Pestana Cardiothoracic/Vascular

Question 1

How are morphological cardiac anomalies (ie. Tertalogy of Fallot) best diagnosed?

Answer 1

Echocardiogram

Question 2

Atrial Septal Defects. What is often elicited on history? Direction of shunt? Characteristic sounds? Tests? Treatment?

Answer 2

Frequent colds. L-> R. Faint pulmonary systolic murmur and FIXED SPLIT SECOND HEART SOUND. Echocardiogram. Surgery or cardiac catherization.

Question 3

A newborn presents with stridor and episodes of respiratory distress (the baby hyperextends and displays crowing respiration), as well as dysphagia? Tests? Tretment?

Answer 3

Vascular ring (double aortic arch with a vascular ring encircling the trachea and esophagus). Barium swallows. Surgical correction.

Question 4

A newborn presents with stridor and episodes of respiratory distress (the baby hyperextends and displays crowing respiration)? Tests? Treatment?

Answer 4

Tracheomalacia (weak trachea). Bronchoscopy. Stenting.

Question 5

Treatment for small ventricular septal defects low in the muscular septum?

Answer 5

Nothing, they will spontaneously close within the first three years.

Question 6

What is the typical location of a ventricular septal defect? When do problems arive? Characteristic sounds (and where to listen)? Tests and signs? Treatment?

Answer 6

High in the membranous septum. Failure to thrive within the first few months. Loud pansystolic murmur (listen near left sternal border). Increased pulmonary vascular markings on Xray, do Echo. Surgical closure.

Question 7

When does a patent ductus arteriosus present? Characteristic sounds and clinical findings? Tests? How can premature babies (without congestive heart failure) be treated? How are all other babies treated?

Answer 7

First few days of life. Bounding peripheral pulses and “machinery like” heart murmur. Indomethacin (NSAID). Surgical division or embolization.

Question 8

A 5 year old child looks small for their age.You note clubbing, a bluish hue on their lip and fingers, and spells of cyanosis relieved by squatting? Characteristic sounds (and location)? Signs on Xray and EKG? Diagnostic test and treatment?

Answer 8

Tetralogy of Fallot. Systolic ejection murmur in left third intercostal space. Diminished pulmonary vascular markings and small heart on Xray, right ventricular hypertrophy signs on EKG. Preform ECHO to diagnose, surgical repair.

Question 9

A 2 day old child looks cyanotic? Why must this be corrected immediately? Diagnostic test?

Answer 9

Transposition of the great vessels. An Atrial septal defect, ventricular septal defect, and/or patent ductus arteriosus is keeping them alive, if they close, the baby will die. Echo.

Question 10

A patient presents with angina and exertional syncopal episodes. You hear a harsh midsystolic murmur over the right second intercostal space, as well as the left sternal border? What congential anomaly would you most likely find on Echo? Treatment?

Answer 10

Aortic stenosis. Bicuspid aortic valve. Valve replacement if symptomatic.

Question 11

A patient presents with years of angina and exertional syncopal episodes. You hear a decrescendo blowing diastolic heart murmur over the right second intercostal space and the left lower sternal border during full expiration? Is pulse pressure decreased, increased or normal? What congential anomaly would you most likely find on Echo? Treatment?

Answer 11

Chronic aortic insufficiency. Widened pulse pressure. Bicuspid aortic valve. Valve replacement if left ventricular dilation occurs.

Question 12

A 30 year old IV drug user develops symptoms of congestive heart failure? Cause? Characteristic sounds and where to listen? Tests? Treatment?

Answer 12

Acute aortic insufficiency. Bacterial endocarditis. Loud diastolic murmur at the right second intercostal space. Echo. Emergency valve replacement and antibiotics.

Question 13

A patient presents with exertional dyspnea, orthopnea, and cough. He complains that he wakes up at night with shortness of breath. You notice a low pitched, rumbling diastolic apical heart murmur? What in his PMH would be suspected? What arrythmia can develop? Tests? Treatment?

Answer 13

Mitral stenosis. Rheumatic fever. Atrial fibrillation. Echo. Valvular repair - comissurotomy.

Question 14

A patient presents with exertional dyspnea, orthopnea, and EKG has shown bouts of atrial fibrillation. You hear an apical, high pitched, holosystolic heart murmur? Where does the murmur radiate? Cause of the murmur? Tests? Treatment?

Answer 14

Mitral regurgitation. Back and axilla. Mitral prolapse. Echo. Annuloplasty (not replacement).

Question 15

A 60 year old man presents with progressive, unstable, disabling angina. He has PMH of smoking, type 2 diabetes, and hypercholesterolemia. You take him to the cath lab, when is intervention necessary? Treatment for single vessel disease? Treatment for multiple vessel disease?

Answer 15

70% stenosis or greater of a coronary vessel. Angioplasty and stent. Coronary artery bypass graft (CABG).

Question 16

A patient on post op day 2 from CABG is not producing adequate urine and has a PCWP of 3? Treatment?

Answer 16

IV fluids.

Question 17

A patient presents with exertional dyspnea, hepatomegaly, and ascites. When looking on his pressure contour, you note a “square root sign?” What will be charactersitic about his diastolic pressures? Treatment?

Answer 17

Chronic constrictive pericarditis. Right atrial, ventricular, pulmonary arterial, PCWP, and left ventricular diastolic pressures will be equal. Surgical therapy.

Question 18

A 60 year old smoker presents with coughing and hemoptysis. On CXR you note a coin lesion in his right lung? What do you do first? If that doesn’t work, what do you do next?

Answer 18

Seek an old CXR - see if the lesion has always been there! Sputum cytology and chest/abdominal CT Scans.

Question 19

A patient presents with coughing and hemoptysis. CXR reveals a new coin lesion. Cytology and CT are inconclusive. Test for central lesion? Test for peripheral lesion? If those tests are inconclusive, then what do you do?

Answer 19

Bronchoscopy and and biopsies. Percutaneous biopsy. Video assisted thoracic surgeyr with wedge resection.

Question 20

Treatment of small cell lung cancer?

Answer 20

Chemoradiation. They are not surgical candidates.

Question 21

How to determine if a patient with non small cell lung cancer can be operated on? If not a surgical candidate, treatment?

Answer 21

Determine FEV1, the fraction that comes out of each lung ( by V/Q scan), and see what the FEV1 would be after resection. A minimum of 800ml is required. Chemoradiation.

Question 22

Difference in surgical treatment between central and peripheral lung cancers?

Answer 22

Pneumonectomy (and removal of hilar nodes if necessary) vs. lumpectomy.

Question 23

Which thoracic nodes can not be curatively resected surgically in metastatic lung cancer? Test for lung metastasis?

Answer 23

Carinal or mediastinal nodes. CT scan.

Question 24

A man complains of coldness, tingling, and muscle pain in his arms, along with dizziness and vertigo when he goes to the gym? Cause? Tests? Treatment?

Answer 24

Subclavian steal syndrome. Ateriosclerotic plaque at the origin of the vertebral, during high metabolic demands, the arm steals blood from the vertebral away from the brain. Duplex scanning shows reversal of flow. Bypass surgery.

Question 25

AAA are typically asymptomatic…until they rupture and kill you of course. What signs exist before that though? When should surgery be preformed?

Answer 25

Pulsatile abdominal mass on PE, and widened mediastinum on CT. If aneurysm is >5cm or grows >1cm per year, elective surgery is required. Percutaneous endovascular stenting.

Question 26

A patient presents with excruciating back pain and is beginning to look SHOCKY but denies trauma. What would CT reveal? Treatment?

Answer 26

A widened mediastinum with an AAA >5cm. Emergency surgery.

Question 27

A smoker complains of leg pain while walking, that quickly resolves once he rests? Tests? Medical therapy?

Answer 27

Intermittent claudication from arteriosclerotic occlusive disease. Doppler studies - look for pressure gradient. Cilostazol (phosphodiesterase inhibitor).

Question 28

A smoker complains of leg pain that is painful while walking and resting, it even wakes him from sleep. PE reveals a shiny atrophic, hairless legs with absent dorsalis pedis pulses. Tests? Treatment (depending on location)?

Answer 28

Rest pain from arteriosclerotic occlusive disease. Doppler studies - look for pressure gradient. CT angio or MRI angio. Bypass graft: Proximal (Dacron graft) Distal (reversed saphenous vein graft).

Question 29

What is the typical PMH for a patient that develops an arterial embolization?

Answer 29

Recent MI (mural thrombus) or atrial fibrillation (clot from atrial appendage)

Question 30

What are the 6 P’s for the presentation of arterial embolization?

Answer 30

Painful, pale, poikilothermic (cold), pulseless, paresthetic, and paralytic - lower extremity.

Question 31

Tests for a patient with arterial embolization? Treatment (early and late)? Complications?

Answer 31

Doppler studies. Clot Busters, Embolectomy with Fogarty catheter. Compartment syndrome if it has been hours between symptoms and revascularization.

Question 32

A patient presents with sudden onset of extremely severe tearing chest pain that radiates to the back and migrates down. Unequal pulses exist between the upper extremities? What tests rule out MI? Diagnostic test? Treatment?

Answer 32

Dissecting aneurysm of the thoracic aorta. EKG normal and normal Troponins. Spiral CT scan. Surgical intervention.

Question 33

What is the difference in treatment between dissecting aneurysms of the descending and ascending aorta?

Answer 33

Descending = medical. Ascending = surgical.