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Cardiology > Surgery > Flashcards

Surgery Flashcards

1
Q

Leriche syndrome is characterized by?

A
  • occlusion at the bifurcation of the aorta into the common iliac arteries (aorticoiliac occlusion)- triad of :-
  • ️⃣bilateral hip, thigh, buttock claudication
  • ️⃣absent or diminished femoral pulses
  • ️⃣impotence- almost always present
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2
Q

A patient comes after being involved in a motor vehicle collision. He is hypotensive, tachycardic with no significant change after 2L NS infusion. CVP (central venous pressure) is 12 and 18 before n after fluid resuscitation (6-8 is normal)
Most likely Dx?

A

Blunt cardiac injury- which can lead to CARDIOGENIC SHOCK (with acute rt heart dysfunction causing elevated CVP n left heart dysfunction causing refractory hypotension) or OBSTRUCTIVE SHOCK (eg cardiac tamponade)

  • ️⃣low CVP (low preload)- hypovolemic or distributive shock
  • ️⃣high CVP (high preload)- cardiogenic or obstructive shock
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3
Q

A male smoker with hx of atherosclerosis comes with acute onset flank pain, abdominal tenderness, CVAT, syncope
-most likely Dx?

A
  • ruptured abdominal aortic aneurysm

- pulsatile abdominal mass at the umbilicus and/or umbilical hematoma can b appreciated on physical examination

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4
Q

A pt presents with sxs of CHF 6months following MI. ECG shows persistent ST elevation n deep Q waves.

  • Dx?
  • echocardiography findings?
  • other manifestations of the condition?
A

Left ventricular aneurism-

  • echo- thinned and dyskinetic myocardial wall.
  • other manifestations- angina, ventricular arrhythmia, systemic embolization (due to mural thrombus inside the aneurysm)
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5
Q

Indications for surgical mx of primary chronic MR (primary means: problem with the valve apparatus eg, leaflets, chordae tendineae)
-secondary MR ( secondary to other diseases such as MI, DCMP) is usually treated with?

A

Indications for Primary MR
🚩LVEF 30-60% regardless of sxs
*️⃣consider surgery if successful valve repair is highly likely:🚩symptomatic n LVEF<30%, 🚩asymptomatic and LVEF >60
- secondary MR - mx is usually medical

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6
Q

A man with hx PAD sxs (intermittent claudication, shiny legs with sparse hair) comes with acute left leg pain and numbness. He has Afib, HTN, hyperlipidemia. Sensation to light touch on the dorsum of left foot n leg is decreased n ankle dorsiflexion is weak.
The best initial step in the mx is?

A

Anticoagulation- IV heparin infusion. - to prevent further propagation of the thrombus
- he is having acute limb ischemia which could b secondary to occlusion from atrial thrombus embolism or thrombosis following atherosclerotic plaque rupture (PAD)

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7
Q

In an unstable patient with suspected AAA (abdominal aortic aneurysm) the best next step is?

A
  • if the pt has known hx of AAA- rupture is considered n emergent transfer to the OR for repair is necessary.
  • if no known hx of AAA- Bed side abdominal U/S should b performed to confirm the dx ( May b completed in the OR)
  • in hemodynamically stable patients, urgent abdominal CT is more appropriate.
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8
Q

A patient is going to undergo a cardiac surgery. He has severe allergy for penicillins. What prophylactic antibiotic should be used in this patient?

A

Vancomycin, clindamycin

- cephalosporins should not be used

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9
Q

A pt comes after motor bicycle crash. He has injury to his chest n left wrist fracture. breath n heart sounds r normal. Chest CT shows a hairline sternal fracture. FAST is negative for free fluid in the abdomen or pericardium. The pt is persistently tachycardic despite adequate pain control; he’s afebrile and normotensive. ECG shows sinus tachycardia with frequent premature ventricular contractions. The best next step in the mx is?

A

The pt sustained blunt chest trauma- sternal fracture, persistent tachycardia and new arrhythmia
-BCI can cause myocardial edema, hemorrhage, necrosis… structural, ischemic n electrical disturbances
🚩ECG ( preferably continuous monitoring in the first 24-48 hrs) should b performed
🚩ECHOCARDIOGRAPHY- to evaluate for structural injuries…( TEE is superior but also invasive so TTE can b done)

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10
Q

Multiple joint dislocations, easy bruising, poor wound healing, wide atrophic scars in a guy with a height of 176 cm and weight of 70kg - most likely Dx?

A

Ehlers-Danlos syndrome- a collection of genetic disorders- impaired synthesis or processing of connective tissue.
- Marfan syndrome can have similar sxs but this patient’s height (short for marfan), atrophic scars make EDS more likely

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11
Q

An 18 yr old has mild dyspnea with climbing stairs.
- after expiration, a high pitched extra sound is heard after S1,
-grade 3/6 systolic crescendo-decrescendo murmur at the left upper sternal border
- S2 is split throughout the respiratory cycle and splitting increases during inspiration
Dx?

A

Pulmonic stenosis- usually occurs as an isolated congenital defect- if mild may present in early adulthood.

  • pulmonic ejection click
  • widened splitting of s2
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12
Q

Retroperitoneal hematoma can occur as a local vascular complication of cardiac catheterization (bleeding from puncture site)
Dx can b confirmed by?
Rx?

A
  • non-contrast CT of abdomen n pelvis

- Rx is supportive

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13
Q

When should aortic valve replacement be considered?

A

Severe AS (patients can have severe AS but still stay asymptomatic) with one or more of the ff criteria.

  • sxs attributable to AS
  • left ventricular ejection fraction <50%
  • undergoing other cardiac surgery ( the valve can be repaired concomitantly)
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15
Q

ECG shows atrial flutter with a pulse rate of approximately 60-70
Next step in the mx is?
What if the rate is high?

A

In this pt, with controlled rate, anticoagulation should be the next step
- if the pulse rate is high, rate control should b achieved with medications (metoprolol, verapamil). If control is difficult to accomplish with drugs, radio frequency ablation to disrupt the reentrant circuit or electric cardioversion is sometimes an option

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16
Q

A 55 yr old had a fall from a 6.2 m height. He has severe chest n back pain, BP-162/90 PR-118 RR-24 his voice is hoarse, tender bruising over the sternum, normal heart n lung sounds, the lower extremities r cool to touch with diminished femoral pulses bilaterally
Most likely Dx?
Confirmatory diagnostic modality?

A

Blunt thoracic aortic injury (BTAI)
- complete rupture (including the adventitia typically results in death right away)
-this pt most likely has incomplete rupture
➡️creation of an intimal flap or intramural hematoma that impedes distal blood flow( pseudocoarctation)- proximal hyper, distal hypotension
➡️compression or stretching of surrounding structures eg recurrent laryngeal nerve- hoarseness
🚩CT angiography of the chest

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17
Q

A type 2 DM pt who had a coronary artery bypass grafting surgery 9 days ago comes with swelling n soft tissue separation at the lower part of the surgical mediastinal wound with copious yellowish discharge. The sternum appears stable to palpation.
The best next step in the evaluation of this patient is?

A
  • The pt has wound dehiscence. Mx depends on the extent
    ➡️soft tissue dehiscence- mm, skin… separation. No signs of sternal instability ️⃣local wound care , debridement followed by primary closure.
    ➡️sternal dehiscence- sternal instability n nonunion cxd by “clicking “ or”rocking “ on sternal palpation. Can even occur without soft tissue dehiscence.    ️⃣surgical emergency
    -a high mortality complication of dehiscence is mediastinitis . Systemic sxs or significant sternal wound drainage should raise the suspicion n evaluation with CHEST n STERNAL IMAGING- mediastinal fluid collection or pneumomediastinum can b seen on CT
18
Q

A man who underwent mechanical aortic valve replacement 5 yrs ago comes for routine physical. He’s on warfarin and has no complaints or concerns. He has diastolic murmur at the left sternal border. INR is 2.9
The best next step in the mx is?

A

Echocardiography
-he has AR in the setting of mechanical prosthetic aortic valve, raising the suspicion for prosthetic valve dysfunction (PVD) even in the absence of sxs
- PVD can also occur secondary to stenosis
🚩Echocardiography should b done

19
Q

A pt had coronary artery bypass graft surgery and a day later he develops decreased UOP, BP-80/50, pr-118, cool extremities. ECG- nonspecific T wave changes. Pulmonary aa catheter reading- RA 20mm Hg(2-8 normal)
RV 35/20 (15-30), pulmonary capillary wedge pressure 20 (6-12)
The most likely dx?
The most appropriate next step?

A

Cardiac tamponade- as a complication of his bypass grafting
- although beck triad (hypotension, distended neck veins/raised JVP, distant heart sounds) is the typical manifestation, elevation n equalization of intracardiac diastolic pressures is characteristic finding in cardiac tamponade
🚩urgent echocardiography confirms the dx
-immediate percutaneous or surgical drainage

20
Q

A pregnant lady with sxs of Turner syndrome presents with sudden constant severe chest pain radiating to the neck. ECG is unremarkable. The most likely dx?
CVS manifestations of Turner syndrome include?

A

Aortic dissection
- bicuspid aortic valve, aortic root dilation, aortic coarctation, hypertension- all these in addition to pregnancy in this pt can increase the risk of aortic dissection.

21
Q

A pt is admitted with the dx of infective endocarditis. On the third day of admission he develops SOB, bibasilar crackles n an apical holosystolic murmur. What happens to the size n pressure of the -LA, -LV, -LV ejection fraction

A

The pt has acute MR (dyspnea, pulmonary edema, the murmur)

  • LA has inadequate time to stretch to accommodate the increased blood volume(back flow from LV) and remains NORMAL in SIZE.➡️ INCREASED LA pressure is transmitted backward to pulmonary circulation ➡️pulmonary edema
  • LV - no change in size, INCREASED LV end-diastolic PRESSURE
  • the ejected blood can flow either forward(thru the aortic valve) or backward to the LA. Although the volume of the forward flow ( CO) is reduced, the total stroke volume ( forward n backward) is increased ➡️normal or increased LV EJECTION FRACTION
22
Q

Unilateral lower extremity edema that worsens when the leg is dependent n improves with elevation, no other associated sxs
Most likely Dx?

A

Venous insufficiency (valvular incompetence)

23
Q

A 63 yr old woman with a hx of hypertension suddenly collapses after experiencing severe chest pain that radiated to her back. She’s hypotensive, has distended jugular vein, variation in systolic BP related to respiratory cycle.
Most likely Dx?

A

Cardiac tamponade as a complication of aortic dissection

24
Q

A pt presenting with chest and neck pain, syncope, hx of hypertension, CXR showing widened mediastinum, pericardial effusion
Most likely has?
What should b the next step in the mx?

A

Acute aortic dissection- the classic sxs of severe chest pain, pressure difference between the upper extremities may not b present
- CT angiography is the initial study in hemodynamically stable pts

25
Q

MS: what happens to

  • Pulmonary aa systolic pressure
  • LA diastolic pressure
  • LV diastolic pressure
  • PCWP
A
  • Pulmonary aa systolic pressure - increases
  • LA diastolic pressure - increases
  • LV diastolic pressure- normal, May become lower in severe MS
    -PCWP- increases
    🚩increased LA pressure n dilation ➡️backward pressure transmission to the pulmonary veins, capillaries, and arteries- clinically evidenced by pulmonary edema
26
Q

A 62 yr old man undergoes surgery for pancreatic ca. He receives packed RBC intraop. He has received multiple doses of morphine. 12 hrs later he develops decreased oxygen saturation, BP 80/40, PR-112, RR-28, bilateral basal crackles. Pulmonary aa catheter readings- cardiac index 2 (normal2.8-4.2), PCWP 20 (6-15) most likely cause of his condition?

A

Cardiogenic Shock secondary to acute MI.

  • perioperative MI is common in pts undergoing noncardiac surgeries; intraop hemorrhage requiring transfusion increases the risk. Antipains (eg morphine in this patient) May cover the chest pain due to MI
  • significant infarction ➡️impaired LV contraction➡️low CO ( low cardiac index, a measure of CO), PCWP is high( estimates LA pressure)
26
Q

The preferred fluid in burn patients is?

A

Ringer lactate

27
Q

A pt who has been involved in multiple trauma comes to the ED. He is tachycardic, BP is 114/72. He has bruising and tenderness in the left side of the chest wall n abdomen. CXR and FAST r unremarkable. The best next step in the mx is?

A

Obtain CT scan of the abdomen
If a patient doesn’t have an indication for immediate laparotomy ( hemodynamically stable,…) FAST should be done but if negative, abdominal CT should b performed if there’s a high suspicion
- low suspicion ( no tenderness, no tachycardia) serial physical examination can b performed

Cardiology (7 decks)

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