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

Complaints on admission: obsessive cough, dyspnoea. Appetite is not reduced. Temperature – normal, weight 4,600 g, the skin is pale, sweating. Mixed dyspnea with a predominance of expiratory component, RR = 44 per min. In the lungs: breathing is rough, percussion box note, whistling dry and moist rales. Precordial area is not changed, the border of the relative cardiac dullness can not be determined accurately because of emphysema. Heart sounds are muffled, tachycardia. HR = 152 per min, the murmur is not heard. Liver +3 cm, spleen +1.5 cm. Diuresis is not reduced. Edema is absent.

Chest X-ray: cardiomegaly, CTI – 0.65.

Questions:

1.Evaluate clinical history (anamnesis) of the child. What might indicate anamnesis vitae?

2.Evaluate changes in the heart.

3.Explain the degree of cardiac insufficiency.

4.Put the preliminary diagnosis. What diseases can be suspected?

5.What can be the causes of respiratory chan-

ges?

6.Define the plan of inspection.

7.What treatment should be appointed immedi-

ately?

Case 4

Child of 3 months old was admitted at a department with a preliminary diagnosis of myocarditis

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(prenatal?) CI IIA d., hypertension-hydrocephalic syndrome.

On examination:

ECG: left deviation of cardiac axis, the left anterior bundle block, incomplete right bundle block, prolonged QT interval for 0.12 seconds, heart rate – 152 per minute.

Chest X-ray: focal and infiltrative changes in the lung are absent, increased vascular and bronchial pattern, CTI = 0.58.

Echocardiography: heart valves, septal defects are absent, moderate left ventricular hypertrophy, dilated left ventricular cavity, ejection fraction of left ventricular 50%, pericardium is thickened up to 5 mm.

A moderate increase in creatinine phosphokinase MB, increased rate of anticardial antibodies.

Cardiac MRI – indirect signs of predominantly septal cardiosclerosis.

MRI of the brain – a moderate internal and external hydrocephalus, small cysts in the periventricular region (effects of meningoencephalitis?).

In the epithelial cells of the urinary sediment of mother and child the Coxsackie virus antigens were found.

Questions:

1.Evaluate the results of the ECG.

2.Evaluate the results of chest radiography.

3.Assess data of echocardiography.

4.What data may indicate the nature of subacute heart disease (more than 3 months)?

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5.Formulate a complete diagnosis.

6.What data help to put the final diagnosis?

7.What caused changes in the central nervous system?

8.What pathogenetic treatment should be used? (Except the cardiac insufficiency treatment.)

Case 5

Child of 2 years old was admitted to infectious diseases clinic with a diagnosis of viral respiratory infections, pneumonia? Intestinal infection?

Anamnesis: antenatal period was normal, birth weight and length are normal, was growing and developing normally. Acutely ill for 10 days before the event: febrile temperature, gerpangina, on the third day – maculopapular rash, disappeared in 2 days. On the third day of illness appeared diarrhea, abdominal pain. On the 10th day he became excited, dyspnea, cyanosis of nasolabial triangle appeared. General condition is serious, low-grade fever, mottled skin, acrocyanosis. RR 36 per min. with participation of accessory muscles. In the lungs, breathing is rough, moist finely rales in the lower part of the lungs. Heart: left border on the left anterior axillary line. Heart sounds are muffled significantly, pericardial rub, heart rate 136-140 per minute., 6-10 extra systoles per minute. Liver +5 cm, reduced diuresis, swelling of feet.

Repeated (in 2 weeks) test of blood serum revealed 4 times increased level of antibodies to Coxsackie B4 virus.

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Questions:

1.Put a preliminary diagnosis.

2.Can we assume the etiology of the disease, what it may confirm?

3.List the main symptoms of the disease

4.Explain the degree of heart failure.

5.Make a plan for the examination.

Case 6

Child of 2 years old was admitted to infectious disease clinic with a diagnosis of viral respiratory infection, pneumonia? Intestinal infection? Anamnesis: antenatal period was normal, birth weight and length are normal, was growing and developing normally.

Acutely ill: sub-febrile fever, catarrhal conditions, rash – small red spots on the face, erythema on the cheeks, then a lacy rash on the trunk and limbs, persists for several days. Three weeks after the acute illness the child became restless, dyspnea, cyanosis of nasolabial triangle appeared. General condition is serious, low-grade fever, mottled skin, acrocyanosis. RR 36 per min. with participation of accessory muscles. In the lungs, breathing is rough, moist finely rales in the lower part of the lungs. Heart: left border on the left anterior axillary line. Heart sounds are muffled significantly, pericardial rub, heart rate 136-140 per min. Liver +4 cm, normal diuresis, swelling is absent.

Questions:

1. Put a preliminary diagnosis.

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2.What is the cause of the changes in the lungs?

3.Explain the degree of cardiac insufficiency.

4.What instrumental changes can characterize: myocarditis, myopericarditis? What laboratory data can characterize acute course of myocarditis?

5.Suppose the etiology of the disease. How can you prove your hypothesis?

6.Prescribe treatment.

Case 7

A boy of 9 years old was admitted to the department with a diagnosis of rheumatic fever. Antenatal and infancy periods were normal. At the age of 2 years suffered pneumonia, after the age of 3 years – acute respiratory infections 7-8 times per year, tonsillitis 2 times a year. 8 months before admission began to complain of fatigue, poor exercise tolerance, 1 month before applying to hospital mother noticed an increase in the abdomen, swelling in the legs and face.

The child was admitted in a very serious general condition, the skin was pale, with a cyanosis of nasolabial triangle on exertion, weight 25 kg, height 125 cm. Dyspnea, RR – 32 per min. In the lungs – multiple different in size moist rales, the borders of the relative cardiac dullness are greatly extended (enlarged), more to the left. Muffled heart sounds, heart rate 100 per minute., BP – 100/60 mm Hg, on the cardiac apex – systolic murmur, without left irradiation. Increased abdomen, ascites, liver +8 cm, swelling in the legs, face.

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Echocardiography – marked dilatation of the left ventricle and the left atrium, the ejection fraction of the left ventricle – 33%. Heart valves and ventricular and atrial septum is not changed.

Questions:

1.What diseases can be suspected?

2.Evaluate the physical development of the child.

3.Assess changes in the heart.

4.What is your plan of investigations?

5.Explain the degree of heart failure.

6.What data can help to exclude chronic rheumatic heart disease?

7.What treatment should be started immedia-

tely?

8.What method of study (the golden standard) allows to differentiate inflammatory cardiomyopathy (chronic myocarditis) and non-inflammatory cardiomyopathy (primary)?

Case 8

A boy of 8 years old , hockey player for 3 years, was admitted for investigation with complaints of fatigue, shortness of breath on exertion, cardialgia, dizziness, and fainting during physical stress and emotional stress. There have been recent complaints of heart attacks and "disruption" in the heart.

On examination: HR 84 per min, the left border of the heart – 2 cm outside of the left mid-clavicular line, diffused apical impulse, loud heart sounds, ar-

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rhythmia (extrasystoles), rough systolic murmur at the apex and along the left sternal border, increasing standing and at the exertion. In the lungs – vesicular breathing, without wheezing and any rales, RR 1820 per minute. Liver +1 cm.

There are not inflammatory changes in blood, CPK, creatinine phosphate kinase MB, troponin were normal.

ECG: signs of left ventricular hypertrophy, and negative T waves in the left precordial leads, deep pathologic Q wave in II, III, V4-V6, frequent ventricular extrasystoles.

Holter ECG: frequent ventricular extrasystoles, ventricular tachycardia.

Echocardiography: the hypertrophy of the ventricular septum and posterior wall of the left ventricle, the peak gradient in the left ventricular outflow tract of 55 mm Hg, the ejection fraction of the left ventricle – 72%

Questions:

1.Describe the changes in the heart, give their assessment.

2.What causes of syncope does this child most likely have?

3.What diseases can be suspected in the child?

4.Which method of research is the most important for the diagnosis?

5.What echocardiographic data indicate ventricular outflow tract obstruction?

6.What types of HCM (hypertrophic cardiomyopathy) are distinguished?

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7.Put the diagnosis.

8.Assign treatment.

Case 9

A boy of 11 months. Acutely ill (before the disease was almost healthy): 2 weeks febrile fever, conjunctivitis, cheilitis, stomatitis. On the third day – polymorphic (maculopapular, annular) rash on the trunk, limbs, after 2 weeks – lamellar desquamation of fingers and toes. In the first week – an increase of cervical lymph nodes to 2 cm. No dyspnea no, no rales in the lungs. Muffled heart sounds, tachycardia, systolic murmur at the apex. Liver +2 cm, spleen is not palpable.

Blood test: Hb = 100 g/l, leucocytes = 12,000, neutrophils – 54%, lymphocytes – 30%, monocytes – 14%, eosinophils – 2%, platelets – 650,000; ESR = 56 mm/h.

ECG: tachycardia, T wave flattening, reduced voltage QRS.

Echocardiography: a moderate increase in diastolic LV size, the ejection fraction of the left ventricle – 54% (N > 60%), mitral insufficiency +2, separation of the pericardium, the expansion of the coronary arteries of 3-4 mm, thickening of their walls.

Questions:

1.Describe the clinical signs of heart disease

2.What changes of the heart structures are revealed by the instrumental investigations?

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3. Select the most significant changes in blood

test.

4.What diseases can be suspected?

5.What treatment should be appointed?

Case 10

A boy of 5 days old was transferred from the maternity hospital to the department of pathology of newborn in serious condition. The boy is of 3rd pregnancy occurring with the threat of miscarriage. Mother is 36 years old, suffers from lupus erythematosus. 1st pregnancy – a healthy boy 7 years old, 2nd pregnancy – miscarriage at 16 weeks. This delivery is at 34 weeks by Caesarean section. Birth weight 2,300 g, length – 43 cm. Caesarean section performed by registration at the beginning of labor due to fetal bradycardia, heart rate = 80-90 per minute.

On examination, the skin is pale, icteric, discoid rash; sucking slowly. RR 46-52 per minute. In lungs – puerile breathing, moist rales. Border of the relative cardiac dullness extended to the left, the heart sounds are muffled, bradycardia, heart rate 72-80 per minute. Apex systolic murmur of medium intensity. Liver +4 cm, spleen +1 cm. Urine output is reduced.

In mother’s blood, serum during pregnancy were identified antinuclear auto-antibodies Ro-52/SSA.

The child identified anti-nuclear factor 1/80, thrombocytopenia, ECG – atrio-ventricular block IIIII degree. On echocardiogram – an increase of left

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ventricular ejection fraction decrease. Signs of CHD were not detected.

Questions:

1.What diagnosis can be assumed according to clinical examination?

2.What is the direct cause (mechanism) of heart failure?

3.What clinical history and laboratory tests indicate the cause of which developed a high degree AV block?

4.Explain the degree of heart failure.

5.Suggest the diagnosis.

6.What is the cause of cardiac pathology development?

7.What measures had to be used during pregnancy and what should be done now?

Diagnostic keys

1.Prenatal carditis? Endomyocardial fibroelastosis? Mitral valve insufficiency. Cardiac failure II B-III degree.

2.Endomyocardial fibroelastosis.

3.Myocarditis (intrauterine?), cardiac failure IIA.

4.Fetal Coxsackie-B virus infection: prenatal carditis: mioperikardit, hydrocephalus, multiple cysts in brain.

5.Acute carditis: mioperikarditis, abnormal heart rhythm. Cardiac failure IIB.

6.Acute mioperikarditis. Cardiac failure IIA.

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