NR602 – Primary Care of the Childbearing & Childrearing Family
WEEK 4 COMPREHENSIVE STUDY GUIDE
Cardiovascular, Hematological, Neurological & Musculoskeletal Disorders
Midterm Exam Coverage: Weeks 1–4 | 75 Questions | Closed Book | ExamSoft
1. CARDIOVASCULAR DISORDERS
1.1 Heart Murmurs — Overview
• Up to 80% of children have a murmur detected on routine physical examination
• Less than 1% of all murmurs are caused by a congenital defect
• Murmur grading scale (Levine Scale): Grades 1–6
Grade Description
Grade 1 BARELY audible; requires quiet room and focused attention
Grade 2 SOFT but easily audible; no thrill
Grade 3 LOUDER but NOT accompanied by a thrill
Grade 4 LOUD with a PALPABLE THRILL
Grade 5 Can be heard with stethoscope PARTIALLY OFF the chest; thrill
palpable
Grade 6 Audible WITHOUT a stethoscope; thrill palpable
KEY RULE
All murmurs LOUDER THAN GRADE 3 are PATHOLOGICAL and require referral to
pediatric cardiology.
1.2 Seven Characteristics of a Murmur (ILTQRPD)
• Intensity — how loud (Grade 1–6)
• Location — where it is loudest (aortic, pulmonic, tricuspid, mitral area, Erb's point)
• Timing — systolic (between S1 and S2) or diastolic (between S2 and next S1)
• Quality — blowing, harsh, musical, rumbling, crescendo-decrescendo
• Radiation — where else the murmur is heard (axilla, neck, back)
• Pitch — high, medium, low frequency
• Duration — holosystolic, early systolic, mid-systolic, late systolic
1.3 Innocent (Physiologic) Murmurs
Type Key Features
Peripheral Pulmonary Ages 1–2 months; blood vessels to lungs are small; resolves by 6
Stenosis (PPS) months; heard in pulmonic area and left axilla
Still's Murmur Ages 2–6 years; MUSICAL or vibratory quality; most common
innocent murmur in school-age children; resolves by age 12
Venous Hum Ages 2–8 years; continuous humming sound; caused by normal
, blood flow in upper chest veins; DISAPPEARS with turning of head
or lying down
Flow Murmur (Innocent) Ages 8–14 years; thin chest walls amplify normal blood flow
sounds; resolves with age
Physiologic Murmur of Temporary; due to increased cardiac output; resolves when
Anemia/Fever underlying condition treated
• Innocent murmur management: reassess at next wellness check; no echocardiogram or chest
X-ray needed for asymptomatic innocent murmurs
• Pathologic murmurs: refer to pediatric cardiologist; echo as directed by cardiology
1.4 Congenital Heart Defects — Classification
Congenital heart defects (CHD) affect ~1% of live births (~40,000 babies/year). CHD is the leading
cause of morbidity and mortality in the first year of life.
Category Description & Examples
ACYANOTIC — Left-to- Oxygenated blood abnormally recirculates: ASD, VSD, PDA
Right Shunt (↑ pulmonary
blood flow)
ACYANOTIC — Obstruction to outflow: Coarctation of aorta, Pulmonary stenosis,
Obstructive (no shunt) Aortic stenosis
CYANOTIC — Right-to- Deoxygenated blood enters systemic circulation: Tetralogy of Fallot,
Left Shunt (↓ pulmonary Tricuspid atresia, Hypoplastic left heart syndrome
blood flow)
CYANOTIC — Mixed Transposition of great vessels, Truncus arteriosus, Critical pulmonic
Blood Flow stenosis
Key Congenital Defects
Defect Pathophysiology / Signs Key Clinical Clue
VSD (Ventricular Septal Opening between ventricles; left-to- Systolic murmur at Erb's
Defect) — MOST right shunt. Most close spontaneously. point or tricuspid; large VSD
COMMON congenital Large VSD: dyspnea, respiratory = heaves and thrill
defect infections, diaphoresis, fatigue.
ASD (Atrial Septal Opening between atria; left-to-right Widely split S2; systolic
Defect) shunt. Often asymptomatic; older murmur at pulmonic or
children may have fatigue or exercise diastolic at tricuspid; right
intolerance. ventricular heave
PDA (Patent Ductus Fetal vessel from pulmonary artery to CONTINUOUS
Arteriosus) aorta remains open. Failure to thrive, 'MACHINERY-LIKE'
tachypnea, diaphoresis with feedings. murmur at pulmonic;
bounding pulses with large
openings
Coarctation of Aorta Narrowing of aortic arch. 60% present ABSENT or DIMINISHED
after infancy with hypertension or femoral pulses; UPPER
failure to thrive. 40% newborns EXTREMITY BP HIGHER
, present with low cardiac output, shock, than lower extremities.
acidosis. Systolic murmur left axilla.
Tetralogy of Fallot Four defects: pulmonic stenosis, VSD, Progressive cyanosis;
aortic shift (overriding aorta), right systolic murmur at Erb's
ventricular hypertrophy. Progressive point; right ventricular
cyanosis; 'TET SPELLS' (hypoxemic heave; 'boot-shaped' heart
spells). on CXR
Transposition of Great Aorta arises from RIGHT ventricle; CYANOSIS AT BIRTH
Vessels pulmonary artery from LEFT ventricle. without respiratory distress;
Cyanosis at birth; no respiratory may or may not have VSD
distress.
Hypoplastic Left Heart Left side of heart underdeveloped. CYANOSIS and SHOCK as
Syndrome Appears stable at birth; rapid ductus arteriosus closes;
deterioration as ductus closes. life-threatening
Pulmonary Stenosis Obstruction through pulmonic valve; ↑ Pulmonic ejection click at
right ventricular pressure. Small- Erb's; right ventricular
moderate: asymptomatic. Severe = heave; widely split S2;
cyanosis. critical PS = life-threatening
Aortic Stenosis Obstruction through aortic valve. Most Harsh systolic murmur with
asymptomatic in infancy; severe = click at aortic area; thrill in
cardiogenic shock. suprasternal notch and
carotid areas
Truncus Arteriosus Aorta and pulmonary artery share one Minimal cyanosis; systolic
large vessel. Heart failure symptoms. murmur ± click at tricuspid;
thrill
Tricuspid Atresia Tricuspid valve closed or absent. Cyanosis at birth; fatigue;
Cyanosis at birth; fatigue with tachypnea; dyspnea
feedings, tachypnea.
EXAM TIP
VSD = most common congenital defect (most close spontaneously). PDA = continuous
machinery-like murmur. Coarctation = absent femoral pulses + upper BP > lower BP.
Tetralogy of Fallot = 4 defects + progressive cyanosis + tet spells + boot-shaped heart.
1.5 Kawasaki Disease
• Systemic vasculitis of UNKNOWN cause affecting medium-sized arteries; occurs primarily in
children UNDER 5 YEARS
• Leading cause of ACQUIRED heart disease in children in the United States
• Boys affected more than girls; seasonal pattern (winter and spring)
• DIAGNOSIS: Clinical — requires FEVER ≥5 days PLUS AT LEAST 4 of 5 classic criteria (or
fever + coronary artery abnormality):
Kawasaki Disease Diagnostic Criteria (CRASH and BURN)
Criterion (Mnemonic) Details
C — Conjunctival Bilateral, nonpurulent (no discharge) bulbar conjunctival injection —
WEEK 4 COMPREHENSIVE STUDY GUIDE
Cardiovascular, Hematological, Neurological & Musculoskeletal Disorders
Midterm Exam Coverage: Weeks 1–4 | 75 Questions | Closed Book | ExamSoft
1. CARDIOVASCULAR DISORDERS
1.1 Heart Murmurs — Overview
• Up to 80% of children have a murmur detected on routine physical examination
• Less than 1% of all murmurs are caused by a congenital defect
• Murmur grading scale (Levine Scale): Grades 1–6
Grade Description
Grade 1 BARELY audible; requires quiet room and focused attention
Grade 2 SOFT but easily audible; no thrill
Grade 3 LOUDER but NOT accompanied by a thrill
Grade 4 LOUD with a PALPABLE THRILL
Grade 5 Can be heard with stethoscope PARTIALLY OFF the chest; thrill
palpable
Grade 6 Audible WITHOUT a stethoscope; thrill palpable
KEY RULE
All murmurs LOUDER THAN GRADE 3 are PATHOLOGICAL and require referral to
pediatric cardiology.
1.2 Seven Characteristics of a Murmur (ILTQRPD)
• Intensity — how loud (Grade 1–6)
• Location — where it is loudest (aortic, pulmonic, tricuspid, mitral area, Erb's point)
• Timing — systolic (between S1 and S2) or diastolic (between S2 and next S1)
• Quality — blowing, harsh, musical, rumbling, crescendo-decrescendo
• Radiation — where else the murmur is heard (axilla, neck, back)
• Pitch — high, medium, low frequency
• Duration — holosystolic, early systolic, mid-systolic, late systolic
1.3 Innocent (Physiologic) Murmurs
Type Key Features
Peripheral Pulmonary Ages 1–2 months; blood vessels to lungs are small; resolves by 6
Stenosis (PPS) months; heard in pulmonic area and left axilla
Still's Murmur Ages 2–6 years; MUSICAL or vibratory quality; most common
innocent murmur in school-age children; resolves by age 12
Venous Hum Ages 2–8 years; continuous humming sound; caused by normal
, blood flow in upper chest veins; DISAPPEARS with turning of head
or lying down
Flow Murmur (Innocent) Ages 8–14 years; thin chest walls amplify normal blood flow
sounds; resolves with age
Physiologic Murmur of Temporary; due to increased cardiac output; resolves when
Anemia/Fever underlying condition treated
• Innocent murmur management: reassess at next wellness check; no echocardiogram or chest
X-ray needed for asymptomatic innocent murmurs
• Pathologic murmurs: refer to pediatric cardiologist; echo as directed by cardiology
1.4 Congenital Heart Defects — Classification
Congenital heart defects (CHD) affect ~1% of live births (~40,000 babies/year). CHD is the leading
cause of morbidity and mortality in the first year of life.
Category Description & Examples
ACYANOTIC — Left-to- Oxygenated blood abnormally recirculates: ASD, VSD, PDA
Right Shunt (↑ pulmonary
blood flow)
ACYANOTIC — Obstruction to outflow: Coarctation of aorta, Pulmonary stenosis,
Obstructive (no shunt) Aortic stenosis
CYANOTIC — Right-to- Deoxygenated blood enters systemic circulation: Tetralogy of Fallot,
Left Shunt (↓ pulmonary Tricuspid atresia, Hypoplastic left heart syndrome
blood flow)
CYANOTIC — Mixed Transposition of great vessels, Truncus arteriosus, Critical pulmonic
Blood Flow stenosis
Key Congenital Defects
Defect Pathophysiology / Signs Key Clinical Clue
VSD (Ventricular Septal Opening between ventricles; left-to- Systolic murmur at Erb's
Defect) — MOST right shunt. Most close spontaneously. point or tricuspid; large VSD
COMMON congenital Large VSD: dyspnea, respiratory = heaves and thrill
defect infections, diaphoresis, fatigue.
ASD (Atrial Septal Opening between atria; left-to-right Widely split S2; systolic
Defect) shunt. Often asymptomatic; older murmur at pulmonic or
children may have fatigue or exercise diastolic at tricuspid; right
intolerance. ventricular heave
PDA (Patent Ductus Fetal vessel from pulmonary artery to CONTINUOUS
Arteriosus) aorta remains open. Failure to thrive, 'MACHINERY-LIKE'
tachypnea, diaphoresis with feedings. murmur at pulmonic;
bounding pulses with large
openings
Coarctation of Aorta Narrowing of aortic arch. 60% present ABSENT or DIMINISHED
after infancy with hypertension or femoral pulses; UPPER
failure to thrive. 40% newborns EXTREMITY BP HIGHER
, present with low cardiac output, shock, than lower extremities.
acidosis. Systolic murmur left axilla.
Tetralogy of Fallot Four defects: pulmonic stenosis, VSD, Progressive cyanosis;
aortic shift (overriding aorta), right systolic murmur at Erb's
ventricular hypertrophy. Progressive point; right ventricular
cyanosis; 'TET SPELLS' (hypoxemic heave; 'boot-shaped' heart
spells). on CXR
Transposition of Great Aorta arises from RIGHT ventricle; CYANOSIS AT BIRTH
Vessels pulmonary artery from LEFT ventricle. without respiratory distress;
Cyanosis at birth; no respiratory may or may not have VSD
distress.
Hypoplastic Left Heart Left side of heart underdeveloped. CYANOSIS and SHOCK as
Syndrome Appears stable at birth; rapid ductus arteriosus closes;
deterioration as ductus closes. life-threatening
Pulmonary Stenosis Obstruction through pulmonic valve; ↑ Pulmonic ejection click at
right ventricular pressure. Small- Erb's; right ventricular
moderate: asymptomatic. Severe = heave; widely split S2;
cyanosis. critical PS = life-threatening
Aortic Stenosis Obstruction through aortic valve. Most Harsh systolic murmur with
asymptomatic in infancy; severe = click at aortic area; thrill in
cardiogenic shock. suprasternal notch and
carotid areas
Truncus Arteriosus Aorta and pulmonary artery share one Minimal cyanosis; systolic
large vessel. Heart failure symptoms. murmur ± click at tricuspid;
thrill
Tricuspid Atresia Tricuspid valve closed or absent. Cyanosis at birth; fatigue;
Cyanosis at birth; fatigue with tachypnea; dyspnea
feedings, tachypnea.
EXAM TIP
VSD = most common congenital defect (most close spontaneously). PDA = continuous
machinery-like murmur. Coarctation = absent femoral pulses + upper BP > lower BP.
Tetralogy of Fallot = 4 defects + progressive cyanosis + tet spells + boot-shaped heart.
1.5 Kawasaki Disease
• Systemic vasculitis of UNKNOWN cause affecting medium-sized arteries; occurs primarily in
children UNDER 5 YEARS
• Leading cause of ACQUIRED heart disease in children in the United States
• Boys affected more than girls; seasonal pattern (winter and spring)
• DIAGNOSIS: Clinical — requires FEVER ≥5 days PLUS AT LEAST 4 of 5 classic criteria (or
fever + coronary artery abnormality):
Kawasaki Disease Diagnostic Criteria (CRASH and BURN)
Criterion (Mnemonic) Details
C — Conjunctival Bilateral, nonpurulent (no discharge) bulbar conjunctival injection —
