儿科学教学课件：心血管

Problembasedlearning病例一患儿女性，

9月。发热伴咳喘2天，发现心脏杂音1天。患儿自幼喂养困难，多汗，体重增长缓慢。无紫绀。心率130次/分，呼吸50次/分。心前区饱满，可扪及震颤。左胸骨旁第3-4肋间闻及收缩期杂音IV级。P2增强，无明显分裂。心尖区闻及舒张期杂音II级。如何临床思考该患儿的杂音？进一步临床诊断和鉴别诊断？

病例一HeartMurmursPresentedbyDr.LiuFangSessionITheHeartSoundFirstheartsoundisproducedbyclosureoftheMVandTVThesecondsoundisproducedbyclosureoftheaorticvalveimmediatelyfollowedbyclosureofthepulmonicvalveTheHeartSoundSplittingofS2

NormalsplitingofS2WideInspiratorysplitting

Pulmonarystenosis---duetodelayedP2MitralregurgitationVSDDuetoearlyA2SplittingofS2

WideandFixedSplitASDRBBBTAPVDRightventricularfailure

RevisedSplittingLBBBAorticstenosisLeftVentricularFailurePDATheHeartSoundSingleS2

—DuetoinducedintensityofcomponentsofS2

pulmonaryatresiasevereTOF,TricuspidatresiaTruncusarteriosusAorticstenosis

—P2SynchronouswithA2

SingleVentriculeTheHeartSoundTheHeartSoundConditionscausingprominentS2Physiology(infantsandchildren)Lefttorightflow(largeQP/QS)PulmonaryhypertensionHyperdynamicventricularwithhighoutputConditionscausingWeakS2

PSTOFTheHeartSoundDifferentialDiagnosis-murmursFunctional/innocentmurmurs(normal)Physiologicmurmurs(duetoanabnormalityofflownotofprimarycardiacorigin)Pathologymurmurs(duetoanabnormalityofprimarycardiacorigin)Describingmurmurs:LocationTimingConductionPitchAmplitude(gradingIV)NatureofthemurmurRelationtoresperationandpostureDifferentialDiagnosis-murmursFunctional/innocentmurmurs(normal)

StillmurmurAged2toearlyadolescenceMayrelatedtoturbulentflowacrosstheleftventricularoutflowtractBestheardatleftlowersternalborderVenousHumNeverassociatedwithathrillDifferentialDiagnosisPhysiologicmurmurs(duetoanabnormalityofflownotofprimarycardiacorigin)

HighcardiacoutputstatesArteriovenousfistulaPeriferalpulmonicstenosisDifferentialDiagnosisPathologymurmurs(duetoanabnormalityofprimarycardiacorigin)

——systolicmurmur

VentricularseptaldefectAtrialseptaldefectPatentductusarteriosusAorticstenosisPulmonarystenosisMitralregurgitationTricuspidregurgitation

………PS,ASVSD,MR,TRSmallVSDorVSDwithPH,TRMVPDifferentialDiagnosisEarlyDiastolicmurmurMid-Diastolicmurmur(overload)Late-Diastolicmurmur(anatomic)Pathologymurmurs

——Diastolicmurmur

AorticregurgitationPulmonaryregurgitationMitralstenosisTricuspidstenosis

DifferentialDiagnosisPathologymurmurs

——Continuousmurmur

PatentductusarteriosusA-PwindowAVfistulaoraneurysmPAwithMPACA

ASDVSDPDA几种常见先心病鉴别表VSDASDPDAPS分类左向右分流梗阻型（无分流）症状肺充血：呼吸道感染，心功能不全体循环血流降低：生长发育落后晚期：青紫通常无症状，重症可有青紫及右心功能不全心脏体征杂音部位3、4LSB2、3LSB1、2LSB2、3LSB时期SMSMCMSM响度II~IV级II~III级II~IV级II~IV级传导

广泛局限颈部传导广泛，颈部震颤有无有有P2增强或亢进增强或亢进，固定分裂增强或亢进减低，分裂X线表现肺血增多增多增多正常或减少肺动脉段突出突出突出突出（狭窄后扩张房室大小LV、LA、RV大RA、RV大LA、LV→RV大RV大心电图LV、LA、RV大RBBB,RV大LA、LV→RV大RV肥厚21肌部VSD堵闭器膜周部VSD堵闭器（非对称）膜周部VSD堵闭器（等边）2224堵闭后2周，左室面堵闭后2周，右室面25右上肺动脉造影显示房缺球囊测量房缺大小ASD堵闭过程26堵闭器放置后经胸超声心动图监测4岁男孩，PDA呈长管型，直径1mm，采用弹簧圈成功堵闭PulmonaryStenosisAorticStenosisCoarctationoftheAorta,CoAStentimplantationforbranchpulmonarystenosis病例二患儿男性，1岁2月。生后6个月出现紫绀，并逐渐加重。平时无反复肺炎史，有蹲踞现象。3个月前突然有一次晕厥。生长发育落后，心率100次/分，呼吸30次/分，SPaO2:82%。左胸骨旁2-3肋间闻及收缩期杂音3-4级，喷射性。P2明显减弱。

如何进行诊断和鉴别诊断？为何蹲踞？晕厥原因？病例二RVLV肺动脉狭窄：漏斗部、瓣膜及肺动脉室间隔缺损（VSD）主动脉骑跨（AO）右心室肥厚法洛四联症（TOF)病理基础：动脉圆锥隔分割不均杵状指蹲踞姿势：

体循环阻力增加腔静脉回流减少保证重要器官血供

CyanosisPresentedbyDr.liufangSessionIICyanosis---HintsCentralcyanosis:impliesdecreasedarterialoxygensaturationPeripheralcyanosis:causedbyadecreasedrateofperipheralbloodflowDifferentialcyanosisDifferentialdiagnosisCardiovasculardisease -Congenitalheartdisease -Eisenmengersyndrome -Pulmonaryarteriovenousfistulae -Primarypulmonaryhypertension-Congestiveheartfailure/lowoutputstateDifferentialdiagnosisRespiratorydiseases -Nasalobstruction -Foreignbodyaspiration -Trachealcompression -Bronchiolitis -ReactiveairwaydiseaseDifferentialdiagnosis -RDS -Meconiumaspiration -Pneumonia -Pluraleffusion -Diaphragmatichernia -LunghypoplasiaDifferentialdiagnosisMetabolicdisease -HypoglycemiaNeurologicdiseases -Seizures -CerebralEdema -CerebralHemorrhageDifferentialdiagnosisMiscellaneous -Crying -Sepsis -Breathholding -Drug:respiratorydepressants胎儿循环产后循环危重的先天性心脏病

在胎儿期症状不明显

生后即出现临床症状肺血流严重的肺动脉瓣狭窄室间隔完整的肺动脉闭锁法洛四联征伴肺动脉闭锁并行循环：完全性大动脉转位左室流出道严重的主动脉瓣狭窄,主动脉闭锁主动脉缩窄

主动脉弓离断

左心室发育不良

综合征肺静脉回流异常完全性肺静脉异位引流DifferentialdiagnosisDiscussionCardiovascular -NeonateswithcyanosisbyCHD1.PoormixingofthesystemicandpulmonarycirculationsPDATranspositionoftheGreatArteries(TGA)完全性大动脉换位

（D-TGA）BalloonAtrialSeptostomy52BalloonAt