PEDIATRIC DISORDERS Flashcards
Auscultatory area of the aortic valve
Right upper sterna border (RUSB)
Auscultatory area of the pulmonic valve
Left upper sternal border (LUSB), 2nd intercostal space
Auscultatory area of the aortic or mitral valve
Apex (erbs point)
Auscultatory area of a ventricular septal defect or tricuspid valve
left lower sternal border (LLSB)
How does blood flow through the heart?
From the body, through the superior vena cava ->right atrium->tricuspid valve->right ventricle->pulmonic valve->pulmonary artery->lungs->pulmonary veins->left atrium->mitral valve->left ventricle->aortic valve-> body
What does S1 signify
mitral/ tricuspid (AV) valves closure
What does S2 signify
Aortic/ pulmonic (semilunar) valves closure
When is systole heard
Period between S1 and S2
When is diastole heard
Period between S2 and S1
What does S3 sound like and what does it mean
“Ken-tuck-y”, increased fluid states
What does S4 sound like and what does it mean
“Ten-ne-ssee” and means stiff ventricular wall, or normal in athlete
What does Ventricular septal defect sound like?
thrill (think tetralogy of fallout)
What does an obstructive defect sound like?
ejection click due to turbulence, may be referred or radiate
Where is the blood shunting with acyanotic lesions?
left to right to shunting
Where is the blood shunting in cyanotic heart lesions?
Right to left shunting
The 3 types of heart defects
acyanotic, cyanotic, and obstructive
What kind of defect is this?
Transposition of the great arteries
What kind of heart defect is this?
acyanotic defect, ventricular septal defect
What kind of heart defect is this?
acyanotic defect, Patent ductus arteriosis
What kind of heart defect is this?
cyanotic defect, transposition of the great arteries
What kind of heart defect is this?
obstructive lesions, aortic stenosis
What kind of heart defect is this?
obtructive lesion, pulmonic stenosis
What kind of heart defect is this?
obstructuve lesion, Coarctation of the aorta
What kind of heart defect is this?
acyanotic defect, atrial septal defect
What kind of heart defect is this?
cyanotic defect, tetralogy of fallot
Where is an atrial septal defect murmer heard best?
HEard best at the left upper sternal border (LUSB)
What does the ECG show for a Atrial Septal defect?
Right ventricular hypertrophy (RVH)
WHat is the most common heart defect?
Ventricular septal defect (VSD)
What kind of thrill will be felt with a Ventricular septal defect (VSD)
A holosystolic thrill, may be felt at the LLSB
What will the ECG show for a ventricular septal defect?
What will X-ray show?
Left ventricular hypertrophy (LVH) progressing to biventricular hypertrophy if large VSD
xray will show cardiomegaly, increased pulmonary vascular markings
What is a common congential heart defect in premature infants?
patent ductus arteriosis (PDA)
What does the murmer for Patent Ductus arteriosis sound like?
Murmer is in the LUSB
Grade II to IV/VI holosystolic
“machinery” sound
What does the murmer sound like for Transposition of the Great arteries?
What might the xray look like?
Grade II to V/VI systolic ejection murmer
xray might look like “egg on a tring” with cardiomargaly and increased pulmonary vascular markings
What are the 4 defects in tetralogy of fallot?
Four defects:
1) Large VSD
2) Pulmonary stenosis
3) overiding aorta
4) RVH
What does the murmer sound like for tetralogy of fallot?
Loud systolic ejection click at the middle and upper left sternal border (M-LUSB)
What will the ECG show is Tetralogy of fallot?
Right axis deviation and right ventricular hypertrophy
What does the x-ray show for tetralogy of fallot?
boot-shaped heart, no cardiomegaly or pulmonary markings
What are TET SPELLS
hypercynotic episodes.
hypoxia- kids pull up knees or squat when SOB to increase peipheral vascular resistance and slow down blood return to the heart
Where will the murmer be heard best in aortic stenosis?
Systolic thrill at the right upper sternal border (RUSB), systolic ejection click present which does not vary with respirations
What does pulmonic stenosis murmer sound like
Systolic, loudest at the LUSB, grade II to V/VI ejection click, intensity of click decreases with inspiration and inreases with expiration, thrill at the LUSB radiating to the back and sides
Corarctation fo the Aorta murmer
Grade II to II/VI systolic ejection murmer with radiation to the left interscapular area
May have ejection click at the apex and RUSB if the bicuspid valve is involved
xray findings for coarctation of the aorta
cardiomegaly, RIB NOTCHING DUE TO COLLATERAL CIRCULATION
What kind of BP findings and pulse ox findings will you find in coarctation of the aorta
BP in lower extremities will be lower than in upper extremitiesand
What to do if suspected cadriac defect
draw labs (CMP, CBC), CXR then refer
Innocent murmers
AKA functional, benign, or physiologic, not associated with symptoms, failure to thrive, or cyanosis.
Occurs in >50% of children
Are low intensity systolic murmers (grades I-III)
May vary with positional changes (sit>standing)
No radiation to neck/back
Most common inncocent murmer
Stills murmer
Musical systolic murmer
HEard best between LLSB and apex
Due to turbulense in the left ventricular outflow tract
Venous hum
Innocent, Continuous humming murmer
RUSB
Hear best in the sitting position, disappears in the supine position
Also obliterated by turning head and or compressing neck ipsilaterally -same side
Definition for hypertension
A persistent elevation of average systolic/ diastolic BP >95th percentile with measurements obtained on at least 3 separate occassions per published tables for age and sex. In children, is secondary
labs/ diagnostics for HTN
CXR (PA and lateral)
plasma aldosterone level to rule out aldosteronism
morning and evening cortisol level to rule out cushings
UA, BMP, CBC, cholesterol, and triglycerides
ECG for dysrhythmias, BBB or LVH
Rhematic fever/ heart disease definition and cause
A post infectious inflammatory disease that can affect the heart, joints and central nervous system
Rheumatic fever followsa group A strep infection of the upper respiratory tract and is most common in ages 6-15
Jone’s criteria
diagnosis of an initial attack for rheumatic fever plus 2 major or 1 major and 2 minor Jone’s criteria
MAJOR CRITERIA:
Carditis, polyathritis, chorea (involuntary jerky movements) erythema marginatum, subcutaneous nodules
MINOR CRITERIA:
Arthralgia without objective inflammation, fever >102.2F, elevated ESR and CRP, prolonged PR interval on ECG with evidence of a group A Bhemolytic streptococcus infection
Kawasaki disease definition
acute febrile syndrome causing vasculitis
Diagnositic criteria for kawasaki disease
The patient MUST have a fever as well as 4 of the following criteria:
1) Fever for >5 days
2) Bilateral conjunctival injections without exudate
3) Polymorphous rash (urticarial or pruitic)
4) Inflammatory changes of the lips or oral cavity (strawberry tongue)
5) Changes in extremities (eg erythema, edema, ect)
6) cervical lymphadenopathy
Management for Kawasaki disease
Immediate referral to cardiovascular specialist, high dose ASA therapy
Labs/diagnositics for kawasoki disease
CBC, ESR, postivie c reactive protein, ECG changes- prolonged PR or QT interval
Mild dehydration in pediatrics- BP, pulse, CAP refill, SKin turgor, fontanel, urine
Mild is 3%-5%
BP-normal
Pulse-normal
CAP refill- WNL
SKin turgor- normal
Fontanel- NOrmal
Urine- slightly decreased
Moderate dehydration in pediatrics- BP, pulse, CAP refill, skin turgor, fontanel, urine
Moderate (6%-9%)
BP- normal
pulse- increased
CAP refill- WNL
skin turgor- decreased
fontanel- sunken in (slightly)
urine- <1ml/kg/hour
heart valve affected by rheumatic fever
mitral valve
Severe dehydration in pediatrics- BP, pulse, CAP refill, skin turgor, fontanel, urine
Severe(>10%)
BP- normal or decreased
Pulse- Severe, decreased
CAP refill- prolonged(>3 seconds)
Skin turgor- decreased
Fontanel- sunken
Urine- <1m/kg/hr
Heart defect with DiGeourge syndrome syndrome
Aortic arch abnormalities
Heart defects with trisomies
Trisomy 18/ edwards
Trisomy XXI/down syndrome-Atrioventricular septal defects, VSD
Heart defect with marfans syndrome
Aortic regurgitation, mitral valve prolapse (leads to anurysm)
heart defect with Turner syndrome
Coarctation of the aorta, bicuspid aortic valve
When to work up gastroenteritis
None indicated unless symptoms persist more than 72 hours or bloody stool present
Oral rehydration therapy for moderate dehydration
50ml/hr
Oral rehydration for severe dehydration
100ml/hr
When to consider antibiotic therapy for gastroenteritis and what antibiotic
consider when more than 8-10 stools daily.
trimethroprim/ sulfamethoxazole (TMP/SMZ), bactrim
definition of GERD
A condition in which gastric contents pass into the esophagus form the stomach though the lower esophageal sphincter (LES)
The three classes of GERD
Physiological: Infrequent, episodix
Functional: Painless, effortless vomitting with no physical sequelae
Pathological: frequent vomiting with alteration in physical functioning such as FTT and aspiration PNA (worrisome)
When will GERD resolve for premature and low birth weight
typucally by 18months
first and second line tx for pediatric GERD
first line- Histamine H2 receptor anatgonist to inhibit gastric scid secretion caused by histamine (ranitidine, famotidine)
Second line- proton pump inhibtor (PPIs) to block gastric acid secretion caused by histamine, acetylcholine or gastrin (omeprazole)
Definition of pyloric stenosis
Obstruction resulting from the thickening of the cicular muscle of the pylorus
s/sx of pyloric stenosis
3 weeks to 4 months old
Projectile non-bilious vomiting after eating
Hungry after vomiting
poor weight gain or weight loss
Eventual dehydration
Visible peristaltic waves
Palpable mass (pyloric olive) after vomiting
Diagnostics for pyloric stenosis
abdominal US, if nondiagnostic, do upper GI imaging, will show a “string sign” or a narrowed pyloric channel
Definition of intussusception
Acute prolapse (telescoping) of one part of the intestine into another adjacent segment of the intestine
Signs/symptoms of intussusception
Previously healthy infant develops acute colicky pain, bilious vs non-bilious vomiting, progressive lethargy, currant jelly stool: late presentation, sausage shaped mass in the right upper quadrant, progressive distention/tenderness, if not reduced, perforation and shock may occur
Diagnostic for intussuseption
U/S or radiograph, barium enema
S/SX of hirschsprung’s disease (aganglionic megacolon)
Failure to pass meconium, BILIOUS vomiting, jaundice, infrequent, explosive bowel movements, progressive abdominal distention, tight anal sphincter with empty rectum, failure to thrive, malnutrition
S/SX of appendicitis
Begins with vague, colicky umbilical pain. After several hours pain shifts to right lower quadrants of the abdomen (RLQ), psoas sign, rebound tenderness, obtrurator sign, McBurneys point tenderness, pain worsens and localizes with cough, nausea with 1-2 episodes of vomiting, sense of constipation, infrequently diarrhea, fever
What are the 2 confirmtatory tests for appendicitis?
Psoas sign and obturator sign
Psoas sign
confirmatory test for appendicits, Pain with right thigh extension
obturator sign
confirmatory test for appendicitis, pain with internal rotation of the right thigh
McBurneys point tenderness
One-third the distance from the anterior superior iliac spine to the umbilicus
Labs/ Diagnostics for appendicitis
CT is diagnositc, WBC 10-20, ESR elevated, US
Malabsorption definition
Impaired intestinal absorption of essential nutrients and electrolytes caused by enzymatic deficiencies (eg cycstic fibrosis), celiac disease (sprue), gluten intolerance, infectious agents, and abnormalities of the intestinal mucosa
S/Sx of malabsoption
FTT
Severe, chronic diarrhea
Bulky, foul stool (steatorrhea) CYSTIC FIBROSIS
Vomitting
Abdominal pain
Protuberant abdomen
Associated with vitmain deficiency of malabroption: pallor, fatigue, hair and derm abnormalities, cheilosis, peripheral neuropathy
labs/ diagnositics for malabsorption
stool (culture, hemoccult, O&P)
Serum Ca, Phos, alk phos, total protein, ferritin, folate, and LFTS
Bone age
Lactose and sucrose breath hydrogen testing (Hpylori)
Sweat chloride test if clinical suspicion of cystic fibrosis
cystic fibrosis test
Sweat chloride
Celiac disease diet modification
No wheat, oats, rye, barley
Cystic fibrosis dietary modifications
pancreatic enzyme replacement: Lipase, amylase, tripsan
Fat soluble vitamins: A, D, E, K
When it comes to hepatitis, most children are _____, so infections frequently go unnoticed
Anicteric
pre-icteric state of hepatitis S/SX
fatigue, malaise, anorexia, n/v, headache, aversion to second-hand smoke and alcohol odors
Icteric state of hepatitis s/sx
weight loss, jaundice, pruritus, right upper quadrant abdominal pain (RUQ), clay colored stool, dark urine
AST and ALT____ prior to onset of jaundice and will ____ after jaundice presents
rise, fall
Neuroblastoma definition
Tumor arising form neural tissue, frequently from the adrenal gland and can spread to bone marrow, liver, lymph nodes, skin, and orbits of the eyes
Serology for Acute Hepatitis A
Anti-HAV, IgM
Serology for recovered hepatitis A
anti-HAV, IgG
Active hepatitis B serology
HBsAg, HBeAg, Anti-HBc, IgM
chronic hepatitis B serology
HBsAg, Anti-HBc, Anti-Hbe, IgM, IgG
Recovered hepatitis B (also vaccinated and seroconverted)
Anti-HBc, Anti-HBsAg, IgG +
Serology for both acute and chronic hepatitis C
Anti-HCV, HCV RNA
how high indicated fever in an infant?
rectal temp of 100.4
what temp can fever convulsions occur?
101F, but more how quickley the fever rises not how high it goes
