By Carel L. Davidson, Ivar A. Mjor, C. L. Davidson
Univ. of Amsterdam, The Netherlands. development within the formula and knowing of glass-ionomer cements and the efficacy of polyacid-modified resin fabrics. For medical and laboratory researchers. colour and halftone illustrations. DNLM: Glass Ionomer Cements.
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Extra resources for Advances in glass ionomer cements
Might be given that the patient is referred to you with the diagnosis of Cushing’s syndrome. Examiners will not want to waste time in the history and physical stage, for the most part—but still must know just in case. Most will want to get at your algorithm for managing the patient (this goes for most scenarios). How to Answer? History Steroid use History of cancer (ACTH producing tumor of lung) Diabetes Hypertension Generalized weakness Physical Exam Buffalo hump Truncal obesity Striae Moon facies Diagnostic Tests 24 h urine for cortisol (most cost-effective test if incidenteloma) Plasma cortisol level at 8 am and 8 pm (check for loss of diurnal variation) ACTH level, two possibilities: (1) If elevated→pt has pituitary tumor or ectopic ACTH producing tumor (2) Low→ pt has adrenal pathology Dexamethasone suppression test, two possibilities (1) Suppress ACTH→ pituitary source (2) Doesn’t suppress ACTH→ ectopic cancer Then obtain CT scan: Of head for pituitary source Of chest/abdomen/pelvis for ectopic cancer source Of abdomen for adrenal source Should see contralateral gland to be atrophied Should not see bilateral enlargement If > 5 cm, suspect adrenocortical carcinoma Surgical Treatment Posterior unilateral adrenalectomy unless suspect malignancy For adrenocortical carcincoma, resection includes adrenal, kidney, and continuous structures (spleen, distal pancreas, diaphragm) If metastatic disease present, debulk Can use mitotane if metastatic disease or pt not a surgical candidate (adrenolytic agent destroys Zona Fasiculata) Common Curveballs Scenario will change with first presentation as pituitary tumor, then presentation as adrenal tumor Will be malignant tumor 39 40 Endocrine—Cushing’s Syndrome Addisonian crisis post-op Being asked difference between Cushing’s syndrome and Cushing’s disease There will be an ACTH or CRF secreting tumor (typically lung) Pt won’t be a surgical candidate Will be given results of tests you order (24 h urine cortisol, plasma cortisol levels, ACTH levels, dexamethasone suppression test) Being asked when to order the above tests Will present as an incidenteloma Describing surgical approach to adrenalectomy Strikeouts Not being able to diagnose location of tumor Not knowing treatment for pituitary tumor Not knowing treatment for adrenal tumor Performing FNA on the adrenal tumor Not recognizing the adrenal tumor for what it is and directing therapy towards a pituitary lesion Discussing bilateal laparoscopic adrenalectomy Endocrine—Hyperthyroidism Concept Multiple etiologies, surgery only for very specific indications.
Important to now how to make diagnosis, the various treatment options, when to treat with surgery, and how to treat hyperthyroid crisis. Way Question May be Asked? “27 y/o female referred to your office by a family practitioner with the recent diagnosis of hyperthyroidism. ” May have symptoms of hyperthyroidism and you need to make diagnosis first: tachycardia, heat intolerance, weight loss, fatigue, palpitations. How to Answer? ) Lugol’s solution (iodine) 2cc BID starting 10–14 days prior to surgery to decrease vascularity of thyroid gland Continue beta blocker post-op for 8–10 days (t 1/2 of hormone) (d) Thyroxin for life post-op (can’t tell true thyroid status until 1–2 years post-op Thyroid Storm—Life-Threatening Initiated by physiologic stresses (surgery, anesthesia, MI, infection, childbirth) Presentation of: fever, tachycardia, abdominal symptoms, change mental status Mortality ~10% Treatment: IVF Sedatives O2 Cooling blankets PTU 250 mg q 4 h Hydrocortisone 100 q 6 h Beta blockers (may need IV inderal for control cardiac arrhythmias) May need intubation Treat precipitating cause!
History can be helpful here. You will probably be pushed into an operation on someone with obstruction secondary to malignancy or diverticulitis related stricture or perhaps a patient that has even perforated secondary to their obstruction. Way Question May be Asked? “61 y/o male evaluated in emergency room with recent constipation and change in bowel habits, complaining of sudden onset of diffuse abdominal pain/distension and has free air on AXR. ” Be prepared to see an x-ray here. How to Answer?