Cardiology

Question 1

what are the presenting features of heart failure in a baby/child?

Answer 1

failure to thrive / poor feeding / weight and development delay

tachypnoea, dyspnoea 
syncope 
palpitations  
decreased exercise tolerance 
(chest pain)

Question 2

what are the 3 main clinical signs of heart failure found in babies/children?

Answer 2

tachypnoea
tachycardia
hepatomegaly

Question 3

where type of murmur is still’s murmur and where is it heard ?

Answer 3

apex - left sternal border

LV outflow murmur

Question 4

what causes a stills murmur/ LV outflow murmur to be increased?

Answer 4

supine position and with exercise

Question 5

what type of murmur is pulmonary outflow murmur?

Answer 5

soft systolic, vibrator

Question 6

at what point during conception can a tetralogy insult affect the heart?

Answer 6

18-60 days post conception

Question 7

what are some of the aetiologies of congenital heart disease?

Answer 7

genetic susceptibility

teratogenic insult

environmental;

• infections: toxoplasmosis, rubella, CMV, herpes
• drugs: phenytoin, lithium, amphetamines, alcohol, ecstasy
• maternal: diabetes, SLE

chromosomal

• trisomy 13, 18, 21
• turners
• williams
• noonans
• 22q11 deletion

Question 8

what heart defect is most commonly associated with downs syndrome?

Answer 8

atrioventricular septal defect (AVSD)

Question 9

what drugs can cause congenital heart defects if taken during?

Answer 9

phenytoin 
lithium 
alcohol 
amphetamines
ecstasy

Question 10

what maternal health conditions can increase risk of congenital heart defects?

Answer 10

SLE

diabetes mellitus

Question 11

what is a risk factor for transposition of the great arteries?

Answer 11

diabetic mother

Question 12

how does transposition of the great arteries present?

Answer 12

usually picked up antenatally

baby is cyanosed at birth or within a few days after birth

Question 13

what is the treatment for transposition of the great arteries?

Answer 13

prostaglandin infusion to maintain shunt (i.e. PDA, ASD, VSD)

balloon septostomy to create ASD

definitive traetment = switch procedure

Question 14

what are the pathologies in tetralogy of fallot?

Answer 14

overriding aorta
pulmonary stenosis
right ventricular hypertrophy
ventricular septal defect

Question 15

how does tetralogy of fallot present?

Answer 15

presents around 1-3 months
cyanosis
clubbing
poor feeding
ejection systolic murmur (pulmonary area - upper left sternal border)
tet spells (precipitated by crying etc causing them to become cyanotic and dyspneic)

Question 16

what feature on x-ray is suggestive of tetralogy of fallot?

Answer 16

boot shaped

- right ventricular hypertrophy lifts up the apex

Question 17

what is the management for tetralogy of fallot?

Answer 17

• prostaglandin infusion to maintain PDA
• palliative shunt formation

6 months - 1 yr later - total surgical repair

Question 18

what treatment would you give to manage test spells in tetralogy of fallot?

Answer 18

IV fluids - improve preload
02 - cyanosis
betablockers - relax r. ventricle to improve pulmonary blood flow
sodium bicarbonate - combat metabolic acidosis
phenylephrine infusion - increase systemic vascular resistance
morphine - reduce resp drive

Question 19

what is the presentation of pulmonary stenosis?

Answer 19

mild - asymptomatic

moderate/severe - exertion dyspnoea + fatigue

Question 20

what clinical sign would you observe on examination of a child with pulmonary stenosis?

Answer 20

ejection systolic murmur
heard loudest over upper left sternal border (pulmonary area)

• murmur radiates tot he back
• made worse on exercise
• worsens with age

palpable thrill in pulmonary area
right ventricular heave (due to RV hypertrophy)
raised JVP

Question 21

what is the treatment for pulmonary stenosis?

Answer 21

if mild - watch and wait

if moderate/severe - balloon valvuloplasty or valve replacement

Question 22

what 3 underlying pathologies can cause Eisenmenger syndrome?

Answer 22

ASD
VSD
patent ductus arterioles

Question 23

what are the signs of eisenmenger syndrome?

Answer 23

pulmonary hypertension
arrythmias
murmurs (ASD, VSD, PDA)
chronic hypoxia
- dyspnoea
- cyanosis 
- clubbing 
- plethoric complexion (red appearance due to polycythaemia)

Question 24

what drug can be used to treat hypertension?

Answer 24

sildenafil

Question 25

what are the complications of Eisenmenger syndrome?

Answer 25

heart failure infection thromboembolism (due to polycythaemia triggered by hypoxia) haemorrhage

Question 26

give 3 differentials of cyanotic heart disease in children.

Answer 26

tetralogy of fallot transportation of the great arteries Eisenmenger syndrome

Question 27

give 4 examples of innocent murmurs in children.

Answer 27

LV outflow murmur pulmonary outflow murmur carotid/brachiocephalic bruit venous hum

Question 28

what are the general features of an innocent murmur in a child?

Answer 28

soft systolic murmur vibrant, localised no other cardiac signs increases with exercise, portion, respiration

Question 29

what are the features of a carotid/brachiocephalic bruit?

Answer 29

systolic harsh murmur head in suprclavicular area radiates to the back increased with exercise decreased with rotating the head or extending neck

Question 30

what are the features of a venous hum?

Answer 30

soft indistinct systolic murmur continuous murmur with diastolic accentuation sometimes heard in suprclavicular area disappears when lying down or turning head

Question 31

what are the symptoms of aortic stenosis?

Answer 31

syncope chest pain dyspnoea

Question 32

what are the clinical features of aortic stenosis?

Answer 32

ejection systolic murmur heard in the upper right sternal border radiates to the carotids

Question 33

what is the treatment for aortic stenosis?

Answer 33

ball valvulotomy | valve replacement

Question 34

what increases a babies risk of patent ductus arteriosus?

Answer 34

pre maturity

Question 35

what is the treatment for PDA in pre-terms?

Answer 35

fluid restriction diuretics prostaglandin inhibitors

Question 36

what is the presentation of co-arctation of the aorta?

Answer 36

``` presents a few weeks after birth with reduced/weak femoral pulses radio-femoral delay (late stage) systolic murmur tachypnoea poor feeding grey and floppy (may look like sepsis) ```

Question 37

what is the treatment for co-arctation of the aorta?

Answer 37

prostaglandins E1 or E2 subclavian patch repair balloon aortoplasty

Question 38

give differentials of non-cyanotic heart disease in children.

Answer 38

``` patent ductus arteriosus co-arctation of the aorta pulmonary stenosis aortic stenosis VSD ASD ```

Question 39

what features of a murmur in a child require further investigations?

Answer 39

diastolic murmur louder on standing other symptoms i.e. failure to thrive, cyanosis, tachypnoea loud murmur

Question 40

you examine the precordium of a boy of 4 years old. you hear a soft systolic murmur in the apex at the left sternal border, and radiates to the back. the murmur gets worse when he stands. the patient is otherwise healthy. what is the most likely diagnosis?

Answer 40

LV outflow murmur (Still's) | not pulmonary outflow because it radiates - pulmonary doesn't)

Question 41

you examine the precordium of a thin 9 year old girl. you hear a soft systolic murmur in the left sternal border that doesn't radiate. it is made worse when she stands up.

Answer 41

pulmonary outflow murmur clues; - thin - doesn't radiate - left sternal border (LV outflow also LSB but radiates to the back)

Question 42

a diabetic mother attends the GP with her baby of 2 months old. she complains he hasn't been feeding well and has become increasing short of breath to the point he has become slightly blue at the lips. on examination you hear an ejection systolic murmur. what is the most likely diagnosis?

Answer 42

tetralogy of fallot risk factors - diabetes ejection systolic murmur presents 1-2 months of birth symptoms - cyanosis, tachypnoea, dyspnoea, poor feeding, clubbing, tet spells

Question 43

where would you hear a VSD murmur?

Answer 43

lower left sternal border