Heart Murmurs in Kids
T/F: CDC recommends screening all infants for congenital heart disease at 24 hrs of life
True.
Describe two treatment considerations for pregnant patients with thalassemia.
1. Lovenox for pregnant patients with transfusion-dependent thalassemia
2. Aspirin for pregnant patients who have had a splenectomy
T/F: Medicare does not cover telemedicine visits at the same rate as it does for in-person visits.
False--it does! And so do many private insurers
Chovstek; hypocalcemia
T/F: physical activity is associated with a lower risk of developing depression.
true
Where is a Still's murmur heard on the chest and in what age group is it most common? (must get both)
Still's murmur is heard between the mid to lower sternal border and the apex.
It is most common in ages 3-6 and should disappear by adolescence.
It is described as a systolic, grade 1-2 murmur with a musical / twanging string quality.
Name two lab findings that are suspicious for a thalassemia.
1. Microcytosis
2. Normal or elevated ferritin
Name some barriers to telemedicine implementation.
- Limited access to internet for some patients (ex: rural areas)
- Systems issues in terms of resources/support for implementation in clinics (ex: support staff need to be trained)
True or false: most cases of primary hyperparathyroidism are managed surgically.
True.
See list of indications in primary hyperPTH (one of them is the desire for surgery in the absence of other medical contraindications):
https://www.aafp.org/afp/2022/0300/hi-res/afp20220300p289-t3.gif
What is the most effective treatment for onychomycosis?
oral terbinafine (12 wk course)
You hear a murmur on a routine well child check that increases in intensity with valsalva. Does this increase or decrease your suspicion for important pathology?
Increases suspicion for Hypertrophic Obstructive Cardiomyopathy (HOCM). Decreases LV preload therefore making the murmur louder
What are the four broad treatment goals of thalassemia?
- Hemoglobin levels 9-10.5
- Promoting normal growth
- Suppressing ineffective erythropoiesis
- Controlling iron overload
(1) What telemedicine intervention has been found to be most effective for telediabetes care, and (2) overall, what reduction in A1c has been seen with telediabetes care?
1. Remote monitoring (CGMs, home BP monitors, then check-ins by nurses and providers via phone, messaging, etc.)
2. Reduction in A1c by 0.6%
Name the most common cause of hypocalcemia
Vitamin D deficiency
True/ False: surgical glue is a reasonable alternative to sutures for repair of first degree obstetric lacerations and studies show that there may be less pain for the patient with this approach.
True. Studies indicate similar cosmetic and functional outcomes, less pain, less time, and reduced local anesthetic use.
True/False: the article recommends referral to pediatric cardiology prior to obtaining an echo in a child w/ persistent murmur throughout newborn hospitalization without other signs/ symptoms of congenital heart disease.
True.
Article states that outcomes are similar but referral to pediatric cardiologist is the more cost-effective approach.
What treatment has shown decreased overall and cardiac-related mortality?
Iron chelation therapy (it reduces liver and myocardial iron concentrations)
Describe teleretinal screening and name one benefit it has over traditional exams for retinopathy.
Teleretinal screening uses cameras that do not require pupillary dilation in primary care clinics to acquire images that are then sent to ophthalmology off-site.
It can increase rates of annual screening from 62% > 90% per two studies.
Name BOTH of the 2 most common causes of hypercalcemia
-primary hyperparathyroidism
- malignancy (often associated with paraneoplastic syndrome mediated by PTH-related peptide)
This medication is effective at reducing the frequency of tension headaches
Amitriptyline
Approximately what % of chest pain in children is cardiac related? (must guess within 5%)
6%
Name 4 possible complications of thalassemia.
1. Skeletal impacts: abnormal bone growth, osteopenia/osteoporosis
2. Endocrine impacts: DM, hypogonadotropic hypogonadism, hypothyroidism, hypoparathyroidism
3. Cardiovascular impacts: myocardial fibrosis, cardiomyopathy, pHTN, HF, arrhythmias, heart valve disease, myo/pericarditis, thromboembolism
4. GI impacts: iron deposition related-liver disease, even cirrhosis
- Focus primarily on the skin and extremities
- Look for hair loss, ulcers, bony deformities, discoloration of the extremities
- Inspect injection sites for firmness, signs of infection
- Try to take note of the patient's living situation (safety, food insecurity)
The article recommends 5 tests to order in the workup of hypercalcemia (beyond a Complete Metabolic Panel), to identify cases of primary hyperparathyroidism.
Name 4 of the 5 tests.
Already included in CMP = serum creatinine, albumin, calcium levels
-ionized calcium
-parathyroid hormone
-25 OH vitamin D
-24 hour urinary calcium and creatinine
-DEXA scan
LINK to algorithm for workup which is excellent: https://www.aafp.org/afp/2022/0300/hi-res/afp20220300p289-f2.jpg
True / False: Recent data shows that ARBs are equivalent to ACE inhibitors in their cardiovascular benefits, providing further ammunition to those who argue that ARBs should be chosen over ACEi's when initiating a new agent for BP control.
TRUE.
pts receiving ACEis were more likely to experience angioedema, acute pancreatitis, cough, and GI bleeds compared to patients receiving ARBs.
Article recommends initiating ARB rather than ACEi when starting a new agent. If patient is doing well on ACEi and tolerating it well, article recommends continuing the ACEi rather than changing to ARB. Long live ARBs (olmesartan is my favorite - see recent curbsiders episode-Jordan)