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Flashcards in cardiothoracic problems Deck (43):
1

75yo woman with a hx of angina is admitted to the hospital for sycope. exam of the pt reveals a systolic mrumur best heard at the base of the heart that radiates into the carotid arteries. ECG reveals an aortic valve area of 0.7cm2. what is the most appropriate next step in her management?
a. medical management with a nitrate and an ACE inhibitor
b. b/l carotid endarterectomies
c. percutaneous coronary artery angioplasty & stenting
d. coronary artery bypass surgery
e. aortic valve replacement

E

aortic stenosis + symptomatic + murmur

aorta = 3cm?

2

68yo man is diagnosed with lung cancer. in preparation for pulmonary resection he undergoes PFTs. which of the following results indicate a favorable prognosis?
a. elevated PCO2
b. FEV1 > 60% of predicted
c. DLCO < 40%
d. low FEV1/FVC
e. normal FEV1/FVC

B

predictors of postop pulmonary reserve
1) FEV 1 >60%

PCO2 = retention
nml FEV1/FVC = could still be restrictive pulmonary disease

3

71yo woman with 40y smoking hx is noted to have a peripheral nodule in her L upper lobe on CXR. workup is consistent with small cell lung cancer with ipsilateral mediastinal lymph node involvement but no extrathoracic disease. what is the best treatment option for this patient?
a. thoracotomy with L upper lobectomy and mediastinal lymph node dissection
b. thoracotomy with L upper lobectomy and mediastinal lymph node dissection, then adjuvant chemotherapy
c. neoadjuvant chemotherapy, then thoracotomy with L upper lobectomy and mediastinal lymph node dissection
d. neoadjuvant chemoradiation, then thoracotomy with L upper lobectomy and mediastinal lymph node dissection
e. chemoradiation

E

aggressive, so will have to do chemo / radiation regardless
--> rarely able to do surgical resection d/t extensive disease at presentation

SCLC = 20% of primary lung cancers

4

42yo homeless man presets with a 3w hx of SOB, fevers, and pleuritic chest pain. CXR reveals a large L pleural effusion. thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose <40 and pH of 6.5. a chest tube is placed, but the pleural effusion persists. which of the following is the most appropriate management of this pt?
a. placement of a 2nd chest tube at the bedside and antibiotic therapy
b. infusion of antibiotics via chest tube
c. IV antibiotics for 6w
d. thoracotomy with instillation of antibiotics into pleural space
e. thoracotomy with decortication and antibiotic therapy

E

only do 2 chest tubes if:
1) at top for air
2) at bottom for fluid

or do it in the OR

==> empyema or accumulation of pus in cavity
--> definitely of exudative quality
"organizing phase" of empyema
- fluid collection is loculated & depositions of fibrin create a thick pleural rind --> prevents apposition of the lung to the pareital pleura

Tx
- thoracotomy + decortication ==> remove purulent fluid & pleural rind
- specific antibiotic

5

63yo man is seen b/c of facial swelling and cyanosis, esp. when he bends over. there are large, dilated subcutaneous veins on his upper chest. his jugular veins are prominent even while he is upright. which of the following conditions is most likely cause of these findings?
a. histoplasmosis (sclerosing mediastinitis)
b. substernal thyroid
c. thoracic aortic aneurysm
d. constrictive pericarditis
e. bronchogenic carcinoma

E --> growth pressing on sympathetics --> SVC syndrome

definitely fluid overload

Causes
-pemberton sign
-sympathetics
-

SXs
- incrased venous pressure --> edema of upper body, cyanosis, dilated subcu collateral vessels in the chest, and HA
- cervical lymphadenopathy

Causes of SVC syndrome
1) bronchogenic carcinoma
2) lymphoma
3) substernal thyroid / thoracic aortic aneurysm

tx
- diuresis
- radiation & chemo for cancers
- surgical intervention / thrombolysis

6

during endoscopic biopsy of a distal esophgeal cancer, perforation of the esophagus is suspected when the pt complains of significant new substernal pain. an immediate CXR reveals air onthe mediastinum. which of the following is the most appropriate management of this pt?
a. placement of an NGT to the level of perforation, Abx, and close observation
b. spit fistula (cervical pharyngostomY) and gastrostomy
c. L thoracotomy, pleural patch oversewing of the perforation and drainage of the mediastinum
d. L thoracotomy with esophagectomy
e. thoracotomy with chest tube drainage and esophageal exclusion

D

perforation

Dx = water-soluble contrast esophagogram

Tx
1) primary repair of the perforation & drainage of mediastinum
2) +/- correction of esophgeal abnormality that led to underlying motility d/o, stricture, or malignancy (esp. esophagectomy for distal esophgeal carcinoma).

7

63yo woman with COPD presents with several week hx of fever, night sweats, weight loss, and cough. her CXR is noted to have a density in the LUL with relatively thin-walled cavity. bronchoscopy and CT are suggestive of lung abscess rather than a malignant process. which of the following is the most appropriate initial management of this pt?
a. percutaneous drainage of the lung abscess
b. systemic antibiotics directed against the causative agent
c. tube thoracostomy
d. left upper lobectomy
e. surgical drainage of the abscess

B. usually a LUNG abscess will drain spontaneously via tracheobronchial tree without drainage

abscess? = "thin walled cavity"

are there concerns of dragging the contents of the absces across if percutanoeus drainage.

Aspergillus?

1) antibiotics
2) drainage (perc / surgical)

8

45yo man with poorly controlled HTN presents with severe chest pain radiating to his back. an ECG demonstrates no significant abnormalities. CT scano f the chest & abdomen is obtained, which demonstrates a descending thoracic aortic dissection extending from distal to the L subclavian takeoff down to above the iliac bifurcation. a foley catheter is placed, and UO is 30-40cc/h. his feet are warm with <2 sec capillary refill. which of the following is the most appropriate initial management?
a. emergent operation for repair of the aortic dissection
b. angiography to confirm the diagnosis of aortic dissection
e. Echo to rule out cardiac complications
d. initiation of B-blocker
e. initiation of a vasodilator such as nitroprusside

D

aortic dissection

Stanford B aortic dissection ==> expectant management

Tx
1) B-blocker ==> reduce rate of change in BP & reduce shear on aortic wall
2) nitroprusside
3) surgery for - end-organ failure; inadequate pain relief refractory to medical treatment, rupture / signs of impending rupture (increasing diameter >5.5cm, periarotic fluid)

9

a stockbroker in his mid-40 presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. diagnostic studies on the esohpagus yield the following results:
-endoscopic examination and biopsy: mid inflammation distally, manometry-prolonged high amplitude contractions from the arch of the aorta distally, lower esophageal sphincter (LES) pressure 20mmHg with relaxation on swallowing:
-barium swallow: 2cm epiphrenic diverticulum.
which of the following is the best management option for this pt?
a. myotomy along with length of the manometric abnormality
b. diverticulectomy, myotomy from the level of the aortic arch to the fundus, fundoplication
c. diverticulectomy, cardiomyotomy of the distal 3cm of esophagus and proximal 2cm of stomach with antireflux fundoplication
d. a trial of CCBs
e. pneumatic dilatation of the LES

A


diffuse esophgeal spasm

tx
--> long motomy guided by manometric evidence

no need to do anything with the diverticulum at this point.

10

4yo boy is seen 1h after ingestion of a lye drain cleaner. no oropharyngeal burns are noted. the CXR is normal, but the patient continues to complain of significant chest pain. which of the following is the most appropriate next step in his management?
a. parenteral steroids and antibiotics
b. esophagogram with water-soluble contrast
c. administration of an oral neutralizing agent
d. induction of vomiting
e. rapid administration of a quart of water to clear remaining lye from the esophagus and dilute material in the stomach.

B

Tx
1) water-solube contrast esophagogram

NOT
- giving fluids to washout when internal ---> b/c can increase gastric volume --> induce N&V --> worsen corrosive injury & possible aspiration

11

a previously healthy 20yo man is admitted to the hospital with acute onset of L sided chest pain. electrocardiographic findings are normal, but CXR shows a 40% L pneumothorax. appropriate treatment consists of which of the following procedures?
a. observation
b. barium swallow
c. thoracotomy
d. tube thoracostomy
e. thoracostomy and intubation

D

<50%, pleuritic chest pain


spontanoeus pneumothorax in thin, young male

tx
1) large pneumothorax > 25% ==> placement o fchest tube
2) recurrent pneumothorax ==> bled excision, pleural abrasion
3) spontanous perforation of esophagus --> hydropneumothorax, pneumomediastinum ==> gastrografin swwallow + barium study

12

50yo salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. he arrives in your ED 4h later and has a chest film in which the left descending aorta is outlined by air density. which of the following is the most appropriate next step in his workup
a. contrast esophagram
b. echocardiogram
c. flexible bronchoscopy
d. flexible esophagogastroscopy
e. aortography

A

pneumoperitonenum
--> boerhaave syndrome

THORAX ==> barium contrast
ABDOMEN ==> water-soluble contrast

** if in doubt, choose water-soluble contrast. If there is no option, then choose "contrast" or "thin-barium contrast"

13

26yo man is brought to the ED after being extricated from the driver's seat of a car involved in a head-on collision. he has a sternal fracture and is complaining of chest pain. he is hemodynamically stable and his ECG is normal. which of the following is the most appropriate management strategy for this patient?
a. admit to telemetry for 24h monitoring
b. admit to the regular ward with serial ECGs for 24h
c. emergent cardiac catheterization
d. immediate operative plating of the sternal fracture
e. discharge to home with NSAIDs for the sternal fracture

A

cardiac contusion

Dx
1) monitor on telemetry for 24h ==> ST or T wave changes, arrhythmias, bundle branch, blocks.

normal EKG does NOT rule out a myocardial constusion b/c it may not have yet happened

14

63yo man underwent a 3 vessel CABG 5h ago. initially his mediastinal chest tube output was 300mL blood/h, but an hour ago, there was no further evidence of bleeding from the tube. his mean arterial pressure has fallen, and several fluid boluses were administered. his CVP is elevated to 20mmHg, and he has required the addition of ionotropes. which of the following is the best management strategy?
a. addition of vasopressors along with ionotropes
b. transfusion of pRBCs
c. return to the OR for exploration of the mediastinum
d. placement of an intraaortic balloon pump
e. infusion of streptokinase into the mediastinal chest tube

C

cardiogenic / obstructive shock ==> cardiac tamponade after CABG
- clotting of mediastinal chest tube, THEN hemodynamic decompensation + decreased MAP, CO + increasing filling pressures
--> equalization of pressures across the 4 chambers on Swan-Ganz catheter monitoring
--> collaps of RA on echocardiography

streptokinase - used as a thrombolytic

Tx
1) bleeding postop --> correct coagulopathy
2) decompensating --> return to OR for exploration & drainage of mediastinal hematoma

15

several days following esophagectomy, a pt complains of dyspnea and chest tightness. a large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. which of the following is the most appropriate initial management of this patient?
a. immediate operation to repair the thoracic duct
b. immediate operation to ligate the thoracic duct
c. tube thoracostomy and low-fat diet
d. observation and low-fat diet
e. observation and antibiotics

C. chylothora after intrathoracic surgery OR malignant invasion / compression of thoracic duct

iatrogenic esophageal injury

tx
ACUTE
- ligation of thoracic duct

CHRONIC
- low-fat diet to lower chyle
- repeated thoracentesis / tube thoracostomy drainage

16

56yo woman presents for evaluation of a murmur suggestive of MS and is noted on echocardiography to have a lesion attached to the fossa ovalis of the LA septum. the mass is causing obstruction of the mitral valve. which of the following is the most likely diagnosis?
a. endocarditis
b. lymphoma
c. cardiac sarcoma
d. cardiac myxoma
e. metastatic cancer to the heart

D

myxoma = VERY RARE; but the most common of the cancers of the heart
--> attach by a pedicle to the fossa ovalis of the LA septum

sxs
- valvular obstruction (mitral / tricuspid valve)
- systemic embolization

tx = surgical resection

17

56yo woman has been treated for 3y for wheezing on exertion , which was diagnosed as asthma. CXR reveals a midline mass compressing the trachea. which of the following is the most likely diagnosis?
a. lymphoma
b. neurogenic tumor
c. lung carcinoma
d. goiter
e. pericardial cyst

D. most common = GOITER

boundaries of mediastinum
- thoracic inelt
- diaphragm
- sternum
- vertebral colum
- b/l pleura

older pt, chronic disease

18

59yo man is found to have a 6cm thoracoabdominal aortic aneurysm which extends to above the renal arteries for which he desires repair, but he is concerned about the risk of paralysis postop. which of the following maneuvers should be employed to decrease the risk of paraplegia after repair.
a. infusion of a bolus of steroids immediately postop with a continuous infusion for 24h
b. maintenance of intraoperative normothermia
c. clamping of the aorta proximal to the L subclavian artery
d. CSF drainage
e. extracorporeal membrane oxygenation

A

operative indications
- thoracic aortic aneuryms > 5.5cm
- increasing in size by >0.5cm per year

C & D are impossible

Complications
- spinal cord ischemia --> paraplegia (5-15%)

prevention of spinal cord ischemia
- aggressive reattachment of segmental & intercostal & lumbar arteries
- monimize cross-clamp time = move clamp sequentially more & more distally as branches are reattached
- hypothermia
- moderate systemic heparinization
- L heart bypass
- CSF drainage= decrease pressure on blood supply to spinal cord; improve perfusion

19

89yo man has lost 30lb over the past 2y. he reports that food frequently sticks when he swallows. he complains of a chronic cough. barium swallow has been done. what is the best treatment option fro this pt?
a. placement of an esophageal stent
d. diverticuloplasty
c. excision of the diverticulum
d. excision of the diverticulum & administartion of a promotility agent
e. excision of the diverticulum and cricopharyngeal myotomy

E

zenker's diverticulum = caused by incoordination of cricopharyngeal relaxation with swallowing: origin @ cricopharyngeal muscle near level of bifurcation of the carotid artery

sxs = dysphagia,weight loss, choking, repeated aspiration, pneumoa, chronic cough
+/- mass, gurgle

dx = barium swallow; endoscopy for malignancy; esophagoscopy CAUTIOUSLY

tx
1) botox
2) Cut through diverticulum & division fo cricopharyngeus muscle.

20

70yo woman undergoes a cardiac catheterization for exertional chest pain. her pain continues to worsen and she is interested in having either surgery or PCI. which of the following would be an indication for her to undergo either CABG or PCI?
a. 2-vessel coronary disease with proximal LAD stenosis and depressed LV ejection fraction
b. isolated L main stenosis, no diabetes, and normal LV ejection fraction
c. isolated L main stnosis & DM
d. L main stenosis & additional coronary artery disease with depressed LV ejection fraction
e. 3-vessel coronary artery disease and DM

A

indications for CABG
- multivessel disease
- L main coronary artery disease
- 1-2-vessel disease + LAD obstruction
--> can be for DM

indications for PCI and CABG
- 2-vessel disease, proximal LAD obstruction.

21

27yo woman seeks your advice regarding pain and numbness in the R arm and hand. she reports that it is exacerbated by raising her arm over her head. on exam, the R radial pulse disappears wheen the pt takes a deep breath and turns her head to the left. a provisional diagnosis is made which of the following is the most appropriate initial treatment for this pt?
a. physical rehab
b. gabapentin to treat neuropathic pain
c. R first rib resection
d. thoracoscopic sympathectomy
e. upper thoracic distectomy

A. thoracic outlet syndrome = compression of brachial plexus / subclavian vells in the anatomic space bounded by the 1st rib, clavicle & scalene muscles
sxs = pain, paresthesiad, edema, venous congestion, digital vasospastic changes.

radial pulse

take deep breath --> increased intrathoracic pressure and movement of the lung space superiorly

turn to the left --> stretch the R brachial

tx
1) exercise program --> strengthen shoulder gidle muscles; decrease shoulder droop
2) operative --> division of anterior and middle scalene, first rib resection, cervical rib resection

22

35yo man with a hx of melanoma s/p wide local excision with negative margins and lymph node dissection presents with 2 peripherally located pulmonary lesions seen on chest CT scan. percutaneous biopsy of the lesion is consistent with metastatic melanoma. he has no evidence of recurrence or extrathoracic disease and is in good general health. which of the following is the appropriate management of this pt?
a. chemotherapy
b. radiation therapy
c. pulmonary metastasectomy
d. pulmonary metastasectomy, followed by radiation therapy
e. neoadjuvant radiation therapy followed by pulmonary metastasectomy

C. pulmonary metastasectomy

criteria for resection
a. control of primary lesion
b. no evidence of extrathoracic disease
c. ability to tolerate pulmonary resection (including possible single lung ventilation)
d. predicted ability to achieve a complete resection
e. lack of better systemic therapy

23

65yo woman has had pain in her R shoulder and has been treated with analgesics without relief. the CXR reveals a mass in the apex of the R chest. a transthoracic needle biopsy documents carcinoma. superior pulmonary sulcus carcinomas (pancost tumors) are bronchogenic carcinomas that typically produce which of the following clinical features
a. atelectasis of the involved apical segment
b. horner syndrome
c. pain in the T4-T5 dermatomes
d. nonproductive cough
e. hemoptysis

B
Horner syndrome ==> miosis, ptosis, and anhidrosis
and carcinoid syndrome

pancoast = peripheral bronchogenic carcnoma.

24

63yo man has a chyothorax that after 2w of conservative therapy appears to be persistent. the chest tube output is approximately 600mL/day. appropriate management at this time includes which of the following procedures?
a. neck exploration and ligation of the thoracic duct
b. subdiaphragmatic ligation of the thoracic duct
c. thoracotomy and repair of the thoracic duct
d. thoracotomy and ligation of the thoracic duct
e. thoracotomy and abrasion of the pleural space

D. Able to get in that way --> at the junciton of the internal jugular and subclavian veins.

tx of chylothorax
1) low fat diet, drain chest cavity, bowel rest
2) thoracic duct ligation (from diaphragm to T6) --> R thoracotomy

25

32 yo woman has a CXR screening, and a 1.5cm mass is noted in the RLL. she is a nonsmoker. bronchoscopy shows a mass in the RLL orifice, covered in mucosa. biopsy indicates that this is compatible with carcinoid tumor. imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. which of the following is the most appropriate treatment plan?
a. R lower lobectomy and mediastinal LN dissection
b. R lower lobectomy and mediastinal LN dissection, followed by adjuvant chemotherapy
c. Neoadjuvant chemotherapy followed by R lower lobectomy and mediastinal LN dissection
d. neoadjuvant chemoradiation followed by R lower lobectomy and mediastinal LN dissection
e. chemoradiation

A

Carcinoid - usually has a good prognosis

no role of chemotherapy / radiation therapy in the treatment of bronchial carcinoids

26

6mo ago at the time of lumpectomy for breast Ca, a 60yo female attorney quit a 30y smoking habit of 2 PPD. she had the chest radiograph as part of her routine f/up examination that shows a mass. based on her age and hx of smoking, you are concerned for either a new primary lung or metastatic breast malignancy. which of the following in the most appropriate next step in the management of this lesion?
a. f/up CT scan in 3mo
b. MRI of b/l breasts to evaluate for recurrence of the breast Ca
c. transthoracic fine need aspiration of the lesion
d. mediastinoscopy
e. thoracotomy with lobectomy

C

you need to see what it is.

27

42yo man presents with a solitary lung lesion. at the time of operation on this pt, a firm, rubbery lesion in the periphery of the lung is discovered. it is sectioned in the OR to reveal tissue that looks like cartilage and smooth muscle. which of the following is the most likely diagnosis?
a. fibroma
b. chondroma
c. osteochondroma
d. hamartoma
e. aspergilloma

D
periphery --> cartilage & smooth muscle = 2 adult-type tissues that are not usually found there

28

45yo woman presents with dysphagia, regurgitation of undigested food and weight loss. she had xrays as part of her workup. upper endoscopy reveals no evidence of malignancy and esophgeal motility studies show incomplete LE sphincter relaxation. which of the following is the next best step in the treatment of this pt?
a. laparoscopic myotomy of the LE sphincter (HELLER)
b. laparoscopic posterior 180deg (Toupet) fundoplication
c. laparoscopic anterior 180deg (Dor) fundoplication
d. laparoscopic 360deg (Nissen) fundoplicaiton
e. transhiatal esophagectomy

A. achalasia

tx
1) botox into LE sphincter
2) balloon dilation of LE sphincter
3) surgical myotomy of LE sphincter (Heller)

B-D = for hiatal hernias / GERD

dx
- Xray = beak-like narrowing of distal exophagus + large, dilated esophagus
- esophageal motility = small-amplitude, repetitive, simultaneous post-deglutition contractions in the body of the esophagus
- incomplete relaxation of the LE sphincter
- higher than normal pressure in the body of the esophagus

risk of carcinoma of the esophagus

29

for each physical finding / group of findings, select the cardiovascular disorder with which it is most likely to be associated.
a. massive tricuspid regurgitation
b. aortic regurgitation
c. coarctation of the aorta
d. thoracic aortic aneurysm
e. myocarditis
an elderly man with abnormal pupillary responses (Argyll Robertson pupil)

D

prostitute pupil --> accommodates but does not react

--> due to treponema pallidum --. invading vasa vasorum --> obliterative endarteritis, necrosis --> thoracic aneurysm

30

for each physical finding / group of findings, select the cardiovascular disorder with which it is most likely to be associated.
a. massive tricuspid regurgitation
b. aortic regurgitation
c. coarctation of the aorta
d. thoracic aortic aneurysm
e. myocarditis
24yo drug addict with jugular venous distention and exophthalmos

A

IVDU mostly affects tricuspid valve due to first valve from blood flow

markedly elevated venous pressure
--> severely engorged & pulsating liver
--> exopthalmos

31

for each physical finding / group of findings, select the cardiovascular disorder with which it is most likely to be associated.
a. massive tricuspid regurgitation
b. aortic regurgitation
c. coarctation of the aorta
d. thoracic aortic aneurysm
e. myocarditis
a pt with flushing and paling of the nail beds (Quincke pulse) and a bounding radial pulse

B

bounding pulses "waterhammer" --> AR

Quincke pulse = alternate flushing paling of hte skin / nail beds

widened pulse pressure

32

for each physical finding / group of findings, select the cardiovascular disorder with which it is most likely to be associated.
a. massive tricuspid regurgitation
b. aortic regurgitation
c. coarctation of the aorta
d. thoracic aortic aneurysm
e. myocarditis
a pt with conjunctivitis, urethral discharge, and arthralgia

E

can't see, can't pee, can't climb a tree
reactive arthritis = systemic inflammation
==> muyocarditis, aortitis, pericarditis

33

for each physical finding / group of findings, select the cardiovascular disorder with which it is most likely to be associated.
a. massive tricuspid regurgitation
b. aortic regurgitation
c. coarctation of the aorta
d. thoracic aortic aneurysm
e. myocarditis
a pt with short stature, webbed neck, low set ears and epicanthal folds

C

Turner's syndrome
- septal defect, valvular stenosis, coarctation of aorta

34

for each clinical scenario, select the mediastinal tumor with which it is most likely to be associated.
a. thymoma
b. hodgkin disease
c. pheochromocytoma
d. parathyroid adenoma
c. cystic teratoma
23yo pt with HTN and increased urinary catecholamine levels

C

pheo

35

for each clinical scenario, select the mediastinal tumor with which it is most likely to be associated.
a. thymoma
b. hodgkin disease
c. pheochromocytoma
d. parathyroid adenoma
c. cystic teratoma
21yo woman presents with generalized weakness and double vision. during her workup, she is noted to have a widened mediastinum on her CXR, prompting a CT scan, which demonstrates an anterior mediastinal mass.

A

something in the pituitary pressing on the

it is in the anterior mediastinum

thymoma --> myasthenia gravis, agammaglobulinemia, RBC aplasia

myasthenia
- exopthalmos
- double vision d/t extra tissue in eye socketss

36

for each clinical scenario, select the mediastinal tumor with which it is most likely to be associated.
a. thymoma
b. hodgkin disease
c. pheochromocytoma
d. parathyroid adenoma
c. cystic teratoma
63yo woman with vague sxs of fatigue and depression presents with hematuria. CT scan of the abdomen and pelvis reveals a stone at the ureteropelvic junction

D

hyperparathyroidism
- recurrent stones
- psychogenic overtones (fatigue, depression)

37

for each clinical scenario, select the mediastinal tumor with which it is most likely to be associated.
a. thymoma
b. hodgkin disease
c. pheochromocytoma
d. parathyroid adenoma
c. cystic teratoma
35yo women with fever and weight loss. CT scan reveals a mediastinal mas, which was biopsied and revealed Reed-Sternberg cells

B

RS cells --> hodgkins

38

for each clinical scenario, select the mediastinal tumor with which it is most likely to be associated.
a. thymoma
b. hodgkin disease
c. pheochromocytoma
d. parathyroid adenoma
c. cystic teratoma
33yo woman presents with cough and chest pain for 2 mo. more recently, she complains of coughing up hair. the CXR reveals a mediastinal mass.

C

mature tissues (hair, teeth)

usually benign

39

for each clinical scenario, select the most appropriate pharmacologic agent for the pt.
a. epinephrine
b. norE
c. phenylephrine
d. dopamine
e. dobutamine
f. nitroprusside
g. nitroglycerin
56yo man presents with BP of 220/110 mmHg, chest pain, and ST elevations on an EKG

G.

myocardial ischemia

vasodilators

40

for each clinical scenario, select the most appropriate pharmacologic agent for the pt.
a. epinephrine
b. norE
c. phenylephrine
d. dopamine
e. dobutamine
f. nitroprusside
g. nitroglycerin
65yo man presents with cardiogenic shock following an MI

E. increases contractility, but mildly increased (to even decreased) BP

41

for each clinical scenario, select the most appropriate pharmacologic agent for the pt.
a. epinephrine
b. norE
c. phenylephrine
d. dopamine
e. dobutamine
f. nitroprusside
g. nitroglycerin
30yo man presents with perforated appendicitis and HR of 120, BP 80/40, and CVP of 17mmHg. the pt remains hypotensive after a continuous infusion of dopamine.

B

high CVP --> cardiogenic
with low BP

dopamine, norE

42

for each clinical scenario, select the most appropriate pharmacologic agent for the pt.
a. epinephrine
b. norE
c. phenylephrine
d. dopamine
e. dobutamine
f. nitroprusside
g. nitroglycerin
21o man undergoes major abdominal surgery after a MVC. he has a cardiac arrest in the ICU shorted after returning from surgery

A

GIVE PRESSORS

cardiac arrest --> need to increase contractility, with low afterload (minimal increased BP)
- epinephrine
- dobutamine

43

for each clinical scenario, select the most appropriate pharmacologic agent for the pt.
a. epinephrine
b. norE
c. phenylephrine
d. dopamine
e. dobutamine
f. nitroprusside
g. nitroglycerin
45yo woman presents with a BP of 220/130 and a HA. after several hours or an IV drip of medication to control her HTN, she becomes acidotic.

F

IV hydralazine
--> leads to reflex tachycardia.

acidotic --> due to CN