all of chest

Question 1

treatment of chylothorax

Answer 1

start with NPO and TPN; if unresponsive after 5-7 days of conservative management then surgical ligation of thoracic duct; lymphoscintigraphy and thoracic duct embolization for patients who are poor surgical candidates

Question 2

most common cause of nontraumatic chylothorax

Answer 2

lymphoma

Question 3

treatment of retained hemothorax

Answer 3

first line tx is VATS; intrapleural fibrinolytics are recommended 2nd line (after surgery) or for patients if risk of surgery is too great

Question 4

most common cause of chronic or fibrosing mediastinitis

Answer 4

Histoplasma, commonly causes mediastinal granuloma

Question 5

true or false. aggressive blood glucose management both intraoperatively and posteroperatively has serious impact on rates of deep sternal wound infections and subsequent development of mediastinitis in both diabetic and nondiabetic patients

Answer 5

true

Question 6

factors predictive on PFTs of ability to tolerate pneumonectomy/pulmonary resection

Answer 6

predicted posteroperative diffusion capacity of lungs for carbon monoxide (DLCO) > 60%; predicted postop FEV1 > 60%

Question 7

patients who smoke should quit for at least _____ before lung surgery

Answer 7

4 weeks

Question 8

patients with PPO FEV1 or DLCO <30% before lung surgery should undergo:

Answer 8

formal preop cardiopulmonary exercise testing with measurement of maximal oxygen consumption

Question 9

confirmation of superior vena cava syndrome on CT scan:

Answer 9

nonopacification of the SVC inferior to the site of obstruction as well as opacification of collateral venous structures in the chest including the azygous and right intercostal veins

Question 10

surgical treatment of primary lung cancers

Answer 10

anatomic lobectomy with lymph node staging

Question 11

what populations should undergo annual low dose CT chest for lung cancer surveillance:

Answer 11

patients 55-80 with 30 pack year smoking history who currently smoke or quit within the past 15 years

Question 12

cell findings consistent with exudative effusion

Answer 12

low glucose, low pH, high LDH; blood tinge is more suggestive of malignancy whereas empyema fluid is purulent

Question 13

risk of recurrence of sponanteous pneumothorax without operative intervention:

Answer 13

60%

Question 14

malignant pleural effusion denotes stage ____ lung cancer

Answer 14

IV; M1a disease present and resection is not recommended in most cases

Question 15

triglyceride level above 110 in CT fluid is diagnostic for:

Answer 15

chylothorax

Question 16

best approach for access to the heart

Answer 16

median sternotomy

Question 17

left posterolateral thoracotomy allows access to what?

Answer 17

left ventricle, descending aorta, and distal esophagus

Question 18

right posterolateral thoracotomy allows access to what?

Answer 18

trachea, bilateral mainstem bronchi, proximal/mid esophagus

Question 19

treatment of malignant SVC syndrome:

Answer 19

often an oncologic emergency due to rapid progression; treat with high dose radiation and chemo initially

Question 20

Lights criteria for exudative effusion:

Answer 20

anyone of these - effusion protein/serum protein ratio of >0.5, effusion LDH/serum LDH ratio >0.6; effusion LDH >2/3 the upper limit of normal range of serum LDH

Question 21

true or false: mediastinal lymphadenopathy (N2 disease) in a tumor of the superior sulcus is not contraindication to surgical resection

Answer 21

false

Question 22

symptoms of SVC syndrome

Answer 22

SOB, facial plethora & cyanosis, headache, papilledema, R UE edema, altered sensorium; 80% due to external compression from mediastinal tumor

Question 23

to proceed with pneumonectomy, the contralateral lung needs what FEV1?

Answer 23

800cc (0.8L)

Question 24

absolute contraindications to oncologic lung resection for lung cancer:

Answer 24

N2 (mediastinal) or N3 (contralateral supraclaviular) nodal disease
>50% vertebral body involvement
brachial plexus involvement above T1 nerve
invasion of esophagus or tracha

Question 25

relative contraindications to oncologic lung rection for lung cancer:

Answer 25

N1 or N3 (ipsilateral supraclavicular) nodal disease invasion of subclavian artery <50% vertebral body involvement intraforaminal extension invasion of common carotid or vertebral artery

Question 26

features of pancoast tumor:

Answer 26

superior sulcus tumor; usually NSCLC near the thoracic inlet at the apex of the lung; commonly invade chest wall including the first through third ribs and vertebrae

Question 27

presentation of pancoast/superior sulcus tumor:

Answer 27

shoulder pain in c8 and t1 dermatomes, paresthesia and weakness in ulnar distribution, horner syndrome (ptosis, miosis, anhidrosis)

Question 28

treatment of pancoast/superior sulcus tumor:

Answer 28

chemorads upfront followed by en bloc resection if resectable

Question 29

most common benign tumor of the lung

Answer 29

hamartoma

Question 30

radiologic features of hamartomas:

Answer 30

well-circumscribed nodule with popcorn calcification

Question 31

most common tumors of posterior mediastinum:

Answer 31

neurogenic tumors

Question 32

features of squamous cell carcinoma of the lung:

Answer 32

usually centrally located and associated with PTH-related peptide production

Question 33

features of small cell lung cancer:

Answer 33

ADH and ACTH paraneoplastic syndromes

Question 34

diagnostic test of choice for suspected TEF in adults:

Answer 34

bronchoscopy

Question 35

true or false. in an upright patient, the lung apex will have the high V/Q ratio and the base will be low

Answer 35

true

Question 36

conditions that cause low V/Q ratios

Answer 36

asthma, pulmonary edema

Question 37

conditions that cause high V/Q ratios

Answer 37

PE and COPD

Question 38

what does V/Q ratio of zero indicate

Answer 38

loss of ventilation; known as shunting

Question 39

what does a V/Q ratio of infinity or undefined indicate

Answer 39

an area with ventilation but no perfusion, called dead space

Question 40

PFT findings that are contraindications to lung resection?

Answer 40

DLCO<40%, postop FVC<1.5L

Question 41

VO2 is a measure of ____. Optimal values are ___

Answer 41

measure of exercise tolerance; optimal values are >10-12 mL/min/kg

Question 42

if preop FEV1<0.8L this study can be performed to see if patient can still tolerate a lobectomy

Answer 42

V/Q scan; can resect if resected lobe has minimal contribution to FEV1

Question 43

type of pneumonia characterized by thick, bloody mucoid sputum

Answer 43

Klebsiella pneumonia (currant jelly sputum)

Question 44

common VAP organisms include:

Answer 44

Pseudomonas, Staph aureus, H. flu, Strep pneumo, Enterobacter cloacae

Question 45

True or false. Smaller chest tubes are not as effective as larger ones in evacuating blood from the pleural space.

Answer 45

False

Question 46

Chest tube placement should be avoided if less than ____cc of blood is in the pleural space.

Answer 46

300cc

Question 47

management of malignant chylothorax:

Answer 47

respond favorably to chemorads; duct ligation and embolization are usually ineffective

Question 48

True or false. Pulmonary metastatectomy improves overall survival in sarcoma patients with isolated pulmonary mets.

Answer 48

True

Question 49

Cause of spontaneous pneumomediastinum:

Answer 49

alveolar rupture with tracking along the bronchovascular bundle to the mediastinum

Question 50

Symptoms and treatment of spontaneous pneumomediastinum:

Answer 50

chest pain, SOB, neck pain/crepitus; fever is uncommon CT shows diffuse pneumomediastinum without pleural effusion or fluid collections treat with pain control and observation

Question 51

True or false. Surgical rib fracture fixation after blunt chest trauma reduces pulmonary morbidity, particularly incidence of pneumonia and duration of mechanical ventilation.

Answer 51

true

Question 52

What is milrinone's mechanism of action and what is it commonly used to treat?

Answer 52

phosphodiesterase type III inhibitor that causes increased contractility in cardiogenic shock and induces pulmonary vasodilation in pulmonary hypertension; improves right ventricular function and pulmonary hemodynamics

Question 53

Normal aortic valve area:

Answer 53

3-4 cm squared

Question 54

Which patients with aortic stenosis should have valve replacement?

Answer 54

those that are symptomatic or who have a valve area <1cm squared

Question 55

What location is thoracentesis performed?

Answer 55

between the scapula and the mid axillary line (posterior axillary line), never below the 8th interspace; typically for large effusions it is performed 2-3 interspaces below the top margin of the effusion (as long as it is above 8); typically do in the sitting position leaning forward

Question 56

Signs and symptoms of post-pericardiotomy syndrome/post cardiac injury syndrome?

Answer 56

fever, pleuritic chest pain 1-3 weeks after injury (surgery/CABG or trauma), pericardial friction rub, elevated wbc, elevated esr, elevated crp; diffuse ST segment elevation with PR depression, pericardial effusion on echo

Question 57

Work up of post-pericardiotomy syndrome?

Answer 57

echo, EKG, labs and CXR

Question 58

Tx of post-pericardiotomy syndrome?

Answer 58

NSAIDS