Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may vary depending on the age of the child and their stage of palliation (surgical procedures to improve blood flow). Common complaints in infants may include:
Tachypnea (rapid breathing)
Feeding difficulties
Poor growth
Cyanosis (bluish discoloration of the skin) – concerning symptom
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at diagnosis of HLHS
Current stage of palliation (e.g., Norwood procedure, Glenn procedure, Fontan procedure)
Recent hospitalizations or emergency department visits (reason for visit)
Feeding history (breastfeeding, formula, feeding difficulties)
Growth parameters (weight, height, head circumference)
Symptoms suggestive of heart failure (tachypnea, fatigue, poor feeding)
Oxygen saturation (if on oxygen therapy)
既往史 (jì wàng shǐ) Past Medical History:
Prenatal history (maternal infections, medications)
Other congenital heart anomalies (if present)
Previous surgeries (cardiac catheterizations, palliation procedures)
History of complications (e.g., infections, arrhythmias)
家族史 (jiā zú shǐ) Family History:
Family history of congenital heart defects (uncommon)
查体 (chá tǐ) Physical Examination:
Vital signs (heart rate, oxygen saturation, blood pressure) – may be abnormal
General appearance (failure to thrive, signs of cyanosis)
Cardiovascular exam:
Heart murmur
Weak pulses (especially femoral pulses)
Hepatomegaly (enlarged liver) – in cases of heart failure
Respiratory exam (assessing for signs of respiratory distress)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – may show signs of chronic illness (anemia)
Electrolytes – to assess for electrolyte imbalances
Blood urea nitrogen (BUN) and creatinine – to assess kidney function
Liver function tests – may be abnormal in cases of heart failure
Brain natriuretic peptide (BNP) – may be elevated in heart failure
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray – may show signs of heart enlargement and lung congestion
Echocardiogram – essential for diagnosis and evaluation of anatomy and function
Cardiac catheterization (if needed) – to assess anatomy and hemodynamics
诊断 (zhěn duàn) Diagnosis:
Hypoplastic left heart syndrome (confirmed by echocardiogram)
Stage of HLHS (based on anatomic features)
Presence of any complications (e.g., heart failure, arrhythmias)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Stage-specific palliation surgeries (Norwood, Glenn, Fontan procedures) – depending on individual anatomy and clinical status
Medications:
Diuretics (to reduce fluid overload)
Inotropic support (to improve heart function)
Prophylactic antibiotics (to prevent infections)
Nutritional support (if needed)
Heart transplant (considered in some cases)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of HLHS, stage of palliation, and response to treatment.
Early diagnosis and staged surgeries are crucial for long-term survival. Long-term follow-up and management are essential for patients with HLHS.
健康指导 (jiàn kāng zhǐ dào) Patient Education (or Parental Education):
Importance of medication adherence (if prescribed)
Importance of regular follow-up appointments with cardiologists
Early recognition of signs of heart failure (increased respiratory rate, poor feeding, fatigue)
Importance of preventative measures (vaccinations, good hygiene) to avoid infections
Support groups and resources for families with children with HLHS
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the stage of palliation and the child’s clinical status.
Regular follow-up with a cardiologist is essential for monitoring heart function, growth, and potential complications.