CLIPP case 18. Congenital heart problem

Question 1

2 week-old infant presents for WCC with poor weight gain and difficulty feeding (respiratory distress, diaphoresis). Exam shows tachypnea, holosystolic murmur, and hepatomegaly. CXR shows cardiomegaly with increased pulmonary vasculature. ECG demonstrates right ventricular hypertrophy.

Answer 1

• CHF (other DDx: bronchiolitis, pneumonia, GERD, m etabolic disorder)
• Etiologies:
  
  • VSD
  • Aortic stenosis
  • Coarctation of the aorta
  • PDA
• Tx: digoxin and furosemide, echo, and f/u to decide whether needs surgery by 6mo (to prevent Eisenmenger’s)

Question 2

VSD physiology

Answer 2

Left-to-right shunting -> increased pulmonary blood flow and increased pulmonary venous return -> LV volume overload.
*The murmur of a VSD will appear when the PVR drops, usually at a few days to weeks of age.

Question 3

VSD presentation

Answer 3

• Murmur and CHF at several days to weeks of age. Hyperactive precordium with thrill at LLSB.
• Small defects usually cause no symptoms.
• VSDs tend to diminish in size with time

Question 4

CHF in infancy etiologies

Answer 4

• VSD
• Aortic stenosis
• Coarctation of the aorta
• PDA
• ASD, Tetralogy of Fallot do not cause CHF

Question 5

Infant murmurs

Answer 5

• Grade ≥ III and diastolic are pathologic
• ASD, coarctation, aortic stenosis, PDA, pulmonic stenosis VSD
• Less common: acute rheumatic fever, endocarditis, and cardiomyopathies

Question 6

ASD murmur

Answer 6

• Fixed split S2

- Presents at 3-5yo

Question 7

Aortic stenosis murmur

Answer 7

• Systolic murmur + early diastolic murmur

- Presents in infancy

Question 8

Coarctation of the aorta murmur

Answer 8

• Murmur, HTN in UE, discrepancy b/t UE and LE BP

- Presents at any age, progresses

Question 9

PDA murmur

Answer 9

• Continuous murmur, but a bit louder in systole

- Presents in infancy

Question 10

VSD murmur

Answer 10

• Holosystolic. Intensity NOT related to defect size

- Present in infancy

Question 11

Pulmonic stenosis murmur

Answer 11

• Prominent systolic ejection click just after S1, + harsh systolic ejection murmur
• Presents in infancy

Question 12

Innocent murmurs

Answer 12

• Most common murmur in children
• Still’s murmur: musical or vibratory, and heard best at the left lower sternal border in the supine position
• Not innocent if any of: child sick, abnormal precordial activity, abnormal S2 split, grade ≥3, abnormal O2 sats