Day 13 Pediatric Cardiology and Emergency Department

Patient 1: Diabetic mom with triplets, difficult echo because need to make sure not examining same heart twice.
One has little bit of pericardial effusion.
Diabetic mothers run the risk of fetal hypertrophy of septum and congenital heart defect.
Depends on how well they are maintaining their diabetes
Very small possible pericardial effusion with one heart.
Suspected ventricular hypertrophy in other heart
Limited view on third heart


Patient 2: Kawasaki disease 1 yr old           http://en.wikipedia.org/wiki/Kawasaki_disease
Messes up coronary arteries 
Right and left coronary artery aneurysm
Left looks big
Hgb 11.4, ESR 46 but CRP 0.44 normal
PE cardiac normal
Treat with aspirin low dose
Had large aneurysms 
Rhuematic arthritis with MR?
Has problem with mitral valve
MV thickens
Mitral regurgitation-Mild
2cm jet
Strep 3rd world disease due to strep pharyngitis not treated in a timely manner
Africa has lots too
Mild-moderate Mr thick valve with peristernal?
20-30% will get rheumatic fever after strep throat, genetic predisposition
Since 2010 RF gotten a little worse
Was prescribed: antibiotics every 3 weeks, but now in army and has problem. 21 IM prophylaxis
6 month return to see if stable.

Patient 3: ASD closure 3yrs ago
Tired think cause of weight gain not previous surgery.
Fight with parents over weight gain 
Recommend dietician 
No murmers, pulses good
45 kilo
141.5 meters
Cathiterization through femoral valve used device like a balloon...easier than surgery if enough room. Device will remain in heart for life. 
Right ventical big should be small after surgery
Weight makes difficult to do echo


Patient 4: Soft murmer in middle of systole otherwise healthy one month old.
Heard in back too, so more serious
PPS peripheral pulmonary stenosis  
http://www.childrenshospital.org/health-topics/conditions/peripheral-pulmonary-stenosis
Could be normal up to six months of age.
Not a wide S2
Prenatal echo with a questionable whole in heart.
ECG NSR normal for age
Patent foramen ovale normal for age no RV dialation
Return in a year to reevaluate, murmer should resolve by then.


Patient 5: WPW (wolf parkinson white syndrome) and dilitation 
Twice in yr had syncope
Systolic murmer
See wpw on ecg avl lead shows famous delta wave
MR jet of 24mm
Aortic valve normal
Mild Mr and valve thickening
Pulmonary septal delta wave
Return if feels inappropriate palpitations
Trace tricuspid regurgitation
Normal right and left venticular function
Stills murmer and no click
Stress test bpm 198 no loss of delta wave
Rare APBs and VPBs
Sports controversial 
Normal physiological split
No excessive sport, 
Good dental care cause risk of endocarditis


Patient 6: Came 2 days old with SVT Which caused cardiomyopathy.
SVT getting deralin and beta blocker
Has wpw syndrome
Deralin 5mg 4x day...want to change to 2x a day
Has not been growing enough
Stills murmer
10th child with GDM during pregnancy
Tachypniac
Now on 3x day 7.5 3x day propanolol(deralin)
Narrow QRS tachycardia
Stable on daralin
Count pr interval...120 normal for his age
30% wpw will pass on own, no delta wave mow, 
30%after age 7 will come back, not sure which though 
Doc want to take of deralin and see how he does
Low pitched vibritory systolic ejection.
Drenalin 10mg2x day po- mother changed dosing
Now no drenalin-doctors choice to see if he does well.
Follow up in 3 months
No special therapy no restrictions
Daily check pulse at home to make sure no svt

Patient 7: ALTE- Apparent life threatening event, possibly SIDS  http://pediatrics.uchicago.edu/chiefs/inpatient/ALTE.htm
Do a holter exam http://en.wikipedia.org/wiki/Holter_monitor
Premature ventricular beats
PVC
Make sure no cardiomyopathy
Just one cell that is sick and does not wait for sinus rhythm and causes PVC
If ok send home for yr and another echo.

Patient 8: Noonan disease pulm stenosis and catdiomyopathy
http://en.wikipedia.org/wiki/Noonan_syndrome
Stills murmer 2.5 wk old
Twin a with cyanotic spells...here for Alta workup 
Infrequent Monomorphic PVCs 
Here for workup
Ecg second pic
Pfo right to lft normal
Ductus closed
Looks normal
Asymptomatic monomorphic PVC normal anatomy and function heart
Benign
Needs repeat halter and echo within a yr

((Note to self: Arabic marrying cousins is more accepted than not....more birth defects than Jewish population.))

ER pediatric department

Patient 1: Gross hematiria IGN nephropathy
Hemoglobinuria 


Patient 2: Ureterohydronephrosis ureter- mild
Nurofen 80 mg ibuprofen for fever

((Note: Look at percent WBC
Neutrophils 80-90 in bacterial infection
If all WBC high leukocytes, neutrophil percent low around 50% , its viral.))