Peds 18

Question 1

Tyler is a 6-week-old former term infant who has recent onset of progressive dyspnea with feedings, diaphoresis, and poor weight gain (having only gained 300 grams from his birth weight). He is acyanotic with a normal temperature, but exam reveals tachypnea, an active precordium, Grade III holosystolic murmur starting with S1, and hepatomegaly.

What is the most likely dx? What diagnostic tests would you order?

Answer 1

Congestive heart failure, VSD

ECG, echo, CXR

Question 2

What 2 congenital heart defects are more likely to be detected in school-age children than in neonates?

Answer 2

• ASD

- Bicuspid aortic valve

Question 3

Where should you expect to palpate a liver edge, assuming it’s normal sized and not enlarged?

Answer 3

1 cm below R costal margin

Question 4

What are 3 hallmark CXR findings of a left to right shunt d/t congenital heart defect?

Answer 4

• Cardiomegaly
• Increased pulmonary vascular markings
• Pulmonary edema

Question 5

What’s important to know about the management of VSD?

Answer 5

VSDs tend to diminish in size with time with spontaneous closure of approximately 75% of small defects and between 25 to 50% of all defects.

If it does not close on its own, the VSD will need to be surgically closed

Question 6

What meds would you prescribe a newly diagnosed symptomatic VSD?

Answer 6

Furosemide
Digoxin
Enalapril

Question 7

A 5-week-old infant is brought to the pediatrician for failure to thrive with a history of prolonged feeding time and tachypnea. What other features does this infant most likely have?

A. Cyanosis from a right-to-left shunt
B. Early systolic click without a murmur
C. Hyperdynamic precordium with a holosystolic murmur
D. Systolic murmur with a widely split second heart sound

Answer 7

C. Hyperdynamic precordium with a holosystolic murmur

Question 8

You have accepted a part-time tutoring job for first-year medical students. One of your students asks if you would please clarify the details of normal fetal circulation. Which of the following best describes the path oxygenated blood takes to reach the fetal brain?

A. RA > foramen ovale > LA > LV > systemic circulation
B. RA > RV > VSD > LV > systemic circulation
C. RA > RV > pulmonary circulation > LA > LV > systemic circulation
D. RA > RV > ductus arteriosus > LV > systemic circulation
E. RA > RV > ductus arteriosus > systemic circulation

Answer 8

A. RA > foramen ovale > LA > LV > systemic circulation

Question 9

A 5-year-old boy is noted to have a grade II systolic murmur and a widely split S2 murmur on cardiac exam. His vital signs are stable and he has been asymptomatic. Which of the following statement is accurate regarding this child’s presentation and likely condition?

A. Chest x-ray, ECG, and echocardiogram would be indicated as next steps to work up a presumed ventricular septal defect
B. No further work-up for a presumed venous hum
C. This patient’s murmur is caused by excessive flow through the pulmonary outflow tract and should be evaluated
D. This patient should be scheduled for cardiac catheterization

Answer 9

C. This patient’s murmur is caused by excessive flow through the pulmonary outflow tract and should be evaluated

Question 10

A 6-week-old infant presents to your office for a check-up. The baby was born full-term by NSVD to a 29-year-old G1P0 mother with no complications. Mother states the baby was feeding well until a week ago, when he developed increased sleepiness, prolonged feeding, and greater duration between feeds. His mother notes he stops to take breaks during feeds because he seems to be trying to catch his breath. He has four to six wet diapers per day and stools three or four times per day. Vital signs: Temperature is 37.6 C (99.7F), respiratory rate is 68 breaths/minute, pulse is 138 beats/minute, blood pressure is 88/58 mmHg, and oxygen saturation is 98%. The physical examination is notable for increased respiratory effort and retractions, and, upon cardiac examination, a murmur with a hyperactive precordium and no cyanosis. Abdominal exam reveals a liver edge palpable to 4 cm below the right costal margin. Which condition would be LEAST LIKELY to be the cause of the infant’s symptoms?

A. Aortic stenosis
B. Atrial septal defect
C. Coarctation of the aorta
D. Patent ductus arteriosus
E. Ventricular septal defect

Answer 10

B. Atrial septal defect

Question 11

What heart defect isn’t present in the immediate newborn period and shows up a few days to weeks after birth? Why?

Answer 11

VSD

A newborn has elevated pulmonary vascular resistance. When systemic and pulmonary vascular resistances are nearly equal, there is no reason for blood to shunt through the VSD. The PVR drops a few weeks into life.

Question 12

What are the 4 heart defects that present with a murmur and signs of CHF in infancy?

Answer 12

• VSD
• aortic stenosis
• coarctation of the aorta
• PDA

Question 13

What is the most common innocent murmur in childhood? Where would you hear it best? How would it sound?

Answer 13

Still’s murmur

• LLSB in supine position
• Musical, vibratory

Question 14

A holosystolic murmur starts with S1 and is characterized by blowing. What is this?

Answer 14

VSD

Question 15

A systolic murmur is widely split S2 and is due to increased flow across a normal pulmonic valve. What is this?

Answer 15

ASD

Question 16

A systolic murmur is followed by an early diastolic murmur of regurgitation. What is this?

Answer 16

Aortic stenosis

Question 17

A harsh systolic ejection murmur that has a prominent systolic ejection click after S1. What is this?

Answer 17

Pulmonic stenosis

Question 18

Continuous murmur that is a bit louder in systole. What is this?

Answer 18

PDA

Question 19

Heard best at the LLSB, is vibratory and low-pitched, and louder when lying supine. What is this?

Answer 19

Innocent murmur