Pretest_8_CT_Problems Flashcards
Patients do not develop symptoms from aortic stenosis until the valve area is less than __ cm
1
What measurement is the most commonly used predictor of postoperative pulmonary reserve?
FEV1 (>60% of predicted = can tolerate a lobectomy)
A PCO2 greater than 45 mm Hg suggests severe pulmonary disease with ___% functional loss of the lung
50%
Small cell lung cancer aggressively metastasizes early to the mediastinal lymph nodes and to distant sites, most commonly ____________
bone marrow and the brain
In an empyema with glucose <7, what is the treatment?
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
90% of the time, superior vena cava syndrome is due to _________. And 3/4 cases is due to
malignancy; invasion of vena cava by bronchogenic carcinoma
What is the treatment for SVC syndrome?
diuretics, and if malignancy, radiation and chemotherapy if applicable
What is the treatment of esophageal perforation?
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)
What is the INITIAL treatment of a descending aortic dissection?
Decrease in blood pressure with B-blockade, followed by nitrates once B-blockade achieved.
What are the indications for operative intervention in descending aortic dissection?
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)
The findings of prolonged high-amplitude contractions in the body of the esophagus in a highly symptomatic patient is diagnostic of
diffuse esophageal spasm
What is the treatment of diffuse esophageal spasm?
Long myotomy guided by the manometric evidence
The treatment of spontaneous PTX is tube thoracostomy; when is thoracotomy indicated?
Thoracotomy with bleb excision and pleural abrasion is generally recommended if spontaneous PTX is recurrent
The presence of air in the mediastinum after an episode of vomiting and retching is virtually pathognomonic of
spontaneous rupture of hte esophagus (Boerhaave syndrome)
What is the treatment of Boerhaave syndrome (after esophagram has confirmed esophageal injury)?
No evidence of sepsis = manage with antibiotics and expectant management
Systemic signs 24h = more extensive surgery
T/F: Antiarrhythmics are indicated prophylactically in a patient withmyocardial contusion.
False! But they should be used to treat rhythm disturbances
Equalizatoin of pressures across the four chambers on Swan-Ganz catheter monitoring or collapse of the right atrium on echocardiography are diagnostic of
cardiac tamponade
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 __________
low fat diet (reduces the flow of chyle) and thoracentesis or thoracostomy drainage
intraoperatively = thoracic duct ligation (too friable for direct repair)
These lesions are often attached by a pedicle to the fossa ovalis of the left atrial septum:
cardiac myxoma (treatment is resection)
What are the three divisions of mediatstinum?
Anterosuperior = in front of pericardial sac Middle = contents of pericardial sac Posterosuperior = behind pericardial sac
What are the most common primary tumors of the 3 divisions of the mediastinum?
anterosuperior = 1) thymomas, 2) lymphomas, 3) germ cell tumors middle = cysts (pericardial, bronchogenic, enteric) anteroposterior = neurogenic
More commonly than neoplasm, a mass in the anterosuperior region of the mediastinum represents
a substernal extension of a benign substernal goiter
How does CSF drainage with a lumbar drain improve prevent spinal cord ischemia in repairing descending aortic aneurysms?
Decreases the pressure on the blood supply to the spinal cord
Zenker diverticulum is an outpouching of mucosa between the lower pharyngeal constrictor and the __________. What is the treatment?
cricopharyngeus muscles (thought to result from an incoordination of cricopharyngeal relaxation with swallowing). Treatment is cricopharyngeal myotomy which can be done under local anesthesia
Zenker diverticulum arises more commonly in elderly patients and on the (right/left)
left
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)
thoracic outlet syndrome
Thoracic outlet syndrome results from…
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
Operative treatment of thoracic outlet syndrome:
division of the scalenus anticus and medius muscles, first rib resection, cervical rib resection, or combo of all three
Another name for superior pulmonary sulcus carcinomas:
Pancoast tumors (peripheral bronchogenic carcinoma)
Horner syndrome triad:
miosis, ptosis, anhidrosis
A pancoast tumor could cause pain in which dermatomes?
C8 and T1 (it involves those nerve roots, as well as the sympathetic trunk)
If conservative management (diet) of chylothorax is not helping and is draining more than 500 mL/day, what is the treatment? On what side?
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)
Carcionid tumors of hte lung are infrequently metastatic, slow-growing that are found __________ and frequently present with bronchial obstruction. The only therapy is __________
found in proximal bronchi; only therapy = operative resection; neither the primary tumor nor the infrequent lymph node metastasis is radiosensitive
What is the pathophysiology of syphilis aortitis?
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)
T/F: If tricuspid regurgitation leads to a sufficiently elevated venous pressure, exophthalmos may result.
True
What is a Quincke pulse?
alternate flushing and paling of the skin or nail beds, and it is associated with aortic regurgitation
Which mediastinal tumors are associated with myasthenia gravis, agammaglobulinemia, and red blood cell aplasia?
thymoma
Reed-Sternberg cells are seen in
Hodgkin lymphoma
Reed Sternberg cell = multinucleated or have a bilobed nucleus (thus resembling an “owl’s eye” appearance) with prominent eosinophilic inclusion-like nucleoli
Coughing up hair or sebaceous material =
connection between dermoid cyst (cystic teratoma) and treacheobronchial tree
What are the results of epinephrine and low vs high doses? What is it typically used for?
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
Does norepinephrine work on alpha or beta receptors?
Both! Ultimately increases afterload and glomerular perfusion pressure with preservation of cardiac output
_________ is an effective agent in increasing BP in hypotensive patients with adequate fluid resuscitation.
Dopamine
What receptors does dopamine act on?
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
_________ is a synthetic cathecolamine that predominately binds to B-adrenergic receptors and enhances myocardial contractility with minimal changes in HR
Dobutamine
What does phenylephrine act on?
Pure alpha agonist used on increasing peripheral vascular resistance and blood pressure (increases left ventricular work and may decrease CO)
WHat is the difference between nitroglycerin and nitroprusside?
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)!
These lung lesions are usually popcorn in appearance:
hamartomas
After this age, there is a 50% and steadily increasing chance that a SPN is malignant:
50yo
____________ occurs in the SW US and _____________ in the Ohio Valley.
SW: coccidiomycosis
Ohio Valley: histioplasmosis
Calcification of an SPN suggests it is (benign/malignant)
benign
If mediastinal lymph nodes are positive for metastasis in lung cancer, it is stage ___
III
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:
Pancoast tumor = superior sulcus mass in apex of lung. Causes erosion of 1st and 2nd ribs (stage 3 = chest wall invasion)
In laryngomalacia, the dyspnea is exacerbated when (supine/prone).
Supine
Why can bronchial carcinoid tumors cause carcinoid tumor even without liver metastases?
Because enough serotonin reaches systemic circulation without breakdown
What is the treatment of mesothelioma?
Extrapleural pneumonectomy is the only cure. Entire lung and parietal and visceral pleura along with, at times, pericardium and diaphragm, are resected
The minimum postoperative FEV1 following lung surgery is
800 mL (split function VQ perfusion scan to calculate)
A patient with recurrent spontaneous pneumothorax, as well as a patient with _____________, should have thorascopic excision of blelbs and pleural abrasion (pleurodesis)
bilateral spontaneous pneumothorax (very dangerous; would NOT want recurrence!)
can use talc, bleomycin, tetracycline for chemical pleurodesis
Name anterosuperior mediastinal tumors:
1) thymoma
2) lymphoma
3) dermoid/teratoma
4) germ cell tumors (seminoma)
5) retrosternal thyroid
Name middle mediastinal tumors:
1) bronchogenic cyst
2) lymphoma
3) tracheal tumor
4) aneurysm of ARCH
Name posterior mediastinal tumors:
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
Cardioplegia solution contains (this electrolyte) in sufficient quantity to stop the heart.
Potassium at 60 mEq/L
What is a critical part of the work up for aortic stenosis to avoid neurologic sequelae?
Carotid Doppler studies to rule out internal carotid artery obstruction
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
7
Causes of dilated cardiomyopathy:
alcohol, Coxsackie, Chagas disease, pregnancy, dauxorubicin, enteroviruses
Where does a Zenker diverticulum develop?
AKA a pulsion diverticulum, develops in area between lower pharyngeal constrictor and the cricopharyngeal muscle. Due to abnormal uncoordinated constriction of the cricopharyngeal muscle
What is the treatment of Zenker’s diverticulum?
transection of cricopharyngeal muscle to relax the esophageal entrance and prevent uncontrolled contraction –> excision and esophageal myotomy (cervical esophagomyotomy), endoscopic stapling
What is the pathophysiology of achalasia?
loss of smooth muscle ganglionic cells of Auerbach plexus and neuronal degeneration. Associated with severe emotional stress, physical trauma, weight loss, Chagas disease
What is the normal lower esophageal sphincter pressure? What is it in achalasia and nut cracker achalasia?
LES < 25 is normal
LES > 100 is achalsia
LES > 200 is nut cracker achalasia.
What is the treatment of achalasia?
CCBs, distal esophageal dilation (surgically w/ Heller myotomy and fundoplication) or endoscopically with transesophageal pneumatic dilation
Cancers in the upper 1/3 and middle of esophagus are usually
squamous cell carcinoma (lower 1/3 can also be SCC, but increasingly represent adenocarcinomas)
Because celiac node involvement in the abdomen is also common in SCC of the esophagus, a ___________ is indicated
CT scan of the upper abdomen and chest
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?
upper: chemoradiation
middle: chemoradiation to allow surgical resection
distal: esophagectomy and proximal gastrectomy
The majority of cases of pancoast syndrome are caused by which kinds of tumors?
squamous cell carcinoma
A collapsed right upper lung lobe in a nonsmoker might be due to
bronchial adenoma, which may obstruct a bronchus resulting in atelectasis and mild wheezing
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?
myxoma: polypoid
thrombus: posterior atrium, “layered appearance”
What is the next best step in patients with atrial fibrillation refractory to medical therapy?
cardiac catheter ablation (best used in patient with structurally normal heart)
What is Maze surgery?
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)
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?
schwannomas are S100 positive, but sarcomas are not
