General Surgery Rotation

General Surgery: Cardiovascular (PEARLS)

General Surgery Rotation

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 angina: Predictable, relieved by rest and/or nitroglycerine Unstable angina: Previously 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? Surgical graft bypass** Angioplasty—balloon dilation Endarterectomy—remove diseased intima and media 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

Back to General Surgery Rotation