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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  • http://www.rad.washington.edu/mskbook/facialfx.html
  • Nir Hus MD, PhD., Absite review q12

    1. 1. Absite Topic Review General Surgery Nir Hus, MD, PhD. Mount Sinai Medical Center Miami Beach
    2. 2. Topics <ul><li>1) Rx Postop Parotitis. </li></ul><ul><li>2) Rx Non-healing burn wound. </li></ul><ul><li>3) Dx Ruptured tubal pregnancy. </li></ul>Nir Hus
    3. 3. Parotitis <ul><li>Can occur in the surgical patient and identified during the postoperative period. </li></ul><ul><ul><li>Particularly in elderly </li></ul></ul><ul><ul><li>Dehydrated individuals. </li></ul></ul><ul><li>Therapy should be directed toward </li></ul><ul><ul><li>Rehydration </li></ul></ul><ul><ul><li>Enhancing salivation </li></ul></ul><ul><ul><li>Ensuring that no mechanical obstruction of the duct of Stensen is present </li></ul></ul><ul><ul><li>Obtaining stains and cultures </li></ul></ul><ul><ul><li>Administering antibiotics directed against S. aureus, which is the most common offending organism. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>I&D </li></ul></ul>Nir Hus
    4. 4. Rx Non-healing burn wound. <ul><li>Q: 30 y.o veteran suffered a burn wound to arm 2 nd or 3 rd degree over one year ago and the wound is ulcerated. What to do next. </li></ul><ul><ul><li>A: Marjolin ’s tumor – need Bx </li></ul></ul>Nir Hus
    5. 5. Ulcers associated with burns <ul><li>Curling ’s ulcer – gastric ulcer that is associated with burns. </li></ul><ul><li>Marjolin ’s ulcer – highly malignant squamous cell CA. </li></ul>Nir Hus
    6. 6. Dx Ruptured tubal pregnancy <ul><li>An ectopic pregnancy occurs when a fertilized ovum implants at a site other than the endometrial lining of the uterus. </li></ul><ul><li>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. </li></ul>Nir Hus
    7. 7. Pathophysiology <ul><li>Ectopic pregnancies are primarily due to prior tubal/genital infection or surgery, fallopian anatomic abnormalities, or endometrial abnormalities. </li></ul>Nir Hus
    8. 8. <ul><li>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: </li></ul><ul><ul><li>Vaginal bleeding may be mild or absent. Abdominal pain may be minimal or severe. </li></ul></ul><ul><ul><li>Shoulder pain is suggestive of peritoneal free fluid (significant hemorrhage). </li></ul></ul><ul><ul><li>Ectopic pregnancies can be accompanied by sloughing material, which is suggestive of a miscarriage. </li></ul></ul><ul><ul><li>Adnexal masses may be palpable in only 60% of patients (under anesthesia). </li></ul></ul><ul><ul><li>Tenesmus or syncope may occur. </li></ul></ul><ul><ul><li>Clinical shock may occur after rupture. </li></ul></ul><ul><ul><li>No combination of physical findings may reliably exclude the diagnosis of ectopic pregnancy. </li></ul></ul>Nir Hus
    9. 9. Lab Studies: <ul><li>Human chorionic gonadotropin (HCG) levels. </li></ul><ul><ul><li>The discriminatory zone of beta-HCG levels is the level above which a normal intrauterine pregnancy reliably is visualized. </li></ul></ul><ul><li>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. </li></ul><ul><li>Serial blood cell counts should be determined to quantify blood loss. </li></ul>Nir Hus
    10. 10. Imaging <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>Nir Hus
    11. 11. Tx <ul><li>Laparotomy is required for ovarian, abdominal, and intraligamentous pregnancy. </li></ul><ul><li>Careful curettage, packing of the cervix and uterine cavity, possible hysterectomy may be required for a cervical pregnancy. </li></ul><ul><li>An unruptured tubal pregnancy of less than 4 mm in diameter may be treated by salpingostomy by means of laparoscopy. </li></ul>Nir Hus

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