Cardiology Flashcards

Question

characteristic murmur of a small VSD

Answer 1

- loud, harsh, or blowing holosystolic murmur over the lower left sternal border - frequently accompanied by a thrill

Answer 2

- pulmonary blood flow and pulmonary hypertension result to dyspnea, feeding difficulties, poor growth, profuse perspiration, recurrent pulmonary infections, and cardiac failure in early infancy. - duskiness during infections or crying - Prominent left precordium - palpable parasternal lift, a laterally displaced apical impulse and apical thrust, and a systolic thrill.

Answer 3

small VSD: normal large VSD: cardiomegaly with prominence of both ventricles, the left atrium, and the pulmonary artery, increased pulmonary markings, pulmonary effusion, and pulmonary edema

Answer 4

- 30-50% of small defects close spontaneously during the 1st 2 yr of life - Small muscular VSDs are more likely to close (up to 80%) than membranous VSDs (up to 35%) - majority close before 4yo - infective endocarditis is a long-term risk

Answer 5

False. | Surgical repair is currently not recommended for patients with small VSD.

Answer 6

- should be encouraged to live a normal life, with no restrictions on physical activity - integrity of primary and permanent teeth should be carefully maintained

Answer 7

antibi otic prophylaxis is no longer recommended for dental visits or surgical procedures

Answer 8

- patients at any age with large defects in whom clinical symptoms and failure to thrive cannot be controlled medically; - infants between 6 and 12 mo of age with large defects associated with pulmonary hypertension, even if the symptoms are controlled by medication; -patients older than 24 mo with a Qp : Qs ratio greater than 2 : 1 - patients with supracristal VSD of any size because of high risk for aortic valve regurgitation

Answer 9

Viridans-type streptococci (α-hemolytic streptococci) and Staphylococcus aureus - no underlying disease: Staph - after dental procedure: viridans Strep - after lower bowel/ GU manipulation: grp D enterococci - IV drug user: Serratia marscesens, P. aeruginosa - indwelling catheter: CoNS

Answer 10

nonbacterial thrombotic embolus - fungating masses >1 cm are at greatest risk for embolization

Answer 11

Duke Criteria 2 major criteria, 1 major and 3 minor, or 5 minor criteria suggest definite endocarditis Major: (+) blood CS, echo evidence of endocarditis (intracardiac mass) Minor: predisposing conditions, fever, embolic-vascular signs, immune complex phenomena (glomerulonephritis, arthritis, rheumatoid factor, Osler nodes, Roth spots), a single positive blood culture or serologic evidence of infection, and echocardiographic signs not meeting the major criteria additional minor criteria: newly diagnosed clubbing, splenomegaly, splinter hemorrhages, and petechiae; a high erythrocyte sedimentation rate; a high C-reactive protein level; and the presence of central nonfeeding lines, peripheral lines, and microscopic hematuria

Answer 12

Target most common organisms: viridans strep and Staphylococci empiric: vanco+genta culture-guided: if highly susceptible, penG or ceftri+penG or ceftri+genta/vanco

Answer 13

patients with cardiac conditions, pxs with prosthetic valves, pxs wit previous IE - prophylaxis for gastrointestinal or genitourinary procedures is no longer recommended in the majority of cases. Prophylaxis for patients undergoing cardiac surgery with placement of prosthetic material is still recommended.

Answer 14

C The murmur may represent a PDA. If the PDA closed, marked cyanosis would supervene and result in acidosis, shock and death. PGE1 maintains patency of the ductus arterious between the pulmonary artery and the aorta.

Answer 15

D Pulmonary atresia Pulmonary atresia is manifested by a small RV, decreased pulmonary vascular markings, early marked cyanosis without heart failure, and ductul dependence to maintain some pulmonary blood flow. Nelsons 19th Ed As the ductus arteriosus closes in the 1st hours/days of life, infants with pulmonary atresia and an intact ventricular septum become markedly cyanotic since their only source of pulmonary blood flow is removed. Untreated, most patients die within the 1st wk of life. Physical examination reveals severe cyanosis and respiratory distress. The 2nd heart sound, representing only aortic closure, is single and loud. Often, no murmurs are audible; sometimes a systolic or continuous murmur can be heard secondary to ductal blood flow. A harsh holosytolic murmur may be heard at the lower left sternal border if there is significant tricuspid regurgitation.

Answer 16

C The child described has TOF with exercise induced cyanosis. The more serious episode is a cyanotic, blue or tet spell and may be due to decreased systemic vascular resistance, increased pulmonary artery pressure, or right ventricular outflow tract obstruction. The murmur of tetralogy (pulmonary stenosis) often disappears or lessens during a spell. 19th Ed In older children with unrepaired tetralogy, dyspnea occurs on exertion. They may play actively for a short time and then sit or lie down. Children assume a squatting position for the relief of dyspnea caused by physical effort; the child is usually able to resume physical activity after a few minutes of squatting. Paroxysmal hypercyanotic attacks (hypoxic, “blue,” or “tet” spells) are a particular problem during the 1st 2 yr of life. The infant becomes hyperpneic and restless, cyanosis increases, gasping respirations ensue, and syncope may follow. Temporary disappearance or a decrease in intensity of the systolic murmur is usual as flow across the right ventricular outflow tract diminishes. Severe spells may progress to unconsciousness and, occasionally, to convulsions or hemiparesis. Spells are associated with reduction of an already compromised pulmonary blood flow, which, when prolonged, results in severe systemic hypoxia and metabolic acidosis.

Answer 17

A Epinephrine is potentially dangerous because it may exacerbate inotropy and contractile forces, which may obstruct the right ventricular infundibulum. Indeed, propranolol has been used to treat tet spells. 19th Ed Treatment for Tet spells (1) knee-chest position (2) oxygen (3) morphine subcutaneously in a dose not in excess of 0.2 mg/kg. 4) for metabolic acidosis, give IV sodium bicarbonate 5) For spells that are resistant to this therapy, intubation and sedation 6) Drugs that increase systemic vascular resistance, such as intravenous phenylephrine, can improve right ventricular outflow, decrease the right-to-left shunt, and improve the symptoms 7) β-Adrenergic blockade by the intravenous administration of propranolol (0.1 mg/kg given slowly to a maximum of 0.2 mg/kg) has also been used.

Answer 18

B Poor pulses, reduced left ventricular forces on ECG, cardiogenic shock, and severe cyanosis are typical of hypoplastic left heart syndrome. 19th Ed Although cyanosis may not always be obvious in the 1st 48 hr of life, a grayish-blue color of the skin is soon apparent and denotes a mix of cyanosis and poor perfusion. The condition is diagnosed in most infants in the 1st few hours or days of life. Once the ductus arteriosus begins to closes, signs of poor systemic perfusion and shock predominate. All of the peripheral pulses may be weak or absent. A palpable right ventricular parasternal lift may be present along with a nondescript systolic murmur. On the chest roentgenogram, the heart is variable in size in the 1st days of life, but cardiomegaly develops rapidly and is associated with increased pulmonary vascularity. The initial electrocardiogram may show only the normal neonatal pattern of right ventricular dominance, but later, P waves become prominent and right ventricular hypertrophy is usual with reduced left ventricular forces

Answer 19

C SVT is a frequent cause of heart failure in this age group with structurally normal heart. 19th Ed Re-entrant SVT is characterized by an abrupt onset and cessation; it usually occurs when the patient is at rest, although in infants it may be precipitated by an acute infection. Attacks may last only a few seconds or may persist for hours. The heart rate usually exceeds 180 beats/min and may occasionally be as rapid as 300 beats/min. In neonates, SVT is usually manifested as a narrow QRS complex (

Answer 20

B Placing an iced saline bag over the neonates face is the vagal maneuver of choice to break SVT. Verapamil may decrease contractility and is dangerous in this age group. 19th Ed Vagal stimulation by placing of the face in ice water (in older children) or by placing an ice bag over the face (in infants) may abort the attack. To terminate the attack, older children may be taught vagal maneuvers such as the Valsalva maneuver, straining, breath holding, or standing on their head. Ocular pressure must never be performed, and carotid sinus massage is very rarely effective. In stable patients, adenosine by rapid intravenous push is the treatment of choice because of its rapid onset of action and minimal effects on cardiac contractility Calcium channel blockers such as verapamil have also been used in the initial treatment of SVT in older children. Verapamil may reduce cardiac output and produce hypotension and cardiac arrest in infants younger than 1 yr; it is therefore contraindicated in this age group. In urgent situations when symptoms of severe heart failure have already occurred, synchronized DC cardioversion (0.5-2 J/kg) is recommended as the initial management

Answer 21

Endocardial cushing defect

Answer 22

Bicuspid aortic valve

Answer 23

Conotruncal anomalies

Answer 24

Complex multiple cyanotic lesions

Answer 25

Dextrocardia

Answer 26

Supravalvular stenosis

Answer 27

Pericarditis

Answer 28

Acquired Heart block

Answer 29

Coronary thrombosis

Answer 30

Aortic insufficiency

Answer 31

Cardiac rhabdomyoma

Answer 32

Bradycardia

Answer 33

Short PR interval

Answer 34

Cardiomyopathy

Answer 35

Congenital heart block

Answer 36

C A large VSD with a large left to right shunt produces significant heart failure. The age of onset usually corresponds to the time when the normally high fetal pulmonary vascular resistance declines in the first 1-3 months of life. With decreasing pulmonary artery pressure, the left to right shunt increases. 19th Ed Large VSDs with excessive pulmonary blood flow and pulmonary hypertension are responsible for dyspnea, feeding difficulties, poor growth, profuse perspiration, recurrent pulmonary infections, and cardiac failure in early infancy. Cyanosis is usually absent, but duskiness is sometimes noted during infections or crying. Prominence of the left precordium is common, as are a palpable parasternal lift, a laterally displaced apical impulse and apical thrust, and a systolic thrill. The holosystolic murmur of a large VSD is generally less harsh than that of a small VSD and more blowing in nature because of the absence of a significant pressure gradient across the defect. It is even less likely to be prominent in the newborn period. The pulmonic component of the 2nd heart sound may be increased as a result of pulmonary hypertension. The presence of a mid-diastolic, low-pitched rumble at the apex is caused by increased blood flow across the mitral valve and indicates a Qp : Qs ratio of ≥2 : 1. This murmur is best appreciated with the bell of the stethoscope.

Answer 37

C Balloon valvuloplasty has greatly improved the management of stenotic lesions of the pulmonic and aortic valves. 19th Ed Patients with moderate or severe isolated pulmonary stenosis require relief of the obstruction. Balloon valvuloplasty is the initial treatment of choice for the majority of patients

Answer 38

A Pericarditis 19th Ed Acute Pericarditis Muffled or distant heart sounds, tachycardia, narrow pulse pressure, jugular venous distension, and a pericardial friction rub provide clues to the diagnosis of acute pericarditis. Cardiac tamponade is recognized by the excessive fall of systolic blood pressure (>10 mm Hg) with inspiration. This pulsus paradoxus can be assessed by careful auscultatory blood pressure determination (automated blood pressure cuffs are inadequate), arterial pressure line wave form, or pulse oximeter tracing inspection. Conditions other than cardiac tamponade, which may result in pulsus paradoxus include severe dyspnea, obesity, and positive pressure ventilator support.

Answer 39

C Rib notching is caused by increased collateral arteries trying to supply the lower trunk and extremities and bypass the aortic coarctation. 19th Ed The enlarged left subclavian artery commonly produces a prominent shadow in the left superior mediastinum. Notching of the inferior border of the ribs from pressure erosion by enlarged collateral vessels is common by late childhood. In most instances, the descending aorta has an area of poststenotic dilatation.

Answer 40

Polysplenia

Answer 41

Fetal alcohol

Answer 42

Aortic stenosis

Answer 43

Heart block

Answer 44

cardiomyopathy

Answer 45

Rhabdomyoma

Answer 46

B Most pediatric patients with an ASD are asymptomatic. Heart failure is rare in childhood. 19th Ed a. Females outnumber males 3 : 1 in incidence. b. A child with an ostium secundum ASD is most often asymptomatic; the lesion is often discovered inadvertently during physical examination. Even an extremely large secundum ASD rarely produces clinically evident heart failure in childhood. c. the characteristic finding is that the 2nd heart sound is widely split and fixed in its splitting during all phases of respiration. d. ECG and echocardiogram shows findings characteristic of right ventricular volume overload. e. ?

Answer 47

D The atrial and/or the atrial-ventricular defects both have a higher tendency for an earlier and more rapid onset of pulmonary hypertension. The ECG of an AV septal defect is characteristic because of the superior left deviation of the QRS axis.

Answer 48

A | A small VSD

Answer 49

C As protection against infective endocarditis, the integrity of primary and permanent teeth should be carefully maintained; with the latest revision of the American Heart Association guidelines, antibiotic prophylaxis is no longer recommended for dental visits or surgical procedures 19th Ed a. Small muscular VSDs are more likely to close (up to 80%) than membranous VSDs (up to 35%). b. A significant number (30-50%) of small defects close spontaneously, most frequently during the 1st 2 yr of life. c. As above d. Small, restrictive VSDs are associated with normal right heart pressures and pulmonary vascular resistance. e. In patients with small VSDs, surgical repair is currently not recommended. Parents should be reassured of the relatively benign nature of the lesion, and the child should be encouraged to live a normal life, with no restrictions on physical activity.

Answer 50

D A PDA often presents like a large VSD except that there is a continuous murmur and the diastolic run off, which produces the wide pulse pressure and bounding pulses 19th Ed A small PDA is usually asymptomatic. A large PDA will result in heart failure similar to that encountered in infants with a large VSD. Retardation of physical growth may be a major manifestation in infants with large shunts. A small PDA is associated with normal peripheral pulses, and a large PDA results in bounding peripheral arterial pulses and a wide pulse pressure, due to runoff of blood into the pulmonary artery during diastole. The classic continuous murmur is described as being like machinery in quality.

Answer 51

E Aortic stenosis without significant aortic regurgitation (insufficiency) produces an inactive precordium, normal or weak pulses, and pressure overload of the left ventricle 19th Ed a- Truncus arteriosus with torrential pulmonary flow also has an “aortic runoff” physiology. b- An aorticopulmonary window defect may rarely be clinically indistinguishable from a patent ductus c-A sinus of Valsalva aneurysm that has ruptured into the right side of the heart or pulmonary artery, coronary arteriovenous fistulas, and an aberrant left coronary artery with massive collaterals from the right coronary display dynamics similar to that of a PDA with a continuous murmur and a wide pulse pressure. d- VSD with aortic insufficiency, repaired tetralogy of Fallot, and combined aortic and mitral insufficiency (usually due to rheumatic fever) may be confused with a PDA

Answer 52

B and C A PDA manifesting in any patient other than a premature infant does not close spontaneously. Surgery carries low morbidity and even lower mortality. However, transcatheter coil closure or umbrellas has reduced the need for surgery in many patients. 19th Ed b- Irrespective of age, patients with PDA require surgical or catheter closure. In patients with a small PDA, the rationale for closure is prevention of bacterial endarteritis or other late complications. In patients with a moderate to large PDA, closure is accomplished to treat heart failure or prevent the development of pulmonary vascular disease, or both. Once the diagnosis of a moderate to large PDA is made, treatment should not be unduly postponed after adequate medical therapy for cardiac failure has been instituted. c- Small PDAs are generally closed with intravascular coils. Moderate to large PDAs may be closed with an umbrella-like device or with a catheter-introduced sac into which several coils are released

Answer 53

E Echocardiography has replaced most methods of visualizing the anatomy of congenital and other heart lesions. In many circumstances, the echo diagnosis is all that is needed before surgery or other therapies.

Answer 54

C Critical pulmonic stenosis often presents in the neonate. Cyanosis is due to elevated right sided pressures and right to left shunting at the patent foramen ovale 19th Ed When severe pulmonic stenosis occurs in a neonate, decreased right ventricular compliance often leads to cyanosis due to right-to-left shunting through a patent foramen ovale, a condition termed critical pulmonic stenosis. A loud, long, and harsh systolic ejection murmur, usually accompanied by a thrill, is maximally audible in the pulmonic area and may radiate over the entire precordium, to both lung fields, into the neck, and to the back. ECG: gross right ventricular hypertrophy, frequently accompanied by a tall, spiked P wave.

Answer 55

D Balloon valvuloplasty is a remarkable nonsurgical method to dilate the valve and partially relieve the obstruction to right ventricular outflow. 19th Ed Balloon valvuloplasty is the initial treatment of choice for the majority of patients

Answer 56

D Echocardiography is essential to identify valve disease, estimate gradients, and detect signs of endocardial fibroelastosis

Answer 57

C | Severe aortic stenosis may develop gradually, progressing over 5-10 years.

Answer 58

aortic insufficiency

Answer 59

Mitral insufficiency Mitral stenosis Aortic insufficiency - it takes 10 yrs or more for MS to develop Tricuspid insufficiency - may occur secondary to left sided lesions Pulmonary insufficiency may occur with pulmonary hypertension - a late finding in severe MS Murmur of pulmonary insufficiency is called Graham Steell murmur, similar to AI but without bounding pulses.

Answer 60

enteroviruses (coxsackie and echovirus), adenovirus, EBV, parvovirus and CMV

Answer 61

dilated cardiomyopathy * etiologies are diverse but ischemic etiology is rare in children * commonly familial with autosomal dominance eg. Duchenne and Becker muscular dystrophies * also the most common cause of cardiac transplantation

Answer 62

Kawasaki Disease

Answer 63

1. bilateral nonexudative bulbar conjunctival injection with limbal sparing; 2. erythema of the oral and pharyngeal mucosa with strawberry tongue and dry, cracked lips; 3. edema and erythema of the hands and feet; 4. rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area; and 5. nonsuppurative cervical lymphadenopathy, usually unilateral, with node size >1.5 cm - Perineal desquamation is common in the acute phase. Periungual desquamation of the fingers and toes begins 1-3 wk after the onset of illness and may progress to involve the entire hand and foot

Answer 64

Pulmonary stenosis

Answer 65

Aortic Stenosis

Answer 66

Coarctation of the Aorta

Answer 67

Boot or wooden shoe appearance (couer en sabot)

Answer 68

Egg shaped heart

Answer 69

Snowman appearance in older children

Cardiology Flashcards

(102 cards)