Berkowitz’s – Section VI: Cardiovascular System
Heart Murmurs
Robin Winkler Doroshow, MD, MMS, MEd
CASE STUDY
A 6-year-old girl is brought to the office for a physical examination for school. Her medical history is unremarkable, and her growth and development have been normal. She is asymptomatic. Her physical examination is normal except for a grade 2/6 low-pitched vibratory systolic ejection murmur that is loudest at the left lower sternal border, with radiation to the apex and upper sternal border. The murmur increases to 3/6 in the supine position.
Questions
1. What is the significance of a heart murmur in asymptomatic children? How reassuring are a negative history and the absence of other physical findings?
2. What workup should be done by primary care physicians?
3. What are the costs of excessive tests and unnecessary consultation? What are the costs of an inadequate workup?
4. When should physicians refer children to specialists for consultation?
Palpitations
Robin Winkler Doroshow, MD, MMS, MEd, and Nefthi Sandeep, MD
CASE STUDY
A previously healthy 10-year-old girl comes to the office complaining of an episode of “racing heart.” This occurred about a week ago while she was watching TV. Her heart suddenly started pounding hard, and the sensation stopped just as suddenly about 30 minutes later. During the episode, the child’s mother felt the girl’s chest and noted her heart was beating extremely fast and hard; the child looked scared but was in no respiratory distress and was alert. Her parents drove her to the local emergency department (ED), but the symptoms stopped en route. On arrival in the ED, she was fine and had normal vital signs and physical examination and a normal electrocardiogram. In retrospect, she has had brief such episodes in the past.
Questions
1. What is the significance of palpitations in an otherwise well child?
2. How likely is this symptom to be cardiac in origin, and if so, how likely to be life-threatening?
3. How can transient cardiac events be documented?
4. What does the primary care physician need to do and know prior to referring the child to a cardiologist?
Cyanosis in the Newborn
Robin Winkler Doroshow, MD, MMS, MEd
CASE STUDY
A 3,500-g term male neonate born to a 29-year-old, gravida 2, para 2, healthy mother by spontaneous vaginal delivery is well until 24 hours of age, when a nurse notes that he is cyanotic. On examination, he appears blue but in no distress. The vital signs are temperature (axillary) 37°C (98.6°F), pulse 130 beats/min, respirations 40 breaths/min, and blood pressure 80/60 mm Hg in the right arm. His general appearance is normal except for the cyanosis. His heart sounds are normal, and no murmur is heard. His liver is not palpable, and the peripheral pulses are normal and equal in all extremities. Capillary refill is normal. Oxygen saturation is 65% by pulse oximetry.
Questions
1. What are the causes of cyanosis in newborns?
2. What is the appropriate evaluation of cyanosis in newborns?
3. How urgent is the assessment? What are the risks and benefits of further evaluation?
4. Which aspects of management should be initiated by a primary physician at a community hospital?
5. Which types of treatment should be undertaken by the consulting pediatric cardiologist at the referral center?
Congestive Heart Failure
Robin Winkler Doroshow, MD, MMS, MEd
CASE STUDY
A 2-month-old boy is brought to the office by his mother, who complains that her son has been eating poorly and breathing oddly for the past few days. The perinatal history is unremarkable. A heart murmur was noted at the 1-month checkup. The infant is scrawny and irritable. Physical examination shows that the baby’s weight, which was at the 50th percentile at birth, is now at the fifth percentile; his height, which was at the 50th percentile, is now at the 25th percentile. He is afebrile, and his heart rate is 165 beats/min, with respirations 70 breaths/min and shallow but without respiratory distress. The skin is pale and diaphoretic, and the mucous membranes are pink. Examination of the head and neck is normal; no jugular distention is present. The lungs are clear. The precordium is hyperdynamic, and the heart sounds are loud; a prominent systolic murmur is audible at the left lower sternal border. The liver edge is palpable 4 cm below the right costal margin in the right midclavicular line, and the spleen is not palpable. The extremities are thin, with normal pulses and no edema. Capillary refill is slightly delayed.
Questions
1. What are acute and chronic signs of cardiac disease in children?
2. What are the signs of congestive heart failure (CHF) in children? How do these signs in children differ from those in adults?
3. What underlying disorders can cause CHF in young infants?
4. What is the appropriate emergent management for infants with CHF? What are the risks of treatment if the diagnosis is incorrect?
Chest Pain
Robin Winkler Doroshow, MD, MMS, MEd
CASE STUDY
A previously healthy 13-year-old boy comes to the office complaining of recurrent chest pain occurring approximately once a week over the past 2 months. The pain is stabbing in nature, located at the mid-sternum, and not associated with any other symptoms, and occurs randomly, at rest and with exercise. It lasts for 2 to 3 minutes, is ranked as 4 on a severity scale of 10, and subsides spontaneously. The patient does not appear very concerned about the pain, but his mother is quite anxious to have it checked out. His teacher has sent him home from school twice because of the pain, and the soccer coach will not let him play until he is cleared by a doctor. His physical examination is unremarkable.
Questions
1. What is the significance of chest pain in an otherwise healthy child?
2. How likely is serious heart disease to be heralded by chest pain?
3. How much testing, and what type, is appropriate in working up chest pain?
4. Which patients with chest pain should be referred to a cardiologist? To other specialists?
Hypertension
Gangadarshni Chandramohan, MD, MS, and Sudhir K. Anand, MD
CASE STUDY
A 16-year-old girl is seen in the emergency department with a history of persistent headaches of 2 weeks’ duration. She has been having occasional headaches for the past 2 years, which have been treated primarily with acetaminophen. She denies any recent weight loss, hair loss, joint pains, sweating, or palpitations. There is no history of swelling of her eyes or legs or blood noticed in the urine. She was born prematurely at 30 weeks’ gestation and stayed in the hospital for 2 weeks. There is no history of urinary tract infection. Her mother (34 years old) and maternal grandma (58 years old) have been on antihypertensives for the past several years. She is an average student at school. There is no known history of drug ingestion. Her diet consists of mostly bread and meat. Also, she regularly eats salty snacks but drinks sodas only occasionally. She never was involved in any physical activity on a regular basis. The physical examination is remarkable for an obeselooking girl with weight, height, and body mass index above the 95th percentile for age. Pulse is 85 beats/min and blood pressure 158/78 mm Hg in the right arm in supine position. Equal pulses are palpable in all 4 extremities. Blood pressure is 164/92 mm Hg in the right lower extremity. Funduscopic examination reveals evidence of arteriovenous nicking but no papilledema. Chest examination finds normal breath sounds and an active precordium with the apical impulse shifted to the left; no murmurs are heard. The liver is palpable 1 cm below the right costal margin. Neurologic examination is unremarkable; no focal neurologic deficit is present. Urinalysis is normal. Hemoglobin is 11.2 g/dL and hematocrit is 33%. Sodium is 139 mEq/L, potassium 3.8 mEq/L, chloride 102 mEq/L, and bicarbonate 22 mEq/L. Blood urea nitrogen is 15 mg/dL and serum creatinine is 0.9 mg/dL. An electrocardiogram shows left ventricular enlargement. Computed tomography scan of the head is normal.
Questions
1. What is the definition of hypertension in children and adolescents?
2. What are the causes of hypertension in children and adolescents?
3. What is the appropriate evaluation of hypertension in children and adolescents?
4. What are the comorbid conditions and long-term complications associated with essential (primary) hypertension?
5. What is the appropriate emergency treatment of symptomatic hypertension?
6. What is the long-term management of children with essential hypertension?