Cardio 1 (through rheumatic fever)

Question 1

Cardiac murmurs in adolescents (1,2c)

Answer 1

1. New congenital heart defects rare in adolescence
2. Two common defects missed until this age are atrial septal defect and bicuspid aortic valve
   a. Wide fixed splitting of second heart sound = ASD
   b. Ejection systolic click = bicuspid aortic valve
   i. Hypertension = undiagnosed coarctation
   ii. Bicuspid aortic valve = ejection click
   iii. Systolic murmurs

Question 2

Holosystolic Murmurs in adolescents (what it is and 5 causes)

Answer 2

what it is: Mitral regurgitation

1. Congenital cleft mitral valve
2. Rheumatic carditis
3. Infective endocarditis
4. Kawasaki disease
5. Annular dilation from Marfan’s syndrome

Question 3

Systolic Murmurs in adolescents: tricuspid regurgitation (6 causes)

Answer 3

1. Congenital: Ebstein anomaly –> Valve is malformed and is positioned too low, allowing blood to leak backward from the ventricle to the atrium.
   * These abnormalities cause enlargement of the atrium and the “atrialization” of the right ventricle
2. Congenital correction of great vessels
3. Infective endocarditis
4. Eisenmenger syndrome
5. Pulmonary hypertension
6. Annular dilation

Question 4

Ejection systolic murmurs in adolescents (5)

Answer 4

Aortic: obstructive lesions

1. Bicuspid aortic valve
2. Dysplastic aortic valve
3. Supravalvular aortic stenosis
4. Coarctation of aorta

Question 5

Causes for increased flow systolic murmurs in adolescents (4)

Answer 5

1. AR
2. Large PDA
   - PDA that hasn’t been picked up
3. Complete heart block

Question 6

Ejection Systolic Murmur: Obstructive causes (3)

Answer 6

PULMONARY

a. Pulmonary valve stenosis
b. Pulmonary artery branch stenosis
c. Compression from pectus or kyphoscoliosis

Question 7

Ejection Systolic Murmur: increased flow causes (3)

Answer 7

PULMONARY

1. ASD
2. Anomalous pulmonary venous return
3. Severe pulmonary regurgitation
   i. Compression murmurs
   ii. Pectus excavatum = surgery may be needed if pectus is pushing heart to the side

Question 8

Respiration maneuvers to change murmurs (2)

Answer 8

1. Right sided cardiac structures get louder during inspiration
2. Left sided cardiac structures get louder during expiration

Question 9

Valsalva maneuvers to change murmurs (2)

Answer 9

1. Increases intrathoracic pressure decrease in preload

2. In Hypertrophic cardiomyopathy and mitral valve prolapse

Question 10

Exercise maneuvers to change murmurs (2)

Answer 10

1. Increases stroke volume increases the intensity of the murmur
2. When increases* cardiomyopathy
3. Exercise = increasing size of murmur

Question 11

Murmurs and positional changes (5 with info)

Answer 11

1. Sitting to standing position reduces preload due to gravity or
2. Standing to squatting increases venous return
   - Most murmurs decrease except for HCM and MVP
3. Lateral decubitus: Apex of heart is closing causes increase in diseases of mitral valve
4. Sitting forward and exhales completely: Decreased heart rate and increases stroke volume
   - Aortic value murmurs get lower
   - Stood up with cardiomyopathy = heard murmur in sitting position, standing up = lower
   - LOUDER = problem
   - Those are the kids you want to squat and lean forward
   - If that murmur gets louder = hypertrophic cardiomyopathy
5. On side = louder in mitral valve disease
   * Do not clear adolescent for sports unless you listen in different positions

Question 12

Evaluation of the child with chest pain (6)

Answer 12

1. Pain from irritation of inflamed or irritates tissue
2. Spinal neurons transmit inflamed chest wall tissue pain to the pain where it can present to the patient as sharp localized pain
3. Spinal neurons receive input from thoracic dermatomes, leading to referred pain
4. Intercostal nerves and phrenic nerve innervate the diaphragm, peripheral diaphragmatic irritation
5. Diaphragmatic irritation, or epigastric regions can cause chest pain
6. Pericardium is inflamed or infected, sharp substernal pain will occur

Question 13

Irritated left lobe of diaphragm (referred pain?) (6)

Answer 13

1. pain will be referred to the shoulder or neck
2. chest pain can be referred to shoulder from diaphragm
3. Ear pain with throat infection
4. Pulmonary and cardiac innervation goes to same ganglions and the message gets mixed
5. Spinal neurons transmit inflamed chest wall tissue — sharp localized pain
6. Splenic rupture = shoulder pain

Question 14

pneumothorax referred pain

Answer 14

can cause ipsilateral shoulder pain

Question 15

pleurodynia referred pain

Answer 15

Can cause pleuritis pain

Question 16

Musculoskeletal causes of chest pain in teens (5)

Answer 16

1. Costochondritis
2. Idiopathic
3. Tietze syndrome
4. Trauma and muscle strain
5. Slipping rib syndrome scoliosis

Question 17

Pulmonary causes of chest pain in teens (3)

Answer 17

I. Chronic cough

ii. Pneumonia/asthma
iii. Pulmonary embolism

Question 18

GI causes of chest pain in teens (3)

Answer 18

I. GERD

ii. Gastritis
iii. Esophagitis

Question 19

Infectious causes of chest pain in teens

Answer 19

herpes zoster

Question 20

Tietze Syndrome (5)

Answer 20

1. History of UTI
2. Excessive cough is a possible mechanism
3. Localized inflammation of a single costochondral joint
4. Can have warm, swelling or tenderness at the joint
5. Inflammation differentiates it from costochondritis

Question 21

Chest pain in adolescents (6)

Answer 21

1. Musculoskeletal pain is very common in adolescents
   - Exercise, overuse, muscle strain, protracted coughing
2. Precordial catch: Transient stabbing pain at left sternal borders which is relieved by forceful inspiration breath
3. Stitch(common): Crampy, costal pain that occurs with running
   Stitch = long distance running with pain in chest
4. Other symptoms suggest a pulmonary, GI cause of chest pain
5. Psychogenic chest pain is diagnosis of exclusion
6. Pneumothorax is rare

Question 22

Chest pain indicating pneumothorax (5)

Answer 22

1. Sudden pain
2. Referred to shoulder
3. Dyspnea
4. Hyperresonance
5. Reduced breath sounds on affected side

KNOW PNEUMOTHORAX**

Question 23

Teen with Chest Pain: Differentials (10)

Answer 23

1. Arrhythmia
   a. SVT
   b. VT
2. Left ventricular outflow tract obstruction from aortic stenosis, subaortic stenosis, supravalvar stenosis
3. Anomalous origin of coronary artery
4. Kawasaki Disease
5. Coronary artery vasospasm
6. Hyperlipidemia (genetic)
7. Cocaine
8. Aortic dissection
9. Ruptured AA
10. Pulmonary hypertension

Question 24

Genetics and chest pain (7)

Answer 24

1. Connective tissue disorders
2. Marfan syndrome
3. Ehlers – Danlos syndrome type IV
4. Pneumothorax
5. Aortic root dissection
6. Turner syndrome at risk for aortic root dissection
7. MVP can be associated with connective tissue disorder

Question 25

Pericarditis (8)

Answer 25

1. May cause severe substernal chest pain
2. described as squeezing or lightening
3. Pain worse with movement, including breathing
4. Patients prefer to lean forward, may refuse to lie down
5. Pain is reproduced by sternal pressure
6. Consider in post=op cardiac patients
7. Usually a friction rub if small or no effusion
8. If large effusion, no rub but distant heart sounds
   a. Friction rub = pericarditis
   b. Patient leaning forward
   c. Post-op cardiac patient = pain with movement and breathing

Question 26

When to consider myocarditis (5)

Answer 26

1. Weakness
2. SOB
3. Chest pain - Especially if associated with preceding prodromal viral illness
4. Distant heart sounds: “Silent Chest”
5. Enlarged heart on CXR

Question 27

CXR of myocarditis

Answer 27

cardiomegaly and prominent vasculature, perhaps even pulmonary edema

Question 28

management of myocarditis

Answer 28

1. Gentle diuretic therapy
2. Afterload reduction
3. Possibly inotropic support
4. Echocardiogram

Question 29

What is myocarditis? (4)

Answer 29

1. Inflammatory disease of the myocardium:
2. Direct infection of the myocardium (e.g., viral myocarditis)
3. Toxin production (e.g., diphtheria)
4. Immune response as a delayed sequela of an infection (post=viral or post infectious myocarditis)

Question 30

what is a common pediatric type of myocarditis?

Answer 30

acute rheumatic fever

*Most common post-immune response to virus

Question 31

Differential dx of myocarditis (9)

Answer 31

1. Acute rheumatic fever
2. Pericarditis
3. Hypertensive crisis
4. Anomalous coronary artery and myocardial ischemia/infarction
5. Valvular disease
6. Structural cardiac disease (e.g., VSD, ASD)
7. Renal failure (e.g., glomerulonephritis) - fluid load
8. Rheumatic fever
9. Missed congenital heart disease

Question 32

Clinical guidelines of acute rheumatic fever (3)

Answer 32

1. Children not from a low risk population may have a moderate to high risk of RF based on their reference population
2. Echocardiography with Doppler should be done in patient with suspect RF
3. Do serial echocardiography even if documented carditis is not initially present
   * This is particularly important in moderate to high risk population even in face of no auscultatory findings.

Question 33

Evidence of preceding streptococcal infection (3)

Answer 33

1. Increased or rising AnL – Streptolysin O titers or other streptococcal antibodies (AnL=DNASE B
   * Rise is better than single titer
2. Positive throat culture for group A β=hemolytic streptococci
3. A positive rapid streptococcal carbohydrate antigen tests in a child with signs of strep

Question 34

ARF Major Criteria (5)

Answer 34

1. Carditis (50% to 70%
2. Arthritis (35% to 66%
3. Chorea (10% to 30% with female dominance)
4. Subcutaneous nodules (0% to 10%)
5. Erythema marginatum (<6%)

Question 35

Echocardiogram Findings: Rheumatic Vavulitis (3 with info for each)

Answer 35

1. Acute mitral valve changes:
   a. Annular dilation, chordal elongation, chorda rupture with leaflets that flail, anterior leaflet tip prolapse
   b. Nodularity or beading of leaflets
2. Chronic mitral valve changes
   a. Leaflet thickening or restrictive motion
   b. Chordal thickening or calcifications
3. Aortic valve changes

Question 36

Arthritis with ARF (4)

Answer 36

1. Migratory polyarthritis with greater affinity for large joints of knees, ankles, elbows, and wrists
2. Rapid improvement with anti-inflammatory drugs is characteristic
3. Arthritis in ARF lasts around 4 weeks
4. Absence of long term joint deformity
   a. Acute rheumatic fever = mitral murmur and followed over 8 years
   b. Bicillin* murmurs get better if they do not get a second rheumatic fever

Question 37

Arthritis/Arthralgia (3 with info)

Answer 37

1. Post-Streptococcal Arthritis
   a. These patients do not fulfill the Jones Criteria
   b. Controversy about prophylaxis for these patients as some patients later develop RF
2. Aseptic Monoarthritis
   a. Aseptic monoarthritis in 16% to 18%
   b. Monoarthritis as a major criteria for ARF or RHD
3. Arthralgia
   a. Polyarthralgia is a major manifestation in only high risk or moderate risk population
   b. Exclusion of major causes such as autoimmune, viral or reactive arthropathies – NOT RHEUMATIC FEVER*

Question 38

Major manifestations with ARF (3)

Answer 38

1. Chorea: Purposeless, involuntary non-sterotypical movements of trunk or extremities
   * Muscle Weakness
2. Emotional lability
3. Erythema Marginatum
   a. Pink rash with pale centers
   b. Rounded or sepiginous margins

Question 39

Minor manifestations of ARF (4)

Answer 39

1. Temperature is usually >38.5 degrees
2. Prolonged PR interval
3. Raised CRP >7.0
4. Erythrocyte sedimentation rate > 60 in first hours but >30 is consistent
   a. If someone has carditis you cannot use PR interval for minor manifestation