A 1-mo-old female infant is presented with a chief complaint of poor feeding and lethargy. Parents report that the child was well until 3 days earlier, when poor feeding began. Pulse rate is 280 beats/min, respiratory rate is 50/min, and blood pressure is 80/50 mm Hg. Physical examination shows a g...
A 1-mo-old female infant is presented with a chief complaint of poor feeding and lethargy. Parents
report that the child was well until 3 days earlier, when poor feeding began. Pulse rate is 280
beats/min, respiratory rate is 50/min, and blood pressure is 80/50 mm Hg. Physical examination
shows a gallop rhythm and an enlarged liver palpable 2-3 cm below the right costal margin. The most
appropriate diagnostic test for this patient would be:
A. Chest radiograph
B. CBC
C. ECG
D. ABG analysis
E. Blood culture - ANSWERC. ECG
Explanation: This is a very high heart rate for a simple sinus rhythm. The child is in heart failure, but
the excessively high heart rate may be the cause, not the result, of heart failure. (See Chapter 428 in
Nelson Pediatrics, 17th ed.)
What would be the most likely diagnosis in the case in Question 1?
A. Reentrant SVT
B. Ventricular tachycardia
C. Sepsis
D. Anemia
E. Pneumonia - ANSWERA. Reentrant SVT
Explanation: This is a classic presentation of supraventricular tachycardia in infancy. It is usually
idiopathic and transient but does require rapid diagnosis and treatment. It may also be present in
utero. Always be sure the parents are not giving the child over-the-counter cold remedies that
contain sympathomimetic agents, which may include "herbal" remedies that could contain ephedra.
(See Chapter 428 in Nelson Textbook of Pediatrics, 17th ed.)
3. What would be the most appropriate next step in treatment for the case in Question 1?
A. Electrical defibrillation
, B. IV verapamil
C. Adenosine therapy
D. Antibiotic therapy
Blood transfusion - ANSWERC. Adenosine therapy
Explanation: Intravenous rapid push adenosine is the drug treatment of choice for all cases of SVT, in
infants and in patients of all ages. Verapamil was once used in older patients, but in infants in heart
failure, verapamil has serious adverse effects (cardiac arrest) owing to its negative inotropic effects
on an already failing myocardium. (See Chapter 428 in Nelson Textbook of Pediatrics, 17th ed.)
Chest pain at rest in a 10-yr-old boy is most likely to be due to all of the following Except:
A. Asthma
B. Overuse injury
C. Musculoskeletal trauma
D. Coronary atherosclerosis
E. Anxiety - ANSWERD. Coronary atherosclerosis
Explanation: Unless there is a strong family history of premature myocardial infarction or sudden
death, or unless symptoms are exacerbated by exercise, chest pain in children is often due to
musculoskeletal or pulmonary disorders. Children may complain of chest pain after an adult family
member has a myocardial infarction. This is less likely to be coronary vessel disease and more likely
to be anxiety. Nonetheless, the clinician should be aware of more serious causes in children with
chest pain, dyspnea, or syncope with exercise. (See Chapter 415 in Nelson Textbook of Pediatrics,
17th ed.)
5. The best management approach in a 10-yr-old with an ostium secundum atrial septal defect with a
3:1 shunt is:
A. Observation until heart failure is present
B. Prophylaxis for endocarditis each month
D. Transvenous device closure
D. Observation until pulmonary hypertension develops
E. Phlebotomies for recurrent polycythemia - ANSWERC. Transvenous device closure
Explanation: Although surgical closure is highly successful, experience with device closure in the
cardiac catheterization laboratory has been quite successful, and this procedure is now approved by
the FDA. (See Chapter 419 in Nelson Textbook of Pediatrics, 17th ed.)
6. Pulmonary stenosis is associated with all of the following Except:
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