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Question 1

71 yr old smoker with cough, and bone pain. story of lung cancer

Answer 1

Youre thinking he has lung cancer. He will have symptoms in the lung ( cough/ SOB), symptoms of thoracic mass ( esophgeal reflux), or phrenic nerve involvement. Ix: CX - you find lesion in the lung- but what is it? Get CT scan. If suspiscious can do biopsy, and then tx lobectomy.

Question 2

suspicious characteristics for lung nodule found on CT

Answer 2

1) spiculated 2) thick walled 3) no calcification 4) a certain type of calcification called Eccentric Calcification 5) growth over time.

Question 3

what are risk factors for lung cancer?

Answer 3

smoking, asbestos, exposure, radiation, family history

Question 4

ddx solitary lung nodule ( under 3cm)

Answer 4

tumour ( benign or malignant options). benign = hamartoma, bronchial adenoma. Malignant = carcinoma, mets. INflammatory causes : TB, histoplasma, bronchial adenoma.. Vascular problems- AV fistula, infarct, embolism

Question 5

tx small cell carcinoma

Answer 5

surgery,

Question 6

tx non small cell carcinoma

Answer 6

surgery not possible, need to do chemotherapy

Question 7

what are the big types of lung cancer?

Answer 7

small cell, and non small cell. NSCL = adenocarcinoma, squamous cell carcinoma, large cell.

Question 8

what do you need to do preop for pts needing lung surgery?

Answer 8

they need a full assessment of their heart and lungs. THink of spirometery, VQ scan, echo, stress test, ECG. You need to know about their lungs, and their heart.

Question 9

pleural effusion- what is the equation and the issues that can cause effusion?

Answer 9

you have fluid accumulation betweenthe parietal and visceral pleural- transudative and exudative. Transudate = low albumin, or increase capillery pressure like CHF o nephortic syndrome. Exudate = cancer, pus going into the space and pulling water with it

Question 10

PLeural effusion

Answer 10

person has SOB, so you get CXR ( supine + upright to look for changing fluid levels). Pull some of the fluid ( thoracentesis), and get tests on the fluid ( glucose, pH, cytology, cell count). Tx - is to drain fluid, tx underlying problem.

Question 11

what are the treatment options for pleural effusions?

Answer 11

simple parapneumonic effusion ( clear, serous fluid) = dont put in a drain, as its free-flowing.
Complicated pleural effusion ( if its lobulated) - sometime need drain
Empyemia- purulent effusion with + culture = ALWAYS drain, or if its stuck on the lung you have to surgery it off

Question 12

what tests can you run on the pleural effusion?

Answer 12

fluid LDH, serum LDH ( so you calculate lights criteria to determine if its exudate or transudate). Also can get cytology ( for cancer), glucose, ph ( low in infnx). etc

Question 13

when do you drain a parapneumonitc effusion?

Answer 13

1) symptomatic ( over half chest full of fluid)

2 Its infected ( full of pus)

Question 14

what is the most common causes of malignant pleural effusion

Answer 14

1) probs guy with lng cancer or woman with breast cancer, who, or asbesto exposure ( malignant mesothelioma- rare but was mentioned in lecture)

Question 15

how do you treat malignant pleural effusions

Answer 15

do some type of mesothelial binding so that the pleural cant accumulate fluid - you put talc in there, or rub it lots so that the layers bind together.

Question 16

DDX mediastinal mass

Answer 16

Thyoma ( myasthenia gravis), Teratoma ( seminoma or non seminoma), Thyroid nodule ( goiter), Lymphoma

Question 17

Myasthenia gravis

Answer 17

Hx- someone gets tired by the end of the day. You think this is a crazy complaint, of course youre tired at end of day. HOWEVER, think myasthenia - autoimmune disorder with antibodies targeting NMJ + resulting muscle weakness. Ix: get anti-acetylcholine receptor antibody but also biopsy to amke sure its not a scary cancer in the neck. Then tx: chiloinesterase inhibitor ( increase amt of acH around), steroids, and in severe cases IVIG/plasmapheresis ( clear out stuff) + take out thymus

Question 18

esophgeal obstruction- GERD. what are the three categories of symptoms that people can present with?

Answer 18

Hx: male presents with heratburn, who smokes, drinks, increased abdominal pressure. Worse after meals lying down, no atypical asthma symptoms like cough, no alarm symptoms of wt loss, dysphagia, melena, anemia Px: IX: barium esophagram, ph monitoring, hpylori breath test. Tx: trial lifestyle mods. Then meds (PPI). then surg- if they have hiatal hernia, can do nissen.

Question 19

what are the four tests needed on hiatal hernia/ GERD?

Answer 19

1) 24 hr ph monitoring which is the gold standard to confirm GERD. 2) Upper GI endoscopy- look at the mucosa, you need ro baretts or cancer 3) contrast study before operation because you need to know how mich of the stomach is in the chest 4) esophageal manometry - to rule out motility disorder, which needs a totally different surgery

Question 20

atelectasis

Answer 20

60 yo with pain on affect side, SOB, decreased BS and dull to percussion. Mediastnium shifted Away. Could be due to cancer, PE, penumonia, trauma,FB. Ix ( assess oxygenation): ABGs, spirometry, CXR. tx: o2, abx, if chronic need surgical resection of that section of lung

Question 21

PE

Answer 21

pleuritic chest pain+sob+hemoptosis. Hx: coagulation risk factors,. Px: fever, diaphorectic, lowe leg swelling. DDX: Mi, pericarditis, COPD, Atelectasis,pneumonia. Ix: CBC, ddimer, Inr/Ptt ,ABGs, CXR, V/Q scan, Pulm angio. tx: heparin + longterm antigcoag. Surg: embolectomy/ thrombolysis.

Question 22

spontaneous pneumothorax

Answer 22

hx: tall thin male with smoking history, sitting on couch and just starting having SOB. due to rupture of small subpleral blebs. px: pleuritic chest pain, tachy, SOB, hyperresonant. ix: CXR,ABGs tx: conservative ( watch 2-3 wks), needle aspiration + confirmatory CXR after, or surgery- mechanical pleurodesis ( meld the two pleura togehter so they dont keep popping away from each other)

Question 23

DR BLAIR talked about this: chest trauma

Answer 23

hx: of trauma to chest. DDX? all the scary things- AAA, Esophgeal rupture, Tension pneumothorax, Cardiac tamponade, pneumothorax, hemothorax, cardiac arrest.px: ABCDEs, ( recall D is like a neuro exam) RBS, SAMPLE, Secondary.
Ix: Basic blood, PTT INR, group screen, 2 large bore Ivs, 02, monitors, CXR, FAST scan, cspine procautions until cleard by Xray. tx: immediate tube thoracostomy.

Question 24

how do you do tube thoracostomy

Answer 24

make incisions at 5th intercostal space at mid axillary line ( use nipple as landmark). Put finger in to remove adhesions/ blunt clamp and cut ontop of ribs. Make sure in the pleural space, then put tube in directed superior and posterior towards apex of lung. Secure with sutures, and hook up tube to suction.