Pediatric Shelf Exam Flashcards
Dx + DGx + Tx: Newborn with cyanosis, tachypnea, absent breath sounds on left, heart sounds shifted further to the right, scaphoid abdomen, mediastinal shift to right, bowel loops within thoracic cavity
Dx: congenital diaphragmatic hernia
DGx:
Tx: intubation + mechanical ventilation, Ng tube placement
Dx + DGx + Tx: tachypnea, subcostal retractions, cyanosis, grunting, decreased breath sounds in pre-term
Dx: Neonatal respiratory distress syndrome (NRDS)
DGx: XRay- low lung volumes + diffuse reticulogranular (ground-glass) densities
Tx: CPAP (continuous positive airway pressure ventilation) + get ABG, consider intubation/surfactant
Dx + Dgx + Tx: low grade fever, mild cough, 1- week, patient cries when neck extended, swelling of posterior pharyngeal wall
Dx: Retropharyngeal Abscess
DGx: contrast enhanced CT scan
Tx: empiric antibiotic (ampicillin-sulbactam, clindamycin), intubation, abscess drainage
Dx + Tx: URI + coughing spells + high pitched inspiratory sound, incomplete vaccinations
Dx: pertussis (whooping cough)
Tx: Macrolide (azithromycin for all ages, but any >1 month
Dx + Tx: 3-day history of fever, headache, earache, sore throat, up-to-date, 102F, 38.9C, enlarged right tonsil + whitish membrane
Dx: acute bacterial tonsilitis (strep pyogenes)
Tx: 1st line- penicillin V, macrolides (if clarithromycin, azithromycin, allergic),
Dx: preemee, respiratory distress—> mechanical ventilation for month after delivery, diffuse granular densities, basal atelectasis
Dx: bronchopulmonary dysplasia Cx of prolonged mechanical ventilation in premature infants
Dx: toddler, dry barking cough worsens at night, mild rhinorrhea and fever, inspiratory stridor on agitation, febrile,
Dx: mild croup (viral etiology—> parainfluenza or RSV
Tx: symptomatic relief—> cold mist- decrease nasal passage irritation, dexamethason- reduce airway swelling
Prevention and treatment of RSV
Tx: Palivizumab -passive immunity- infants at risk for severe bronchiolitis
Dx DGx Tx: young boy + coughing, intermittent wheezing, hx of eczema, 3 URIs, otitis media with abx, scattered wheezing on pulm exam
Dx: asthma
DGx: spirometry with obstructive lung pattern reversible
Tx: albuterol
Dx: thick purulent ocular discharge, eyelid swelling, newborn within 2-7 days
Neonatal conjunctivits with N.gonorrhea
Dx: mucoid watery nasal discharge (rhinorrhea) + tachypnea, wheezing, nasal flaring, low grade fever, intercostal retractions, cyanosis, late neonatal period
RSV
Dx: child 6 months to 3 years old—->croup = nasal congestion, barking seal cough, tachypnea, hypoxemia + low grade fever, inspiratory stridor, hoarseness
Parainfluenza virus type 1
Dx: within 6 days of birth + pneumonia what bug?
Strep Agalactiae
Dx: 5-14 days after birth, mucopurulent eye, discharge, swelling
Neonatal conjunctivitis due to Chlamydia
Dx: 4-12 weeks post birth + mucopurulent eye discharge + eyelid swelling + short repetitive coughs with deep inspirations between (staccato cough)
Dx: chalmydial pneumonia
Dx: child under 3 y/o + acute onset coughing/shortness of breath, elevated respirations, abnormal hyperinflation of right lung with air trapping.
Foreign Body Aspiration
DGx + Tx: bronchoscopy
Dx + Tx: teenager + fever and sore throat worsening, dysphagia, hoarseness, febrile, anterior cervical lymphadenopathy, erythematous tonsils, swelling, white exudate on tonsillar pillar, uvula deviated to left
Tonsilitis, peritonsillar abscess
Incision, drainage + IV ampicillin-sulbactam therapy
Most common side effect of inhaled corticosteroids
Oropharyngeal candidiasis (thrush)
Tx: child from TB endemic contry with HBsAb + and Interferon 𝛄 release assay- + , chest X-ray is negative
Latent TB infection:
Tx: start isoniazid + rifapentine for 3 months or 4 months of rifampin
Give Vit B6 (pyridoxine) to avoid peripheral neuropathy + sideroblastic anemia
Vertical gaze palsy, nystagmus, eyelid retraction when looking upward, pupils that accommodate but don’t react to light
Parinaud syndrome- compression of the tectum + medial longitudinal fasciculus
Wt loss, headache, insomnia, + parinaud syndrome
Pinealoma
Common sequel of untreated pinealoma
Obstructive hydrocephalus (headaches, vision abnormalities, nausea, vomiting, ataxia
Complication of precocious puberty
Increased short stature,- trigger early epiphyseal plate closure
Dx: 17 y.o no menarche, normal breast development, scant axillary hair, firm, nontender left inguinal mass, does not show a uterus or ovaries
AIS- XY—> formation of testes undifferentiated fetal gonad, testes remain in inguinal canal, female external genitalia, cutaneous andorgen receptors lack sensitivity
6 mo infant - cataracts in early infancy,
Galactokinase deficiency
Infant hepatomegaly, hypoglycemia, generalized muscle weakness, cramps, hyperlipidemia, ketosis
Debranching enzyme
Infant, jaundice, vomiting, hepatosplenomegaly, infantile cataracts, failure to thrive
Galactose-1 Phosphate Uridyl transferase
Infant, vomiting, poor feeding, hypoglycemia, jaundice, hepatomegaly, around time of weaning from breastmilk
Aldolase B deficiency- lifelong fructose + sucrose free diet
Fructose in urine,
Fructokinase deficiency
Short stature, delayed puberty, delayed bone age, and family history of delayed growth
CDGP- constitutional delay of growth and puberty
Development of secondary sex characteristics under 8
Precocious puberty, bone age > 1yr difference- measure LH or low LH + GnRH stimulation-> check if high—> GnRH-dependent precocious puberty,
Menorrhagia, fatigue, weight gain, bradycardia, facial myxedema (puffy appearance), thinning of the eyebrows, diminished deep tendon reflexes
Hypothyroidism
Cx of Gestational Diabetes Mellitus
Fetal macrosomia— big birth weight, shoulder dystocia- upper brachial plexus palsy
Severe acne, excess hair growth, accelerated bone maturation)
Hyperandrogenism
Hyperandrogenism before age 9, elevated 17-hydrocyprogesterone, androstenedione, DHEAS, low levels of deoxycorticosterone and cortisol despite administering ACTH
Non-classic congenital adrenal hyperplasia (late-onset CAH)
Dx + DGx + Tx: newborn, abdominal distention, multiple episodes of bilious vomiting, increased anal sphincter tone/empty rectal vault, delayed passage of meconium, narrow sigmoid colon, squirt sign
Dx: Hirschsprung Disease- defective migration of Neural Crest Cells from proximal to distal bowel- aganglionic rectum/distal sigmoid
DGx: ABXR- megacolon + rectal biopsy
Tx:
Mechanism of appendicitis
Lymphatic Tissue Hyperplasia- children
Fecalith obstruction- adults
Dx+ DGx + Tx: 3-month history stool incontinence, frequent nocturnal urination, large hard stools + painful bowel movements- firmness to palpation in left lower quadrant.
Dx: retentive encopresis (involuntary elimination of feces)
DGx: Clinical
Tx: fecal disimpaction + enemas for 6-24 months
What is Meckel Diverticulum
incomplete obliteration/ of vitelline duct
can cause lower GI bleeding
Dx + DGx + Tx: young child, multiple episodes of n/v + ab pain, missed several days of school intermittently, recent psych stressor
Dx: cyclical vomiting syndrome
DGx: diagnosis of exclusion no anatomical anomalies
Tx:
Failure of duodenal recanalization
duodenal atresia- complete intestinal obstruction- double bubble sign, gasless distal small bowel, maternal polyhydramnios
nonrotation of the intestine
complete non-rotation–> cecum in left lower quadrant, small bowel obstruction, small bowel on right, colon on left
incomplete intestinal rotation
malpositioned duodenojejunal junction (located left of midline, cecum) + duodenal obstruction–> bilous vomit
Dx + DGx + Tx: infant + acute watery diarrhea + dehydration + not fully vaccinated + no abdominal pain
Dx: rotavirus
DGx: enzyme immunoassay of stool
Tx: Oral Hydration Solution, IV fluids
Dx: newborn with poor feeding, lethargy, prolonged newborn jaundice, pale facies, increased head circumference, abdominal distention, macroglossia
congenital hypothyroidism
dx: congenital hypothyroidism + abdominal protrusion + enlarges with crying, easily reducible
Dx: congenital umbilical hernia
Dx + DGx + Tx: child with recurrent skin infections + catalase positive bacteria/fungi (stapha A/ Serratia marcescens) + diffuse granulomas
Dx: CGD - Chronic granulomatous disease (X-linked recessive mutation of NADPH oxidase)- decreased superoxide
DGx: Dihydrorhodamine flow cytometry
Tx: prophylaxis: TMP- SMX + Itraconazole + INF-y, Hematopoietic cell transplant
Dx + DGx + Tx: recurrent swelling episodes w/o urticaria/pruritis no trigger, colicky ab pain, vomit, diarrhea, laryngospasm
Dx: Hereditary Angioedema
DGx: low C4/ C1 inhibitor protein/function- C2 inhibitor deficiency/dysfunction
Tx: C1 inhibitor concentrate + bradykinin antagonists (icatibant) + kallikrein inhibitor ecallantide)
Low risk vs high risk food allergy management
Low Risk: early introduction- trial at home
High Risk: trial in office referral to allergy testing
Wiskott- Aldrich Syndrome
Eczema, recurrent infections, microthrombocytopenia (low platelets
X-linked agammaglobulinemia (Bruton)
B-cell deficiency- disorder of B-cell maturation, low on all levels of IgGs and no response to vaccines
Dx + DGx + Tx: recurrent non purulent infections (cellulitis/periodontitis), impaired wound healing, delayed umbilical cord separation > 3weeks), leukocytosis neutrophilia
Dx: LAD leukocyte adhesion deficiency
DGx: reduced CD1 antigen
Tx:
Dx + DGx + Tx: recurrent severe sinopulmonary infections, poor growth, low IgA, low IgG, elevated IgM, encapsulated bacteria, increased risk of opportunistic infections
Dx: hyper IgM syndrome X-linked defect in CD40 ligand
Dgx: clinical + Lab
Tx:
Selective IgA deficiency
Asymptomatic or recurrent respiratory, GI, or UTI
IgA low
IgM, IgG- normal
Hyper IgE syndrome
Everything normal except IgE elevated
Defective JAK-Stat Th17
Severe chronic eczema, non inflammatory abscesses (cold)- staph or candida
IgE + Eosinophils high,WBC always normal
Dysmorphic facies (broad nose, prominent forehead, retained primary teeth
Hyper IgM syndrome
Severe recurrent sinopulmonary infections
- B cell normal
- IgG + IgA + IgE low
- IgM high
Common Variable Immunodeficiency
Normal B cell count but all Ig’s are Low
Presents in adolescence- recurrent sinopulmonary and GI infections, failure to thrive, chronic pulmonary disease
Tx: IV IG
Bruton’s agammaglobuliemia (x-linked)
B cells and Igs all low
Recurrent sinupulmonary infections
Immunizations
All kids pre-term or not receive it on chronological age
ICU infant, respiratory distress, multiple episodes of pneumonia, chronic thrush, otitis media,
No T cells, and dysfunctional B cells- Severe Combined Immunodeficiency
Tx: urgent stem cell transplantation
Recurrent sinopulmonary infections + anaphylaxis with blood transfusion
Selective IgA deficiency
Associated Complications of DiGeorge 22qDS syndrome?
CATCH-22
C- cardiac outflow anomalies- ToF + persistent truncus arteriosus
A- anomalous face- nasal bridge, low set ears,
T- thymic hypoplasia- decreased T-cell immunity
C- cleft palate
H- hypoparathyroidism- hypocalcemia
cyanosis, fatigue with feeding,
Harsh crescendo-decrescendo systolic murmur at left upper sternal border
Tetralogy of Fallot
-> R Ventricular outflow tract obstruction
- R ventricular hypertrophy
- Overriding Aorta
-VSD
Diversion- r A—> aorta—> hypoxemia
Tx: Knee chest positioning, O2, surgical intervention
Dx + Tx: syncope + normal BP, no trauma to head, returns to alert state, reports events which occurred during episode
Dx: psychogenic pseudosyncope- conversion disorder
Dx + DGx + Tx: infant + noisy breathing with birth, no improvement with steroid, afebrile, nml vitals, biphasic stridor, improves with neck extension
Dx: vascular rings (great vessels encircle/compress trachea)
DGx: CT scan
Tx: surgical division of structures creating ring
Which murmurs must be evaluated?
Holosystolic/ Diastolic Murmurs
Harsh
Grade > 3 intensity persists with standing and Valsalva maneuver
DGx: get echo
Dx + Tx: febrile illness with development of pain in swelling in multiple joints, 2/6 holosystolic murmur at apex, mild mitral regurg
Dx: Rheumatic Heart Disease- chronic valvular damage- group A strep
Tx: IM benzathine Penicillin G every 4 weeks
Cx:
Common heart defect in trisomy 18 (edwards syndrome)
VSD- holosystolic murmur
Trisomy 18- micrognathia, microcephaly, rocker bottom feet, overlapping fingers, absent palmar creases
Tx of Persistent Pulmonary Hypertension of the Newborn ( PPHN)
Inhaled Nitric Oxide, O2,
Dx: post surgery infant, —> decreased appetite/ vomiting, fever + tachycardic, tachypnea, distal heart sounds, enlarged cardiac silhouette
Dx: pericardial effusion
DGx: ECHO
Tx: drainage
Dx + DGx + Tx: abrupt onset of fever, pharyngitis, severe myalgias, and pale mottled skin, strep and flu are negative
Dx: Meningococcal meningitis
DGx: Lumbar Puncture
Tx: Ceftriaxone
Difference between orbital vs. preseptal cellulitis
Preseptal- Eyelid Erythema/Swelling + Chemosis—> Tx with Oral Abx
Orbital cellulitis- Pain with EOM, proptosis/opthalmoplegia with diplopia—> IV abx
Dgx and Tx of Retropharyngeal Abscess
Dx: fever, difficulty/ pain with swallowing, neck pain, drooling, muffled hot potato voice
DGx; widening of pre-vertebral space lateral neck X-ray + CT
Tx: IV abx (ampicillin-sulbactam, clindamycin) + surgical drainage
high fever, drooling stridor, non-vaccinated, thumb sign
epiglottitis
fever, muffled voice, throat pain, uvular deviation to contralateral tonsillar pillar
peritonsillar abscess
URI–> croup-like symptoms, fever, stridor, tracheal narrowing, steeple sign
Tracheitis
when to use topical vs. oral abx in impetigo?
non-bullous impetigo-> topical
bullous impetigo–> oral (amox, cephalexin, dicloxacillin
Dx + Dgx + Tx + Cx: newborn + sensorineural hearing loss, cataracts, PDA, red reflex absent, loud harsh murmur, blueberry muffin rash
Dx: Rubella
DGx: IgM serology
Tx: Nothing
Prevention: Vaccination
Cx:
Dx, Dgx, Tx: chid, uncontrollable writhing of arms/grimacing of face, previous sore throat/fever resolved without treatment, pericardial friction rub, prolonged PR interval/diffuse ST elevations
Dx: Acute Rheumatic Fever - Strep Pyogenes- (Joints (migratory arthritis), Carditis, Nodules (subq), Erythema marginatum, Sydenham chorea
DGx: clinical + major/minor
Tx: prophylatic oral penicillin, Tx: IM benzathine penicillin G
Dx + DGx + Tx: neonate + irritability, poor feeding, lethargy, leukopenic,
Dx: neonatal sepsis- Group B strep, E Coli, Listeria Monocytogenes
Tx: IV ampicillin + gentamicin
Dx + DGx + Tx: neonate, macrocephaly, jaundice, mother travel abroad + fever/swollen lymph nodes, spontaneous resolution hepatomegaly, hydrocephalus, diffuse intracranial calcifications
Dx: Congenital Toxoplasmosis
DGx: toxoplasma serology/ PCR
Tx: pyrimethamine, sulfadiazine, folinic acid
Dx + DGx + Tx: neonate + microcephaly + ventriculomegaly, periventricular califications growth restriction, hepatosplenomegaly, thrombocytopenia
Dx: Congenital Cytomegalovirus- transmission by urine/saliva
DGx: PCR testing, viral culture
Tx: antiviral therapy (valganciclovir)
Bugs to watch out for in SCD sepsis?
Strep Pneumo, H Flu, N Meningitidis
Bugs to watch out for in CF, recurrent pneumonia?
Staph A- kids/young children Pseudomonas Aeruginosa- adults
Good vs. Bad Lymphnodes
Good: soft, mobile, <2cm, localized, no symptoms
Bad: firm, hard, immobile, > 2cm, systemic symptoms
Transmission + Dx + DGx + Tx + Cx: Congenital Toxoplasmosis
Tr: Feces/ Uncooked Food Meat/ Unpasteurized Goat Milk
Dx: Chorioretinitis, Hydrocephalus, Diffuse, Intracranial Calcifications
DGx: PCR + IgM Toxo
Tx: Mom- spiramycin
Baby: pyrimethamine, sulfadiazine, folinic acid
Cx: epilepsy/intellectual disability, visual/hearing impairments
Tr + Dx + DGx + Tx + Cx: Congenital Syphillis
Tr: Sexual
Dx: Early: < 2 yearsRhinorrhea, Skeletal Anomalies, Desquamating Rash (Palms/Soles), Lymphadenopathy
Late: > 2 years- saddle nose, frontal bossing, notched, widely spaced teeth, vision/hearing impairment
DGx: RPR + VDRL, dark field microscopy, PCR
Tx: IV penicillin
Cx: miscarriage, stillbirth,
Tr + Dx + DGx + Tx + Cx: Congential Rubella
Tr: Airborne Droplets, transplacental
Dx: miscarriage, preterm, fetal growth restriction
PDA, Cataracts, Cochlear Defects, Hepatosplenomegaly, Jaundice, hemolytic anemia, thrombocytopenia, blue berry muffin rash,
DGx: PCR, IgM antibody serology,
Tx: Immunization, <16 weeks, termination, >16weeks self-resolving
Cx: microcephaly, intellectual disability, skeletal abnormalities.
Tr + Dx + DGx + Tx + Cx: Congenital CMV
Tr: Any Fluids, Transplacental
Dx: Sensorineural Hearing Loss, Chorioretinities, Microcephaly, Periventricular Calcifications,
DGx: CMV IgM antibodies or PCR
Tx: Baby: Ganciclovir, foscarnet, blood/platelet transfusions
Mother: Valacyclovir
Cx: Audio/Visual Complications
Tr + Dx + DGx + Tx + Cx: Congenital HSV
Tr: HSV-2, oral, transplacental, perinatal
Dx: vescicular/ ulcerative rash, keratocunjunctivitis, meningoencephalitis
DGx: viral culture + PCR
Tx: IV acyclovir/valacyclovir
Prevention
When to Proxphlaxis with Varicella Vaccine vs. Varicella IG
No immunizations + immunocompetent–> vaccine only
No immunization + immunocompromised–> VZIG
Dx + DGx: 2 y/o- recurrent cough/ SOB, multiple lobar pneumonias, mild retractions, inspiratory crackles, hyperresonance, clubbing of nail beds, generalized hyperinflatio, bronchial thickening, patchy atelectasis
CF
Sweat Chloride Test
Dx + DGx + Tx: tachypnea, hypoxia, accessory muscle use, cyanosis,
Dx: NRDS or hyaline membrane disease- not enough pulmonary surfact
treatement of Von Willebrand Disease
platelet count normal, PT elevated
supportive care + desmopressin
hypotonia, downturned palpebral fissures, prominent epicanthal folds, flat facies, single palmar creases, intellectual disability,
Downs Syndrome
intellectual disability, elongated face with prominent jaw, high arched palate, large ears, hyperextensible joints, postpubertal macroorchidism
Fragile X syndorme (X linked Dominant)
dysgenesis of seminiferous tubules, testicular atrophy, decreased spermatogenesis, eunuchoid body shape, long extremities, gynecomastia
Klinefelter Syndrome XXY
intellectual disability, cleft lip/palate, holoprosencephaly, microphthalmia, cutis aplasia,
Trisomy 13 (Patau Syndrom)
widening of the wrist in infant
Rickettes + Vitamin D deficiency –> increased alkaline phosphatase activity
female, low estrogen, underdeveloped sexual characteristics, increased LH,FSH
Turner Syndrome (Gonadal Dysgenesis)
Tx: growth hormone replacement, estrogen replacement
easy bruising, active, scattered petechiae + ecchymoses at various stages of healing, very low platelet count
ITP (Immune Thrombocytopenic Purpura)- self limiting
virilization, hirsutism, elevation of dehydroepiandrosterone sulfate, 17-ketosteroid excretion, normal testosterone, normal pelvic US
Adrenal Adenoma in zona reticularis
neonate, hydronephrosis, urine flow is poor with dribbling, bilateral hydronephrosis/hydroureter, thick walled bladder
posterior urethral valve- abnormal remnant of the mesonephric (wolfian duct)
DGx: US- hydronephrosis, oligohydramnios, fetus, voiding cystourethrogram
Tx: endoscopic valve ablation
acute onset of weakness, headache, nausea/vomiting, AMS, hx of recent viral gastroenteritis, large amounts of water, no meals, edema on hands/feet
dilutional hyponatremia
Tx: hypertonic saline
infant, poor linear growth, no vomit/diarrhea, hypokalemia, hyperchloremia, non-anion gap metabolic acidosis, respiratory alkalosis
Renal Tubular Acidosis
neonate, systolic ejection murmur radiation to back/ lung fields and loudest at right axilla, ejection click/ split S2, left parasternal heave
Pulmonary Stenosis
crescendo-decrescendo systolic murmur upper right sternal border, radiating to carotid arteries
aortic stenosis (bicuspid aortic valve)
fixed widely split S2, pulmonary hypertension,
Atrial Septal Defect
extracardiac left-right shunt, continuous machine-like murmur
PDA
holosystolic murmur at lower left sternal border + palpable thrill
VSD
infant, recurrent episodes of severe abdominal pain, nausea, vomiting, bloody/mucoid stools,
Dx: Intussusception
DGx: history, exam, imaging
Tx: contrast enema- diagnostic/therapeutic, surgery
female, pain in lower abdomen/pelvis, nausea, diarrhea, headaches, flushing,
Dx: primary dysmenorrhea
DGx: clinical, exclusion
Tx: NSAIDS, topical heat, oral contraceptives + progestin IUD
Definitive Treatment of SCFE
Physis stabilization with screw fixation
microthrombocytopenia, eczema, recurrent infections
Wiskott- Aldrich Syndrome- X-linked recessive defect in WAS protein- impaired cytoskeleton
Tx: stem cell transplant
What increases the risk of shoulder dystocia (brachial nerve palsy/clavicle fractures) during birth
Gestational Diabetes, hyperglycemia + Fetal hyperglycemia
post- birth what can happen due to withdrawal of maternal hormones
neonatal withdrawal bleeding in females via vagina
Tx: child, pruritic vulva, labial adhesions
estrogen cream
Tx of neonatal clavicular fractures
Reassurance, Gentle Handling, Analgesics, Long-sleeve garment, elbow flexed at 90
Dx + DGx + Tx: macrocytic anemia, webbed neck, cleft palate, mild hypertelorism, flat nasal bridge, pale mucous membranes, triphalangeal thumbs
Dx: Diamond-Blackfan Anemia
DGx: Clinical + Lab
Tx: corticosteroids + RBC transfusions
Dx: pigmented peri oral macules, GI hamartomatous polyps, abdominal pain, anemia of chronic bledding, rectal prolapse
Peutz-Jeghers Syndrome
Genetic Testing
Annual Anemia Screening
Upper/Lower Endoscopy
Mother with HBsAg positive, Anti-HBsAg negative, IgM Anti-HBcAg negative, and Anti- HBcAg positive, how to treat neonate
Administer Hep B IG and Hep B Vaccine
child, lethargy + AMS, post- URI, —> nausea, vomit, hepatomegaly, diffuse cerebral edema
Reye’s Syndrome- Aspirin for viral illness–> cerebral edema
Tx: supportive, but no aspirin for kids
NF1 vs NF2
NF1 - neurofibromin, Chromosome 17- Cafe au Lait Spots, multiple neurofibromas, optic pathway glioma, lisch nodules
NF2- merlin- Chromosone 22, Bilateral Acoustic neuromas
nasal sinusitis, unilateral, foul-smelling purulent, bloody
nasal foreign body–> mechanical extraction/positive pressure expulsion
treatment of Left Ventricular Outflow Obstruction
Propranolol
