How to write the diagnosis for left left scrotal hydrocele
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I now have enough information from the textbooks to provide a thorough answer. Here is a complete guide on how to write the diagnosis for a left scrotal hydrocele:
Writing the Diagnosis for Left Scrotal Hydrocele
1. Formal Clinical/Written Diagnosis
The correct way to write the diagnosis depends on the type and context:
| Setting | How to Write It |
|---|---|
| Short surgical/clinical note | Left scrotal hydrocele |
| Formal long case write-up | Primary left scrotal hydrocele OR Secondary left scrotal hydrocele |
| ICD-10 coding | N43.2 (Other hydrocele) |
| Operative/procedure note | Preoperative Diagnosis: Left hydrocele; Postoperative Diagnosis: Left hydrocele |
2. Full Clinical Write-Up Structure (Long Case)
When writing a complete diagnosis in a clinical or surgical case format, you should include these elements:
Provisional / Final Diagnosis:
Left primary (idiopathic) scrotal hydrocele - or, if cause is known: Left secondary scrotal hydrocele secondary to [cause e.g., epididymo-orchitis / filariasis / testicular tumor]
Supporting the diagnosis - the features you document:
a) Clinical features supporting hydrocele:
- Painless swelling of the left scrotum
- Able to "get above the swelling" (meaning you can feel above it in the inguinal region - confirming it is scrotal, not inguinal/descending hernia)
- Fluctuation test: positive
- Translucency test: positive (red glow transmitted - the hallmark of hydrocele)
- Testis impalpable separately within the swelling (in primary hydrocele the fluid surrounds the testis)
- Dull on percussion (differentiates from hernia, which is resonant due to bowel)
- Skin: normal color and temperature
b) Type of hydrocele (specify in diagnosis):
| Type | Key Feature | Write as |
|---|---|---|
| Primary (idiopathic) | No underlying cause; middle-aged men; tense | "Left primary scrotal hydrocele" |
| Secondary | Small, lax; secondary to infection/tumor | "Left secondary scrotal hydrocele secondary to..." |
| Congenital | Reduces when lying down, returns on standing; patent processus vaginalis | "Left congenital communicating hydrocele" |
| Infantile | Entire tunica + processus patent; does not communicate with peritoneum | "Left infantile hydrocele" |
| Encysted hydrocele of cord | Separate from testis; moves with cord | "Left encysted hydrocele of the cord" |
3. Differential Diagnoses to Mention (when writing a case)
Per S Das - A Manual on Clinical Surgery, you should always note you have excluded:
- Inguinal hernia (resonant, reducible, bowel sounds)
- Haematocele (fluctuant but not translucent)
- Spermatocele (testis palpable separately; fluid is milky)
- Epididymal cyst (separate from testis; clear fluid)
- Testicular tumor (heavy testis, loss of testicular sensation, not translucent) - excluded with ultrasound
4. Investigations to Write in Support of Diagnosis
- Ultrasound scrotum - confirms fluid around testis, excludes malignancy (Bailey & Love)
- Aspiration (if done): amber fluid, specific gravity 1.022-1.024, contains cholesterol and 6% albumin - supports hydrocele (S Das)
5. ICD-10 Codes
| Code | Description |
|---|---|
| N43.0 | Encysted hydrocele |
| N43.1 | Infected hydrocele |
| N43.2 | Other hydrocele (most used for left scrotal hydrocele) |
| N43.3 | Hydrocele, unspecified |
For a left scrotal hydrocele without specification of type, use N43.2 (Other hydrocele). For a communicating/congenital type in a child, use N43.0.
Summary: The One-Line Diagnosis
"Left primary scrotal hydrocele" (if idiopathic) "Left secondary scrotal hydrocele secondary to [cause]" (if a cause is identified)
The diagnosis is confirmed clinically by a positive translucency test and supported by scrotal ultrasound. - S Das: A Manual on Clinical Surgery, 13th Ed., p. 626-630; Bailey and Love's Short Practice of Surgery, 28th Ed., p. 952-1094
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