There is a critical skill station.
As I said, we're rushing through a few of
these things, just to make sure that you get
an idea of what to revise afterwards.
The last bit of the presentation is on --
Okay we'll quickly go through this, clearly.
This is just to, in short giving
you a scenario in detail, I’m just going
to look at this and ask you what it is?
What's the diagnosis? Lipoma. Yeah, that's
what you’re looking for.
Yeah, yes it's probably most likely to
be a lipoma. What could be the differentials?
What else can it be?
Sebaceous cyst. So anything else? It could
be a fibroma or an osteoma. It's quite unlikely.
Lipoma, sebaceous cyst is fine. Then, management.
If at all you are asked in the exam, patient
comes with a lipoma. Management. Management
depends on what the patient wants. And is
the patient symptomatic or asymptomatic? If
the patient is asymptomatic, wait and watch.
No treatment. The patient is symptomatic,
offer surgery under local anaesthetic, and
excise it. Make an incision on the lesion,
take the lipoma out. So that's all you need
to know for the exam.
Okay another diagnosis. Similar scenario.
44 year old man, with a lump over
his left shoulder.
Lipoma, sebaceous cyst.
Lipoma, sebaceous cyst.
Myofibroma, no. Something more important
they're asking for the exam. A big lump, big
soft tissue lump in a person. Sarcoma.
So what sort of sarcoma?
This could be a liposarcoma. Any lump more
than five centimetres, it should be considered
as a sarcoma. How do you manage if at all
you are given a clinical scenario, not
an image but with a scenario saying this
patient has got a 8cm lump, what is your
most appropriate investigation?
First one? Before MRI?
X-ray won’t show. What will an x-ray show?
Ultrasound. Always go for a non-invasive and
the next is invasive. For the purpose of your
exam, anything abdomen, go for ultrasound
first and then go for CT. Soft tissue, joints,
hip, knee, go for ultrasound. Hip, knee, shoulder
and toes or something for ultrasound?
So for soft tissues, if they offer you two choices,
ultrasound or MRI, which would you go first?
Most appropriate statement will be ultrasound.
Ultrasound. Then, the best would be a MRI.
MRI, yes. What would be the best
That pretty much applies to your entire exam.
What they're asking you is if you have a choice,
if you have all the investigations in this
room, the patient is here, what do you do?
MRI. But what is realistic, what do you really
do it in your clinical practice? Ultrasound.
So they're saying, best is MRI. What do you
do is ultrasound. Don’t go for CT. Any
soft tissue, always
go for MR. Okay, as ultrasound, MRI and the
management depends on the above.
So sarcoma. Why do you have to do MRI? Why MRI?
Why not ultrasound?
It’s to see how much is infiltrated. Yeah, if it
has gone under the trapezius muscle,
because you just can't excise it.
So that's why you need to do an MR scan.
Multiple painful lipomas. What's
the diagnosis? Neurofibromatosis? No, no.
There's a name for this condition.
Dercum’s disease. Multiple painful lipomas.
So you get patients, in a scenario, they'll
give you patient presenting with a painful
lipoma. Either they'll ask you the direct
diagnosis or management. Management is similar
to a lipoma, you excise only those which are painful,
very similar to a neurofibroma. Neurofibroma, you
can't cut out everything. You just excise
those which are symptomatic.
In this scenario, I will skip the questions.
What do you think diagnosis is?
Could be a lipoma? Could be a lipoma. No, okay.
Let's say this
patient has come to you, or in the exam situation,
you're given a scenario, lump over the lateral
canthus of the eye. And it's present since
birth. They've given 2 clues, present since
birth, on lateral canthus of the eye. Now
let's say you saw in the medial glabellar
region. What's in the mid-line structure?
What’s the lump? Classical scene.
Dermoid? Dermoid cyst, yes.
So these are the questions
you need to ask, most likely the diagnosis
A dermoid cyst normally arises at the sites
of embryological fusion. So either the
midline or wherever there are sites of embryological
fusion like the lateral canthus. Lateral canthus,
the pretty much whole of the midline, yes, near the
mastoid process. Yeah yeah. I think that's all, mainly.
Management again depends
on, you'll have to do an ultrasound, plus a CT/MR.
Why do you have to do an MR or a CT for this?
To determine if it’s actually cyst?
No, even before that. Intracranial extension.
Because it is a congenital thing, it can be
coming from inside the brain. So you need
a rule out intracranial extension by doing
a CT or an MR. Probably CT in this because you're
going into the skull.
Types of dermoid? Congenital and acquired.
Where do you get acquired dermoid or who gets
it? Classically? Hair-dressers, between the
cleft of fingers, the hair going in and it's
called the inclusion dermoid. When the epidermis
is pushed into the skin, into the skin, and
then you develop a dermoid cyst. So that's
called an inclusion dermoid or an epidermoid
cyst. Is that called pilonidal?
Similar to that, yeah. Pilonidal is also very,
very similar to a dermoid. But it's not classified
as a dermoid though. Pilonidal you really
don’t have a clear definition, but you're
right, it is very similar to pilonidal.
If it is congenital, they arise in the sites
of embryological fusion. If it is acquired,
it can happen anywhere.
Principles of management. If they're asking,
in the exam the most appropriate investigation
here, you can say ultrasound, because if the
ultrasound, says that it's a dermoid and its
outside the cranium, then you do not need any
further investigation. Only if the ultrasound
is ambiguous or says well it may be going in,
then you go for the MR scan. You know even
in your exam, always think of ultrasound as
your first investigation because that's what
we do. How many times will you get an MRI
done within two days? It's very, very rare,
isn't it? Ultrasound. You have the patients
waiting there, send them for an ultrasound.
You have diagnosis within half an hour. And
then you have something to discuss. How long
does an outpatient ultrasound take?
Well, actual time yes, it only takes.
But waiting hour we say, it takes a little longer than that.
Okay. If you're given a scenario like this,
what do you think it is? Here. Ganglion.
What you don’t want to miss? What's the
structure there? Radial artery. So if you
have a radial artery, either radial artery aneurysm or a
pseudoaneurysm. So whenever they give anything
related to a blood vessel, intravenous
drug abuser, or even a normal person, anything
related to a vessel, always think of aneurysm.
Pseudoaneurysm. So they could have damaged
their artery and lead to a pseudoaneurysm.
Why do you think it's not a ganglion? It's
quite far away from the joint.
Plus it’s on the extensor surfaces. You can
get it at the flexor surface as well,
but it has to be quite close to the joint,
as you see here, this one. That's a ganglion.
There's a classical history they'll give you in the
exam. And they usually say it's transilluminant,
it's more of a spherical swelling, cystic
and it is not attached to the skin. If they
say attached to the skin, what is your first
diagnosis? Sebaceous cyst. If they say something
lump is attached to the skin, they may give
a punctum, but otherwise they'll say it's
just attached to the skin, always think of
sebaceous cyst. Okay.
If it is not attached to the skin, you can
think of a lipoma, or a ganglion. Ganglion is
always next to the joint. Dorsal wrist
ganglion. So that is a ganglion, it's
a cystic swelling arising in relation to the
tendons of joint. They're not cysts because
they are not lined by any epithelium.
So that's the ganglion coming out of the joint.
Management of a ganglion. What are the things
you can think of? How do you manage a ganglion?
Conservative. Before, hit it with a book.
It was hitting with a Bible.
Yeah, that's probably because Bible was the only book
available. Anything else, apart from hitting
with the Bible? That won’t be option in your
option in the exam! It would be too politically
incorrect. Anything else you can think of?
Excision is one. You can aspirate. You can
aspirate and inject steroid. Wait and watch,
like that. You can aspirate the ganglion and
inject the steroids into it. Surgical excision
is the preferred option. What's the biggest
problem with any of these? Recurrence. Huge
chance, about forty percent, is it? Fifty
percent. With aspirations, it's about fifty
percent; with surgery, it's about forty percent
recurrence. So you got a fair
idea about sebaceous cyst,
ganglion, lipoma and dermoid cyst. These are
things which come up.
What is this diagnosis? Incisional hernia,
very good. Incisional hernia. How do
you confirm the diagnosis? Cough? What did
you say? Clinical examination and one simple
test you can ask him to do? Lift the head
up and flex the hip as well. So that's your
incisional hernia. That's fine. I'll quickly
go through this.
Hang on a minute. Hang on a minute. I'm sorry,
I shouldn't have said to you that. This is an
incisional hernia. Hernia, always cough
impulse. If it's a divarication of the rectii,
that's why we said, lifting the head up and
flexing the hip. That's the next patient.
That's the next patient. So that is divarication
of the rectii and this is what protrudes when
we flex the neck and flex the hip.
Any hernia is cough impulse.
Lifting head and flexing the hip simultaneously.