore throat Regurgitation Nocturnal Chock Dysphagia wt loss Aspiration - Pneumonia | Disfugurement Painless swelling | Sore tongue hoarseness cough smike tramp addist HIV Immunizes/ Prev/Family H/O Weight loss | Fever Bone pain Pruritus Night sweat | ||
1.Number Uni/Bi | Multiple –Neurofibromatosis Diphyseal Swelling ( Multiple) Dercum;s Disease | Single Diffuse (Neck shonlder) Multiple-Dercum’s | ||||||
2. Site | Lower 1/3rd of SCM | @ Hyoid | Behind SCM( below Thyroid Cartilage) | Post triangle @ Neck Base | 1.superficial (Along ant. Bord of SCM) *upp-Above Hyoid *Mid- larynx Trachea *Supraclav-abd Thoracic vis 2. Deep Cx (Post lviangle) Reactive TB Tonsillitis Glanduler fever toxoplasmosis Sarcoidosis) | Posr. Triangle (Other then Reactive) | Diffuse- Neck Shoulder Back Buttock Promineat-S/C Disappears intramuscular | |
3.Size | 5-10 cm | 2-10 cm | 5cm rarely > 10 cm | 10 cm | Descrcte-1-2 cm Caseated-larger | |||
4.shape | ovoid/Spherical | Round | indistinct | lobulated | innegular | |||
5.Surface Cauliflower-S.C.C Branched-Papilloma | Smooth | Smooth | Indidstinct | Descrete /Matted |
6.Edge | Distirct | Indistirct | Indistirct | Indistirct | ||||
7.Overlying skin Color Red- Arlerial Haemangioma Purple-V.Haemangioma Blue-Ranula Black-Melanoma Tebse-glossy-verins Prominece-Sarcoma | ||||||||
8.Axis | ||||||||
9.Temp | ||||||||
10.Movenut Visible Peris-CHPS Pulsation Deglutition-Thyoid Thyroglossal cyst Subhtyoid Bursitis Pre/ Paratracheal L.N Potrusion of tongue -TGC Cough Resp-Liver,spleen, sp.fiexors, Trans colon |
Ok, On Inspection-there is 1. A lump 2.over ant. Triangle of Neck @. the level of lower third of ant.bord of SCM which is 3. Nontender 4.measuring roughly about 2x2 cm in dia, 5. Spherical in shape, 6. Surface is smooth and 7. Distinct edge, directing8. downward and forward 9. does not move with cough/ deglutation and not pulsatile/No visible pulsation seen and 10. overlying skin is normal apparently.
Now I want to palpate the swelling. Can I toucj it? If it hurts you at all please let me know and I will just stop it.
Ok, Fine.
General finding | Brancheal cyst | Carotid body Tumor | Pharyngeal ponch | Cystic Hygroma | Lymphadeno –pathy | Lympoma | lipoma | |
Temp | ||||||||
Size | ||||||||
Movement | ||||||||
Impulse | (touching in bet fingers) caugh/crying impluse | |||||||
Edge (By finger tips) | Smooth-cyst(yield ing bet fingers) Begins lesion (sleeps away) Well diff- ch. Inf. Mitotic | |||||||
consistency | Hard | Hard | soft | soft | Hard | soft | ||
Flactualion | + | + | ||||||
pulsatality | Transmitled (2 fingers raised only/ Goes back in knee-elbow position) Expansile(raised and separated) arterial origin | + |
Auscultation (all Pulsatile) | Bruit Mechanical Murmur (aneurismal varix) | Bruit(20% Cases) | ||||||
Overlying Skin | Move over the lesion Pinch at different sites All lesion originated from skin moves freely except epithelioma | |||||||
Underlying Structure | Fixed | Fixed ( apparently behind trachea but actually from pharynx | fixed | |||||
Lymph node |
(D)
Movement of adjacent Free from overlying and underlying structure-S/C
Joints: less freely mobile – fixed to deep fascia.
Fixed to underlying structure
(when muscle is taut)- below deep fascia.
If Prominent on cont-S/C
Diminished on cont – muscle origin
Disappears on cont –deep to muscle
Evident only on cont –muscle/tender tcar
Absolutely fixed when relaxed- Bony origin
(E)
Pressure.
· Distal arterial pulse
· Nerve entrapment
· Bone erosion ( Dermoid aneurysm)
It is about (1) 2-3 cm in dia (2) moves side to side but not along the axis (3) Soft in consistency (4) Non pulsatile (5) Non fiactuating (6) Non reducible (7) Non compressible (8) Non transilluminating ( and fluid thrill is absent) (9) Free from overlying skin and (10) not fixed to underlying structure.
Its dull on Percussion and no bruit/Murmnr auscultated
Now I want to examine the regional Lymphnodes, adjucent structures/ for any pressure effect and joint involvement
F. Conclusion
My provisional Diagnosis is branchial cyst and my D/Ds are
Lymphadenopathy
Carotid body tumor
Lipoma
I want to have following investigations to reach a confirmatory diagnosis.
Thank you. You were very fine and co-operative.
| Others | | Dimple along ant border (fistula/sinus) | | Empties on pressure and remains until taking food | | | |
| Investigations | | CBC CT | DSA (Splaying of bifurcate on & contrast filling small vessels, collateral is | CXR Va. Swallow Careful endoscopy | | Full E.N.T CXR CT | CBC- B/M CXR CT |
| Rx Protocol | | I/D fld by antibiotic And then elective excision | | | Wait till age of 4>4- excision | If primary found> enblok Dissection If no Prim> excision n biopsy if mitotic> curat ive enbd | CHOP |
| Advice | | | | | | Wait till age of 4 | |
Provisional Diagnosis:
Plan:
Advice:
Follow-up:
Dr. Tanvir Rahman
MBBS (SSMC), MS ( Cardiothoracic surgery) – Part2
MRCS (Edinburgh)- Part-B
MRCS(England)- Final Part
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