Day 11 Pediatric Cardiology

Patient 1: Interrupted aortic arch and VSD had fixed after birth 
Arch not complete more than coarctation
Good pulses
Scars from drainage tube
Scar down chest open surgery
Systolic murmer of vsd
Check Bp response from aortic arch

Aortic stenosis RV hypertrophy
Gradient of stenosis in sound waves.
Did not have AS before but now does, may need another surgery.
Eating and growing well.
Qrs complete break on the branch.
Normal sinus rhythm.
Lvh with normal function
Aortic stenosis up to 36mmhg gradient.
20mmhg with discrete subaortic membrane.
Small vsd closed spontaneously, excellent repair.
No PDA 
Mild AR

Follow up 3 months
Recommendation now a developing sub AS with mild AR with previous seen BAV repeat study in 3 months my need AS repair soon. 
No restrictions or need for therapy in mean time.
ECT- positive in VII, should be negative in kids, because of LVH makes it positive.

Patient 2: Baby girl 8 month old healthy house Dr heard murmer
Femoral pulses LV pulse equal pulse and timing apex in right place, 
Systolic murmer

Maybe valvular murmer, listen to clicks
Has click opening,early systolic pulmonary click fist heart sound louder inspiration softer expiration
S1clickS2
Listen with bel--l click
Mild is because of frequency. It is related to gradient over valve
CO looks normal.
Listen to back no murmer, serious would hear in back of child
ECG-RVH high VII- R waves
Echo-look for ES pulmonary valve stenosis
Guess 20mmhg 18-25 based on frequency of murmer.
AV and  MV are ok
Pulm valve turbulance makes murmer and RVH
Measure LV wall thickness
Co sine and sine angle is used with the Doppler, we can get gradient by how fast blood moves.
Patent foramenal ovale valve open which is fine.pfo
Doppler works better at a 180 degree angle 
Red towards us blue away. 90degree angle not as good as 180
                
Patient 3: Husband stays home with kids and wife works 
Hr 150
Pulmonic ejection click
Harsh low pitch
Normal aortic valve, mildly thickens pulmonic valve up to 28mmhg gradient from LLSB
Mild MPA arteries.
Follow up need to know natural history, this age very benign, so follow up in a year. 
Genetic caused
Everything genetic except trauma in medicine.

Patient 4: Rheumatic fever, had emergency valve replacement.
Has mechanical mitral valve now.
Heard valve in front and back
Pulses normal
PMI very lateral.can see pulse.
Bp 116/68 pulse 80bpm
AR from RF
Amazing can see sutures and mech valve in echo
Shadowing on valve because not tissue US does not go thru it
No stenosis on valve 
L atruim good
BMI 19.5 height 152cm
1st degree av block from the episode ir surgery
205 milliseconds

Medications:
Coumadin 
Digoxin
Captopril
Penicillin

LV precordial impulse increaed
Loud mechanical S1
S2normal
Loud s1 click
No vegitations on mechanical valve
LV is smaller

Patient 5: PVCs lots of them 13yr old boy.
Early beat w pause because goes retrograde and causes sinus rhythm to re start
2nd heart sound normal expiration inspiration its single
Most causes by cell in heart acting up like virus...only one cell can cause premature beat without needing sinus node.
Monomorphine, all from the same spot.
Continue to follow up, 
Hard to see RV w echo so look from below.
Early beat not as much filling
Venticular arrythmia 17%of total beats.
Found initially on sports exam.
Multiple momomorphic pvcs  with RVOT with 9 episodes of accelerated venticular rhythm125-136bpm was active the same day playing basketball.
AVF coming from top down from right bundle branch, can see on ecg.
Stable rvot with normal beat functionally
No sports restrictions, no special therapy
Usually self limiting

Patient 6: Rheumatoid heart disease born in  2002 .
Second heart sound louder on inspiration and abnormal split
Systolic murmer

ECG: Last rhythm is artifact cause he moved, normal before and after so no other way to explain it.
RF in 2011
Had a lol mr pathogenic
Since several months stopped taking prophylaxis. Penicillin IM
Sydenham's Chorea ( http://medical-dictionary.thefreedictionary.com/Sydenham's+chorea ), st vincents dance uncontrolled throwing of limbs, neurological after rheumatic fever 
occurs 2-3 times a year 10%of cases. 2-3 m after strep through 2-3m later the RF
MR
ADHD ritallin
PE cardiac normal
Post rhuematic endocarditis
Recomend to continue peniccilin250mg p/o if po required
Penicillin 1.2million unit IM every 28days,
Followup 6 months

Patient 7: Baby with fever for a long time without a source, so gonna look in heart,
Drank chicken water, that was start of fever.
Normal PE
Valves all normal
(See atria best from belly but only in kids)
No vegitations
No coronary arteritis or myocarditis

Patient 8: 26 + 2 week fetus fetal probe, 3rd pregnancy, with one spontaneous early abortion and one healthy kid at home.
Now with echo foci in LV
And now dialated renal pelvices.
26yrs old woman
Pfo right to left
No vsd
No peri membranous vsd
Echogenic foci is seen but is not a cardiac problem.
Normal fetal heart

Patient 9: 22plus 5 weeks child number 9 with one spontaneous abortion. 
Son had coarctation when born in Florida
Left ventricle is smaller in coarctation..no coarctation found
Arch is little smaller than ductus but should be same size, one sign or a coarctation...must suspect a coarctation with this sign
Repeat exam in one month
Genetic trait

Patient 10: 8yrs after kidney transplant
Heart looks good.

Patient 11: kidney transplant

Mitral regurgitation significant
Can't see on ecg, but could see LVH
11.5 yrs old child
Normal LV and RV size and function 


Patient 12: Sinus arrythmia common in kids upon breathing

Lung congestion on chest xray.
He is a premature twin

Chest X-ray
Dopler tells us pressure difference between the two ventricles
Make sure no abnormal pulmonary flow


C section gets TTN because lungs not squeezed right