Is it the heart?
2019 CLEVELAND CLINIC
When to refer to
pediatric cardiology
A. If the pulse oximetry reading is 93%
B. If the tongue is blue
C. If there is a IV/VI murmur at the LSB
D. B & C
E. A & C
ANSWER
CYANOSIS — WHEN TO BE CONCERNED
When to refer for murmur
ANSWER
A. III/VI systolic at mid LSB, louder supine
B. III/VI continuous murmur below left clavicle, louder sitting
C. II/VI SEM mid LSB and fixed split S2
D. B & C
E. A, B & C
D
C
› Chest pain with exertion / exercise
› Family history of unexplained sudden cardiac death
› Family history of cardiomyopathy
CHEST PAIN RED FLAGS
ANSWER
A. An 8-year-old girl complains of chest pain while running
and riding her bike uphill
B. A 14-year-old boy with pain with breathing and
tenderness at left costochondral junction
C. A 17-year-old girl very severe stabbing pain over left
chest at random times, 3 x/week
D. A & B
E. A, B & C
Which of the following patients with chest pain should you refer to cardiology?
› Abnormal electrocardiogram
— Depending on finding
› Family history of premature coronary artery disease
› Recent fever, malaise
CHEST PAIN YELLOW FLAGS
› Abnormal murmur
› Abnormal heart sounds
› Concern for indolent infectious or inflammatory process
— Rheumatic fever
— Infectious endocarditis
— Kawasaki
A
SYNCOPE RED FLAGS
ANSWER
E
› Peripheral cyanosis is usually normal when symptoms are:
— Perioral
— Fingers, toes
› Central cyanosis should be considered abnormal:
— Tongue, mucous membranes
— Pulse oximetry reading ≤ 85%
— Clubbing
› Infrequent events with sudden onset
› Associated with dizziness or syncope
› Occur during athletic events
— But not all exertion triggers symptoms
PALPITATIONS RED FLAGS
ANSWER
A. A 16-year-old boy who notes fast heart rate of 140
on monitor during gym class
B. An 8-year-old girl with racing heart about one time
per month, sudden onset
C. A 14-year-old boy who complains of beeping heart
several times per week
D. B & C
E. A, B & C
Which of the following patients with palpitations should be referred to cardiology?
A 2-month-old presents with intermittent blue discoloration
of the hands and feet. You should refer to cardiology in which of the following scenarios?
A 5-year-old boy presents with murmur. You should refer to cardiology under the following conditions:
Which of the following patients with syncope should be referred to cardiology?
› During exercise
— Full sprint, mid stride
— Possible exception – distance sports
› “Dead man’s faint”
— Fall hard – not wilt – no warning
— Injury with fall
› Sudden fright or startle or emotion — some crossover
with neurocardiogenic
A
A. A 6-month-old infant with syncope
B. A 16-year-old girl, felt dizzy before but tried to keep
walking, afterward felt hot
C. A 12-year-old boy who faints when he raises both arms
over his head together
D. An 8-year-old who fainted during running relay in
gym class
E. A & D
› Family history of heritable cardiac disorder
— Cardiac referral
› Symptoms
— Chest pain
— Syncope
— Palpitations
— Fatigue or SOB with exercise
› Signs
— Abnormal cardiac exam
— Abnormal chest x-ray
— Elevated BNP
› Medication therapy
— Follow published recommendations.
— No longer indicated before starting stimulant
medications to treat ADD or ADHD.
Appropriate indications for ECG in pediatrics
ANSWER
A. A 6-year-old girl with chest pain when sprinting during
soccer games
B. A 15-year-old boy in whom you starting a stimulant
medication to treat ADD
C. A 2-year-old girl with classic breath holding spells
D. A 9-year-old boy in whom you are starting ziprasidone
hcl to treat bipolar disorder
E. A & D
In which situations is it appropriate to order an ECG?
E
› Family history of first degree relative with a cardiac
disorder, autosomal dominant, includes:
— Cardiomyopathy – hypertrophic or dilated
— Inherited arrhythmia syndrome
— Dyslipidemia
WHEN TO REFER TO CARDIOLOGY BASEd ON FAMILY HISTORY
ANSWER
A. A 4-year-old girl whose mom has long QT syndrome
B. A 15-year-old boy whose dad has hypertrophic cardiomyopathy
C. An 11-year-old girl whose grandmother has atrial fibrillation
D. A & B
E. A, B & C
Which of the following patients should be referred to cardiology to assess cardiac family history?
D
To refer a patient to Cleveland Clinic Children’s Department of Pediatric Cardiology, call 855.REFER.123 (855.733.3712) or visit my.clevelandclinic.org/pediatrics/medical-professionals/referrals.
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