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Surgery Block 2 Flashcards

1
Q

Classically, what are the 3 compartments of the mediastinum?

What angle is formed here and by ? structures?

A

Superior Anterior Posterior

T4 to Sternomanubral Junction= Angle of Louis

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2
Q

What are the 3 compartments of the mediastinum and what is located in them according to the Burkell classification?

A

Anterior:
Areolar Transverse Great Nodes Ascending Thymus

Middle: Phrenic Hila Areolar Trachea Pericardium Heart

Posterior: Sympathetic Vagus Esophagus Nodes Ducts Descending

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3
Q

What is the fundamental unit of lung anatomy?

How many lobes does each lung have?

What lung segments are homologous to each other?

A

Bronchopulmonary segment

R: Upper Middle Lower
L: Upper Lower

L upper lobe lingular segment = R middle lobe

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4
Q

How many fissures are in the right lung?

A

R:
Minor/horizontal divides middle from upper
Major/oblique divides upper/middle from lower

L:
Oblique separates upper/lower lobes

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5
Q

Skin tests can be used for Dx of ? lung issues

What are the two types of endoscopy and their use?

A

TB Histo Coccidio

Laryngo- assess vocal cord mobility after change in voice d/t suspected lung carcinoma
Broncho- flex/rigid

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6
Q

What procedure is the mainstay of evaluation of the mediastinum?

Define Chamberlain procedure and it’s alternate?

A

Cervical mediastinoscopy: 3 sample collection: paratracheal 2/7, subcarinal 7

Anterior mediastinomy to sample nodes/biopsy tissue in aortopulmonary window.
Video Assisted Thorascopic Surgery

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7
Q

What are the 3 methods to collect a pleural biopsy?

Where is the incision for mediastinoscopy?

Where is the incision for Chamberlin procedure?

A

Percutaneous needle
Open surgery
VATS

Above sternal notch

2-3rd interspace

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8
Q

What is the MC indication and secondary indication to use transthoracic needle biopsy of the lung?

What is the standard approach for a surgical biopsy but w/ ? caveat?

A

Eval solitary pulm nodule
Confirm metastatic Dz

Thoracoscopy
Single lung ventilation

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9
Q

Cytology of ? can be used for detecting lung Ca

What is the cornerstone of chest pathology evaluation?

A

Sputum from abrasions

CT

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10
Q

What niche does MRI have in evaluating thoracic structures?

MRI is used in this niche to evaluate for involvement of ?

A

Superior sulcus (Pancoast) tumors

Brachial plexus
Subclavian vessel
Bony chest wall

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11
Q

Where does PET use fall into thoracic malignancy?

PETs are more accurate than CTs to detect ?

A

Staging/work up

Spread to mediastinal nodes

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12
Q

Define Infiltrate

Define Effusion

A

Fluid in lung

Fluid in pleural space

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13
Q

PTs w/ pneumonia, fluid in the infiltrate is ?

PTs w/ pulmonary edema, fluid in infiltrate is ?

PTs w/ pulmonary contusion, fluid in infiltrate is ?

A

Pus

Serous

Blood

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14
Q

Pleural effusions are divided into ? or ? depending on?

Where are each ones more likely to develop/form?

A

Exudate/Transudate
Protein/LDH

Transudates: inc capillary hydrostatic pressure/dec osmotic pressure

Exudates: inflammation

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15
Q

Transudates are MC caused by or can be created d/t ? underlying processes?

Exudate pleural effusions are MC caused by ? or can be due to ?

A

CHF (L sided failure)
Hypoalbumin
Cirrhosis
Nephrotic syndrome

Malignancy

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16
Q

Empyema is classified as ? type of effusion?

This classification can include ? other types of effusions

A

Exudate

Hemothorax- Hct +50%
Chylothorax- inc TG/cholesterol

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17
Q

What structures carry contents for a chylothorax to develop?

Where does it begin/end?

A

Thoracic duct, carries chyle from intestine to blood

Cisterna chyli (L2) to L-subclavian/jugular vein

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18
Q

? sign on CXR indicates fluid in chest cavity?

How can the fluid be removed?

A

Meniscus sign

Thoracentesis
Chest tube

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19
Q

? forms the interlobar fissures?

Space between visceral and parietal pleura is a potential space normally holding ? mL of fluid

A

Enfolds of visceral pleura

2-5mL

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20
Q

How much fluid is needed to blunt intercostal angles or whole hemithorax on frontal views?

Because of the natural elastic recoil of lungs, pleural fluid appears to be ? than reality

A

> 300mL- angles
2L- hemi

Higher on lateral margin than medially= meniscus sign

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21
Q

Pleural effusion must be larger than __mL to be detectable on standard upright AP CXR?

? PT position is used to detect smaller effusions of ? size

How much is needed to be accessible for thoracentesis?

A

> 150mL

Lateral decubitus; <50mL

1cm thick

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22
Q

? physiological process occurs in order for a pulmonary edema to occur?

What CXR appearance does this cause?

A

Pulm venous pressure >25mmHg

Bat wing appearance

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23
Q

Cephalization is only beneficial once ? has been verified?

Difference in appearance of a lung abscess and a COPD bleb/bulla?

A

Certain PT was upright during x-ray

Abscess: thick w/ fluid
Bleb: thin w/ air

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24
Q

Pulmonary edema starts by filling ? seen on CXR

What is common in all forms of atelectasis?

A

Large vessels in hilum

Dec volume, inc density

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25
Q

What is the first imaging study of choice for small pericardial effusions?

What are the different types of pneumothoraxes?

A

Pericardial US or,
CT

Simple- - VS changes
Tension- + VS changes
Open- penetration w/ suck
Closed- blunt trauma, closed wall

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26
Q

How are the different types of pneumothoraxes Tx?

How does this kill PTs?

A

Simple- - lung re-expansion, thoracostomy
Tension- needle-D, thoracostomy
Open- valve, thoracostomy
Closed- thoracostomy

Pressure on heart/vena cava impedes venous return= CV collapse

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27
Q

How are tension pneumos recognized on PE?

All spot pneumos are truly ? type

A

Unilateral dec sounds
Tympany on affected side
Deviation
JVD

Secondary

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28
Q

What is the MC cause of spot pneumos?

Classically, these present in ? PT populations?

A

Ruptured bleb in apex of lobe

Asthenic male 16-24y/o w/ smoking Hx

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29
Q

What is the standard test for Dx of Ptx?

What size of small/stable and ASx Ptx can be Tx w/ observation and f/u?

Once Ptx is above ? require chest tubes of ? size

A

PA/Lat CXR w/ exhalation

<20-25%

> 30%
8-20F

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30
Q

What type of valve is used during Tx of Ptx >30%?

How does this valve’s performance dictate the PTs prognosis?

A

Heimlich

Maintains expansion= out pt
Failure to maintain= admit

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31
Q

What are the land marks for chest tube placement?

How does repeat Ptx inc the chance for future and repeated Ptx?

A

Mid-axillary 5-6th intercostal line, nipple level

1st: 40-50%
2nd; 50-75%
3rd: +80%

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32
Q

What is the MC cause of pleural issues?

Primary pleural tumors are not common but involvement of the pleura is common w/ ?

A

Ptx

Metastatic cancer

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33
Q

What are the MC Sxs of pleural Dz?

Pleural pain is mediates through ? nerves and leads to ? type of pain

A

Pain Dyspnea

Pleural pain:
Somatic intercostal nerves (cervical/costal pleura)= chest wall/back pain

Phrenic nerve (diaphragm/mediastinal pleura)= shoulder

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34
Q

Visceral pleura is insensate w/ only S/PNS fibers but ? can be done to produce typical pleural chest pain?

What could cause mediastinum to remain fixed during pleural effusion?

A

Extension of visceral process

Fibrosis/tumor infiltrate
Ipsilateral lung infiltrated by tumor
Malignant mesothelioma

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35
Q

Why would interventional radiology be ordered for pleural effusions?

How much fluid is needed for lab eval of thoracentesis?

A

Loculated effusion to be managed w/ percutaneous drain placement w/ CT guidance

20mL

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36
Q

Criteria for Transudate

What is the proper land mark for thoracentesis procedures?

What must be done after the procedure?

A

CHF/LF:

Total protein <3g (ratio

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37
Q

Pleurodesis should be performed post-thoracostmy when output falls below ?

What is MC used for pleurodesis?

? type of pleurectomy can control 99% of pleural effusions?

A

<200mL/day

Talc or Doxy

Mechanical pleurectomy w/out chemical installation

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38
Q

How are malignant effusions Tx

How are thoracic empyemas Tx

A

Palliative w/ expansion as goal
20-28F chest tube x 24-48hrs, pleurodesis

Thoracentesis

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39
Q

How are hemothoraces Tx

How are chylothoraxes Tx

A

32-36F chest tube

Same as malignant but w/ low fat diet

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40
Q

? type of infection can lead to a hemothorax?

? procedure may be safer for PTs on high pressure vents w/ pleural effusions?

PEs can cause ? type of effusion to form

A

TB

Chest tube thoracostomy, no US requirement

Exudative

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41
Q

Since the exudative criterias miss so many HF/diuretic Tx exudates, ? lab findings are used to differentiate exudate from transudate

How is a pyothorax re-classified if there’s underlying suppurative lung Dz and usually due to ? type of microbe

A

Pleural fluid cholesterol >55mg
Pleural LDH >200

Parapneumonic empyema
Gram neg

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42
Q

What is the MC microbe causing empyemas?

What Gram Neg microbes can cause these?

What fungi can rarely cause them?

What parasite can cause this?

A

Staph

E Coli, Pseudomonas
Klebsiella Enterobacter Proteus Salmonella

Blastomyces Aspergillus Coccidieo Histo

E histolytica

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43
Q

What is one of the MC complications of staph pneumo in adults and kids?

What is the average number of bacterial species isolated from empyema PTs?

A

Staph empyema

3.2/PT

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44
Q

What is the most important, non-invasive Dx test for thoracis empyemas?

What is the procedure of choice for Dx?

All empyema PTs get ? procedure?

A

CXR as posterolateral D-shaped density

Thoracentesis

Bronchoscopy to r/o endobronchial obstruction

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45
Q

What are the presenting S/Sxs of thoracic empyema

Define Pulmonary Infiltrate

A 
Clubbing
Osteroarthropathy
Anemia
Tachy/Tachy
Dec sounds w/ dull percussion

Fluid in interstitial space

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46
Q

What are the etiologies of pulmonary infiltrates

Edema occurs when lung water is increased by ?

How can pulmonary edema be dec?

A 
ARDS- inflammatory mediators/TRALI/Ptx expansion
Pneumonia
Inhalation injury
Contusions
Sepsis

Excess ECF, Inc hydrostatic pressure, Dec oncotic pressure

Dec ECF Inc plasma oncotic Dec hydrostatic

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47
Q

What is the MC cause of pulmonary capillary leakage/ARDS?

PTs that develop post-op pulmonary insufficiency need to have ? DDxs r/o

A

Infection/inflammation distant from lungs

Deep abscess Infection Pancreatitis Septic phlebitis

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48
Q

How are thoracic empyemas from abscesses Tx

When is operative interventions indicated?

If surgery is indicated ? procedures are done?

A

ABX x 4-6wks= mainstay
Percutaneous drainage

No improvement after 4-6wks of ABX
Empyema/BPF
Abscess >6cm
Hemoptysis
Bronchial obstruction

Thoracoscopic/open lobectomy

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49
Q

What are the 3 goals of empyema Tx

What is a common sequelae to thoracic empyema surgery?

How is this sequelae avoided/reduced?

A

Control infection
Remove purulent material
Eliminate underlying Dz process

Pneumonia

Broad spectrum ABX

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50
Q

Post-thoracic empyema PTs that develop ? triad need to be intubated and mechanically ventilated?

What are the largest etiologies of lung cancer?

A

Atelectasis
Edema
Pneumonia

Non-small cell carcinomas= Squamous Large cell Adenocarcinoma

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51
Q

Peripheral tumors cause ? presenting issues?

Neoplasms touching bronchus have ? Sxs

Neoplasms that mass in pleura have ? Sxs

A

Pancoast syndrome- shoulder pain C8-T1, Horner, Superior sulcus (squamous)

Cough/hemoptysis

Chest pain

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52
Q

Neoplasms that cause bronchus narrowing present w/ ? Sxs

Neoplasms causing mid parenchyma from bronchus present w/ ? Sxs

A

Atelectasis

Hemoptysis

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53
Q

Neoplasms that cause paraneoplastic syndromes present w/ ? due to depletion/production of hormones

Central tumors are responsible for causing ? presenting Sxs

A

Clubbing
Osteroarthropathy

Cough Hemoptysis Dyspnea Pain Pneumonia

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54
Q

What type of paraneoplastic syndrome is produced by NSCLC, SCLC, and Adrenal insufficiency

A

HyperCa d/t PTH substance production

ADH like substance production (hypoNa Hyperpigment inc ACTH)

Salt craving, HypoNa, HyperK

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55
Q

What are the MC metastases sites for NSCLC

PT w/ ulnar compression, horners and SVC may have ? type of Ca

A

Nodes Liver Brain Bones Adrenals

Pancoast in lung apex

56
Q

Pancoast tumors can invade/compress ? structures

What is an early presenting Sx of SVC Syndrome

A

Subclavian Innominate Phrenic Recurrent Vagus

Nasal congestion

57
Q

When doing CT for lung neoplasm, include ? areas that are the MC site for metastases?

What is added to the CT for assessment of the mediastinum?

What f/u tests are ordered if there is Inc ALP, Neuro Sxs, Bone pain or Dz is advanced?

A

Upper abdomen, metastases to liver/adrenals

Contrast

Bone scan
MRI brain scan

58
Q

What test is used for clinically staging neoplasms of the lung

This form of test is also the most effective for assessing ?

A

FDG PET

Distant occult Dzs

59
Q

All PTs w/ pleural effusions are getting one of what two procedures, if not both

Chest CT w/ contrast are most sensitive for defining ? types of lesions?

A

Throacentesis
Thoracosopy

Parenchymal
Small

60
Q

Characteristics of benign neoplasms?

Characteristics of malignant neoplams?

A 
<2cm
Stable over 24mon
Concentric/calcified
Smooth border
Solitary
>2cm
Inc/unstable over 24mon
Irregular/calcified
Spiculated
Multples
61
Q

What are the two MC types of NSCLC?

How does each types appear on images?

A

Adenocarcinoma
Squamous cell

Adeno: ground glass nodule
Sq: spiculated, irregular appearing

62
Q

Once Dx of lung Ca is suspected, how is a definitive Dx made?

What is the standard Dx modality for assessing Dz of airway, lung and pleura?

A

Bronchoscopy if lesion is proximal
Fine needle aspiration for peripheral

Bronchoscopy

63
Q

Define Unresectable

Define Inoperable

A

Tumor invaded vital structures, can’t be removed

PT is unstable for surgery due to comorbidities

64
Q

What is the most accurate factor for predicting successful outcomes of lung neoplasms?

What are two absolute c/is for conducting a standard resection?

A

PTs performance status/functional classification

PHTN
MI <3mon

65
Q

What underlying issues need to be surgically corrected prior to any pulmonary resections?

What are high risk PT findings during lung neoplasm pre-op work up?

A

Coronary artery Dz

MI <6mon
Ventricular arrhythmias
Heart blocks- LPFH

66
Q

T sizes for TNM staging

N criteria

A

T1: <3 T2: 3-7cm T3: >7cm T4: invastion

N0: no nodes N1: broncho/hilar N2: mediastinal/subcarinal
N3: contralateral

67
Q

Any PT who smokes and presents w/ SIADH Sxs needs to have ? DDx

What imaging would be ordered?

A

Lung Ca

CXR then CT

68
Q

What part of a vessel structure must be preserved for it’s integrity?

What are the two broad categories of arterial dz and their sequelae

A

Adventitia

Occlusive: ischemia, necrosis
Aneurysmal: rupture, hemorrhage (aortic) or thrombus, embolization (peripheral)

69
Q

Arterial aneurysm is normally ?% bigger than normal and involves ? layers

What are the two MC causes

What is the MC site of aneurysmal dz

A

> 50%
All 3: intima media adventitia

Atherosclerosis
HTN

Abdominal aorta

70
Q

What is the MC of the true aneurysms
What is the 2nd MC

In descending order, what are the MC areas

A

Infrarenal AAA
False aneurysm in femoral artery 2/2 catheterization

Iliac
Popliteal 
Arch/Descending aorta 
Common femoral 
Carotid
71
Q

What are the 3 subtypes of pseudoaneurysms?

What is the MC cause of pseudo aneurysms?

A

Saccular- out pouch of wall
Fusiform- diffuse; entire circumference of artery
Mycocit- infection related (Staph from IVDA), used to be Salmonella

Trauma

72
Q

Pulsatile hematoma is synonumous for ? aneurysm

What is the MC but other possible etiologies of aneurysms?

A

Adventitia/periarterial invovlement and hematoma

Degenerative*
Inflammatory
Infectious
Congenital

73
Q

What physics law applies to AAA?

Once they reach ? size they are usually palpable where?

What PE finding indicates urgent need for surgery

A

LaPlace- inc radius, wall tension inc and weakens wall

5cm, above and L of umbilicus

Extreme tenderness, “symptomatic AAA”

74
Q

Rarely, AAAs can cause ? presenting complaint

Severe AAA pain w/out rupture indicates ? characteristic issue?

A

Back pain

Inflammatory aneurysm surrounded by perianeurysm retroperitoneal reactions

75
Q

Where does the abdominal aorta begin?

Where does it travel through the abdomen?

Where does it bifurcate into the iliac arteries

A

Diaphragm/T12

Retroperitoneal space anterior and L of spine

Umbilicus/L4

76
Q

S/Sxs of anterior AAA rupture

S/Sxs of posterior AAA rutpture

A

Abdominal pain
CV collapse

Back pain
+/- HOTN

77
Q

How do PTs w/ Frank rupture of AA present

What is the MC complaint if the AAA is leaking and why does it present this way?

A

Shock
HOTN and absent distal pulses

Back pain- blood leaks from L-posterior corner below L renal artery (weakest point of aorta)

78
Q

What imaging is best for following AAA progression

What imaging is used for Dx and details nd is the gold standard of pre-op imaging

What image is done right before a scheduled procedure?

A

US

Thin sliced CT angiography

Aortogram

79
Q

What are the 3 indications a AAA needs to be repaired

What are the two AAA Tx methods

A

ASx >5.5cm
Sx, emergent repair regardless of size
Expands >1cm/year

Open
EVAR: endovascular aneurysm repair

80
Q

How are AAA PTs managed Post-op

AAA fistulization w/ IVC leads to ?

AAA fistulization w/ GI tract leads to ?

A

Full mobilization and diet same day
D/c post-op day 1 or 2

CHF

Aorto-enteric fistula

81
Q

Define Blue Toe Syndrome

? PT presentation indicates limb threatening problem

A

Distal embolization impairing blood flow to toes

Sudden onset of pain w/ toe discolorization w/ palpable pulses

82
Q

What type of mechanisms causes aortic transections

Where does the transection usually occur?

Most will die at the scene unless ? structure remains intact?

A

Rapid deceleration (auto, motorcycle, fall)

Distal to subclavian artery at aorta isthmus at connection of ligamentum arteriosum

Adventitia

83
Q

What is the MC imaging finding indicating torn thoracic aorta

What is the most reliable imaging test for this type of injury

What is used for BP control w/ ? goal

A

Mediastinal widening

CT angiography

BBs, HR/SBP <100

84
Q

What are the grades of aortic transections

How are these repaired?

A

1: intimal injury
2: intramural hematoma
3: pseudoaneurysm
4: rupture

TEVAR- bilateral groin access to place endograft

85
Q

What is the MC catastrophic event involving the aorta?

How is this different than transection

What is the difference between DeBakey and Stanford classifications

A

Dissection/rupture

Longitudinal tear that is rarely due to trauma

DeBakey 1/2= Stanford A- proximal dissection, more likely to rupture
DeBakey 3= Stanford B- distal dissection

86
Q

Where is a murmur due to aortic dissection heard?

What is the first step in Dx of aortic dissection

What is the standard imaging modality

A

R sternal border

R/o MI/PE w/ EKG and CXR

CT

87
Q

Why would a TEE be ordered after a CT to assess aortic dissections?

What TEE finding is critical for Dx of aortic dissection

How are these Tx

A

Ascending aorta involvement
Aortic valve insufficiency

Intimal flap

Esmolol, Nitroprusside w/ BP goal 100-120
Ascending= emergent surgery
Descending= medical management

88
Q

PTs w/ Type A aortic dissection receive immediate surgery to prevent death from ? 3 things

What presenting finding is more common in ascending dissections?

A

Tamponade
Aortic valve insufficiency
MI

HOTN

89
Q

Define “Triple R/o”

What 3 structures provide the most of the blood to the stomach and intestine?

What structures supply the distal colon?

A

CT used to eval for PE, dissection, MI

Celiac axis
Sup/Inf mesenteric arteries

Inf mesenteric
Internal iliac artery

90
Q

What is the MC presenting issue of messenteric ischemia?

What imaging is preferred?

What is used for first line therapy?

A

Post-prandial abdominal pain

CTA/arteriorgraphy

Percutaneous transluminal angioplasty and stenting

91
Q

What part of the GI tract is vulnerable to colonic ischemia

What causes this

A

Watershed area between SMA/IMA

Hypoperfusion to large intestine

92
Q

Superior messenteric artery supplies ?

Inferior messenteric artery supplies?

? supplies the lower rectum?

A

S: large intestine, lower duodenum, transverse colon

I: 1/3 transverse, descending, sigmoid, upper rectum

Middle rectal artery, branch of internal iliac
inferior rectal artery, branch of internal pudendal artery

93
Q

How is ischemic colitis Tx

What are the 3 causes of carotid related CVAs

A

IV fluids
Bowel rest
ABX

Embolization- MC*
Cardioembolism from A-fib
Flow related brain ischemia

94
Q

Sxs of extracranial carotid disease are most often caused by ?

How can carotid artery dz present

A

Embolization

ASx
TIA- hemiparesis, slurred speech, amaurosis fugax
Frank CVA- may be 1st Sx

95
Q

What is the first branch off of the internal carotid artery

If this structure is occluded, what occurs?

Define Hollenhorst plaques and what is the next thing ordered after their discovery

A

Ophthalmic artery

Monocular vision- amaurosis fugax

Atherosclerotic emobli visible as bright flecks
Neck US

96
Q

What is the most useful test for Carotid Artery Dz

What imaging is the gold standard but only ordered if ?

How long does it take to return to baseline after stroked?

A

Duplex US- assesses diameter and flow

Carotid arteriography- surgery is anticipated

6mon

97
Q

How is Carotid Artery Dz Tx

A

Smoking cessation
ASA (dont start Clopidogres if pending surgery)
Serial duplex scans

Carotid endarterectomy
Carotid stents w/ Clopidogrel x 6wks post-op

98
Q

Carotid stenosis exceeding ? should be Tx w/ surgery

Define Subclavian Steal Syndrome

A

75%

Use of arm moves blood from vertebral artery, retrograde flow in ipsilateral vertebral artery leading to brain ischemia

99
Q

Normally a Dz of the LE, where can peripheral vascular dz occur?

Where do they MC occur?

A

Subclavian arteries

Superficial femoral/iliac artery

100
Q

What test offers the strongest indicator for mortality due to peripheral vascular dz?

Occlusion of ? vessels leads to ? hallmark presenting Sxs

PTs can remain ASx w/ up to ?% occluded

A

Ankle brachial index

Femoral artery= calf pain
Buttock/thigh= iliac
Impotence/gluteal pain= hypogastric arteries
Prox thigh= proximal to profunda femoris

40%

101
Q

What presenting issues of peripheral vascular dz are critical findings?

What is the unit of measurement for peripheral artery dz impacting a PTs ability to walk

A

Rest pain
Night pain being more prominent
Hang leg off bed/sleep in chair

City blocks

102
Q

What is the MC type of foot pain at rest?

How is it differentiated from peripheral artery dz

What ABI measurement is concerning

A

Diabetic neuropathy

Hanging leg off bed improves PADz

<1.0

103
Q

What is the single most important part of PADz Tx

What meds can be used for Tx?

A

Smoking cessation

Statin w/ LDL goal <100
ASA/Clopidogrel
Cilostazol- vaso dilator, FDA recommended/better efficacy
Pentoxphyline- dec viscosity

104
Q

What is the first step done after undergoing claudication Tx surgery?

What are the 6 Ps of arterial occlusions?

A

Assess peripheral pulses at doralis pedis, posterior tibialis and peroneal

PooP
Pallor
Poikilothermia
Parathesia
Pulseless
Paralysis- late indicator
105
Q

Transected arteries must be corrected w/in ? to avoid ?

? type of injury usually avulses arteries from attachments?

What is the time frame for correcting/Tx a warm ischemia

A

Few hrs, gangrene

Blunt injury

6hrs

106
Q

When is popliteal entrapment Dx suspected?

How is it visualized?

A

Young healthy PT w/ calf claudication due to medial muscle head

MRI and CT show no atherosclerosis

107
Q

Define Buerger Dz

Why does this lead to amputations so often?

What is the presenting complaint usually?

A

Thromboangiitis Obliterans- male smokers w/ ischemia

Distal arteries are affected most

Foot/arch claudication

108
Q

AV malformation can lead to ? deadly sequelae

These can be created for hemodialysis PTs and require a vein larger than ? and runs continuously for ?

What vein is usually ideal

A

High output HF

> 5mm, 20cm

Cephalic

109
Q

Fistula made from radial artery to cephalic vein are AKA ?

DM Pts that have fistulas created are most at risk for ? adverse event ? but rarely have ? result

A

Cimino fistula

Arterial steal
Distal ischemia
HOHF

110
Q

Define Branham sign

? type of injury has the most risk for limb salvage efforts compared to ? types of injury

A

Pulse rate slows when fistula is compressed and occluded

Stab
Blunt/high kinetic forces

111
Q

Where does the thyroid isthmus cross the trachea

What structures supply it w/ blood?

A

2-4th rings

Superior artery- first branch of external carotid, along inferior constrictor muscle to upper pole
Inferior artery- thyrocervical trunk from subclavian artery

112
Q

What is the major stimulus for thyroid gland activity and growth?

When is a thryoid abnormality more likely to be Ca

What are the most important parts of the Hx

A

TSH due to stimulus from TRH release or decreased T3

M>F
<20 or >60y/o

Age Gender Place of birth FamHx Radiation Hx

113
Q

What are the RFs for thyroid malignancy

What are the 3 surgical referral indications

A

Age Gender FamHx Ionizing radiation

Bulky Sx relief
Definitive Dx of lesions
Definitive therapy of malignancy

114
Q

Most multi-nodular goiters are ? and a solitary hard thyroid nodule is more likely to be ?

What lab results indicate a functioning nodule?

A

Benign, Ca

Low TSH
High T3 T4

115
Q

What labs are first ordered for solitary thyroid nodules

What is the follow on test if one of the lab results is low

A

Function test

Iodine uptake if TSH is low
Normal TSH= FNAB w/ US

116
Q

Hot nodules are likely to be ? and have ? lab result

When are solitary thyroid nodules referred to surgery?

A

Benign
High T3/T4, Low TSH

Suspected/proven Ca
Hormonally active
Cysts reappear after 2 aspirations/>4cm
Functionally malignant
Cosmesis
117
Q

What are the 4 types of benign thyroid tumors

What are the 3 reasons these are removed?

A

Adenoma- most are follicular
Involutionary nodule
Cyst
Localized thyroiditis

Ca suspicion
Hyperthyroidism
Cosmetic

118
Q

? type of thyroid growth doesn’t require any investigation

What are the MC malignant thyroid tumors

A

Incidental cyst finding

Papillary- MC, multifocal, unencapsulated, lymph spread
Follicular- solitary, encapsulated, hematogenous spread

119
Q

Papillary thyroid maligancy is MC in ? PTs

How are follicular neoplasms managed?

A

Iodine deficient

Most benign, can’t differentiate by FNBA
Biopsy to pathology
Follicular adenoma- no further Tx
Follicular carcinoma- thyroidectomy

120
Q

How are differentiated and medullary thyroid Ca Tx

What adjuvent therapies are offered?

A

Thryoidectomy

Thyroxine
Radioactive iodine
XRT
Chemo

121
Q

Thyroid bone metastases survival rate is ?

? type of thyroid cancer has the most bone metastases and to which ones?

A

5yrs of 40-80%

Follicular: Axial skeleton, Vertebrae

122
Q

Define Thyroglossal duct cyst

How is it Tx

What is avoided?

A

Benign condition from embryology failure of thyroglassal tract persists as cyst

Function test
ABX prior to elective surgery

InD

123
Q

What causes thyroid goiters?

How does it present

What will be seen on lab results

A

Iodine deficiency

Mass Dypsnea Dysphagia

Normal/suppressed TSH, inc uptake

124
Q

What type of neoplasms develop in anterior mediastinum?

What type of neoplasms develop in middle mediastinum?

What type of neoplasms develop in posterior mediastinum?

A

Thymoma- MC neoplasm
Substernal thyroid- MC presentation

Lymphoma
Broncheogenic cyst

Neurogenic tumor
Bronchogenic cyst

125
Q

What are the MC causes of thyrotoxicosis

What happens if this form of hyperthyroidism is not Tx?

A

Graves- hyper secretory goiter
Plummer Dz- toxic multi nodular goiter

Death from thryoid storm, HF, cachexia

126
Q

How does Achilles reflex time reflect thyroid health

How does thyrotoxicosis appear on labs?

A

Short- hyperthyroid
Long- hypothyroid

Dec TSH, Inc T3/T4

127
Q

What are additional tests ordered for mild hyperthyroidism to aid w/ Dx?

How is thyrotoxicosis Tx

A

T3 suppression- hyperthyroid PTs fail to suppress uptake
TRH test- TSH fails to rise after TRH administration

Methimazole PO
Radioiodine
Thyroidectomy

128
Q

If PTs w/ thyroid storms are taken to surgery, ? meds are used?

What labs do PCMs order for thyroid nodules?

A

Lugol iodine
BBs
Propythiouracil- dec T4 to T3 conversion

TSH T3 T4 CBC CMP
US CXR

129
Q

Where are thyroid nodules referred to?

How does hyperparathyroidism present

A

IM if hyperthyroid/thyroiditis
GenSurg/ENT- nodule, thyroglossal duct cyst

ASx or Inc PTH/Inc Ca

130
Q

What causes secondary hyperparathyroidism

What would be seen on a hand x-ray in these PTs?

What image is ordered for primary hyperparathyroidism if a substernal gland is found

A

Dec Ca, Inc PTH- RF, malabsorption

Osteitis fibros cystica
Skull molting

Sestamibi/CT/MRi

131
Q

What are the indications to refer primary hyperparathyroid to surgery

What labs do PCMs order for parathyroid induced hyperCa

A

Renal stones
Osteoporosis
HyperCa crisis

CMP PTH
CXR

132
Q

What are the 3 zones of the adrenal glands and what does each one release

What is the function of the adrenal medulla?

A

Glomerulosa- aldosterone
Fasciculata- cortisol
Reticularis- testosterone

Produce catecholamine
Sympathetic stimulation

133
Q

Where do malignant masses on adrenal metastasize to?

Suspicion for Ca increases if size is bigger than?

Incidentalomas can present as a ? crisis

A

Breast Lung Melanoma Lymphoma

> 5cm

Addisons crisis- HypoNa HyperK Hyperpigmentation

134
Q

Adrenal cortical hyperplasia manifests as ?

Adenomas of the pituitary leads to ?

How are these Tx

A

Cushings syndrome

Cushings Dz- failes dexameth suppression test

Pituitary adenoma
Failure- adrenalectomy

135
Q

Triad of Pheos

How are these worked up

How are these PTs prepped for surgery?

A

HA Palpitations Eiaphoresis

Urine/Serum metanephrines

HTN control w/ A and B blockers 10 days prior

136
Q

How are Pheos Dx

Why are CT/MRIs ordered?

Why are PETs ordered?

A

24hr catecholamine/metanephrines collection
Plasma free metanephrines

Find tumor

Find metastasis

137
Q

How are adrenal masses Tx if they are or are not hormonally active

A

Active: adrenalectomy
Inactive: >5cm= ectomy, <5cm and confirmed to be benign= repeat CT 3-6mon

IPAP (212 decks)

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