Surgery final questions Flashcards
A 24-year-old Indian man is seen after a syncopal episode that occurred while he was watching a football game on TV. His wife noticed that after a particularly exciting play, the patient suddenly slumped over. She shook him hard, and, after about 30 seconds, he woke up and said that he remembered nothing of the incident. This has never happened before. Up until this time, he has had no limitation of physical activity. His past medical history is significant in that he had repair of tetralogy of Fallot at age 4, at which time a VSD was patched and a right ventricular infundibulectomy was done.
Physical examination finds no cyanosis. Blood pressure is 100/70 mmHg, and pulse is 65 per minute with an occasional premature contraction. The lungs are clear to auscultation and percussion. Neck veins are 4cm. There is a mid sternal incision that is well healed. There is a slight precordial systolic lift. S2 is single. There is a Grade II/VI systolic ejection murmur with a short Grade II/VI diastolic low-pitched murmur along the left sternal border. There is no S3 or S4.
The ECG shows right bundle branch block with left anterior hemiblock. The PR interval is 0.12 seconds. The echocardiogram reveals a slightly dilated right ventricle and paradoxical motion of the interventricular septum. Doppler gradient across the right ventricular outflow tract is 35 mmHg. There is evidence of moderately severe pulmonic regurgitation, and there are no left-to-right or right-to-left shunts.
What is the most important diagnostic test needed for this patient?
B. Electrophysiology study.
Catheter-delivered balloon expansion techniques are now the treatment of choice for which one of the following lesions in adults?
Valvular pulmonic stenosis.
An important predisposing cause for late atrial fibrillation following closing of an atrial septal defect is:
The age of the patient at the time of surgery.
What determines the physiology in tetralogy of Fallot?
The degree of RV outflow tract obstruction.
A 36-year-old man is referred for suspected ASD. He is employed, active, and asymptomatic. ECG shows a normal axis and incomplete right bundle branch block. Chest x-ray shows an enlarged right heart silhouette and increased pulmonary vessels throughout the lungs. Echocardiography confirms a 3cm diameter secundum ASD with a large shunt. There is a mild tricuspid regurgitation jet of 2 m/sec.
Your recommendation is which one of the following?
Cardiac surgical repair.
The best approach for the adult patient with a calcified ductus is:
Closure of the defect at cardiac catheterization.
A 50-year-old Asian woman is seen because of the onset of palpitations for the past 24 hours. She had finished a 2-day bus ride just prior to the onset of the symptoms. She reports that for the past year, she has had to stop after one flight of stairs because of fatigue and shortness of breath. She denies chest discomfort. On questioning, she admits heavy alcohol intake.
Physical examination reveals a healthy appearing woman with blood pressure 150/70 mmHg and pulse irregularly irregular at 140 per minute at the apex. The lungs are clear to auscultation and percussion. The neck veins are 8cm with a predominant V wave. S2 is widely split with little respiratory variation. There is no S3 or S4. There is a Grade III/VI systolic ejection murmur at the second interspace at the left sternal border. There is no peripheral edema.
The chest x-ray is shown ( Figure 1). The ECG shows atrial fibrillation with left axis deviation and right bundle branch block.
The most probable diagnosis is:
Ostium primum atrial septal defect.
A 48-year-old man with known Eisenmenger’s syndrome (ventricular septal defect with high pulmonary vascular resistance) is seen for his annual visit. He continues to work full-time as a computer operator. During the past year he has had chest discomfort “a few times.” It’s vague, visceral in character, and substernal in location. It may be at rest or with activity, and never lasts more than a few minutes. He has no gastrointestinal complaints and doesn’t think this is related to eating. He has also had minimal hemoptysis with severe coughing paroxysms–“maybe when I had a little cold.” He has also had vague ankle and toe aching periodically–“maybe I need a new style of shoe!”
His examination is not changed from previous years. He is well nourished and well muscled. He has mild clubbing, and minimally evident jugular veins with an A wave made more prominent by abdominal compression. He has a striking left peristernal lift. On auscultation, S2 is split, P2 is strikingly increased, and there is a Grade II decrescendo diastolic murmur along the left sternal border. There are several ejection clicks but no systolic murmur.
The electrocardiogram shows striking RVH with STT abnormalities (no change) and his hematocrit is 65 (has varied from 63 to 67 during the past few years).
Which of the following do you believe should be done in this patient?
Refer to specialized center for work-up and consideration for future heart/lung transplant.
Which one of the following is most consistent with the findings in the figure? (x-ray)
Congenital pulmonic stenosis.
Which of the following conditions are amenable to repair by the Fontan operation?
Tricuspid atresia.
A common difficult management problem following the Fontan operation is:
Atrial arrhythmia, particularly atrial flutter.
In which of the following diseases is pregnancy difficult, but not highly risky to mother and fetus?
Hypertrophic obstructive cardiomyopathy.
In long-term follow-up of patients after surgical repair of tetralogy of Fallot, the most common dysrhythmia observed is:
Ventricular tachycardia.
A 42-year-old man is referred for evaluation of a systolic murmur. Your exam shows normal carotid pulses, a prominent apical impulse, an early systolic sound, and a grade III/VI mid-systolic murmur at the base. Respiration did not change the character of these auscultatory findings. After an extrasystole, the systolic murmur increased in intensity. Handgrip did not alter the systolic murmur. Valsalva decreased the intensity of the murmur, and it returned to baseline intensity after seven heart beats.
Which one of the following diagnoses is most likely?
Bicuspid aortic valve.
A 30-year-old woman with inoperable cyanotic congenital heart disease is scheduled for total abdominal hysterectomy for uterine cancer. You are asked to see her for preoperative cardiac evaluation. Her hematocrit is 66%. This is unchanged from previous values over several years. The patient denies any bleeding tendencies or hyperviscosity symptoms such as fatigue, headache, or lethargy.
Which of the following is most appropriate?
The patient should undergo phlebotomy preoperatively.
