Week 4 - Cardiovascular

Question 1

Kawasaki disease

Answer 1

Acute generalized systemic small and medium vessel vasculitis occurring throughout the body. Macrophages invade the vasculature

Question 2

Symptoms of Kawasaki Disease

Answer 2

Persistent fever for at least 5 days plus four of the following:

• bilateral conjunctival redness
• changes of the lips and oral cavity
• cervical lymphadenopathy
• polymorphous exanthema (swelling of the hands or feet) or perineal area

Question 3

Six components when suspected Kawasaki’s disease but no complete diagnosis

Answer 3

1. albumin ≤3.0 g/dL;
2. urine ≥10 WBC/HPF;
3. platelet count ≥450,000 after 7 days of fever;
4. anemia consistent with age values;
5. total white blood cell count ≥15,000/mm3; and
6. elevation of alanine aminotransferase.

Question 4

Kawasaki’s disease - acute phase

Answer 4

• Conjunctival hyperemia
• erythematous rash of hands and feet
• unilateral lymph node swelling

Question 5

Kawasaki’s disease -subacute phase

Answer 5

• Fever, rash and cervical lymphadenopathy abate
• Arthralgias
• Desquamation of the skin over the fingertips
• Thrombocytosis (elevated platelets)
• Cardiac disease

Question 6

Kawasaki’s disease -convalescent phase

Answer 6

• Starts around day 25
• Elevated ESR
• Abnormalities of the coronary vessels
• Myocarditis

Question 7

Diagnosis of Kawasaki’s Disease

Answer 7

Diagnosis of exclusion. May run CBC with differential, ESR, CRP

Question 8

Management of Kawasaki’s disease

Answer 8

1. IVIG therapy
2. High dose ASA for anti inflammatory properties
3. Second dose IVIG
4. Anticoagulation if coronary aneurysm is present
   a. Warfarin
   b. clopidogrel

Question 9

Atrial Septal defect s/s

Answer 9

asymptomatic; older children may have fatigue, exertional dypnea, be thin, history of frequent URI or pneumonia

Question 10

Atrial septal defect PE

Answer 10

1. Murmur not noticed until 2-3
2. Mild left anterior chest bulge
3. S1 normal or split
4. S2 widely split
5. Grade 1-4 rating, medium pitched, not harsh systolic crescent-decrescendo

Question 11

Diagnostics for atrial septal defect

Answer 11

X-ray shows cardiac enlargement

Question 12

Management of atrial septal defect

Answer 12

1. small defects may close on own
2. large defects require closure through cardiac catheterization
3. Aspirin or clopidogrel

Question 13

Ventricular septal defect

Answer 13

Opening in septum between ventricles; most common congenital defect; most close spontaneously

Question 14

Ventricular septal defect PE

Answer 14

1. Low pitch grade 2-6 holosystolic murmur
2. Thrill on left sternal border
3. Signs of progressing CHF
4. S3 or s4 gallop

Question 15

Ventricular septal defect S/S

Answer 15

asymptomatic with small to moderate openings

infants with large openings exhibit symptoms (dyspnea, respiratory infections, diaphoresis, fatigue)

Question 16

Ventricular septal defect diagnosis

Answer 16

Chest x-ray shows normal or enlarged heart depending on the size of the defect

Question 17

Management for heart defects

Answer 17

Small defect – monitor Q6 months

Large defects – diuretics, ACE, Beta blockers, monitor intake and weight gain, teach s/s of HF, surgery to repair

Question 18

Left sided systolic heart failure

Answer 18

Heart cannot pump enough blood to supply the body – walls of the ventricle are thin and weak, unable to pump out meaning blood remains in the ventricle reducing output

Question 19

Causes of left sided systolic heart failure

Answer 19

a. structural defects of heart valves
b. disease of heart muscle (cardiomyopathy)
c. arrhythmias
d. heart attack

Question 20

Right sided systolic heart failure

Answer 20

1. Walls of right ventricle are think and weak, unable to pump blood out, reduced cardiac output
2. Commonly caused by left sided heart failure

Question 21

Risk factors for right sided systolic heart failure

Answer 21

a. HTN
b. CAD
c. Metabolic syndrome
d. DM
e. Structural heart abnormalities

Question 22

Symptoms of right sided systolic heart failure

Answer 22

a. Fatigue
b. Weakness
c. SOB
d. Swelling of lower limbs
e. Decreased alertness
f. Reduced ability to exercise

Question 23

Characteristics of heart murmur

Answer 23

1. intensity - easily heard upon auscultation, soft, no thrill
2. timing - systolic
3. location - pulmonic area
4. radiation - also heard in the left axilla
5. quality - harsh crescendo-decrescendo
6. duration - heard in mid systole
7. pitch - medium sound

Question 24

Grades of heart Murmur

Answer 24

A grade 1 murmur is barely audible.

A grade 2 murmur is soft but easily audible.

A grade 3 murmur is louder but is not accompanied by a thrill.

A grade 4 murmur is loud with a palpable thrill.

A grade 5 murmur can be heard with the stethoscope partially off the chest and a thrill is palpable.

Finally, the grade 6 murmur is audible without a stethoscope.

All murmurs louder than grade 3 are pathological.

Question 25

Peripheral pulmonary stenosis murmur

Answer 25

usually heard at 1 to 2 months if the blood vessels to the lungs are small. This type of murmur resolves around 6 months of age. Soft blowing sound.

Question 26

Flow murmur

Answer 26

more common in 8- to 14-year-olds with thinner chest walls and is the sound of normal blood flow. Early to mid systolic, decreases with standing increases with CO. Soft blowing sound.

Question 27

Still’s murmur

Answer 27

most common between the ages of 2 and 6. This murmur has a musical characteristic and usually resolves by age 12. Short, vibratory, musical “twangy string” sound

Question 28

Venous hum

Answer 28

common between the ages of 2 and 8 and is the normal blood flow through the veins of the upper chest. It disappears with the turning of the head or jugular vein compression. All these murmur types are innocent.

Question 29

Qualities that may indicate pathological murmur

Answer 29

1. Murmur in child with CHD 2. Diastolic murmur 3. Systolic murmur with thrill 4. Pansystolic murmur 5. Continuous murmur (not suppressed with pressing carotid) 6. Systolic clicks 7. Opening snaps 8. Fixed splitting 9. Accentuated s2 10. Not positional 11. Grade 4 or higher 12. Harsh quality

Question 30

Hypertension in a child

Answer 30

Systolic, diastolic or both in the 95%+ percentile for age, sex and height on at least three separate occasions Over age 13, 130/80 is considered hypertensive

Question 31

Things to assess when looking at HTN in a child

Answer 31

1. Neonatal history 2. Prior hospitalizations or trauma 3. Diet and exercise 4. Sleep history (OSA) 5. Medications 6. Chronic illnesses 7. Headache, chest pain, dyspnea 8. History for family – HTN, MI, stroke, DM, HLD

Question 32

Hypertension PE

Answer 32

1. BMI, growth 2. Edema, pallor, flushing 3. Pulses upper and lower 4. Elevated BP on 3+ occasions

Question 33

Diagnostics HTN in a child

Answer 33

1. Search for secondary causes of HTN (renal function, plasma renin levels) 2. CBC, ESR, CRP, UA & culture, electrolytes, BUN, creatinine, plasma renin

Question 34

Treating HTN in children

Answer 34

1. BP check annually 2. Two follow-up measurements within 1-2 months 3. If overweight a. Caloric restriction b. Exercise 30-60 min per day w/relaxation techniques c. Avoid smoking, caffeine, drug and alcohol intake 4. If HTN persistent refer to cardiology for treatment (ACE, ARB, beta blocker, CCB, diuretic)

Question 35

Sickle Cell Disease

Answer 35

Vaso-occlusion of blood vessels and periods of inadequate supply to the body’s tissues. Can impact all parts of the body Caused by mutated gene that causes abnormal hemoglobin which are sickled and stick more easily to vessel walls causing interrupted blood and oxygen flow.

Question 36

S/S of sick cell disease

Answer 36

1. Chronic pain 2. Anemia 3. Frequent infections 4. Delay of growth and puberty 5. Underweight 6. Fatigue 7. Swollen hands and feet 8. Eye problems (blocked vessels in the retina)

Question 37

Education for patients with sickle cell disease

Answer 37

1. Fluid intake – dehydration an trigger a crisis 2. Avoid infection – good hand hygiene and avoiding sick people 3. Activity – moderate activity with rest – hypoxia can trigger crisis 4. Rest and adequate nutrition 5. Maintain immunizations 6. Wear medical identification 7. Avoid the cold and elevation – they can be triggers 8. Pain control with crisis – tyelnol, advil, narcotics 9. Daily folic acid 10. Penicillin V prophylaxis daily until age 5

Question 38

How is sickle cell anemia diagnosed

Answer 38

Diagnosis via isoelectric focusing (IEF), hemoglobin electrophoresis, or sickle solubility testing