Infant in the newborn nursery 3 days after birth. Failed the congenital heart disease screening testing performed 3 days after birth. Examination reveals a soft 1/6 systolic murmur at the left lower sternal border, clear lungs, and weak femoral pulses bilaterally, and a capillary refill of 4 to 5 seconds in the lower extremities.

Arterial blood gas includes a pH of 7.25, Pco2 of 39 mm Hg, Po2 of 45 mm Hg, bicarbonate of 17 mEq/L (17 mmol/L), and base deficit of -9.

Next step:

You walk into a mother’s room to perform a newborn discharge examination at 72 hours after birth to find a mottled infant with cool extremities. The term newborn is appropriate for gestational age and was born by scheduled repeat cesarean section following an unremarkable pregnancy. Vitals signs include a temperature of 36.6°C, heart rate of 180 beats/min, respiratory rate of 74 breaths/min, blood pressure of 50/35 mm Hg (mean blood pressure, 38 mm Hg), and oxygen saturation of 90% on room air. The examination is notable for diffuse mottling, a capillary refill of 5 to 6 seconds, tachycardia with a single S2 and no murmur, liver down 2 centimeters below the right costal margin, and weak pulses.

A 10-year-old boy comes to your office for an initial visit. He has been in foster care for several years, but is reunited with his mother. He had heart surgery at 2 years of age, but the patient does not have any records from that procedure. As far as his mother knows, he has never been hospitalized for respiratory illnesses such as asthma or pneumonia. He does not take any medications. He has decreased exercise tolerance. On PE, he is a slender boy is no acute distress. His weight is at the 10th percentile for his age, and height is at the 50th percentile. His heart rate is 100 bpm and respiratory rate is 28 breaths/min. Oxygen saturation on room air is 89%. His blood pressure is 96/65 mmHg in the right arm, and his blood pressure is 115/90 mmHg in the right leg. His neck veins are not distended. His chest shows clear and equal breath sounds. There is a well-healed sternotomy scar. His heart examination shows a normal S1 with a very loud P2 component to S2. There is a 2/6 soft systolic murmur at the right midsternal border that does not radiate to either axilla. There is no organomegaly on abdominal examination. The femoral pulses are 2+. His Hg level is 17 g/dL. Diagnosis :

2-month-old male. History of moderate-size ventricular septal defect. Feeding poorly for the last few days. During feedings the infant coughs and SOB. Mild subcostal retractions. Fine bilateral crackles. Precordium active. Grade 3/6 holosystolic murmur, maximal at lower left sternal border. Liver palpable 3 cm below right costal margin.

The medication MOST likely to provide significant clinical improvement is oral:

3-week-old FT newborn. SOB with feeds. Mom had no prenatal care. Physical examination is remarkable for a blood pressure of 100/60 mmHg in the right arm, redundant skin overlying the posterior neck, and edema of the lower extremities.

MURMUR: Gallop rhythm and a regurgitant murmur at the mid-precordium.

Femoral pulses are diminished. Subcostal retractions. Rales on auscultation of the lungs.

MOST appropriate next step in the evaluation of this infant is:

16 yo F, lacrosse player. 2 months of chest pain during activity. Episodes of pain last 3-5 minutes and have been associated with palpitations and pre-syncope.

MURMUR: Soft 2/6 systolic ejection murmur at lower left sternal border. Normal EKG.

Of the following, the MOST appropriate next step in evaluation of this teenager is to:

18 yo M “passes out” while running sprints during football practice. Coach states that the patient appeared alert and exhibited no seizure-like activity. Drank plenty of water and Gatorade before and during practice. On physical examination, the patient is alert and oriented. Vital signs are stable. Which of the following may be identified during work-up?

Hi Dr. Zonana, this is Mrs. Girgis. My son Stephen had his ASD closed 10 months ago. His echo said “residual L-->R shunting across device.” He has cavities and his dentist is asking if he’ll need antibiotics before he fills them.

Which of the following is correct regarding coronary artery pathology in a child with KAWASAKI?

Irritable and febrile 3 yo M. Morbilliform rash. Bulbar conjunctival injection. Found to have a L coronary aneurysm.

Which of the following is most likely to be identified during additional evaluation:

7 day old newborn boy. Grade 2/6 medium-pitched systolic ejection murmur, best heard at L upper sternal border. Murmur radiates to the back and axillae.

Most likely etiology?

15 yo girl with anorexia nervosa. HR 52 bpm. BP 95/60.

Which of the following is most likely to be identified during additional evaluation?

1 week old F. Murmur noted at 48 hours of age.

Which of the following describes the MOST COMMON CONGENITAL HEART LESION?

3 hour old M. Cyanotic. RR 88 breaths/minute . Parasternal heave on cardiac physical exam. Single loud S2. Soft systolic ejection murmur at the mid-left sternal border.

Echo: pulmonary artery arises posteriorly from the left ventricle. Aorta arises anteriorly from the right ventricle.

Which of the following best describes expected findings on a radiograph of the chest in patients with this disorder?

Following the sudden death of his twin brother during high school football practice, a 16-year-old boys is evaluated with an echocardiogram. Results include evidence of asymmetric left ventricular and septal hypertrophy associated with anterior motion of the anterior leaflet of the mitral valve.

Which of the following best describes findings on cardiac auscultation in this patient

Following evaluation of a 6 year old girl with multiple systemic complaints, a diagnosis of acute rheumatic fever is made based upon both clinical findings and documentation of an elevated streptococcal antibody titer.

Which of the following is considered a major manifestation of acute rheumatic fever?

A 12-year-old boy presents to the clinic for a preparticipation sports exam. He is currently asymptomatic and his past history and family history are both unremarkable. His review of systems evaluation is noncontributory.

Which of the following findings on physical examination would be of greatest concern for a potential cardiac complications during athletic participation?