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MINISTRY OF HEALTH OF UZBEKISTAN TASHKENT MEDICAL ACADEMY DEPARTMENT OF "INFECTIOUS DISEASES AND PEDIATRICS" CASE - TECHNOLOGY For Education on "The course of non-rheumatic cordites in young children. Etiopathogenesis, clinical manifestations, diagnosis, differential diagnosis, treatment and prevention. Tactics GP” Case Solve the problem, what is the tactic of a general practitioner with cordites in children TASHKENT – 2012 MINISTRY OF HEALTH OF UZBEKISTAN TASHKENT MEDICAL ACADEMY DEPARTMENT OF "INFECTIOUS DISEASES AND PEDIATRICS" I "CONFIRM" The pro-rector on study Professor Teshaev O.R. ___________________ _______________ 2012 CASE - TECHNOLOGY For Education on "The course of non-rheumatic carditis in young children. Etiopathogenesis, clinical manifestations, diagnosis, differential diagnosis, treatment and prevention. Tactics GP' Compiled by: docent Mirrahimova M.H. The pedagogical summary Subject: "Pediatrics" Topic: "The course of nerevmatichekogo cordites in young children. Etiopathogenesis, clinical manifestations, diagnosis, differential diagnosis, treatment and prevention. GP tactics. " The purpose of this case: • To teach students the criteria for diagnosis of cordites in children; • To discuss the right choice of antibacterial drugs and drug correction of violations, the main vital functions of organs and systems; • Demonstrate the principles of the differential diagnosis; • Review the criteria for possible complications of cordites in children; • Giving students draw up plan recreational activities; Expected learning outcomes - the results of the work with a case students learn how to: • Assessment and analysis of the situation and the general condition of children with cordites. • Choosing the right algorithm for the diagnosis of action. • Independently provide emergency assistance if needed • Refer to hospital for treatment • Be able to make qualified post inpatient rehabilitation. For the successful resolution of the case study student should know Anatomical and physiological features of the cardiovascular apparatus in different age periods; Know the etiology and pathogenesis; Criteria for diagnosing cordites in children; Classification nerevmatichekogo cordites in children; The main clinical manifestations, diagnosis and treatment principles nerevmatichekogo cordites in children. Clinical options for the various forms of cordites, the principles of differential diagnosis; Major complications carditis; Principles of treatment and prevention; Indications for consulting cardiologist. This case reflects the real situation in primary care Information sources CASE Medical History MAIN REFERENCES 1. Childhood illnesses. Daminov TA Khalmatova BT, Boboeva WR, Tashkent, 2010 2. Pediatrics. N.N.Shabalov. St. Petersburg, 2008 3. Propaedeutics childhood diseases. AA Baranov. M., Medicine, 2007 4. Pediatrics. Isayev. St. Petersburg, 1997 ADDITIONAL 1. Anatomy and physiology of children and adolescents. Sain MR, St. Petersburg, 2008. 2. www.medafarm.ru 3. www.tma.uz 4. www.medlincs.ru Characteristics of case study according to typological features This case is classified as a desk, scene. He volume, structured. This case-issue For didactic purposes Case Training, stimulating thinking in the real world in a hovercraft. Case can be used in the disciplines: Pediatrics, tuberculosis, Emergencies I CASE "The course of nerevmatichekogo cordites in children. Etiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention. Tactics GPs' Introduction Nonrheumatic cordites - damage the heart muscle, caused by the development of non-specific inflammatory changes. According to the autopsy, the prevalence of cordites in children is higher than in adults, severe forms occur in young children. Cordites frequency increases significantly during epidemics of viral infections. The solution proposed case study will enable students to achieve the following learning outcomes: Assessment and analysis of the situation and the general condition of children with carditis. Choosing the right algorithm for the diagnosis of action. Independently provide emergency assistance when needed. Refer to hospital for treatment. Be able to make qualified post inpatient rehabilitation. Situation №1. Boy, 3 years, joined the SVP gravity. From history we know those 5 days ago, he suffered a respiratory viral infection. Received inadequate treatment. Soon she began to notice that the boy's temperature was increased periodically to sub febrile figures catarrhal symptoms were not. Go to a doctor, it was a blood test, which revealed no changes. Was diagnosed with the flu, aesthetic syndrome. Oxacillin received within 7 days without effect, connection with which the patient was hospitalized. When you receive a serious condition, the boy whiny, irritable, tires easily. Complaints of shortness of breath and weakness. In the lungs, vesicular breathing, wheezing stagnant. Visual area of the heart is not changed. The border of the heart: the right - on the right edge of the sternum, the top - at the edge III, left - 1 cm medially from the mid - clavicle line. Heart sounds - moderately suppressed, tachycardia, structurally unstable auscultator systolic murmur at the apex, the weakening of one tone, gallop rhythm. Abdomen soft, available deep palpation, the liver and spleen were not enlarged. Complete blood count: Hb - 90 g / l, Air - 3.5 h1012 / l Lake - 10.5 x 10 ^ 9, p / n - 2%, c 46%, E-2%, L48%, m -2%, ESR-20 mm / hour. C - Recto protein + +. General urine analysis: Shares - 1018, protein - as, leukocytes -2-3 in p / s, red blood cells - are absent. Responses 1. What is your diagnosis and justify it? 2. In your, look, with some pathologies to make a differential diagnosis? 3. Specify tactics GP. Task: On the basis of the patient's condition should be a preliminary diagnosis, make the necessary diagnosis, and make an informed decision for the future conduct of a patient with cordites. II. Guidelines for students 2.1 The problem: Choice of tactics and determination of the need for hospitalization in patients with cordites in a hovercraft. 2.2. Subproblems 1. Analysis of appearance 2. Preliminary analysis of the history and events that are the etiologic factor in the occurrence of cordites 3. Analysis of the survey 4. Selecting the appropriate diagnostic methods 5. Correlate the results and make a differential diagnosis 6. Come to a certain address in SVP 2.3. Algorithm solutions 1. Analysis of appearance includes the following research: - Inspection of the skin and visible mucous - The face (eyes, tongue) 2. Analysis of history - Past medical - Family and social history - The duration and nature of the disease 3. Analysis of the survey - Ps, BH. - Percussion and auscultation of the lungs - Percussion and auscultation of the heart - Palpation of the abdomen 4. Selecting the appropriate diagnostic methods - KLA, OAM - B / c of blood - Chest X-Ray ECG 5. Correlate the results and make a differential diagnosis with: - CHD myocardiodystrophy. 6. Come to a certain address in SVP - Treatment if necessary - Emergency hospitalization - Emergency care Instructions for independent work in the analysis and solution of practical situations. Leaf analysis of the situation Stages Recommendations and advice 1. Familiarization with First check with case case Reading, Do not try to analyze the situation 2. Acquaintance with a Once again, read the information, select the paragraphs that seemed given situation important to you. Try to describe the situation. Determine that it is important and what is secondary. 3. Identification, The problem: formulation and Choice of tactics and determination of the need for hospitalization of justification of the key children with cordites in a hovercraft. issues and subproblems 4. Diagnosis of the When analyzing the situation, answer the following questions: situation. What range of common and dangerous diseases are accompanied by a systolic heart murmur? What nosologies to make a differential diagnosis and determine the most likely causes of carditis. Which diagnostic methods must be applied, make a plan and justify the level survey SVP and CRH. What additional advice specialists needed for a final diagnosis? Determine the degree of need for follow-up (medical and non-medical treatment.) 5. Selection and List all the possible ways to solve the problem in this situation. justification of ways and means to solve the problem. 6. Development and Put the diagnosis, decide the issue in a hovercraft. resolution of problem situation the Instructions for group work to analyze and solve practical situation. Stages Reconciliation of the situation and the problem. Analysis and evaluation of the proposed methods and means of solving problems, the choice of priority the idea to solve the problem. Develop mutually acceptable solution to the problem and detailed design implementation. prepare a presentation Recommendations and advice Discuss and agree on different views of members on the situation, the problem of the subproblems. Discuss and evaluate the proposed options and ways to address the problem. Select the priority, in your opinion, the idea of solving the problem. Develop a mutually acceptable solution to the problem and the detailed design implementation. Justify your diagnosis; Justify your tactics. Arrange the results in the form of an oral presentation on behalf of the group. Discuss and decide the question of who will represent the results of the group work: the leader of the whole group or with the division between the participants (co-reports), depending on the tasks to be solved by them in the course of analyzing and solving problems. Prepare illustrative materials in the form of posters, slides or multimedia. In the preparation of reports, especially, mark the approximate outline of what you say, does not go into detail! Sheet analysis and problem solving The name of the stage with a briefcase The content of work stage Acquaintance with a given situation in Review given the particular situation and a case determination essential to solving the problem of information. Analysis of the situation When analyzing the situation, answer the following questions: Preliminary analysis of the history and events that are the etiologic factor in the occurrence of non-rheumatic carditis in children. Analysis of the physical examination. Selecting the appropriate diagnostic methods. Correlate the results and make a differential diagnosis. Come to a certain address in SVP Substantiation Justification of the problem and its key components. Choice of alternatives addressing Formulation of alternatives solutions situational problem. Development and justification of Detailed development and justification of a particular solution decision. III. OPTION ACTION CASEY Teachers - KEYSOLOGOM CASE IV - TECHNOLOGY TRAINING WORKSHOP 4.1 Model of learning technologies Topic Duration – 2 hours Form of lesson Nonrheumatic caditis Number of students: 10 people Workshop on widening and deepening of knowledge, development of skills, management of carditis Plan workshop ntroduction to the training session actualization of knowledge Work with a case of mini - groups presentation of the results Discussion, evaluation and selection of the best option strategies Conclusion. Evaluation of the groups and students, the degree of achievement of lesson The purpose of the training session: expanded knowledge of the tactics of children with carditis. Developing the ability to access, analyze the situation, the choice of tactics, diagnosis, emergency care and post-hospital rehabilitation of children with carditis at primary care level. Tasks the teacher: Learning outcomes: • Consolidate and deepen the knowledge to • Access and analyze the situation and the assess and analyze the situation and the general condition of children with cordites general condition of patients with carditis. • Select action algorithm for diagnosis. • Develop the ability to select the correct • Develop skills of independent decision-making algorithm of actions for diagnosis. in the management of children with carditis in • Develop skills to provide emergency SVP assistance • Produce a sequence of actions for emergency • To develop the skills of independent assistance if required decision-making in the management of children with carditis in a hovercraft. Training methods Case studies, discussion, practical method Learning tools Case, guidance Form of training Individual, front, group work Conditions of learning Audience with the technical equipment, work in groups Monitoring and evaluation Observation, blitz poll presentation, evaluation Flow chart of lesson based on the case. Stage and the Activities content of the work Tutor’s Stages Explains the purpose of case - the stage and its effect on the development of professional knowledge. Distributes materials case and introduces the algorithm for analysis of the situation (see Guidelines for students). Gives the task independently analyze and record the results in the "List of analysis of the Students’ listen Independently examine the contents of an individual case and fill the sheet of the situation. situation" 1.1. Thread class is called, the plan, its goals, objectives and expected learning outcomes. 1.2. Introduces the mode of operation for employment and evaluation criteria (see the instructions for students) II stage main part 2.1. Justifies the statement of the problem and 60 min the choice of the situation - relevance. Conducting a poll in order to enhance students' knowledge on the topic (application number 1): Why there carditis? List the causes of carditis? What complications are possible with late diagnosis of the disease? 2.2. Divides students into groups. Reminiscent of the content and objectives of the case. Introduces (like) the rules of the group and the rules of the debate. 2.3. Gives the task, specify the correct perception of the job (application number 2): What nosologies to make a differential diagnosis and determine the most likely causes of carditis in children. Diagnostic methods used in SVP Clinical management and treatment of patients with carditis. 2.4. Coordinates, advises, directs the learning activities. Evaluates the results of individual work: Sheets of the situation. 2.5. Of the presentation on the results of the work done to address the case study, discussion. Organizer of the discussion: ask questions, remarks, recalled the theoretical material 2.6. Organizer - GP algorithm of actions in this situation (application number 3) 2.7. Tells own solution CASE (Application number 4) III Summary of 3.1. Summarizes the results of training activities, studies, analysis and announces a joint evaluation of individual work. evaluation Analyzes and evaluates the group, notes the 20 min positive and negative points. 3.2. Stresses the importance of case - the stage and its impact on the future specialist I stage. Introduction to the training session (10-15 min) Listen records appropriate Answer questions, discuss, ask clarifying questions. Are divided into groups Discuss, conduct a joint analysis of individual problems, determine the most important aspects of the situation, the main problems and their solutions, process, results of the decision Present options to address issues 10-15 minutes after the end of the presentation, choose the best option Develop a unified system, the discussion Listen. Can a self-assessment mutual evaluation and Express their opinions Appendix № 1. The theoretical part "The course of carditis in children. Etiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention. Tactics GPs’ ” Nonrheumatic carditis - damage the heart muscle, caused by the development of non-specific inflammatory changes. According to the autopsy, the prevalence of carditis in children is higher than in adults, severe forms occur in young children. Carditis frequency increases significantly during epidemics of viral infections. Etiology and pathogenesis. Carditis may be complicated by any infectious disease, regardless of the causative agent. However, in most cases MN arise in children with acute viral infection. The greatest value in their appearance is given coxsackievirus, especially groups A and B, and ECHO. Other etiologic factors include influenza and parainfluenza viruses, measles, mumps, cytomegalovirus, etc. MN can be caused by bacteria, rickettsia, fungi, and other infectious agents. Funds are also MH infectious origin, in particular, allergic and toxic myocarditis. Bacterial carditis in infants often arise in connection with an umbilical, skin, otogenic sepsis, and the older - on the background of osteomyelitis. In this case, heart disease may be due to metastatic disease or have an infectious-allergic mechanism. Fungal carditis occur in patients with chronic diseases receiving long-term antibiotic therapy. In recent years, attracting the attention of hereditary factors in non-rheumatic carditis. Carditis malosimptomno in such cases, with the development of heart failure only in the final. At the heart probably lies genetically determined defect of antiviral immunity. Pathogenesis of acute and chronic carditis is probably different. In acute carditis matter exposure to infectious factor (the trigger), the selection of mediators of inflammation, the occurrence of immediate hypersensitivity reactions (severe immune inflammation under the influence of immune complexes) with an increase in vascular permeability and cellular infiltration, often with damage to blood vessels. Autoallergy with acute course can only be a component, but not the leading mechanism. Due to the different structure of immune complexes, their size, location and deposition of reparative reactions infarction possible benign or malignant outcome of acute carditis. During the chronic pathogen is not critical and the basis of the disease are autoimmune disorders. In this case, the interaction of autoantibodies (antibodies antikardialnye) and / or sensitized lymphocytes autoallergenami amid altered immune tolerance. In response to autoantigens secondary (only property damage, heart tissue damage or a combination of this with the viral antigen) antibodies formed antikardialnye usually aggressive. The reason for such a state is decreased formation of T-suppressors, which leads to the activation of helper effects of hyperstimulation and B-lymphocytes. Especially chronic carditis (self-sustaining process, systemic, malignant and recurrent, refractory to therapy) can think of autoimmune mechanism as the basis of their formation. Based on many years of observation Belokon NA et al. proposed a working classification of nonrheumatic carditis in children. In practice, not always possible to determine whether the disease in the child, especially young children, congenital or acquired. Often, its etiology remains unknown. The question of diffuse or focal nature of carditis is controversial. Back in 1836 an outstanding student corvisart J. Bouillaud established "law of simultaneous presence" for the heart, by which this body can not be amazed one shell. Community and ample blood supply, the rhythm of the single, hematogenous route of infection, impaired immune homeostasis as the basis of the pathogenesis of carditis exclude isolated lesion, as well as patchy, myo-, endo-or pericardium. It could be a different diffusion processes that the clinic is equivalent severity (mild, moderate, severe). Period of disease Classification of non-rheumatic carditis Congenital (antenatal) early and late acquired Causative factor Viral, bacterial, viral, bacterial, parasitic, fungal, iersienozny, allergic, idiopathic Form Carditis The defeat of the cardiac conduction system Flow Sharp - up to 3 months Subacute - up to 18 months Chronic - more than 18 months (relapsing, primary chronic): static, hypertrophic, restrictive options The severity of carditis easy moderate heavy The form and extent of CH Left ventricular I, IIA, IIB, III degree Right ventricular I, IIA, IIB, III degree total Infarction, myocardial hypertrophy, rhythm and conduction disturbances, pulmonary hypertension, valvular lesion, constrictive mioperikardit, thromboembolic syndrome Outcomes and complications Nonrheumatic carditis are congenital and acquired. In the classification of any disease necessarily reflect its course. When non-rheumatic carditis can distinguish acute during the rapid onset and development of the PRS with respect to (2-3 months) Rapid effects of therapy. Subacute carditis may in some cases begin as acute, but recovery is delayed up to 18 months, in others it is possible to note a softer start and a gradual development (primary subacute). Chronic carditis long (more than 18 months), some patients can distinguish acute or subacute onset, the other is not (primarily chronic). Congenital carditis may also have sub-acute and chronic. Carditis severity determined by a complex clinical and instrumental data: the size of the heart, the severity of heart failure, ischemic symptoms and metabolic changes in the ECG, the nature of arrhythmias, the state of the pulmonary circulation. Evaluation for CH carditis is different. Comprehensive survey of patients allowed allocating extent of left and right heart failure. CONGENITAL cordites The diagnosis of congenital carditis is considered valid if symptoms of heart disease detected in utero or in the hospital, likely - if they occur in the first months of life without prior intercurrent illness and / or anamnestic data about the illness of the mother during pregnancy. Anatomical substrate for congenital carditis divided into early and late. Mandatory early morphological sign of carditis is fibroelastoz elastofibroz or endo-and myocardium. Late congenital carditis do not have this feature. Large amount of elastic tissue in retrospect indicates damage to the heart in the early fetal period (4-7th month of intrauterine development), when fetal tissue respond to alteration of cell proliferation with the development of elastosis and fibrosis. With the defeat of the heart after the 7th month ("late fetopathy"), there is a common inflammatory response and does not develop fibroelastoz. Macroscopically with early congenital carditis detected cardiomegaly with mild dilatation and hypertrophy of the left ventricle, it is much thickened endocardium. Almost two thirds of patients with a valvular lesion (hemodynamic or postinflammatory). The first signs of a heart suffering in both cases of early congenital carditis occur within the first 6 months of life (at least 2-3-year) Criteria for diagnosis of early congenital carditis Histories: genetic predisposition to cardiovascular diseases, diseases of the mother during pregnancy, decreased body weight at birth. The first symptoms appear zabbolevaniya in the first half of life, the children postmiokardicheskim elastofibrozom - for 6-18 months of life. Clinical: Extracardiac: unmotivated poor weight gain, stunted physical development, delayed development of static functions, paleness, weakness, sweating, aphonia, unexplainable anxiety attacks. Cardiac: moderate cyanosis of the mucous membranes, the tips of the fingers, left-sided heart hump; apical impulse is weakened or is not defined, muted tones or deafness, tachycardia, resistant to treatment, cardiovascular disease, usually total, but with a predominance levozhulodochkovoy Paraclinical: Laboratory: erythrocyte sedimentation rate, white blood cells, protein fractions of blood serum titer ASL and AST are normal or slightly altered Radiographic: atelectasis of the left lower lobe of the lung. Spherical or oval shape of the heart, increasing the cardiac cavities with marked dilatation of the left ventricle On the ECG in congenital fibroelastoze fixed high voltage complexes QRS, rigid frequent rhythm (often without arrhythmias and conduction disturbances), left ventricular hypertrophy with signs of ischemia it subendocardial departments (down below the contour of ST-negative T wave) Pathologic examination of late congenital carditis involving simultaneously detects two or three layers of the heart, vascular system, sometimes the coronary vessels, a cardio and myocardial hypertrophy. However, the duration of the disease is not as significant as evidenced by the absence of active inflammation and elastic tissue in the endo-and myocardium. Criteria for the diagnosis of late congenital carditis Clinical: Extracardiac: average weight at birth is less common intrauterine malnutrition, fatigue, breast feeding, stunted physical development in 3-5 months. life, the delay in development of static functions, frequent respiratory diseases; sweating changes in the nervous system as a sudden attack of anxiety, shortness of breath, tachycardia, sometimes with loss of consciousness, seizures, noisy breathing. Cardiac: shortness of breath, existing from birth, tachycardia or bradycardia, pallor, cyanosis of mucous and fingertips, symptoms CLO; reinforced, raised, shifted down apex beat, heart sounds loud enough, can be a systolic murmur, arrhythmias. Paraclinical: ECG dominated elektropotentsialy left ventricular arrhythmias and conduction, ST-segment lower contours. Radiographically: normal or trapezoidal shape of the heart. The increase in cardiac shadow by dilatation of the cavities, especially the left. Laboratory: a change in the peripheral blood are not, negative revmotesty PURCHASED cordites The clinical features and course of acquired carditis divided into acute, subacute and chronic. Among the acute carditis can distinguish cases with diffuse myocardial damage and mainly affecting the conduction system of the heart in the form of atrioventricular block and persistent tachycardia. Acute carditis occur at any age, but severe forms are characteristic of children during the first 3 years of life. They occur on the background or soon after undergoing viral infection. Significant place in the event of carditis is the child's prior sensitization and / or allergic mood. As the symptoms of SARS subsided extracardiac signs of heart are leading. Criteria for diagnosis of acquired carditis Histories: diseases of the mother during pregnancy, industrial hazards, prolonged use of certain medications, alcohol abuse. The first symptoms appear against SARS or in 1 - 2 weeks after her previous sensitization of the body of the child, the presence of anomalies in the constitution, failure to observe the vaccination. Clinical: Extracardiac: decreased appetite, lag or poor weight gain, weakness, sweating, fatigue, irritability, fits of excitement, sometimes loss of consciousness, seizures, hemiparesis, anxiety and cries at night, nausea and vomiting, pallor, with gray color of the skin; compulsive cough, worse with a change of position. Cardiac: heart failure, left ventricular first and then total, cyanosis nasolabial triangle, acrocyanosis, arrhythmias, conduction apex beat weakly resistant or not defined at all, the border of the relative cardiac dullness shifted, or muffled tone deafness I, II Tone emphasis on the pulmonary artery , systolic murmur of a functional nature, or relative deficiency of the mitral valve. Paraclinical: Laboratory: laboratory results provide little information ECG electrical axis deviation to the right. Reducing voltage teeth complex QRS. Various arrhythmias, conduction. Change in segment ST (offset lower contour) and T wave Radiographically: pulmonary venous congestion, increased heart shadow, dilatation of the left ventricle. The first cardiac symptoms are signs of left ventricular failure: dyspnea ¸ wheezing in the lungs, and tachycardia. Following this reduced urine output, there pastoznost tissues, the liver increases. Heart hump is absent, indicating that the severity of the disease. The boundaries of the heart in acute diffuse carditis in most cases expanded moderately, sometimes dramatically. Auscultation notes muted or voiceless one tone at the top, with cardiomegaly - gallop. Noise is absent or it function and is associated with dysfunction of the papillary muscles. In patients with lesions of the conduction system of the heart is more often normal sonority tones and full antioventrikulyarnoy blockade on top auscultated intermittent popping "cannon" one tone. Tachyarrhythmia is due to premature beats, atrial flutter, chronic ectopic tachycardia. Beats by which often diagnosed myocarditis occurs in 5.2% of cases and often disappears after treatment. To engage in the process of conducting system of heart attacks indicates persistence of paroxysmal tachycardia. Heart failure is observed in all patients with acute diffuse carditis and is mainly left ventricle, with the defeat of the conducting system of the heart of its display is minimal. Symptoms and the degree of heart failure in non-rheumatic cordites in children degree I II A II B III failure Left ventricular Right ventricular Symptoms of heart failure at rest not in peace and there are no after exercise in the form of tachycardia or shortness of breath Heart rate and the number of breaths The liver performs at 2-3 cm from the costal per minute, respectively increased by 15-30 and 30-50% relative to the norm Heart rate and the number of breaths The liver performs at 3-5 cm from the edge per minute, respectively increased of the arc, and swelling of the neck veins by 30-50 and 50-70% relative to the norm, the ability to acrocyanosis navyaz chivy cough, wet finely wheezing in the lungs Heart rate and the number of breaths Heart rate and the number of breaths per per minute, respectively increased minute, respectively increased by 50-60 and by 50-60 and 70-100% relative to 70-100% relative to the norm, SC Kleene the norm, SC Kleene predoteka and predoteka and lung edema lung edema To engage in the process of conducting system of heart attacks indicates persistence of paroxysmal tachycardia. The diagnostic criteria for acute cordites as reduced QRS voltage on ECG is only important first 2-3 weeks of the disease. If the ECG was first made after the deadline, the voltage may be normal or even high. In addition, the typical deviation EOS right or left, the overload of the left ventricle. One of the diagnostic criteria for acute cordites is the regression of clinical and instrumental data for 6-18 months. Recovery will be half of the children, the rest takes carditis subacute and chronic. Subacute cordites may be torpid development with a gradual increase in heart failure in 4-6 months after the SARS (primary subacute cordites) and delineated the acute phase, transforming the treatment in a lengthy process. For subacute carditis all typical manifestations of acute, but planned heart hump, more often loud tones, systolic murmur of mitral valve insufficiency, persistent emphasis II tone of the pulmonary artery, the torpid heart failure despite treatment. Changes in the ECG are as rigidity rhythm, electrical axis deviation to the left atrioventricular disruption and intraventricular conduction, overload of the left ventricle and both atria, are often positive T wave last two features distinguish subacute to acute carditis. Chronic carditis occupy the main place in non-rheumatic carditis in older children. Chronic carditis may be a primary chronic (with clinically asymptomatic initial phase) and develop from acute or subacute. There are two variants of chronic carditis: - With increased left ventricular hypertrophy and its small infarction (static, or dilated version) expressed cardiosclerosis, it is based on preemptive violation of myocardial contractile function of the left ventricle; - With normal or slightly reduced left ventricular cavity due to severe cardiac hypertrophy (hypertrophic variant), and a sharp decrease in left ventricular hypertrophy with or without the (restrictive version) it is based on primary diastolic (relaxation) of left ventricular function . Common clinical manifestations of chronic carditis should be considered relatively long asymptomatic dominated noncardiac symptoms: stunted physical development, recurrent pneumonia, hepatomegaly, seizures, loss of consciousness, vomiting, and other full-blown acute PRS often after SARS first identifies a Long-suffering heart. The most common symptoms in chronic dilated version cordites are lagging in body weight, tachypnea, weak apex beat, heart hump, dramatically expanded the boundaries of the heart, systolic murmur of mitral valve insufficiency, persistent arrhythmias, liver enlargement, more moderate. As a rule, in dilated version of chronic carditis detected discrepancy between cardiomegaly and satisfactory state of health, due to the development of compensatory mechanisms with prolonged illness. Heart failure is not a long time, then it is mainly left ventricular, and, finally, becomes total. Prolonged malosimptomno restrictive option for chronic carditis causes of late diagnosis, typical lag not only in body weight, but also growth, crimson cyanosis, apnea-type dyspnea, raised apical impulse. In two thirds of children at the top is defined by clapping or enhanced I tone combined with a sharp accent II tone of the pulmonary artery, sometimes muted tones. No noise or determined mezadiastolichesky on top or systolic in the fourth - fifth intercostal space on the left (relative tricuspid valve). The first symptom is shortness of breath, later joined and become the leading signs of right heart decompensation, up to severe ascites, the liver can serve at 7-8 cm from the edge of the arc. ECG also differ in different types of chronic carditis. Thus, for a variant of chronic dilatation carditis typical high or low voltage curve, rhythm and conduction disturbances in two thirds of patients, the symptoms of moderate predsekrdy overload and left ventricular hypertrophy. In restrictive version suffers chronic carditis atrioventricular and intraventricular conduction, there are branches of bundle branch block in various combinations, bradycardia, an overload of both ventricles and significant overload atrial subendocardial signs of hypoxia with a positive, negative or biphasic T wave relative safety of repolarization due to compensatory hypertrophy. Laboratory diagnosis In acute non-rheumatic cordites laboratory data contain little information. Blood tests - increased erythrocyte sedimentation rate, leukocytosis, increased ά2 and γ-globulin, C-reactive protein - shows the current viral infection. The most reliable confirmation of the diagnosis is the isolation of the virus from the blood, nasopharyngeal mucus, faeces. Differential diagnosis Before considering the question of differential diagnosis of syndromes discuss the main characteristic of the non-rheumatic carditis in children: • Chronological relationship with acute nasopharyngeal (often viral) infection • Shortening (less than 5 - 7 days) or no latency • Gradual development of the disease • Lack of arthritis and arthralgia expressed • Active and emotionally charged nature of cardiac complaints • Clear clinical and ECG signs of myocarditis • No valvulita • A rare discovery of pericarditis • The symptoms of asthenia, violation of thermoregulation in the debut of the disease • The dissociation of clinical and laboratory parameters • Slow dynamics under the influence of anti-inflammatory therapy In young children causes significant difficulties differential diagnosis of cordites with congenital heart defects. This is the case of incomplete forms of atrioventricular communication anomaly Ebstein corrected transposition of the great arteries. For atrioventricular communication is characterized by two different timbre and localization systolic murmur, signs of hypertrophy of the right ventricle and right atrium, incomplete blockade veivi right bundle branch block in the ECG, increased lung markings on the arterial bed in combination with satisfactory pulsation amplitude of left ventricular X-ray examination. In favor of Ebstein anomaly shows no association between the occurrence of the disease and transferred SARS, the prevalence in clinical signs of right heart failure in the absence of data on pulmonary hypertension, the increase of the right atrium, the ECG is no evidence of left ventricular hypertrophy and hypoxia. Corrected transposition differ on ECG deflection EOS left, no Q waves in the left chest leads in the presence of their rights. In young children with clinical fibroelastoza endomiokarda should be suspected abnormal discharge of the left coronary artery from the pulmonary artery (Bland-White syndrome-Garlyanda) on sistolodiastolicheskomu noise in the second intercostal space on the left, alone or in combination with mitral valve insufficiency, sudden bouts of anxiety, deep Q waves in leads I, aVL, V5, V6. At older ages, when mitral valve to differential diagnosis with rheumatic fever. Syndrome, characteristic of rheumatic heart disease • The chronological relationship with the A strep throat (pharyngitis, tonsillitis) • The latent period of 2 - 4 weeks • The young age of the patient • Mainly acute or subacute onset • Polyarthritis or acute disease in the opening arthralgia • «passive" nature of cardiac complaints • Availability valvulita combined with myocarditis or pericarditis • High mobility symptoms of carditis • Correlation of laboratory and clinical signs of disease activity Treatment of non-rheumatic cordites Treatment of non-rheumatic carditis has two phases: a stationary and outpatient or sanatorium. In acute and subacute carditis is recommended to limit the motor activity of the child in 2-4 weeks, food must be complete with plenty of vitamins, proteins, restriction of salt, the increased amount of potassium salts. Drinking schedule determined by the amount of urine, the child is given 200-300 ml of fluid less diuresis. Carditis etiological treatment is not developed. Antibiotic therapy be sick for 2-3 weeks, more for the prevention of complications in young children. Glucocorticoids are shown in diffuse process with HF, subacute onset of chronic process as the harbinger, cardio, mainly affecting the conduction system of the heart. Prednisolone is used inside a rate of 1-1.5 mg / kg during the month, followed by a gradual decrease of 1/3 - ¼ tablet every 3-4 days in children during the first 3 years of life and ½ tablets - the older. With little effect maintenance dose of prednisone - 0.5 mg / kg / day, given a few weeks. If, in spite of treatment, the process becomes subacute or chronic, it is recommended to prescribe aminohinolinovogo series (delagil, plakvinil) in combination with indomethacin or Voltaren 3 mg / kg. Salicylates rate of 0.05-0.06 mg / kg administered at 1-1.5 months. Simultaneously, treatment CLO. To improve myocardial contractility used cardiac glycosides, digoxin is preferred. Its loading dose should not exceed 0.03-0.05 mg / kg intramuscularly or inside. Intravenous administration of glycosides shown acute process with edema of the lung. Loading dose is introduced uniformly for 3 days every 8 hours under the supervision of the ECG. In the absence of the effect of saturation can be administered medication for 3 times for 1-2 days. This slow introduction of digoxin helps avoid intolerance (intoxication), which occurs in patients with carditis in the forced administration of the drug and its large doses. After administration of the loading dose a maintenance dose, her choice is different. If the patient is satisfactory saturation transfer digoxin with obvious effects (normalization of heart rate, shortness of breath decrease and reduction of the liver), the maintenance dose is 1/5 of the loading dose. The tendency to bradycardia dose should be reduced to 1/6 - 1/8, and at a constant tachycardia increased to ¼. Maintenance dose of digoxin is given for 2 doses in 10-12 hours in, with little effect of its type in / m, and further give the inside. Introduction glycosides should be careful when anuria and oliguria. In such cases, treatment is initiated with diuretics and after the restoration of diuresis added cardiac glycosides. Select effective dose of digoxin give long. Indication to remove the drug is the normalization of clinical and instrumental data. Important place in the treatment of patients with acute carditis and CH otvolitsya diuretics. Depending on the stage of heart failure can recommend the following plan of diuretics with carditis: Left ventricular failure stage I-IIA - veroshpiron, left ventricular stage IIA + right ventricular IIAB - inside and furosemide veroshpiron; total IIB-III - Lasix furosemide or parenterally in combination with veroshpiron, the ineffectiveness or add brinaldiks Uregei. Furosemide dose - 2-4 mg / kg, veroshpirona - 1-4 mg / kg, and brinaldiksa uregita 1-2 mg / kg. In order to increase diuresis in refractory heart failure can assign aminophylline (no more than 3 ml of 2.4% solution). Inpatient diuretics appointed day for 1-1.5 months, if left ventricular, and the more total CH kept within IIA-B stage, they continue to give and at home with a possible transition subsequently to receive 2-3 times per week Measures aimed at improving the metabolism in the myocardium include transfusion polarizing mixture (10% glucose 10-15 mg / kg, 1 IU of insulin injected at 3 g sugar, Panangin 1 ml / year of life, 2.5 ml of 0.25 % solution of novocaine) riboksin to ½ - 1 tablet 2 times a day for 1 month, followed by ½ - 1 tableke 2 times a day is 1 month, potassium orotate, Panangin, vitamin B12 with folic acid, calcium pantothenate. Anabolic steroids should enter no earlier than 1.5 - 2 months from the onset of the disease in order to prevent relapse. When atrioventricular block shows anti-inflammatory treatment and the means to eliminate myocardial dystrophy. Those at risk for the syndrome Stokes-Adams-Morgagni patients should be referred to the rhythm of 30-50 beats / min or less. Such patients in the hospital to conduct a sample izadrinom, alupent, which aims to clarify the possibility of increasing the heart rate. If, after the β-agonist (izadrina to ½ - 1 tablet under the tongue to complete resorption) comes increased heart rate of 10-15 beats / min, then the parents should have the money with them and use them at the slightest change in the child's condition (dizziness, weakness, syncope). In chronic carditis should not prescribe bed rest for a long time (an exacerbation of the process no more than 2-3 weeks). For purposes of prednisone must be treated individually, as a chronic immune inflammation often resistant to hormone therapy. In refractory heart failure positive effect is a combination of cardiac glycosides with low doses of prednisone (0.5 mg / kg) and furosemide. Courses delagila and Plaquenil with Voltaren or indomethacin can be repeated 2-3 times a year. Due to the fact that chronic carditis occur in older children, digoxin, prescribed rate of 0.02-0.04 mg / kg (the higher the weight, the lower the dose). This is usually ¼ - 1/3 tablets at 9-12 stages (3-4 days). Maintenance dose - ¼ -1 / 2 tablets, 2 times a day (1 tablet of 0.25 mg), depending on the severity of cardiac changes. The damaging effect of kinins released in the antigen-antibody reaction, cause chronic carditis add anginin (prodektin, paprmidin) contrycal at 0.25-0.75 g / day for 1.5-2 months. Showing drugs that enhance the metabolic processes in the myocardium, particularly anabolic hormones. Prophylaxis Primary prevention involves prevention of infection of the fetus during pregnancy, hardening of the child, treatment of acute and chronic focal infection, dispensary observation of children at risk for cardiovascular disease. Secondary prevention is aimed at preventing complications and recurrence of the process, achieved a clear focus of follow-up of patients. Forecast Depends on the version. Early congenital carditis occur, usually hard and often lead to death in the early years and months of life. In case of late congenital cardia with adequate and timely administration of therapy process may acquire chronic progression-free change of heart, perhaps, and recovery. Acute carditis option in 44.1% of children complete recovery, approximately 50% of patients with subacute or becomes chronic and often fatal if slowly, gradually evolving process, persistent arrhythmia Subacute carditis occurs less favorably with higher mortality, are resistant to therapy, and often becomes chronic variant In chronic carditis also often unfavorable weather, especially in the development of cardiosclerosis, progressive heart failure, pulmonary hypertension, persistent arrhythmias and conduction that can lead to the formation of arrhythmogenic cardiomyopathy. Clinical examination and rehabilitation of children with cordites The frequency of inspection specialist: after hospital discharge 1 per month - 3 months, 1 time per quarter - 6-9 months, then one every 6 months. pediatrician cardiorheumatology, ENT doctor, a dentist, in the treatment of drug aminohinolinovogo - optometrist 1 every 3-6 months, and the rest on the testimony of experts On examination, pay attention to: the frequency of intercurrent diseases, fatigue, temperature, signs of NC, heart size, volume, tones, noise, their dynamics, and the adequacy of response to physical stress. More research: Complete blood count - 1 time in 3 months, then 2 times a year A blood test for C-reactive protein, protein fraction, sialic acid - 2 times a year Total urine 2 times a year FEKG - 1 time in 3 months, then 1 every 6 months X-ray of the heart in 3 projections veloergometry Functional tests The main ways of healing: Remediation of foci of chronic infection. Treatment of intercurrent diseases. In the presence of chronic infection - prevention of seasonal bitsilino 1-3 years. Seasonal prophylaxis for 4 weeks, 2 times a year, non-steroidal drugs in half the dose in combination with kardiotroficheskimi means. In protracted and chronic carditis - 4 amirnohinlinovye preparations 1 -2 years. Duration of observation: Not less than 3 years, with the aggravation, protracted course of the process is not less than 5 years, the chronic course of transfer from 15 years under the supervision of the doctor's office teen Appendix № 2 Instructions for independent work in analyze and solve practical situation List analysis of the situation Stages Recommendations and advice 1. Familiarization with First check with case case Reading, Do not try to analyze the situation 2. Acquaintance with a Once again, read the information, select the paragraphs that seemed given situation important to you. Try to describe the situation. Determine that it is important and what is secondary. 3. Identification, The problem: formulation and Choice of tactics and determination of the need for hospitalization in patients justification of the key with carditis in a hovercraft. issues and subproblems 4. Diagnostic analysis When analyzing the situation, answer the following questions: of the situation What range of common and dangerous diseases are accompanied by carditis? What nosologies to make a differential diagnosis and determine the most likely causes of carditis. Which diagnostic methods must be applied, make a plan and justify the level survey hovercraft. What additional advice specialists needed for a final diagnosis? Determine the degree of need for follow-up (medical and non-medical treatment) 5. Selection and List all the possible ways of solving this problem in a given situation justification of the methods and means of addressing 6. Development and Put the diagnosis, decide the issue in a hovercraft. resolution of the problem situation Appendix № 4 Solution to case study teacher-keysologom Based on complaints: a boy and, 3 years, joined the SVP gravity. From history we know that 5 days ago, he suffered a respiratory viral infection. Received inadequate treatment. Soon she began to notice the boy periodically raises the temperature to subfebrile figures catarrhal symptoms were not. Go to a doctor, it was a blood test, which revealed no changes. Was diagnosed with the flu, asthenic syndrome. Oxacillin received within 7 days without effect, connection with which the patient was hospitalized. When you receive a serious condition, the boy whiny, irritable, tires easily. Complaints of shortness of breath and weakness. In the lungs, vesicular breathing, wheezing stagnant. Visual area of the heart is not changed. The border of the heart: the right - on the right edge of the sternum, the top - at the edge III, left - 1 cm medially from the mid - clavicular line. Heart sounds - moderately suppressed, tachycardia, structurally unstable auscultated systolic murmur at the apex, the weakening of one tone, rhythm golopa. Complete blood count: Hb - 90 g / l, Air - 3.5 h1012 / l Lake - 10.5 x 10 ^ 9, p / n - 2%, c 46%, E-2%, L48%, m -2%, ESR-20 mm / hour. C - Recto protein + +. General urine analysis: Shares - 1018, protein - as, leukocytes -2-3 in p / s, red blood cells - are absent. The diagnosis: Community: Acquired nonrheumatic cordites, acute flow. Collateral: Anemia of 1 degree. Differential diagnosis: CHD. Hospitalization in cardiology department.