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

and adenoids of a 2-nd grade. The tongue is covered with white bloom. Heart and lungs are sound. Abdomen is bloated, painless at palpation; liver is near the rib margin. Stool and diuresis are normal.

At EGDS mucus of the abdominal part of esophagus is irritated, there is a short-time prolapse of esophagus wall and tonus dysfunction of lower esophagus sphincter. No pathology of stomach and duodenum is revealed.

Questions:

1.What is the final diagnosis?

2.What investigations can prove the diagnosis?

3.What is the mechanism of night cough as-

saults?

4.What treatment should be prescribed?

5.What should be the treatment and observation course?

Case 8

Mother of a 6-year-old girl came to a pediatrician. Anamnesis: the girl is from the 1-st pregnancy, with threat of termination. There was a term labor. Screamed after mucus suction. Was under neurologist’s observation because of perinatal encephalopathy. Physically and neurologically she developed according to her age. Previous diseases: acute respiratory infections up to 4-5 times a year, at 3,5 years – intestinal infection.

111

For the last 4 months the girl has complained of frequent abdominal pains, which sometimes appear after fat food or active games. Appetite is low, she prefers baked and fried food. Likes ice-cream as well.

At the medical check the girl looks normotrophic. She has dystrophic changes in teeth enamel and adenoids of the 2-nd grade. The tongue is covered with white bloom. Her belly is soft, but painful at palpation in gull bladder projection. Ortner symptom is positive. Liver is out the rib margin up to 2 cm. Stool is unstable.

At ultrasound investigation of abdominal cavity gull bladder is a bit enlarged and with sediment at bottom. Walls are thin. In 30 minutes after cholagogic breakfast gull bladder is contracted at 35%.

Questions:

1.Give your assessment to the patient complaints and clinical data.

2.Comment on instrumental investigations re-

sults.

3.Formulate the diagnosis.

4.What additional investigations should be done?

5.What regime and diet should be prescribed?

6.What is the treatment?

Case 9

A 10-year-old boy was transported to the admission department with suspected acute appendicitis.

112

The surgical diagnosis was excluded, and the boy was hospitalized to the therapeutic department. In the process of collecting anamnesis it turned out that such attacks of acute stomach aches with vomiting have happened already twice.

At the medical check the boy looks hypotrophic, skin is dry, unevenly pigmentated. The tongue is coated. Belly is soft, there is a mild muscular defense in a right subcostal area. Liver edge is palpated up to 1,5 cm below costal margin. Ortner, Merphi and Ker symptoms are positive. There has been no stool in the last two days.

In several days ultrasound investigation with cholagogic breakfast was done.

Gull bladder is placed typically, but with deep strangulation in the bottom. After cholagogic breakfast bladder contracted at 75%, but strangulation persists.

Questions:

1.Give your assessment of the patient’s complaints and anamnesis.

2.What is the differential diagnosis?

3.Give comments on the clinical symptoms.

4.Give comments on the instrumental data ob-

tained.

5.Formulate the diagnosis.

6.Give recommendations for regime and diet.

7.Prescribe the treatment.

113

Case 10

12-year-old boy was hospitalized with complains of acute abdominal pains with irradiation to the right scapula and lumbar area, also nausea and multiple vomiting. Pain appeared 15 min after breakfast (sandwich with butter, egg, coffee).

From his anamnesis: 6 months ago the boy had the same episode of pains, released by No-spa tablet. Heredity: mother has bile stone disease (cholecystectomy performed), father has chronic gastroduodenitis, grandmother-chronic cholelithiasis.

At the medical examination: the child is hypotrophic, skin is pale, scleras are subicterus. Mucus membranes are pink. Lungs and heart are sound. Belly is round and soft, but there is a muscular defense in right subcostal area. Liver edge is +2 cm from the rib edge, soft and mildly painful. Merfi, Myssi, Ortner symptoms are positive. No symptoms of peritoneum irritation.

Clinical investigation performed: General blood test: hemoglobin – 125 g/l, erythrocytes – 4,3х1012/l, color index – 0,87, leucocytes – 12х109/l, thrombocytes – х109/l, neutrophils: band forms – 8%, segmented forms – 65%, lymphocytes – 22%, eosinofiles – 2%, monocytes – 3%, sedimentation rate – 18 mm/h.

General urine check: color is light-yellow, transparency is full, рН – 6,5, density – 1020, protein – abs, glucose – abs, leukocytes – 1-2, erythrocytes – abs.

Biochemistry of blood: general protein – 6 g/l, albumins – 57%, α1-globulins – 4%, α2-globulins –

114

11%, β-globulins – 13%, γ-globulins – 19%, AlAt – 60 u/l (norm is up 40 u/l), AsAt – 70 u/л (norm is up to 40 u/л), alkaline phosphatase – 180 u/l (norm is up to 140 u/l), amylase – 90 u/l (norm up to 120 u/l), bilirubin – 32 mm/l, direct – 20 mm/l.

Ultrasound investigation of abdominal cavity: liver – not enlarged, borders are smooth, parenchyma is homogeneous, echo is strengthened, vascular net is not dilated, portal vein is normal; gull bladder has usual shape, thickness of walls – up to 4 mm (norm is up to 2 mm), in the neck area – hyperechogenic structure (6х7 мм) with acoustic shadow. Pancreas: parenchyma is unhomogenic, head – 19 mm (norm is up to 18 mm), corpus – 15 mm (norm is 15 mm), tale – 20 mm (norm is up to 18 mm).

Questions:

1.Formulate the final diagnosis and prove it.

2.What is the differential diagnosis?

3.What are modern theories of aetiology and pathogenesis of this disease?

4.What are the main treatment principles?

5.What diet should be recommended?

Case 11

14-year-old boy with complains of cramping abdominal pain in the navel area, bloating, stool delay of 2-3 days, headaches and dizziness and "sheep dung stools", after bowel movement, relief. Abdominal pains are usually not associated with food intake, but

115

they appeared as a result of worrying, for example, before the exams at school. The boy is emotionally labile.

Examination: satisfactory condition. Skin and visible mucous are clean. White dermographism. The tongue is covered with white bloom. Lung breathing is without wheezing. Cardiac tones are rhythmic. BP 115/80 mm Hg.

The abdomen was soft, moderately painful in the right upper quadrant. The liver and spleen were not palpable. Fragmented stool of the type of "sheep feces", urine output normal.

CBC, urine test, biochemical blood test – without pathologies

Coprogram – increased amount of mucus. Esophagogastroduodenoscopy – no abnormalities. Ultrasound – no pathological changes. Consultation of neurologist – cerebra-asthenic

syndrome, headaches of migraine-type.

Questions:

1.Put and justify diagnosis, list the criteria for this disease.

2.Differential diagnosis.

3.Etiology and pathogenesis of this disease.

4.Principles of treatment.

5.Assign and justify treatment for this patient.

Diagnostic keys

1. Gastritis, duodenitis.

116

2.Erosive bulboduodenit complicated by bleeding.

3.Chronic duodenitis, erosive.

4.Chronic hypertrophic gastritis with increased secretion in the acute stage.

5.12 duodenal ulcer, acute phase, stage 1.

6.Ulcer healing scar, stage 3.

7.Gastritis, gastroduodenitis peptic ulcer disease, gastroesophageal reflux disease.

8.Gastroesophageal reflux disease, esophagitis 1st degree.

9.Biliary dyskinesia, hypotonic type.

10.Biliary dyskinesia, hypertension type. Anomaly of gallbladder.

11.Irritable bowel syndrome.

117

Questions:

1.What is a preliminary diagnosis? What diseases can be suspected?

2.Estimate the size of the heart percussion, RR,

HR.

3.What clinical signs point to the heart disease?

4.What signs indicate the nature of fetal cardiac disease?

5.List the signs of circulatory (cardiac) failure; estimate the stage of cardiac failure.

6.Explain investigation plan for differential dia-

gnosis.

7.What treatment should be started immedia-

tely?

Case 2

The baby 2 of months old. After analysis of clinical and anamnestic data suspected intrauterine carditis?, pale CHD? The following additional methods were used:

ECG: normal position of the electrical axis of the heart, the heart rate of 148-152 per min, high QRS voltage, left bundle branch block, left ventricular and left atrium overloading, signs of subendocardial ischemia.

Chest X-ray: pulmonary venous vascular pattern marked enhanced, focal and infiltrative lesions in the lung tissue are absent, aortic configuration of heart shadow, CTI – 0.71.

Echocardiogram: myxomatous changes of the mitral valve, other valves, the atrial, ventricular septum

119

are intact, diastolic blood flow in the pulmonary artery is absent. The left atrium and left ventricle increased, ejection fraction of the left ventricle 38% (N > 60%). Dramatically amplified echo-signal of the endo-cardium of the left ventricle.

LDG1/LDG2, CPC, CPC MB, troponin I, anticardiac antibodies – in the normal range

Blood culture (the sterility) – three times – no growth.

Peripheral blood test – without inflammatory changes.

Questions:

1.Evaluate the results of the ECG.

2.Evaluate the results of chest radiography.

3.Evaluate the results of echocardiography.

4.Evaluate the results of laboratory tests.

5.Put the diagnosis based on all investigations.

6.What treatment is indicated?

7.What is the prognosis of the disease?

Case 3

3-months-old infant was admitted to the hospital with a diagnosis of acute respiratory infection, obstructive bronchitis. The child of 1st pregnancy with acute respiratory infection (ARI) at 7 months, late hestosis. Term birth, birth weight 3,200 g, length 51 cm. Perinatal encephalopathy was diagnosed in neonatal period: hypertension-hydrocephalic syndrome. There is no evidence of the patient’s contact with ARI.

120