You are asked to evaluate a newborn at 1 minute of life. The infant is pale, with slow, irregular respirations and a heart rate of 80 bpm. There is some flexion of the extremities, and the infant grimaces when you suction the nares.
The 1-minute Apgar score of this infant is:
Correct Answer B:
The Apgar score is a useful tool in determining the need for infant resuscitation at both 1 minute and 5 minutes. It is not, however, a good tool to determine long term outcome. The five categories that the Apgar score evaluates are: heart rate, respiratory effort, muscle tone, reflex irritability, and color. 0, 1, or 2 points are awarded for each category, for a maximum score of 10. This infant scores 1 for heart rate, 1 for respiratory effort, 1 for muscle tone, 1 for reflex, and 0 for color, for a total score of 4 at 1 minute.
→ An Apgar score of 2 (choice A) would be a blue limp infant, with no response to stimuli and a heart rate of less than 100 with minimal breathing effort (or the same with a heart rate over 100 and no breathing effort).
→ Infants with Apgar score of 6 (choice C) may need some stimulation and resuscitation efforts.
→ Infants with Apgar score of 8 (choice D) are usually vigorous and require no significant resuscitation efforts.
→ Infants with Apgar score of 10 (choice E) This would be a vigorous infant, with pink extremities, vigorous tone, respiration, heart rate, and good reflex. Most infants only score a 9 at best at 5 minutes.
A 3-year-old child has a blood pressure of 138/95 mmHg. He has a systolic murmur in the right 2nd intercostal space, femoral pulse is not palpable. He was born premature.
What is the most likely diagnosis?
Correct Answer A:
Coarctation of the aorta is localized narrowing of the aortic lumen that results in upper extremity hypertension, left ventricular hypertrophy, and mal-perfusion of the abdominal organs and lower extremities. Symptoms vary with the anomaly's severity and range from headache, chest pain, cold extremities, fatigue, and leg claudication to fulminant heart failure and shock. A soft bruit may be heard over the coarctation site.
Diagnosis is by echo-cardiography or by CT or MR angiography. Treatment is balloon angioplasty with stent placement, or surgical correction.
A 6-year-old boy presents to your clinic for a routine physical examination. His right arm blood pressure is 150/110 mmHg, while his left leg blood pressure is 80/60 mmHg. On auscultation a systolic murmur best heard over the mid-upper back is detected. You also find that his femoral pulses are delayed when compared with his brachial. An ECG shows left axis deviation.
Correct Answer C: Coarctation of the aorta is localized narrowing of the aortic lumen that results in upper extremity hypertension, left ventricular hypertrophy, and mal-perfusion of the abdominal organs and lower extremities. Symptoms vary with the anomaly's severity and range from headache, chest pain, cold extremities, fatigue, and leg claudication to fulminant heart failure and shock. A soft bruit may be heard over the coarctation site.
A 9-month-old infant on routine physical examination is found to have the following blood pressure readings: in the left arm 80/40 mmHg and in the right arm 100/80 mmHg.
Which one of the following clinical signs would you find on physical examination?
Coarctation of the aorta is localized narrowing of the aortic lumen that results in upper extremity hypertension, left ventricular hypertrophy, and mal-perfusion of the abdominal organs and lower extremities. Symptoms vary with the anomaly's severity and range from headache, chest pain, cold extremities, fatigue, and leg claudication to fulminant heart failure and shock. Unequal pressures in the upper extremities is recorded. Diagnosis is by echo-cardiography or by CT or MR angiography. Treatment is balloon angioplasty with stent placement, or surgical correction. Endocarditis prophylaxis is recommended.
A grade 2 to 3/6 ejection systolic murmur is best heard in the left interscapular area. A soft bruit may be heard over the coarctation site. Additional murmurs that result from the presence of associated abnormalities, such as VSD or aortic valve stenosis, may also be detected. An ejection click may be audible when an associated bicuspid aortic valve and a murmur of aortic stenosis or insufficiency are present, whereas a gallop rhythm may indicate ventricular dysfunction.
→ Wide pulse pressure, and diastolic murmurs are seen in aortic dissection
→ Patients with acute adrenal insufficiency (Addison disease) generally present with acute dehydration, hypotension (especially orthostatic hypotension and tachycardia), symptomatic hypoglycemia, or altered mental status.
→ Clinical presentation of viral myocarditis may include: presence of S3, and a heart murmur caused by atrioventricular valve regurgitation; hepatomegaly; rales; jugular venous distention and edema of the lower extremities.
A 4-year-old black boy on trimethoprim/sulfamethoxazole for tonsillitis presents with jaundice. Labs show anemia, and a reticulocyte count of 8%.
Correct Answer D:
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzymatic defect common in blacks that can result in hemolysis after acute illnesses or intake of oxidant drugs (including salicylates and sulfonamides). Diagnosis is based on assay for G6PD, although tests are often falsely negative during acute hemolysis. Treatment is supportive.
Hemolysis occurs commonly after fever, acute viral and bacterial infections, and diabetic acidosis. Hemolysis also occurs after exposure to drugs or to other substances that produce peroxide and cause oxidation of Hb and RBC membranes. These drugs and substances include primaquine, salicylates, sulfonamides, nitrofurans, phenacetin, naphthalene, some vitamin K derivatives, dapsone, phenazopyridine and fava beans.
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