CARDIOLOGY

Name of examiner & signature ________________________________________________

Examinee reads the trigger problem to the examinee.

Jobert, 4-years old, male came to the Emergency Room because of fever.

1. WHAT PERTINENT INFORMATION FROM THE P RESIDENTS

HISTORY WOULD YOU LIKE TO KNOW? O
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A. Onset, character & pattern of fever 2

B. Associated signs & symptoms:
- Cough, colds, changes in BM, dysuria, vomiting 2
- Change in appetite 1
- Rash 2
C. Medications given 1
D. Immunization history – measles and Influenza 1
vaccine
E. Past Medical History
- Measles 0.5
- Dengue Fever 0.5
- Food Allergy 0.5
- Drug Allergy 0.5
F. Environmental history – other Household Members
with the same symptoms, Endemic areas with 1
Malaria
Other pertinent data not included in the list (1 point each
but the total score should not exceed 10 points).
TOTAL SCORE 10
SHOW THE HISTORY.
History of the Present Illness:
5 days PTA – he had fever (tmax of 39oC), associated with cough & watery nasal discharge. He was seen by a private MD &
was diagnosed with Acute Viral Illness. He was given Paracetamol (10mkd) which afforded temporary relief.

3 days PTA – still with fever, he had 2-3 episodes of watery stools, non-bloody, non-mucoid, approximately ¼ cup per
episode. He also had decreased appetite & was irritable.

2 days PTA – still febrile (38oC) with 2 episodes of pasty stools, his mother noted erythematous rash over the perianal area &
applied zinc oxide ointment. He had occasional cough, no DOB, & dry lips.

Day of admission – due to the persistence of fever, this time associated with body malaise, he was brought for consult.

Immunization History:
The following vaccines were given at a Local Health Center, with no note of any adverse effects:
BCG, 3 doses of DPT, Hepa B, and OPV

Environmental History:
The patient had no history of travel. He had a cousin who was diagnosed with Dengue Fever a week ago.
2. WHAT WILL YOU LOOK FOR IN THE PE? P RESIDENTS
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A. Vital signs: especially temperature & BP (since he 2
had fever, diarrhea & decreased oral intake)
B. Eye exam: conjunctivitis without discharge 2
C. Mouth: oral ulcers, strawberry tongue, dry cracked 2
lips
D. Neck: CLADS (Description: Size, Solitary or multiple) 1
E. Cardiac findings: precordium, presence of murmur 1
F. Extremities: edema & desquamation 2
Other pertinent data not included in the list (1 point each
but the total score should not exceed 10 points).
TOTAL SCORE 10
SHOW THE PE FINDINGS.

• Awake, irritable
• Wt: 15kg
• BP: 90/60, HR 115, RR 30, Temp 39oC
• Macular rash on all extremities & trunk
• Erythematous conjunctiva
• Dry lips; hypertrophic & non-hyperemic tonsils, no exudate
• Lymphadenopathy 1 cm in size over the left cervical area
• Clear BS
• AP, NRRR, no murmur
• Soft abdomen, globular, non-tender
• Full pulses, warm extremities, CRT 2 sec, edema on hands and feet

3. GIVE 3 DIFFERENTIALS and your RATIONALE for

considering the ff: diagnosis.
A. Kawasaki Disease 2
- Patient presented with fever of 5 days, and
fulfilled 4 of the principal criteria
1. Macular rash over the extremities 1
2. Erythematous conjunctiva 1
3. Dry lips 1
4. Cervical Lymphadenopathy 1
B. Scarlet Fever 2
- Since patient presented with rash, however in 1
Scarlet fever the rash is diffuse, finely papular,
erythematous eruption producing bright red
discoloration of the skin, which blanches on
pressure, which may desquamate after 4 days.
- The tongue of the patient may appear swollen 1
and coated and usually present as strawberry
tongue.
 P RESIDENTS
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C. Measles 2
- Because the patient has fever and rash 1
(maculopapular), and did not receive any
vaccination
- He presented with Conjunctivitis, however in 0.5
Measles but usually with exudates
There is associated lymphadenopathies but not 0.5
solitary
Other pertinent differentials not included in the list (4
point each but the total score should not exceed 14
points).
- Adenovirus
- Since patient presented with conjunctivitis and
fever, however patients with Adenovirus
infections presents with exudative
conjunctivitis, and pharyngitis, which were not
seen in our patient
- Systemic Onset Juvenile Idiopathic Arthritis
- Since patients with sJIA may present with fever
and rash, however, Lymphadenopathies are
diffuse and there should be associated
hepatosplenomegaly and arthritis
TOTAL SCORE 14

4. (To ask the resident)

WHAT LABORATORY EXAMINATIONS SHOULD BE
REQUESTED? STATE THE RATIONALE FOR EACH.
A. Complete blood count – to differentiate the
Differential diagnosis in terms of the possible
etiology: bacterial or viral cause; to determine any 1
changes in the levels of platelet
(To ask the resident:)
Considering your differentials, what are your expected
results?
In Kawasaki Disease
- Leukocyte count often elevated with
predominance of neutrophils & immature forms; 1
platelet count generally normal in the 1st week of
illness & rapidly increases by the 2-3 week
- Normocytic, normochromic anemia is common
In Measles
- WBC is elevated but it is predominantly 0.5
lymphocytic
In Scarlet fever
Elevated WBC with Segmenter predominance 0.5
 P RESIDENTS
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B. ESR / CRP – it is a test that may determine an acute
phase of the illness 1
(Then ask resident:)
Considering your differentials what are your expected
results?
- Elevated ESR &/or CRP universally present in the 1
acute phase of the illness in KD
- In Measles: it is usually normal 1
C. Echocardiography 2
- To check for aneurysm 2
TOTAL SCORE 10

SHOW THE LABORATORY RESULTS:

CBC: Hgb: 100 Hct: 32 WBC: 17 Neutrophil: 22% Lymphocyte: 78% Monocyte: 2% Platelet: 450
ESR: 50mm/Hr CRP: 4.0mg/dL
2dEcho: Dilated Left Coronary Artery, with EF:75%

5. WHAT IS YOUR PRIMARY IMPRESSION?

Kawasaki Disease 2

TOTAL 2

6. WHAT IS THE CRITERIA FOR DIAGNOSING

KAWASAKI DISEASE (KD)?
4 DAYS OF FEVER PLUS (4 OF THE 5 PRINCIPAL 2
CRITERIA)

(TO ASK RESIDENT:) What are the 5 Principal Criteria?

1. Bilateral non-exudative conjunctival injections 1
with limbal sparing

2. Erythema of the oral and pharyngeal mucosa with 1

strawberry tongue and red, cracked lips

3. Edema and erythema of the hands and feet 1

4. Rash of various forms (maculopapular, erythema 1

multiforme or scarlatiniform)
2
5. Nonsuppurative cervical lymphadenopathy,
UNILATERAL, LESS THAN 1.5 CM in size

TOTAL SCORE 8
 P RESIDENTS
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7. WHAT IS THE PATHOPHYSIOLOGY OF KD?
A vasculitis that predominantly affects medium-sized 3
arteries, most commonly the coronary arteries.
TO ASK RESIDENT: What are the 3 phases of KD?)
MAY ANSWER ONLY THE ONES IN RED.
A. Neutrophilic necrotizing arteritis – occurs in the 3
first 2 weeks of the illness; begins in the
endothelium & moves through the coronary wall ->
saccular aneurysms
B. Subacute / chronic vasculitis – may last for weeks 3
to years; affected vessels develop smooth muscle
myofibroblasts which cause progressive stenosis;
thrombi may form & obstruct blood flow
C. Progressive Stenosis – development of smooth 3
muscle cell myofibroblasts; causing thrombi
formation that may obstruct the blood flow
TOTAL SCORE 12

8. OUTLINE A PLAN OF MANAGEMENT.

(Must ask the resident the Rationale for giving the
Medication/ for the Management)
1. IVIG at 2 g/kg 1
- Shown to reduce incidence of coronary artery dilation 1
to <3% and decrease duration of fever if given in the first
10 days of illness
- Current recommended regimen is a single dose of 1
IVIG, 2 g/kg over 10–12 hours.
2. ASPIRIN 2
- recommended for both its antiinflammatory and 1
antiplatelet effects
- High dose aspirin at 80-100 mg/kg/day divided into 4 1
doses then decreased to 3-5 mg/kg/day OD once 48
hours afebrile
3. Corticosteroids 1
- used as adjunct with IVIg for its anti-inflammatory 1
effects
- Dose: (Any) 1
Methyprednisolone: 30mg/kg as IV pulse therapy
with IVIg
Prednisolone: 2mg/kg plus IVIg
TOTAL SCORE 10
 P RESIDENTS
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9. WHAT IS IVIG-RESISTANT KD?
Persistent or recrudescent fever 36 hours after 2
completion of the initial IVIG infusion
(To ask resident:)
WHAT IS THE SIGNIFICANCE OF IVIG-RESISTANT
KD?
The affected patients are at increased risk for coronary 2
artery aneurysms.
(To ask Resident:)
HO DO YOU MANAGE IVIG-RESISTANT KD?
Give another dose of IVIG at 2 g/kg is given. 2
TOTAL SCORE 6

10. HOW SHOULD PATIENTS WITH KD BE FOLLOWED

UP?
If the patient has a small solitary aneurysm, aspirin 2
should be continued indefinitely.
Those patients with larger or numerous aneurysms may 2
require the addition of other antiplatelet agents or
anticoagulants.
The long term follow-up of patients with coronary artery 2
aneurysms should include periodic echocardiography
with stress test & possibly angiography if large
aneurysms are present.
Patients on long term aspirin therapy should receive 2
influenza vaccination annually to reduce the risk of
Reye syndrome.
TOTAL SCORE 8

11. COMMUNICATION SKILLS & MENTAL ALERTNESS 10

TOTAL SCORE 100