Week 9 Cardiothoracic & Thoracic

A 65 year old male presents to your office with a painful mass in the right groin. He is a chicken farmer
and he noticed the mass immediately after he lifted a 50 lb bag of chicken feed. He denies fever, nausea,
vomiting, abdominal distension or decreased bowel movements. He has a 30 pack year history of smoking
filterless cigarettes. He has a history of sigmoidectomy for adenocarcinoma 7 year ago. His vital signs are
temperature 98.8, P 83, RR 16 and BP 130/74. He has no cervical, axillary or inguinal lymphadenopathy.
He has scattered rhonchi bilaterally that clear with coughing. The heart has a regular rate and rhythm
with no murmur, gallops, rubs or clicks. The abdomen has no distension or tympany and bowel sounds are
normal. The rectal examination is normal and guaiac negative. There is a soft, reducible right inguinal
hernia. The testes are normal and there is no hydrocele. For the preoperative evaluation you order a CBC,
serum chemistry panel, urinalysis, EKG and chest radiograph. The chest radiograph shows a 2.5 cm solitary
pulmonary nodule in the perihilar region of the right lung. A chest radiographs obtained 2 years ago shows
no perihilar mass.
Dx: Lung cancer
o Types
Adeno CA (30% of lung cancers)-peripheral
Next step consult oncology for chemotherapy because surgery not an option
Squamous CA (20% of lung cancers)-central
Small cell CA (15-20%) limited, diffuse has a different treatment
Often advanced at presentation
Paraneoplastic syndromes
o Eaton Lambert myasthenia gravis like effect
o Hypercalcemia
o Cushings syndrome
o SIADH
o Paraneoplastic cerebellar degeneration
Large cell
Adenoma (misnomer-this is CA)
Workup
o Complete H&P
Smoking history
Cough
Hemoptysis
Infections
o Review old CXRs
CXR shows coin lesion lung cancer until proven
otherwise
If mass the same > 2 y, close observation with
CXR yearly
o CT Chest
Including liver and adrenals to look for metastasis
Determines anatomical location of lung mass & presence of any enlarged intrathoracic/
mediastinal lymph nodes
o Next step(s)
Repeat CXR
PET scan
Sputum cytology
Location
Peripheral Transthoracic FNA
Perihilar Bronchoscopy & biopsy
Mediastinal nodes Mediastinoscopy
VATS for diagnosis
Thoracentesis for pleural effusion
Bone scan for bone pain
CT of head for mental status changes
o Staging (non-small cell) TNM
Must define Stage I and II (and IIIA) vs IIIB and IV
Must define non small cell vs small cell
Any direct tumor extension is T3
Positive mediastinal nodes is N2
T3N1 or any N2 = Stage III disease

Treatment
o Surgical resection for early stage (I, II and IIIA)
o Chemotherapy +/- radiation for late stage
o Chemotherapy +/- radiation for small cell
A 25 year old male presents to the Emergency Room at University Hospital with sudden left chest pain and
shortness of breath that occurred while he watched television. He denies diaphoresis, nausea, neck or jaw
pain. The patient denies fever, cough or chest trauma. He smokes cigarettes and drinks alcohol every
weekend. The vital signs are temp 99, P 110, RR 30, BP 110/70, weight 148 pounds and height 63. The
patient appears anxious. There is no jugular venous distension and trachea is in the midline. The heart has
tachycardia but normal heart tones. The left chest has tympany
and decreased breath sounds. The abdomen is soft and
nondistended with normal bowel sounds. The chest radiograph
shows a simple 30% left sided pneumothorax.
Dx: Spontaneous pneumothorax
o Primary
Rupture of subpleural bleb
Young men (15 35)
o Secondary
COPD, malignancy, infection (PCP, TB), asthma, cystic fibrosis
Older patients
Treatment
o Small, stable, asymptomatic Observation
o Large, symptomatic thoracentesis Immediate CXR and 2 hr CXR
o Large, symptomatic Chest tube thoracostomy
o Surgery (VATS, pleurodesis, resection) for:
Persistent airleak (>3 days), failure of re-expansion
Recurrence (ipsilateral or contralateral)
Bilateral occurence
Limited access to health care
High risk occupation
o Note: for needle decompression
Hear air? Put chest tube
Dont hear air? Still put chest tube
Risk of recurrence with
o One PTX 30-50%
o Two PTX 50-75% **Intervene here**
o Three PTX >80%
Other pneumothorax
o Tension PTX
Build up of pressure in the chest that prevents blood
return
o Open PTX (sucking chest wound)
Air sucked directly into the chest preventing air from
being taken in through the trachea
Communication with atmosphere and thoracic cavity
creates negative pressure so air travels into chest cavity
Temporizing measure to cover with 3 of 4 sides
taped
o Flail chest
Injury to multiple ribs causing paradoxical movement
Respiratory distress caused by pulmonary contusion
Tx supportive care
Pulmonary toilet = aggressive respiratory therapy (cough, deep breaths, IS)
incr ventilation
A 42 year old Caucasian female presents to your office for a pre employment history and physical
examination. On close interrogation she complains of easy fatigability and weakness (fatigue/burnout from
her old job). The vital signs are temp 98, P 100, RR20 and BP 130/82. She appears to have mild ptosis
bilaterally. She has decreased motor function of the upper extremities with repetitive exercise. You order
CBC, serum chemistry, urinalysis, EKG and chest radiograph for baseline studies. The PA and lateral chest
radiograph shows a 4.5 solid, well circumscribed mass in the anterior mediastinum.
Dx: Myasthenia Gravis
o Disorder of the neuromuscular junction from autoimmune damage to the nicotinic cholinergic
receptor
o Symptoms = Weakness, ptosis, diplopia, dysarthria, dysphagia, and respiratory complications
Diagnosis-tensilon test
Medical management
o Anticholinesterase drugs (neostigmine)
o Glucocorticoids (prednisone)
o Immunosuppressants (aza, cyclophosphamide)
o Plasmaphersis for acute crisis
Mediastinal Tumors
o Anterior
Thymoma (15-20%)
Lymphoma
Teratoma
Aberrant thyroid
Parathyroid adenoma
Lipoma, hemangioma, thymic cyst
o Posterior
Neurogenic tumors (20%)
Dx: Thymoma
o Most common anterior mediastinal tumor
o 30-50% have myasthenia but only 15% of pts with MG have thymomas
o 50% thymomas are incidentally discovered on CXR
o Bordeline malignant potential
o Produces many paraneoplastic syndromes-MG, cytopenias, red cell aplasia, hypogamma
Diagnosis-CXR, CT scan (MR good for vasc invasion), FNA rarely very helpful
Treatment is surgical resection
Staging based on surgical findings (gross and micro)
A 65 year old male becomes intoxicated, falls posteriorly and strikes his head on the pavement. He is
stuporous from intoxication for 8 hours. He presents to the Emergency Department at University Hospital
with fever, right chest pain and a productive yellow cough. The vital signs are temp 103, P 116, RR 26
and BP 110/60. The patient appears malnourished. The neck is normal. The heart has tachycardia. The
right lung has decreased breath sounds with dullness to percussion at the base. The abdomen is soft and
nondistended. A chest radiograph shows a 6 cm cavity with an air fluid level in the right lower lung.
Dx: Lung abscess
o Aspiration pneumonia
o Fever, WBC, productive sputum
o Alcoholism common
o Micro
Bacteroides
Staph, Klebsiella, Pseudomonas
Candida, Aspergillus
Treatment
o IV antibiotics (6 weeks), good pulmonary toilet
o Drainage
o Bronchoscopy
Rule out obstructing lesion
Improve drainage
o Surgery
Rarely required
An 8 week old female presents to your outpatient pediatric CT surgery clinic with progressively worsening
shortness of breath and difficulty with feeding/poor weight gain. On examination the infant appears
dyspneic. There is a widened pulse pressure. The lungs have scattered rales. The heart shows a classic
machinery type murmur and there is palpable thrill on the 2
nd
intercostal space at the left sternal border.
There are bounding peripheral pulses but there is no peripheral cyanosis. The EKG shows left ventricular
strain, left atrial enlargement and right ventricular hypertrophy. The chest radiograph shows increased
pulmonary vasculature and cardiomegaly.
Dx: Patent Ductus Arteriosus
o Left to right shunt after birth from failure of DA to close
o Classic machinery type murmur
o Common in preemies
Treatment
o Indomethicin
o Ligation
MCC congenital heart defect? Ventricular septal defect
A 54 year old female with a history of tuberculosis presents to your outpatient CT clinic with shortness of
breath, abdominal swelling and edema in the lower extremities. The vital signs are temp 99, P 110, RR
28 and BP 100/70. There is pulsus paradoxus of 10 mmHg and a Kussmal sign. She appears fatigued with
muscle wasting. She has prominent jugular venous distension. The heart has tachycardia and muffled
distant heart tones. There is an occasional pericardial knock. The lungs have dullness to percussion and
decreased breath sounds in the bases. The abdomen shows hepatomegaly, an almost pulsatile liver, shifting
dullness and a fluid wave with decreased bowel sounds. There is moderate pitting peripheral edema.
Dx: Constrictive pericarditis
o Thickening that does not allow veonus blood return/diastolic filing
o Increased RV, RA and central venous pressures (equalization) leads to hepatomegaly, ascites,
peripheral edema
o 50% idiopathic
o TB common cause in 3
rd
world
Workup
o CXR-normal size heart, calcified pericardium
Treatment
o Pericardiectomy
Acute pericarditis
o Symptoms
Chest pain radiating to back
Relieved by sitting up, worse by lying down
Cough, fever, fatigue, anxiety
o Findings
ST, Friction rub, ST elevation
o Causes
Idiopathic
Infectious
Viral: Coxsackievirus, CMV, herpes, HIV
Bacterial: Pneumococcal, TB
Fungal: Histoplasmosis
Autoimmune: SLE, RA
Post-MI
Treatment
o NSAIDS
A 56 year old male with a 40 pack year history of smoking presents to the emergency department with edema
of the face. He complains of headache and nasal congestion. On examination there is edema of the face,
shoulders and upper extremities. The face has a slight bluish discoloration. There is prominent jugular
venous distension and veins across the temples are markedly distended. The heart has a regular rate and
rhythm. The right thorax has decreased breath sounds superiorly. The chest radiograph shows a 4.5 cm
solid, spiculated lesion in the apex of the right lung.
Dx: Superior vena cava syndrome by pancoast tumor
o Compression of the SVC by tumor
o Commonly a RUL bronchogenic carcinoma
o Symptoms
Edema of the head and bilateral UE
Cyanosis
Distended neck and chest veins
Edema of larynx/pharynx
Cough, dyspnea, dysphagia, stridor
Cerebral edema
Confusion, coma, migraines
Treatment
o Steroids to reduce swelling
o Diuretics to decrease circulating blood volume
o Radiation (emergency radiation to reduce tumor)
o Surgery as last resort
A 43 year old female requires long term parenteral nutrition for complication of Crohns disease. You place
a central line into the left subclavian vein. The placement is difficult and you require multiple punctures to
access the subclavian vein. The chest radiograph shows good position of the catheter in the superior vena
cava. The next day the patient describes slight dyspnea with increased activity. The vital signs are temp 99,
P 98, RR 20 and BP 120/60. The left thorax has decreased breath sounds and dullness to percussion. A chest
radiograph shows a moderate left pleural effusion. You perform thoracentesis and the fluid has a white
milky color.
Dx: Chylothorax
o Injury to the thoracic duct (thoracic duct drains into L SCV
where L IJV joins L SCV)
o Lymph white due to high TG
Treatment
o Drain chest
o Low fat diet
o TPN
o Pleurodesis
Cause lung to scar to chest wall to remove potential space (can also be used to prevent
pneumothorax); can be chemical or mechanical
o R thoracotomy-ligation of duct over spine
Also can have IR embolyze lymphatic channel prior to surgery as last resort
A 65 year old male with a long history of GERD presents to the emergency room with nausea, vomiting and
diaphoresis. His troponin levels are elevated. His EKG shows ST segment depression in the inferior leads. What is
the most likely diagnosis for the nausea and vomiting?
Dx: Myocardial infarction
A 63 year old male with a history of CVA, hypertension and heavy smoking develops unstable angina and
undergoes coronary catheterization. The patient has been on aspirin 325 mg daily on the advice of his primary care
physician. His coronary angiogram shows a 95% stenosis of the mid LAD and a 95% stenosis of the circumflex
artery. You call the operating room for an emergent 2 vessel coronary artery bypass graft. The anesthesiologist
places a Swan Ganz catheter and a radial arterial catheter for intraoperative hemodynamic monitoring. The operation
goes "smoothly", and the patient recovers in the cardiac care unit. During the operation the patient has heparin
therapy which is completely reversed by protamine sulfate. Three hours after the operation the nurse contacts you
urgently to state that your patient has sudden hypotension to 90/60. The nurse notes that the mediastinal chest tube
just drained 600 cc of frank blood over the last 10 minutes. What is the most likely cause of hemorrhage in your
patient?
inadequate surgical hemostasis/ hemorrhage from mediastinal structure
After one month in the ICU a 50 year old male patient recovers from multiple blunt thoracic and abdominal injuries
and is finally discharged from the hospital. He does not require operative intervention at that time for any intra-
thoracic or intra-abdominal injury. Six months after discharge he presents to the Emergency Room at University
Hospital with worsening shortness of breath, nausea, vomiting and decreased bowel movements. His vital signs
are temperature 98, pulse 70, respiratory rate 28 and blood pressure 130/82. On physical examination he has
slightly labored breathing at rest. The left chest shows dullness to percussion and decreased breath sounds. The
abdomen is slightly scaphoid and slightly tender in the epigastrium with decreased bowel sounds. You seem to
appreciate "bowel sounds" in the left chest. The rectal examination shows no masses but is occult positive. You
provide supplemental oxygen, place 2 large bore IV catheters into the upper extremities and administer Lactated
Ringer's solution. You place a nasogastric tube. An EKG shows no acute cardiac changes. A chest radiograph shows
the gastric bubble in the left thorax and the nasogastric tube curled in the left thorax. What is the most likely cause
of the intra-thoracic findings?
Delayed presentation of diaphragmatic perforation