neck lump

Describe the lump and give your differential diagnosis 

CYST

lalala... finally i've time to do some notes ..

Cyst is defined as:

Pathological cavity

- unlike anatomical cavity

- disease entity

Content of cyst

- filled by varieties material

(keratin, fluid, gases)

Lined by

- epithelium

- absent epithelium!! /pseudo

Question of pus??

- no pus!!

- except secondary to infection

case study 3

Ms Lee, a 49 year old unmarried Chinese lady came to the hospital with complaint of painless lump at the left breast for 4 months prior to admission. On examination there was a single lump at the lower inner quadrant of the left breast.

what's your differential diagnosis??

what investigations you want to do for this patient and how would you manage her?

management of breast symptoms

 

In any patient who present with breast lump or other symptoms suspicious of carcinoma, the diagnosis should be made by a combination of clinical assessment, radiological imaging and a tissue cytological or histological analysis the so called triple assessment.

starting with the clinical, lets imagine that a patient come to our clinic for the first time, so we take a proper history and do physical examination to reach our diagnosis. 

Then we can proceed with the imaging which are ultrasound and mammography but we must first know what are the indication for the patient. Ultrasound is suitable for women <35 years old because the breast tissue is dense and can distinguish cystic from solid lump. Compared to mammogram, it is for women >35 years old and routinely done in 2 views : cranio-caudal ( CC ) and mediolateral oblique view ( MLO ). 

ultrasound of breast

Mammogram.cranio-caudal view (CC) and the mediolateral oblique view, which is taken from an oblique or angled view

CC position

MLO position

 Next is pathology. We can do either fine needle aspiration or core cut needle ( Tru cut ) biopsy.Histology can be obtained under local anaesthesia using a spring-loaded core needle biopsy device. Cytology is obtained using a 21G or 23G needle and 10 ml syringe with multiple passess through the lump with negative pressure in the syringe. The aspirate is then smeared on to a slide, which is air dried or fixed. FNAC is least invasive technique of obtaining a cell diagnosis. 

CORECUT BIOPSY

FNAC

NG tube

 From it word, nasogastric tube means that this special tube is inserted to the nose until it reach the stomach. It is usually has different sizes . 

What is the indication of inserting nasogastric tube?

• feeding for example in a case of dysphagia due to esophageal ca
• gastric aspiration which we can use to analyze the pH of the stomach
• stomach decompression in a case of intestinal obstruction
• use in unconscious patient esp to prevent aspiration pneumonia
• to make the bowel become inactive as the preparation for surgery

How long should we insert it? 

• there is a scale on the tube which guide us to measure tubing : from the bridge of nose to the earlobe until to the point halfway between the end of the sternum and the navel

STEPS

Wear a gloves

Patient should be in a sitting or 45 degree position. 

Once we had note the distance of it, put the lubricant gel and insert the tube to the nose. Please check first is there any nasal obstruction so that we can avoid from put it from there because we are actually causing trauma to the nasal part. 

Then we insert it to the posterior pharyngeal wall then continue until the patient will have a gag reflex . Ask the patient to swallow so that it would not enter the trachea. Finally u aspirate a sample of gastric contents. 

Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6

Secure tube with tape

Look for colour,nature and amount of the gastric contents

**In a unconscious patient, we use laryngoscope as an aid during the procedure and confirm the position of the tube by inject air and auscultate for air entry. Then do the x-ray.

Complications

• perforation of stomach
• aspiration pneumonia
• trauma
• pain
• loss of electrolytes
• oesophagitis
• necrosis