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RRCCPA Clin Med Exam 4 > Peds Cardiology (Exam 4) > Flashcards

Peds Cardiology (Exam 4) Flashcards

1
Q

What is an innocent heart murmur?

A

One that occurs in the absence of anatomic or physiological abnormalities of the heart or circulation

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2
Q

Roughly ___ of kids will have a murmur at some point

A

50%

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3
Q

What are the 6 types of innocent murmurs?

A
  1. New born murmurs
  2. Vibratory systolic murmur (Still’s murmur)
    - mc- L sternal boader/apex
  3. Venous hum
  4. Pulmonary systolic murmur
  5. Peripheral pulmonic systolic murmur
  6. Supraclavicular systolic murmur
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4
Q

What useful HPI concerns for a murmur?

A
  • Easily fatigable, including difficulty w/ feeding
    • disinterest, diaphoresis, change in resp patterns, cynaosis
  • Claudication
  • Sx that worsen w/ exertion (feeding)!!
  • Syncope (Babies passing out is never a good thing!)
  • Sig. Fam hx
  • CP IS NOT USEFUL
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5
Q

What are concerning PE findings with murmurs?

A
  • Falling off growth charts
  • Unequal pulses/pressures
  • Hyperactive precordium, displaced PMI
  • Murmur itself (diastolic or continuous, Grade IV+)
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6
Q

What type of murmur is almost always abnormal?

A

Diastolic

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7
Q

Are lab studies necessary in dx of a peds murmur?

A

No if asymptomatic- It adds practically nothing to the initial evaluation of an asymptomatic kid with a murmur (refer to peds cardiology)

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8
Q

When do you need to order an echo on a peds?

A 
If the kiddo is symptomatic or 
asymptomatic with: 
-suspected diastolic or continuous murmur
-ejection clicks
-radiate to back or neck
-grade 3 or louder
-murmurs ass. with abnorm ekg or cx
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9
Q

Rheumatic fever is an ________ dx that occurs after a ______ infection

A

autoimmune/inflammatory dx

GROUP A STREP

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10
Q

If a pt comes in with rheumatic fever sx when would you do a rapid strep test?

A

Only if the HPI is consistent with an acute strep infection

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11
Q

What is the time frame of RF onset after a group A strep infection?

A

1-5 weeks

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12
Q

What lab tests do you want to get for a RF pt?

A

ASO titer (rises 1-3 wks after strep infx, peaks 3-5 wks)
CBC
CMP
ESR + CRP (if neg=not RF)

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13
Q

What is the diagnostic criteria for rheumatic fever?

A

Jones Criteria

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14
Q

What is the Jones Criteria?

A

DX based on presence of known group A strep infection PLUS:
2 major OR
1 major and 2 minor criteria

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15
Q

What are the 5 major criteria of the Jones Criteria?

A
  1. Migratory polyarthritis (MC-80%)
    - insanely painful joint pain that jumps to a new spot every 3-10 days
    - must have associated swelling and limited movement
  2. Carditis (valvulitis, myocarditis, pericarditis)
    - Most serious complication
    - present 40%
    - Tachy, new murmur, cardiomegaly, CHF
    - MV and AV mc affected
  3. Erythema marginatum (less than 5%)
    - macular, red, non itchy rash on trunk
  4. Chorea (Sydenham’s)
    - less than 15%
    - rapid, purposeless movement (like Huntington’s dx)
    - delayed onset (mo to yrs)
  5. Subcutaneous nodules (uncommon <5%)
    - non-tender, freely moving, over a joint
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16
Q

What are the 6 minor criteria of the Jones Criteria?

A
  1. Arthralgia (no joint swelling)
  2. Fever
  3. Elevated acute phase reactants (ESR, CRP)
  4. Prolonged PR interval (can’t use if pt has carditis as a major)
  5. Leukocytosis
  6. Previous h/o RF
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17
Q

What is the treatment for acute RF?

A

Antibiotics ONLY if evidence of acute strep infx:

  • Penicillin
  • Erythromycin (if pen allergic)

Otherwise:

  • ASA for sx
  • (+/-) steroids
  • (+/-) valve replacement
  • Tx heart failure if present
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18
Q

What is the preventative treatment for pts w/ h/o RF or RHD?

A

H/o RF: very low threshold for ABX with c/o ST
RHD: 5-10 yrs or until 21 yo prophylatic abxs
-DOC: Pen G Q4 weeks

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19
Q

What is Reye Syndrome? What is it mc associated with?

A

Reyes syndrome: rapidly progressive encephalopathy
Sx: vomiting, AMS, seizures
90% of cases associated with ASA use
VERY RARE (less than one in a million kiddos per yr)

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20
Q

What is Kawasaki Dx?

A

AKA mucocutaneous lymph node syndrome

Systemic Vasculitis
MEDIUM sized blood vessels become inflamed (Coronary arteries!!)

Etiology: unknown

MC acquired heart dx- 9/100,000 kids <5

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21
Q

What is the criteria for diagnosing Kawasaki Dx?

A

Must have a FEVER plus 4 of the 5 other sx OR coronary aneurysms:

  • Fever
  • Conjunctivitis- bilateral w/o exudates, painless
  • changes in hands and feet- erythema and swelling, followed by desquamation
  • mucous membrane involvement: swollen lips, pharyngitis, “strawberry tongue”
  • cervical adenopathy: often unilateral
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22
Q

If a question mentions “strawberry tongue” as an PE finding you should be thinking of??

A

Kawasaki disease

-mucosal membrane involvement

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23
Q

What are the complications of Kawasaki dx?

A
  • fatal coronary artery aneurysms
  • coronary lesions–thrombosis–MI
  • myocarditis/pericarditis
  • valvular dx
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24
Q

When do coronary artery aneurysms form during Kawasaki dx?

A

after day 10 of illness, peaks at 4 wks

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25
Q

Coronary artery aneurysms develop in ___ of kawasaki dx pts who go untreated

A

20-25%

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26
Q

What is the tx for Kawasaki Dx?

A

-IVIG
-Aspirin
high dose= acute phase
low dose= after acute phase
-Repeat ECHO’s (minimum: at 2wks and 6-8wks)

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27
Q

What is Infective Endocarditis?

A

An infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium or the septum

  • may lead to intractable CHF and myocardial abscesses
  • Fatal if left untreated
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28
Q

What are the 3 most common causes of infx endocarditis in PEDS?

A
  1. Streptococci Viridans
  2. staph aureus
  3. Fungal
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29
Q

What are the 3 most common causes of infx endocarditis in adults?

A
  1. streptococcus
  2. staphylococcus
  3. enterococcus
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30
Q

What is the most likely cause of acute endocarditis?

A

staph aureus

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31
Q

What is the most likely cause of subacute endocarditis?

A

streptococci viridans

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32
Q

What are the 5 major risk factors for IE?

A
  1. H/O congenital heart disease!!
  2. H/o prosthetic valve
  3. indwelling catheters
  4. h/o rheumatic heart disease
  5. IVDU (right sided valves)
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33
Q

What are the sxs of IE?

A 
FROM JANE
F- fever (97%)
R- Roth spots (eye hemorrhages)
O- Osler's nodes (Ouch! painful spots)
M- esp if new!!

J- Janeway lesions (non-tender hem. macules on hands and feet)
A- Anemia
N- Nail hemorrhage (splinter hem.)
E- Emboli

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34
Q

Duke’s Criteria is used to dx what disease? What does it include?

A

Used for infective endocarditis

Need 2 major OR 1 major and 3 minor OR 5 minor

Majors:

  • 2/3 full sets of blood cultures positive with a typical microorganism
  • positive ECHO

Minor:

  • predisposing risk factor
  • fever >38
  • evidence of embolism
  • immunological problems: glomerulonephritis, Osler’s nodes
  • Positive blood culture (that doesn’t meet a major criterion)
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35
Q

What is the work-up for Infective Endocarditis?

A 
CBC
CMP
Blood cultures x3
ESR
CRP
Lactate
ECHO
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36
Q

Why are the valves most commonly affected by endocarditis?

A

Because they have no blood supply

-more likely to adhere to prosthetic or damaged valves

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37
Q

What is the treatment for IE?

A
  • Start BS ABX immediately
  • Hospitalization
  • ID consult
  • anticoagulation is NOT recommended
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38
Q

What is the prophylaxis tx for IE?

A

Oral amoxicillin 1 hr before the procedure

If pen allergic:

  • Azithromycin
  • clarithromycin
  • Clindamycin
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39
Q

What is heart failure?

A

When the heart fails to meet the circulatory and metabolic demands of the body
-can result from volume/pressure overload (congestion) or from an abnormality of the ventricular myocardium (hypertrophic, restrictive, infiltrative)

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40
Q

What are the sx of HF in a peds pt?

A
  • tires easily feeding
  • periorbital edema, wg not consistent w/ growth chart
  • rales and rhonchi
  • dyspnea, orthopnea, tachypnea
  • diaphoretic/sweating
  • tachycardia
  • failure to gain weight–late SX
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41
Q

What is the tx for pediatric HF?

A

no good standard approach

must be targeted at underlying cause

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42
Q

What are the 2 fetal shunts that exist to bypass the fetuses non-functioning lungs?

A
  1. Foramen ovale: b/w atria

2. Ductus Arteriosus: connects the pulm artery to the descending aorta

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43
Q

What fetal shunt allows oxygenated blood from the placenta to bypass the liver?

A

Ductus Venosus: shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava

44
Q

What type of shunt produces a cyanotic baby?

A

R–L shunt or parallel circuit

45
Q

What type of shunt produces acyanotic baby?

A

L–R shunt or obstruction

46
Q

What are the six types of acyanotic defects? (L–R shunts)

A
  1. Atrial Septal Defect (ASD)
    - patent foramen ovale (PFO)
  2. Ventricular spetal defect (VSD)
  3. Patient ductus arteriosis (PDA)
  4. Pulmonary stenosis (PS)
  5. Coarctation of the aorta (CoA)
  6. Aortic stenosis (AS)
47
Q

What are the six types of acyanotic defects? (L–R shunts)

A
  1. Atrial Septal Defect (ASD)
    - patent foramen ovale (PFO)
  2. Ventricular spetal defect (VSD)
  3. Patient ductus arteriosis (PDA)
  4. Pulmonary stenosis (PS)
  5. Coarctation of the aorta (CoA)
  6. Aortic stenosis (AS)
48
Q

What is an Atrial Septal defect?

A
  1. oxygenated blood is shunted from the L to R side of heart via defect
  2. Inc. in blood vl in right side of heart leads to R sided hypertrophy
  3. causes extra blood to pass through the pulm artery into lungs–pulm HTN–CHF
49
Q

Do most peds with an ASD defect have sx?

A

No most are asymptomatic

However, roughly 70% develop sx by 40 yos

50
Q

What are the complications if an ASD goes unrecognized/untreated?

A
  1. CHF
    - poor growth
    - SOB
  2. cor pulmonale is a rare and late occurrence (R heart failure due to pulm HTN)
51
Q

What is the MUST KNOW heart sound associated with an ASD?

A

Widely split and fixed S2 (duhhhhh)

52
Q

What is the 1st line dx test for ASD?

A

ECHO

53
Q

What is the tx for an ASD if the pt is symptomatic?

A

refer to cardiology

54
Q

What is the tx for an ASD if the pt is asymptomatic?

A

Get an ECHO then discuss with cardiology

55
Q

Roughly ___ of ASDs will spontaneously close within the 1st year

A

40%

56
Q

ASDs present after ___ will not spontaneously close

A

2 yrs

57
Q

What is the tx of an ASD plus CHF in a peds patient?

A

Same as adults:

-diuretics and ACEIs

58
Q

When is surgery necessary for an ASD?

A

Immediately if larger–assoc. w/ HF

age 1-3 if stable

59
Q

What is a foramen ovale defect?

A

Small flaplike opening b/w the atrial septa (ASD) that allows blood flow from R–L atria (too small to cause cyanosis)

60
Q

Does a foramen ovale defect close on its own?

A

Generally yes, shortly after birth.
If not it is referred to as a patent foramen ovale (PFO) which is a type of ASD.
-about 25% of people have PFO
-rarely cause sx

61
Q

What is the most common congenital heart defect?

A

Ventricle Septal Defect

62
Q

Which way is blood shunted in a ventricle septal defect?

A

Left to Right

63
Q

What is the result of the increased amount of blood entering the right side of the heart due to a VSD?

A

right sided hypertrophy

64
Q

With a VSD:
More blood is returning to the right side of the heart which also means more blood is going through the pulmonary artery into the lungs than usual…what does this cause?

A

Pulmonary hypertension which causes congestive heart failure

65
Q

If a patient has a small VSD they will be?

A

Asymptomatic and 90% close spontaneously by age 6

66
Q

How will a pt with a large VSD appear?

A

Sick! show up in ED by 6 mos

  • not eating
  • poor growth
  • SOB
  • recurrent respiratory infx
  • Need surgery!
67
Q

What is going to be the dx test of choice for all CHDs?

A

ECHO

68
Q

What is the prognosis for a VSD?

A

Very good!

69
Q

What is Eisenmenger syndrome?

A

Refers to any untreated congenital cardiac defect with in intracardiac communication that leads to pulm HTN, reversal of flow and cyanosis. L to R shunt is converted to R to L shunt secondary to elevated pulm artery pressures and associated pulm vascular dx

70
Q

What is a patent ductus arterious?

A
  • L to R shunt
  • connection b/w the aorta and pulm artery
  • causes right hypertrophy due to excess blood going through right side
  • same with pulm art—pulm htn—CHF
71
Q

PDA usually closes ___ after birth

A

1-5 days

72
Q

Why in some cases do you want the PDA to remain open?

A

It is often present with more serious CHD’s and without it the baby would not be viable due to lack of oxygenated blood

73
Q

What is the murmur associated with a PDA?

A

Rough, continuous machine-like murmur at left 2nd ICS

74
Q

What medication keeps a PDA open?

A

Prostaglandin E1

75
Q

What medication closes a PDA

A

NSAIDS (inhibits prostaglandins)

76
Q

What is the general rule for treatment for all of these CHD?

A

Refer to cardiology
Surgery is necessary if symptomatic
If asymptomatic monitor closely with ECHOs

77
Q

What is coarctation of the aorta (CoA)?

A

Narrowing in the aortic arch causing obstruction of left ventricular blood flow

This results in L ventricular hypertrophy and decreased systemic blood flow

78
Q

What are sx of CoA?

A 
Severe: CHF and CV collapse
Mod: 
-absent or weak fem pulses**(I have this starred!)
-leg cramps
-chronic pulm congestion
-HA
-epistaxis
-BP discrepancies
-differential cyanosis (pink U and blue LE)
79
Q

What is the murmur associated with a CoA?

A

Blowing systolic murmur that radiates to the back or left axilla. Ejection click if pt has concurrent bicuspid aortic valve (80%)

80
Q

How can a CoA be clinically dx?

A

weak or absent femoral pulses

81
Q

What is the tx for newborns in extremis with CoA?

A
  • resuscitation
  • prostaglandins (keep PDA open)
  • inotropic drugs (increase squeeze)
82
Q

Aortic stenosis causes?

A

left ventricle hypertrophy

83
Q

What are the 3 types of aortic stenosis?

A
  1. valvular
  2. subvalvular- membranous or fibrous ring
  3. supravalvular- constriction of the ascending aorta obs flow
84
Q

What type of murmur is associated with AS?

A

high pitched crescendo-decrescendo systolic ejection murmur that radiates into the neck
-systolic click at apex

85
Q

What is pulmonic stenosis?

A

narrowing of entrance into pulm artery–increased R vent pressure

86
Q

What type of murmur is present in mod to sev pulm stenosis?

A

widely split S2 w/ sys ejection click at LSB and radiates to back

87
Q

What are the 6 cyanotic CHDs?

A

5 Ts and 1 E

88
Q

What are the four problems associated with Tetra(4)logy of Fallot (ToF)?

A
  1. Pulm stenosis
  2. RV hypertrophy
  3. Large, overriding aorta
  4. VSD
89
Q

What type of shunt is a ToF and what is the major concern with it?

A

R to L

  • limitation of pulm blood flow
  • oxygen-poor blood enters the aorta w/ varying degrees of hypoxemia
90
Q

What is the most common cyanotic CHD?

A

ToF (wont be profoundly blue)

91
Q

What are the sx of ToF?

A
  • progressive cyanosis
  • irritability, poor feeding, BUT growth and development are usually not delayed
  • hypoxemic spells–“tet spells”
  • loud, rough sys ejection murmur that radiates to the back
92
Q

If a test question mentions a boot shaped heart you are thinking of??

A

ToF

93
Q

What are the tx options for ToF?

A

Depends on the presenting sx–aggressive or palliative

  • prostaglandin infusion (keep PAD open)
  • Beta blockers (slow HR)
  • emergency systemic to pulmonary shunt
  • complete repair (open heart)
94
Q

What is Tricuspid atresia?

A

Tricuspid valve is missing–no flow between RA and RV
Blood must flow from the RA to the LA through an ASD and a VSD is present to pump blood btw the ventricles

They will be very blue at birth!

95
Q

What would a CXR show in a bebe with tricuspid atresia?

A

an enlarged RA

96
Q

What is the tx for Tricuspid atresia?

A

Medical: prostaglandin infusion to keep PDA open and diuretics

Surgical: major cardiovascular surgery

prognosis is guarded

97
Q

What is Transposition of great vessels?

A

aorta arises from the right ventricle, and the pulm artery arises from the left ventricle—completely incompatible with life unless there is a ASD, VSD, or PDA that allows mixing

98
Q

What is the degree of hypoxia dependent upon in a TGA?

A

the degree of mixing

Infants whose PDA has closed and who have a small ASD will be intensely cyanotic

99
Q

You are delivering a baby (like the badass you are) and it comes out blue…(oh shit) you remember Prof Jaynsteins lecture on CHD and you’re thinking it probably has Transposition of Great Vessels…will putting oxygen on the lil bebe help?

A

Nope! if it is TGA, hypoxia does not respond to O2 administration

PANCE loves this one (so I heard in lecture)

100
Q

What is a Totally anomalous pulmonary venous return (TAPVR)?

A

Instead of the pulm veins returning oxygenated blood to the left atrium, they empty into the systemic venous system

101
Q

What must be present for a TAPVR to be compatible with life?

A

ASD or PFO

102
Q

What is truncus arteriosus?

A

A single arterial trunk arises from both ventricles that supplies the systemic, pulmonary and coronary circulation
-VSD is always present

103
Q

What are the sx of truncus arteriosus?

A

Min cyanotic but in HF at birth
Systolic thrill at LSB
Loud, early sys click w/ a single S2
Need an ECHO and surgery

104
Q

What is Ebstein’s anomaly?

A

The tricuspid valve is abnormal and inserts well down into the RV. There is often severe tricuspid regurgitation which can lead to death of fetus or infant

105
Q

What is a dx finding of Ebsteins anomaly on a CXR? EKG?

A

“wall to Wall heart”

Right atrial enlargement, RBBB

RRCCPA Clin Med Exam 4 (20 decks)

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