Pre-Test Questions Flashcards
A 75 y/o woman w hx of angina admitted to hospital for syncope. Exam of pt reveals systolic murmur best heard at base of heart that radiates into carotid arteries. ECG notable for left ventricular hypertrophy with evidence of left atrial enlargement. ECG revolves aortic valve area of 0.7 cm^2. What is the most appropriate next step in her management?
a. Medical mgmt w nitrate and ACEI
b. Bilateral carotid endarterectomies
c. Percutaneous coronary artery angioplasty and stenting
d. CABG
e. Aortic valve replacement
e. Aortic valve replacement
- Percutaneous coronary artery angioplasty and stenting helpful for pts who are not candidates for aortic valve replacement… valvuloplasty involves passing balloon catheters through aortic orifice and inflating them in an effort to break the calcium that is retarding leaflet motion
- Carotid endarterectomy –> tx for carotid artery stenosis
- Medical mgmt –> tx for CAD
68 y/o man dx with lung cancer
In prep for pulmonary resection, he undergoes pulmonary function tests. Which of the following results indicate a favorable prognosis?
a. Elevated PCO2
b. FEV1 > 60% predicted
c. DLCO less than 40%
d. Low FEV1/FVC
e. Normal FEV1/FVC
b. FEV1 > 60% predicted
Most pts will tolerate a lobectomy with FEV1 > 60% predicted
- CO diffusing capacity measures rate at which CO moves from alveolar space to combine with Hb in RBCs. It is determined by calculating difference between inspired and expired samples of gas. DLCO levels less than 40% to 50% associated with increased perioperative risk.
71 y/o woman with 40 year smoking hx noted to have peripheral nodule in L upper lobe on CXR. Workup consistent with SCLC with ipsilateral mediastinal lymph node involvement but no extrathoracic disease. What is the best tx option for this patient?
Chemotherapy + radiation
SCLC are rarely amenable to surgical resection b/c of extensive disease at presentation.
42 y/o homeless man presents with 3 week hx of SOB, fevers, pleuritic chest pain. CXR reveals large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate mgmt of this patient?
a. Placement of 2nd chest tube at bedside and abx
b. Infusion of abx via chest tube
c. IV abx for 6 weeks
d. Thoracotomy with instillation of abx into pleural space
e. Thoracotomy with decortication and abx therapy
e. Thoracotomy with decortication and abx therapy
A 63 y/o man is seen because of facial swelling and cyanosis, especially when he bends over. They are large, dilated subcutaneous veins on his upper chest. His jugular veins are prominent even while he is upright. Which of the following conditions is the most likely cause of these findings?
a. Histoplasmosis (sclerosing mediastinitis)
b. Substernal thyroid
c. Thoracic aortic aneurysm
d. Constrictive pericarditis
e. Bronchogenic carcinoma
e. Bronchogenic carcinoma
SVC obstruction almost always due to malignancy (90% of cases) and in 3 out of 4 cases, results from invasion of vena cava by bronchogenic carcinoma. Lymphomas = 2nd most common cause of SVC syndrome.
Although constrictive pericarditis may decrease venous return to the heart, it does not produce obstruction of the SVC. Whatever the cause of SVC syndrome, the resultant increased venous pressure produces edema of the upper body, cyanosis, dilated subcutaneous collateral vessels in the chest, and headache.
What is the initial mgmt for SVC syndrome?
Diuresis
For malignancies: radiation and chemotherapy
During endoscopic biopsy of distal esophageal cancer, perforation of the esophagus is suspected when the pt complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate mgmt of this pt?
a. Placement of NGT to level of perforation, abx, and close observation.
b. Spit fistula (cervical pharyngostomy) and gastrostomy
c. Left thoracotomy, pleural patch oversewing of the perforation, and drainage of the mediastinum.
d. L thoracotomy with esophagectomy
e. Thoractomy with chest tube drainage and esophageal exclusion
* What is the mgmt for pts with no underlying esophageal disorder?*
d. L thoracotomy with esophagectomy
Perforation of the esophagus in chest = SURGICAL CATASTROPHE
Dx confirmed with contrast esophagogram
What is the mgmt for pts with no underlying esophageal disorder?
Repair of perforation and drainage of mediastinum
A 63 y/o woman w/ COPD presents with a several-week hx of fever, night sweats, weight loss, and cough. Her CXR noted to have a density in the L upper lobe with a relatively thin-walled cavity. Bronchoscopy and CT scan suggestive of a lung abscess rather than malignant process. Which of the following is the most appropriate initial mgmt of this patient?
a. Percutaneous drainage of lung abscess
b. Systemic antibiotics directed against causative agent
c. Tube thoracostomy
d. Left upper lobectomy.
e. Surgical drainage of abscess
b. Systemic antibiotics directed against causative agent
Often, the abscess drains spontaneously via tracheobronchial tree, but, if it fails to resolve with medical therapy, intervention may be required, ranging from percutaneous to surgical drainage of the abscess or resectional therapy.
A 45 y/o man with poorly controlled HTN presents with severe chest pain radiating to his back. An ECG demonstrates no significant abnormalities. A CT scan of the chest and abdomen is obtained, which demonstrates a descending thoracic aortic dissection extending from distal to the left subclavian takeoff down to above the iliac bifurcation. A Foley is placed, and urine output is 30 to 40 cc/h. His feet are warm, with less than 2-sec capillary refill. Which of the following is the most appropriate initial mgmt?
a. Emergent operation for repair of dissection
b. Angiography to confirm dx of dissection
c. B-blocker
d. Initiation of vasodilator such as nitroprusside
c. B-blocker
Initial tx is to reduce rate of change in blood pressure and reduce shear on the aortic wall
Nitroprusside may be added after beta-blockade has been achieved.
A stockbroker in his mid-40s presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. Diagnostic studies on the esophagus yield the following results:
- endoscopic examination and biopsy–mild inflammation distally;
- manometry–prolonged high-amplitude contractions from aortic arch distally, LES pressure 20 mm Hg with relaxation on swallowing (normal < 26… achalasia > 100)
- barium swallow–2 cm epiphrenic diverticulum
Which of the following is the best mgmt option for this pt?
a. Myotomy along length of manometric abnormality
b. Diverticulectomy, myotomy from level of aortic arch to fundus, fundoplication
c. Diverticulectomy, cardiomyotomy of the distal 3 cm of esophagus and proximal 2 cm of stomach
d. CCB
e. Pneumatic dilatation of LES
a. Myotomy
The finding of prolonged high-amplitude contractions in the esophagus body dx of diffuse esophageal spasm.
A previously healthy 20 y/o man is admitted to the hospital with acute onset of L-sided chest pain. Electrocardiographic findings are normal, but CXR shows a 40% L pneumothorax. Appropriate tx consists of which of the following procedures?
a. Observation
b. Barium swallow
c. Thoracotomy
d. Tube thoracostomy
e. Thoracostomy and intubation
d. Tube thoracostomy
Spontaneous pneumothorax usually results from rupture of subpleural blebs in young men (age 20-40 years), which is often signaled by sudden onset of chest and shoulder pain. Large pneumothoraxes require placement of a chest tube; thoracotomy with bleb excision + pleural abrasion is generally recommended if spontaneous pneumothorax is recurrent
A 50 y/o salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your ER 4 hrs later and has a chest film in which the left descending aorta is outlined by air density. Which of the following is the most appropriate next step in his workup?
a. Contrast esophagram
b. Echocardiogram
c. Flexible bronchoscopy
d. Flexible esophagogastroscopy
e. Aortography
a. Contrast esophagram
Contrast esophagram indicated with barium for suspected thoracic perforation
Water-soluble contrast (gastrografin) for abdominal perforation
**barium is inert in the chest but causes peritonitis in abdomen, whereas aspirated gastrografin can cause severe pneumonitis
A 26 y/o man is brought to the ER after being extricated from the driver’s seat of a car involved in a head-on collision. He has a sternal fracture and is complaining of chest pain. He is hemodynamically stable and his ECG is normal. Which of the following is the most appropriate mgmt strategy for this patient?
a. Admit to tele for 24 hr monitoring
b. Admit to regular ward with serial ECGs for 24 hrs
c. Emergent cardiac acath
d. Immediate operative plating of sternal fracture
a. Admit to tele for 24 hr monitoring
There are no universally accepted criteria for dx of myocardial contusion. Therefore, if there is significant clinical suspicion, then the pt should be monitored on tele or in ICU for 24 hrs
A 63 y/o man underwent a 3-vessel CABG 5 hours ago. Initially, his mediastinal chest tube output was 300 mL blood/h, but an hr ago, there was no further evidence of bleeding from the tube. His MAP has fallen, and several fluid boluses were administered. His CVP is elevated to 20 mm Hg, and he has required the addition of inotropes. Which of the following is the best mgmt strategy?
a. Addition of vasopressors along with inotropes
b. Transfusion of packed RBCs
c. Return to the OR for exploration of the mediastinum
d. Placement of intraaortic balloon pump
e. Infusion of streptokinase into mediastinal chest tube
c. Return to the OR for exploration of the mediastinum
Cardiac tamponade = life-threatening complication that can occur after CABG. If the pt has bleeding post-op, the patient’s coagulopathy should be corrected. Clotting of the mediastinal chest tube followed by hemodynamic decompensation with decreased MAP.. and CO with increasing filling pressures suggestive of tamponade.
Equalization of pressures across 4 chambers on Swan-Ganz or collapse of RA on echo = dx of tamponade
Several days following esophagectomy, a patient compalins of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial mgmt of this pt?
a. Immediate operation to repair thoracic duct
b. Immediate operation to ligate thoracic duct
c. Tube thoracostomy and low-fat diet
d. Observation and low-fat diet
e. Observation and abx
c. Tube thoracostomy and low-fat diet
To reduce flow of chyle
Chylothorax may occur after intrathoracic surgery, or it may follow malignant invasion or compression of thoracic duct. Intraoperative recognition of thoracic duct injury is managed by ligation of duct. Direct repair is impractical owing to extreme friability of thoracic duct. Injuries not recognized until several days after surgery frequently heal following low-fat diet + tube thoracostomy drainage
A 63 y/o man has a chylothorax that after 2 weeks of conservative therapy appears to be persistent. The chest tube output is approximately 600 mL/day. Appropriate mgmt at this time includes which of the following procedures?
a. Neck exploration and ligation of the thoracic duct
b. Subdiaphragmatic ligation of the thoracic duct
c. Thoracotomy and repair of the thoracic duct
d. Thoracotomy and ligation of the thoracic duct
d. Thoracotomy and ligation of the thoracic duct
The initial tx for a chylothorax consists of nonoperative therapy: drainage of the chest cavity, bowel rest, and TPN.
However, if chyle drainage continues to be greater than 500 mL/day, then operative ligation of teh thoracic duct should be performed.
The thoracic duct is ligated from teh diaphragm to T6. The thoracic duct enters the chest from the abdomen through the aortic hiatus of the diaphragm, courses on the R side of the chest, and then curves to the L at the level of the 5th thoracic vertebra.
