NMS Q&A Family Medicine

Pediatric Cardiology 65by placing one or two fingers in a transverse position in theaforementioned position. The murmur is also said to dissipatewhen the child lies supine, but this is not reliable.Furthermore, the venous hum often dissipates with theturning of the child’s head. The quality of the murmur issoft, not harsh. The murmur tends to be both systolic anddiastolic in timing; that is, it is machinery like. Neither PSnor venous hum may manifest cyanosis with the exceptionthat, in the case of PS, cyanosis may occur in advanced andsymptomatic cases (this patient manifested no other signsor symptoms). S 2 is normal not only in venous hum, ofcourse, but also in mild-to-moderate cases of PS. Jugularvenous hum occurs after the age of 2 years, often in preschoolers,but never as late as adolescence.9. The answer is D. VSDs account for 30% of congenitalheart defects and are the most common type. Tetralogy ofFallot manifests cyanosis early on, as there is a right to leftshunt from the beginning. ASDs cause a murmur that islocated more cephalad, at about the second left intercostalspace near the left sternal border, and is characterized by afixed split second sound. Patent ductus is characterized bya continuous murmur that is loudest in systole (themachinery murmur). Venous hum has been described. Itdoes not make an appearance until about 2 years of age.10. The answer is E, all of the above. Patients with VSDmay develop several complications, most of which relateto the increased pulmonary blood flow. This can lead topulmonary hypertension, the more likely the larger thedefect. The latter, of course, leads to a reversal of the shunt,then becoming right to left (the Eisenmenger syndrome).Smaller VSDs often spontaneously close in the first fewyears of life, but this is less likely with larger defects and inolder children. Patients with VSD are prone to bacterialendocarditis, and prophylaxis is recommended.11. The answer is D. Radiation of a systolic murmur tothe left axilla is virtually pathognomonic of mitral insufficiency.The murmur of aortic stenosis is loud and harsh,both at the base and at the left sternal border, and radiatesto the carotids. There may be palpable thrills in thesuprasternal notch, the right base (point of S 2 ), and overthe carotid arteries. The intensity of the suprasternalnotch thrill best correlates with the size of the gradientacross the area of stenosis. An ejection click is common(thus, not all clicks are caused by MVP). Of all cases, 75%are of the valvular stenosis type, 23% are subvalvular, and1% to 2% are supravalvular.12. The answer is D. Cyanosis of the lips and clubbing ofthe fingernails will not be observed in coarctation. Maleindividuals are significantly more often affected thanfemale individuals. However, if a phenotypic female isaffected, she is quite likely to be an XO genotype. Thefemoral pulse delay and collateral formation are usuallynot evident in children. Although delayed femoral pulsesare not usually found in children, by the age of adolescencethis finding is common. Also, by adulthood, ribnotching is commonly found in coarctation. The mostcommon locus of coarctation is the thoracic aorta justdistal to the origin of the left subclavian artery.13. The answer is A. PS occurs most often as valvularstenosis, comprising 10% of congenital heart diseaselesions. In mild to moderate cases, an opening click maybe heard more prominent during expiration than inspiration.In severe cases, S 2 is not heard at all, and hence, nosplit is discernible. In the most severe cases, there is earlycyanosis, often caused by right to left shunting through apatent foramen ovale. Other cases do not become symptomaticuntil later in life, constituting an indication forballoon valvuloplasty and occasionally valve replacement,which is best accomplished before the individual reachesthe age of 20 years. Aortic stenosis, 75% of which cases areof the valvular type, do not become symptomatic untilthe fourth or fifth decades, if ever. The murmur radiatesto the carotids. ASD manifests a fixed split S 2 . VSD exhibitsa systolic ejection murmur, loudest along the lower leftsternal border. MVP murmur radiates to the left axilla.14. The answer is E, indomethacin. Most hemodynamicallysignificant PDAs in premature infants will close withthe use of intravenous indomethacin if they do not spontaneouslyclose within the first 2 days with supportivecare. Indomethacin is dosed orally at 0.1 to 0.3 mg/kgevery 8 hours or intravenously at 0.1 to 0.3 mg/kg every12 hours. Indomethacin does not usually effect closure ofPDA in full-term infants. If indomethacin is not successful,then surgery is advised.15. The answer is E, observation only. Carotid bruits area common physiologic murmur in children and can beheard in conjunction with a still murmur. There are alsomurmurs that occur within the first 2 days of life, transitionalmurmurs , a nonspecific term for benign and transientfunctional murmurs often present in newbornswithin minutes to hours (but not at the moment) of birth,one of which may be the PDA.16. The answer is B. Transposition of the great vesselsaccounts for delayed onset of cyanosis in a newborn.Transposition of the great vessels presents with cyanosisearly in life. A patent ductus is necessary along with thetransposition to allow any oxygenated blood to reach thesystemic circulation. Without either a patent ductus orother pathway for shunting of oxygenated blood into theleft side of the heart, the condition is incompatible withlife. The ductus arteriosus serves the purpose but closeswithin a few days. Those cases that are associated with