Examkin

Question

Difficulty: EasyPediatric Cardiovascular Disorders

During a routine well-child visit, the parents of an 18-week-old female infant express concern regarding her feeding habits. They note that she consistently breaks into a sweat and appears fatigued after only a few minutes of bottle feeding. The patient's weight has dropped from the 50th percentile at birth to below the 5th percentile. Vital signs indicate a heart rate of 162/min and a respiratory rate of 68/min, with an oxygen saturation of 98% on room air. Auscultation of the lungs reveals scattered expiratory wheezes. Cardiac auscultation demonstrates a hyperdynamic precordium and a loud, harsh holosystolic murmur over the left lower sternal border. The abdomen is soft, but the liver edge is palpable 3.5 cm below the right costal margin. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Trial of nebulized albuterol and inhaled corticosteroids
  2. B
    Reassurance and transition to a higher-calorie, extensively hydrolyzed formula
  3. C
    Admission for empiric broad-spectrum intravenous antibiotics
  4. D
    Nasal suctioning, antipyretics, and discharge home with supportive care
  5. Transthoracic echocardiography and initiation of diuretic therapyAnswer

Answer

Transthoracic echocardiography and initiation of diuretic therapy
The correct answer is transthoracic echocardiography and initiation of diuretic therapy. This patient's presentation of diaphoresis during feeds, failure to thrive, marked tachypnea, hepatomegaly, and a harsh holosystolic murmur at the left lower sternal border is classic for congestive heart failure secondary to a large Ventricular Septal Defect (VSD). The left-to-right shunt causes significant pulmonary overcirculation. This excess fluid in the lungs leads to interstitial edema, which narrows the small airways and produces expiratory wheezing (often termed 'cardiac asthma'). Concurrently, the systemic hypoperfusion triggers a compensatory increase in sympathetic tone, resulting in the classic finding of an infant sweating during the physical exertion of feeding. The next most appropriate step in management is to confirm the structural anatomy with a transthoracic echocardiogram and to initiate diuresis (e.g., with furosemide) to manage the symptomatic volume overload.

Step-by-Step Solution

1
Identify the key clinical findings in the vignette.
The infant presents with diaphoresis with feeds, failure to thrive, tachypnea, hepatomegaly, expiratory wheezing, and a harsh holosystolic murmur at the left lower sternal border.
Synthesizing the physical exam and history is the first step in formulating a differential diagnosis.
2
Correlate the physical findings with the underlying pathophysiology.
The holosystolic murmur indicates a ventricular septal defect (VSD). The tachypnea, wheezing, and hepatomegaly are signs of congestive heart failure resulting from a large left-to-right shunt and pulmonary overcirculation.
Understanding the hemodynamic consequences of a VSD is necessary to choose the appropriate intervention.
3
Determine the next best step in management for a symptomatic VSD.
The most appropriate next step is to obtain a transthoracic echocardiogram to define the cardiac anatomy and initiate diuretic therapy (e.g., furosemide) to reduce the volume overload.
Diuretics are the first-line pharmacologic treatment to relieve pulmonary congestion in pediatric heart failure, and echocardiography is the gold standard for definitive diagnosis.

Key Concept

Ventricular Septal Defect (VSD) with Heart Failure
Rate this question

Topics

Pediatric Cardiovascular Disorders

More questions from this topic