Surgery Block 2 Flashcards
Classically, what are the 3 compartments of the mediastinum?
What angle is formed here and by ? structures?
Superior Anterior Posterior
T4 to Sternomanubral Junction= Angle of Louis
What are the 3 compartments of the mediastinum and what is located in them according to the Burkell classification?
Anterior:
Areolar Transverse Great Nodes Ascending Thymus
Middle: Phrenic Hila Areolar Trachea Pericardium Heart
Posterior: Sympathetic Vagus Esophagus Nodes Ducts Descending
What is the fundamental unit of lung anatomy?
How many lobes does each lung have?
What lung segments are homologous to each other?
Bronchopulmonary segment
R: Upper Middle Lower
L: Upper Lower
L upper lobe lingular segment = R middle lobe
How many fissures are in the right lung?
R:
Minor/horizontal divides middle from upper
Major/oblique divides upper/middle from lower
L:
Oblique separates upper/lower lobes
Skin tests can be used for Dx of ? lung issues
What are the two types of endoscopy and their use?
TB Histo Coccidio
Laryngo- assess vocal cord mobility after change in voice d/t suspected lung carcinoma
Broncho- flex/rigid
What procedure is the mainstay of evaluation of the mediastinum?
Define Chamberlain procedure and it’s alternate?
Cervical mediastinoscopy: 3 sample collection: paratracheal 2/7, subcarinal 7
Anterior mediastinomy to sample nodes/biopsy tissue in aortopulmonary window.
Video Assisted Thorascopic Surgery
What are the 3 methods to collect a pleural biopsy?
Where is the incision for mediastinoscopy?
Where is the incision for Chamberlin procedure?
Percutaneous needle
Open surgery
VATS
Above sternal notch
2-3rd interspace
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?
Eval solitary pulm nodule
Confirm metastatic Dz
Thoracoscopy
Single lung ventilation
Cytology of ? can be used for detecting lung Ca
What is the cornerstone of chest pathology evaluation?
Sputum from abrasions
CT
What niche does MRI have in evaluating thoracic structures?
MRI is used in this niche to evaluate for involvement of ?
Superior sulcus (Pancoast) tumors
Brachial plexus
Subclavian vessel
Bony chest wall
Where does PET use fall into thoracic malignancy?
PETs are more accurate than CTs to detect ?
Staging/work up
Spread to mediastinal nodes
Define Infiltrate
Define Effusion
Fluid in lung
Fluid in pleural space
PTs w/ pneumonia, fluid in the infiltrate is ?
PTs w/ pulmonary edema, fluid in infiltrate is ?
PTs w/ pulmonary contusion, fluid in infiltrate is ?
Pus
Serous
Blood
Pleural effusions are divided into ? or ? depending on?
Where are each ones more likely to develop/form?
Exudate/Transudate
Protein/LDH
Transudates: inc capillary hydrostatic pressure/dec osmotic pressure
Exudates: inflammation
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 ?
CHF (L sided failure)
Hypoalbumin
Cirrhosis
Nephrotic syndrome
Malignancy
Empyema is classified as ? type of effusion?
This classification can include ? other types of effusions
Exudate
Hemothorax- Hct +50%
Chylothorax- inc TG/cholesterol
What structures carry contents for a chylothorax to develop?
Where does it begin/end?
Thoracic duct, carries chyle from intestine to blood
Cisterna chyli (L2) to L-subclavian/jugular vein
? sign on CXR indicates fluid in chest cavity?
How can the fluid be removed?
Meniscus sign
Thoracentesis
Chest tube
? forms the interlobar fissures?
Space between visceral and parietal pleura is a potential space normally holding ? mL of fluid
Enfolds of visceral pleura
2-5mL
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
> 300mL- angles
2L- hemi
Higher on lateral margin than medially= meniscus sign
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?
> 150mL
Lateral decubitus; <50mL
1cm thick
? physiological process occurs in order for a pulmonary edema to occur?
What CXR appearance does this cause?
Pulm venous pressure >25mmHg
Bat wing appearance
Cephalization is only beneficial once ? has been verified?
Difference in appearance of a lung abscess and a COPD bleb/bulla?
Certain PT was upright during x-ray
Abscess: thick w/ fluid
Bleb: thin w/ air
Pulmonary edema starts by filling ? seen on CXR
What is common in all forms of atelectasis?
Large vessels in hilum
Dec volume, inc density
What is the first imaging study of choice for small pericardial effusions?
What are the different types of pneumothoraxes?
Pericardial US or,
CT
Simple- - VS changes
Tension- + VS changes
Open- penetration w/ suck
Closed- blunt trauma, closed wall
How are the different types of pneumothoraxes Tx?
How does this kill PTs?
Simple- - lung re-expansion, thoracostomy
Tension- needle-D, thoracostomy
Open- valve, thoracostomy
Closed- thoracostomy
Pressure on heart/vena cava impedes venous return= CV collapse
How are tension pneumos recognized on PE?
All spot pneumos are truly ? type
Unilateral dec sounds
Tympany on affected side
Deviation
JVD
Secondary
What is the MC cause of spot pneumos?
Classically, these present in ? PT populations?
Ruptured bleb in apex of lobe
Asthenic male 16-24y/o w/ smoking Hx
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
PA/Lat CXR w/ exhalation
<20-25%
> 30%
8-20F
What type of valve is used during Tx of Ptx >30%?
How does this valve’s performance dictate the PTs prognosis?
Heimlich
Maintains expansion= out pt
Failure to maintain= admit
What are the land marks for chest tube placement?
How does repeat Ptx inc the chance for future and repeated Ptx?
Mid-axillary 5-6th intercostal line, nipple level
1st: 40-50%
2nd; 50-75%
3rd: +80%
What is the MC cause of pleural issues?
Primary pleural tumors are not common but involvement of the pleura is common w/ ?
Ptx
Metastatic cancer
What are the MC Sxs of pleural Dz?
Pleural pain is mediates through ? nerves and leads to ? type of pain
Pain Dyspnea
Pleural pain:
Somatic intercostal nerves (cervical/costal pleura)= chest wall/back pain
Phrenic nerve (diaphragm/mediastinal pleura)= shoulder
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?
Extension of visceral process
Fibrosis/tumor infiltrate
Ipsilateral lung infiltrated by tumor
Malignant mesothelioma
Why would interventional radiology be ordered for pleural effusions?
How much fluid is needed for lab eval of thoracentesis?
Loculated effusion to be managed w/ percutaneous drain placement w/ CT guidance
20mL
Criteria for Transudate
What is the proper land mark for thoracentesis procedures?
What must be done after the procedure?
CHF/LF:
Total protein <3g (ratio
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?
<200mL/day
Talc or Doxy
Mechanical pleurectomy w/out chemical installation
How are malignant effusions Tx
How are thoracic empyemas Tx
Palliative w/ expansion as goal
20-28F chest tube x 24-48hrs, pleurodesis
Thoracentesis
How are hemothoraces Tx
How are chylothoraxes Tx
32-36F chest tube
Same as malignant but w/ low fat diet
? 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
TB
Chest tube thoracostomy, no US requirement
Exudative
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
Pleural fluid cholesterol >55mg
Pleural LDH >200
Parapneumonic empyema
Gram neg
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?
Staph
E Coli, Pseudomonas
Klebsiella Enterobacter Proteus Salmonella
Blastomyces Aspergillus Coccidieo Histo
E histolytica
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?
Staph empyema
3.2/PT
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?
CXR as posterolateral D-shaped density
Thoracentesis
Bronchoscopy to r/o endobronchial obstruction
What are the presenting S/Sxs of thoracic empyema
Define Pulmonary Infiltrate
Clubbing Osteroarthropathy Anemia Tachy/Tachy Dec sounds w/ dull percussion
Fluid in interstitial space
What are the etiologies of pulmonary infiltrates
Edema occurs when lung water is increased by ?
How can pulmonary edema be dec?
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
What is the MC cause of pulmonary capillary leakage/ARDS?
PTs that develop post-op pulmonary insufficiency need to have ? DDxs r/o
Infection/inflammation distant from lungs
Deep abscess Infection Pancreatitis Septic phlebitis
How are thoracic empyemas from abscesses Tx
When is operative interventions indicated?
If surgery is indicated ? procedures are done?
ABX x 4-6wks= mainstay
Percutaneous drainage
No improvement after 4-6wks of ABX Empyema/BPF Abscess >6cm Hemoptysis Bronchial obstruction
Thoracoscopic/open lobectomy
What are the 3 goals of empyema Tx
What is a common sequelae to thoracic empyema surgery?
How is this sequelae avoided/reduced?
Control infection
Remove purulent material
Eliminate underlying Dz process
Pneumonia
Broad spectrum ABX
Post-thoracic empyema PTs that develop ? triad need to be intubated and mechanically ventilated?
What are the largest etiologies of lung cancer?
Atelectasis
Edema
Pneumonia
Non-small cell carcinomas= Squamous Large cell Adenocarcinoma
Peripheral tumors cause ? presenting issues?
Neoplasms touching bronchus have ? Sxs
Neoplasms that mass in pleura have ? Sxs
Pancoast syndrome- shoulder pain C8-T1, Horner, Superior sulcus (squamous)
Cough/hemoptysis
Chest pain
Neoplasms that cause bronchus narrowing present w/ ? Sxs
Neoplasms causing mid parenchyma from bronchus present w/ ? Sxs
Atelectasis
Hemoptysis
Neoplasms that cause paraneoplastic syndromes present w/ ? due to depletion/production of hormones
Central tumors are responsible for causing ? presenting Sxs
Clubbing
Osteroarthropathy
Cough Hemoptysis Dyspnea Pain Pneumonia
What type of paraneoplastic syndrome is produced by NSCLC, SCLC, and Adrenal insufficiency
HyperCa d/t PTH substance production
ADH like substance production (hypoNa Hyperpigment inc ACTH)
Salt craving, HypoNa, HyperK
What are the MC metastases sites for NSCLC
PT w/ ulnar compression, horners and SVC may have ? type of Ca
Nodes Liver Brain Bones Adrenals
Pancoast in lung apex
Pancoast tumors can invade/compress ? structures
What is an early presenting Sx of SVC Syndrome
Subclavian Innominate Phrenic Recurrent Vagus
Nasal congestion
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?
Upper abdomen, metastases to liver/adrenals
Contrast
Bone scan
MRI brain scan
What test is used for clinically staging neoplasms of the lung
This form of test is also the most effective for assessing ?
FDG PET
Distant occult Dzs
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?
Throacentesis
Thoracosopy
Parenchymal
Small
Characteristics of benign neoplasms?
Characteristics of malignant neoplams?
<2cm Stable over 24mon Concentric/calcified Smooth border Solitary
>2cm Inc/unstable over 24mon Irregular/calcified Spiculated Multples
What are the two MC types of NSCLC?
How does each types appear on images?
Adenocarcinoma
Squamous cell
Adeno: ground glass nodule
Sq: spiculated, irregular appearing
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?
Bronchoscopy if lesion is proximal
Fine needle aspiration for peripheral
Bronchoscopy
Define Unresectable
Define Inoperable
Tumor invaded vital structures, can’t be removed
PT is unstable for surgery due to comorbidities
What is the most accurate factor for predicting successful outcomes of lung neoplasms?
What are two absolute c/is for conducting a standard resection?
PTs performance status/functional classification
PHTN
MI <3mon
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?
Coronary artery Dz
MI <6mon
Ventricular arrhythmias
Heart blocks- LPFH
T sizes for TNM staging
N criteria
T1: <3 T2: 3-7cm T3: >7cm T4: invastion
N0: no nodes N1: broncho/hilar N2: mediastinal/subcarinal
N3: contralateral
Any PT who smokes and presents w/ SIADH Sxs needs to have ? DDx
What imaging would be ordered?
Lung Ca
CXR then CT
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
Adventitia
Occlusive: ischemia, necrosis
Aneurysmal: rupture, hemorrhage (aortic) or thrombus, embolization (peripheral)
Arterial aneurysm is normally ?% bigger than normal and involves ? layers
What are the two MC causes
What is the MC site of aneurysmal dz
> 50%
All 3: intima media adventitia
Atherosclerosis
HTN
Abdominal aorta
What is the MC of the true aneurysms
What is the 2nd MC
In descending order, what are the MC areas
Infrarenal AAA
False aneurysm in femoral artery 2/2 catheterization
Iliac Popliteal Arch/Descending aorta Common femoral Carotid
What are the 3 subtypes of pseudoaneurysms?
What is the MC cause of pseudo aneurysms?
Saccular- out pouch of wall
Fusiform- diffuse; entire circumference of artery
Mycocit- infection related (Staph from IVDA), used to be Salmonella
Trauma
Pulsatile hematoma is synonumous for ? aneurysm
What is the MC but other possible etiologies of aneurysms?
Adventitia/periarterial invovlement and hematoma
Degenerative*
Inflammatory
Infectious
Congenital
What physics law applies to AAA?
Once they reach ? size they are usually palpable where?
What PE finding indicates urgent need for surgery
LaPlace- inc radius, wall tension inc and weakens wall
5cm, above and L of umbilicus
Extreme tenderness, “symptomatic AAA”
Rarely, AAAs can cause ? presenting complaint
Severe AAA pain w/out rupture indicates ? characteristic issue?
Back pain
Inflammatory aneurysm surrounded by perianeurysm retroperitoneal reactions
Where does the abdominal aorta begin?
Where does it travel through the abdomen?
Where does it bifurcate into the iliac arteries
Diaphragm/T12
Retroperitoneal space anterior and L of spine
Umbilicus/L4
S/Sxs of anterior AAA rupture
S/Sxs of posterior AAA rutpture
Abdominal pain
CV collapse
Back pain
+/- HOTN
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?
Shock
HOTN and absent distal pulses
Back pain- blood leaks from L-posterior corner below L renal artery (weakest point of aorta)
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?
US
Thin sliced CT angiography
Aortogram
What are the 3 indications a AAA needs to be repaired
What are the two AAA Tx methods
ASx >5.5cm
Sx, emergent repair regardless of size
Expands >1cm/year
Open
EVAR: endovascular aneurysm repair
How are AAA PTs managed Post-op
AAA fistulization w/ IVC leads to ?
AAA fistulization w/ GI tract leads to ?
Full mobilization and diet same day
D/c post-op day 1 or 2
CHF
Aorto-enteric fistula
Define Blue Toe Syndrome
? PT presentation indicates limb threatening problem
Distal embolization impairing blood flow to toes
Sudden onset of pain w/ toe discolorization w/ palpable pulses
What type of mechanisms causes aortic transections
Where does the transection usually occur?
Most will die at the scene unless ? structure remains intact?
Rapid deceleration (auto, motorcycle, fall)
Distal to subclavian artery at aorta isthmus at connection of ligamentum arteriosum
Adventitia
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
Mediastinal widening
CT angiography
BBs, HR/SBP <100
What are the grades of aortic transections
How are these repaired?
1: intimal injury
2: intramural hematoma
3: pseudoaneurysm
4: rupture
TEVAR- bilateral groin access to place endograft
What is the MC catastrophic event involving the aorta?
How is this different than transection
What is the difference between DeBakey and Stanford classifications
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
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
R sternal border
R/o MI/PE w/ EKG and CXR
CT
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
Ascending aorta involvement
Aortic valve insufficiency
Intimal flap
Esmolol, Nitroprusside w/ BP goal 100-120
Ascending= emergent surgery
Descending= medical management
PTs w/ Type A aortic dissection receive immediate surgery to prevent death from ? 3 things
What presenting finding is more common in ascending dissections?
Tamponade
Aortic valve insufficiency
MI
HOTN
Define “Triple R/o”
What 3 structures provide the most of the blood to the stomach and intestine?
What structures supply the distal colon?
CT used to eval for PE, dissection, MI
Celiac axis
Sup/Inf mesenteric arteries
Inf mesenteric
Internal iliac artery
What is the MC presenting issue of messenteric ischemia?
What imaging is preferred?
What is used for first line therapy?
Post-prandial abdominal pain
CTA/arteriorgraphy
Percutaneous transluminal angioplasty and stenting
What part of the GI tract is vulnerable to colonic ischemia
What causes this
Watershed area between SMA/IMA
Hypoperfusion to large intestine
Superior messenteric artery supplies ?
Inferior messenteric artery supplies?
? supplies the lower rectum?
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
How is ischemic colitis Tx
What are the 3 causes of carotid related CVAs
IV fluids
Bowel rest
ABX
Embolization- MC*
Cardioembolism from A-fib
Flow related brain ischemia
Sxs of extracranial carotid disease are most often caused by ?
How can carotid artery dz present
Embolization
ASx
TIA- hemiparesis, slurred speech, amaurosis fugax
Frank CVA- may be 1st Sx
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
Ophthalmic artery
Monocular vision- amaurosis fugax
Atherosclerotic emobli visible as bright flecks
Neck US
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?
Duplex US- assesses diameter and flow
Carotid arteriography- surgery is anticipated
6mon
How is Carotid Artery Dz Tx
Smoking cessation
ASA (dont start Clopidogres if pending surgery)
Serial duplex scans
Carotid endarterectomy
Carotid stents w/ Clopidogrel x 6wks post-op
Carotid stenosis exceeding ? should be Tx w/ surgery
Define Subclavian Steal Syndrome
75%
Use of arm moves blood from vertebral artery, retrograde flow in ipsilateral vertebral artery leading to brain ischemia
Normally a Dz of the LE, where can peripheral vascular dz occur?
Where do they MC occur?
Subclavian arteries
Superficial femoral/iliac artery
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
Ankle brachial index
Femoral artery= calf pain
Buttock/thigh= iliac
Impotence/gluteal pain= hypogastric arteries
Prox thigh= proximal to profunda femoris
40%
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
Rest pain
Night pain being more prominent
Hang leg off bed/sleep in chair
City blocks
What is the MC type of foot pain at rest?
How is it differentiated from peripheral artery dz
What ABI measurement is concerning
Diabetic neuropathy
Hanging leg off bed improves PADz
<1.0
What is the single most important part of PADz Tx
What meds can be used for Tx?
Smoking cessation
Statin w/ LDL goal <100
ASA/Clopidogrel
Cilostazol- vaso dilator, FDA recommended/better efficacy
Pentoxphyline- dec viscosity
What is the first step done after undergoing claudication Tx surgery?
What are the 6 Ps of arterial occlusions?
Assess peripheral pulses at doralis pedis, posterior tibialis and peroneal
PooP Pallor Poikilothermia Parathesia Pulseless Paralysis- late indicator
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
Few hrs, gangrene
Blunt injury
6hrs
When is popliteal entrapment Dx suspected?
How is it visualized?
Young healthy PT w/ calf claudication due to medial muscle head
MRI and CT show no atherosclerosis
Define Buerger Dz
Why does this lead to amputations so often?
What is the presenting complaint usually?
Thromboangiitis Obliterans- male smokers w/ ischemia
Distal arteries are affected most
Foot/arch claudication
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
High output HF
> 5mm, 20cm
Cephalic
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
Cimino fistula
Arterial steal
Distal ischemia
HOHF
Define Branham sign
? type of injury has the most risk for limb salvage efforts compared to ? types of injury
Pulse rate slows when fistula is compressed and occluded
Stab
Blunt/high kinetic forces
Where does the thyroid isthmus cross the trachea
What structures supply it w/ blood?
2-4th rings
Superior artery- first branch of external carotid, along inferior constrictor muscle to upper pole
Inferior artery- thyrocervical trunk from subclavian artery
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
TSH due to stimulus from TRH release or decreased T3
M>F
<20 or >60y/o
Age Gender Place of birth FamHx Radiation Hx
What are the RFs for thyroid malignancy
What are the 3 surgical referral indications
Age Gender FamHx Ionizing radiation
Bulky Sx relief
Definitive Dx of lesions
Definitive therapy of malignancy
Most multi-nodular goiters are ? and a solitary hard thyroid nodule is more likely to be ?
What lab results indicate a functioning nodule?
Benign, Ca
Low TSH
High T3 T4
What labs are first ordered for solitary thyroid nodules
What is the follow on test if one of the lab results is low
Function test
Iodine uptake if TSH is low
Normal TSH= FNAB w/ US
Hot nodules are likely to be ? and have ? lab result
When are solitary thyroid nodules referred to surgery?
Benign
High T3/T4, Low TSH
Suspected/proven Ca Hormonally active Cysts reappear after 2 aspirations/>4cm Functionally malignant Cosmesis
What are the 4 types of benign thyroid tumors
What are the 3 reasons these are removed?
Adenoma- most are follicular
Involutionary nodule
Cyst
Localized thyroiditis
Ca suspicion
Hyperthyroidism
Cosmetic
? type of thyroid growth doesn’t require any investigation
What are the MC malignant thyroid tumors
Incidental cyst finding
Papillary- MC, multifocal, unencapsulated, lymph spread
Follicular- solitary, encapsulated, hematogenous spread
Papillary thyroid maligancy is MC in ? PTs
How are follicular neoplasms managed?
Iodine deficient
Most benign, can’t differentiate by FNBA
Biopsy to pathology
Follicular adenoma- no further Tx
Follicular carcinoma- thyroidectomy
How are differentiated and medullary thyroid Ca Tx
What adjuvent therapies are offered?
Thryoidectomy
Thyroxine
Radioactive iodine
XRT
Chemo
Thyroid bone metastases survival rate is ?
? type of thyroid cancer has the most bone metastases and to which ones?
5yrs of 40-80%
Follicular: Axial skeleton, Vertebrae
Define Thyroglossal duct cyst
How is it Tx
What is avoided?
Benign condition from embryology failure of thyroglassal tract persists as cyst
Function test
ABX prior to elective surgery
InD
What causes thyroid goiters?
How does it present
What will be seen on lab results
Iodine deficiency
Mass Dypsnea Dysphagia
Normal/suppressed TSH, inc uptake
What type of neoplasms develop in anterior mediastinum?
What type of neoplasms develop in middle mediastinum?
What type of neoplasms develop in posterior mediastinum?
Thymoma- MC neoplasm
Substernal thyroid- MC presentation
Lymphoma
Broncheogenic cyst
Neurogenic tumor
Bronchogenic cyst
What are the MC causes of thyrotoxicosis
What happens if this form of hyperthyroidism is not Tx?
Graves- hyper secretory goiter
Plummer Dz- toxic multi nodular goiter
Death from thryoid storm, HF, cachexia
How does Achilles reflex time reflect thyroid health
How does thyrotoxicosis appear on labs?
Short- hyperthyroid
Long- hypothyroid
Dec TSH, Inc T3/T4
What are additional tests ordered for mild hyperthyroidism to aid w/ Dx?
How is thyrotoxicosis Tx
T3 suppression- hyperthyroid PTs fail to suppress uptake
TRH test- TSH fails to rise after TRH administration
Methimazole PO
Radioiodine
Thyroidectomy
If PTs w/ thyroid storms are taken to surgery, ? meds are used?
What labs do PCMs order for thyroid nodules?
Lugol iodine
BBs
Propythiouracil- dec T4 to T3 conversion
TSH T3 T4 CBC CMP
US CXR
Where are thyroid nodules referred to?
How does hyperparathyroidism present
IM if hyperthyroid/thyroiditis
GenSurg/ENT- nodule, thyroglossal duct cyst
ASx or Inc PTH/Inc Ca
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
Dec Ca, Inc PTH- RF, malabsorption
Osteitis fibros cystica
Skull molting
Sestamibi/CT/MRi
What are the indications to refer primary hyperparathyroid to surgery
What labs do PCMs order for parathyroid induced hyperCa
Renal stones
Osteoporosis
HyperCa crisis
CMP PTH
CXR
What are the 3 zones of the adrenal glands and what does each one release
What is the function of the adrenal medulla?
Glomerulosa- aldosterone
Fasciculata- cortisol
Reticularis- testosterone
Produce catecholamine
Sympathetic stimulation
Where do malignant masses on adrenal metastasize to?
Suspicion for Ca increases if size is bigger than?
Incidentalomas can present as a ? crisis
Breast Lung Melanoma Lymphoma
> 5cm
Addisons crisis- HypoNa HyperK Hyperpigmentation
Adrenal cortical hyperplasia manifests as ?
Adenomas of the pituitary leads to ?
How are these Tx
Cushings syndrome
Cushings Dz- failes dexameth suppression test
Pituitary adenoma
Failure- adrenalectomy
Triad of Pheos
How are these worked up
How are these PTs prepped for surgery?
HA Palpitations Eiaphoresis
Urine/Serum metanephrines
HTN control w/ A and B blockers 10 days prior
How are Pheos Dx
Why are CT/MRIs ordered?
Why are PETs ordered?
24hr catecholamine/metanephrines collection
Plasma free metanephrines
Find tumor
Find metastasis
How are adrenal masses Tx if they are or are not hormonally active
Active: adrenalectomy
Inactive: >5cm= ectomy, <5cm and confirmed to be benign= repeat CT 3-6mon
