General Surgery Rotation

General Surgery: Cardiovascular (PEARLS)

The General Surgery End of Rotation Blueprint cardiovascular section includes 9 topics and represents 9% of your general surgery EOR exam

Aortic aneurysm/dissection Aortic Dissection

sudden "ripping" or "tearing" CP radiating to back

  • Older, history of HTN, smoking, Marfan syndrome
  • PE will show asymmetric pulses/BP CXR= widened mediastinum

DX= CT or transesophageal echocardiogram

Treatment is reducing BP, surgery

Aortic Aneurysm

Flank pain, hypotension, pulsatile abdominal mass

Screening: Ultrasound, if male >65 and ever a smoker

Treatment:

  • Immediate surgical repair (even if asymptomatic) if >5.5 cm or expands >0.6 cm per year
  • Monitor annually if >3 cm. Monitor every 6 months if >4 cm
  • Beta-blocker
Arterial embolism/thrombosis Caused by a sudden arterial occlusion

The P's of arterial emboli: P ain, P allor, P ulselessness, P aresthesia, P aralysis, P oikilothermia

  • Atrial fibrillation and mitral stenosis are common causes of thrombus formation
  • Angiography is considered the gold standard for diagnosis
  • Acute arterial occlusion: Treat with IV heparin if not limb threatening then call the vascular surgeon for angioplasty, graft or endarterectomy
Arterial/venous ulcer disease Edema, atrophic shiny skin, brawny induration, stasis dermatitis,  brown hyperpigmentation, varicosities, ulcers above the medial malleolus

  • ABI, Trendelenburg tests, ultrasound

Treatment: Sclerotherapy, vein stripping, compression hose

Chest pain; history of angina Stable anginaPredictable, relieved by rest and/or nitroglycerine

Unstable anginaPreviously stable and predictable symptoms of angina that are more frequent, increasing or present at rest

Prinzmetal variant angina: Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot

Claudication Reduction in blood flow to the leg muscles, most commonly by an atherosclerotic plaque.

  • pain in the leg with walking
  • relieved within a few minutes of rest
  • reproducible at the same walking distance each time

PAD is defined as an ABI < 0.9. The ABI Confirms the Diagnosis of PAD:

  • Normal ABI 1.2–1.0
  • Mild disease 0.9–0.7
  • Moderate disease 0.7–0.4
  • Severe disease/rest pain <0.4

Angiography is considered the gold standard for diagnosing PAD/PVD

Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel

  • Treat lipids - Statins
  • Revascularization with PTA, bypass grafts, stenting
  • Exercise - walking to the point of claudication

***βblockers are contraindicated in isolated PAD – it will worsen claudication!

Treatment options for severe PVD?

  1. Surgical graft bypass
  2. Angioplasty—balloon dilation
  3. Endarterectomy—remove diseased intima and media
  4. Surgical patch angioplasty (place patch over stenosis)
Dyspnea on exertion Arrhythmia: Atrial fibrillation, inappropriate sinus tachycardia, sick sinus syndrome/bradycardia

  • Hx: Palpitations, syncope
  • PE: Irregular rhythm, pauses
  • DX: ECG, event recorder, Holter monitor, stress testing

Myocardial: Cardiomyopathies, coronary ischemia

  • Hx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, chest pain or tightness, prior coronary artery disease or atrial fibrillation
  • PE: Edema, JVD, S3, displaced cardiac apical impulse, hepatojugular reflex, murmur, crackles, wheezing, tachycardia, S4
  • Dx: ECG, brain natriuretic peptide, echocardiography, stress testing, coronary angiography

Restrictive: Constrictive pericarditis, pericardial effusion/tamponade

  • Hx: chest pain, dyspnea
  • PE: Paradoxical pulse (exaggerated variation in blood pressure with respiration).
  • Dx: EKG showing low voltage QRS along with electric alternans (see media section). Echocardiogram with increased pericardial fluid. Radiograph: Water bottle heart

Valvular: Aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis

  • Hx: Dyspnea on exertion
  • PE: Murmur, JVD
  • Dx: Echocardiography
Peripheral arterial disease Intermittent claudication,  Ankle-brachial-index< 0.9

  • Lower extremity loss of hair, brittle nails, pallor, cyanosis, claudication, hypothermia
  • Ulcers are pale to black, well circumscribed and painful, located laterally and distally
  • Arteriography is the gold standard for diagnosis

Treatment:

  • Definitive treatment: Arterial bypass
  • Medical treatment: Antiplatelets, anti lipids, manage risk factors, cilostazol Aspirin, Plavix,
Syncope Structural cardio-pulmonary:

  • Aortic Stenosis - angina, syncope, and CHF - 3 -years life expectancy if left untreated (if experiencing syncope)
  • Cardiomyopathy: HOCM - (young athlete with a positive family history has sudden death or syncopal episode)
  • Pulmonary hypertension
  • Acute MI

Pericarditis: Chest pain that is relieved by sitting and/or leaning forward. Pericardial friction rub heard best with patient upright and leaning forward

Orthostatic hypotension: drug-induced, volume depletion, cardiogenic shock

Cardiac arrhythmia: Brady (sick sinus, AV block), Tachy (SVT, VT), prolonged QT

Vasovagal - a drop in pressure with a sudden slowing of the heart. This type of syncope is often triggered by pain or emotional shock

Subclavian steal syndrome - arm pain and syncope with the use of the left arm

Varicose veins Presentation: Dilated tortuous superficial veins, venous stasis ulcers, ankle edema, lower extremity pain after sitting/standing

  • Treatment: leg elevation and compression stockings
General Surgery: Acid/base disorders (Prev Lesson)
(Next Lesson) General Surgery: Chest pain; history of angina
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