Read the diagnosis and treatment of congenital heart disease in children

The child was 9 months old, male, Dongguan, Guangdong Province, because of shortness of breath for 1 month, coughing for 3 days, aggravated the accompanying hair for 4 hours on March 5 at 12:00 hospital.
children 1 month ago no cause of shortness of breath, the initial gas is seen in the milk, accompanied by sweating more, after rest to improve, parents did not pay attention to.
Later in the milk also has shortness of breath, the middle need to stop 3-4 times (about 5 minutes each time) オ to eat enough, after eating milk to see a full head of sweat, there is crying, crying when the gas is more obvious, but no hair.
treatment at the local health facility has not improved (not known).
3 days ago by cold after runny nose, fever, body temperature of 38 degrees C, no chills, convulsions, cough, dry cough at first, then turned to a number of cough, sputum but no sputum cough, gas exacerbation.
4 hours ago crying, coughing drama, air is obvious, accompanied by hair, refused milk.
The local hospital with PG and other drugs treatment did not improve, physical examination found heart murmurs, for further diagnosis and treatment of my hospital after the amount of milk reduced, irritable, sleep easy to wake up, nearly 1 day crying low, urine volume than usual less than 1/3, no vomiting, edema, stool normal, no history of foreign inhalation.
in addition to 3 colds (taking Chinese medicine to improve), there is no history of twitching, convulsions and other diseases.
personal history: full moon, birth weight of 3 kg, has been breastfeeding, occasionally take fish liver oil and calcium tablets.
will rise in the next 3 months, 8 months out of teeth and sit alone.
have been made card seedlings, white broken vaccine vaccination, have taken polio sugar pills.
mother 35-year-old father 39 years old, mother 2 months pregnant with fever for 3 days, after taking Chinese medicine to recover.
parents are not close relatives, there is no special medical history.
: T37 degrees C, P170 times/min, R68 times/min, BP17/7kPa, Wt8kg.
developmental nutrition is medium, the response is general, crying low, shortness of breath, lips and mouth light hair, residual skin, mucous membranes without hair, no rash, bleeding point, yellow dye.
shallow lymph nodes are small, the skull is deformed, the frontis soft, 1 × 1cm2.
sclere without yellow dyeing, pupils and other large equal circles, the presence of light reflection.
2 breast teeth, pharynx full of blood .
neck is soft, neck veins are full, the trachea is centered, the thyroid gland is not big.
chest without deformities, respiratory symmetry, three concave signs.
double lung breathing sound thick, can smell and dense small and medium blister sound.
the pre-heart area slightly bulging, heart-tip throbbing dispersion, range 3x3cm2, no tremor, heart enlargement, heart rate 170 times / minute, heart rhythm neat, first heart tone slightly lower, pulmonary valve The second heart tone of the region, there is a third heart tone, in the left edge of the chest bone 3rd and 4th ribs can smell the full contraction period reflow murmur 3 degrees / 6 degrees, conduction is extensive, heartless wrap friction sound.
abdominal flat soft, no bag block, liver under the right rib 3cm, medium, edge blunt, liver and neck signs (plus), spleen under the left rib, mobility turbid tone (-).
spinal limbs without deformities, lower limbs without edema, normal boy vulsion, knee reflexes exist, did not lead to pathological neuroreflexes.
laboratory examination: hemoglobin 120g/L, red blood cell 4.0×1012/L, white blood cell 12.0x109/L.
: neutral 0.60, lymph 0.40, plate plateboard 160×109/L.
urine, stool routine normal.
liver function is normal.
chest, electrocardogram, color echocardocardat examination has been done, the results have not returned.
to discuss intern A: the characteristics of the disease in this case: (1) 9 months of infants; 3) Mother fever at 2 months of pregnancy for 3 days; (4) signs: shortness of breath, low crying, light hair on the lips and mouth, neck vein filling, three concave signs ( s), double lungs have dense small and medium blisters Tone; heart beat dispersion, no tremors, enlargement of the heart, heart rate 170 times / minute, the first heart tone slightly lower, the second heart tone, there is a third heart tone, chest bone left edge 3, 4 There is a full-shrink period reflow noise 3 levels, wide conduction, liver ribs under 3cm, edge bluntness, liver and neck signs (-) ;(5) blood white blood cells increased, classification neutral increase, liver function is normal.
based on these characteristics, the diagnosis may be considered as: (1) bronchitis combined with heart failure; Teacher: Students have a good grasp of bronchitis, but the heart problems do not seem to be clear enough or with questions.
indeed, harmless noise should be excluded in cases of heart murmurs.
some infants and young children may have heart murmurs, but noise limitations, softness, easy to change, more in 2 degrees / 6 degrees below, asymptomatic, does not affect growth and development, not to increase the heart, clinically called harmless noise.
characteristics of this example can be excluded harmless noise, should be the quality of the noise.
less than 3 years old are mostly congenital heart disease.
example is a 9-month-old baby, not only has the deviceic noise, but also has the symptoms of shortness of breath, can be diagnosed as congenital heart disease (congenital heart disease).
there are many types of heart disease, which disease does this case belong to? Intern B: The main symptoms of children are shortness of breath, no hair before shortness of breath, no tingling when of shortness of breath, nearly 3 days after the combination of pneumonia, heart failure, the first consideration for left-to-right stethology type is lurking blue-purple type of congenital heart disease.
the results of the current auxiliary examination have not been returned, and will wait for the results to come back for further diagnosis.
examinations we have done without results include chest tablets, electrocardograms, and color Doppler echocardats.
: These complementary tests are needed and play an important role in diagnosis.
we don't wait for all the auxiliary test results to come out before diagnosis, we should learn clinical analysis.
is very important for heart stethosis of pre-cardiac disease in children, and some children can rely on heart murmur characteristics to make accurate diagnoses.
according to the characteristics of this example, can we make further diagnosis? Intern C: Yes.
left-to-right severity of pre-heart disease is common room space defects, room space defects and arterial catheters are not closed, clinical symptoms are similar.
noise of defective room space is the 2nd to 3rd stage shrinkage jet noise between the left edge of the chest bone 2nd and 3rd ribs, the conduction range is small, and the second heart tone in the pulmonary valve area has a fixed division.
the arterial catheter is not closed and there is a continuous machine-like murmur between the 2nd rib on the left edge of the thoracic bone, which is transmitted to the neck.
example, there is no continuous murmur and the second heart tone fixed split, the loudest part of the noise is lower in the 3rd and 4th ribs, and the conduction is extensive.
does not support room space defects and arterial catheters are not closed, can be diagnosed as room space defects.
Intern D: Does not support the arterial catheter is not closed there is not much pulse pressure, no aortic shooting sound.
diagnosis is still considered for room space defects, but why is there no tremor? Teacher: Good analysis, I agree with everyone's diagnosis.
room space defect noise is due to the left room blood flow through the defect into the right room to the right room, so that the right chamber blood discharge increased, causing the right chamber outflow path relatively narrow caused by the jet.
that the artery catheter is not closed and the chamber space is defective is produced by the blood flowing through the defective part.
the artery catheter is not closed, blood flows from the aorta to the pulmonary artery, regardless of the contraction or esophotosis period, producing continuous murmurs.
if the pulmonary circulation pressure is high, only the systolic murmurs may be heard, not continuity.
so in addition to the noise nature, the loudest part of the noise is also one of the identification methods, combined pulmonary hypertension is even more important.
this case due to pulmonary valve second pitch, should be added may be combined with the diagnosis of pulmonary hypertension.
the strength of the heart murmur and the severity of the illness is not necessarily balanced.
the noise is not serious, on the contrary, the noise light or no noise condition may be serious.
room spacer defect noise is related to defect size and pulmonary vascular resistance.
cases include pneumonia, heart failure, and pulmonary hypertension, which can affect the intensity of noise.
tremor removal is closely related to the intensity of noise, in addition to factors such as under-skin fat in the baby's chest.
example of infant subskin fat thick, shrinking period noise level 3, can be no tremors.
E: Teacher, what if there is no abnormality in the ultrasound heartbeat check? Teacher: There are fewer opportunities for this to occur, and ECHO played the most important role in the diagnosis ofheart disease, but it was not 100% accurate.
results can not exclude congenital heart disease, should be combined with clinical and other examination comprehensive consideration, if necessary to redo.
intern F: Teacher, color echo heartbeat results came out.
: Thank you! The results showed that the left and right chambers were hypertrophy, the room space was 1cm, and the pulmonary artery was high -pressure (moderate).
is in line with our analysis just now.
room space defect is the most common congeneral heart disease, and its clinical manifestations are determined by the size of the defect.
small defects (less than 0.5cm) are generally asymptomatic, with only loud, coarse full-shrink period murmurs between the 3rd and 4th ribs of the left edge of the thoracic bone.
Medium-sized, large-scale defective children have fatigue, shortness of breath, sweating, wasting, prone to pneumonia and heart failure, heart enlargement, heart-tip throbbing diffuse, chest bone left edge 3, 4 ribs between the 3rd and 4th full-shrink period murmurs, conduction wide, pulmonary valve second heart tone.
pulmonary hypertension is severe, left-to-right severity decreases or even right-to-left stethosal, heart murmurs decrease, and the child appears bruising.
clinically pay special attention to pulmonary hypertension, if pulmonary hypertension is significant, resulting in persistent right-to-left stection, which may be obstructive pulmonary hypertension, or Eisenmengre Syndrome, at which point the opportunity for surgery is lost.
this case defect is between medium and large defect, the current combination of bronchial pneumonia, heart failure, pulmonary hypertension (moderate), how should be handled? Intern A: We have been treated with secondary antibiotics, and with the strong heart drug sedallan, plan to continue anti-inflammatory and treatment of the disease? Intern G: Surgical repair defects.
teachers: strong heart and anti-infection are important, the relationship between the two affect each other.
interval between the patient's lungs to fill the blood, combined with heart failure when the lung bruising, lung blood silt on the basis of easy to develop pneumonia.
lung signs are associated with heart failure and pneumonia.
blood in the lungs when heart failure is not under control, and the effect of antibiotics alone is often poor.
heart failure treatment, in addition to strong heart medicine, should also choose diuretics, vascular drugs.
it is worth noting that, unlike other heart failure treatments, the rules should be adhered to, medication should be maintained to prevent repeated development into stubborn heart failure, and preparation for surgery.
H: Teacher, how to master the timing of surgery? Teacher: Simple room space defect children, defects do not necessarily need surgery, but should be reviewed regularly.
with symptoms of medium-sized defects, it is advisable to do defect repair in the early part of school.
large-scale defects have difficulty controlling heart failure, including repeated pneumonia and growth retardation, should be treated with timely surgery.
6 months to 2 years of age, although heart failure can be controlled, but pulmonary arterial pressure continued to rise, greater than 1/2 of the circulatory artery pressure, should also be early surgery to repair defects.
of course, specific cases should be specifically analysed.
Combined with this example, the first heart failure can be controlled, pulmonary hypertension relief, can not be operated on, but need to continue to use strong heart medicine and regular follow-up, to prevent heart failure and pulmonary hypertension re-occurrence, exacerbation, until early school age to consider surgical treatment.