1. SEMINAR SUZIE LEE ASSISTANT PROFESSOR UNIVERSITY OF OTTAWA Clinical Problems in Pediatric Cardiology

2. Objectives Describe the symptoms of congestive heart failure in an infant Describe the major clinical features of Kawasaki Syndrome (including diagnostic criteria) and its cause and racial prevalences; give a differential diagnosis Outline an approach to the child with syncope, listing the signs and symptoms suggesting a cardiac cause for syncope and describe the basic mechanism of vasovagal syncope Distinguish the features of an innocent vs. pathologic murmur Outline an approach to the child with chest pain, including a differential diagnosis Outline an approach to the child with palpitations

3. Case 1 A nine-day-old infant girl presents to emergency with a 2 day history of poor feeding and increasing lethargy. She is the mother's second child, born at term from an uncomplicated pregnancy and delivery. She was discharged home on day three and was doing well until yesterday.

4. Case 1 (continued) At the time of your initial assessment the oxygen saturation is 96% on room air, heart rate 280 bpm, blood pressure 58/38 mmHg. She is afebrile with a respiratory rate of 78/minute.Weight 4.2 kilograms. On examination she is pale with mildly increased work of breathing. Pulses are equal in the arms and legs, but weak on palpation. Heart sounds are normal with no murmurs heard. The liver edge is 2 cm beneath the costal margin.

5. Analytical Exercise What elements of this child’s history and physical examination are concerning? What further investigations should be obtained in order to diagnose and treat this infant?

7. Case 1 (continued)

8. Analytical Exercise What is this child’s diagnosis and how does it explain all of her symptoms? Discuss the immediate treatment options for this child and steps required to safely treat her.

9. Case 1 (continued)

11. Case 2 Colin is a 3 year old boy of Korean descent who comes to your office with a 6 day history of fevers and a rash. He was previously well with no significant past medical history

12. Case 2 (continued) On examination Colin is a rather miserable young man with a temperature of 38.9 C and otherwise normal vital signs. He appears to have a non-purulent conjunctivitis and reddened cracked lips and a very red tongue. There are ‘shotty’ cervical lymph nodes palpable. The palms of his hands and soles of his feet appear red and swollen. There is a macular-papular rash over the trunk. Cardiac examination is normal and no murmurs are heard.

13. Case 2 (continued)

14. The child is diagnosed with Kawasaki Disease and is admitted to hospital for treatment Mother becomes very concerned that her other two children, aged 6 years and 8 months could contract the disease and asks what she should do to protect them.

15. Analytical Exercise Discuss the diagnosis made and the importance of early treatment. What is the diagnostic criteria for Kawasaki Disease? What further investigations are required? Discuss the differential diagnosis for this young man Address mother’s concerns about her other two children contracting KD

16. Case 3 Megan, a 13 year old female is seen in emergency following an episode of loss of consciousness She states that she had been in band practice, playing her instrument when she began to feel somewhat nauseous and sweaty, prior to feeling quite dizzy. She does not remember falling but was told by her band teacher that she had lost consciousness for perhaps 30 seconds She feels somewhat tired but otherwise well now

17. Case 3 (continued) On physical exam, her HR is 90/minute, bp 105/60, RR 15/minute, saturation 99%. Her chest is clear Cardiovascular examination reveals a normal S1 and normally split S2. There is a I/VI vibratory systolic murmur heard at the left lower sternal border. Peripheral pulses are palpable, equal and regular. Neurological exam is grossly normal

18. Analytical Exercise What general systems can cause loss of conciousness? What symptoms would suggest a serious cardiac issue as a cause for her LOC? Does this patient have any signs suggestive of a cardiac cause for her LOC  Is her murmur of concern?

19. Analytical Exercise What investigations would you suggest to aid in your diagnosis

20. Case 3 (continued) ECG

21. Case 3 (continued) What is this patient’s most likely diagnosis?

22. Case 3 (continued)

24. How would you treat this patient?

25. Case 4 Adam, a 7 year old black male is seen in clinic for complaints of chest pain and ‘heart thumping’ His mother states that he has been complaining of heart ‘thumping’ or palpitations 1-2x/week for the past month, occasionally following exercise but generally in the evenings prior to falling asleep For the past two days he has been complaining of brief episodes of sharp chest pain, not associated with exercise, in the central precordial area Upon questioning, mother states that he had a cold last week, which is now resolving

26. Case 4 (continued) On physical exam, Adam is a well looking boy with mild coryza HR 93 beats/min, bp 102/62, RR 17 breaths/min Cardiac examination reveals a quiet precordium. The patient complains of reproducible chest pain on palpation just lateral to the sternum. On auscultation a normal S1 and S2 is heard with a II/VI continuous murmur in the right infraclavicular area, that disappears on supine positioning His femoral pulses are easily palpable The rest of his examination is unremarkable

27. Analytic exercise What are the most common causes of chest pain in childhood? What symptoms would suggest a cardiac origin to chest pain in children?  Is his murmur of concern? Discuss the differential diagnosis of palpitations? Is there any further history that would be useful in this child’s workup?

28. Analytic Exercise Are there any further investigations which may aid in your diagnoses?

29. ECG

30. TTM ‘chest tight, heart thumped then stopped before bed’

31. Does this child have a cardiac condition that requires treatment?