Outpatient Flashcards
2/6 low pitched vibratory murmur heard best when Supine
Still’s murmur
Definition of pulsus paradoxus
Decrease in SBP by > 10 mmHg with inspiration (normal is 4-6 due to increased capacity of pulmonary venous bed with decreased intrasthoracic pressure but with tamponade this decreases the LV diastolic volume and decreases pulmonary venous return)
S2 heart sound in patient with aortic stenosis
- Mild to moderate AS have normal physiologic splitting of S2
- Severe AS has a single S2 due to prolongation of LV ejection time and in severe cases there may be paradoxical splitting of S2
What happens to aortic stenosis murmur after PVC and why
- It increases due to increased gradient with increased diastolic filling after the compensatory pause
Click heard early or mid systole with patient in standing position but moves later in systole with squatting or supine
Mitral valve prolapse
What makes up Beck’s triad
Hypotension
Distant heart sounds
JVD
- TAMPONADE
CXR findings for coarctation
- Figure 3 sign
- Rib notching
Why is right arm pressure higher than left arm in supravalvar AS
Choanda effect - systolic jet propagates further than the aortic valvar stenosis and transmits its energy into the right innominate artery
Definition of “normal” BP by percentile
- 50th percentile
- Elevated is > 90th
- Stage 1 HTN > 95th
- Stage 2 HTN > 95th plus 12 mmHg
Age to start screening BP for healthy child
3
Management/workup for elevated BP
- Lifestyle changes x 6 months
- More workup if still elevated - coarc screen w/ BPs and then consider ambulatory BP monitor
Most common causes of pediatric HTN
- Primary
- CKD
- Cardiac/vascular
- Endocrine (rare)
- Environmental (lead)
- Stimulants
- Neurofibromatosis type 1
What is DASH diet
- High in fruits/veggies
- Low fat dairy
- Limit sugar and sodium
First line pharmacotherapy for HTN
- ACE/ARB (especially if proteinuria)
- Long acting CCB
- Thiazide (but this is often considered 2nd line)
How much to lower BP in acute severe HTN
- By 25% in first 8 hours
- Then do the rest over 12-24 hours to a goal of 95th percentile
Hyperlipidemia screening ages
- Age 2-8 only if high risk (family hx early CV disease or parent with dyslipidemia)
- Age 9-11: universal screening
- Age 17-21: universal screening
Can screen with non-fasting labs
Familial hypercholesterolemia defects
LDL receptot defect
Can be heterozygous or homozygous
Cut offs for LDL treatment
- > 130 do lifestyle x 6 months - rule out thyroid/diabetes
- > 160 with family history (and more than age 10)
- > 190 (if 10 or older)
Diet recommendations for elevated LDL, TG and low HDL
- High LDL - low saturated and trans fat
- High TG - low carbs and sugar
- Low HDL - Increase exercise and healthy fats
Side effects of statins
Rhabdo, renal failure, LFTs, muscle aches
No in pregnancy, liver failure, with cyclosporine or gemfibrozil
Mechanism of action for statins
HMG CoA reductase inhibitors
Inhibit cholesterol synthesis and increase LDL receptors to increase LDL reuptake
Drug to use for high triglycerides
Fibrates if TG > 500 due to risk for recurrent pancreatitis
At what age to start statin therapy if there are risk factors
Not until age 8
Lifestyle modification prior to that
Pre procedure anticoagulation management for mechanical valves
Check INR 72 hrs before and if normal stop warfarin 48 hours before for mechanical aortic
Mitral and right sided valves need heparin bridge
What happens to mitral valve prolapse murmur with squatting
The click moves closer to S2 due to increased preload and delayed prolapse
