Практикум по педиатрии. Practicum in Pediatrics. Учебное пособие для студентов 5-го курса

tent ductus arteriosus (clipping). Mechanical ventilation was complicated by pneumonia. At the age of 45 days, the child was extubated.

On examination: 2 months old. He spent 7 days at the department of pathology of newborn in severe condition. Perioral and periorbital cyanosis noticed. The child is oxygen dependent , SatO2 – 90-92% when applying humidified oxygen through oxygen tent (FiO2 above 30%). When weaning from oxygen, observed anxiety and SatO2 decreased to 84-85%. In breath involved supporting musculature. Auscultation: respiratory depression, bubbling wheezing of various sizes, scattered dry wheezing.

Chest X-ray: focal and infiltrative changes. Lung fields of enhanced transparency, there is an alternation of band-shaped seal with areas of lung tissue swelling. Vascular pattern is not observed in the periphery. Heart is in middle position. CTI 0.65 (norm. – to 0.6), contour is fuzzy.

Echocardiogram: CHM data is not received. Systolic pulmonary artery pressure 40 mm Hg.

Questions:

1.Put the diagnosis, justify it.

2.Which form of this disease can be in this case and why?

3.Which risk factors are present in this child?

4.Which criteria are used to assess the severity of the disease? Assess the severity of the disease in this patient.

5.The development of what complications should be suspected in this child? Justify.

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6.Which medications with proven efficacy are used for treatment of this disease?

7.Which damage of eye is typical of such pa-

tients?

Case 4

A girl was born from a 20-year-old woman, first pregnancy, during pregnancy recurrent acute pyelonephritis. At hospital, in the mother’s vaginal smears discovered streptococcus group B (Streptococcus agalactiae). Term birth at 39-40 weeks, long anhydrous period (26 hours). Birth weight 3,300 g, height 52 cm Apgar score 8/9. Impairment observed at the age of 18 hours, cyanosis of naso-labial triangle, tachypnea to 50 per minute, the appearance of regurgitation. In the lungs, breathing is weakened, absent in the lower divisions, crepitation wheezing. In the neurological status – moderate depression. Muffled heart sounds, tachycardia 167 per min. Abdomen is soft, available deep palpation, liver +3.5 cm, the spleen – at the edge costal arch. Decreased urine output – 0.3-0.5 ml/kg/h, urine is transparent.

CBC: Hb – 180 g/l, erythrocyte 5x1012/l, leukocytes – 35x109/l, stab – 21%, segment – 50%, lymphocytes – 20%, monocytes 9%.

Throat swab (preliminary results) – Gram-posi- tive cocci arranged in chains, 5х105.

At 20 hours of life in severe condition, cyanosis, on mechanical ventilation, retraction of the subcostal, respiratory rate 80 per minute, no breathing in the

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lungs, the analysis of acid-base balance: pH – 7,10, pCO2 – 69 mm Hg , pO2 – 40 mm Hg, BE – 7mmol/l.

Questions:

1.Put a preliminary diagnosis.

2.What are the diagnostic criteria for this dise-

ase?

3.Evaluate the results of laboratory tests. Which criteria indicate the presence of bacterial infection in this child according to the blood count?

4.Which other methods are helpful for clinical diagnosis?

5.What is presumably the etiology of the disease? Which is, most likely, the source of the pathogen?

6.Make a plan of treatment.

Case 5

A boy 5.5 months old, was sick with upper respiratory infection after contact with his older sister (four years old). The disease developed gradually with nasal breathing difficulties, cough. Temperature 37.2°C. On the third day of illness mother noticed frequent occurrence of breathing difficulties while feeding.

Examination – the state is moderate, health suffers a little, cheerful. Pale skin, perioral cyanosis during exercise. Respiration rate – 56 per min., HR – 148 per min. Nasal breathing is moderately difficult. The chest inflated; there is expiratory wheezing with

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retractions of intercostal spaces, aggravated by physical effort. Auscultation: dry wheezing. Liver +3 cm.

Anamnesis – child from second physiological pregnancy. On mixed feeding.

Family and personal history for atopic diseases is not burdened.

Radiographs of the chest – no focal infiltrative shadow, lung fields of enhanced transparency.

SatO2 – 96%.

Questions:

1.Which disease, most likely, does the patient

have?

2.Which agent most commonly causes this dis-

ease?

3.What is the mechanism of development of bronchial obstruction in this disease?

4.Evaluate the results of additional methods of examination.

5.Assess the severity of the disease. Does this child need to be hospitalized?

6.Which treatment should be assigned to the pa-

tient?

Case 6

A boy at the age of 2.5 months, hospitalized due to upper respiratory infection (URI). From anamnesis we know that the boy was from a woman with complicated gynecological (salpingo-oophoritis , erosion of the cervix), and somatic (gastritis, peptic ulcer) an-

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amnesis, from third pregnancy (1st – medical abortion, 2nd – term delivery ), occurred with a viral respiratory infections in the I trimester (receiving palliative care), toxicosis, the threat of interruption in the II trimester. Second independent delivery at 32 weeks, birth weight – 1,600 g, length – 38 cm, Apgar score 6/7 points. Condition at birth was severe due to severe respiratory distress syndrome, depression. From birth for 5 days was on mechanical ventilation. At the age of 20 days he started breathing freely without mechanical ventilation. He was discharged at the age of 1.5 months in good condition with a weight of 2,030 g. He got ill 1 day before admission to the hospital, loss of appetite, shortness of breath, dry cough and vomiting. At home he had a contact with his brother (7 years old) who had URI.

On admission, severe condition. T 37.5°C. Pale skin with marble pattern, perioral cyanosis. Nasal breathing is difficult, mucous discharge. Frequent unproductive cough. Retraction of the intercostal spaces in breathing, respiratory rate up to 76 per minute. In lung percussion – sound box. Auscultation in the lungs – harsh breathing, exhale extended, on both sides dry and wet wheezing. Heart sounds mildly muffled, rhythmic. HR 150 per minute. Abdomen is soft, liver +4.5 cm.

On radiographs of the chest, swelling of the lung tissue, focal-infiltrative changes are not detected. Segmental atelectasis at S2 to the right, pulmonary pattern is strengthened, the shadow of the heart is not enlarged, visible small shadow of thymus gland.

Express-test for RSV – positive.

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Complete blood count: Hb – 141 g/l, RBC – 5.13 x1012/l, WBC – 11.62x109/l, stab – 2%, segment – 35%, lymphocytes – 51%, monocytes – 12%, ESR – 2 mm/h.

Sat O2 – 87%.

Questions:

1.Diagnose.

2.Rate the severity of the disease

3.What risk factors for the severe flow of this infection do you know?

4.What are the signs of respiratory failure detected in this child? Which investigation determines the degree of respiratory failure?

5.Does this child need oxygen therapy, and

why?

6.Which kind of therapy can be assigned to the child? Which medicines have proven efficiency in this disease?

7.How to carry out prevention of the infection in children who are in groups of risk?

Case 7

A girl, 3 years 10 months, examined by pediatrician on the third day of the disease. Mother of the child noticed lethargy, subfebrile temperature, runny nose, infrequent cough. Pediatrician diagnosed upper respiratory viral infection, assigned symptomatic treatment with a positive effect. However, on the 5th day of the disease the child's temperature

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rose again to 38.6°C, cough increased. Mother called the doctor again.

When re-examination – capricious. Skin is pale, clean. Wet unproductive cough. RR 48 per minute. No dyspnea. Auscultation-harsh breathing, weakened in the interscapular region on the right, wet bubble wheezing. Heart sounds loud, rhythmic. Heart rate: 100 per minute. The abdomen is soft and painless. Liver +1.0 cm. The spleen is not palpable. Stool and urine output are normal. The girl was hospitalized.

Complete blood count: hemoglobin – 124 g/l, erythrocytes 4.2x1012/l, platelets 223x109/l, leukocytes – 15.3x109/l, Stab neutrophil – 3%, segment neutrophil – 62%, lymphocytes – 34%, monocytes 1%, ESR – 16 mm/h.

X-rays of the chest: reduced pneumatization by inflammatory infiltration in the projection of the right upper lobe with distinct concave contours. Pulmonary drawing enriched, deformed on the right. The median shadow heart is not displaced. The sinuses are free.

Questions:

1.Put a diagnosis according to the classification.

2.What is the most important agent in the development of diseases in normal conditions (at home) in this age?

3.What is the treatment of this patient?

4.Does this patient need oxygen? What additional research is necessary for determination of the indications for oxygen therapy?

5.What factors determine the rational choice of antibiotic?

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6. Define time and criteria for evaluation of effectiveness of antibiotic therapy.

Case 8

A boy 10 months old, hospitalized with a suspicion of pneumonia. From anamnesis we know that the child was from the 2nd pregnancy (1st med. Abortion), birth weight 3,250 g, height 51 cm, Apgar score 4/6. 2 weeks ago for the first time suffered upper respiratory infection, acute purulent otitis media, received amoxicillin. Three days before admission to the hospital temperature increases to febrile figures, cough, difficulty in nasal breathing.

In the hospital – T 38,7oC. Skin is pale with marble pattern, hyperthermia. Perioral cyanosis. Frequent unproductive cough. Retraction of the lower parts of the chest when breathing, swelling of the nose, wheezing breathing, respiratory rate 56 per minute. In the lungs – breathing is harsh, weakened in the lower right part, there are wet wheezing, palpation – trembling sound. Heart tones are rhythmic. HR 128 per minute. Liver +1.5 cm. Urine output is adequate.

CBC: RBC 4.76x1012/l, platelets – 319 l – 18.4x109/l, Stab neutrophil – 2%, segment neutrophil – 69%, lymphocytes – 22%, monocytes – 7%; ESR – 25 mm/h.

Biochemical test of blood: CRP – 12 g/l (normal 6 g/l).

Chest X-ray – pneumatization reduced at right lung fields in the projection of the middle lobe, repeating its outlines, by inflammatory infiltration.

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Right contour of heart on the background of infiltration is not clearly observed. The sinuses are free.

Questions:

1.Put a diagnosis according to the classification.

2.Assess the severity of the disease.

3.What is the etiology of this disease?

4.Which risk factors, unfavorable for the course of pneumonia, can be identified in this child? What other risk factors do you know?

5.Does this child need oxygen therapy? Why?

6.Evaluate the results of the general and biochemical blood tests.

7.Assign treatment, explain the choice of antibi-

otic.

Case 9

A girl, 7 months old, was born in term from second physiological pregnancy. Apgar score 8/9 points. Sudden onset, with difficulty in nasal breathing, profuse mucus-purulent discharge from the nose, temperature 37.4°C. At home she had contact with ill upper respiratory virus infection (URVI) older brother. Pediatrician diagnosed URVI, assigned symptomatic treatment. After 2 days the condition worsened; temperature rose to 38.6°C, the girl become restless, refused the breast, vomiting, dyspnea. She was hospitalized.

On examination – severe condition. Skin is pale with a grayish shade, central cyanosis. Refuses from

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feeding. Respiratory rate – 68 per minute, there is swelling of the nose, compliant places retraction of the chest while breathing, shaking her head during breathing. The chest inflated. On the right – shortening of percussion, respiratory depression, there is wet wheezing, percussion box sound, harsh breathing on auscultation. Muffled heart sounds, pulse 160 per minute. Distended abdomen, liver +3 cm, spleen +1 cm.

Complete blood count: Hb – 174 g/l, RBC – 5.2x1012/l, WBC – 20.1x109/l, Stab neutrophil – 10%, segment neutrophil – 61%, eosinophils – 1%, lymphocytes – 19%, M – 9%, ESR 34 mm/hour.

Oxygen saturation – 88%.

Chest radiograph: the projection of the upper and middle lobe of the right lung – homogeneous inflammatory infiltration of lung tissue, the right borderline of the heart is not observed.

Questions:

1.Put diagnosis according to the classification.

2.List the symptoms of respiratory failure in children. Estimate the severity of this disease.

3.Which pathogenic variants of respiratory failure do you know? Which of them play the leading role in pneumonia?

4.Suppose the etiology of this disease.

5.Assign treatment.

Case 10

A girl of 2 months of age. Sudden rise in body temperature to 39.2°C, there was dry cough, runny

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