Pretest_8_CT_Problems

Question 1

Patients do not develop symptoms from aortic stenosis until the valve area is less than __ cm

Answer 1

1

Question 2

What measurement is the most commonly used predictor of postoperative pulmonary reserve?

Answer 2

FEV1 (>60% of predicted = can tolerate a lobectomy)

Question 3

A PCO2 greater than 45 mm Hg suggests severe pulmonary disease with ___% functional loss of the lung

Answer 3

50%

Question 4

Small cell lung cancer aggressively metastasizes early to the mediastinal lymph nodes and to distant sites, most commonly ____________

Answer 4

bone marrow and the brain

Question 5

In an empyema with glucose <7, what is the treatment?

Answer 5

This is the most advanced, organized phase of empyema–pleural rind surrounds it! Ned thoractomy with decortication (to remove purulent material and pleural rind) AND antibiotic therapy

Question 6

90% of the time, superior vena cava syndrome is due to _________. And 3/4 cases is due to

Answer 6

malignancy; invasion of vena cava by bronchogenic carcinoma

Question 7

What is the treatment for SVC syndrome?

Answer 7

diuretics, and if malignancy, radiation and chemotherapy if applicable

Question 8

What is the treatment of esophageal perforation?

Answer 8

When no underlying esophageal abnormality: primary repair of the perforation and drainage of the mediastinum

When underlying abnormality (motility disorder, stricture, malignancy) = esophagectomy (esp. if distal esophageal carcinoma)

Question 9

What is the INITIAL treatment of a descending aortic dissection?

Answer 9

Decrease in blood pressure with B-blockade, followed by nitrates once B-blockade achieved.

Question 10

What are the indications for operative intervention in descending aortic dissection?

Answer 10

End-organ failure (renal failure, lower extremity or intestinal ischemia, etc), inadequate pain relief despite maximum medical therapy, and rupture or signs of impending rupture (increasing diameter or periarotic fluid)

Question 11

The findings of prolonged high-amplitude contractions in the body of the esophagus in a highly symptomatic patient is diagnostic of

Answer 11

diffuse esophageal spasm

Question 12

What is the treatment of diffuse esophageal spasm?

Answer 12

Long myotomy guided by the manometric evidence

Question 13

The treatment of spontaneous PTX is tube thoracostomy; when is thoracotomy indicated?

Answer 13

Thoracotomy with bleb excision and pleural abrasion is generally recommended if spontaneous PTX is recurrent

Question 14

The presence of air in the mediastinum after an episode of vomiting and retching is virtually pathognomonic of

Answer 14

spontaneous rupture of hte esophagus (Boerhaave syndrome)

Question 15

What is the treatment of Boerhaave syndrome (after esophagram has confirmed esophageal injury)?

Answer 15

No evidence of sepsis = manage with antibiotics and expectant management
Systemic signs 24h = more extensive surgery

Question 16

T/F: Antiarrhythmics are indicated prophylactically in a patient withmyocardial contusion.

Answer 16

False! But they should be used to treat rhythm disturbances

Question 17

Equalizatoin of pressures across the four chambers on Swan-Ganz catheter monitoring or collapse of the right atrium on echocardiography are diagnostic of

Answer 17

cardiac tamponade

Question 18

Chylothorax, which may occur after intrathoracic surgery or following malignant invasion or compression of the thoracic duct, is treated by__________
If it is recognized intraoperatively, it is treated by __________

Answer 18

low fat diet (reduces the flow of chyle) and thoracentesis or thoracostomy drainage

intraoperatively = thoracic duct ligation (too friable for direct repair)

Question 19

These lesions are often attached by a pedicle to the fossa ovalis of the left atrial septum:

Answer 19

cardiac myxoma (treatment is resection)

Question 20

What are the three divisions of mediatstinum?

Answer 20

Anterosuperior = in front of pericardial sac
Middle = contents of pericardial sac
Posterosuperior = behind pericardial sac

Question 21

What are the most common primary tumors of the 3 divisions of the mediastinum?

Answer 21

anterosuperior = 1) thymomas, 2) lymphomas, 3) germ cell tumors
middle = cysts (pericardial, bronchogenic, enteric)
anteroposterior = neurogenic

Question 22

More commonly than neoplasm, a mass in the anterosuperior region of the mediastinum represents

Answer 22

a substernal extension of a benign substernal goiter

Question 23

How does CSF drainage with a lumbar drain improve prevent spinal cord ischemia in repairing descending aortic aneurysms?

Answer 23

Decreases the pressure on the blood supply to the spinal cord

Question 24

Zenker diverticulum is an outpouching of mucosa between the lower pharyngeal constrictor and the __________. What is the treatment?

Answer 24

cricopharyngeus muscles (thought to result from an incoordination of cricopharyngeal relaxation with swallowing). Treatment is cricopharyngeal myotomy which can be done under local anesthesia

Question 25

Zenker diverticulum arises more commonly in elderly patients and on the (right/left)

Answer 25

left

Question 26

Pain and numbness in the right arm and hand exacerbated by raising her arm over her head: (other symptoms = edema, venous congestion, digital vasospastic changes)

Answer 26

thoracic outlet syndrome

Question 27

Thoracic outlet syndrome results from...

Answer 27

compression of the brachial plexus or subclavian vessels or both in the anatomic space bounded by the first rib, the clavicle, and the scalene muscles

Question 28

Operative treatment of thoracic outlet syndrome:

Answer 28

division of the scalenus anticus and medius muscles, first rib resection, cervical rib resection, or combo of all three

Question 29

Another name for superior pulmonary sulcus carcinomas:

Answer 29

Pancoast tumors (peripheral bronchogenic carcinoma)

Question 30

Horner syndrome triad:

Answer 30

miosis, ptosis, anhidrosis

Question 31

A pancoast tumor could cause pain in which dermatomes?

Answer 31

C8 and T1 (it involves those nerve roots, as well as the sympathetic trunk)

Question 32

If conservative management (diet) of chylothorax is not helping and is draining more than 500 mL/day, what is the treatment? On what side?

Answer 32

RIGHT thoracotomy with operative ligation from diaphragm (t12 for thoracic duct) to T6 (the thoracic duct courses on the right side of the chest and curves to the left at T5)

Question 33

Carcionid tumors of hte lung are infrequently metastatic, slow-growing that are found __________ and frequently present with bronchial obstruction. The only therapy is __________

Answer 33

found in proximal bronchi; only therapy = operative resection; neither the primary tumor nor the infrequent lymph node metastasis is radiosensitive

Question 34

What is the pathophysiology of syphilis aortitis?

Answer 34

T pallidum invasdes the vasa vasorum and causes obliterative endarteritis and necrosis, ultimately weakining the aortic wall and predisposing it to aneurysm formation (ascending is characteristic)

Question 35

T/F: If tricuspid regurgitation leads to a sufficiently elevated venous pressure, exophthalmos may result.

Answer 35

True

Question 36

What is a Quincke pulse?

Answer 36

alternate flushing and paling of the skin or nail beds, and it is associated with aortic regurgitation

Question 37

Which mediastinal tumors are associated with myasthenia gravis, agammaglobulinemia, and red blood cell aplasia?

Answer 37

thymoma

Question 38

Reed-Sternberg cells are seen in

Answer 38

Hodgkin lymphoma Reed Sternberg cell = multinucleated or have a bilobed nucleus (thus resembling an "owl's eye" appearance) with prominent eosinophilic inclusion-like nucleoli

Question 39

Coughing up hair or sebaceous material =

Answer 39

connection between dermoid cyst (cystic teratoma) and treacheobronchial tree

Question 40

What are the results of epinephrine and low vs high doses? What is it typically used for?

Answer 40

``` Lower = Beta 1 and 2 (increase heart rate, stroke volume, contractility) Higher = alpha adrenergic receptors stimulate = increased BP and systemic vascular resistance ``` used as short-term agent given as IV bolus in cardiac arrests

Question 41

Does norepinephrine work on alpha or beta receptors?

Answer 41

Both! Ultimately increases afterload and glomerular perfusion pressure with preservation of cardiac output

Question 42

_________ is an effective agent in increasing BP in hypotensive patients with adequate fluid resuscitation.

Answer 42

Dopamine

Question 43

What receptors does dopamine act on?

Answer 43

``` low = specific dopamine receptors (increased urine output and natriuresis) modest = cardiac B1 = increased myocardial contractility and increased HR high = alpha-adrenergic; causes increase in BP and peripheral vascular resistance ```

Question 44

_________ is a synthetic cathecolamine that predominately binds to B-adrenergic receptors and enhances myocardial contractility with minimal changes in HR

Answer 44

Dobutamine

Question 45

What does phenylephrine act on?

Answer 45

Pure alpha agonist used on increasing peripheral vascular resistance and blood pressure (increases left ventricular work and may decrease CO)

Question 46

WHat is the difference between nitroglycerin and nitroprusside?

Answer 46

Nitroglycerin = venous smooth muscle vasodilator; used in myocardial ischemia by reducing excessive preload Nitroprusside = arterial and venous smooth muscle vasodilator; watch out for cyanide toxicity by monitoring serum thiocyanate and arterial pH (will become acidotic)!

Question 47

These lung lesions are usually popcorn in appearance:

Answer 47

hamartomas

Question 48

After this age, there is a 50% and steadily increasing chance that a SPN is malignant:

Answer 48

50yo

Question 49

____________ occurs in the SW US and _____________ in the Ohio Valley.

Answer 49

SW: coccidiomycosis | Ohio Valley: histioplasmosis

Question 50

Calcification of an SPN suggests it is (benign/malignant)

Answer 50

benign

Question 51

If mediastinal lymph nodes are positive for metastasis in lung cancer, it is stage ___

Answer 51

III

Question 52

Horner's involvement of the sympathetic ganglia (i.e., miosis, ptosis, and ipsilateral facial anhydrosis), and weakness and atrophy of the upper extremity musculature, typically in the ulnar nerve distribution:

Answer 52

Pancoast tumor = superior sulcus mass in apex of lung. Causes erosion of 1st and 2nd ribs (stage 3 = chest wall invasion)

Question 53

In laryngomalacia, the dyspnea is exacerbated when (supine/prone).

Answer 53

Supine

Question 54

Why can bronchial carcinoid tumors cause carcinoid tumor even without liver metastases?

Answer 54

Because enough serotonin reaches systemic circulation without breakdown

Question 55

What is the treatment of mesothelioma?

Answer 55

Extrapleural pneumonectomy is the only cure. Entire lung and parietal and visceral pleura along with, at times, pericardium and diaphragm, are resected

Question 56

The minimum postoperative FEV1 following lung surgery is

Answer 56

800 mL (split function VQ perfusion scan to calculate)

Question 57

A patient with recurrent spontaneous pneumothorax, as well as a patient with _____________, should have thorascopic excision of blelbs and pleural abrasion (pleurodesis)

Answer 57

bilateral spontaneous pneumothorax (very dangerous; would NOT want recurrence!) can use talc, bleomycin, tetracycline for chemical pleurodesis

Question 58

Name anterosuperior mediastinal tumors:

Answer 58

1) thymoma 2) lymphoma 3) dermoid/teratoma 4) germ cell tumors (seminoma) 5) retrosternal thyroid

Question 59

Name middle mediastinal tumors:

Answer 59

1) bronchogenic cyst 2) lymphoma 3) tracheal tumor 4) aneurysm of ARCH

Question 60

Name posterior mediastinal tumors:

Answer 60

1) neurogenic (eg neurilemoma; most are benign by type but malignant by location). CT scan to determine if tumor is in spinal canal. 2) cyst 3) descending thoracic aneurysm

Question 61

Cardioplegia solution contains (this electrolyte) in sufficient quantity to stop the heart.

Answer 61

Potassium at 60 mEq/L

Question 62

What is a critical part of the work up for aortic stenosis to avoid neurologic sequelae?

Answer 62

Carotid Doppler studies to rule out internal carotid artery obstruction

Question 63

While tissue valves (human, porcine, bovine) are nonthrombogenic (and thuse do not require anticoagulation), they deteriorate in the body and require replacement beginning at about __ years

Answer 63

7

Question 64

Causes of dilated cardiomyopathy:

Answer 64

alcohol, Coxsackie, Chagas disease, pregnancy, dauxorubicin, enteroviruses

Question 65

Where does a Zenker diverticulum develop?

Answer 65

AKA a pulsion diverticulum, develops in area between lower pharyngeal constrictor and the cricopharyngeal muscle. Due to abnormal uncoordinated constriction of the cricopharyngeal muscle

Question 66

What is the treatment of Zenker's diverticulum?

Answer 66

transection of cricopharyngeal muscle to relax the esophageal entrance and prevent uncontrolled contraction --> excision and esophageal myotomy (cervical esophagomyotomy), endoscopic stapling

Question 67

What is the pathophysiology of achalasia?

Answer 67

loss of smooth muscle ganglionic cells of Auerbach plexus and neuronal degeneration. Associated with severe emotional stress, physical trauma, weight loss, Chagas disease

Question 68

What is the normal lower esophageal sphincter pressure? What is it in achalasia and nut cracker achalasia?

Answer 68

LES < 25 is normal LES > 100 is achalsia LES > 200 is nut cracker achalasia.

Question 69

What is the treatment of achalasia?

Answer 69

CCBs, distal esophageal dilation (surgically w/ Heller myotomy and fundoplication) or endoscopically with transesophageal pneumatic dilation

Question 70

Cancers in the upper 1/3 and middle of esophagus are usually

Answer 70

squamous cell carcinoma (lower 1/3 can also be SCC, but increasingly represent adenocarcinomas)

Question 71

Because celiac node involvement in the abdomen is also common in SCC of the esophagus, a ___________ is indicated

Answer 71

CT scan of the upper abdomen and chest

Question 72

How does the treatment compare between cancers of the cervical/upper 1/3 of the esophagus; the middle 1/3 of the esophagus; and the lower 1/3?

Answer 72

upper: chemoradiation middle: chemoradiation to allow surgical resection distal: esophagectomy and proximal gastrectomy

Question 73

The majority of cases of pancoast syndrome are caused by which kinds of tumors?

Answer 73

squamous cell carcinoma

Question 74

A collapsed right upper lung lobe in a nonsmoker might be due to

Answer 74

bronchial adenoma, which may obstruct a bronchus resulting in atelectasis and mild wheezing

Question 75

While both a myxoma and a thrombus are high on the differential for atrial mass and can cause embolization, they are different on imaging how?

Answer 75

myxoma: polypoid thrombus: posterior atrium, "layered appearance"

Question 76

What is the next best step in patients with atrial fibrillation refractory to medical therapy?

Answer 76

cardiac catheter ablation (best used in patient with structurally normal heart)

Question 77

What is Maze surgery?

Answer 77

most effective technique for curing atrial fibrillation (involves incisions of left and right atrium to form scar tissue and disrupt the normal electrical impulse. Best suited for patients needing concomitant open surgery and is rarely performed standalone)

Question 78

Since both schwannomas and soft tissue sarcomas look histologically similar (numerous spindle cells with moderate atypia and occasional mitotic figures), how can they be distinguished?

Answer 78

schwannomas are S100 positive, but sarcomas are not