Chest Wall, Pleura and Mediastinum (TCVS) Flashcards
All of the following increase the risk or tracheal stenosis EXCEPT
A. Age over 70years
B. Radiation
C. Male gender
D. Excessive corticosteroid therapy
Answer: C
Intubation-related risk factors include:
1) prolonged intubation;
2) high tracheostomy through the first tracheal ring or cricothyroid membrane;
3) transverse rather than vertical incision on the trachea;
4) oversized tracheostomy tube;
5) prior tracheostomy or intubation; and
6) traumatic intubation.
Stenosis is also more common in older patients, in females, after radiation, or after excessive corticosteroid therapy, and in the setting of concomitant diseases such as autoimmune disorders, severe reflux disease, or obstructive sleep apnea and the setting of severe respiratory failure.
However, even a properly placed tracheostomy can lead to tracheal stenosis because of scarring and local injury.
Mild ulceration and stenosis are frequently seen after tracheostomy removal.
Use of the smallest tracheostomy tube possible, rapid downsizing, and a vertical tracheal incision minimize the risk for post-tracheostomy stenosis.
(See Schwartz 10th ed., p. 607.)
Adenoid cystic carcinomas
A. Spread submucosally
B. Exhibit aggressive growth
C. Are not radiosensitive
D. Have a 5-year survival rate of >50%
Answer: A
Squamous cell carcinomas often present with regional lymph node metastases and are frequently unresectable at presentation.
Their biologic behavior is similar to that of squamous cell carcinoma of the lung. Adenoid cystic carcinomas, a type of salivary gland tumor, are generally slow-growing, spread submucosally, and tend to infiltrate along nerve sheaths and within the tracheal wall.
Although indolent in nature, adenoid cystic carcinomas are malignant and can spread to regional lymph nodes, lung, and bone.
Squamous cell carcinoma and adenoid cystic carcinomas represent approximately 65% of all tracheal neoplasms.
The remaining 35% comprises small cell carcinomas, mucoepidermoid carcinomas, adenocarcinomas, lymphomas, and others.
Postoperative mortality, which occurs in up to 10% of patients, is associated with the length of tracheal resection, use of laryngeal release, the type of resection, and the histologic type of the cancer.
Factors associated with improved long- term survival include complete resection and use of radiation as adjuvant therapy in the setting of incomplete resection.
Due to their radiosensitivity, radiotherapy is frequently given post-operatively after resection of both adenoid cystic carcinomas and squamous cell carcinomas.
A dose of 50 Gray or greater is usual. Nodal positivity does not seem to be associated with worse survival.
Survival at 5 and 10 years is much better for adenoid cystic (73 and 57%, respectively) than for tracheal cancers (47 and 36%, respectively; P <0.05).
For patients with unresectable tumors, radiation may be given as the primary therapy to improve local control, but is rarely curative.
For recurrent airway compromise, stenting or laser therapies should be considered part of the treatment algorithm.
(See Schwartz 10th ed., pp. 610–611.)
Which of the following is NOT a non-small-cell tumor of the lung?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Carcinoid tumor
D. Large-cell carcinoma
Answer: C
The term non–small-cell lung carcinoma (NSCLC) includes many tumor cell types, including large cell, squamous cell, and adenocarcinoma.
Historically, these subtypes were considered to be a uniform group based on limited understanding of the distinct clinical behaviors of the subtypes as well as the act that there were few treatment options available.
With increasing understanding of the molecular biology underlying these tumor subtypes, however, the approach to diagnosis and management and the terminology used in describing these tumors is evolving rapidly.
(See Schwartz 10th ed., p. 614.)
The most common pattern of benign calcifcation in hamartomas is
A. Solid
B. Diffuse
C. Central
D. Popcorn
Answer: D
Computed tomography (CT) indings characteristic of benign lesions include small size, calcification within the nodule, and stability over time.
Four patterns of benign calcification are common: diffuse, solid, central, and laminated or “popcorn.”
Granulomatous infections, such as tuberculosis, can demonstrate the first three patterns, whereas the popcorn pattern is most common in hamartomas.
In areas of endemic granulomatous disease, differentiating benign versus malignant can be challenging.
Infectious granulomas arising from a variety of organisms account for 70 to 80% of this type of benign solitary nodules; hamartomas are the next most common single cause, accounting or about 10%.
(See Schwartz 10th ed., p. 622.)
For an adenocarcinoma that has pleural invasion, tumor necrosis, and has lymphovascular invasion the correct subtype is
A. Minimally invasive adenocarcinoma (MIA)
B. Lepidic predominant adenocarcinoma (LPA)
C. Invasive adenocarcinoma
D. Adenocarcinoma in situ
Answer: B
If lymphovascular invasion, pleural invasion, tumor necro- sis, or more than 5 mm of invasion are noted in a lesion that has lepidic growth as its predominant component, minimally invasive adenocarcinoma (MIA) is excluded, and the lesion is called lepidic predominant adenocarcinoma (LPA), and the size of the invasive component is recorded for the T stage.
(See Schwartz 10th ed., p. 615.)
The grade of neuroendocrine carcinoma (NEC) that is associated with hemoptysis, pneumonia, and tumor cells arranged in cords and clusters is
A. Grade VI NEC
B. Grade IV NEC
C. Grade II NEC
D. Grade I NEC
Answer: D
Grade I neuroendocrine carcinoma (NEC) (classic or typical carcinoid) is a low-grade NEC; 80% arise in the epithelium of the central airways.
It occurs primarily in younger patients. Because of the central location, it classically presents with hemoptysis, with or without airway obstruction and pneumonia.
Histologically, tumor cells are arranged in cords and clusters with a rich vascular stroma. This vascularity can lead to life-threatening hemorrhage with even simple bronchoscopic biopsy maneuvers.
Regional lymph node metastases are seen in 15% of patients, but rarely spread systemically or cause death.
(See Schwartz 10th ed., p. 617.)
Which of the following is NOT a known predictive or prognostic tumor marker for adenocarcinoma?
A. EGFR
B. KRAS
C. AFP
D. EML4-ALK
Answer: C
Establishing a clear histologic diagnosis early in the evaluation and management of lung cancer is critical to effective treatment.
Molecular signatures are also key determinants of treatment algorithms or adenocarcinoma and will likely become important for squamous cell carcinoma as well.
Currently, differentiation between adenocarcinoma and squamous cell carcinoma in cytologic specimens or small biopsy specimens is imperative in patients with advanced stage disease, as treatment with pemetrexed or bevacizumab-based chemotherapy is associated with improved progression-free survival in patients with adenocarcinoma but not squamous cell cancer.
Furthermore, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab.
Finally, EGFR mutation predicts response to EGFR tumor kinase inhibitors and is now recommended as first-line therapy in advanced adenocarcinoma.
Because adequate tissue is required for histologic assessment and molecular testing, each institution should have a clear, multidisciplinary approach to patient evaluation, tissue acquisition, tissue handling/processing, and tissue analysis.
In many cases, tumor morphology differentiates adenocarcinoma rom the other histologic subtypes. If no clear morphology can be identified, then additional testing or one immunohistochemistry marker for adenocarcinoma and one for squamous cell carcinoma will usually enable differentiation.
Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology.
Additional molecular testing should be performed on all adenocarcinoma specimens for known predictive and prognostic tumor markers (eg, EGFR, KRAS, and EML4-ALK fusion gene).
Ideally, use of tissue sections and cell block material is limited to the minimum necessary at each decision point.
This emphasizes the importance of a multidisciplinary approach; surgeons and radiologists must work in direct cooperation with the cytopathologist to ensure that tissue samples are adequate or morphologic diagnosis as well as providing sufficient cellular material to enable molecular testing.
(See Schwartz 10th ed., p. 627.)
Desmoid tumors
A. Arise from the periosteum of the rib
B. Are treated with wide local excision with a 2- to 4-cm margin
C. Require radical excision (sacrificing neurovascular structures) to obtain 4-cm margins
D. Require chemotherapy to treat or prevent metastatic disease
Answer: B
Because the lesions have low cellularity and poor yield with fine needle aspiration (FNA), an open incisional biopsy or lesions over 3 to 4 cm is often necessary.
Surgery consists of wide local excision with a 2- to 4-cm margin and intraoperative frozen section assessment of resection margins.
Typically, chest wall resection, including the involved rib(s) and one rib above and below the tumor with a 4- to 5-cm margin of rib, is required.
A margin of less than 1 cm results in much higher local recurrence rates.
If a major neurovascular structure would have to be sacrificed, leading to high morbidity, then a margin of less than 1 cm would have to suffice.
Survival after wide local excision with negative margins is 90% at 10 years.
(See Schwartz 10th ed., p. 666.)
A 57-year-old non-small-cell lung cancer patient with a potentially resectable tumor found on computed tomography (CT) scan who can walk on a flat surface indefinitely without oxygen or stopping to rest, secondary to dyspnea will most likely tolerate
A. Lobectomy
B. Pneumonectomy
C. Single-lung ventilation
D. Wedge resection
Answer: A
Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy.
The surgeon should first estimate the likelihood of pneumonectomy, lobectomy, or possibly sleeve resection, based on the CT images.
A sequential process of evaluation then unfolds.
A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefinitely, without oxygen and without having to stop and rest secondary to dyspnea, he will be very likely to tolerate lobectomy.
If the patient can walk up two lights of stairs (up two standard levels), without having to stop and rest secondary to dyspnea, he will likely tolerate pneumonectomy.
Finally, nearly all patients, except those with carbon dioxide (CO2) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection.
(See Schwartz 10th ed., pp. 635–636.)
An “onion-peel” appearance of a rib on CT is suggestive of
A. Chondroma
B. Ewing sarcoma
C. Plasmacytoma
D. Osteosarcoma
Answer: B
Primitive neuroectodermal tumors (PNEs) (neuroblastomas, ganglioneuroblastomas, and ganglioneuromas) derive from primordial neural crest cells that migrate from the mantle layer of the developing spinal cord.
Histologically, PNEs
and Ewing sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup.
They also share a consistent pattern of proto-oncogene expression and have been found to express the product of the MIC2 gene.
Ewing sarcoma occurs in adolescents and young adults who present with progressive chest wall pain, but without the presence of a mass.
Systemic symptoms of malaise and fever are often present.
Laboratory studies reveal an elevated erythrocyte sedimentation rate and mild white blood cell elevation.
Radiographically, the characteristic onion peel appearance is produced by multiple layers of periosteum in the bone formation. Evidence of bony destruction is also common.
The diagnosis can be made by a percutaneous needle biopsy or an incisional biopsy.
(See Schwartz 10th ed., p. 669.)
Pancoast tumors are identified as involving all of the following except:
A. The chest wall at or below the second rib.
B. Tumors of the parietal pleura or deeper structures overlying the first rib.
C. The superior sulcus.
D. The extreme apex of the chest.
Answer: A
Carcinoma arising in the extreme apex of the chest with associated arm and shoulder pain, atrophy of the muscles of the hand, and Horner syndrome presents a unique challenge to the surgeon.
Any tumor of the superior sulcus, including tumors without evidence for involvement of the neurovascular bundle, is now commonly known as Pancoast tumors, after Henry Pancoast who described the syndrome in 1932.
The designation is reserved for tumors involving the parietal pleura or deeper structures overlying the first rib.
Chest wall involvement at or below the second rib is not a Pancoast tumor.
Treatment is multidisciplinary; due to the location of the tumor and involvement of the neurovascular bundle that supplies the ipsilateral extremity, preserving postoperative function of the extremity is critical.
(See Schwartz 10th ed., p. 642.)
The most likely cause of aspiration pneumonia is
A. A mixture of aerobes and anaerobes
B. Aerobes only
C. Anaerobes only
D. Gram-negative bacteria
Answer: C
Normal oropharyngeal secretions contain many more Streptococcus species and more anaerobes (approximately 1 × 108 organisms/mL) than aerobes (approximately 1 × 107 organisms/mL).
Pneumonia that follows from aspiration, with or without abscess development, is typically poly- microbial.
An average of two to four isolates present in large numbers have been cultured from lung abscesses sampled percutaneously.
Overall, at least 50% of these infections are caused by purely anaerobic bacteria, 25% are caused by mixed aerobes and anaerobes, and 25% or fewer are caused by aerobes only.
In nosocomial pneumonia, 60 to 70% of the organisms are gram-negative bacteria, including Klebsiella pneumoniae, Haemophilus influenzae, Proteus species, Pseudomonas aeruginosa, Escherichia coli, Enterobacter cloacae, and Eikenella corrodens.
Immunosuppressed patients may develop abscesses because of the usual pathogens as well as less virulent and opportunistic organisms such as Salmonella species, Legionella species, Pneumocystis carinii, atypical mycobacteria, and fungi.
(See Schwartz 10th ed.,p.650.)
Laboratory evaluation of a chest wall mass showing elevated erythrocyte sedimentation rates indicates
A. Osteosarcoma
B. Plasmacytoma
C. Ewing sarcoma
D. Multiple myeloma
Answer: C
Laboratory evaluations are useful in assessing chest wall masses or the following:
- Plasmacytoma: Serum protein electrophoresis demonstrates a single monoclonal spike, which is measuring the overproduction of one immunoglobulin rom the malignant plasma cell clone.
- Osteosarcoma: Alkaline phosphatase levels may be elevated.
- Ewing sarcoma: Erythrocyte sedimentation rates may be elevated.
(See Schwartz 10th ed., able 19-18, p. 665.)
The most common benign chest wall tumor is
A. Chondromas
B. Osteochondromas
C. Desmoid tumors
D. Fibrous dysplasia
Answer: A
Chondromas, seen primarily in children and young adults, are one of the more common benign tumors of the chest wall.
They usually occur at the costochondral junction anteriorly and may be confused with costochondritis, except that a painless mass is present.
Radiographically, lesion is lobulated and radiodense; it may have diffuse or focal calcifications; and it may displace the bony cortex without penetration.
Chondromas may grow to huge sizes if left untreated.
Treatment is surgical resection with a 2-cm margin.
Large chondromas may harbor well-differentiated chondrosarcoma and should be managed with a 4-cm margin to prevent local recurrence.
(See Schwartz 10th ed., p. 666.)
Which of the following is an indication for surgical drainage of a lung abscess?
A. Abscess >3 cm in diameter.
B. Hemoptysis.
C. Failure to decrease in size after 1 week of antibiotic therapy.
D. Persistent ever.
Answer: B
Surgical drainage of lung abscesses is uncommon since drainage usually occurs spontaneously via the tracheobronchial tree.
Indications for intervention are:
- Failure of medical therapy
- Abscess under tension
- Abscess increasing in size during appropriate treatment
- Contralateral lung contamination
- Abscess >4–6 cm in diameter
- Necrotizing infection with multiple abscesses, hemoptysis, abscess
rupture, or pyopneumothorax - Inability to exclude a cavitating carcinoma
What percentages of chest wall masses are malignant?
A. 10–20%
B. 20–30%
C. 50–80%
D. 40–50%
Answer: C
Patients with chest wall tumors, regardless of etiology, typically complain of a slowly enlarging palpable mass (50–70%), chest wall pain (25–50%), or both.
Interestingly, growing masses are often not noticed by the patient until they suffer a trauma to the area.
Pain from a chest wall mass is typically localized to the area of the tumor; it occurs more often and more intensely with malignant tumors, but it can also be present in up to one-third of patients with benign tumors.
With Ewing sarcoma, fever and malaise may also be present.
Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found in older patients (average age 40 years).
Overall, between 50 and 80% of chest wall tumors are malignant.
(See Schwartz 10th ed., p. 665.)
The population most at risk for developing active tuberculosis is
A. Elderly
B. Minorities
C. Urban residents
D. Human immunodeficiency virus (HIV) infected
Answer: D
Tuberculosis is a widespread problem that affects nearly one-third of the world’s population. Between 8.3 and 9 million new cases of tuberculosis and 12 million prevalent cases (range 10–13 million) were estimated worldwide in 2011 according to the World Health Organization. Only 10,521 new cases were reported to the World Health Organization in the United States in 2011.
Human immunodeficiency virus (HIV) infection is the strongest risk factor for developing active tuberculosis. The elderly, minorities, and recent immigrants are the most common populations to have clinical manifestations of inection, yet no age group, sex, or race is exempt from infection.
In most large urban centers, reported cases of tuberculosis are more numerous among the homeless, prisoners, and drug-addicted populations.
Immunocompromised patients additionally contribute to an increased incidence of tuberculosis infection, often developing unusual systemic as well as pulmonary manifestations.
(See Schwartz 10th ed., p. 654.)
The fungi associated with the highest mortality rate due to invasive mycoses in the United States is
A. Aspergillus
B. Cryptococcus
C. Candidia
D. Mucor
Answer: A
The genus Aspergillus comprises over 150 species and is the most common cause of mortality due to invasive mycoses in the United States.
It is typically acute in onset and life-threatening and occurs in the setting of neutropenia, chronic steroid therapy, or cytotoxic chemotherapy.
It can also occur in the general intensive care unit population of critically ill patients, including patients with underlying chronic obstructive pulmonary disease (COPD), postoperative patients, patients with cirrhosis or alcoholism, and post-inluenza patients, without any of these factors present.
The species most commonly responsible for clinical disease include A. fumigatus, A. flavus, A. niger, and A. terreus.
Aspergillus is a saprophytic, filamentous fungus with septate hyphae.
Spores (2.5–3 μm in diameter) are released and easily inhaled by susceptible patients; because the spores are microns in size, they are able to reach the distal bronchi and alveoli.
(See Schwartz 10th ed., p. 655.)
A patient presenting with a history and findings of dyspnea, wheezing, hemoptysis, and a mediastinal mass in the visceral compartment yields a diagnosis of
A. Lymphoma
B. Thymoma with myasthenia gravis
C. Mediastinal granuloma
D. Germ cell tumor
LYMPHOMA
- Hx/PE: Night sweats, weight loss, fatigue, extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosis
- Location: Any compartment
THYMOMA WITH MYASTHENIA GRAVIS
- Hx/PE: Fluctuating weakness, early fatigue, ptosis, diplopia
- Location: Anterior
MEDIASTINAL GRANULOMA
- Hx/PE: Dyspnea, wheezing, hemoptysis
- Location: Visceral (middle)
GERM CELL TUMOR
- Hx/PE: Male gender, young age, testicular mass, elevated levels of human chorionic gonadotropin and/or α- fetoprotein
- Location: Anterior
A patient with an anterior mediastinal mass and elevated serum α- etoprotein (AFP) most likely has
A. A teratoma
B. A nonseminomatous germ-cell tumor
C. A seminomatous germ-cell tumor
D. Metastatic hepatocellular carcinoma
Answer: B
The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonseminomatous and seminomatous germ-cell tumors can frequently be diagnosed and often distinguished from one another by the levels of α- etoprotein (AFP) and human chorionic gonadotropin (hCG).
In over 90% of nonseminomatous germ-cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specificic if the level of either AFP or hCG is greater than 500 ng/mL.
Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than 100 ng/mL.
Other serum markers, such as intact parathyroid hormone level or ectopic parathyroid adenomas, may be useful for diagnosing and also for intraoperatively confirming complete resection.
After successful resection of a parathyroid adenoma, this hormone level should rapidly normalize.
(See Schwartz 10th ed., p. 672
The primary site for male patients with malignant pleural effusions is
A. Gastrointestinal tract
B. Lung
C. Genitourinary tract
D. Melanoma
Answer: B
Malignant pleural effusions may occur in association with a number of different malignancies, most commonly lung cancer, breast cancer, and lymphomas, depending on the patient’s age and gender.
(p. 132 Schwartz ABSITE)
Eosinophilic granulomas are associated with
A. Langerhans cell histiocytosis (LCH)
B. Parasitic infections
C. Crohn disease
D. Gardner syndrome
Answer: A
Eosinophilic granulomas are benign osteolytic lesions. Eosinophilic granulomas of the ribs can occur as solitary lesions or as part of a more generalized disease process of the lymphoreticular system termed Langerhans cell histiocytosis (LCH).
In LCH, the involved tissue is infiltrated with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas.
The cause is unknown. Of all LCH bone lesions, 79% are solitary eosinophilic granulomas, 7% involve multiple eosinophilic granulomas, and 14% belong to other forms of more systemic LCH.
Isolated single eosinophilic granulomas can occur in the ribs or skull, pelvis, mandible, humerus, and other sites. They are diagnosed primarily in children between the ages of 5 and 15 years.
Because of the associated pain and tenderness, they may be confused with Ewing sarcoma or with an inflammatory process such as osteomyelitis.
Healing may occur spontaneously, but the typical treatment is limited surgical resection with a 2-cm margin.
(See Schwartz 10th ed., p. 666.)
A chylothorax is likely to be present in a patient whose pleural fluid analysis results show a triglyceride level of
A. 80mg/100mL
B. 100mg/100mL
C. 45mg/100mL
D. 130mg/100mL
Answer: D
Laboratory analysis of the pleural fluid shows a high lymphocyte count and high triglyceride levels.
If the triglyceride level is greater than 110 mg/100 mL, a chylothorax is almost certainly present (a 99% accuracy rate).
If the triglyceride level is less than 50 mg/mL, there is only a 5% chance of chylothorax.
(See Schwartz 10th ed., p. 686.)
Osteosarcoma of the rib
A. Is considered nonoperable if pulmonary metastases are present
B. Is treated with radiation therapy before resection
C. Is treated with adjuvant chemotherapy before resection
D. Requires excision with a 6-cm margin
Answer: C
While osteosarcomas are the most common bone malignancy, they represent only 10 to 15% of all malignant chest wall tumors.
They primarily occur in young adults as rapidly enlarging, painful masses; however, osteosarcomas can occur in older patients as well, sometimes in association with previous radiation, Paget disease, or chemotherapy.
Radiographically, the typical appearance consists of spicules of new periosteal bone formation producing a sunburst appearance.
Osteosarcomas have a propensity to spread to the lungs, and up to one-third of patients present with metastatic disease.
Osteosarcomas are potentially sensitive to chemotherapy. Currently, preoperative chemotherapy is common. After chemotherapy, complete resection is performed with wide (4-cm) margins, followed by reconstruction.
In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection of the primary tumor and of the pulmonary metastases.
Following surgical treatment of known disease, additional maintenance chemotherapy is usually recommended.
(See Schwartz 10th ed., p. 667.)
Excisional biopsy of a chest wall mass is allowed if
A. Needle biopsy was nondiagnostic.
B. Imaging reveals classic appearance of a chondrosarcoma.
C. It is >3cm.
D. None of the above.
Answer: B
- Needle biopsy: Pathologists experienced with sarcomas
can accurately diagnose approximately 90% o patients using FNA cytology. A needle biopsy (FNA or core) has the advantage of avoiding wound and body cavity contamination (a potential complication with an incisional biopsy). - Incisional biopsy: If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and oriented to allow subsequent scar excision; skin laps and drains should be avoided. However, if the surgeon believes a hematoma is likely to develop, a drain is useful for limiting soft tissue contamination by tumor cells. At the time of definitive surgical resection, the en bloc resection includes the biopsy scar and the drain tract along with the tumor.
- Excisional biopsy: Any lesion less than 2.0 cm can be excised as long as the resulting wound is small enough to close primarily. Otherwise, excisional biopsy is performed only when the initial diagnosis (based on radiographic evaluation) indicates that the lesion is benign or when the lesion has the classic appearance of a chondrosarcoma (in which case, definitive surgical resection can be under- taken).
(See Schwartz 10th ed., p. 666.)
A 77-year-old male who is a former smoker (quit 10
years ago; smoked 1 pack per day for 50 years) with
COPD, type 2 diabetes mellitus, and CAD status post
CABG x 3 10 years ago, presents with a 4 month history of a non-productive cough and 10 pound weight loss in the past 3 months. A CXR and CT chest demonstrate a 2 x 3.1 cm mass in his right upper lung that was not present on a CXR taken 5 years earlier.
What is the best appropriate next step in the management of this patient?
A. Positron emission tomography (PET) scan
B. Cervical mediastinoscopy
C. Right upper lobectomy
D. Right upper lobectomy with mediastinal lymph
node sampling
E. Bone scan and abdominal CT scan
A. PET scanning uses fluorodeoxyglucose (FDG)
with radiolabeled fluorine to help detect malignant cells. Malignant cells metabolize glucose at a higher rate than normal cells, resulting in a radiolabeled metabolite of FDG, which results in a visual marker to help identify malignant cells, nodal stage, and metastases.
Surgical resection without any attempt at preoperative staging is not appropriate.
Although cervical mediastinoscopy may be an important step in assessing the stage of thÿs patients lung cancer, PET scanning may identify suspicious nodes and
distant metastasis and helps guide the surgeon on where to obtain the appropriate tissue for diagnosis.
Assuming this patient was diagnosed with a primary
non-small cell lung cancer (NSCLC) in the right upper lobe of his lung, which of the following is an absolute contraindication to surgical resection?
A. A post-operative predicted FEV1 of 45%
B. A malignant pleural effusion in the right chest
C. Tumor directly invading the chest wall
D. Tumor directly invading the right main bronchus 0.5 cm away from the carina
E. Tumor directly invading the mediastinal pleura
B. Surgery is contraindicated for Stage IIIB and IV lung cancer.
T4 lesions are classified as stage IIIB if they are associated with N2 disease.
Tumors of any size are T4 if they invade the heart, great vessels, trachea, esophagus, vertebral body, or carina. Tumors associated with malignant pleural or pericardial effusions are considered to have MIA disease, which precludes
surgical intervention.
T3 tumors include tumors of
any size that directly invade any of the following: diaphragm, chest wall, mediastinal pleura, parietal pericardium, or a tumor invading the main bronchus less than 2 cm from the carina (without involvement of the
carina).
Depending on nodal and metastatic involvement, T3 tumors may not result in a staging level of
IIIB or IV. Thus, surgery may be appropriate in select
patients presenting with T3 tumors.
Preoperative testing of pulmonary functional
reserve is essential prior to determining whether a
patient is a candidate for surgical resection. In gen¬
eral, a predicted post-operative FEVj less than 40% is thought to be a contraindication to surgical resection.
Although a post-operative predicted FEV1 of 45% is
not an absolute contraindication to surgical resection, it certainly merits thorough preoperative patient
assessment (including evaluation of comorbidities,
and predicted lung diffusion capacity). It is also important to remember that if the lung to be resected is not actually functional (secondary to collapse or bronchial
obstruction) than the post-operative predicted FEV,
should not be expected to change significantly from the preoperative FEV1.
Conversely, if the lung to be
resected happens to be functional, but the patient has
other areas of lung that are non-functional, than the
FEV1 will actually decrease more dramatically when
this functional lung is resected.
When performing a right upper lobectomy, after the pleura overlying the anterior hilum are divided from anterior to posterior, what is the order o structures that would need to be divided?
A. Superior pulmonary vein/Upper lobe bronchus/
Truncus anterior
B. Truncus anterior/Superior pulmonary vein/
Upper lobe bronchus
C. Superior pulmonary vein/Truncus anterior/
Upper lobe bronchus
D. Upper lobe bronchus/Truncus anterior/Superior
pulmonary vein
E. Truncus anterior/Upper lobe bronchus/Superior
pulmonary vein
C. Structures that would be need to be divided for a
right upper lobectomy from anterior to posterior are
the superior pulmonary vein, truncus anterior, and
upper lobe bronchus.
This is a simplified description of the most commonly encountered anatomy for the main structures seen.
During dissection the surgeon must be mindful of aberrant anatomy (often noted on preoperative imaging) and more commonly branching vessels, which may appear in different planes than listed above.
After resection of his tumor by a right upper lobectomy, pathology demonstrated squamous cell
carcinoma with negative margins. Lymph nodes sampled were also negative for malignancy. Which
of the following is true?
A. The patient will not need any further surveillance.
B. The only surveillance needed will be a repeat CT
chest in 2 years.
C. The most common site of relapse for NSCLC is
bone.
D. The patient will require radiation therapy for
6 months post-operatively.
E. Most recurrences occur within the first two years
after surgery.
E. NSCLC is most likely to relapse within the first two
years after resection (over 60%).
Thus, oncologic surveillance should be done every 3 to 4 months during this time.
Though there is no single recommendation for surveillance beyond 2 years, coordinated oncologic
surveillance should be performed long-term.
Though relapse of NSCLC is common in the bone, the most
common site of relapse for all stages of NSCLC is the
brain. Other sites of relapse include the lung (ipsilateral or contralateral), liver, and adrenal glands. There is
no indication for radiation therapy post-operatively.
If another patient presented with significant hyponatremia and seizures and was incidentally found to have similar sized lung mass in the right upper lobe, the patient would most likely benefit
from which of the following treatment modalities?
A. Surgical resection of the tumor alone
B. Single agent chemotherapy
C. Radiation therapy alone
D. Combination chemotherapy alone
E. Combination chemotherapy and radiation therapy
E. Paraneoplastic syndromes develop in as many as 40% of patients with newly diagnosed lung cancers.
Significant hyponatremia in the setting of a newly diagnosed lung mass is highly suspicious of syndrome of inappropriate antidiuretic hormone (SIADH). It is important to recognize that SIADH is most commonly associated with small cell lung cancer (SCLC).
In addition to hyponatremia, the diagnosis of SIADH is confirmed by demonstrating a
serum osmolarity <275mOsm/kg, urine osmolarity > serum osmolarity, and urine sodium > 25 meq/L.
Associated symptoms may include lethargy, nausea,
vomiting, altered mental status, and seizures.
SCLC account for D20% of all lung cancers. These tumors are known for rapid growth, and thus often present with necrosis. They commonly invade vascular and lymphatic tissue, and metastasize early.
Up to 70% of patients present with metastasis at the time of diagnosis. Given that SCLC is a systemic disease, chemotherapy is the primary medical treatment.
Combination chemotherapy with the addition of radiotherapy for locorégional control has been shown to improve survival. Additional prophylactic cranial irradiation has been shown to decrease the incidence brain metastasis, but has not been shown
to improve overall survival.
Other paraneoplastic syndromes associated with
hormone alterations should also be recognized.
Often Patients with SCLC may exhibit elevations in adrenocorticotropic hormone (ACTH). This may manifest with hypokalemia, hyperglycemia, and metabolic alkalosis.
Diagnosis can be confirmed by
measuring elevated ACTH in the blood or elevated
17-hydroxycorticosteroid levels in the urine.
- A 14-year-old boy is seen by a pediatric cardiologist because of increasing shortness of
breath. Studies reveal increased pulmonary
vascular resistance, left axis deviation on
Electrocardiogram (ECG), and mitral regurgitation murmur. What is the most likely
diagnosis?
(A) Ostium primum defect
(B) Tetralogy of Fallot
(C) Right aortic arch
(D) Ostium secundum defect
(E) Atrioventricular canal
- (A) Ostium primum. Typically ostium primum
in an adolescent would be diagnosed by
increasing symptoms, increased pulmonary
resistance, left axis on ECG, and a mitral regurgitation murmur due to a cleft mitral valve.
Ostium secundum would cause increased pulmonary resistance later in life, not at age 14. AV
canal is seen most commonly in Down syndrome. Right aortic arch and tetralogy of Fallot
do not have this symptom complex.
- A cyanotic female neonate is born with transposition of the great arteries. Metabolic acidosis and hypoxemia are present and are life
threatening. Which of the following is the best
initial treatment?
(A) Urgent Mustard operation
(B) Prostaglandin E1
(C) Atrial septotomy
(D) Pulmonary artery banding
(E) Prostaglandin E1 and atrial septotomy
- (E) Prostaglandin E1 and Aterial septotomy.
Prostaglandin E1 is used to keep the ductus
arteriousus open in transposition. Desaturated
“systemic” blood can pass through the pulmonary circulation to be oxygenated. The aterial septotomy creates an ASD, which aids in
saturated blood being pumped peripherally,
decreasing the cyanosis. The mustard operation is not commonly done as the arterial
switch operation is most common in this era,
and in this acutely ill neonate definitive operation would not be the best initial treatment.
Pulmonary artery banding does not apply.
- A 65-year-old man undergoes cardiac surgery
for triple vessel coronary artery disease. What
can he anticipate?
(A) 95% chance his grafts will occlude after
12 months.
(B) 5% chance of living for 5 years.
(C) If the internal mammary artery is used
as a conduit, patency is increased.
(D) Mortality if 10–20% in most centers.
(E) Functional improvement with the
saphenous vein graft is better than
internal memory artery.
- (C) Internal thoracic artery. The internal thoracic artery is the conduit of choice especially
for grafting the left anterior descending (LAD)
artery. Arterial and venous grafts 95% of the
time do not occlude after 12. Seventy-five percent of patients under coronary artery bypass
graft (CABG) survive 5 years. Mortality is 2%
or lower in most centers.
- Three months after aortic valve replacement
with a mechanical prosthesis, a 60-year-old
man describes malaise, and increasing shortness of breath. Examination reveals pulsus
paradoxus. ECG shows low voltage precordially. What test is most useful for making the
diagnosis?
(A) Stress thallium exam
(B) Computer Tomography (CT)
examination of chest
(C) Coronary angiography
(D) Echocardiography
(E) Serum creatinine phosphokinase (CPK)
- (D) Echocardiography. This patient has a pericardial effusion. Echocardiography is the most
useful in making the diagnosis. CAT scan of the
chest can be used but is not the best exam. The
other choices do not apply.
5. In the patient described above urine output decreases to 20 cc/h. Studies reveal paradoxical septal motion. What is the next course of therapy? (A) Expectant medical therapy (B) Redo aortic valve surgery (C) Left chest tube (D) Ontra-aortic balloon (E) Pericardial window
- (E) Pericardial window. The patient developed
decreased cardiac output (decreasing urine
output,)and cardiac tamponade. Emergent
pericardial window is the treatment of choice.
Medical therapy will result in the patient’s
death. The other choices do not apply.
- A 58-year-old man is in cardiogenic shock in
the emergency department after sustaining an
acute myocardial infarction (MI). An intraaortic balloon pump (IABP) is inserted. Which
statement is TRUE about IABP?
(A) The balloon increases coronary
perfusion during diastole.
(B) The balloon increases coronary
perfusion during systole.
(C) The balloon increases peripheral
resistance.
(D) The balloon is inflated in systole and
diastole.
(E) The pump must be removed after
24 hours.
- (A) IABP increases coronary perfusion during
distole. The IABP inflates during diastole and
propels blood into the coronary circulation.
IABP decreases peripheral resistance and
decreases afterload on the heart. The IABP can
stay in the patient for longer than 24 hours.
- A 66-year-old female has had two MIs in the
past. She is admitted to the emergency department in congestive heart failure. After admission and appropriate therapy her Holter
monitor shows frequent PVCs and her ejection
fraction is found to be 35%. Appropriate treatment would include which of the following?
(A) Single chamber pacemaker
(B) Cardioversion
(C) Dual chamber pacemaker
(D) Internal cardiac defibrillator (ICD)
(E) Greenfield filter
- (D) ICD. In a patient with history of MI, congestive heart failure, and decreased ejection
fraction coupled with frequent premature ventricular beats studies have shown that this
subset of patient benefits from internal cardiac
defibrillators, as the most frequent cause of
death in these patients is sudden cardiac death
from ventricular fibrillation. Single and dual
chamber pacemakers are used for bradyarrythmias. The other choices do not apply.
- During a routine examination of a 30-year-old
female actuary seeking life insurance, she is
found to have a ventricular septal defect (VSD).
She undergoes subsequent studies including
ECG, chest x-ray, echocardiography, and
Doppler ultrasound. What is the major determinant of operability in VSD?
(A) Age of patient
(B) Pulmonary vascular resistance
(C) Size of the VSD
(D) Location of the VSD
(E) Presence of cyanosis
- (B) Increase in pulmonary vascular resistance
causes an increased cardiac output. Small shunts
(with a pulmonary/systemic flow ratio >1.5) do
not require surgery but must be treated with
prophylactic antibiotics. Larger shunts should be
repaired, because the mortality rate exceeds 50%
when severe pulmonary pressure (>85 mm Hg)
occurs. Closure of the VSD in the presence of
cyanosis with established reversal of the direction of flow (right to left) would be detrimental, carrying a very high mortality.
- At the age of 3 years, a child with a VSD
becomes progressively short of breath and
requires urgent surgery. What is the most
common type of VSD (Fig. 4–1)?
(A) Defect anterior to the crista
supraventricular
(B) Membranous septal defect
(C) Posterior septal defect
(D) Low muscular defect
(E) Right-to-left shunt
- (B) VSD is the most common cardiac congenital abnormality and results from failure of
fusion of the uppermost part of the interventricular septum with the aortic septum.
Membranous septal defects account for 90% of
VSDs. There is usually a left-to-right shunt and
cyanosis does not occur until pulmonary
hypertension is severe enough to reverse flow
across the VSD. Surgery is indicated in large
shunts only when symptoms occur and pulmonary hypertension is evident. Forty percent
will close spontaneously in childhood.
- A 1-year-old girl is found to have a posterior
membranous VSD. Peripheral resistance of the
pulmonary system is 40% that of the systemic.
How should you proceed?
(A) Observe the child, because most VSDs
close spontaneously.
(B) Band the pulmonary artery and fix the
defect at age 6.
(C) Repair electively at age 14.
(D) Repair electively between ages 4 and
6 years.
(E) Repair immediately as an emergency.
- (D) Increase in pulmonary resistance would
require more urgent intervention. Because
nearly half the cases of VSD in childhood will
close spontaneously, elective surgery is deferred
to late childhood. Banding procedures are used
less frequently today because of the high mortality rate. If symptoms increase in severity and
pulmonary pressure is high, more urgent intervention is indicated. If the pulmonary systolic
pressure is over 85 mm Hg and the left-to-right
shunt is small, surgical mortality exceeds 50%.
- At birth, the 6 weeks premature infant is
noted to have progressive dyspnea. There is a
continuous murmur in the pulmonic area (second left intercostal space), and cyanosis is
absent. ECG findings are normal. An x-ray of
the heart shows cardiomegaly, and the pulse
is bounding. Patent ductus arteriosus (PDA)
is diagnosed. What does treatment include?
(A) Immediate surgical correction
(B) Administration of indomethacin
(C) Administration of cortisone
(D) Renal dialysis
(E) Endotracheal intubation in all cases
- (B) Management of compromised respiratory
status in the premature infant with PDA
includes fluid restriction, adequate oxygenation, attempted closure by medication with
indomethacin, and surgical ligation (undertaken when indomethacin is contraindicated).
Good results can be anticipated in the absence
of other serious complications.
- During a routine preschool physical examination, the physician notes that a 3-year-old girl
has a machinery-type murmur on auscultation
of the chest. The pulse is bounding and palpable in the femoral and radial region of both
sides of her body. There were no symptoms,
and she has excellent exercise performance.
Persistent PDA is confirmed on subsequent
examination. The parents should be advised
that the girl requires which of the following:
(A) Surgical correction and closure of the
PDA
(B) Indomethacin
(C) Coronary angiography
(D) No treatment unless symptoms occur
(E) CT scan of the heart
- (A) In full-term infants born with persistent
PDA, the anomaly must be closed or excised
between 6 months and 3 years of age to avoid
cardiac complications, including endocarditis.
In PDA, persistence of the communication
between the pulmonary trunk and aorta
increases pulmonary blood flow, left atrial
flow, left ventricular flow, and ascending aorta
flow. PDA accounts for 15% of all congenital
cardiac abnormalities. Cyanosis does not occur
initially, because oxygenated blood is shunted
from the aorta to the pulmonary trunk. The
murmur is continuous (sounds like machinery)
and has harsh features. Its intensity is maximum over the left second intercostal space but
radiates to the chest wall and the neck.
- At the age of 34 years, a female long-distance
runner notes increasing dyspnea after running
more than 10 mi. On inspection and palpation,
a prominent right ventricular heave is noted.
There is a loud systolic murmur in the left third
interspace. The ECG shows right-axis deviation with right bundle branch block. An x-ray
of the chest shows a small aortic knob. What
sign or test will most likely reveal the cause of
the congenital heart abnormality thought to be
atrial septal defect?
(A) Beading (scalloping) of the ribs on x-ray
(B) Decreased carotid pulse
(C) Left ventricular hypertrophy on ECG
(D) Elevated sedimentation rate
(E) Increased oxygen saturation gradient
between the superior vena cava and the
right ventricle
- (E) Cardiac catheterization is the definitive test
for confirming the diagnosis of ASD. It quantifies the size of the shunt and confirms the
increase in oxygen saturation between the right
ventricle and the superior vena cava. Beading
of the ribs is seen in coarctation, and a
decreased carotid pulse is found in aortic stenosis. An elevated sedimentation rate occurs in
the presence of infection such as bacterial
endocarditis.
- The only son of a physiology instructor dies
suddenly at the age of 12 years following worsening symptoms of tetralogy of Fallot. What
would an autopsy reveal?
(A) Dextroposition of the appendix
(B) Brachiocephalic vein draining into the
right renal vein
(C) Inferior vena cava (IVC) draining to the
superior mesenteric vein
(D) Atrial Septal Defect (ASD)
(E) Decreased vascularity of the lung field.
- (E) There is decreased vascularity of the lungs
seen on chest x-ray. Tetralogy of Fallot includes
VSD, right ventricular outflow obstruction,
dextroposition of the aorta, and right ventricular hypertrophy. Tetralogy of Fallot accounts
for over one-half the cases of congenital cyanotic heart disease.
- After suffering a streptococcal throat infection,
a 12-year-old immigrant boy develops cardiac
symptoms that are attributed to rheumatic
fever. Years later, at the age of 34 he is admitted
to the hospital with pulmonary edema. Further
examination reveals a diastolic murmur at the
apex and mitral stenosis is diagnosed. Before
surgical evaluation, which of the following
findings can be attributed to mitral stenosis?
(A) Large left ventricle
(B) Indentation of the middle third of the
esophagus by an enlarged left atrium
(C) Notching of the ribs
(D) Bounding, full pulse
(E) Angina pectoris
- (B) Dilation of the left atrium is the obvious complication following long-standing mitral stenosis.
Echocardiography is the simplest and most precise method of showing enlargement of the left
atrium. Frequently, there is a latency period of
15–20 years before symptoms become evident.
Important complications of mitral stenosis
include exertional dyspnea caused by an increase
in left atrial pressure and backup of blood with
possible pulmonary edema, decreased cardiac
output, atrial fibrillation, emboli (15%), and pressure in the intermediate third of the esophagus as
seen on an esophogram after barium swallow.
The pulse in mitral or aortic stenosis is reduced.
- A 23-year-old ballet dancer is concerned about
the recent sudden death of a young famous
Russian dancer on a New York stage. The
patient seeks advice about his own risk for
developing cardiac disease. His father died
suddenly from ischemic heart disease at the
age of 40. What is the most important risk
factor that would further indicate the possibility of coronary artery heart disease?
(A) Diabetes mellitus
(B) Personality type
(C) Elevated high-density lipoprotein
(D) Elevation of total cholesterol/
high-density lipoprotein ratio
(E) Obesity
- (D) Elevation of total cholesterol/high-density
lipoprotein is a useful predictor of coronary
artery disease (CAD). Other known main risk
factors include genetic predisposition, high
cholesterol level, arterial hypertension, and cigarette smoking. Obesity, diabetes mellitus, and
personality type are of probable importance as
independent risk factors. The presence of
elevated high-density lipoprotein is a favorable factor.
- In evaluating the risk factors involved in advising elective cholecystectomy in a 52-year-old
man with heart disease, which of the following
conditions should alert the surgeon to avoid
an elective procedure?
(A) MI 9 months earlier
(B) Persistent nonspecific changes on ECG
(C) Increased frequency and severity of
attacks of angina
(D) Elevated alkaline phosphatase levels
(E) Hypertension controlled with diuretics
- (C) Changes in the nature of angina should alert
the physician to the possible progression of the
underlying cardiac status. The pain may become
more severe and more frequent, may last longer,
and may occur with a lesser degree of exertion.
Nocturnal pain should likewise signal concern.
In the face of unstable angina, 30% of patients are
likely to develop MI within a 3-month period.
- After his first heart attack 3 years ago, a 63-
year-old painter complained of central chest
pains that radiated to the left arm after exercise.
The pain was alleviated by nitroglycerin.
Recently, he fell on a steel object and severed
the median nerve and flexor tendons at the
wrist. The skin was sutured but he is now
scheduled to have a second operation that will
require anesthesia. What is the best method to
diagnose angina pectoris?
(A) Cholesterol/high-density lipid ratio
(B) Isoenzymes
(C) Stress electrocardiography
(D) Echocardiography
(E) Chest x-ray
- (C) In about one-quarter of patients with angina
pectoris, the ECG findings will be normal.
Exercise electrocardiography will reveal STsegment depression and possibly precipitate
symptoms if angina pectoris is present. There is
a risk of myocardial death in patients tested, and
patients with symptoms after minimal exertion
and/or unstable angina are at particular risk
with this procedure. If hypotension, ventricular
arrhythmia, and supraventricular arrhythmia
occur or if the ECG shows a fall in segment ST of
over 3 mm, the test should be discontinued.
In these cases, 201Tl scintigraphy would be
used to detect cardiac ischemia or infarction.
Echocardiography during supine exercise may
be a helpful test in selected circumstances.
- Eight days after undergoing a hysterectomy, a 64-year-old woman complains of chest pain.
After 12 hours, the internist orders tests to
exclude MI. Which test will most likely support
this diagnosis?
(A) Serum glutamic oxaloacetic
transaminase (SGOT) elevation
(B) Increased sedimentation rate
(C) 99mTc pyrophosphate scintigraphy
showing a “hot spot”
(D) Thallium 201 (201Tl) scintigraphy
showing a (“hot spot”)
(E) Dimethyliminodiacetic acid (HIDA) scan
- (C) 99mTc pyrophosphate scintigraphy showing a
“hot spot.” Following injection of 99mTc pyrophosphate, scintigraphy may show a hot spot in the
infarcted area. The hot spot is developed as the
radiotracer forms a complex with calcium in
necrotic tissue. The test should be requested
within the first 18 hours following the onset of
acute MI. It is not sensitive enough to detect
small infarctions. Following 201Tl scintigraphy, a
“cold spot” occurs because of hypoperfusion.
The test is performed where exercise or dipyridamole (Persantine) injection can be given.
SGOT levels are elevated in liver disease. The
HIDA scan is used to exclude gallbladder disease. Cardiac enzyme levels and ECG findings
are useful to establish a diagnosis of MI.
- After undergoing repair of a left indirect
inguinal hernia, a 72-year-old obese man is
admitted to the emergency department with
severe retrosternal pain of 1-hours duration.
The pain radiates to the medial aspect of the left
hand. The ECG shows Q waves and an elevated ST-segment. A diagnosis of acute MI is
established 1 hour after admission. Immediate
management should include which of the
following?
(A) Thrombolytic therapy with tissue
plasminogen activator (tPA)
(B) Vitamin K
(C) Ampicillin, 2 mg tid PO
(D) Hydrochlorthiazide, 50 mg/d
(E) Sodium, nitroprusside 0.5 mg/kg/min
- (A) Thrombolytic therapy intravenously with
streptokinase, urokinase, or tPA is indicated
in most patients with MI presenting early for
treatment. This therapy, however, is effective
only if initiated within 6 hours after the onset
of pain in patients with acute MI. These drugs
are fibrinogenolytic, and aspirin and heparin
are frequently included in the anticoagulant
protocol. Reperfusion rates of 60% can be
anticipated; reocclusion rates of 15% usually
occur. Vitamin K is not indicated, because it
would increase the coagulability of blood. If
a diuretic, such as hydrochlorothiazide, 25–50
mg/d is indicated to treat milder hypertension, hypokalemia must be avoided.
- Following recovery from an acute MI, a 44-
year-old embryology lecturer is discharged
from the hospital with what instructions?
(A) Angiogram every 3 months to evaluate
the degree of atherosclerosis
(B) Nitroglycerin three times a day
(C) Digoxin
(D) 325 mg of aspirin on alternate days
(E) Pacemaker insertion
- (D) Studies have shown that in men over the
age of 50, taking 1 tablet of aspirin (325 mg) on
alternate days reduces the incidence of subsequent CAD complications. Nitroglycerin is prescribed if angina pectoris develops, and
digoxin would be indicated if congestive heart
faliure (CHF) is evident. Progression of atherosclerosis should be minimized by appropriate
diet and exercise. The intake of excess of cholesterol and saturated fats in the diet causes
changes in the vascular endothelium and
smooth muscle proliferation, with subintimal
fat and fibrous tissue accumulation leading to
occlusion of the coronary arteries, their
branches, and other arteries.
- A 63-year-old woman fell while crossing the
street after her Thursday afternoon bridge
game. Attempts at resuscitation for cardiac
arrest by the emergency medical service (EMS)
team were unsuccessful. The woman had previously been diagnosed as having aortic stenosis and left ventricular hypertrophy. In addition
to these factors, which of the following predisposes to sudden cardiac death?
(A) Split first heart sound
(B) Hypokalemia
(C) Soft murmur at left of sternum that
varies with inspiration
(D) Failure of the central venous pressure
(CVP) to rise more than 1 cm H2O with 30-second pressure on the liver (hepatojugular reflux)
(E) CVP of -1 cm H2O
- (B) Sudden cardiac death is defined as an unexpected death occurring within 1 hour after the
beginning of symptoms in a patient who was
previously hemodynamically stable. In asymptomatic patients presenting initially with cardiac disease, 20% will die within the first hour
of symptoms. Electrolyte imbalance, hypoxia,
and conduction system defect are additional
factors that increase the risk of sudden death
syndrome. Split first heart sound accentuated
on inspiration occurs in normal individuals. In
CHF, the CVP changes more than 1 cm when
pressure is applied below the right costal
margin to the liver (hepatojugular reflex) for a
30-second period.
New York Classification of Functional
Changes in Heart Disease
Class Limitation of Physical Activity
I None
II Slight
III Marked
IV Complete (even at rest)
- Three days after a patient underwent hip
replacement for a fracture of the neck of the
femur, the resident is called to examine the
patient and notes hypotension ( 85/60 mm Hg)
and a pulse rate of 104 beats per minute (bpm).
Fluids are administered, but there is no improvement. The ECG shows peaked T waves
and ST-elevation. Bedside monitoring reveals a
cardiac index (CI) of 1.7 L/min/m2 (normal
>2.2), stroke work index of 16 g/m2 (normal
>30), and a pulmonary artery wedge pressure
(PAWP) of 22 mm Hg (normal <15). Urgent
treatment should involve which of the
following?
(A) Rapid hypertonic saline solution
administration
(B) Adrenaline
(C) Inotropic agents and, if necessary,
intra-aortic balloon counterpulsation
(D) Indomethacin
(E) Atropine
- (C) The patient described has cardiogenic
shock due to postoperative MI. The mortality
rate for patients who develop MI is increased to
more than 60% if hypotensive cardiogenic
shock also supervenes. Pathology studies of
patients dying after such episodes reveal that
more than 40% of the heart will have infarcted.
Inotropic drugs such as dobutamine are used.
If a rapid response is not obtained, intra-aortic
balloon tamponade is provided to unload the
left ventricle during systole and increase diastolic coronary arterial flow. Hypertonic solutions in graded amounts would be given only
if hypovolemia is evident. Atropine and adrenaline would be contraindicated.
- A 58-year-old neurologist is admitted to the
emergency department with persistent hypotension and shock following an acute MI. He is
placed on an IABP. Which following statement is
true about IABP?
(A) The balloon is inflated during systole.
(B) The balloon is inflated during diastole
and systole.
(C) The pump must be removed after
10 minutes.
(D) The balloon usually is inserted via the
femoral artery.
(E) Use of an IABP worsens diastolic
coronary blood flow.
- (D) The balloon usually is inserted via the
femoral artery. The balloon is inflated during
diastole and deflated during systole. It is
important that the balloon be adequately
deflated during systole to avoid damage to the
left ventricle. The pump can be used for a few
days if required.
- While lying on the examining table before
colonoscopy, a 68-year-old electrician notes palpitations. The colonoscopy was scheduled as a
routine procedure following removal of a
benign polyp 1 year earlier. He had rheumatic
fever in infancy. His atrial rate on ECG is 450
bpm, and his ventricular rate is 160 bpm. His
pulse rate is 88 bpm. The left atrium is enlarged.
Similar findings were noted 1 year ago, but he
declined to take any medication. Treatment
should entail which of the following?
(A) Continue with colonoscopy
(B) Continue with colonoscopy after
administration of parenteral antibiotics
(C) Immediate administration of antibiotics
and follow-up colonoscopy at a later date
(D) Immediate administration of
anticoagulation and digoxin and
follow-up colonoscopy at a later date
(E) Immediate electrocardioversion with a
current of 300–400 J
- (D) The major complications occurring in
atrial fibrillation are cardiac failure, coronary
ischemia, and emboli. Emboli may lead to
stroke. Urgent cardioversion is required in
patients with auricular fibrillation if heart failure, hypotension, or angina are also present.
Immediate cardioversion is indicated in ventricular tachycardia or ventricular fibrillation. If
treatment with lidocaine is ineffective, electrocardioversion with 100–200 J for ventricular
tachycardia or 300–400 J for ventricular fibrillation is urgently indicated.
- During routine clinical examination of a 23-
year-old seeking consultation to remove a mole
on her left cheek, she develops tachycardia
with a pulse rate of 186 bpm. Her pulse is regular and is otherwise asymptomatic. An ECG
reveals supraventricular tachycardia. What
should the treatment be?
(A) Alternate pressure on the right and left
carotid sinus
(B) Bilateral simultaneous pressure over
right and left carotid sinus
(C) Deep eyeball pressure
(D) Morphine sulfate, 4–8 mg IV, given
cautiously
(E) Electrical cardioversion
- (A)Alternate pressure over the carotid sinus
for 20 seconds will end an attack of paroxysmal
tachycardia in nearly one-half of cases. The
procedure is contraindicated in patients who
have had a cerebral TIA or those who have a
carotid bruit. Bilateral simultaneous pressure
on the carotid sinus carries an additional risk of
stroke and must be avoided. The common
carotid artery usually divides at the level of
the upper border of the thyroid cartilage or
hyoid bone (C3). The carotid sinus may be
located either on the proximal internal carotid
artery or distal common carotid bifurcation.
Eyeball pressure may be effective but carries
the risk of retina detachment. If initial measures
are unsuccessful, the arrhythmia is treated with
intravenous administration of verapamil or a
similar drug. Electrocardioversion is indicated
in severe cases, particularly if there are adverse
symptoms caused by the tachycardia.
- After experiencing progressive chest pain for
2 months, a surgical-supply store owner undergoes a CT scan that reveals a space-occupying
lesion of the wall of the left atrium, which was
confirmed to be a myxoma. There is no evidence of disease elsewhere. What would the
next line of treatment be?
(A) Excision of a myxoma performed with a
bypass procedure
(B) Excision of a myxoma performed
without a bypass procedure
(C) Insertion of a pacemaker
(D) Chemotherapy
(E) Radiotherapy
- (A) Myxomas constitute more than 50% of all
primary cardiac tumors. They are usually polypoid and attached to the septum. Sarcomas
constitute 20–25% of primary cardiac tumors.
Cardiac metastases are seen in patients with
metastatic disease.
- During examination of a 49-year-old male
schoolteacher who presents with a swelling in
the neck, palpation by a bounding pulse. Which
test would be most likely to establish a possible
cause of the underlying condition?
(A) Funduscopic eye examination
(B) Liver–spleen scan
(C) Thyroid function studies
(D) X-ray of the chest and cervical spine
(E) Carotid sinus pressure
- (C) The pulse is bounding when the pulse pressure is magnified because of a wide difference
between the systolic and diastolic pressure. It
may be due to aortic incompetence, PDA, or
noncardiac causes that result in increase in cardiac output and decreased peripheral resistance (e.g., hyperthyroidism, peripheral AV
fistula, or anemia).
