Case 6

Question 1

What are symptoms of dizziness and visual disturbance classic for?

Answer 1

Hypotension

Question 2

What is hypotension sometimes triggered by?

Answer 2

Volume depletion and skipping meals

Question 3

What are the symptoms of Precordial Catch syndrome?

Answer 3

Chest pain, unrelated to exercise or meals. Chest pain reproducible with palpation. Otherwise, normal physical exam.

Question 4

What is the differential diagnosis for chest pain?

Answer 4

Precordial catch syndrome, Musculoskeletal/costochondritis, GI/GERD, Cardiac, Respiratory/asthma.

Question 5

What are the primary objectives of a sports pre participation physical exam?

Answer 5

Ensure adolescent athlete is healthy enough to participate in rigors of interscholastic competition. Meet legal and insurance requirements. Ensure cardiovascular health: In particular, the absence of undiagnosed cardiac illnesses such as hypertrophic cardiomyopathy, which could place the student athlete at significant risk of sudden cardiac death. Ensure neurological health. Detect conditions that may predispose to injury (eg musculoskeletal or neurological)

Question 6

What are the secondary objectives of a sports pre participation physical exam?

Answer 6

Assess general health. Counsel on health-related issues. Assess fitness level for specific sports.

Question 7

How do you evaluate chest pain in teenagers?

Answer 7

Chest pain is the second most common referral to pediatric cardiologists. In most cases, possible to make a correct diagnosis by careful history and examination.

Question 8

What is a good mnemonic to use to assess for pain?

Answer 8

OPQESTAAA:
OnsetX
Position
QualityX
Radiation
Severity
TimingX
Aggravating factorsX
Alleviating factors
Associated symptomsX
X - especially important in differentiating chest wall pain (or pain of precordial catch syndrome) from cardiac, or ischemic, pain

Question 9

What is different in onset between chest wall pain and cardiac pain?

Answer 9

Chest wall pain is sporadic and not associated with exertion. Cardiac pain is usually prompted by exertion or stress.

Question 10

What is different in quality of pain between chest wall and cardiac?

Answer 10

Chest well pain is sharp and well localized. Cardiac pain is pressure and a crushing sensation.

Question 11

What is the difference in timing between chest wall and cardiac pain?

Answer 11

Chest wall pain is very brief (seconds to a few minutes) and cardiac pain typically lasts 10-15 minutes.

Question 12

What is the difference between aggravating factors for chest wall pain and cardiac pain?

Answer 12

Chest wall pain is made worse by deep inspiration and can be “broken” with forced deep inspiration. Cardiac pain is NOT affected by deep inspiration.

Question 13

What associated symptoms with chest pain raises level of concern and requires prompt referral to cardiologist?

Answer 13

Syncope, difficulty breathing, or palpitations associated with chest pain.

Question 14

What might the presence of fever with chest pain suggest?

Answer 14

Infectious etiology (pericarditis, pneumonia)

Question 15

What does reproducibility of chest pain imply?

Answer 15

Musculoskeletal, not cardiac origin.

Question 16

What is the Tdap?

Answer 16

(“adult”). Tetanus, diphtheria, and acellular pertussis. First recommended to be given at the pre-adolescent visit (11-12 yrs). Used for adults and children 11 yrs and older who need booster doses of diphtheria, tetanus toxoid, and acellular pertussis.

Question 17

What is the DTap?

Answer 17

(“pediatric”) Diphtheria, tetanus, and acellular pertussis. Contains three to five times more diphtheria toxoid than the “adult” Tdap.

Question 18

What is the DT?

Answer 18

Used for children who cannot receive the pertussis component of the DTap vaccine.

Question 19

What is the Meningococcal conjugate vaccine (MCV4)?

Answer 19

Recc. first at age 11-12 yrs. Booster dose at age 16. For adolescents who receive the first dose at age 13 through 15 years, one-time booster dose should be admin. preferably at age 16 through 18 years, before the peak in increased risk. Adolescents who receive their first dose of MCV4 at or after age 16 yrs do NOT need a booster dose. Routine vaccination of healthy ppl older than 21 yrs who are not at increased risk for exposure to neisseria meningitidis is not recommended.

Question 20

What is the Human papillomavirus vaccine (HPV)?

Answer 20

It is recommended for all males and females starting at age 11-12 yrs. A second dose is rec. 2 months after the first dose and a third dose 6 mo after the first dose. The quadrivalent HPV vaccine (HPV4) is approved for men between the ages of 9 and 26 years to reduce their likelihood of acquiring genital warts, anal cancer and anal intraepithelial neoplasia (AIN). The bivalent HPV vaccine (HPV2) is approved only for women and only for the prevention of cervical cancer, not genital warts of other neoplasms.

Question 21

Hepatitis A and B vaccines in adolescents?

Answer 21

Many will have completed the 2 dose series of hepatitis A given at 12 and 18 months of age. Most will have already completed the 3 dose series of Hep B vaccines in early infancy.

Question 22

Inactivated polio vaccine (IPV) in adolescents?

Answer 22

Most adolescents will have received the four required doses of IPV in early childhood.

Question 23

What is good advice to give to parents of adolescents?

Answer 23

Est. expectations and reach agreement with adolescent about rules, limits, consequences, and decision-making. Enhance adolescents’s self esteem, minimize criticism, and respect privacy. Continue to show interest in adolescents plans and activities and continue to affirm family values. Be a role model for responsible behavior, safe driving practices and discuss healthy behavior, avoiding substance abuse and living responsibly.

Question 24

How to assess for coarctation of the aorta?

Answer 24

Palpation of the radial and femoral pulses.

Question 25

When is the murmur of hypertrophic cardiomyopathy louder?

Answer 25

While standing!

Question 26

What types of murmurs require further evaluation?

Answer 26

Murmurs are common in healthy adolescents, but any murmur louder than a grade III/VI, any diastolic murmur, or any murmur that increases with standing or Valsalva deserves further evaluation.

Question 27

When is checking the male athlete for inguinal hernia particularly important?

Answer 27

In sports that involve sprinting and weight lifting.

Question 28

What is tanner stage 1 for a male?

Answer 28

Prepubertal. Childlike phallus, testicular volume < 1.5 ml. No pubic hair.

Question 29

What is tanner stage 2 for a male?

Answer 29

Childlike phallus, testicular volume 1.6-6 mL, reddened, thinner and larger scrotum, small amount of fine hair along the base of the scrotum and phallus.

Question 30

What is tanner stage 3 for a male?

Answer 30

Increased phallus length, testicular volume 6-12 mL, greater scrotal enlargement, and moderate amount of more curly, pigmented, coarser hair extending laterally.

Question 31

What is tanner stage 4 for a male?

Answer 31

Increased phallus length and circumference, testicular volume 12-20 mL, further scrotal enlargement and darkening, and coarse curly adult-type hair that does not yet extend to the medial surface of thighs.

Question 32

What is tanner stage 5 for a male?

Answer 32

Adult scrotum and phallus, testicular volume > 20 mL. Adult-type hair extending to medial surface of thighs.

Question 33

What is on the differential diagnosis for precordial catch syndrome?

Answer 33

Costochrondritis, respiratory/asthma, GI/GERD, cardiac.

Question 34

What is precordial catch syndrome?

Answer 34

Benign cause of chest wall pain. By far the most common cause of chest pain in children but of unknown etiology. It occurs most commonly in adolescents and is characterized by a sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. These pains are brief, lasting seconds to a few minutes, and resolve spontaneously. The pain can often be “broken” with a forced deep inspiration.

Question 35

What is costochrondritis?

Answer 35

A benign cause of chest pain but is much less common than precordial catch syndrome. The pain of costochondritis is due to inflammation and typically will last for hours or days. The pain usually follows a recent viral infection, muscle strain, trauma or overuse. Reproducibility by direct pressure over costochondritis joints is diagnostic.

Question 36

How can respiratory/asthma cause chest pain?

Answer 36

Pain during exercise can point to exercise-induced bronchospasm or asthma. These may also present with coughing, respiratory distress and wheezing.

Question 37

How can GI/GERD cause chest pain?

Answer 37

Gastrointestinal causes of chest pain such as gastritis or esophagitis secondary to GERD may present as retrosternal, burning, non-radiating chest pain associated with meals.

Question 38

How can cardiac cause chest pain?

Answer 38

Pain during exercise points to cardiac causes or exercise-induced bronchospasm or asthma.

Question 39

When is an EKG (electrocardiogram) needs for adolescents with chest pain?

Answer 39

Indicated for any pt. with syncope. Impossible to rule out some important arrhythmic causes of syncope - such as Wolff-Parkinson-White syndrome and long QT syndrome - without an ECG. Hypertrophic cardiomyopathy is the most common cause of sudden death in young athletes and can first present with syncope. The ECG is abnormal in >90 percent of patients with hypertrophic cardiomyopathy and is thus an essential screening test.