Lecture 5: Cardiology Flashcards
1
Q
chest pain
A
- frequent pediatric complaint
- most pediatric chest pain is musculoskeletal in origin
- older children are more likely to have psychogenic reasons
- younger children are more likely to have a cause related to respiratory disease
2
Q
chest pain etiologies
A
- etiologies
- musculoskeletal (>20% prevalence)
- idiopathic (>20% prevalence)
- psychogenic/psychiatric (<30% prevalence)
- respiratory disorders (<10% prevalence)
- gastrointestinal (<8% prevalence)
- cardiac (<6% prevalence)
- breast (<5% prevalence)
- pulmonary vascular disorders
- toxic exposure
3
Q
approach to chest pain
A
- distinguish acute vs. chronic
- distinguish pleuritic from non-pleuritic
- identify co-morbid risk factors
- herald signs of serious causes (red flags)
- chest pain with exertion
- exertional syncope
- acute pain that is acutely worsening
- acute onset of fever with chest pain
- findings on history or exam referable to cardiac or respiratory systems
- rule out severe distress
- chest tenderness is very reassuring against a cardiac source
- initial workup typically starts with EKG and chest plain film
4
Q
musculoskeletal source of chest pain
A
- chest tenderness with or without movement
- overuse injury or strain of chest wall muscle
- direct trauma
- rib fracture
- contusion of chest wall
- precordial catch (Texidor’s twinge)
- sharp pain at the left sternal border, lasts less than 3 minutes, associated bubble or popping sensation
- costochondritis
- pain at sites of costal cartilage reproduced by eliciting tenderness over the costochondral junctions or with AP compression of the chest
5
Q
respiratory source of chest pain
A
- illnesses with persistent or forceful cough
- pneumonia +/- pleural effusion
- asthma +/- pneumomediastinum
- spontaneous pneumothorax
- asthma
- cystic fibrosis
- Marfan’s syndrome
- pleurisy
6
Q
pulmonary vascular disorder source of chest pain
A
- pulmonary embolism
- rare in children but can occur in those with risk factors
- oral contraceptives
- termination of pregnancy
- trauma, particularly of lower extremities
- classic presentation
- acute onset of pleuritic chest pain, dyspnea, hypoxia
- presentation is not always classic
- rare in children but can occur in those with risk factors
- pulmonary hypertension
- pain typically related to underlying heart or lung disease
- acute chest syndrome
- chest source crisis in patients with sickle cell disease
7
Q
psychogenic source of chest pain
A
- anxiety disorder or conversion disorder
- relative or friend with cardiac disease
- family history of depression, somatization
- triggered by stress
- hyperventilation
8
Q
GI source chest pain
A
- reflux esophagitis
- burning, substernal pain
- worse with reclining or certain foods
- may be associated with esophageal spasm (mimicks angina)
- severe cases complicated by esophageal candidiasis
- burning, substernal pain
- intrathoracic foreign body
9
Q
mammary source chest pain
A
- females
- mastitis
- pregnancy
- fibrocystic disease
- males
- gynecomastia
10
Q
cardiac source chest pain
A
- Rare cause of chest pain in children
- Co-morbid risk factors raise likelihood of cardiac-source chest pain
- diabetes mellitus
- Kawasaki’s disease
- stimulant use
- cocaine
- amphetamines
- cardiac ischemia
- may result from
- anomalous coronary arteries
- left ventricular outflow tract obstruction (LVOTO)
- cardiac infection - endocarditis
- embolic phenomena
- Vasculitis
- pulmonary hypertension
- valvular disease (congenital or acquired)
- cardiomyopathy
- subaortic stenosis
- arrhythmia
- may result from
- myocardial infarction
- rare in children
- herald sign – pain with exertion
- mitral valve prolapse
- pericarditis and myocarditis may cause chest pain without ischemia
- hypertrophic obstructive cardiomyopathy (HOCM)
- autosomal dominant inheritance
- systolic murmur worsening with change from lying to standing or with squat to standing or Valsalva
- procedures that reduce blood return to ventricles (reduce preload).
- pain with exertion
11
Q
cardiac infections: pericarditis
A
- inflammation of the pericardium
- fever
- respiratory distress
- sharp, stabbing substernal chest pain
- often unable to lie flat
- pain improves with sitting up or leaning forward
- friction rub, distant heart sounds
- jugular venous distension
- pulsus paradoxus
- Abnormal EKG – Diffuse ST elevations
12
Q
cardiac infections: myocarditis
A
- inflammation of the heart muscle
- pain develops over a few days
- fever
- systemic symptoms consistent with CHF
- vomiting, lightheadedness, etc.
- gallop rhythm (S3, S4 sounds)
- Tachycardia, hepatomegaly
- orthostatic hypotension
- CXR - cardiomegaly
- abnormal EKG, elevated CK and troponins
13
Q
pediatric arrhythmias
A
- sinus arrhythmia can be very pronounced in children
- HR slows with expiration
- most common pediatric dysrhythmia is supraventricular tachycardia
- mechanisms include
- intra-atrial reentry
- AV nodal reentrant tachycardia
- AV accessory conduction
- Wolff-Parkinson-White syndrome
- slurred upstroke of the QRS (delta wave) à
- Babies normal heartrates when they’re born are 130-160, a 2-3yo is around 100 etc. so tachycardia for younger ones is different than tachy in an adult
14
Q
approach to chest pain
A
- distinguish acute vs. chronic
- distinguish pleuritic from non-pleuritic
- identify co-morbid risk factors
- herald signs of serious causes (red flags)
- chest pain with exertion
- acute pain that is acutely worsening
- acute onset of fever with chest pain
- findings on history or exam referable to cardiac or respiratory systems
- rule out severe distress
- chest tenderness is very reassuring against a cardiac source
- initial workup typically starts with EKG and chest plain film
15
Q
describing a murmur
A
- intensity (grade I-VI)
- quality
- timing
- relationship to cardiac cycle
- Duration
- “shape”
- location
- variation with position
