Congenital Heart
Disease from the Block
(as in J-Lo from the block, pun definitely intended!)
Premchand Anne, MD, MPH
PGY IV
9/1/2005
Objectives
►Fetal and neonatal
► DA
► Pathophysiology




circulation
Left to Right shunts
Obstructive
Valvular regurgitation
Cyanotic congenital heart disease
Fetal Circulation
Fetal Circulation: four shunts
 Placenta
► Receives
55% of total CO
► Lowest vascular resistance
 Ductus venosus
► From
placenta: has 70% sats
► Highest PO2: umbilical vein
(30)
 Foramen ovale
► 1/3
of RA return goes to LA
 Oxygenate brain and
coronaries better (PO2=28)
 Lower body: PO2=24
 Ductus arteriosus
► PA
=> Descending Aorta =>
placenta
Neonatal Circulation
► Change
in gas exchange from placenta to lungs
 Increase in systemic vascular resistance due to
absence of placenta and closure of DA due to
presence of increased PO2
 Reduction of PVR after lung expansion due to oxygen,
increased LA return, fall in RA pressure due to DA
closure and increase in systemic pressure => closure
of foramen ovale
 Rapid initial fall, slower fall by 6-8 weeks and then
after 2 years
Objectives
► Fetal
and neonatal circulation
►DA
► Pathophysiology




Left to Right shunts
Obstructive lesions
Valvular regurgitation
Cyanotic congenital heart disease
DA closure
► Within
10-15 hours of birth
► Postnatal increase in Oxygen is the strongest
stimulus for closure; premies don’t respond as well
to oxygen.
► PGE2 decreases after birth due to loss of placenta
and increased pulmonary blood flow to wash it off.
► Indomethacin closes PDAs
► Maternal ingestion of ASA can cause Persistent
Pulmonary Hypertension of the Newborn
(premature closure of DA and poor development
of arterioles)
► PGE1 keeps DA open.
Pulmonary arteries and DA
respond in opposite manner
Objectives
► Fetal
and neonatal circulation
► DA
► Pathophysiology
 Left to Right shunts
 Obstructive lesions
 Valvular regurgitation
 Cyanotic congenital heart disease
Left to Right Shunts
► ASD
► VSD
► PDA
► ECD
Left to Right Shunts-ASD
ASD
► RA
and RV dilated
► RV dilation => increased time for
repolarization => RBBB on EKG
► NO CHF until 6-8 weeks when PVR drops
considerably.
ASD
Left to Right Shunts-VSD
VSD
► LA
and LV dilated in a small to moderate
VSD: does this make sense?
 Shunt occurs only during systole, where the
blood goes from LV to pulmonary artery
 There is increased pulmonary return to LA and
then to LV => dilation
► RV,
LA, LV are all dilated in a large size VSD
► Complication of large VSD=Eisenmenger’s
=> generalized cyanosis
VSD
Left to Right Shunts-PDA
PDA
► Onset
of CHF is similar to that of a VSD
► Complication of a large PDA=>
Eisenmenger’s => differential cyanosis
(lower body cyanosis): WHY?
PDA
ECD
► Endocardial
cushion is responsible for upper
part of ventricular septum and lower part of
atrial septum
► Absence leads to VSD, primum ASD, clefts
in mitral and tricuspid valves
Left to Right Shunts-ECD
ECD
► Primum
ASD = Secundum ASD; RA and RV
are dilated with widely split and fixed S2 and
systolic ejection murmur at left upper
sternal border.
► RBBB due to prolonged repolarization
► Obligatory shunt with LV -> RA lesion
ECD
Objectives
► Fetal
and neonatal circulation
► DA
► Pathophysiology
 Left to Right shunts
 Obstructive lesions
 Valvular regurgitation
 Cyanotic congenital heart disease
Obstructive Lesions
► Ventricular
Outflow obstruction
 Aortic stenosis
 Pulmonary stenosis
 Coarctation of the aorta
► Stenosis
of AV valves
 Mitral stenosis
 Tricuspid stenosis
Ventricular Outflow Obstruction
AS, PS, COA
► All
three lesions produce the following:
 Ejection systolic murmur
 Hypertrophy of the respective ventricle
 Post-stenotic dilatation is present with the
obstruction at the valvular level; absent in
subvalvular stenosis
Aortic Stenosis
► Murmur
is loudest in
RUSB
► Loudness is
proportional to severity
► LVH
Pulmonary Stenosis
► Murmur
is loudest at LUSB
► Loudness is proportional to severity
► RVH
Coarctation of Aorta
► Ejection
type SEM over the descending aorta,
distal to COA
► Often see Bicuspid aortic valves
► Delayed or absent pulses in LE
► Post stenotic dilation => figure-of-3 sign on xray
► Lesion is juxtaductal
► Symptomatic patients have a VSD and may see
RVH and RBBB rather than LVH
A-V valve obstruction
Mitral Stenosis
► More
often rheumatic than congenital
► Diastolic murmur due to pressure gradient
between LA and LV; subsequently LA,
Pulmonary veins, RV dilation; best at apex
► Pulmonary edema if hydrostatic > osmotic
pressure; dyspnea with or without exertion.
► Loud S1 due to widely parted MV leaflets at
onset of systole due to prolongation of
diastole
► Dilated LA leads to A-fib
A-V valve obstruction
Tricuspid Stenosis
► Rare
and usually congenital
► Dilation and hypertrophy of RA
► If severe, can lead to hepatomegaly and
JVD.
► (+) mid diastolic murmur
Objectives
► Fetal
and neonatal circulation
► DA
► Pathophysiology
 Left to Right shunts
 Obstructive lesions
 Valvular regurgitation
 Cyanotic congenital heart disease
Valvular Regurgitation
► Mitral
regurgitation
► Tricuspid regurgitation
► Aortic regurgitation
► Pulmonary regurgitation
Mitral Regurgitation
► Volume
overload of the LA and LV with LVH
and LAH on EKG
► Regurgitant systolic murmur at the apex
► (+) S3 due to rapid early diastole due to
fluid overload of LA
► Pulmonary hypertension occurs occasionally
due to dampening of pressure by dilated LA
Mitral Regurgitation
Tricuspid Regurgitation
► RV
and RA enlarge
► RAH and RVH with RBBB on EKG
► Systolic regurgitant murmur with S3 in
tricuspid area.
► Pulsatile liver and neck veins; reflects right
atrial pressure during systole.
Aortic Regurgitation
► Overload
of LV
► LV enlargement on xray and LVH on ECG
► Wide pulse pressure and bounding
peripheral pulse due to rapid drop in BP in
the aorta due to leakage
► High pitched decrescendo murmur at the
apex
► AUSTIN FLINT MURMUR due to mitral valve
flutter during diastole (blood in opposite
directions)
Aortic Regurgitation
Pulmonary Regurgitation
► RV
enlargement and prominent PA segment
► The direction of regurgitation is to the RV,
aka along Left sternal border and diastolic.
Objectives
► Fetal
and neonatal circulation
► DA
► Pathophysiology
 Left to Right shunts
 Obstructive lesions
 Valvular regurgitation
 Cyanotic congenital heart disease
Cyanotic Congenital Heart Lesions
Cyanotic Congenital Heart Lesions
►Complete
Transposition of the Great
Arteries (TGA)
►Persistent Truncus Arteriosus and single
ventricle
►Tetralogy of Fallot
►Tricuspid atresia
►Pulmonary Atresia
►Total Anomalous Pulmonary Venous
Return
Complete Transposition of the Great
Arteries
► D-TGA
is the most common cyanotic lesion
► Aorta from RV and Pulmonary artery from
LV
► Normally, aorta is under and over the RPA
► In TGA, aorta is to the right of the RPA
because of opening to the RV, hence D-TGA
► In L-TGA, aorta is to the left of the PA and
congenitally corrected TGA
► A PFO is normally present in D-TGA
TGA
► Newborn
is cyanotic, with metabolic
acidosis, detrimental to myocardium
► Leads to CHF in the first week of life.
► Associated with hypoglycemia
► Consider TGA if CYANOSIS, CHF WITH CXR
FINDINGS, AND NO MURMUR
► Must do BALLOON ATRIAL SEPTOSTOMY
(RASHKIND PROCEDURE) to increase
mixing, if only PFO.
TGA
► Small
PFO: rashkind procedure
► Large VSD: RVH with LV and LA dilation
► Corrective procedures
 Mustard or Senning Procedure
 Jatene Switch
Persistent Truncus Arteriosus and
Single Ventricle
► Single
arterial blood vessel arises from heart in TA,
along with a large VSD; PAs come off the TA
► In single ventricle, both AV valves empty into the
single ventricle, with the aorta or PA coming off
the rudimentary ventricle.
► Similarities
 Complete mixing of systemic pulmonary venous blood in
the ventricle
 Pressures in both ventricles are identical
 Level of oxygen saturation in systemic circulation is
dependent on the magnitude of pulmonary blood flow
Tetralogy of Fallot
►4




main findings:
VSD
Overriding Aorta (not always present)
Pulmonic stenosis
RVH (secondary PS)
► With
mild PS, shunt is left to right, leading
to PINK TOF, LV and RV pressures are same
► With severe PS, the shunt is right to left,
with PBF from PDA
Tetralogy of Fallot
► Murmur
is the superimposition of PS
murmur on top of the VSD murmur
► In cyanotic TOF, severe PS produces Right
to left shunt at the ventricular level and
systolic pressures are equal in LV, RV and
aorta
► Extreme TOF is in pulmonary atresia where
there is complete R to L shunt, and
complete arterial desaturation
Tetralogy of Fallot-TET spell
►
hypoxic spell consists of
 Hyperpnea=increased systemic venous return
 Worsening cyanosis=causes hyperpnea
 Disappearance of heart murmur
►
►
►
May cause death
Provoked by anything decreasing SVR
such as crying, defecation, and increased
physical activity => vicious cycle
Treatment:




MSO4 abolishes hyperpnea
Pick up in knee chest position
NaHCO3 to decrease acidosis
Add O2
Tetralogy of Fallot
Tricuspid Atresia
► Tricuspid
valve and a portion of RV do not
exist
► RA return goes through PFO or ASD to LA
due to increased RA pressure =>dilation of
RA, and dilation of LA and LV due to
increased volume
► PA gets blood from LV to remnant RV by
VSD with decreased PA flow=>cyanosis
► CXR: decreased pulmonary vascular
markings, dilated RA and LV
Tricuspid
Atresia
Pulmonary Atresia
► PDA
is the source of blood to lungs
► Systemic return => RA =>LA => LV =>
aorta =>PDA => lungs =>LA
► RV normally hypoplastic; if normal, expect
Tricuspid regurg
► Rapid deterioration of clinical status if DA
closes; give PGE1 to keep open
Total Anomalous Pulmonary Venous
Return (TAPVR)
► Defect:
Pulmonary veins drain into RA
► Andy, you know this to be yet another prob!
► ASD is usually present for RA => LA flow
► Three kinds:
 Supracardiac: drain into SVC
 Cardiac: drain into RA; Andy, the last one is:
 Infracardiac: drain into hepatic vein, portal vein,
or IVC
Total Anomalous Pulmonary Venous
Return (TAPVR)
► Normally,
consider obstructive vs
nonobstructive; infracardiac is obstructive to
venous return
► In nonobstructive: volume overload of RV
due to small ASD. +RBBB.
► In obstructive: pulmonary venous
hypertension and secondary RA and RV
hypertension.
Supracardiac and cardiac confluences
Infracardiac confluence
Question-1-2005
You are evaluating a 4-year-old healthy girl at her annual health
supervision visit. You note clear breath sounds, strong pulses, a quiet
precordium, and a murmur. Your partner noted a murmur at last year’s
visit.
Of the following, the finding MOST consistent with the diagnosis of an
innocent murmur is
►
continuous machinery murmur under the left clavicle
►
harsh systolic murmur at the right upper sternal border
►
high-pitched systolic murmur in the back between the scapulae
►
low-pitched,long, diastolic murmur in the left axilla
►
low-pitched,vibratory systolic murmur at the left sternal border
Question-1
You are evaluating a 4-year-old healthy girl at her annual health
supervision visit. You note clear breath sounds, strong pulses, a quiet
precordium, and a murmur. Your partner noted a murmur at last year’s
visit.
Of the following, the finding MOST consistent with the diagnosis of an
innocent murmur is
►
continuous machinery murmur under the left clavicle
►
harsh systolic murmur at the right upper sternal border
►
high-pitched systolic murmur in the back between the scapulae
►
low-pitched,long, diastolic murmur in the left axilla
►
low-pitched,vibratory systolic murmur at the left sternal border
Question-2
►
You are evaluating a 16-year-old boy for preparticipation sports
screening. The boy states that his older brother was diagnosed with a
seizure disorder and died suddenly during high school track practice.
He also has a younger sister who has a history of syncope.
Before approving him for sports participation, which of the following
tests must be performed?
►
computed tomography of the head
►
electrocardiography
►
electroencephalography
►
genetic testing for ion channel abnormalities
►
tilt table test
Question-2
►
You are evaluating a 16-year-old boy for preparticipation sports
screening. The boy states that his older brother was diagnosed with a
seizure disorder and died suddenly during high school track practice.
He also has a younger sister who has a history of syncope.
Before approving him for sports participation, which of the following
tests must be performed?
►
computed tomography of the head
►
electrocardiography
►
electroencephalography
►
genetic testing for ion channel abnormalities
►
tilt table test
Question-3
►
A 750-g infant who was born at 27 weeks’ gestation was weaned
successfully from the ventilator on postnatal day 3. Two days later, the
infant has bounding pulses, tachypnea, and a new murmur.
Echocardiography confirms the diagnosis of patent ductus arteriosus.
Hemoglobin is 13 g/dL (130 g/L). Electrolytes, creatinine, and platelets
are within normal imits.
Of the following, the MOST appropriate initial management strategy for
this infant is
►
intravenous indomethacin
►
oxygen therapy at an Fio2 of 1.0
►
surgical ligation of the ductus arteriosus
►
transcatheter closure of the ductus arteriosus
►
transfusion with packed red blood cells
Question-3
►
A 750-g infant who was born at 27 weeks’ gestation was weaned
successfully from the ventilator on postnatal day 3. Two days later, the
infant has bounding pulses, tachypnea, and a new murmur.
Echocardiography confirms the diagnosis of patent ductus arteriosus.
Hemoglobin is 13 g/dL (130 g/L). Electrolytes, creatinine, and platelets
are within normal imits.
Of the following, the MOST appropriate initial management strategy for
this infant is
►
intravenous indomethacin
►
oxygen therapy at an Fio2 of 1.0
►
surgical ligation of the ductus arteriosus
►
transcatheter closure of the ductus arteriosus
►
transfusion with packed red blood cells
Question-4
►
During the physical examination of an otherwise healthy 2-month-old
infant, you note a harsh grade 3/6 holosystolic murmur that is lowpitched and heard best over the lower left sternal border.
Of the following, the diagnosis MOST consistent with these
auscultatory findings is
►
aortic stenosis
►
atrial septal defect
►
patent ductus arteriosus
►
tetralogy of Fallot
►
ventricular septal defect
Question-4
►
During the physical examination of an otherwise healthy 2-month-old
infant, you note a harsh grade 3/6 holosystolic murmur that is lowpitched and heard best over the lower left sternal border.
Of the following, the diagnosis MOST consistent with these
auscultatory findings is
►
aortic stenosis
►
atrial septal defect
►
patent ductus arteriosus
►
tetralogy of Fallot
►
ventricular septal defect
Question-5
►
Your assistance is sought by a resident who is preparing a presentation
for her colleagues on the differential diagnosis of stroke in pediatrics.
You point out that certain patients who have cardiovascular pathology
may be at increased risk for cerebrovascular accident.
Which of the following cardiac conditions is MOST likely to be
associated with a cerebrovascular accident?
►
congestive heart failure
►
constrictive pericardial disease
►
cyanotic congenital heart disease
►
Kawasaki disease
►
rheumatic fever
Question-5
►
Your assistance is sought by a resident who is preparing a presentation
for her colleagues on the differential diagnosis of stroke in pediatrics.
You point out that certain patients who have cardiovascular pathology
may be at increased risk for cerebrovascular accident.
Which of the following cardiac conditions is MOST likely to be
associated with a cerebrovascular accident?
►
congestive heart failure
►
constrictive pericardial disease
►
cyanotic congenital heart disease
►
Kawasaki disease
►
rheumatic fever
Question-6
►
You are evaluating a 7-day-old infant because of poor feeding,
tachypnea, and lethargy. According to his mother, the symptoms began
24 hours earlier and have progressed throughout the day. Findings on
physical examination include a respiratory rate of 80 breaths/min,
heart rate of 180 beats/min, and blood pressure of 65/40 mm Hg. The
infant is cool, mottled, and pale. There are no murmurs, but there is a
gallop. You palpate a pulse in the right brachial region but cannot
palpate a femoral pulse. You discuss your diagnosis with the parents,
who want to know the immediate plan and possible long-term
complications.
Of the following, the MOST appropriate answer to the parents inquiry
is
►
immediate treatment for
hypertension
immediate treatment for
replacement
immediate treatment for
transplantation
immediate treatment for
immediate treatment for
ventricular dysfunction
►
►
►
►
aortic coarctation; risk for chronic
aortic stenosis; risk for aortic valve
cardiomyopathy; risk for cardiac
double aortic arch; risk for tracheomalacia
hypoplastic left heart syndrome; risk for right
Question-6
►
You are evaluating a 7-day-old infant because of poor feeding,
tachypnea, and lethargy. According to his mother, the symptoms began
24 hours earlier and have progressed throughout the day. Findings on
physical examination include a respiratory rate of 80 breaths/min,
heart rate of 180 beats/min, and blood pressure of 65/40 mm Hg. The
infant is cool, mottled, and pale. There are no murmurs, but there is a
gallop. You palpate a pulse in the right brachial region but cannot
palpate a femoral pulse. You discuss your diagnosis with the parents,
who want to know the immediate plan and possible long-term
complications.
Of the following, the MOST appropriate answer to the parents inquiry
is
►
immediate treatment for
hypertension
immediate treatment for
replacement
immediate treatment for
transplantation
immediate treatment for
immediate treatment for
ventricular dysfunction
►
►
►
►
aortic coarctation; risk for chronic
aortic stenosis; risk for aortic valve
cardiomyopathy; risk for cardiac
double aortic arch; risk for tracheomalacia
hypoplastic left heart syndrome; risk for right
Question-7
►
You are evaluating a 3-day-old infant brought to the emergency
department for lethargy. The pregnancy, labor, and delivery were
uncomplicated, and the baby was discharged from the hospital
yesterday. On physical examination, the heart rate is 180 beats/min,
the respiratory rate is 80 breaths/min, and the blood pressure is 50/30
mm Hg. The infant is pale and mottled and has cool extremities and
weak distal pulses.
Of the following, the MOST likely cardiac diagnosis is
►
atrioventricular septal defect
►
critical aortic stenosis
►
large ventricular septal defect
►
tetralogy of Fallot
►
transposition of the great arteries
Question-7
►
You are evaluating a 3-day-old infant brought to the emergency
department for lethargy. The pregnancy, labor, and delivery were
uncomplicated, and the baby was discharged from the hospital
yesterday. On physical examination, the heart rate is 180 beats/min,
the respiratory rate is 80 breaths/min, and the blood pressure is 50/30
mm Hg. The infant is pale and mottled and has cool extremities and
weak distal pulses.
Of the following, the MOST likely cardiac diagnosis is
►
atrioventricular septal defect
►
critical aortic stenosis
►
large ventricular septal defect
►
tetralogy of Fallot
►
transposition of the great arteries
Question-8
►
A 10-year-old girl had recent pharyngitis with culture-proven group A
Streptococcus. She was noncompliant with antibiotic therapy. She now
presents with fever to 102°F (38.9°C), a heart rate of 120 beats/min,
and a respiratory rate of 24 breaths/min. She has no murmurs or
gallop rhythm. She has a nonpruritic, macular rash that appears as a
serpiginous, erythematous circle surrounding normal skin. She also has
an erythematous, warm, swollen left knee and right ankle.
Of the following, the MOST appropriate diagnostic study for this girl is
►
chest radiography
►
echocardiography
►
left knee and right ankle radiography
►
rheumatoid factor
►
skin biopsy of the rash
Question-8
►
A 10-year-old girl had recent pharyngitis with culture-proven group A
Streptococcus. She was noncompliant with antibiotic therapy. She now
presents with fever to 102°F (38.9°C), a heart rate of 120 beats/min,
and a respiratory rate of 24 breaths/min. She has no murmurs or
gallop rhythm. She has a nonpruritic, macular rash that appears as a
serpiginous, erythematous circle surrounding normal skin. She also has
an erythematous, warm, swollen left knee and right ankle.
Of the following, the MOST appropriate diagnostic study for this girl is
►
chest radiography
►
echocardiography
►
left knee and right ankle radiography
►
rheumatoid factor
►
skin biopsy of the rash
Question-9
►
You are evaluating a 4-month-old girl in your office whom you know to
have tetralogy of Fallot. Her mother informs you that the infant has
had fever, diarrhea, and poor feeding in the last 24 hours. On physical
examination, you note cyanosis of the extremities and perioral area,
tachypnea, hyperpnea, and a heart rate of 180 beats/min. You do not
hear a murmur.
Of the following, the MOST appropriate management strategy is to
►
►
administer antipyretics for fever
►
encourage oral intake of fluids
►
order echocardiography
►
place her in the knee-chest position with oxygen
►
reassure her mother because the murmur is gone
Question-9
►
You are evaluating a 4-month-old girl in your office whom you know to
have tetralogy of Fallot. Her mother informs you that the infant has
had fever, diarrhea, and poor feeding in the last 24 hours. On physical
examination, you note cyanosis of the extremities and perioral area,
tachypnea, hyperpnea, and a heart rate of 180 beats/min. You do not
hear a murmur.
Of the following, the MOST appropriate management strategy is to
►
►
administer antipyretics for fever
►
encourage oral intake of fluids
►
order echocardiography
►
place her in the knee-chest position with oxygen
►
reassure her mother because the murmur is gone
Question-10-2004
►
A 14-year-old boy complains of fatigue, weight loss, and night sweats
over 2 months. His parents noted the recent onset of generalized
swelling of the face and neck that has a dusky color.
Of the following, the MOST useful diagnostic test for this boy is
►
chest radiography
►
computed tomography of the sinuses
►
cranial computed tomography
►
serum antinuclear antibody test
►
tuberculin skin test
Question-10-2004
►
A 14-year-old boy complains of fatigue, weight loss, and night sweats
over 2 months. His parents noted the recent onset of generalized
swelling of the face and neck that has a dusky color.
Of the following, the MOST useful diagnostic test for this boy is
►
chest radiography
►
computed tomography of the sinuses
►
cranial computed tomography
►
serum antinuclear antibody test
►
tuberculin skin test
Question-11
►
A 16-year-old girl who has systemic lupus erythematosus has been
vomiting for 1 day after having vague abdominal discomfort associated
with anorexia for 3 days. Physical examination reveals tachycardia,
with a heart rate of 130 beats/min. All peripheral pulses diminish in
strength when she inhales.
Of the following, the MOST important study to obtain initially is
►
►
abdominal computed tomography
chest radiography
►
electrocardiography
►
erythrocyte sedimentation rate
►
upper gastrointestinal radiographic series
Question-11
►
A 16-year-old girl who has systemic lupus erythematosus has been
vomiting for 1 day after having vague abdominal discomfort associated
with anorexia for 3 days. Physical examination reveals tachycardia,
with a heart rate of 130 beats/min. All peripheral pulses diminish in
strength when she inhales.
Of the following, the MOST important study to obtain initially is
►
►
abdominal computed tomography
chest radiography
►
electrocardiography
►
erythrocyte sedimentation rate
►
upper gastrointestinal radiographic series
Question-12
►
An 11-year-old girl has a 1-week history of dyspnea, malaise, and
fatigue. She developed vomiting after 24 hours of feeling abdominal
fullness and discomfort. Physical examination reveals a blood pressure
of 85/50 mm Hg, tachypnea, rales, hepatomegaly, and no cardiac
murmur. The heart rate by auscultation is 120 beats/min. Palpation of
the pulses reveals a regular rate of 60 beats/min.
Of the following, the MOST likely diagnosis is acute
►
hepatitis
►
lobar pneumonia
►
myocarditis
►
pancreatitis
►
pericarditis
Question-12
►
An 11-year-old girl has a 1-week history of dyspnea, malaise, and
fatigue. She developed vomiting after 24 hours of feeling abdominal
fullness and discomfort. Physical examination reveals a blood pressure
of 85/50 mm Hg, tachypnea, rales, hepatomegaly, and no cardiac
murmur. The heart rate by auscultation is 120 beats/min. Palpation of
the pulses reveals a regular rate of 60 beats/min.
Of the following, the MOST likely diagnosis is acute
►
hepatitis
►
lobar pneumonia
►
myocarditis
►
pancreatitis
►
pericarditis
Question-13
►
Two weeks after having a perimembranous ventricular septal defect
repaired, a 4-year-old child presents with anorexia and occasional
vomiting. On physical examination, there is pallor of the lips, and the
pulses are difficult to feel. The auscultated heart rate is 140 beats/min,
but the heart rate by radial pulse is only 70 to 80 beats/min. There is
no palpable radial pulse during the inspiratory phase of respiration.
Of the following, the intervention that is MOST likely to be effective is
►
direct current cardioversion
►
intravenous methylprednisolone
►
pericardiocentesis
►
thoracentesis
►
transvenous cardiac pacing
Question-13
►
Two weeks after having a perimembranous ventricular septal defect
repaired, a 4-year-old child presents with anorexia and occasional
vomiting. On physical examination, there is pallor of the lips, and the
pulses are difficult to feel. The auscultated heart rate is 140 beats/min,
but the heart rate by radial pulse is only 70 to 80 beats/min. There is
no palpable radial pulse during the inspiratory phase of respiration.
Of the following, the intervention that is MOST likely to be effective is
►
direct current cardioversion
►
intravenous methylprednisolone
►
pericardiocentesis
►
thoracentesis
►
transvenous cardiac pacing
Question-14
►
An asymptomatic 4-year-old girl has long, spidery fingers and a pectus
carinatum deformity. Her height is at the 50th percentile and weight is
at the 5th percentile. Cardiac auscultation reveals a systolic click that
occurs later in systole with squatting and earlier with standing.
Of the following, the MOST likely finding on echocardiography would
be
bicuspid aortic valve
Ebstein anomaly of the tricuspid valve
idiopathic hypertrophic subaortic stenosis
mitral valve prolapse
sinus of Valsalva aneurysm
Question-14
►
An asymptomatic 4-year-old girl has long, spidery fingers and a pectus
carinatum deformity. Her height is at the 50th percentile and weight is
at the 5th percentile. Cardiac auscultation reveals a systolic click that
occurs later in systole with squatting and earlier with standing.
Of the following, the MOST likely finding on echocardiography would
be
bicuspid aortic valve
Ebstein anomaly of the tricuspid valve
idiopathic hypertrophic subaortic stenosis
mitral valve prolapse
sinus of Valsalva aneurysm
Question-15
►
A newborn who has cyanosis has pulse oximetry values of 95% in head
hood oxygen at 100% Fio2. Arterial blood gas from the right radial
artery shows: pH, 7.34; Po2, 65 torr; and Pco2, 38 torr.
Of the following, the MOST likely diagnosis is
►
coarctation of the aorta with bicuspid aortic valve
►
double-inlet single ventricle with mild pulmonic valve stenosis
►
pulmonary atresia with restrictive ductus arteriosus
►
transposition of the great vessels with restrictive foramen ovale
►
ventricular septal defect with mild pulmonic valve stenosis
Question-15
►
A newborn who has cyanosis has pulse oximetry values of 95% in head
hood oxygen at 100% Fio2. Arterial blood gas from the right radial
artery shows: pH, 7.34; Po2, 65 torr; and Pco2, 38 torr.
Of the following, the MOST likely diagnosis is
►
coarctation of the aorta with bicuspid aortic valve
►
double-inlet single ventricle with mild pulmonic valve stenosis
►
pulmonary atresia with restrictive ductus arteriosus
►
transposition of the great vessels with restrictive foramen ovale
►
ventricular septal defect with mild pulmonic valve stenosis
Question-16
►
►
Which of the following laboratory findings is either a major
or minor Jones criterion for the diagnosis of acute
rheumatic fever?
decreased PR interval by electrocardiography
►
decreased serum complement
►
decreased serum haptoglobin
►
elevated antistreptolysin O titer
►
elevated C-reactive protein
Question-16
►
►
Which of the following laboratory findings is either a major
or minor Jones criterion for the diagnosis of acute
rheumatic fever?
decreased PR interval by electrocardiography
►
decreased serum complement
►
decreased serum haptoglobin
►
elevated antistreptolysin O titer
►
elevated C-reactive protein
Jones Criteria
► Major





Joints
Obvious as in Carditis
Nodules
Erythema marginatum
Sydenham’s Chorea
► Minor




JONES
criteria
Elevated acute phase reactants
Increased PR interval
Arthralgias
fever
References