Nir Hus MD, PhD., Absite review q12

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Slides with topics that are covered and were tested in the recent Absite exams.
Nir Hus MD., PhD.
http://www.nirhus.com

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Nir Hus MD, PhD., Absite review q12

  1. 1. Absite Topic ReviewGeneral SurgeryNir Hus, MD, PhD.Mount Sinai Medical CenterMiami Beach
  2. 2. Topics  1) Rx Postop Parotitis.  2) Rx Non-healing burn wound.  3) Dx Ruptured tubal pregnancy. Nir Hus
  3. 3. Parotitis  Can occur in the surgical patient and identified during the postoperative period.   Particularly in elderly   Dehydrated individuals.  Therapy should be directed toward   Rehydration   Enhancing salivation   Ensuring that no mechanical obstruction of the duct of Stensen is present   Obtaining stains and cultures   Administering antibiotics directed against S. aureus, which is the most common offending organism.   In ICU patients who are often colonized with gram-negative bacteria, the possibility of gram-negative bacterial parotitis should be considered and appropriate empiric therapy used.   I&D Nir Hus
  4. 4. Rx Non-healing burn wound.  Q:30 y.o veteran suffered a burn wound to arm 2nd or 3rd degree over one year ago and the wound is ulcerated. What to do next.  A: Marjolin’s tumor – need Bx Nir Hus
  5. 5. Ulcers associated with burns  Curling s ulcer – gastric ulcer that is associated with burns.  Marjolin s ulcer – highly malignant squamous cell CA. Nir Hus
  6. 6. Dx Ruptured tubal pregnancy  An ectopic pregnancy occurs when a fertilized ovum implants at a site other than the endometrial lining of the uterus.  Ectopic pregnancies occur in the fallopian tube in 97% of cases, with 55% in the ampulla; 25% in the isthmus; 17% in the fimbria; and 3% of cases within the abdomen, ovary, and cervix. Nir Hus
  7. 7. Pathophysiology  Ectopic pregnancies are primarily due to prior tubal/genital infection or surgery, fallopian anatomic abnormalities, or endometrial abnormalities. Nir Hus
  8. 8.   Physical: Physical examination is unreliable for clinicians who face this significant diagnostic challenge. Abbott et al and Stovall et al reported an alarming rate of missed and/or delayed diagnoses in the ED. Although findings at physical examination may be variable, they may include the following:   Vaginal bleeding may be mild or absent. Abdominal pain may be minimal or severe.   Shoulder pain is suggestive of peritoneal free fluid (significant hemorrhage).   Ectopic pregnancies can be accompanied by sloughing material, which is suggestive of a miscarriage.   Adnexal masses may be palpable in only 60% of patients (under anesthesia).   Tenesmus or syncope may occur.   Clinical shock may occur after rupture.   No combination of physical findings may reliably exclude the diagnosis of ectopic pregnancy. Nir Hus
  9. 9. Lab Studies:  Human chorionic gonadotropin (HCG) levels.   The discriminatory zone of beta-HCG levels is the level above which a normal intrauterine pregnancy reliably is visualized.  The absence of an intrauterine pregnancy when the HCG level is above the level in the discriminatory zone represents an ectopic pregnancy or a recent abortion.  Serial blood cell counts should be determined to quantify blood loss. Nir Hus
  10. 10. Imaging  A definite ectopic pregnancy is characterized by the presence of a thick, brightly echogenic, ringlike structure outside the uterus, with a gestational sac containing an obvious fetal pole, yolk sac, or both.  Pregnancy of unknown location occurs with an empty uterus on endovaginal sonograms in patients with serum beta-HCG levels greater than the discriminatory cutoff value. In this case, an ectopic pregnancy is considered present until proven otherwise. An empty uterus may also represent a recent abortion.  Other ultrasonographic findings include an adnexal mass, free cul- de-sac fluid, and/or severe adnexal tenderness upon palpation with the probe. Patients with no definite intrauterine pregnancy and the aforementioned findings are thought to have a high risk for ectopic pregnancy. Nir Hus
  11. 11. Tx  Laparotomy is required for ovarian, abdominal, and intraligamentous pregnancy.  Careful curettage, packing of the cervix and uterine cavity, possible hysterectomy may be required for a cervical pregnancy.  An unruptured tubal pregnancy of less than 4 mm in diameter may be treated by salpingostomy by means of laparoscopy. Nir Hus

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