Outpatient

Question 1

2/6 low pitched vibratory murmur heard best when Supine

Answer 1

Still’s murmur

Question 2

Definition of pulsus paradoxus

Answer 2

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)

Question 3

S2 heart sound in patient with aortic stenosis

Answer 3

• 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

Question 4

What happens to aortic stenosis murmur after PVC and why

Answer 4

• It increases due to increased gradient with increased diastolic filling after the compensatory pause

Question 5

Click heard early or mid systole with patient in standing position but moves later in systole with squatting or supine

Answer 5

Mitral valve prolapse

Question 6

What makes up Beck’s triad

Answer 6

Hypotension
Distant heart sounds
JVD

• TAMPONADE

Question 7

CXR findings for coarctation

Answer 7

• Figure 3 sign
• Rib notching

Question 8

Why is right arm pressure higher than left arm in supravalvar AS

Answer 8

Choanda effect - systolic jet propagates further than the aortic valvar stenosis and transmits its energy into the right innominate artery

Question 9

Definition of “normal” BP by percentile

Answer 9

• 50th percentile
• Elevated is > 90th
• Stage 1 HTN > 95th
• Stage 2 HTN > 95th plus 12 mmHg

Question 10

Age to start screening BP for healthy child

Answer 10

3

Question 11

Management/workup for elevated BP

Answer 11

• Lifestyle changes x 6 months
• More workup if still elevated - coarc screen w/ BPs and then consider ambulatory BP monitor

Question 12

Most common causes of pediatric HTN

Answer 12

• Primary
• CKD
• Cardiac/vascular
• Endocrine (rare)
• Environmental (lead)
• Stimulants
• Neurofibromatosis type 1

Question 13

What is DASH diet

Answer 13

• High in fruits/veggies
• Low fat dairy
• Limit sugar and sodium

Question 14

First line pharmacotherapy for HTN

Answer 14

• ACE/ARB (especially if proteinuria)
• Long acting CCB
• Thiazide (but this is often considered 2nd line)

Question 15

How much to lower BP in acute severe HTN

Answer 15

• By 25% in first 8 hours
• Then do the rest over 12-24 hours to a goal of 95th percentile

Question 16

Hyperlipidemia screening ages

Answer 16

• 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

Question 17

Familial hypercholesterolemia defects

Answer 17

LDL receptot defect
Can be heterozygous or homozygous

Question 18

Cut offs for LDL treatment

Answer 18

• > 130 do lifestyle x 6 months - rule out thyroid/diabetes
• > 160 with family history (and more than age 10)
• > 190 (if 10 or older)

Question 19

Diet recommendations for elevated LDL, TG and low HDL

Answer 19

• High LDL - low saturated and trans fat
• High TG - low carbs and sugar
• Low HDL - Increase exercise and healthy fats

Question 20

Side effects of statins

Answer 20

Rhabdo, renal failure, LFTs, muscle aches

No in pregnancy, liver failure, with cyclosporine or gemfibrozil

Question 20

Mechanism of action for statins

Answer 20

HMG CoA reductase inhibitors
Inhibit cholesterol synthesis and increase LDL receptors to increase LDL reuptake

Question 21

Drug to use for high triglycerides

Answer 21

Fibrates if TG > 500 due to risk for recurrent pancreatitis

Question 22

At what age to start statin therapy if there are risk factors

Answer 22

Not until age 8
Lifestyle modification prior to that

Question 23

Pre procedure anticoagulation management for mechanical valves

Answer 23

Check INR 72 hrs before and if normal stop warfarin 48 hours before for mechanical aortic
Mitral and right sided valves need heparin bridge

Question 24

What happens to mitral valve prolapse murmur with squatting

Answer 24

The click moves closer to S2 due to increased preload and delayed prolapse