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
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
26
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
27
How are tension pneumos recognized on PE? All spot pneumos are truly ? type
Unilateral dec sounds Tympany on affected side Deviation JVD Secondary
28
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
29
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
30
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
31
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%
32
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
33
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
34
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
35
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
36
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
37
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
38
How are malignant effusions Tx How are thoracic empyemas Tx
Palliative w/ expansion as goal 20-28F chest tube x 24-48hrs, pleurodesis Thoracentesis
39
How are hemothoraces Tx How are chylothoraxes Tx
32-36F chest tube Same as malignant but w/ low fat diet
40
? 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
41
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
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
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
50
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
51
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
52
Neoplasms that cause bronchus narrowing present w/ ? Sxs Neoplasms causing mid parenchyma from bronchus present w/ ? Sxs
Atelectasis Hemoptysis
53
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
54
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
55
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
56
Pancoast tumors can invade/compress ? structures What is an early presenting Sx of SVC Syndrome
Subclavian Innominate Phrenic Recurrent Vagus Nasal congestion
57
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
58
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
59
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
60
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 ```
61
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
62
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
63
# Define Unresectable Define Inoperable
Tumor invaded vital structures, can't be removed PT is unstable for surgery due to comorbidities
64
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
65
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
66
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
67
Any PT who smokes and presents w/ SIADH Sxs needs to have ? DDx What imaging would be ordered?
Lung Ca CXR then CT
68
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)
69
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
70
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 ```
71
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
72
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
73
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"
74
Rarely, AAAs can cause ? presenting complaint Severe AAA pain w/out rupture indicates ? characteristic issue?
Back pain Inflammatory aneurysm surrounded by perianeurysm retroperitoneal reactions
75
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
76
S/Sxs of anterior AAA rupture S/Sxs of posterior AAA rutpture
Abdominal pain CV collapse Back pain +/- HOTN
77
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)
78
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
79
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
80
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
81
# 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
82
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
83
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
84
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
85
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
86
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
87
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
88
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
89
# 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
90
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
91
What part of the GI tract is vulnerable to colonic ischemia What causes this
Watershed area between SMA/IMA Hypoperfusion to large intestine
92
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
93
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
94
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
95
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
96
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
97
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
98
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
99
Normally a Dz of the LE, where can peripheral vascular dz occur? Where do they MC occur?
Subclavian arteries Superficial femoral/iliac artery
100
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%
101
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
102
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
103
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
104
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 ```
105
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
106
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
107
# 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
108
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
109
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
110
# 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
111
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
112
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
113
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
114
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
115
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
116
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 ```
117
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
118
? 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
119
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
120
How are differentiated and medullary thyroid Ca Tx What adjuvent therapies are offered?
Thryoidectomy Thyroxine Radioactive iodine XRT Chemo
121
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
122
# 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
123
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
124
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
125
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
126
How does Achilles reflex time reflect thyroid health How does thyrotoxicosis appear on labs?
Short- hyperthyroid Long- hypothyroid Dec TSH, Inc T3/T4
127
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
128
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
129
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
130
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
131
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
132
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
133
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
134
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
135
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
136
How are Pheos Dx Why are CT/MRIs ordered? Why are PETs ordered?
24hr catecholamine/metanephrines collection Plasma free metanephrines Find tumor Find metastasis
137
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