Pediatric Cardiology for the Community Pediatrician. Case 1: Chest Pain. Learning Objectives. Case 1 (cont) Diagnostic approach 9/12/2018.

Transcription

1 Pediatric Cardiology for the Community Pediatrician Lindsey Malloy-Walton, DO, MPH, FAAP Division of Pediatric Cardiology Children s Mercy Hospital 2401 Gillham Road Kansas City, MO Phone (office): Disclosure I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Division of Pediatric Cardiology The University of Kansas Medical Center Pediatrics 3901 Rainbow Blvd Kansas City, KS Phone (office): Learning Objectives Understand the evaluation and treatment of the most common presentations in pediatric cardiology Understand when to refer to pediatric cardiology Case 1: Chest Pain 13 year old male presents with chest pain: Left sided Feels like pressure Not reproducible with palpation 6/ Case 1 (cont) Maternal cousin who died age 40, unknown reason Physical exam benign (no reproducible pain) Chest x-ray normal EKG pending (waiting on fax from OSH ER to review) 5 6 1

2 Musculoskeletal (costochondritis) Reassurance, rest, ibuprofen Respiratory Cause Frequency Idiopathic Gastrointestinal % Musculoskeletal 15-43% Antacids, PPIs Respiratory 12-21% Psychogenic Idiopathic 5-17% GI 4-7% Psychogenic Others 4-21% Counseling, medications Miscellaneous Cardiac 0-4% Worsened by physical activity Associated with other symptoms (palpitations, dizziness, syncope) 7 8 Case 1 (cont) Referral Process Complete the New Patient Appointment Form Available at ChildrensMercy.org or through the provider portal Submit online or fax to Specify referral timeframe We will contact the patient within 2 days We are currently working on projects to continue to enhance your referral experience 9 10 Case 2: Palpitations 11 year old girl reports her heart races at times beeps, lasts less than a minute, no associated symptoms

3 Case 2 (cont) (including family history) is negative Physical exam benign EKG ordered Normal physiologic event Reassurance Psychogenic Reassurance, counseling, biofeedback Drugs/substances Avoidance/modifying dosage, change medications Other medical conditions Labs Worsened by physical activity Associated with other symptoms (chest pain, dizziness, syncope) Case 2 (cont) EKGs When not to worry when you get this reading RSR' in V1- likely normal variant for age (when the R is not much taller than the R and there is not a deep S wave in V5-V6) Short PR, no obvious delta wave (with normal Q wave in V5-V6) Borderline prolonged QT (450 ms for males, 460 ms for females, with normal T wave morphology, not very low amplitude or plateau or bifid T waves and normal ST segment) LVH by voltage criteria (>25 mm in V5-V6), without abnormal Q waves and without T wave abnormalities Nonspecific ST segment elevation (early repolarization pattern) Sinus arrhythmia T wave inversion in III Case 3: Syncope 15 year old female presents with new onset syncopal events over the past 6 months: Does feel heart racing prior, not too fast to count Some associated presyncope

4 Case 3 (cont) Mom has a history of a sudden cardiac arrest, now has an ICD Physical exam benign EKG Orthostatic intolerance syndromes 2L of water a day, 2g of salt a day, compression stockings, Physical therapy Florinef, midodrine, beta blockers,?ssris Situational Reassurance, biofeedback Neuropsychiatric Reassurance, counseling, biofeedback Other Worsened by physical activity Associated with other symptoms (chest pain, palpitations) Case 3 (cont) Complex Syncope Clinic (CSC) Opened in 2016 Now collaboration between Adolescent Medicine and Cardiology At the Broadway building Developing a Redcap intake form to streamline referral process

5 Case 4: Murmur 1 month old, well baby visit, noted to have a new murmur Case 4 (cont) Dad has a history of Tetralogy of Fallot, has been repaired 2-3/6 systolic murmur noted at the LLSB Chest X-ray normal Innocent/Functional Clinically follow Pathologic Symptoms (poor weight gain, respiratory distress) Abnormal cardiac size/silhouette, cyanosis, diastolic murmur 29 5

6 References Thank You Questions? Moss & Adams Heart Disease in Infants, Children, and Adolescents, Including the Fetus and Young Adult. March 2016 Warnes CA, Liberthson R, Danielson GK, et al: Task Force 1: The changing profile of congenital heart disease in adult life. J Am Coll Cardiol 2001;37: Park MK. Pediatric Cardiology for Practitioners. 5 th edition