Surgery Block 2 Flashcards
Skin tests can be used for Dx ?
What are the two types of Endoscopy and what are they used for?
TB Histo Coccidio
Laryngo: vocal cord mobility
Brncho: flex/rigid
How are mediastinum samples acquired
Define Chamberlain procedure
How are pleural biopsys done?
Mediastinoscopy, samples from 3 stations
Ant mediastinotomy biopsy
Alternate- videoscopic guidance
Percutaneous needle
Open surgery
VATS
Two types of lung biopsy
How are sputum samples acquired for analysis?
Needle- MC indicated for eval of SPN
Surgical- thoracoscopy for open lung biopsy
Deep cough
Abrasion-brush/wash
What image is the cornerstone of chest pathology
MRI has particular niche for evaluating ?
CT
Superior sulcus for pancoast tumors
What is the use of PET
Since this is more accurate than CT, what can it be used to detect?
Staging/work up Ca PT
Spread to mediastinal lymph nodes
What are the A-F of assessing CXRs
Define Infiltrate
Define Effusion
What is the infiltrate during pneumonia, edema or contusions?
Air Bones Cardiac silhouette Density Edema Foreign body
In: fluid in lung
Eff: fluid in pleural
Pneumo- pus
PulmEdema- serous
PulmCont- blood
? CXR sign indicates fluid
Pleural effusion is fluid located in ?
What procedure could be done to remove the effusion?
Meniscus
Chest, not lungs
Thoracentesis
Cavitation on CXR indicates ?
What if the cavitation has a thicker wall
How does this differ than thin walled cavitations?
TB Fungal infection
Abscess w/ fluid and inflammatory cells
COPD has blebs/bulla
Define Cephalization
Pulmonary edema w/ cephalization indicates ?
Fluid leaking into alveoli, begins near hila and spreads out/up
Bilateral perihilar infiltrates
If PT has diaphragmatic hernia, what procedure is done to decompress air in stomach prior to repair surgery?
Define atelectasis
NG tube suction
Air trapped in alveoli reabsorbed= collapsing alveoli, pulls tissue together
Define Simple PneumoThx and what is the urgent Tx
What does the PT have once the above definition changes
Collapse w/out change to VS
Expand lung
Tension- VS changes HOTN
Needle-D, Thoracostomy
What PT populations are at risk for Spot PTx
S/Sxs of PTx
What would be seen on PE?
SMELT C
Smoker Margan Emphysema Lung ca Thin CF
Pleuritic pain/dyspnea
Sev= cyanosis HOTN CV collapse
Tachy Tachy Deviation Dec sounds Hyper resonance
What would be seen on ABG results of PTx
What would the EKG show
Hypoxia, Hypercapnia
Axis deviation
Non spec ST change
T inversion
What is the standard test for PTx Dx
What can PTs do to make appearance more pronounced
Why would a CT be ordered
PA, Lat CXR
Exhale- inc contrast and collapse
Differentiate PTx from large bulla
How are PTx Tx
Any form can become persistent and then needs ?
Simple- thoracostomy
Tension- needle-d (emergent), thoracostomy (definitive)
Open- valve, thoracostomy
Closed- thoracostomy
Pleurodesis
What is the MC pleural problem
What types of pleural tumors are un/common?
PTx
Primary pleural
Metastatic Ca
The MC Sxs of pleural Dzs are ?
What type of referred pain do they have?
How does pain originate in visceral pleura
Pain
Dyspnea
Back/shoulder from somatic intercostals
Pleuritic pain, visceral pleura insensate
What are the 7 reasons pleural effusions accumulate
Inc hydrostatic press
Dec colloid press
Inc capillary membrane
Dec intrapleural press
Dec lymph drainage
Trandiaphragm movement of abd fluids
Ruptured vascular/lymph structure
How do pleural effusions present
What anatomical/structural change occurs in advanced stages
Dec excursion Dec sounds Dull Friction rub Local tenderness
Contraction of hemithorax
How much fluid does it take to blunct costaphrenic angles on CXR
How much does it take to opacify the entire hemithorax?
300-500mL
2-2500mL
Why would a CT be ordered for pleural effusions
Why would interventional radiology be ordered
Complex Loculated Recurrent
Loculated effusions
Percutaneous drain placement w/ CT guidance
How are pleural effusions Dx
Throcentesis- 20mL
Protein LDH Total/Diff cell count
Glucose pH Cytology Gram w/ culture
What causes transudates
What causes exudates
What type of lab results are seen
CHF LF (not Ca) Ca Pneumonia
Dec total protein
Dec LDH
SpecGrav <1.016
What are the two MC pleurodesis agents used
How are effusions Tx
Talc
Doxycycline
Malignant: palliative, expand lung/pleural symphysis
Chest tube 20-28F and drainage
Empyema: procedure of choice for Dx= thoracentesis
Hemothoraces- 32-36F closed drainage
Chylothorax- similar to malignant, low fat diet initiated
What is the MC organism causing empyema and the average number of species isolated is ?
This is also the MC complication of ? in adults and kids
What Gram-neg can be seen here too
Staph
3.2/PT
Staph pneumonias
E Coli
Pseudomonas
If fungus is found in thoracic empyema, what can cause it?
What parasites can cause it?
Blasto Aspergillus Coccidio Histo
E Hystolytica
Mhoracic empyema causes a mediastinal shift to ?
What procedure should be performed?
What is the procedure of choice for Dx
Affected side w/ D-shaped density
Bronchoscopy
Thoracentesis
Total protein >3g= exudate
Pulmonary infiltrates can cause ? issues
How are thoracic empyemas Tx
Sepsis ARDS Pneumonia Pulm contusion Inhalation injury
Abscess= ABX w/ drainage Emyema= thoracoscopic/open lobectomy removal and sterilization
What is the MC cause of cancer related deaths of men and women in US
Smoking cessation dec risk after ?yrs of quitting
Previous smokers reach almost no risk after ? of no smoking
Lung Ca
6yrs
15yrs
What are the types of lung cancers seen
What types of Cas are more likely to be central or peripheral
Squamous Large Adeno
Small cell- non-small cell
Bronchial gland adenomas/carcinoid
Small cell- central
Adeno- peripheral
How do central tumors present
How do peripheral tumors present
Give two examples of peripheral tumors
Hemoptysis Pain Pneumonia
Pain Pleural effusion Pulmonary abscess
Horners- PIA
Pancoast- ____
How do neoplasms present if they touch bronchus, mass, narrowed bronchus or mid parenchyma from bronchus
How do paraneoplastic syndromes present
Cough/hemoptysis
Wall pain
Atelectasis
Hemoptysis
Produce/deplete hormones=
Clubbing
Hypertrophic osteoarthropathy
How do non small Ca present
How do small cell present
How do adrenal insufficiency present
PTH-like production= HyperCa
ADH like= SIAD, MAH, ACTH
Fatigue, Na craving Weight loss E+ imbalance HypoNa HyperK
How does Panocast present
Brachial impingement
Ulnar compression
Cervical lymph strain
SVC
Horners
SVC syndrome- worse laying/flat
How are neoplasms of lung Dx
CXR CT SAP FDG PET Thoracentesis/scopy
What are the characteristics of benign/malignant neoplasms of lung
Benign= <2cm Stable x 24mon Concentric calcification Smooth border Solitary
Malignant= >2cm Inc/Unstable x 24mon Irregular calcification Spiculated border Multiples
How are lung neoplasms tissue Dx
Sputum cytology
Bronchoscopy
Percutaneous/Tran-T biopsy
Wedge biopsy
Define Unresectable
Define Inoperable
Tumor invaded vital structures, not removeable
Unstable PT due to comorbidities
How are lung neoplasms PTs assessed Pre-Op
Cardiopulm reserve
Most accurate factor
How are lung neoplasms Tx
Observe
Conserve/support- steroid ABX throracentesis
Excistion
Chemo/Rad
How are lung neoplasms staged
3 layers of a artery
T- tumor size
N- nodal involvement
M- etastasis
Intima Media Adventitia
What are the two MC causes of arterial aneurysms
What causes psudoaneurysms?
Pseudoaneurysm can present as ?
Atherosclerosis
HTN
Puncture/lacerated artery
Pulsatile hematoma
What are the 3 subtypes of pseudoaneurysms
What is the MC cause
Saccular- outpouch of wall
Fusifrom- diffuse
Mycotic- Staphylococcus infection
Trauma
What physics law applies to AAA
These become at ? size?
What PE finding indicates the need for urgent surgery
Laplace
5cm
Extreme tenderness
What are the S/Sxs of a ruptured AAA
How is it Dx
Gray Turner sign
HOTN
TTP flank/back pain
Dec fem pulse
Seen on x-ray
Confrimed w/ US- LRA?
Ruprture Dx w/ CT
What is the name of the procedure done prior to an AAA repair for assessment/planning
When are these indicated for repair?
Aortogram- contrasted x-ray but nephrotoxic
Elective >5.5cm
Sx= emergent
Growth >1cm/yr
How are AAA Tx
Post aorto-bifemoral bypass PT w/ dec urine output to 30mL, what is the next step?
Open
Endovascular stent- endovascular aneurysm repair
Bolus isotonic fluids
What complications can occur out of AAAs?
What are 3 etiolgies of aortic transection?
Mycotic aneurysm
Fistula w/ IVC= CHF
Fistula w/ GI= GI bleed
Blue toe syndrome
Auto crash
Motorcycle crash
Fall from height
Where do aortic transections usually occur?
PTs can survive if ? structure holds?
What would be seen on CXR?
Distal to subclavian artery
Adventitia holds
CXR- wide mediastinum
What is the most reliable test for aortic transections?
When is repair preferred?
What can be done to dec forces on site of injury?
CT angiography
Delayed- tight BP control and hemodynamically stable
BBs then dilators
What are the two Tx methods for repairing aortic transections
What is the MC catastrophic event of the aorta
Endovascular repair w/ graft
Open repair
Aortic dissection
What are the two classifications of aortic dissections?
What type is more likely to rupture?
DeBakey
Stanford
Stanford type A, rupture in ascending aorta
How does aortic dissection present
What findings may be seen on PE?
Male >60y/o
Sharp tearing pain to back
Hx of HTN surgery cocaine
Pulse different between arms
Diastolic aortic regurgitation
How are aortic dissections Dx
Nearly all PTs present w/ ? trifecta of Sxs?
EKG to r/o MI/PE
CXR- wide mediastinum, pulm edema, pleural effusion
CT- standard image modality
TEE
Abrupt onset of tearing
Pulse deficit >20mmHg
Wide mediastinum on CXR
