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

nose. Received amoxicillin, symptomatic treatment without any effect. On the third day of the disease the condition worsened, lethargy, refused to eat, dyspnea, increased cough, T 39°C. Was hospitalized.

From anamnesis we know that the girl was on the breastfeeding, the mother has recently been diagnosed with mastitis, staphilodermia.

In hospital, severe condition. Loss of appetite, refuses to eat. Severe shortness of breath with involvement of accessory muscles of the chest. Skin of greyish colour with "marble" pattern, perioral cyanosis, acrocyanosis, elements of staphilodermia. Respiratory rate – 64 per minute. Auscultation: breathing in the upper right lung is weak with bubbling wheezing, crepitation, deadened sound. Muffled heart sounds, tachycardia up to 160 per minute. Distended abdomen, bloating, rumbling palpation along the intestine. Liver +4 cm, spleen +2 cm. Stool with green mixture and mucus.

Complete blood count: Hb – 104 g/l, RBC – 3.8x1012/l, WBC – 22.1x109/l, myeloma – 4%, Stab neutrophil – 10%, segment neutrophil – 69%, lymph. – 15%, monocytes – 2%, ESR 44 mm/hour.

Sat O2 – 88%.

Sputum culture – numerous gram-positive cocci. Chest radiograph: the projection of the upper lobe of the right lung in the background of inflammatory infiltration revealed a cavity with a horizontal fluid level, the response of the pleura, increased transparency of lung fields on the left. The sinuses

are free.

101

Questions:

1.Put diagnosis according to the classification.

2.What are the complications of this disease?

3.Suppose the etiology of the disease, specify the characteristics of this form of the disease.

4.The consultation of which specialists does this child need?

5.Assign treatment.

6.Justify antibiotics treatment.

Diagnostic keys

1.Respiratory distress syndrome.

2.Community-acquired mycoplasmal pneumonia.

3.Bronchopulmonary dysplasia. Classical form,

severe.

4.Congenital pneumonia caused by streptococcus group B.

5.Acute bronchiolitis.

6.RSV-infection. Acute bronchiolitis.

7.Community-acquired right-sided segmental pneumonia.

8.Community-acquired pneumonia. Severe.

9.Community-acquired pneumonia. Very severe.

10.Community-acquired purulent necrotizing pneumonia, right-sided, abscess of the right upper lobe (bacterial destruction of the lungs).

102

Questions:

1.What are the risk factors for this disease to form in this very patient?

2.Which pathological symptoms from gastrointestinal tract can you reveal in this patient while taking anamnesis and manual check?

3.What diagnosis can be supposed?

4.What diagnostic methods and in which order will you prescribe to this patient to verify the final diagnosis?

5.What is your differential diagnosis?

Case 2

11-year-old boy complains of periodical acute epigastric pains, especially when he is hungry or after hot and spicy food. The pains have had place for the last 6-7 months. Frequently episodes of pains were followed by vomiting. He also has heartburn and constipations. He takes food irregularly and dry. Had dysentery at the age of 3, epidemic parotitis at 8, several episodes of acute tonsillitis, at the age of 10,5 – appendectomia. In family anamnesis – father has peptic ulcer disease .

At the medical examination the child looks normotrophic. Skin is a bit dry and pale. Belly is soft, but at palpation significant muscular defense appears in a lower epigastric and Shoffar zones.

At endoscopia at an empty stomach there is a significant amount of liquid in stomach, with mixture of bile. Mucus of duodenum is irritated and red,

104

there are multiple erosions 3х2 мм, partially covered with fibrin. Benzidin test is positive.

Questions:

1.What is your preliminary diagnosis?

2.What are the risk factors here?

3.What is your diagnostic and treatment plan for this patient?

4.What investigations should be done in a hos-

pital?

Case 3

11-year-old boy complains of periodical acute epigastric pains, quite often after hot and spicy food during the last 6-7 months. He often has vomiting after food. He also has heartburn and constipations. His meals are irregular and often dry. He had Dysentery at 3, epidemic parotitis at 8 years, several episodes of acute tonsillitis, appendectomy at the age of 10.5. In the family anamnesis – his father was diagnosed with peptic ulcer.

At the medical checkup the child looks normotrophic. Skin is bit dry and pale. His belly is soft, but at palpation a significant muscular defense appears in a lower epigastrium and Shoffar zone.

At endoscopy of an empty stomach a significant amount of liquid mixed with bile was found. Mucus of duodenum is irritated and brightly red, there are multiple erosions 3х2 mm, partially with fibrin plaques. Benzidin test is positive.

105

At the hospital ammonium test for Helicobacter pylori was positive.

Basal pH-level was 1,5, stimulated – 1,1.

Questions:

1.Give your comments on endoscopy results.

2.Formulate the diagnosis.

3.What is the connection between Helicobacter pylori infection and the described disease?

4.What regime and diet will you prescribe?

5.Prescribe treatment.

Case 4

Mother of a 8-year-old girl came to a doctor. During the last 6 months her daughter has suffered from stomach ache after food. She feels satiety of stomach just in the beginning of meal, also has air or sower belching.

From her anamnesis: the girl studies in 2-nd class, she often refuses from breakfast, has school meals irregularly and is allergic to citruses and chocolate.

Girl looks hypotrophic, pale. She has chronic tonsillitis and is a carrier. Her tongue is covered with white bloom. Belly is soft, but painful at palpation, and there is a splash-sound at palpation in epigastrium. Rumbling sound during intestine palpation. Stool is unstable.

At esophagogastroduodenoscopy a significant amount of liquid in an empty stomach, mucus of

106

stomach is irritated with diapedesis hemorrahages. Folds are oedimatous , cobblestone symptoms present .

At fraction-zonding procedure: basal acidity production is 2,5 me/h, followed, stimulated – 12,5 me/h.

Questions:

1. What are the reasons for the chronic GIT dise-

ase?

2.What additional diagnostic methods should be

used?

3.Give your comments on instrumental procedures performed.

4.Form the diagnosis and prescribe treatment.

5.Comment on the results of fractionzonding.

Case 5

Mother of a 13-year-old boy came to a doctor. Her son goes to a sport club 3 days a week after

school. He has meals irregularly, often has snack with sandwiches instead of complete lunch. His father had peptic ulcer in anamnesis.

For a year the boy has sometimes complained of stomach aches, but did not receive any treatment. In the last month, pains have become more frequent and regular. Now pains usually appear 2-3 hours after food, they are quite strong and attack-like. Food intake releases pains for a short time, sometimes he wakes up at night because of pains. Periodically has heartburn.

107

At the medical check the boy is pale, tongue is covered with white bloom, and belly is bloated. Mendel symptom is positive, splash sound at palpation in epigastrium. Stomach palpation is painful in pyloroduodenal area and there is a muscular defense there. Stool has tendency to constipations.

At esophagogastroduodenoscopy: there is a significant amount of liquid in the stomach. Mucus of duodenum is irritated, easily traumatised , partially covered with fibrin. At the anterior wall of duodenal bulb there is a round-shape mucus defect of 8 mm in diameter, surrounded with high inflammatory bolster. The boarders are restricted, bottom is covered with grey fibrin.

Questions:

1.What factors were predisposing for this disease development?

2.Characterize pain syndrome. For what kind of disease is it typical?

3.Formulate the diagnosis.

4.What is your treatment plan?

5.What is your investigation plan?

6.What complications of this disease do you

know?

Case 6

Mother of a 13-year boy came to a doctor.

From his anamnesis: the boy goes to sport club 3 days a week after school. He has meals irregularly,

108

often has sandwiches instead of complete lunch. His father has a history of peptic ulcer.

For a year the boy has sometimes complained of stomach aches, but he did not receive any treatment. In the last month, pains have become more frequent and regular. Now pains usually appear 2-3 hours after food, they are quite strong and attack-like. Food intake releases pains for a short time, sometimes he wakes up at night because of pain. Periodically has heartburn.

At the medical checkup boy looks pale, tongue is covered, Mendel symptom is positive, splash sound at palpation in epigastrium. Stomach palpation is painful in pyloro-duodenal area and there is a muscular defense there. Stool has tendency for constipation.

At esophagogastroduodenoscopy: there is a significant amount of liquid in stomach. Mucus of duodenum is irritated, easily traumatised, partially covered with fibrine. At the anterior wall of duodenal bulb there is a round-shape mucus defect 8 cm in diameter, surrounded with inflammatory bolster. Borders are restricted, bottom is covered with grey fibrin.

The boy was hospitalised to the gastroenterology department, where some additional investigations were done. Helicobacter test was positive, рН-level measuring showed increased acidity production of stomach, benzidine probe was negative. Doctors formulated the diagnosis: Peptic ulcer disease of duodenum bulb. Acute phase of 1-st stage – “fresh ulcer”. He had a 7-week treatment course. At present the boy periodically feels hunger and discomfort in epigastrium at night. At the medical check there is transitional pain at palpation in pyloro-duodenal and

109

paraumbilical area. At endoscopic investigation of duodenum: picture of duodenitis, but mucus defect is replaced by linear scar.

Questions:

1.Describe the child’s condition.

2.Describe endoscopic picture.

3.Give discharge recommendations.

4.Give principles for the patient’s future obser-

vation.

5.Anti-reccurent treatment.

Case 7

Mother of a 6-year-old boy came to a pediatrician. Anamnesis: the child is from the second pregnancy with threat of termination of term labor. Birth weight was 3,200 g, screamed after mucus suction. After birth he was under neurologist’s supervision because of perinatal encephalopathy. Previous diseases: acute respiratory infections, Chicken pox.

From the early age the boy has suffered from regurgitations and belching, later heartburn appeared. During the last six months the symptoms have become worse and more frequent, sower belching and feeling of lump in a throat appeared. At night cough assaults appear, in the morning voice is hoarse. Recently he started complaining of epigastrial pains after food, at a physical load and in horizontal position.

At the medical check: the boy has excessive weight, skin is clean. He has symptoms of pharyngitis

110