Questions from Nelson

Question 1

When does the PFO close functionally in most normal neonates?

a) within 48 hours
b) within 3 months
c) within 6 months
d) within 1 year

Answer 1

b) within 3 months closes functionally in most healthy neonates
can pass a probe through the overalapping flaps in large percentage of children and 15-25% of adults

Question 2

What is the most important factor controlling the closure of the PDA in a full term neonate?

a) oxygen
b) CO2
c) amount of prostaglandin being released
d) increase in SVR

Answer 2

a) oxygen is the most important factor controlling ductal closure in the term neonate
when blood passing through the ductus has a paO2 of 50 mmHg, it causes the ductal awl to contract (effect may be direct or mediated by effects on prostaglandin synthesis)

Question 3

How many infants with congenital heart disease have extra cardiac manifestations?

a) 5-10%
b) 10-20%
c) 20-45%
d) 50%

Answer 3

c) 20-45% of patients with congenital heart disease have extra cardiac manifestations
5-10% have known chromosomal abnormality

Question 4

Which of the following conditions does not usually produce bounding pulses?

a) PDA
b) AV fistula
c) anemia
d) cardiomyopathy

Answer 4

d) cardiomyopathy has decreases pulses in all extremities
Nelson pg 1958
increased pulses with wide pulse pressure
- PDA, aortic insufficency, AV ommunication, increased cardiac output (from anemia, anxiety, increased catecholamine or thyroid)
Decreased pulses
- pericardial tamponate, LVOT obstruction, cardiomyopathy

Question 5

Which of the following lesions does not have a wide splitting of S2

a) ASD
b) pulmonary stenosis
c) pulmonary hypertension
d) right bundle branch block

Answer 5

c) pulmonary hypertension

wide splitting - ASD, pulmonary stenosis, Ebstein anomaly, TAPVR, RBBB
narrow splitting - pulmonary hypertension with accentuated pulmonic component of second sound
Single 2nd sound: pulmonary or aortic atresia (or SEVERE stenosis), truncus arteriosus, transposition

Question 6

Which of the following is unlikely to cause a pan systolic murmur?

a) tricuspid valve insufficiency
b) aortic valve stenosis
c) VSD
d) mitral valve insufficiency

Answer 6

b) aortic valve stenosis - systeolic ejection murmur, between 1st heart sound and 2nd, if severe, it CAN extend beyond the second heart sound
systolic ejection murmur - imply increased flow or steonis across ventricular outflow (aortic or pulmonic valve)
**clear 1st hear sound - most likely to be ejection murmur

vs.

pansystolic or holosystolic - behind WITH the 1st heart sound continue throughout systole, occasionally decrescendo.

to remember: after closure of AV valves (tricuspid/mitral) brief period where ventricular pressure increases but semilunar valves (aortic and pulmonic) stay closed) during isovolumic contraction THEREFORE pansystolic murmurs CANNOT be related to problems with aortic or pulmonic valves (semilunar valves)
instead, pan systolic murmurs caused by blood exiting the ventricle via a abnormal opening (VSD) or AV valve insufficiency (mitral/tricuspid)

Question 7

Which of the following is not generally the cause of a loud murmur?

a) severe anemia
b) extra cardiac AVM
c) anomalous insertion of a coronary artery
d) myocarditis

Answer 7

c) does not usually cause a loud murmur (Nelson 1864)
loud murmurs without structural heart disease : i.e. non cardiac AVM, myocarditis, severe anemia or hypertension
may not have loud murmur in patients with severe aortic steonosis, ASD, anomalous pulmonary venous return, AVSD, anomalous insertion of a coronary artery, coarctation

Question 8

Which of the following is the most common innocent heart murmur in children?

a) vibratory, musical Still’s murmur
b) venous hum
c) pulmonary flow murmur
d) peripheral pulmonary stenosis

Answer 8

a) most common innocent murmur - medium-pitched, vibratory or musical stills murmur, relatively short systolic ejection murmur, heard best along left lower and mid sterna border, no radiation to apex, base or back
age 3-7 year old most common, intensity of the murmur often changes with respiration and position
less loud in the sitting or prone position (vs organic lesion usually louder when heart brought closer to the surface)

Innocent pulmonary murmurs: children/adolescents - high pitched, blowing brief early systolic murmurs grade 1-2 intensity, best detected in the 2nd left parasternal space

Venous hum: turbulence of blood in the jugular venous system, heard in the neck of anterior test , varies with position of head

more than 30% of children may have an innocent murmur at some point

Question 9

Which of the following ECG findings is abnormal and needs further evaluation for cardiac anomaly?

a) newborn with right axis deviation
b) 2 month old with upright T waves in V1, V3R and V4R
c) newborn with upright T waves in V1, V3R and V4R
d) 7 year old with upright T waves in V1, V3R and V4R

Answer 9

b) upright T waves generally disappear by 48 hours, and should become downward by 1 week at the latest. Upright T waves in V1, V3R and V4R which reflect the right ventricle forces, are abnormal BEFORE age 6, and raises suspicion for RVH even without other voltage criteria
may remain negative into adolescence

Question 10

Which of the following conditions is not associated with a broad P wave?

a) Ebstein anomaly
b) VSD
c) PDA
d) severe mitral regurgitation

Answer 10

a) Ebstein is associated with RIGHT atrial enlargement, which is shown by TALL P waves (>2.5 mm) which are narrow and spiked

left arial enlargement - broad P wave, including bifid P wave
causes -L->R shunt (VSD, PDA), mitral regurg/severe stenosis (because blood spills back into left atrium causing it to get bigger)

Question 11

What is the normal axis of a newborn baby on ECG?

a) +150 to + 220 degrees
b) +110 - +180 degrees
c) +30 to + 120 degrees
d) +10 to +90 degrees

Answer 11

b) is the normal axis 110-180 degrees (according to Nelson, different in different sources)

+30 to +120 is for 1-3 month old
+10 to +90 is 3-6 month old

as kid gets older the axis gets more and more leftward as the pulmonary pressures fall and the pressures change

Question 12

Which of the following factors does not increase the risk of cerebral vein thrombosis in patients with cyanotic heart disease?

a) iron deficiency
b) dehydration
c) hot weather
d) decreased dose of diuretic

Answer 12

d) decreased dose of diuretic

patients with R-L shunting cyanotic heart disease are at risk of thrombosis because of polycythemia (Hct >65%) especially of the cerebral veins
this risk increase with dehydration (so need to be careful in hot weather and with GI illnesses) and the risk can worsen with iron deficiency
may need to decrease dose of diuretic when their is concern of fluid intake

Question 13

What causes the systolic murmur in an ASD?

a) increased flow across the tricuspid valve
b) flow across the ASD
c) increased blood flow via right ventricle outflow tract to the pulmonary artery
d) increased blood volume in right ventricle in diastole

Answer 13

c) increased blood flow via right ventricle outflow tract to the pulmonary artery causes the murmur, not the low-pressure flow across the ASD (Nelson 1884)

diastolic murmur produced by increased volume of blood across the tricuspid valve (left lower sternal border tricuspid area where it is heard best)
increased blood volume in right ventricle in diastole (vs normally with inspiration only) leads to fixed split S2

Question 14

What are the EKG findings in Pompe disease?

a) long PR, low voltage QRS
b) short PR, high voltage QRS
c) LVH
d) none of the above

Answer 14

b) short PR, high voltage QRS
Echo shows hypertrophic cardiomyopathy

Pompe disease: glycogen storage disease in lysosomes
infantile form very severe/fatal
often presents with hypotonia, macroglossia, feeding difficulties, hepatomegaly
Labs: increased CK, AST, LDH
diagnosis: demonstrate acid alpha glucosidase deficiency

Question 15

Which of the following syndromes is not commonly associated with pulmonary stenosis?

a) Noonan
b) Alagille
c) Trisomy 18

Answer 15

c) Trisomy 18
the other 2 are commonly associated with PS
- associated with Noonan syndrome – PS as a result of valve dysplasia
- associated with Alagille syndrome – PS of valve or branch pulmonary arteries

Question 16

Which of the following findings is not associated with pulmonary stenosis with an intact septum in a 5 year old?

a) cyanosis
b) systolic ejection murmur loudest at the LUSB
c) pulmonic click
d) split S2
e) upright T wave in V1 in a 5 year old

Answer 16

a) cyanosis is not associated with PS even with small hole, as long as there is no septum defect available for shunting
ONLY in critical pulmonary stenosis (in the neonate) we may see some cyanosis because the PFO is around for shunting to happen

the rest are findings of PS
upright T wave in V1 - indicates RVH (should be inverted till about 6-8 year old)

Question 17

Which of the following is the least likely finding of severe pulmonary stenosis with intact ventricular septum?

a) pulmonary hypertension
b) hepatomegaly and peripheral edema
c) tall spiked P waves on ECG
d) severity graded on the ratio of pulmonary pressure to the systemic pressure

Answer 17

a) pulmonary pressures are either normal or decreased - remember that because the hole is so small, not much blood can get through so the pressure can’t be high

the others - LVR and peripheral edema can be from right heart failure (since the blood can’t get through to the lungs it backs up into the RA and then the body)

do remember that findings can vary based on the severity of the lesion
treatment: usually ballon valvuloplasty

Question 18

Which of the following about aortic stenosis is false?

a) if moderate -severe, no competitive sports
b) supravalvular AS is associated with Williams syndrome
c) can present in infancy with heart failure and shock like state
d) needs endocarditis prophylaxis prior to repair

Answer 18

d) does not as per the new guidelines (double check)

however if there was a prosthetic valve then would need

Question 19

A child presents with peripheral pulmonary stenosis and hypercholesterolemia, which of the following is not associated with the likely syndrome present in this child ?

a) hypercalcemia
b) butterfly vertebrae
c) liver disease
d) growth defect

Answer 19

a) NOT hypercalcemia, this is part of Williams syndrome not Alagille

Alagille: Jagged 1 gene
liver problem and PPS
peripheral pulmonary stenosis , liver disease, hypercholesterolemia, peculiar facies, butteryfly vertebrae and growth defects
high cholesterol though to be from LVR disease

Question 20

Which of the following statements is false?

a) blood pressure in the legs is normally 10-20 mmHg higher than in the arms
b) the femoral pulse is normally felt after the radial pulse
c) blood pressure should be done in BOTH arms to rule out coarct
d) with severe coarctation, one can have palpable femoral pulses and no BP gradient , as well as pulmonary congestion

Answer 20

b) FALSE - normally, femoral pulse is slightly before, in radio femoral delay (which happens in coarctation) femoral is felt after because the lower limbs blood supply is via collaterals, which are slower

the rest are true
c) because if the coarctation is in the region of the left subclavian, may have right arm BP>left arm

d) truein differential cyanosis in coarctation, RV blood goes via the ductus to supply the descending aorta, since blood is getting there, you will palpate femoral pulses and there may not be BP gradient, there will be a saturation gradient though because the lower limbs won’t be getting as much O2 (pre ductal >post ductal)

remember AS (can be critical with shock like picture, severe heart failure) vs coarct (differential cyanosis and BP, decreased lower limb pules, can get heart failure signs; in infants if super severe can result in similar picture as AS with hypo perfusion, acidosis and severe heart failure )

Question 21

Which of the following is not associated with PHACE syndrome?

a) posterior fossa brain anomalies
b) facial hemangiomas
c) arterial anomalies
d) coarctation of the aorta
e) ear anomalies

Answer 21

e) false - in fact it is eye anomalies
the others are features
can also have other cardiac problems
the risk with this syndrome is stroke

Question 22

What are two causes of short PR

Answer 22

1. glycogen storage disease - i.e. Pompe

2. where you bypass AV node - i.e. WPW

Question 23

Causes of prolonged QT

Answer 23

hypocalcemia
severe hypokalemia
prolonged QT syndrome
drugs - including quinidin erythromycin TCAs etc (look at detailed answer in questions)

Question 24

true or false - digoxin is a good choice in WPW

Answer 24

no, digoxin is contraindicated in WPW

Question 25

Treatment of 3rd degree heart block

Answer 25

depends on ventricular rate and presence of symptoms

often needs a pacemaker

Question 26

most common congenital heart diseases

Answer 26

VSD 25%
ASD 10% (secundum is most common - at the PFO area), then primum (which is near AV canal) then sinus venous
PDA (5-10%, excluding prems)
pulmonary stenosis 10%
Aortic stenosis 5%
Coarctation - 10%
TOF - most common cyanotic - 10%
transposition - 5% (but most common to present in newborn out of the cyanotic lesions)
tricuspid atresia - 2%
truncus <1% of all cases
Hypoplastic left heart - 1% - but most common cause of death from cardiac defcects in first month

Question 27

Findings in VSD

Answer 27

small VSD - normal ECG and CXR
large VSD: get increased volume on left side of the heart - Left atrial and ventricular enlargement and hypertrophy (since increased blood going to lungs via VSD and coming back to La and LV.
can get pulmonary hypertension from increased flow/PVR

Question 28

how many VSDs close spontaneously

Answer 28

1/3 can close, small ones usually do
initial treatment for moderate to large: diuretics, after load reduction
surgery if poor growth or pulmonary hypertension

Question 29

ASD findings?

Answer 29

grade 1 -2 systolic ejection murmur at right ventricular outflow tract , and fixed split S2
ECG: increased blood flow into right atrium, right ventricle, pulmonary arteries and lungs
ECG might show RVH and right axis deviation

Question 30

why fixed split S2 in ASD

Answer 30

overload of right ventricle with prolonged ejection into pulmonary circuit
larger shunt, might get a mid-diastolic murmur also

Question 31

management of ASD

Answer 31

if lots of shunting by age 3, then consider closure

use a device for secundum, surgery for primum and sinus venous

Question 32

true or false - it is common for a PDA to close spontaneously in term infants after a few weeks of age

Answer 32

false - not common for it to close after a few weeks of age in full-term infants
controversy whether small asymptomatic PDAs need to be closed

Question 33

AVSD ECG findings

Answer 33

LVH (since have tones of blood in LV)
combined ventricular hypertrophy
may show combined atrial enlargement

Question 34

symptoms in mild pulmonary stenosis?

Answer 34

mild pulmonary stenosis is usually asymptomatic
moderate to severe in exertional dyspnea and easy fatigability
newborns might shunt right to left and be even cyanotic with severe stenosis
can be valvular, subvalvular or supravalvular

Question 35

Clinical and ECG findings in pulmonary stenosis

Answer 35

systemolic murmur at second left intercostal space - radiates to back
might have a thrill
can hav e widely split S2 with a quiet pulmonary component
if more severe get RVH impulse at LLSB

Question 36

imaging in pulmonary stenosis

Answer 36

mild - nomal findings
moderate to severe - right axis deviation and RVH (so same as ASD)
hear size usually nomal, can have dilation of the main pulmonary artery

Treatment - if mild - usually doesn’t progress
if more significant - consider balloon valvuloplasty or surgical repair

Question 37

Where is the murmur of aortic stenosis

Answer 37

systolic ejection murmur
right second intercostal space
radiate to neck
systolic ejection click when it is a valve problem
Imaging: LVH with moderate/severe, can get dilation of ascending aorta or aortic known
Treatment: can get AI as progresses, need to follow, tx balloon valvuloplasty (although can often fail) surgery if doesn’t work

Question 38

Coarctation - associated abnormalities

Answer 38

hypoplastic aortic arches
abnormal aortic valves
VSD
symptoms when duct closes

Question 39

true or false - can present mainly with shock no murmur with coarct

Answer 39

true - if cardiac function is poor, might not notice mumur or BP gradient until you resuscitation
femoral pulses weaker and delayed compared to radial pulse

Question 40

story for an older kid presenting with coarctation

Answer 40

usually asymptomatic
may have history of leg discomfort with exercise, headache or epistaxis
hypertension, decreased lower extremity pulse or murmur may be present
abnormal aortic valve in 50% of the time

Question 41

how many people with coarctation have abnormal aortic valve

Answer 41

50% (unclear if this is only in oleo peeps)

Question 42

what cardiac abnormality is associated with rib notching in older kids

Answer 42

coarctation in oleo kids
will also see LVH and mild large heart in these kids

in younger kids - get RVSH and hypertrophy, with cardiomegaly and pulmonary edema

Question 43

treatment of coarct

Answer 43

young kids - prostaglandin, iotropes, diuretics, supportive care

Question 44

What is the core reason that tetralogy of fallout happens

Answer 44

abnormal septation of the truncus into the aorta and pulmonary artery at 3-4 weeks
features: pulmonary stenosis, VSD, RVH, overridding aorta
ECG findings: right axis deviation and RVH
boot shaped heart
5% have coronary abnormalities

Question 45

Tetralogy of fallout findings

Answer 45

may initially be cyanotic
initially usually have pulmonary stenosis murmur
amount of shunting right to left (bypassing lungs) and the degree of cyanosis increases as the degree of pulmonary stenosis increases
murmur becomes shorter and softer as the pulmonary stenosis gets worse

The ‘Tet spell’ (also called ‘hypoxic spell’, ‘cyanotic spell’, ‘hypercyanotic spell’ or ‘paroxysmal dyspnea’) most frequently occurs in young infants with Tetralogy of Fallot but may occur with other congenital heart defects that have pulmonary or subpulmonary stenosis and a VSD, and at any age. Common precipitants include crying, defecation, feeding, waking from naps (low systemic resistance), fever, dehydration, tachypnoea / tachycardia due to any cause, and medications (e.g. ACE inhibitors). They tend to occur in those with mild-to-moderate cyanosis at rest and are more common in children who are iron deficient.

They are characterised by:
· Period of uncontrollable crying / panic,
· Rapid and deep breathing (hyperpnoea),
· Deepening of cyanosis,
· Decreased intensity of heart murmur,
· Limpness, convulsions and rarely, death.

Hypercyanotic spells need to be recognised quickly and effectively controlled to prevent the development of serious complications from prolonged hypoxia. While medical intervention is indicated, many episodes are self-limiting. Those involved in the care of a child with Tetralogy of Fallot should be familiar with a spell’s presentation and early management.

Pathophysiology é

Hypercyanotic spells may be best thought of as an imbalance between pulmonary and systemic vascular resistance favouring decreased pulmonary flow and increased right-to-left shunting. Hypoxemia, metabolic acidosis, hyperpnoea, increased systemic venous return, catecholamines, and pulmonary vasoconstriction are thought to be involved in an interaction that results in a self-perpetuating cycle. Infundibular spasm is not required.

(from internet)

Question 46

kid with tetraology of fallot, kid becomes restless, agitated, cries, ambulatory kid squats , becomes cyanotic , treatment

Answer 46

knee to chest position - to increase venous return
morphine for pain control (will help to relax the pulmonary vessels and for sedation)
can try to increase the SVR with phenylephrine
**cyanotic spell - need surgery

Question 47

Risk factors for kids with unprepared tetralogy of fallout

Answer 47

increased cerebral thromboemolism
cerebral abscesses
(from right to left shunt )

Question 48

which cyanotic heart disease is most likely to present in newborn period?

Answer 48

transposition (even though it is only 5% of congenital heart defects)
remember that need to have a mixing lesion to be alive with transposition

Question 49

Transposition clinical features

Answer 49

cyanosis
quiet tachypnea and single S2 
ECG: right axis deviation and RVH 
increased pulmonary vascularity 
CXR: egg on a string

Question 50

management of transposition

Answer 50

prostaglandin
balloon atrial septostomy
arterial switch is the main surgery

Question 51

Tricuspid atresia ECG findings

Answer 51

no tricuspid so right side is teeny
left side bigger
therefore get LVH and axis will be superior (i.e. 0-negative 90) (which is left axis deviation i believe)
CXR - less blood flow
need to have VSD or PDA - way for the blood to get to lungs

Question 52

Surgery (BASICS) for tricuspid atresia

Answer 52

1. connect the subclavian artery to pulmonary - Blalock-Taussig
2. bidirectional cavopulmonary shunts and Fontan - connect the systemic venous return to the pulmonary arteries

Question 53

What determines how cyanotic someone with truncus is?

Answer 53

depends on how much pulmonary blood flow there is
if not diagnosed, the PVR might decrease and then get heart failure
usually will have a VSD below the truncal valve

Question 54

Imaging in truncus

Answer 54

combined ventricular hypertrophy and cardiomegaly

CXR: increased pulmonary blood flow may show displaced pulmonary arteries

Question 55

total anomalous pulmonary venous return what do they need to survive

Answer 55

atrial level communiation
2 types of TAPVR:
1. without obstruction of pulmonary venous drainage - may have minimal cyanosis and asymptomatic ; clinical : hyperactive RV impulse with widely split S2, systolic ejection murmur ; can also have a mid diastolic murmur from flow across the tricuspid valve
2. with obstruction - cyanosis, tachypnea, dyspnea, right sided heart failure ; may or may not have murmur or changes in S2
ECG findings: without obstruction: righ ventricular volume overload, increased pulmonary flow on CXR; if they have obstruction then right atrial and right ventricle are bigger (will have RAD and RVH) , left side is smaller, CXR will show increased pulmonary vasculature
if they have lots of obstruction of right sided flow, will present with hepatomegaly and other signs of right sided heart failure

Question 56

Treatment of TAPVR

Answer 56

pulmonary vein open into left atrium

Question 57

most common congenital cardiac disease cause of death in first month

Answer 57

HLHS

Question 58

Hypoplastic left heart findings on ECG

Answer 58

small left side, therefore RVH and decreased LV forces
can get cardiometagly (with increased right side) and can get increased pulmonary congestion and edema
depend on right to left shunt of PDA< as it constricts, the kid gets critically ill because get excess lung flow and no perfusion to body, weak pulses
usually no murmur
low cardiac output
why it happens: failure of development of the mitral or aortic valve or the aortic arch, small left ventricle can’t support

Question 59

Treatment of HLHS

Answer 59

prostaglandin supportive care
surgery:
norwood -
systemic source for lung circulation - bldnn/Fontain ext

Question 60

name extra cardiac complications of cyanotic congenital heart disease

Answer 60

1. polycythemia
2. relative anemia
3. CNS abscess
4. CNS thromboembolic stroke
5. gingival disease
6. gout
7. arthritis/clubbing
8. pregnancy - can have more trouble
9. infectious disease - i.e. RSV
10. poor growth
11. psychosocial

Question 61

Major findings in rheumatic fever

Answer 61

need either 2 major or 1 major and 2 minor
Major Criteria:
1. polyarthritis
2. chorea
3. subcutaneous nodules
4. erythema marginatum
5. carditis
Minor manifestations: fever, elevated ESR/CRP, arthralgias , increased leukocytes, prolonged PR interval
**and also need evidence of antecedent strep infection

Question 62

treatment of acute rheumatic fever

Answer 62

benzathine to eradicate the beta-hemolytic strep , long term penicillin prophylaxis then needed IM benzathin penicillin 1.2 million U q 28 days - ORAL not as effective

Question 63

prognosis in rheumatic fever

Answer 63

depends on extent of cardiac involvement
cardiac involvement gets worse with more episodes
what are the common manifestations:
pancarditis, valves, pericardium myocardium, can get tachycardia greater than explained by fever, new murmur of mitral or aortic insufficiency, heart failure

Question 64

Types of cardiomyopathy

Answer 64

1. dilated **most common, often idiopathic, may be due to infection (echo or Coxsackie) or be postinfectius, familial or secondary to systemic disease or to cardiotoxic drugs (i.e. doxorubicin, ipecac, iron, irradiation, cocarine, amphetamines)
2. hypertrophic : usually familial with autosomal dominant inheritance canb be sporadic
3. restrictive : rare, may be idiopathic or from systemic illness - i.e. amyloidosis , saroidosis ; storage disease (hemochromatosis, Frabry)

Question 65

Causes of dilated cardiomyopathy

Answer 65

infectius - most common are coxsackie and echo virus among others
metabolic
toxic
idiopathic

get decreased systolic function
posivie inotropes, diuretics, after load reduction, beta blockers, antiarrhthmics, anticoagulants, may need transplant

Question 66

Causes of hypertrophic cardiomyopathy

Answer 66

1. sporadic
2. inherited autosomal dominant

get diastolic dysfunction - i.e. the ventricle can’t fill
beta blockers and ca channel blockers are used to treat this

Question 67

Cause of restrictive cardiomyopathy

Answer 67

infiltrative - amyloidosis and sarcoidosis
non infiltrative - idiopathic, familial
storage disease - hemochromatosis, Fabry disease
endomyocardial disease

get diastolic dysfunction

Tx. : diureics, anti-coagulant, transplant

Question 68

which type of cardiomyopathy associated with prolonged QT

Answer 68

primary hypertrophic cardiomyopathy

ECG in hypertrophic cardiomyopathy will be abnormal but the changes are nonspecific

Question 69

ECG in dilated cardiomyopathy

Answer 69

non specific st-t wave changes, and LVH; RVH in 25% of cardiomyopathy

Question 70

ECG in restrictive cardiomyopathies

Answer 70

may show atrial enlargement on ECG

Question 71

Causes of pericarditis

Answer 71

1. infectious - viral most likely (include coxsackie, echo, mumps, influenza, EBV, CMV); bacterial more likely to be series - Staph aureus and strep most likely , also mycobacterium on the list
2. collagent vascular diseases: ie RA, SLE, RF, Kawasaki disease, scleroderma, mixed connective tissue disease, IBD
3. metabolic - uremia, hypothyroidism, chylopericardium
4. trauma - i.e. including postpericardiotomy syndrome
5. neoplastic
6. other - drug, pancreatitis, MI, thalssemia, CV perforation, heart failure, hemorrhage

Question 72

what position is most comfy for patient with pericarditis

Answer 72

sitting position, will also have chest pain worsened by lying down or with inspiration, dyspnea, malaise

Question 73

ECG findings in pericarditis

Answer 73

tachycardia
elevated ST segments
reduced QRS voltage
electrical alternans (variable QRS amplitude)

Treatment: if Hd significant - then do pericardiocentesis; for viral pericarditis, no specific treatment, other than anti-inflammatory meds

Question 74

Who should be checked for high cholesterol (kids)

Answer 74

2-10 year old with
1. family history of atherosclerosis or MI age <55
2. parent with high cholesterol
3. unknown family history
4. child with risk factors:
increased BMI, diabetes, hypertension, smokers, nephrotic syndrome
Treatment: lifestyle x 6 months then retest
medical treatment - usually not before 8 year old - start with statin
need to check liver enzymes and CK to do this