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. 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
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5. Ulcers associated with burns
Curling s ulcer – gastric ulcer that is
associated with burns.
Marjolin s ulcer – highly malignant
squamous cell CA.
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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. Pathophysiology
Ectopic pregnancies are primarily due to
prior tubal/genital infection or surgery,
fallopian anatomic abnormalities, or
endometrial abnormalities.
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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.
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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.
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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.
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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