Tài liệu Bs chi benh an kenh nhi that

CASE REPORT PERSONNAL DETAILS • Patient name : NGUYEN THI TO UYEN • Gender : Female • Birthdate : April 14, 1999 • Address : Dac Lac province • Date of consultation • Chief complaint : Feb 14, 2003 : Dyspnea HISTORY • The congenital heart disease had been detected at 10 months old after an episode of acute bronchitis. • Recurrent respiratory infections. • Exertional dyspnea, diaphoresis, failure to thrive . • No cyanosis PAST HISTORY • Birth weight : 3kg ; 2nd daughter, the elder is normal • Mother : normal gestation PHYSICAL EXAMINATION • 1st examination (April 8, 2002 - 3 years old) W : 8.5 kg H : 82 cm HR : 130bpm • Cardiac apex : 5th LICS, on MCL Systolic murmur grade 4/6 at 2nd LICS Systolic click (+). No pulmonary rales Liver : 2 cm below costal margin No other abnormalities PHYSICAL EXAMINATION • 2nd examination (Feb 14, 2003 – 4 y.o) Hypotrophic W : 9kg H : 82cm HR : 136 bpm RR : 36/mn Paroxysmal nocturnal dyspnea, orthopnea Precordial bulge Cardiac apex : 6th LICS, 1 cm out of MCL Systolic murmur grade 2/6 at 2nd LICS ; Diastolic murmur of pulmonary regurgitation (+) P2 accentuated Liver : 4 cm below costal margin No other abnormalities ECG (1) (April 8, 2002) Sinus rhythm; regular rate 120 bpm QRS axis North-Westh region Right atrial and ventricular enlargement Incomplete RBBB ECG (2) (Feb 14, 2003) Sinus rhythm; regular rate 136bpm Right QRS axis Right atrial and ventricular enlargement Incomplete RBBB First-degree atrioventricular block Chest radiograph (1) (April 8, 2002) Chest/thorax ratio 0.73; Right atrial and ventricular enlargement, left atrial and ventricular enlargement . Main pulmonary artery is prominent, increased pulmonary vascular markings. Chest radiograph (2) (Feb 14, 2003) • Cardiomegaly. • Main pulmonary artery is prominent. • Increased pulmonary vascular markings. TTE (Feb 14, 2003) (H: 82cm; W: 9 kg; BSA: 0.42m2) ▪ Levocardia with situs solitus . ▪ Common atrium. ▪ Both atrioventricular valves are inserted downward at the same level. Two AV valves annuli. ▪ The cleft of the anterior leaflet of the mitral valve results in mitral regurgitation (4/4). Two papillary muscles of the left ventricle are lateralized ▪ Tricuspid regurgitation (4/4). Systolic pulmonary artery pressure: 100mmHg ▪ Pulmonary insufficiency (++). Mean pulmonary artery pressure: 50mmHg ▪ Left and right ventricular enlargements. The septal motion is paradoxical.