CARDIOLOGY

Learning Objectives:
1. Understand significance of heart murmurs in children.
2. Distinguish between innocent murmur and murmur due to heart disease.
3. List the causes of cyanosis in neonates.
4. Describe the Initial management of cyanotic conditions in neonates.
5. Understand symptoms and causes of heart failure in children.
Case 1
A six-year-old girl is brought to the office for a physical examination for school. Her past medical history
is unremarkable and her growth and development have been normal. She is entirely asymptomatic. Her
physical examination is normal except for a grade II/VI 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 III/VI in supine position.
1. What is the significance of a heart murmur in asymptomatic children? How reassuring are negative
findings and history?
2. What work-up should be done by primary care physicians?
3. What are the costs of excessive tests and unnecessary consultation? What are the costs of inadequate
work-up?
4. When should physicians refer children to specialists for consultation?
5. What signs and symptoms would you tell the patient and their parents to monitor for? When should
they seek an additional evaluation or treatment?
Case 2
A 3500-gram, term male infant born to a 29-year-old, gravida II para II, 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 axillary temperature 37C (98.6F); pulse, 130;
respiration, 60; and blood pressure, 80/60 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.
1.
2.
3.
4.
5.

What are the causes of cyanosis in newborns?

What is the appropriate evaluation of cyanosis in newborns?
How urgent is the assessment? What are the risks and benefits of further evaluation?
Which aspects of management a primary physician at a community hospital should initiate?
Which types of treatment should be undertaken by the consulting pediatric cardiologist at the referral
center?

Case 3
A 2-month-old infant is brought to the office by his mother. She 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 one-month checkup. The infant is scrawny and irritable. Physical examination shows that
the boys 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/min, with
respirations 60/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; likewise, 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 coastal margin in the right mid-clavicular line, and the spleen is not palpable. The
extremities are thin, with normal pulses and no edema. Capillary refill is slightly delayed.

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 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 correct?
5. What signs and symptoms would you tell the patient and their parents to monitor for? When should
they seek an additional evaluation or treatment?
Below is appropriate case www.clippcases.org
2-week-old with poor weight gain Tyler. Norm Berman, M.D., Dartmouth Medical
School