Pediatric Cardiology Flashcards
Objectives
- Review
- Important physical exam findings for the pediatric patient with a cardiac condition
- Clinical presentation of these patients
- Different differential diagnoses
- Differentiate transitional nursery murmurs vs. pathological murmurs
- Differentiate acyanotic lesions and associated clinical presentation
- Understand the clinical presentation of heart failure in pediatric patients
- Understand the chest pain and Kawasaki Disease
- Learn how to perform a pre-participation sports physical
Transitional nursery murmurs: natural flip from pediatric to normal circulation that happens in babies
Normal Heart
Murmurs overview
Murmur sound is caused by?
Caused by disease/malformation of cardiac valves and structures 4 main causes (4)
turbulent blood flow
- Valvular Stenosis
- Valvular Insufficiency
- Congenital anomaly
- Increased blood flow
Valvular Stenosis
- Blood flow is forced through ____ area
- Turbulent blood flow ensues
- Increased stenosis = ______ murmur BUT
- Development of heart failure may _____ pressure and turbulent flow; murmur may decrease or dissappear
- tight
- louder
- decrease
Valvular Insufficiency
- Abnormal ____flow of blood via ineffective/defective valve
- Turbulence occurs when it meets normal, ____ blood flow causing murmur
Congenital Anomaly
- Atrial or Ventricular _____ defects
- Blood forced through congenital anomaly from one ____ to another = turbulence = murmur
- Backflow (valves aren’t closing properly and causes backflow)
- forward
- Septal defects (ASD, VSD)
- chamber
Increased Blood Flow
- Increased blood flow through a normal valve happens often in high output states: an____, s_____
- Large v_____ passes through the cardiac valve, and the normal blood flow is disrupted
- ____’s murmur is a benign aortic flow murmur frequently heard in childhood that frequently dissappears over time
- anemia, sepsis
- volume
-
Still’s
- example of a flow murmur - literally from too much blood flow
Timing and Grading of Murmurs
Reference Slide
- Systolic Murmurs
- Midsystolic (4)
- Holosystolic (2)
- Late systolic (1)
- Diastolic Murmurs
- Early diastolic (3)
- Mid late diastolic (2)
- Other rare murmurs (1)
- Grading generally the higher the grade =
- Aortic stenosis, Pulmonic stenosis, ASD, HOCM
- Mitral regurg, Tricuspid regurg, VSD
- Mitral valve prolapse
- Aortic regurg, Pulmonic regurg, Austin-flint
- Mitral stenosis, Tricuspid stenosis
- Patent ductus arteriosus
- Higher the grade, the louder the murmur
Where Murmurs are Heard
Reference Slide
- Aortic area
- Pulmonic area
- Left Sternol border
- Tricuspid area
- Mitral area
- Ejection type murmur (Aortic stenosis, flow murmur)
- Ejection type murmur (Pulmonic stenosis, flow murmur)
- Early diastolic murmur (Aortic regurgitation, Pulmonic regurgitation)
- Pansytolic murmur (Tricuspid regurgitation, Ventricular septal defect), Mid to late Diastolic murmur (Tricuspid stenosis, Atrial septal defect
- Pansystolic murmur (Mitral regurg), Mid-to late diastolic murmur (Mitral stenosis)
Ex) in mitral area usually a mitral valve issue
Causes of Systolic Murmur
- Turbulence caused by ventricular _____
- ______ of aortic or pulmonary valve, aorta or pulmonary artery
- Increased _____
- Ticuspid and mitral valve _______
- Abnormal ventricular or arterial comm_____
- Ventricular ____ defect or _ _ _
- outflow
- Narrowing
- flow
- regurgitation
- Communications
- VSD, PDA
Causes of Diastolic Murmur
- Turbulence in ventricular ______
- N______
- Increased ____
- Semilunar (____ and _____) valve regurgitation
- inflow
- Narrowing
- flow
- aortic and pulmonary
Causes of Continuous Murmurs
- Abnormal systemic _____ artery communications
- Abnormal ar___v____ communications
- P _ _
- (1): abnormal connection of arterial blood flow direct to vein
- (1): abnormal connection of a coronary artery and heart chamber or blood vessel
- pulmonary artery communications
- arteriovenous communications
- PDA
- AV fistula
- Coronary artery fistula
Continuous murmurs kind of rare dt abnormal communication for ex when blood mixes ex) when PDA doesn’t close, fistulas
Common Murmurs in the First Few Days of Life
-
Normal
-
(1)
- Narrowing of pulm arteries in newborns develops in utero = less blood flow to ____
- Post partum arteries are narrow until they grow and relax
- While slightly narrow before growth may hear a _____
- Resolves sp______
- (1)
-
(1)
-
Transitional
-
(1)
- Ductus arteriosus is a normal part of fetal blood circulation in _____
- is an ____ blood vessel that connects the pulmonary artery to the ____
- In utero the ductus arteriosus lets blood ____ the lungs bc oxygen is from the mother
- (1)
-
(1)
-
Abnormal
- O_____ obstruction
- Aortic and Pulmonic _____
- C_____ of aorta
- Abnormal comm_____
- V _ _ , _ _ _ (if open for too long)
-
Normal
-
Peripheral Pulmonary Stenosis
- lungs
- murmur
- spontaneously
- Pulmonary flow murmur
-
Peripheral Pulmonary Stenosis
-
Transitional murmurs
-
Closing PDA
- utero
- extra blood vessel, pulm art to aorta
- bypass the lungs
- Transient tricuspid regurgitation
-
Closing PDA
-
Abnormal
- Outflow
- Stenosis
- Coarctation
- communications
- VSD, PDA
Pulm stenosis most often benign but CAN be pathological, on this slide its benign bc baby in utero gets blood from placenta, so pulm arteries are narrow when baby is first born and will resolve when pressure from blood normalizes
Transitional Nursery Murmurs
- ____ left sternal border or left infra_____ area
- Systolic or continuous
- often louder as PDA gets ____
- Occasional v_____
- Typically 12-48 hrs of age then goes ____
- Transient ______ Regurgitation
- ____ left sternal border
- regurgitant, systolic
- takes several days to resolve
- Upper LSB, infraclavicular
- smaller
- vibratory
- away
- Transient Tricuspid Regurgitation
- Lower LSB
Acyanotic Congenital Heart Disease
No cyanosis, no drop in O2, no blue lips
(2)
(2), (3)
Septal Defect
ASD, VSD
Obstruction to Ventricular Outflow
Valvar, Subvalvular or Supravalvar aortic or pulmonic stenosis
Coarctation (narrowing of aorta)
PDA
Atrial Septal Defect (ASD)
- Systolic ejection murmur
- Upper left sternal border
- Wide fixed split S2
- Right ventricular impulse (p_____ palpation)
- Diastolic r_____ at lower left sternal border
- do we see CHF?
- Subtle _____ intolerance may be noted
- palpable palpation
- rumble
- no
- exercise intolerance dt less oxygenated blood getting to body
Blood is mixing, but left side can still pump out blood
ASD Workup and Treatment
Workup =
Treatment
- Spontaneous ____ before 2 years of age possible, ____ based on clinical condition
- Cardiac c______ placement of closure device
- ____ heart surgery if Large ASD and/or complext heart anatomy, surgeons use stitches or ______ to close the hole
- Refer to Cardiology
- Echocardiogram (sound waves create an image of the heart)
- EKG
- Chest X-ray
- closure, watchful waiting
- catheterization
- Open heart, patches
Watchful waiting, usually asymptomatic as long as child is growing, eating, drinking
Ventricular Septal Defect
- Holosystolic murmur
- H____, ___ pitched if VSD is small
- Diastolic rumble at Apex for larger VSD
- Will you see CHF?
- Increased left arterial pressure
- Pulmonary _____
- Increased ____ of breathing
- ____ growth
- Can lead to pulmonary ____ if not found
- Harsh, high pitched
- CHF if VSD is large
- Edema
- work of breathing
- poor growth
- pulm HTN
- Pulm artery should have deoxygenated blood but its getting mixed w oxygenated blood*
- CHF if large bc blood isn’t getting pushed out*
- Pulm edema- to the point kids can’t eat while breathing -> poor growth*
VSD
- At birth
- Pulmonary Vascular Resistance __ Systemic Vascular Resistance bc
- Shunt is ___ to ____ or bidirectional
- As PVR falls, then ___ to ___ shunt and murmur appears
- Murmur pitch depends on whether right to left or left to right
- Diastolic rumble at Apex
- Caused by vibration of the ____ valve
- Large volume of flow from the lungs goes into the left ventricle
- much more likely to be moderate in intensity
At birth
- PVR > Systemic vascular resistance
- Right to left
PVR falls, then left to rigth shunt and murmur appears
Diastolic rumble at Apex
- vibration of mitral valve
VSD Workup and Treatment
Diagnosis of VSD may require?
Treatment for VSD prn to prevent permanent cardiac damage
- Dependent on
- Child’s ____
- S___ of the VSD
- Watchful _____ to see if VSD will close on its own
- Many small VSDs will do so before child is __ yrs old
- Surgical repair may be postponed if possible to allow for ____ and _____
- Higher _____ feedings to help with sx and growth
- Echo, EKG, chest X-ray, Cardiac cath (could potentially repair via cath), cardiac MRI
- Tx
- health
- Size
- waiting
- 2
- growth and development (better outcome for surgery)
- HIGHER CALORIC FEEDINGS
Coarctation of Aorta
- narrowing of aortic arch adjacent to the site of ductus
- _____ ejection murmur below left _____
- Decreases pulse and BP in lower extremities
- If severe, causes _______ dt no output
- Often associated with _____ aortic valve (should be tricuspid)
- Systolic, left scapula
- SHOCK
- Bicuspid aortic valve
Aortic Valve Stenosis
- Occurs in 5% of children with CHD
- May have _____ defect such as coarctation, VSD, or PDA
- Non obstructive isolated bicuspid aortic valve is the most common congenital defect and even then occurs in 1% of the population (pretty much is very rare)
- May be valvular, subvalvar or supravalvar
- Valvar AS usually cases a systolic ejection _____ at the apex (click is not present in most severe cases)
- Most common presentation is just a murmur BUT
- If very narrow valvular opening, needs the right to left shunting available through the ____
- May present acutely with ____ or CHF if ductus closes
- Can progress over months
- Systolic ejection murmur begins in early systole after the click
- Click helps distinguish it from a pulmonary flow murmur
- medium to high pitched
- upper right sternal border to apex
- radiates to neck
- May have a _____ in suprasternal notch or ____ arteries area
- associated
-
CLICK
- PDA
- shock
- thrill, carotid
Pulmonic Stenosis
- Systolic ejection murmur
- _____ left sternal border
- Radiates to ____
- Systolic ejection ____ at LLSB which varies with r_____
- May have thrill at suprasternal notch
- Upper left sternal border
- back
- click, respiration
Patent Ductus Arteriosus (PDA)
- Blood from (1) into (1), ____ the lungs
- Normally closes by __hrs after birth
- Shunt direction depends upon the differential resistance between aorta and pulmonary artery
- Right to left ductal shunting occurs with severe left heart obstructive lesions
- Severe co______
- _____ (underdeveloped) left heart
- Normally ____ to ____ shunting
- right ventricle into descending aorta, bypasses
- 48
- coarctation
- hypoplastic
- left to right
PDA Presentation
- Infants and children tend to be completely _____
- ___maturity
- May have pulmonary _____ (blood to lungs)
- Will present early
- If going to have pulmonary overcirculation, does so when pulmonary resistance ___ at 4-6 wks
- Single S2 = pulmonary _____
- ____ pulse pressure
- _____ pulses (waterhammer pulse) - bounding and forceful pulse, rapidly increasing and subsequently collapsing
- Quinke pulse on finger tips =
- asymptomatic
- prematurity
- overcirculation
- falls
- hypertension
- wide
- Bounding
- visualization of capillary pulsations with light compression to the tip of the fingernail bed
Complex Congenital Heart Disease Diagnoses
(5)
Big bad conditions - will usually cause cyanosis
Common AV canal (truncus)
Tetralogy of Fallot
Hypoplastic left heart
Transposition of the Great Arteries
Ebstein’s Anomaly of the Tricuspid Valve
Common AV Canal (truncus)
=
- Abnormal valves
- _____ of blood: backflow to _____
- Increased work = _______ of heart
- Symptoms (4)
- Work up (6)
- Treatment =
Large central septal hole where atria and ventricles meet
- Mixing, lungs
- enlargement
- Symptoms
- Cyanosis
- difficulty breathing
- poor weight gain and growth
- heart murmur
- Work up
- Echo, EKG, cardiac MRI, cardiac cath, pulse ox, CXR
- Tx
- 1-2 mths of life
- Repair hole
Tetralogy of Fallot
4 Defining Characteristics
VSD
Overriding aorta
Pulmonary stenosis
Hypertrophy of R ventricle
Tetralogy of Fallot
Symptoms (3)
Workup?
Treatment?
- Cyanosis
- Heart murmur
- Clubbing
ECHO, EKG, Pulse ox monitoring, Cardiac MRI, Cardiac Cath
Temporary repair then Full patch and opening
Hypoplastic Left Heart
(3)
Mitral valve is atretic
Aortic valve is atretic
Left ventricle is very small
Hypoplastic Left Heart
Symptoms (4)
Workup
Treatment
- Cyanosis
- Difficulty breathing
- Difficulty feeding
- Lethargy (sleepy or unresponsive)
ECHO, EKG, pulse ox monitoring, cardiac MRI, cardiac cath
Fatal if untreated, requires open heart surgery to re-direct the oxygen rich blood, post op right side of heart will do what is usually the job of the left side (will flip the heart, bc less effort/work for the deoxygenated side)
EMERGENCY- baby fine at first then all of a sudden will be lethargic
Transposition of the Great Arteries
=
Symptoms (3)
Aorta is attached to R ventricle
Pulmonary artery is attached to L ventricle
Cyanosis
Tachypnea
Difficulty feeding, poor appetite, poor weight gain
Transposition of the Great Arteries
Workup
Treatment
ECHO, EKG, Pulse Ox monitoring, Cardiac MRI, Cardiac Cath
- 1/3 of newborns with TGA have extreme hypoxia at birth
- Requires urgent intervetion = balloon atrial septostomy (BAS)
- BAS creates or enlarges a hole between to allow blood to mix (temp fix just to oxygenate)
TGA Surgery: Arterial Switch Operation
- Happens in _____ of birth
- Reconstruct the heart
- Attach the aorta to the (1)
- Attach the pulmonary artery to the (1)
- days
- L ventricle
- R ventricle
Later need 3 surgeries
Ebstein’s Anomaly of Tricuspid Valve
Description
- Caused by malformation of a _____ in utero
- 1-3 ______ missing/malformed
- R atrium may be _____ and R ventricle ____
- Blood “leaks” back into (1) bc valve doesn’t _____ completely
- Severe cases may cause?
- Some may have ASD
- Some may have _ _ _ and associate arrhythmias
- Valve
- leaflets
- enlarged, small
- R atrium, close
- heart failure
- WPW
Malformation of tricuspid valve - usually 3 leaflets hence tricuspid but could not have all three leaflets -> backflow bc valve doesn’t close properly
may have wolfe-parkinson’s syndrome
Ebstein’s Anomaly of Tricuspid Valve
Workup
Treatment
- If mild =
- Severe =
- WPW =
ECHO, EKG, Exercise Chest, Chest-X ray, Cardiac Cath less common
- none
- surgery to repair valve
- ablation
Acute CHF in Children
- End organ hypoperfusion causes symptoms
- Decreased blood flow to _____
- Renin/angiotensin based salt and water _____ and increased circulating v_____
- Results in _____
- Decreased perfusion to _____ -> pallor and mottling, diaphoresis during feeding, due to catecholamine release
- Increased systemic vascular resistance -> increased myocardial ____ causing _____ or dilation
- Hypoperfusion
- kidney
- retention, volume
- edema
- skin
- demand -> hypertrophy
Causes of CHF in Children
Contractility Reduction
Primary Cardiomyopathy (3)
Secondary Cardiomyopathy (3)
Inflammatory (3)
Traumatic (2)
- Types: dilated, hypertrophic, restrictive
- Myocarditis, MI, Arrhythmogenic (complete heart block w bradycardia, SVT, or VT)
- Kawasaki disease, Systemic Lupus, MIS-C with COVID (multisystem inflammatory syndrome)
- Cardiac Tamponade, Myocardial contusion
Hypertrophic Cardiomyopathy
- May have bi_____ outflow tract ______ in infancy
- Older children are ________
- May have murmur
- _____may be diminished as ventricular ejection is impeded
- How to listen to the murmur?
- MURMUR WILL greatly ______ IN INTENSITY as child stands
- biventricular, obstruction
- Asymptomatic
- Pulse
- squatting then stand
- INCREASE
Hypertrophic Cardiomyopathy
Maneuvers that increase the intensity and duration of the murmur
- ______ preload - Strain of Valsalva
- _____ contractility - Exercise
- _____ afterload - stand suddenly
Maneuvers that will decrease the intensity and duration of the murmur
- ______ afterload - squat or hand grasp
- _____ preload - raise legs
- Decrease
- Increase
- Decrease
- Increase
- Increase
CHF History Findings
Infant, Child, or Adolescent?
- Decreased exercise capacity, fatigability, SOB, weight gain or loss
- Poor weight gain, Cachexia, Malnutrition, Sweating when feeding
- Fatigue, cold intolerance, exercise intolerance, syncope, dizziness
- Child
- Infant
- Adolescent
Syncope and dizziness are red flags
Weight gain or loss (gain may be cuz activity intolerance)
CHF PE Findings
- First sign + _______
- Infant heart is ____ and less distensible so they increase rate as they cannot stroke volume
- Tachy____
- Hepato____
- Ed____
- As_____
- Diminished per_____
- Pedal edema and neck vein distention are ____
- Listen for g______
- Tachycardia
- stiffer
- Tachypnea
- Hepatomegaly
- Edema
- Ascites
- perfusion
- rare
- gallop
Chest Pain in Children
Some Differential Dx include
(6)
Musculoskeletal Pain
Respiratory Conditions
Psychogenic Disturbances
Gastrointestinal Disorders
Cardiac Disease
Idiopathic = 20-45% in some studies
in order of prevalence bc most of the time is MSK then resp conditions
Chest Pain - Common MSK Causes
(3)
Strain of chest wall muscles
New exercise, new activity, wrestling, heavy books, backpacks
Chest wall trauma
Bruise, fracture
Costochondritis
tenderness on palpation, worse with breathing, persistent
Chest Pain: Respiratory Causes
(4)
Overuse of chest wall musculature from
Persistent cough, asthma, PNA, new exercise
Spontaneous pneumothorax
Pulmonary emoblism
Pleuritic pain/cough/back pain, hemoptysis, more common w h/o leg trauma
Infection
Fever and Dyspnea (PNA, bronchitis, COVID)
Chest Pain - Psychogenic Origin
- _____ common in males and females*
- ______ may not be readily apparent
- _____ history of anxiety, ______
- S_____ history
- Family member/friend with chest pain as presenting sx of cardiac disease
- Equally
- Anxiety
- Family, depression
- Social
Chest Pain - GI Origin
- R_____/Es______
- ______ body
- Hiatal ______
- Sub-diaphragmatic ab______
- Reflux, Esophagitis
- Foreign body
- hernia
- abscess
Chest Pain - Cardiac Origin
- Previously undiagnosed cardiac disease is ______
- Myocardial ischemia = ______ anomalies
- K_______ Disease
- ______ and other drug abuse
- Arr______
- Hypertrophic _______
- ______ Syndrome
- Peri______
- rare
- coronary
- Kawasaki
- Cocaine
- Arrhythmia
- cardiomyopathy
- Marfan
- Pericarditis
Chest Pain: Myocardial Ischemia
- _____ in children
- Suspect if known history of coronary disease (2)
- ______ of coronary arteries
- P______ sensation + b______
- ______ to neck, shoulder or arm
- Occurs during or following ______**
- Improves with _____
- Rare
- Kawasaki, Transposition of Great arteries
- Anomalies
- Pressure, burning
- Radiation
- exercise
- rest
Chest Pain - Aortic Dissection
- Pain is typically acute and sharp
- Present where? (2)
- Depends on the area of the aorta affected
- Medical and surgical ______!
- Suspect in patients with what diagnosis?
- Autosomal ____
- Disorder of f_____
- Chromosome ___, _____ gene
- May also occur in (1) syndrome (connective tissue dx)
- anterior chest or back
- EMERGENCY! (bc basically bleed out in themselves)
- Marfan Syndrome or Marfan body habitus
- dominant
- fibrillin
- 15, FBN1 gene
- Ehlers-Danlos Syndrome
Chest Pain - Pericarditis
- May cause severe sub_____ chest pain
- Described as s_____ or t_____
- Respiratory _____, C _ _
- Precordial “____” or ____ (like the sound of shoes walking on snow)
- Classic signs include
- exercise _____, fatigue
- ______ distension
- lower extremity _____
- hepato____
- poor distal _____
- ______ heart tones
- pulsus _____
- Pain worsens with movement, including _______
- Patients prefer to lean _____, may refuse to lie down
- Pain is ______ by sternal pressure
- Consider in post - ___ cardiac pts
- Pericardial Effusion
- Usually a friction rub if small or no effusion
- if large effusion, no rub but distant/m____ heart sounds
- t_______
- substernal
- squeezing, tightening
- distress, CHF
- “knock”, rub
- intolerance
- jugular
- edema
- hepatomegaly
- pulses
- diminished
- paradoxus
- breathing
- forward
- reproducible
- post-op
- muffled
- tamponade
Chest Pain Work-Up
- _____ if MSK
- ____ if cardiac concern
- Exercise, palpitation
- ____ if respiratory suspected
- fever, cough, dyspnea
- _____ is generally not indicated unless
- rub
- family hx of hypertrophic cardiomyopathy
- congenital heart disease
- None
- EKG
- Chest radiograph
- Echocardiogram
If needs echo probably will refer to cardiologist
Chest Pain - When to Refer
- Chest pain with or after _____
- Chest pain with or near _____
- Chest pain in pt with _____ cardiac _____ or hx of cardiac ______
- A_____, S_____ onset
- ______ Syndrome
- exercise
- syncope
- previous cardiac disease or hx of cardiac surgery
- Acute, sudden
- Marfan
Marfan Syndrome Criteria (FYIs)
Congenital ______ Tissue Disorder
Ghent diagnostic criteria for marfan syndrome was revised and includes any of the following
Connective
Marfan Syndrome Systemic Criteria (FYIs)
Marfan Syndrome Craniofacial Features
- Criteria for Marfan Syndrome = ___ of following Craniofacial features
- Dolichocephaly
- Downward-slanting palpebral fissures
- Enopthalmos, retrognathia, and malar hypoplasia
- Skin straie
- Myopia
- Mitral valve prolapse
3
Pre-Participation Sports Physica and Cardiac Problems
Cardiac Causes of Sudden Death
- Vary with Age: Younger than ___ years
- ________
- Hypertrophic cardiomyopathy
- Coronary anomalies
- Aortic stenosis
- Arrhythmia (WPW, long QT syndrome, etc
- _______
- Myocarditis
- Dilated Cardiomyopathy
- Coronary Artery Disease
- _______
- Commotio cordis (cardiac concussion)
- 35
- Congenital
- Acquired
- Trauma
FAM HISTORY*
Non-Cardiac: Causes of Sudden Death
- Cerebral ______
- _____ Cell Disease
- Bronchial ______
- ___ use (cocaine, amphetamines)
- Unknown
- Aneurysm
- Sickle
- Asthma
- Drug
- Unknown
AHA Recommendations for Sports Physical
Targeted History and Physical Exam
- Identify (or raise suspicion of) ______ lesions known to cause sudden death in young athletes in all high school and college aged participants prior to training
- Repeat full _____ every 2 years
- Interval History and _ _ yearly
- cardiovascular
- history every 2 yrs
- BP yearly
AHA 14 Point Pre-participation Recommendations
- Chest ____ or pressure related to exertion
- Unexplained s_____ or presyncope
- Dy_____, fa______, or pal_____ related to exercise
- History of a heart _____
- Elevated _ _
- Previous _____ from sports
- Previous cardiac ______
- Family history of premature d_____
- Family history of dis_____ from heart disease
- Family hx of hypertrophic or dilated ______, long __ syndrome, or other iron ch_____opathies, M_____ syndrome, significant arr_____, or specific gen____ cardiac conditions
- Heart _____ on examination
- Feel the _____ pulses for aortic coarctation
- Physical examination findings consistent with M_____ syndrome
- _____ artery blood pressure (both arms)
- pain
- syncope
- Dyspnea, fatigue, palpitations
- murmur
- BP
- restrictions
- testing
- deaeth
- disability
- cardiomyopathy, QT, channelopathies, Marfan, arrhythmia, genetic
- murmur
- femoral
- Marfan
- Brachial
Expectations of Screening
- Even the Best H and P won’t detect everything!
- Should Detect:
- (1) - systolic ejection murmur
- (1) - physical stigmata
- May Not Detect:
- Hy_____ ______
- ______ Artery ______
- Others
- Aortic Stenosis
- Marfan’s
- Hypertrophic Cardiomyopathy
- Coronary Artery Anomalies
The Athlete With Symptoms
- Symptoms During Exercise Should be Evaluated Thoroughly
- Chest pain or _____
- Palpitation or _____ Heart Beat
- Syncope is _____ normal during exercise
- Refer to a trained ______
- H/P
- 12 lead ECG
- Exercise ____ test
- Echo
- tightness
- Irregular
- NEVER
- Specialist
- exercise stress test
“ITIS” and Infection
Myocarditis
=
- _____ infection of the myocardium (e.g viral myocarditis)
- ____ production (e.g diphtheria)
- Immune response as a delayed sequela of an infection
- ___viral or postinfectious myocarditis
- Common type of myocarditis is acute _____ fever (ARF)
Inflammatory disease of the myocardium
- Direct
- Toxin
- Delayed sequela
- Postviral
- Acute rheumatic fever
Acute Rheumatic Fever: Jones Criteria Revised 2015
-
(1)
- Clinical and/or subclinical traits
- Seen on echo
- Monoarthritis, polyarthritis and/or polyarthralgia
- Chorea =
- Erythema marginatum
- Subcutaneous nodules
-
(1)
- Prolonged PR interval
- Monoarthralgia
- Temp > 38C
- Peak ESR > 30mm in 1 h and/or CRP > 3.0mg/dL
-
Major Criteria
- Chorea = jerky, involuntary movements
-
Minor Criteria
- has to do with inflammatory markers
Endocarditis
= An infection of the endothelial ____ of the heart, with a propensity for the ____
- Increased risk in children with ____ valves and patches, and patients with ____ lines
- 90% of cases are caused by (1)
- Alpha strep, ____ aureus, pneumococcus, group A B hemolytic streptrococci
- Clinical Features
- F____
- ___cardia, CHG, dys____, cardiogenic ____
- History of recent cardiac ____ or indwelling vascular ____
- Heart ____
- P____, septic em____ dt DIC, splen______
infection of endothelial surface of the heart, propensity for the valves
- artificial valves, patches, central lines
-
Gram positive cocci
- staph
- Clinical features
- Fever
- Tachycardia, dysrhythmia, shock
- surgery, indwelling vascular catheter
- murmur
- Petechiae, septic emboli, splenomegaly
SEPTIC, in shock, hospitalized, super sick
Kawasaki Disease
=
- Medium vessel vasc____
- _____ etiology - toxin mediated?
- Affects infants and children
- Vasculitis = propensity for coronary _____ (develop in 20% if untreated)
- May cause subsequently scar, resulting in coronary artery st_____ (early onset coronary artery disease)
- Coronary artery th_____ and myocardial ______
- Myocarditis, dys______
- Treatment (2)
Mucocutaneous Lymph Node Syndrome
- Vasculitis
- Unclear
- aneurysms
- stenosis
- thrombosis, infarction
- dysrhythmia
- IVIG, Aspirin if plts > 1 million
- Platelets go up -> thrombosis and MI*
- Usually don’t give aspirin to children dt reyes but don’t want them to clot*
Kawasaki Disease
Diagnostic Criteria
- Fever > __ days
- Plus 4/5 of
- Non-purulent c_____
- Oral _____ changes
- Red fissured lips
- _____ tongue
- Phar_____
- Extremity changes ie _____
- Swelling or peeling
- R_____ - often nonspecific, perineal in many
- Cervical adenopathy
- Fever > 5 days
- 4 out of 5
- Conjunctivitis
- mucosal
- Strawberry
- Pharyngitis
- edema
- Rash
- 4 out of 5
Prolonged QT
10% present with s_____
15% of pts with prolonged QTc ___ during their first episode of arrhythmia
30% of deaths occur during the ____ year of life
seizures
die
first
A lot of times we don’t know they have it
Critical Concepts
Consider (1) in all patients presenting with brief nonspecific changes in LOC
Fainting, syncope, seizures, breath-holding, apparent (1) events
-
Take home message
- ____ murmurs go away
- _____ may not pick it up, _____ bad need immediate intervention
- ____ murmurs bad, ___ murmurs less bad
cardiac arrhythmias
life-threatening events
- Flow
- Acyanotic, Cyanotic
- Loud, quiet
