Circuit C

Circuit C






STATION 4


This station assesses your ability to elicit clinical signs:









STATION 7


This station assesses your ability to communicate appropriate, factually correct information in an effective way within the emotional context of the clinical setting:











STATION 9


This station assesses your ability to take a focused history and explain to the parent your diagnosis or differential management plan:



This is a 22-minute station of spoken interaction. You will have up to 4 minutes beforehand to prepare yourself. The scenario is below. Be aware that you should focus on the task given. You will be penalised for asking irrelevant questions or providing superfluous information. When the bell sounds you will be invited into the examination room. You will have 13 minutes with the patient (with a warning when you have 4 minutes left). You will then have a short period to reflect on the case while the patient leaves the room. You will then have 9 minutes with the examiner.





COMMENTS ON STATION 1



DIAGNOSIS: AORTIC STENOSIS


It would be nice if every child seen in the cardiovascular station has obvious signs and symptoms – but they don’t. You may have a child with an unusual congenital heart defect whose abnormality is impossible to determine on clinical examination. So it is important to know what to rule out if your child has a murmur of indeterminate origin.


In this case you know the child has a systolic murmur without the presence of previous surgery or heart failure. What could this be?



As the child is not cyanosed, and there are no scars, this child does not have an uncorrected cyanotic heart condition (tetralogy of Fallot, pulmonary atresia without a ventricular septal defect, etc.). Ventricular septal defect is a fair guess in a well child, although it is unusual to have a defect which isn’t loudest at the lower left sternal edge. How do you rule out potentially more sinister defects? Pulmonary stenosis classically presents with an ejection systolic murmur maximal at the left sternal edge with an ejection click and split second heart sound. If all patients presented classically I think the exam would be a lot more fun! Fortunately aortic stenosis has a sign which cannot be present with other anomalies: a carotid thrill. The textbooks tell you a suprasternal thrill but pulmonary stenosis may also produce this. If a thrill is felt in the carotid region (and it is obvious, I promise!) then the murmur must be due to aortic stenosis. If you don’t feel a thrill you are not much better off, as it could still be aortic stenosis, and all the other differentials! But it is an important negative.


If you ascertain the presence of a thrill then you should start feeling comfortable as there are a number of other features to start looking for, all relatively easy to learn.


Did you remember to ask the examiner to check peripheral pulses and perform a blood pressure?



REMINDERS


Turner’s syndrome (full details can be found on p. 184) 5X (although mosaicism possible)


Proportional short stature


Cardiac disorders are the cause of increased mortality in this syndrome


Aortic coarctation most common cardiac defect


Dental malocclusion increased, so prophylaxis vital


Predisposition to keloid scar formation (child may have cardiac surgical scars)


Indication for using growth hormone (and consider using steroid to increase final height).































Aortic stenosis Tips
Exam Apex beat (do you always examine this?) may be displaced
  Suprasternal and carotid thrill
  Systolic murmur in aortic region and left sternal edge
  Have you felt for peripheral pulses? (Associated with coarctation)
  The slow rising pulse is a very difficult sign to elicit
  Have you listened to the back? (Not always helpful but there shouldn’t be radiation, unlike in coarctation)
  A budding cardiology professor may pick up the diastolic murmur of aortic incompetence, which is more likely to occur post-surgery
Investigation ECG normal in the well child but may show signs of left ventricular hypertrophy:

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Feb 14, 2017 | Posted by in PEDIATRICS | Comments Off on Circuit C

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