Cardiac: Cases and Questions
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Objectives:
1) Describe a complete cardiac exam including proper use of a stethoscope.
2) Recognize the warning signs in a neonate for cyanotic congenital heart disease.
3) Distinguish between innocent and pathologic murmurs.
4) Describe a murmur using the 6 characteristics.
5) Recognize warning signs in an adolescent.
Resources:
- Biancaniello. Innocent Murmurs, Circulation 109 (11): e162. (2004)
- *Menashe. Heart Murmurs, Pediatrics in Review, 28 (4): e19. (2007) – also included an audio supplement at http://pedsinreview.aappublications.org/cgi/content/full/28/4/e19/DC1
- *Park, Myung, Pediatric Cardiology for Practitioner, 3rd ed. 1996
- WBC CARDIOLOGY PAGE - http://wbc.babiespeds.org/articles/show_library.php?id=17
* indicates primary resources
Case #1: A 2day old infant waiting to be discharged is found to be tachypneic to the 60’s. This young boy had a chest xray and was put on oxygen after he was found to be tachypneic. His VS were temp 98.8, HR 165, RR 66, BP 72/44, O2 sat 41% with a cardiac exam significant for PMI at the LSB and no murmur. It was difficult to hear whether there was a split. After the O2 was placed and the CXR revealed an ‘egg-shaped’heart , the cardiologist was called and prior to the echo gave the diagnosis.
Questions:
1) What is the hyperoxitest? How did this patient respond to the O2?
2) What are the cyanotic heart lesions? Which one is likely here?
Case #2: A Four year old girl comes in for a schedule well child visit has been remarkably well since the last visit. She is growing well and has normal vital signs. On exam there is a murmur that is heard near the LUSB, perhaps more laterally. It does not vary during the cardiac cycle but goes away when she lies down. It also changed when she looked at her mother to one side. When you look over to her mother you note that she is very nervous. “My grandfather had a murmur and died… does my daughter have a murmur?”
Questions
1) Is this murmur an innocent murmur? How would you explain this to your patient’s mother?
2) How would you go about the exam? Why do we use a stethoscope? Are there maneuvers to increase or decrease these murmurs?
Case #3-
A 16 yr athletic male comes in for a preparticipation physical; coincidentally, his first visit with you. He says “he just needs the form so he can play basketball”. He is 6’3” and his BMI is 50%. His PMH is completely normal and he has never had a significant injury or surgery.
Questions
1) What question on history should you ask to distinguish if it is safe from a cardiac standpoint for him to play? What findings on physical would you look for?
2) What evaluation would you do if any of these questions were positive? Would you get a CXR and EKG or refer?