[02.20] CMD - Acute Rheumatic Fever and Rheumatic Heart Disease V2.2.pdf

Placenta

What fetal organ is the main site of gas and nutrient exchange with the maternal circulation

Ductus venosus

Through which fetal vascular structure does oxygenated blood from the placenta enter the fetal circulation

Inferior vena cava

Which major vein drains the lower part of the fetal body and the placenta

One third

What fraction of blood from the inferior vena cava is shunted directly to the left atrium via the foramen ovale in the fetus

Foramen ovale

Through which interatrial opening does blood pass to supply the upper half of the fetal body

Two thirds

What fraction of inferior vena cava blood drains into the right ventricle and pulmonary artery in the fetus

Superior vena cava

Which major vessel drains the upper part of the fetal body and directs most of its blood to the right ventricle

Patent ductus arteriosus

Through which vascular connection does blood from the pulmonary artery bypass the fetal lungs to supply the lower body

Removal of the placenta

What perinatal event is the primary cause for the increase in systemic vascular resistance after birth

Loss of blood supply from the placenta

What physiologic change triggers the closure of the ductus venosus at birth

Lung expansion and high oxygen tension

What two physical factors in the newborn cause a decrease in pulmonary vascular resistance and increase in pulmonary blood flow

Functional closure of foramen ovale

What occurs in the newborn heart due to an increase in left atrial pressure

Increased left atrial pressure

What pressure change drives the functional closure of the foramen ovale at birth

Functional closure of the patent ductus arteriosus

What newborn circulatory change is prompted by increased oxygen saturation

Increased oxygen saturation

What chemical signal promotes the functional closure of the patent ductus arteriosus in the newborn

Right atrium

Where does blood from the superior vena cava and inferior vena cava drain in the normal heart

Tricuspid valve

Which valve does blood pass through when traveling from the right atrium to the right ventricle

Pulmonary valve

Which valve does blood cross as it exits the right ventricle into the pulmonary artery

Pulmonary veins

Through which vessels does oxygenated blood drain into the left atrium from the lungs

Mitral valve

Which valve does blood cross when moving from the left atrium to the left ventricle

Aortic valve

Which valve does blood cross to exit the left ventricle into the systemic circulation

Intracardiac pressures

What diagnostic values are helpful in determining the presence of shunting in certain heart defects

Blood pressure

What does the intracardiac pressure of the aorta represent clinically

0-4 mmHg

What is the normal pressure of the right atrium in mmHg

8-10 mmHg

What is the normal pressure of the left atrium in mmHg

25/4 mmHg

What is the normal pressure of the right ventricle in mmHg

120/10 mmHg

What is the normal pressure of the left ventricle in mmHg

25/10 mmHg

What is the normal pressure of the pulmonary artery in mmHg

120/80 mmHg

What is the normal pressure of the aorta in mmHg

Gestational history

Which component of the focused cardiac history should always be asked first

Maternal infections

Why does the clinician ask about maternal Rubella or Varicella during gestational history taking

Teratogens

What are retinoic acid and lithium examples of when evaluating a cardiac patient's history

Maternal conditions

Why are diabetes, phenylketonuria, and systemic lupus erythematosus asked about during gestational history

Gestational age

What historical detail helps explain why a premature baby might have an open ductus arteriosus and foramen ovale

Gestational diabetes

What maternal condition is suspected if a baby's birth weight is classified as large for gestational age

Progress of delivery

Which historical factor during birth might have a direct bearing on the baby's pulmonary pressures

Syndromic features

What is observed in the general appearance of a baby at birth to help identify underlying genetic conditions

Intermittency of feeding

What specific feeding pattern in infants with heart failure leads to poor weight gain

Heart failure

What clinical state is suspected in an infant with poor weight gain, diaphoresis, and interrupted feeding patterns

Frequent lower respiratory tract infections

What does a history of recurrent pneumonias in a pediatric patient suggest

Arthralgia

What joint-related history is evaluated alongside arthritis, skin rashes, and recurrent tonsillopharyngitis

Chorea

What neurologic symptom in pediatric patients is characterized by purposeless, involuntary movements

Family history

In which section of the history does the clinician screen for known cases of congenital or rheumatic heart disease in relatives

Buccal mucosa, nail beds, and skin

Which three physical regions are inspected first to evaluate a pediatric patient's oxygenation color

Precordium

Which anatomical area is inspected to determine if it is dynamic or adynamic or has a visible bulge

Pectus excavatum and pectus carinatum

What are two sternal deformities looked for during inspection of the pediatric chest

Harrison's groove

What structural chest depression is assessed on physical inspection in children with chronic respiratory issues

Neck vein engorgement

Which physical exam finding is assessed on the neck, although jugular venous pressure is no longer performed in children

Palpation

During which part of the physical exam does the clinician check for heaves, thrills, and the point of maximal impulse

Left and right liver edges

What must be palpated to rule out situs inversus in a pediatric patient

Situs inversus

What congenital condition is checked for by palpating both the left and right liver edges

Percussion

Which physical examination technique is not performed on the chest of children and adolescents

Regular, regularly irregular, and irregularly irregular

What are the three descriptors used to document heart rhythm during auscultation

Distinct, muffled, and distant

What are the three main descriptors used to characterize heart sounds during auscultation

Heart murmurs

Which cardiac auscultation findings are classified as either innocent or pathologic

Grade one

Which murmur grade is described as very faint, heard only after the listener has tuned in, and may not be heard in all positions

Grade two

Which murmur grade is quiet but heard immediately after placing the stethoscope on the chest

Grade three

Which murmur grade is described as moderately loud with no palpable thrill

Grade four

Which murmur grade is loud and accompanied by a palpable thrill

Grade five

Which murmur grade is very loud with a thrill, and may be heard with the stethoscope partly off the chest

Grade six

Which murmur grade is the loudest with a thrill, and may be heard with the stethoscope entirely off the chest

Innocent murmurs

Which general class of murmurs is characterized by no clicks, an intensity of less than 3/6, and is never diastolic

Regurgitant

What type of systolic murmur is always pathologic and never innocent

Clicks

What extra heart sound is associated with pathologic systolic murmurs and is absent in innocent murmurs

Less than three over six

What is the maximum intensity grade for an innocent systolic murmur

Diastolic murmurs

Which timing of heart murmurs is always pathologic

Venous hum

What is the only innocent continuous murmur

Pathologic continuous murmurs

How are all continuous murmurs other than a venous hum classified

Radiation in the axilla, neck, and back

Which three radiation directions are key when assessing pediatric heart murmurs

Acyanotic congenital heart disease

What condition is characterized by pink buccal mucosa, pink nail beds, and an oxygen saturation of more than 95 percent

Hyperoxia test

What diagnostic test can be performed to differentiate cardiac from non-cardiac cyanosis in the gray area

Arterial blood gas

What laboratory test on room air is the first step of a hyperoxia test

One hundred percent

What concentration of inspired oxygen is administered during a hyperoxia test

Ten minutes

How long after administering 100 percent oxygen is the arterial blood gas repeated in a hyperoxia test

Non-cardiac cyanosis

What is the diagnosis if the partial pressure of oxygen rises to more than 150 mmHg during a hyperoxia test

Equivocal finding

How is a hyperoxia test result interpreted if the partial pressure of oxygen is between 100 and 150 mmHg

Likely cyanotic heart disease

What does a partial pressure of oxygen of less than 100 mmHg during a hyperoxia test indicate

Reduced hemoglobin

An increased concentration of what substance causes the blue coloring of the skin and mucous membranes in cyanosis

Five g/dL

At what critical level of reduced hemoglobin does cyanosis become clinically apparent

Central cyanosis

What form of cyanosis is seen in the tongue and lips and is due to desaturation of central arterial blood

Tongue and lips

In which two physical locations is central cyanosis specifically assessed

Centrally cyanosed

What is the peripheral saturation state of all patients who are centrally cyanosed

Secondary polycythemia

What hematologic complication is a characteristic feature of chronic central cyanosis

Anemia

What hematologic condition masks cyanosis because of low total hemoglobin levels

Eighty to eighty-five percent

At what peripheral oxygen saturation level does cyanosis become apparent in a patient with a hemoglobin of 12

65-75%

At what peripheral oxygen saturation level does cyanosis become apparent in an anemic patient with a hemoglobin of 9

Aortic stenosis

What lesion is suspected with a systolic ejection murmur heard at the right upper sternal border

LUSB systolic ejection murmur

What physical exam finding is shared by pulmonic stenosis and atrial septal defect

Ventricular septal defect

What lesion is associated with a holosystolic murmur heard at the left lower sternal border

Mitral stenosis

What lesion is characterized by a mid-diastolic rumble heard at the apex

Patent ductus arteriosus

What lesion produces a continuous murmur in the left infraclavicular area

Chest X-ray

What imaging modality is assessed to check for pulmonary congestion or decreased flow in suspected acyanotic heart disease

ASD, PAPVR, and PVOD

What are the three differential diagnoses for increased pulmonary blood flow with right ventricular hypertrophy on chest X-ray

VSD, PDA, and CAVSD

What are the three differential diagnoses for increased pulmonary blood flow with left or combined ventricular hypertrophy on chest X-ray

Pulmonic stenosis and Mitral stenosis

What two valvular defects cause decreased to normal pulmonary blood flow with right ventricular hypertrophy on chest X-ray

Aortic stenosis and Coarctation of the aorta

What two lesions cause decreased to normal pulmonary blood flow with left ventricular hypertrophy on chest X-ray

Truncus arteriosus, Single ventricle, and TGA plus VSD

What are the three differentials for cyanotic heart disease with increased pulmonary blood flow and left or combined ventricular hypertrophy

TGA, TAPVR, and HLHS

What are the three differentials for cyanotic heart disease with increased pulmonary blood flow and right ventricular hypertrophy

TGA plus PS and SV plus PS

What are the two differentials for cyanotic heart disease with decreased to normal pulmonary blood flow and combined ventricular hypertrophy

Tricuspid valve atresia and Hypoplastic right heart syndrome

What are the two differentials for cyanotic heart disease with decreased pulmonary blood flow and left ventricular hypertrophy