CVS

Question 1

Are heart murmurs common in pediatric populations?

Answer 1

Yes
-50-80% of children have audible heart murmurs at some point in childhood

Question 2

T/ F most heart murmurs discovered in pediatric patients are due to a structural cause

Answer 2

False
Most are innocent/ functional (i.e., caused by turbulent blood flow) and are not associated with a structural abnormality.

Question 3

Describe the following for an innocent heart murmur
-signs and symptoms
-grade
-sound
-relationship with position
-typical history

Answer 3

-Asymptomatic
-Grade is <3/6
-Soft, blowing, vibratory, musical
-No extra sounds or clicks
-Murmur varies with positional changes (lower intensity sitting)
-No family or personal history CHD, no phx genetic anomalies

Question 4

Describe the following for a pathologic heart murmur
-signs and symptoms
-grade
-sound
-relationship with position
-typical history

Answer 4

S/S of cardiac disease (failure to thrive, exercise intolerance)
-Diastolic, pansystolic, or continuous
-Grade 3/6+
-Palpable thrill
-Harsh, hit pitch, better heard with diaphragm
-May have extra sounds/ clicks (abnormal S2, gallop, friction rubs)
-Unchanged by position
-Family or phx CHD, phx of genetic condition

Question 5

You are taking the history of a child with a heart murmur. What are some associated signs/ symptoms you will ask about?

Answer 5

dyspnea, resp difficulties, cyanosis, poor growth, feeding intolerance/ poor feeding, diaphoresis, chest pain, syncopal episodes

Question 6

What physical exam will you conduct for a child with a heart murmur?

Answer 6

-Gen appearance (congenital anomalies)
-VS (HR and rhythm, difference in SCP between R arm and leg)
-CVS- complete assessment including pulses (asymmetry, deficits?), inspection of chest, palpation for thrills and apical impulse, listening at each area of the heart with bell and diaphragm
-Hepatomegaly
-Resp

Question 7

When would you refer a child with a murmur to cardiology?

Answer 7

Criteria as outlined by up to date:
 Abnormal fetal echo, underlying genetic disorder associated with increased risk CHD, and symptoms suggestive of heart disease
 Murmur is grade 3+ intensity, holosystolic timing, maximum intensity at left upper sternal border, harsh or blowing quality, increased in upright position, diastolic murmur
 Other abnormal heart sounds (S2, gallop rhythm, systolic click, friction rub)
 >10mmHg SBP gradient between R arm and leg
 Abnormal pulses
 Abnormal CXR (i.e., cardiomegaly, pulmonary edema) or ECG

Question 8

What education will you provide the the patient/ family about a heart murmur?

Answer 8

• A murmur is a physical assessment finding, not necessary a specific diagnosis
• It is heart sound that comes from turbulent blood flow in the heart
• Heart murmurs are common in children. ~50% of healthy children have heart murmurs and the majority (~98%) of these are not pathological/ harmful
• Red flags/ signs to seek reassessment or urgent care (i.e., if develops signs/ symptoms of cardiac disease such as dyspnea, cyanosis, poor growth, diaphoresis, chest pain, syncope)

Question 9

What is a systolic murmur??

Answer 9

Starts with or after S1, stops before or at S2

Question 10

What is a diastolic murmur?

Answer 10

Starts with or after S2, ends at or before S1

Question 11

What is a holosystolic murmur?

Answer 11

Starts with S1 and obscures S1 and S2

Question 12

What is a continuous murmur?

Answer 12

Continuous murmurs begin in systole and continue without interruption through the second heart sound (S2) into all or part of diastole.

Question 13

Describe each grade of heart murmur

Answer 13

1- faint
2- soft, readily detectable
3- loud, no thrill
4- louder, with palpable precordial thrill
5- very loud, audible with stethscope placed lightly on chest, with precordial thrill
6- loudest, audible with stethoscope off chest, with precordial thrill

Question 14

What are some risk factors for congenital heart disease?

Answer 14

Genetic predisposition

Prenatal exposure to teratogens

Prenatal viral illness (coxsakie virus, cytomegalovirus, influenza B, mumps, rubella, parvovirus, varicella, etc)

Maternal factors (age>40, IDDM, lupus)

Congenital infection with GABHS

Prematurity

Question 15

What are red flags in the general peds history that may lead to an urgent cardiac assessment?

Answer 15

Lethargy

Tiredness

Failure to thrive

Syncope – acute collapse (often with exertion), few warning symptoms preceding the event

Question 16

What are red flags in the general inspection of peds patients that may lead to an urgent cardiac assessment?

Answer 16

Cyanosis, clubbing, abnormal breathing (tachypnea, intercostal indrawing)

Question 17

What are red flags in the palpation section of the assessment of peds patients that may lead to an urgent cardiac assessment?

Answer 17

Parasternal or apical impulse, abnormal pulses – diminished, absent or delayed femoral pulses

Question 18

What features of murmurs would lead to an urgent cardiac referral?

Answer 18

Systolic murmur which is pansystolic or grade 3 or higher

Purely diastolic murmur

Radiation of the murmur to the back

Question 19

Any other findings that would warrant a cardiac referral?

Answer 19

Abnormal heart sounds

Presence of an early or mid-systolic click

Cardiac failure or arrhythmia

Question 20

Common presenting symptoms of infants with heart disease

Answer 20

Lethargy, irritability, tachypnea, sweating, poor feeding, poor weight gain

Question 21

Common presenting symptoms of older children with cardiac disease

Answer 21

Lethargy

Exercise intolerance

Respiratory distress

Question 22

What are initial diagnostics recommended to determine need for referral if unsure

Answer 22

Chest x-ray

ECG

These are usually not diagnostic, but can be helpful in differentiating resp/cardiac disease and identifying children who need further assessment

Question 23

T/F: Chest pain in children is often of a cardiac origin

Answer 23

FALSE – majority of chest pain in peds is not cardiac related.

Question 24

What are common causes of pediatric chest pain?

Answer 24

MSK pain/strain

Inflammation (pericarditis/myocarditis)

Gastroesophageal irritation

Psychogenic

Pulmonary

Question 25

T/F: Anxiety/emotional stress is the most common source of pediatric chest pain

Answer 25

FALSE – Costochondritis is the most common cause (20-75%)

Anxiety and emotional stress accounts for 9-20%

Question 26

Cardiac chest pain is rare, but does need to be considered. When would you refer to a cardiologist?

Answer 26

Abnormal physical exam

Abnormal ECG

Personal history of CHD

Prior arrhythmia

Severe familial hypercholesterolemia

Kawasaki disease with coronary artery aneurysm

Question 27

What is acute rheumatic fever and when does it occur?

Answer 27

Rheumatic fever is a nonsuppurative sequela of GAS pharyngitis, occurs 2-4 weeks after infection

Question 28

What are the major manifestations of Acute Rheumatic Fever (ARF)?

Answer 28

History of GAS pharyngitis

THESE WOULD BE THE RED FLAG SYMPTOMS TO WATCH FOR *

Has to meet criteria for a minimum number of symptoms. Symptoms can include:

Migratory arthritis – usually large joints

Carditis – pancarditis affecting the pericardium, epicardium, myocardium and endocardium. Valvulitis is the most common.

Sydenham chorea – neurological disorder – abrupt, nonrhythmic movements, muscular weakness

Erythema marginatum – a rash

Subcutaneous nodules

Arthralgia, fever, prolonged PR interval

Question 29

How is ARF treated?

Answer 29

Abx – Pen G

NSAIDs for arthritis

Supportive management of carditis

Question 30

What is the serious sequelae of ARF? When does this occur?

Answer 30

Rheumatic heart disease. Usually 10-20 years after original illness.

Question 31

T/F: Rheumatic heart disease is the most common cause of acquired valvular heart disease in the world

Answer 31

TRUE

Question 32

How can we prevent acute rheumatic fever?

Answer 32

Prompt recognition and treatment of GAS pharyngitis

Question 33

How can we prevent rheumatic heart disease in someone who has had acute rheumatic fever?

Answer 33

Subsequent exposures to GAS infections can trigger ARF and lead to development/progression of RHD. Chronic antimicrobial prophylaxis is recommended – typically long acting pen G q28days

Question 34

d

Answer 34

d