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Pediatric Emergency Medicine

Pediatric Cardiology Quiz- 6/11

 

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Cardiology quiz- June 2011

American College of Emergency Physicians Section of Pediatric Emergency Medicine

Rajender Gattu, MD, Assistant Professor of Pediatrics, Division of Pediatric Emergency Medicine, University of Maryland School of Medicine

John S. Kim, MD, Department of Pediatrics, University of Maryland Hospital for Children, Baltimore, MD

1. A 5-day-old full term girl born via spontaneous vaginal delivery presents to the ED with a few hours of fussiness and poor feeding.  The mother also reports that the baby’s color is different.  The mother denies any history of fever for the baby.  Vital signs are as follows: temperature 36.5ºC, heart rate 180 bpm, respiratory rate 80 with a pulse oximetry that was unobtainable.  On examination, the child is active and alert, fussy but consolable with a capillary refill time of greater than 3 seconds.  Femoral pulses are weakly palpable, dorsalis pedis is not palpable, and auscultation of the heart reveals 3/6 systolic murmur over the precordium.

 

Which of the following emergency interventions will show immediate clinical improvement?

a. Intravenous PGE2 infusion

b. Intravenous ampicillin and cefotaxime

c. Intravenous normal saline bolus

d. Albuterol nebulizer and inhaled oxygen via 100% non rebreather.

 

2. All of the following statements regarding the incidence of congenital heart disease are true, EXCEPT:

a. Congenital heart disease occurs in 8 per 100 live births.

b. Congenital heart disease occurs in 8 per 1000 live births.

c. 2-6% of children born to parents of congenital heart disease will be affected.

d. Bicuspid aortic valve is one of the most common isolated congenital heart defects.

 

3. An 8-year-old obese boy presents to the ED with a history of intense retrosternal chest pain and difficulty breathing on exertion for several hours.  Past medical history is significant for asthma for which patient receives albuterol nebulizations as needed with daily inhaled fluticasone and oral montelukast.  He has been hospitalized twice in the past for asthma and once for Kawasaki disease at the age of 4.  Vital signs are as follows: temperature 37ºC, heart rate 144 bpm, respiratory rate 36, and pulse oximetry 95% on room air.  On physical examination, he is diaphoretic with capillary refill time less than 2 seconds, and normal heart sounds with no murmur auscultated.  Respiratory examination revealed no wheezing and no intercostal retractions.

                                   

What is the next best step in management of this patient?

a. Inhaled albuterol nebulizer treatment, nasal cannula oxygen, oral corticosteroids, chest x-ray

b. Reassurance, breathing in a paper bag, oral lorazepam

c. Morphine, inhaled oxygen, sublingual nitroglycerine, aspirin, chest x-ray, ECG, cardiac enzymes, and cardiology consult

d. Chest x-ray, intravenous antibiotics, and admission to general pediatrics

 

4. A 12-week-old full term boy presents to the ED with a 2-day history of irritability, difficulty feeding, and trouble breathing.  The mother reports that his only health concern is poor weight gain.  Vital signs are as follows: afebrile, heart rate 190, respiratory rate 70, and pulse oximetry 92% on room air. Cap refill is >3 seconds.  Physical examination reveals an irritable but consolable infant. Air entry is good bilaterally with occasional rales in both lung bases. Cardiac auscultation reveals a rapid rate but regular rhythm, faint or questionable murmur.  Abdominal examination reveals a liver palpable 5 centimeters below the right costal margin. Chest radiography reveals cardiomegaly and pulmonary congestion.

 

Of the following, which are possible etiologies of this patient’s current presentation?

a. Large ventricular septal defect (VSD)

b. Anomalous left coronary arising from the pulmonary artery (ALCAPA)

c. Myocarditis

d. All of the above

e. a and c

 

5. A 9-year-old boy is brought to the pediatric ED by his mother because of fever to 103 degrees Fahrenheit associated with generalized malaise and fatigue. Upon further questioning, the mother reports the boy was seen by his pediatrician last week for low-grade fevers associated with muscle and joint soreness thought to likely be caused by a flu-like viral illness. The patient’s past medical history is significant only for a heart murmur caused by “a problem with one of his valves.”  Vital signs are temperature 39.6ºC, heart rate 145, respiratory rate 38, blood pressure 102/56 and pulse oximetry 98%.  Physical examination reveals a tired-appearing child with a loud systolic murmur heard best over the right upper sternal border.

  

What is the most common organism causing infective infective bacterial endocarditis in children?

a. Staphylococcus aureus

b. Viridans streptococcus

c. Streptococcus pyogenes (Group A Streptococcus)

d. Staphylococcus epidermidis

6. A 5-day-old newborn girl is brought by her mother to the pediatric ED because of poor feeding and lethargy.  The baby was delivered via Cesarean section for fetal bradycardia with APGARS 8 and 9 (at 1 and 5 minutes, respectively) to a 31-year-old mother with a history of lupus.  The baby was discharged home on day of life 3 with normal vital signs and adequate breast feeding.  On presentation vital signs are temperature 36.6ºC, pulse 62, respiratory rate 25, blood pressure 82/44, and pulse oximetry 96%.  Physical examination reveals a lethargic baby with bradycardia.  P waves are visible on telemetry; however, they are not regularly associated with QRS complexes.

  

All of the following can be used to treat complete heart block, EXCEPT:

a. Isoproterenol infusion

b. Cardioversion

c. Epinephrine

d. Pacemaker

 

7.  An 8-year-old boy with a history of heart failure secondary to idiopathic dilated cardiomyopathy presents to the pediatric ED for slow heart rate and exercise intolerance despite being paced via a pacemaker placed 2 years ago.

  

Of the following, what is/are the possible cause(s) of the patient’s pacemaker dysfunction?

a. Lead malposition / malfunction

b. Battery depletion

c. Inflammation and fibrosis of electrode

d. High in capture threshold

e. All of the above

 

8. A 16-year-old girl with end-stage renal disease secondary to focal segmental glomerulosclerosis presents to the pediatric ED presents with a headache for the last 48 hours.  The patient is currently on oral corticosteroids and peritoneal dialysis therapy for her renal disease.  Vital signs are temperature 37ºC, pulse 80, respiratory rate 18, blood pressure 192/128, pulse oximetry 100%.  Physical examination reveals an alert and interactive teen, heart rate regular with no murmurs, clear lungs, and a nontender abdomen with PD catheter in place.  Neurologic examination is unremarkable.

  

Of the following, what is your next best step in management of this patient?

a. Intravenous hydralazine

b. Nitroprusside infusion

c. Oral nifedipine

d. Esmolol infusion

e. Intravenous labetolol

 

Copyright 2011 American College of Emergency Physicians. Pediatric Emergency Medicine Section quizzes may be reproduced for educational purposes only. To obtain permission to reprint for any other purpose, please submit your written request to: Deputy Executive Director, American College of Emergency Physicians, PO Box 619911, Dallas, TX 75261.

 

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