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Surgery NBME > Cardiothoracic Disorders > Flashcards

Cardiothoracic Disorders Flashcards

1
Q

first step in asymptomatic pt who has a coin-lesion on CXR found pre-op?

A

previous previous CXR films for comparison

next step should include CT scan w/ possible CT-guided needle biopsy

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2
Q

symptomatic coin lesion found on CXR and confirmed with CT scan - what next?

A

bronchoscopy - obtain tissue diagnosis and determine location

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3
Q

lung lesion associated with dental abscess or sinus tract with chest wall involvement

A

actinomycosis

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4
Q

lung lesion with concentric or homogenous calcification in an endemic area

A

histoplasmosis

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5
Q

lung lesion with thin-walled cavity often w/ air-fluid level in a pt living in endemic area

A

coccidiomycosis

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6
Q

lung lesions with associated chronic skin ulcers in an endemic area

A

blastomycosis

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7
Q

lung lesions in immunocompromised patient, often with meningeal involvement

A

cryptococcosis

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8
Q

lung lesion that presents as mycetoma with air-crescent sign

A

aspergillosis

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9
Q

lung lesion that presents with well-defined border with slight lobulations

A

hamartoma

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10
Q

lung lesion that is adjacent to thickened pleura and comet-tail vessel pattern

A

round atelectasis

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11
Q

what is the next step in a patient who presents with a stage 1 adenocarcinoma of the lung

A

thoracotomy

- explore the mediastinum; if no spread outside lung, can proceed with lobectomy

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12
Q

what kind of tx. can you do for a hilar mass that involves a mainstem bronchus?

A

exploratory thoracotomy

- pneumonectomy will likely be needed for complete removal

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13
Q

what is involved in a pneumonectomy?

A
  1. dividing the mainstem bronchus just distal to carina and sewing/stapling it closed
  2. dividing the pulmonary artery and two pulm. veins
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14
Q

what is involved in a sleeve lobectomy?

A
  1. dividing the mainstem bronchus above and below the origin of the right upper lobe bronchus and reattaching the bronchus by suture technique
  2. blood supply to the unaffected lobes is left in tact
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15
Q

tx. for stage 2 lung cancer

A

stage 2 - involvement of hilar LN

- tx. is surgical resection but prognosis is worse

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16
Q

pt with lung mass has mediastinal LN positive for mets - stage ?

A

stage 3 lung cancer

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17
Q

tx. for stage 3 lung cancer

A

chemotherapy and radiation therapy

- if tumor decreases in size, then can undergo resection

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18
Q

pt with lung cancer has PET scan positive for distant mets - stage? tx?

A

stage III or IV

- tx. chemo and radiation

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19
Q

what can the Pancoast tumor invade?

A

lower cords of brachial plexus
subclavian artery
sympathetic ganglia
chest wall

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20
Q

tx. of Pancoast tumor

A
  1. irradiation of area over 6 week period

2. surgical resection of involved chest wall and lung

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21
Q

hemoptysis in otherwise healthy young woman with atelectasis….dx?

A

obstructed bronchus - most likely a bronchial adenoma

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22
Q

two types of “bronchial adenomas”

A
  1. carcinoid tumors - usually benign when in lung

2. adenocystic carcinomas - MC in upper airway; invade locally

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23
Q

how can you diagnose bronchial adenoma?

A

CT scan but ultimately, bronchoscopy w/ biopsy is needed for diagnosis

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24
Q

tx. of bronchial adenoma

A

lobectomy - with removal of tumor-containing bronchus

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25
Q

an older patient comes in with a pleural effusion…what are you concerned about?

A

a pleural effusion in an older patient signifies cancer until proven otherwise

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26
Q

what is the next step in diagnosis of a pleural effusion in an old man (w/o CHF)?

A

thoracentesis and pleural biopsy

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27
Q

only potential tx. of mesothelioma

A

extrapleural pneumonectomy

- irradiation and chemotherapy are ineffective

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28
Q

what is an extraplural pneumonectomy?

A

entire lung along with parietal/visceral pleura, pericardium and diaphragm are resected en bloc

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29
Q

tx. for pneumothorax

A

chest tube (tube thoracostomy)

  • polyethylene tube (size 24) w/ a one way-valve (Heimlich valve)
  • tube attached to a water-seal type drain
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30
Q

what is the purpose of a water seal in the chest tube?

A

maintains negative pressure in the pleural space and chest tube so that air and fluids may escape from the chest

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31
Q

how do you tx. persistent or recurrent pneumothorax?

A

thoracoscopic excision of blebs and pleurodesis (pleural abrasion)
- also used for bilateral spontaneous PTX

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32
Q

pt with pneumonia tx at home with antibiotics improves; she then notes an increased pain in her chest, increased cough and recurrent fever - CXR shows a pleural effusion in the right lung - diagnosis?

A

empyema

  • community - strep pneumo
  • hospital - staph or gram negatives
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33
Q

tx. of empyema of lung

A
  1. antibiotics

2. chest tube drainage - evacuates pus and re-expands the lung

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34
Q

tx. of empyema that has become loculated (i.e. bc it was not drained early enough)

A

thoracotomy and decortication (removal of the thick inflammatory tissue trapping the lung)

35
Q

tx. for pt with three-vessel disease and reduced EF

A

CABG

36
Q

MC grafts used in CABG

A

greater saphenous vein grafts

internal mammary artery grafts - best graft patency

37
Q

what are the MC reasons of death following cardiac transplantation?

A

infection - related to immunosuppressive drugs

accerelated coronary atherosclerosis (form of chronic rejection)

38
Q

histopath findings in achalasia

A

loss of sm mm. ganglionic cells of Auerbach plexus and neuronal degeneration

39
Q

what is the proper sequence of diagnostic tests in a patient presenting with dysphagia?

A
  1. barium swallow
  2. endoscopy w/ biopsy
  3. CT scan
40
Q

best test for staging of esophageal cancer

A

endoscopic USG

- assesses wall penetration and can identify adjacent node enlargement

41
Q

primary tx for cancers of the cervical and upper third of esophagus

A

chemoradiation therapy

42
Q

primary tx. of cancers of the middle third of esophagus

A

neoadjuvant tx. with irradiation and chemo followed by surgical resection

43
Q

transhiatal esophagectomy

A

stomach is brought up well into the neck and joined w/ the pharynx

44
Q

formal esophagectomy (Ivor Lewis procedure)

A

gastroesophgeal anastomosis in the chest or may be altered to permit anastomosis in the neck

45
Q

if stomach is used in reconstruction of esophagus after esophagectomy, what other procedure is necessary?

A

pyloroplasty - to prevent gastric outlet obstruction

46
Q

tx. of esophageal cancer with distant mets

A

chemotherapy only

47
Q

tx. of esophageal cancer in lower 1/3 of esophagus

A

esophagectomy and proximal gastrectomy with intra-thoracic esophagogastric anastomosis

48
Q

what tumors arise in the anterior mediastinum?

A 
thymomas - look for sx. of myasthenia gravis
teratomas
lymphomas - both Hodgkins and NHL
germ cell tumors
benign dermoid tumors (calcium deposits)
49
Q

tx. for thymomas (and other tumors other than lymphomas in ant. mediastinum)

A

surgery (median sternotomy)

50
Q

MC tumors of middle mediastinum

A

lymphatic tumors

cysts

51
Q

bronchogenic cysts

A

from foregut remnants; found in both lung and mediastinum - benign growths lined by columnar epithelium

52
Q

what type of cysts have a “water bottle” appearance/

A

pericardial cysts

53
Q

tx. of cysts in middle mediastinum

A

surgical removal w/ posterolateral thoracotomy

54
Q

MC tumors in posterior mediastinum

A 
neurogenic tumors (MC - neurilemoma)
- arise from nerves and nerve sheaths near vertebral bodies and contain both fibrous and neural elements
55
Q

what test is indicated next if you find a tumor in the posterior mediastinum?

A

CT scan - to indicate whether tumor is present in spinal canal also

56
Q

Noise with breathing OUT?

A

Think asthma

57
Q

Noise with breathing IN?

A

Think tracheomalacia

58
Q

Noise with breathing AND difficulty swallowing?

A

Think vascular ring

59
Q

Baby presents with strider and episodes of respiratory distress with crowing respiration during which he assumes a hyperextended position; there is also mild difficulty swallowing

A

Vascular ring

60
Q

What diagnostic test(s) do you order if you suspect a vascular ring?

A

Barium swallow
- will show extrinsic compression from the abnormal vessel
Bronchoscopy
- confirms segmental tracheal compression and R/O tracheomalacia

61
Q

Tx of vascular ring compressing airway and esophagus

A

Surgery - dividing smaller of the double aortic arches

62
Q

12 yo girl found to have a pulmonary flow systolic murmur with a fixed split second heart sound; she has a history of frequent colds and URIs - dx? Test?

A

Atrial septal defect

Test - echo

63
Q

Tx of ASD

A

Closure of defect by open surgery or cardiac catheterization

64
Q

3 month old baby with failure to thrive has a loud pansystolic murmur best head over left sternal border; chest shows increased pulmonary vascular markings

A

Ventricular septal defect

  • mc in membranous septum
  • dx with echo tx with surgery
65
Q

What type of VSD has good chance to close on its own within first 2-3 years?

A

Small, restrictive VSD located low in the muscular septum

66
Q

3 day old premature baby has trouble feeding and pulmonary congestion; on exam she has bound peripheral pulses and a continuous machinery like murmur- shortly thereafter the baby goes into overt heart failure

A

Patent ductus arteriosus

67
Q

What are indications for surgical closure of PDA?

A

Failed indomethacin tx
CHF
Full term babies (intraluminal coils or surgery)

68
Q

What are characteristics of R–>L SHUNTS

A

Decreased vascular markings on CXR

Cyanosis

69
Q

72 yo man with history of angina, SOB and Exertional syncope has a harsh midsystolic murmur best heard at right 2nd intercostal space - dx? Test?

A

Aortic stenosis

- do echo

70
Q

When is surgery indicated for aortic stenosis?

A

Pressure gradient >50 mmHg

First indication of CHF, angina or syncope } symptomatic patients have limited life expectancy

71
Q

72 yo man with wide pulse pressure, blowing diastolic murmur heard best at right 2nd intercostal space and along left lower sternal border; on echo, there is evidence of beginning LV dilatation - dx? What should you do?

A

Chronic aortic insufficiency

- tx with aortic valve replacement at first sign of LV dilatation

72
Q

Tx for acute aortic insufficiency caused by endocarditis

A

Emergency valve replacement and antibiotics

73
Q

35 yo lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis progressive for about 5 years; she has atrial fibrillation and a low pitched rumbling diastolic apical heart murmur. At age 15 she has rheumatic fever - dx?

A

Mitral valve stenosis

- start with echo

74
Q

Tx of mitral valve stenosis

A

Surgical repair - mitral commissurotomy or balloon valvuloplasty

75
Q

55 yo lady has had mitral valve prolapse for many years, she now has developed signs of LHF and atrial fibrillation; she has an apical high pitched holo systolic heart murmur that radiates to the axilla and back

A

Mitral regurgitation

76
Q

Tx of mitral valve regurgitation

A

Surgical repair (annuloplasty) or possibly valve replacement

77
Q

Candidates for coronary revascularization

A
  • stenosis > 70% in atleast one vessel
  • good distal vessels (often bad in smokers and diabetic)
  • minimal LV damage (measured by EF)
78
Q

Cardiac index

A

CO / BSA

normal = 3 L/ min /m2

79
Q

How do you interpret PCWP, LAP or LEDV, in the setting of low cardiac index or cardiac output?

A

0-3- need more fluids (dehydrated)

> 20 - ventricular failure

80
Q

What is the first step after you find a solitary coin lesion on an XR?

A

Find a previous CXR to compare
- if same lesion is found on older XR ( one year or more) it is likely not cancer and no further work up is needed for now but follow up with CXR in a few months

81
Q

What is the management approach to a coin lesion in the lung that was no previously there?

A
  1. Sputum cytology and CT scan
  2. Biopsy
    - bronchoscopy if central, percutaneously if peripheral
    - if unsuccessful, thoracoscopy with wedge resection
82
Q

What is the minimal FEV1 to survive pulmonary resection/pneumonectomy?

A

800 ml

83
Q

How do you calculate how much FEV1 patient would have after resection of lung?

A

Take the percent from V/Q scan (%) and multiple it by calculated fev1 during assessment

84
Q

How do you adequately assess extent of disease in lung cancer ?

A

CT scan
CT scan plus PET - if status of mediastinal nodes unclear
Endobronchial USG - to same nodes
- do not need to determine fev1 or nodal status in small cell ca. Bc it not treated surgically

Surgery NBME (16 decks)

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