(A) The collection of past medical history is not careful
With the introduction of a number of advanced instruments one after another, the diagnosis level of heart disease has been improved accordingly, but clinicians cannot rely only on instruments and neglect the questioning of medical history. Lack of detailed history taking and analysis by doctors makes it easy to consider only common diseases and ignore rare diseases or some other coexisting diseases. Because the careful collection of medical history can provide a lot of valuable information for diagnosis, broaden the physician’s diagnostic thinking and reduce unnecessary misdiagnosis. For example, a middle-aged patient visited the hospital because of “chest tightness and shortness of breath after activity”, and the physician found a diastolic murmur in the apical region on auscultation, so it was easy to consider rheumatic heart disease, but careful history taking revealed that the patient had never had a history of rheumatic activity and had often caught a cold when he was young, and when he visited the hospital, the physician informed him that he had a heart murmur after auscultation, which made people think of This makes one think of the possibility of congenital heart disease rather than rheumatic heart disease. The above case reminds us that we should develop the good habit of taking detailed medical history in clinical work, especially the medical history which is meaningful for diagnosis and differential diagnosis, so that physicians can take less detours in diagnosis.
(2) Diagnostic thinking limitations, lack of comprehensive analysis of clinical symptoms and signs
A physician’s diagnostic thinking can reflect his diagnostic level, because many diseases have the same or similar clinical symptoms and signs, when a patient complains of a clinical symptom or a physician finds a sign on physical examination, should consider a variety of related diseases, and a comprehensive analysis of clinical symptoms, signs, and then try to exclude some diseases, so as to obtain the most likely diagnosis.
The limitations of diagnostic thinking are manifested in the following aspects.
(1) Only common diseases are considered. For example, if an adult presents with “recurrent cough and hemoptysis”, the physician can easily make the diagnosis of “bronchiectasis” without careful history and physical examination, but if on auscultation a systolic murmur is found between the 3rd and 4th ribs at the left edge of the sternum, and P2 is hyperactive, and the history is taken, the diagnosis of “bronchiectasis” can be made. If the cough and hemoptysis do not last long, and there is no recurrent fever or pus coughing in the past, the possibility of hemoptysis due to precardiac disease with pulmonary hypertension will be considered.
(2) Influenced by the initial clinical diagnosis or induced by their own subjective assumptions. Physicians are often deeply influenced by the initial diagnosis, often with a tendency to look for supporting bases, when certain clinical information obtained and the initial diagnosis, will easily maintain the original diagnosis, so that some of the less reliable, specious findings as the basis for diagnosis, resulting in misdiagnosis. For example, if the initial clinical diagnosis is pulmonary heart disease, physicians will tend to look for diagnoses that support pulmonary heart disease, such as recurrent cough and sputum, reduced mobility; electrocardiogram shows: pulmonary P wave, right ventricular hypertrophy; cardiac X-ray; prominent pulmonary artery segment, enlarged right ventricle, etc., but if the medical history reveals no previous pulmonary disease, careful auscultation reveals murmurs in the heart, chest X-ray shows pulmonary congestion, not emphysema-like changes, it will be considered that pulmonary heart disease is unlikely, but may be precordial disease with pulmonary hypertension.
③ Overconfidence in their own judgment. The physician is not solid in the basics of physical examination and is overconfident in what he/she finds and makes conclusions easily. If a child with dilated cardiomyopathy comes to the clinic with shortness of breath, feeding difficulties, limited activity or cyanosis, and a heart murmur is found on physical examination, and an enlarged heart is found on x-ray and electrocardiogram, the physician will confidently diagnose congenital heart disease. But in fact the murmur heard is not as coarse as the murmur of common congenital heart disease such as ventricular septal defect and arteriovenous insufficiency, etc. The loudest part of the murmur is between 2 and 4 ribs at the left edge of the sternum, while the main reason for murmur in dilated cardiomyopathy is the relative insufficiency of mitral valve closure due to heart enlargement, so the murmur is loudest at the apical part and relatively soft in nature.
④ No coexisting disease was considered. Once a disease is diagnosed clinically, it is often not looked for other abnormalities, or attention is focused on the primary lesion and ignores secondary lesions, or even finds minor problems and misses major ones. For example, when endocardial elastosis coexists with various precardial diseases, the loud murmur becomes a more obvious sign, and then the diagnosis of endocardial elastosis is often overlooked by considering only precardial diseases. At this time, attention should be paid to whether the clinical symptoms and the degree of heart failure are parallel to the cardiac abnormality. If the cardiac abnormality is mild and the hemodynamic changes are not sufficient to cause severe heart failure, the possibility of cardiac elastosis should be thought of.
⑤ Over-reliance on the results of medical-technical examinations. Clinicians should not only pay attention to medical examination, but also should not take medical examination as the only diagnostic basis, and must combine with clinical symptoms and signs, because medical examination also has a certain rate of misdiagnosis. In many clinical cases, right ventricular hypertrophy is found during cardiac ultrasound examination in precordial disease with pulmonary hypertension, and the shunt bundle is not detected due to pulmonary hypertension, which is often diagnosed as hypertrophic cardiomyopathy. However, the age of onset, location, nature and direction of conduction of the murmur can help differentiate the two. 55% of hypertrophic cardiomyopathies have a family history, and the onset in young children is mostly manifested by recurrent congestive heart failure, and the murmur is mostly located in the apical part of the heart and between the third and fourth ribs of the sternal rib margin, and is a jet murmur that does not conduct. The murmur of precordial disease with pulmonary hypertension is mostly found within 3 years of age, with obvious conduction to all parts of the body and hyperactive P2.
(6) Neglect the process of disease diagnosis and treatment. After the initial treatment of a disease, if the effect is not good, other diseases should be considered as possible. For example, a young woman with a history of rheumatic fever, systolic murmur on auscultation and atrioventricular block on electrocardiogram, first thought of rheumatic myocarditis, but after a long period of anti-rheumatic treatment, the condition did not improve, repeatedly examined the blood sedimentation is not fast, ASO (-), not in line with the changes of rheumatic myocarditis, coupled with complete right bundle branch conduction block, easy to catch a cold, and considered the possibility of viral myocarditis, after The effect of myocardial nutrient drugs and other treatments was not obvious, and the myocardial enzyme spectrum has been normal, careful study of the electrocardiogram is: V1 was rsR’, the electrical axis left deviation with atrioventricular block, X-ray pulmonary artery segment protrusion, pulmonary hilar vascular shadow thickening, pulmonary field congestion, aortic shadow narrowing, right ventricular enlargement, at this time should consider the diagnosis of atrial septal defect.
(C) Lack of correct pathological anatomical concept or sufficient attention to congenital heart disease
There are many kinds of congenital heart diseases, and various preconditioning diseases have their own pathological anatomical basis. Primary hospitals and physicians who have less contact with preconditioning diseases have insufficient knowledge of this disease and are not vigilant, believing that preconditioning diseases are only seen in infants or children, and never considering the possibility of preconditioning diseases for the heart murmurs found in adults and middle-aged and elderly people on physical examination. In fact, many clinical misdiagnosis is due to the failure to think of possible diagnoses, if each possible diagnosis is thought of, will find ways to exclude or confirm, so as to minimize the misdiagnosis.
(D) Over-reliance on cardiac ultrasonography and neglect of other auxiliary findings
1. Technical constraints of ultrasound diagnosis
At present, echocardiography has become an indispensable tool in the diagnosis of cardiovascular diseases, and is one of the most rapidly developing fields in the diagnosis of heart disease today, and the comprehensive application of ultrasound technology has been able to diagnose cardiovascular diseases in terms of anatomy, function, hemodynamics, myocardial tissue characteristics, etc. However, influenced by the ultrasound conditions around the world, the technical level of ultrasonographers and the different understanding of precordial diseases, sometimes doctors tend to CDFI and PDE are important diagnostic tools for preoperative cardiac surgery, with a high diagnostic compliance rate, but there are still misdiagnoses that cannot be ignored. The diagnosis was later confirmed by cardiac surgery, cardiovascular angiography or right heart catheterization.
In addition to a solid theoretical foundation in ultrasound, operational techniques and extensive clinical knowledge, it is crucial for ultrasonographers to examine carefully and responsibly. Some ultrasound physicians are not skilled in examination techniques, resulting in large deviations in the angle of the acoustic beam.
2, do not pay attention to other auxiliary examinations
Although echocardiography has become the first choice of noninvasive examination for the diagnosis of cardiovascular diseases, due to the outdated instrumentation and poor resolution of some hospitals, the echographic artifacts are mistaken for disease signs; the limitations of lung gas and obesity affect the examination results; the lesions of the heart itself (anatomical variants, transposition, complex malformations, etc.) are sometimes difficult to be diagnosed by ultrasound alone; the limitations of transthoracic ultrasound technology itself cause a certain The limitations of transthoracic ultrasound technology itself cause a certain number of misdiagnoses.
In fact, clinicians tend to trust the results of cardiac ultrasound examinations, so they usually do not carefully analyze other symptoms, signs, and ancillary examinations, which can easily lead to misdiagnosis if the ultrasound examination is wrong or the diagnosis is incomplete. For example, in patients with coronary arteriovenous fistula, the positive rate by cardiac ultrasound Doppler examination is low, and if no abnormal coronary flow shunt bundle is found, it may be misdiagnosed as other diseases, but careful history taking patients have clinical manifestations of different degrees of myocardial ischemia, continuous heart murmur can be found on auscultation, hemodynamic is left-to-right shunt change, chest X-ray and electrocardiogram can have atrial and ventricular hypertrophy, and then combined with If the patient is suspected of the disease, early coronary angiography is recommended to make a clear diagnosis and to show the morphology of the affected coronary artery, its course, the location of the fistula and the fistula entry site, which can help in the choice of treatment plan.