Pediatric Examination and Board Review Read Online Free PDF Page B

usually welllocalized without much radiation and are usually graded between 1 and 3 with no associated precordial thrill. The murmurs are usually described as vibratory, musical, or blowing, and they are louder in the supine position compared with the sitting or standing position. This is not the case with the innocent venous hum that is often louder in the sitting position. A venous hum can be distinguished by the great amount of variability in quality with position changes and with turning the head. Innocent murmurs do not typically have a diastolic component. A split, fixed second heart sound is associated with an atrial septal defect.
    3. (D) Common tests performed in evaluation of innocent heart murmurs include 12-lead ECGs, chest radiographs, 4-extremity blood pressure (to rule out coarctation of the aorta) and echocardiograms. The use of these tests is at the discretion of the examining physician and depends on the findings on physical examination as well as the past medical and family history. An invasive procedure such as a cardiac catheterization is usually not recommended for evaluation of an innocent heart murmur if the tests just listed have been normal.
    4. (C) Innocent heart murmurs are not associated with any increased risk for bacterial endocarditis; thus prophylaxis is not needed. Sports participation is not restricted because there is not an increase in cardiac events associated with innocent heart murmurs. Innocent murmurs, by definition, are not associated with structural heart disease, so yearly echocardiograms are usually not recommended. There is no familial association with structural heart disease. Depending on the age at time of diagnosis, a followup visit is occasionally recommended for younger patients.
    5. (C) The child presents with evidence of congestive heart failure. In addition to the clinical findings described, other findings associated with congestive heart failure include edema, usually of the eyelids or in dependent areas, jugular venous distention, an S3 or S4 gallop on examination, and cardiomegaly or pulmonary edema demonstrable on chest radiograph.
    6. (D) Evaluation of a young patient with congestive heart failure requires a physical examination to assess for edema, hepatomegaly, pulmonary congestion, and cardiac gallop. An echocardiogram is used to assess cardiac function and any associated cardiac structural abnormalities. A 12-lead ECG is used to assess for any ischemic changes, arrhythmias, or bradycardia. A chest radiograph is helpful to assess for cardiomegaly or pulmonary edema as well as to assess for any obvious primary pulmonary disorders. A throat culture would not be useful at this age for evaluation of heart failure.
    7. (C) Cardiac lesions that present with heart failure at this age are usually a result of an increase in the amount of left-to-right shunting secondary to the natural decrease in the pulmonary vascular resistance. Common left-to-right shunting lesions include a ventricular septal defect, a patent ductus arteriosus, a large coronary artery fistula, and an aortopulmonary window. Atrial septal defects do not usually present with heart failure at this age mainly because the amount of left-to-right shunting depends on the compliance of the right ventricle rather than the drop in pulmonary vascular resistance.
    8. (A) An anomalous left coronary artery arising from the pulmonary artery is a rare congenital heart defect. The right coronary artery arises normally from the aorta. A number of collateral vessels develop between the right and left coronary arteries, and thus, when there is a drop of pulmonary vascular resistance, a “steal phenomenon” occurs with coronary blood essentially flowing from the aorta to the right coronary artery across the collaterals to the left coronary artery and into the pulmonary artery. Because of this, certain areas of the myocardium are at risk for ischemia. Patients with this lesion often present at 6-8 weeks of age with