Cardio

Question 1

What are innocent murmurs?

Answer 1

Flow related heart murmurs, that are not associated with any significant haemodynamic abnormalities, present in 30% of children

Question 2

What are common causes innocent murmurs in children

Answer 2

1. Systolic ejection
2. Venous hum
3. Vibration Murmur

Question 3

What are common pathological paediatric heart murmurs?

Answer 3

1. VSD (Pansystolic LL Sternal border)
2. ASD (soft systolic 2ICS Left)
3. Aortic stenosis
4. Corctation of the Aorta
   (Others include Pulmonary Valve stenosis, Patent ductus ateriosus, Fallot Teratology, Mitral Valve incompetence)

Question 4

What are the most common signs and symptoms of heart failure in children?

Answer 4

Symptoms
- Fatigue
-Breathlessness

Signs
- cyanosis
- Failure to thrive
- (Extreme) Tachycardia
- Dependant on Pathology (e.g. murmur, Pulses, Heaves, thrills, etc.)
- Absent femoral pulses (Coarctation of the Aorta)

Question 5

What are signs for Innocent heart murmurs on examination?

Answer 5

Sound
- mid-systolic or continuous (venous hum). No added clips
- Musical humming or vibratory quality

Position
- Left sternal border, neck , upper chest and no radiation
- Vary with intensity or posture/respiration/head position

Examination
- Asymptomatic
- Normal peripheral pulses

Question 6

What are signs for pathological heart murmurs on examination (vs innocent)

Answer 6

Sound
- Harsh or long
- Mid or pan systolic murmur or diastolic continuer (PDA)
- Clicks and abnormal 2nd sound

Signs (ALWAYS Pathological)
- thrill
- Cardiomegaly
- Any cardiac symptoms

Question 7

What murmur would a VSD present with?

Answer 7

harsh, pan systolic at left lower sternal border
- radiating all over chest

Question 8

What murmur would a ASD present with ?

Answer 8

Soft Systolic in 2nd left ICS
Wide fixed splitting of 2nd HS

Question 9

what Murmur would a Coarctation of Aorta present with?

Answer 9

Systoic murmur over left side of chest, especially in back

Question 10

What murmur would pulmonary stenosis present with?

Answer 10

Systolic ejection murmur
Upper part of left chest
(Anterior, radiation to the back or axillae usually preceded by opening click)
2nd HS might be split, but not fixed

Question 11

What Murmur would a PDA present with?

Answer 11

Patent ductus Ateriosus
Continous murmur after 3 months of age
Usually Pansystoic/Ejection systolic murmur in neonates

Question 12

What additional examination finding would you expect in a 4 months old presenting with a continous (diastolic) murmur?

Answer 12

PDA

Associated with collapsing pulse O/E

Question 13

How would you investigate innocent murmurs?

Answer 13

No investigation required (except if not all pathological murmur can be excluded)

Question 14

You have a baby presenting with Cyanosis.
What features would you make lean more towards a cardiac cause of cyanosis, that a Pulmonary or benign cause?

Answer 14

1. Persistent central cyanosis
   (Low O2 sats (60-70%)
   Admission of oxygen makes little different to sats

Question 15

What features of a faint episode (e.g. in teenagers) makes you think more of a cardiac cause than vasovagal/ neurological?

Answer 15

Generally rare if child is otherwise well

1. Exercise-induced syncope (during or just after exercise)
2. Fainting with lying down/sitting
3. Underlyign disease/infection
4. Family History of cardiac disease or premature death

Question 16

What is an aortic flow murmur? What does it sound like?

Answer 16

It is an innocent (Functional murmur)
1. short systolic murmur during left ventricular ejection
2. heart left sternal edge (2nd ICS or apex)
3. Musical in character (Like vibration of tuning fork)

Question 17

When does a aortic flow murmur intensifies?

Answer 17

Fever
Exitement
Exercise

Question 18

When does a innocent aortic flow murmur decrease in intensity?

Answer 18

Positional change from lying to standing/sitting
(If this intensifies, suggest pathology e.g. hypertrophic cardiomyopathy)

Question 19

What is a pulmonary flow murmur?
What does it sound like?

Answer 19

Innocent murmur
Systolic ejection murmur caused by rapid flow over normal pulmonary valve

Brief, high pitched blowing, best heard in 2nd left ICS when child lying down

Question 20

What is venous hum?
What does it sound like?

Answer 20

Innocent murmur

Caused by flow through systemic great veins

blowing, continous murmur heart at base of heart (just below clavicles), during both systole and diastole

Varies with position/ change of head
Usually disappears when child lies down ^

Question 21

What are the commonest Causes for a Left to Right Cardiac shunt in paediatrics

Answer 21

1. VSD
2. ASD

Question 22

What is Eisenmengers Syndrome?

Answer 22

Irreversible complication from severe, longstanding ASD or VSD

Prolonged pulmonary hypertension due to a left-to-right shunt causes reactive constriction with permanent remodeling of pulmonary vessels → irreversible pulmonary hypertension

Management
Needs Cardio-pulmonary transplant or lung transplant with VSD repair

Question 23

What is a Cyanotic Congenital Heart Defect?

Answer 23

A congentital Heart defect, that cases a Right to Left Shunt –> entering of non-oxygenated blood into the circulation –> cyanosis and hypoxia

Generally Present with Cyanosis earlier

Question 24

What are examples for “common” cardiac cyanotic congenital heart diseases?

Answer 24

1. Teratology of Fallot
2. Transposition of the Great Vessels

Question 25

What are Acyanotic Congenital Heart disease

Answer 25

congenital Heart defect, that cause Left to right Shunting (generally present with cyanosis later)

Generally Associated with Right sided high pressures, leading to Pulmonary hypertension and right sided hypertrophy

Question 26

What are Examples for Acyanotic Congenital Heart diseases?

Answer 26

1. ASD &VSD
   PDA
   Coarctation of the Aorta