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Questions and Answers
What is a characteristic feature of atrial septal defect and ventricular septal defect in congenital heart disease?
Which congenital heart defect is characterized by cyanosis with decreased pulmonary blood flow?
What major change occurs at birth with respect to pulmonary vascular resistance?
Which of the following lesions results in increased pressure load?
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What is indicated by the presence of cyanotic congenital heart lesions?
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What familial condition shows a strong relationship with essential hypertension and coronary artery disease?
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Which physical examination finding suggests right ventricular enlargement?
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What does a gallop rhythm indicate?
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Which of the following findings might suggest coarctation of the aorta in neonates?
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What aspect of a heart murmur is NOT analyzed?
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Which vital sign is NOT typically included in a physical examination?
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Cardiac size and shape can be assessed using which diagnostic tool?
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What does the appearance of muffled and distant heart sounds indicate?
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What is a common symptom of heart failure in infants?
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Which of the following is a key indicator of cyanosis that should be observed?
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Congestive heart failure in children can present with which of the following symptoms?
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What is a characteristic feature of a 'cyanotic spell' in infants?
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Family history of which condition increases the likelihood of congenital heart disease in a child?
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What is the recurrence risk of congenital heart disease in siblings if one child is affected?
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Which symptom is considered an unusual presentation of cardiac problems in children?
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For which of the following conditions is a history of stroke most suggestive?
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Study Notes
Pediatric Cardiac Evaluation - History
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Postnatal History
- Feeding pattern, weight gain, and development are essential.
- Heart failure symptoms differ by age.
- Infants often struggle with feeding.
- Exercise intolerance is common in older children.
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Cyanosis and Cyanotic Spells
- Cyanosis onset (at birth, several days after birth?) is crucial.
- Severity of cyanosis can be permanent or paroxysmal.
- Note the body parts affected (fingers, toes, lips) and whether cyanosis worsens after feeding.
- Cyanotic spells, particularly in infants with tetralogy of Fallot, require immediate attention.
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Dyspnea, Tachypnea, and Puffy Eyelids
- These are signs of congestive heart failure.
- Frequent lower respiratory tract infections are also worrisome.
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Chest Pain
- While a common reason for referral, it is an unusual presentation of cardiac problems.
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Syncope
- An unusual presentation.
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Palpitation
- A subjective feeling of rapid heartbeats.
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Joint Symptoms
- Migratory joint pain involving large joints can indicate acute rheumatic fever.
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Stroke
- Suggests thromboembolism from cyanotic congenital heart disease with polycythemia or infective endocarditis.
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Medications
- Consider the impact of cold medications or antiasthmatic drugs on cardiac function.
Pediatric Cardiac Evaluation - Family History
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Hereditary Diseases
- Marfan's syndrome and Holt-Oram syndrome have genetic components.
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Congenital Heart Disease (CHD)
- The general population has a 1% incidence of CHD.
- A family history of CHD raises the risk for a child.
- When one child has CHD, the risk of recurrence in siblings increases three-fold to 3%.
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Hypertension and Atherosclerosis
- These conditions have a strong familial pattern.
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Rheumatic Fever
- Relatives of children with rheumatic fever have a higher incidence.
Pediatric Cardiac Evaluation - Physical Exam
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Inspection (Do not disturb the child)
- Assess general appearance and nutritional status (distress, well-nourished, or undernourished).
- Look for chromosomal syndromes like Down syndrome.
- Note skin color (cyanosis, pallor, or jaundice).
- Check for clubbing, respiratory rate, dyspnea, and retractions.
- Observe for sweat on the forehead.
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Vital Signs
- Measure pulse rate, respiratory rate, blood pressure, oxygen saturation, and temperature.
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Inspection of the Chest
- A precordial bulge, with or without visible cardiac activity, indicates chronic cardiac enlargement.
- Substernal thrust suggests right ventricular enlargement.
- An apical heave signifies left ventricular enlargement.
- Observe the apical impulse.
- Note any pigeon chest (pectus carinatum), pectus excavatum (sternum depression), or Harrison's groove.
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Palpation
- Feel for thrills (vibrations) and heaves (impulses).
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Auscultation
- Analyze heart sounds before examining murmurs.
- Muffled and distant heart sounds indicate pericardial effusion or heart failure.
- A gallop rhythm (loud S3, with or without S4 plus tachycardia) is concerning.
- Listen for pericardial friction rubs and pericardial knocks.
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Heart Murmurs
- Assess the intensity (grade 1-6), timing (systolic or diastolic), location, transmission, and quality (musical, vibratory, blowing, etc.)
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Abnormal Physical Findings in Neonates
- Cyanosis that doesn't improve with oxygen administration.
- Decreased or absent peripheral pulses in the lower extremities suggest coarctation of the aorta.
- Irregular rhythm and abnormal heart rate.
- Heart murmurs.
- Hepatomegaly (enlarged liver).
- Tachypnea (rapid breathing).
Pediatric Cardiac Evaluation - Investigations
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Chest X-ray
- Evaluate cardiac size and shape.
- Determine pulmonary blood flow (vascularity).
- Look for pulmonary edema and associated lung and thoracic abnormalities.
- A cardiothoracic ratio greater than 50% (heart wider than half the chest) indicates cardiac enlargement.
- May show characteristic appearances like "boot-shaped" or "egg-shaped" heart for specific conditions.
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Electrocardiogram (ECG)
- Helps assess heart rate, rhythm, and electrical activity.
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Hematologic Data
- Check for polycythemia (high red blood cell count).
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Echocardiography
- Provides a detailed view of the heart's structure and function.
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Exercise Testing
- Evaluates cardiac response to physical stress.
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Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA)
- Detailed imaging for evaluating cardiac structure and blood flow.
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Diagnostic and Interventional Cardiac Catheterization
- A specialized procedure used for diagnosis and treatment.
Fetal and Perinatal Circulation
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Changes at Birth
- Systemic vascular resistance increases.
- Umbilical vein blood flow stops, closing the ductus venosus.
- Pulmonary vascular resistance (PVR) decreases.
- The foramen ovale functionally closes.
Evaluation of Infants and Children with Congenital Heart Disease
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Grouping of Defects
- Congenital heart defects are broadly classified into cyanotic (with blue discoloration) and acyanotic (without blue discoloration).
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Chest Radiograph
- Assess pulmonary vascular markings (increased, normal, or decreased).
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Electrocardiogram (ECG)
- Evaluate for right, left, or biventricular hypertrophy (enlarged chambers).
Acyanotic Congenital Heart Lesions
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Increased Volume Load
- Atrial septal defect (ASD), ventricular septal defect (VSD), AV septal defects (AV canal), and patent ductus arteriosus (PDA) increase blood volume in the heart chambers.
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Increased Pressure Load
- Valvular pulmonic stenosis (narrowing of the pulmonary valve), valvular aortic stenosis (narrowing of the aortic valve), and coarctation of the aorta (narrowing of the aorta) increase pressure in the heart chambers.
Cyanotic Congenital Heart Lesions
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Decreased Pulmonary Blood Flow
- Tricuspid atresia (absence of tricuspid valve), tetralogy of Fallot (combination of defects), and various single ventricle conditions with pulmonary stenosis reduce blood flowing to the lungs.
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Increased Pulmonary Blood Flow
- Transposition of the great vessels (switched aorta and pulmonary artery position), truncus arteriosus (single trunk for both aorta and pulmonary artery) increase the volume of blood flowing to the lungs.
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Description
This quiz focuses on the key aspects of taking a pediatric cardiac history. It covers postnatal information, cyanosis symptoms, heart failure indicators, and other relevant signs in children. Understanding these details is crucial for effective diagnosis and management.
