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

7.Cardiomyopathy (inflammatory), chronic myocarditis, rheumatic heart disease Cardiac failure II B-III degree.

8.Hypertrophic cardiomyopathy, obstructive form. HCM, obstructive form

9.Kawasaki disease.

10.Neonatal lupus syndrome.

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5.Develop plan of investigation.

6.Develop the treatment plan.

7.Indicate required time of surgical treatment and indications for surgery.

8.What changes in the ECG and chest X-ray are characteristic for this disease?

Case 2

Child of 6 months of normal pregnancy, 2nd normal delivery. The mother was operated at the age of 1.5 years – CHD. Birth weight 3,000 g, length – 50 cm. Three times suffered acute respiratory infections, pneumonia once.

On admission the child's weight is 5,800 g, the head is held from 4 months, not sitting. Pale skin, RR – 40 per min. In the lungs – isolated rales in the lower parts. The left border of the relative cardiac dullness 1 cm outside from the left anterior axillary line, right – the right edge of the sternum, upper – I intercostal space. Heart tones loud, heart rate – 140 per min. Palpation determined systolic tremor at the Ist intercostal space on the left of the sternum, systolic-diastolic murmur at the II-III intercostal space on the left, the accent of second tone at the pulmonary artery. Liver +4.0 cm. Spleen +1.0 cm. Edema is absent.

Questions:

1.Put a preliminary diagnosis.

2.Describe the hemodynamics of this disease.

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3.List the symptoms of the disease.

4.Explain the degree of cardiac insufficiency.

5.Clinical signs of what complications of this disease occur in the child?

6.Examination plan.

7.What changes in the ECG and chest X-ray are characteristic for this disease?

8.Treatment plan, the optimal age of surgical correction for this disease.

Case 3

Child of 9 months of 3rd pregnancy, with acute respiratory infection in the first trimester: III term birth, birth weight – 2,700 g, length 46 cm. The child from the 2nd pregnancy – CHD.

At admission: complaints of attacks of breathlessness, cyanosis, which recently began daily. Weight – 8,200 g, length 65 cm, cyanosis of the lips, visible mucous membranes, hands, feet, enhanced by a crying .Dyspnea, RR – 44 per min. In the lungs, weakened breathing, wheezing not heard. Area of the heart is not changed, percussion border of relative cardiac dullness: left – 1.5 cm outside of the left mid-clavicular line, right – 0.5 cm outside from the right edge of the sternum, upper – edge of the II rib. Heart sounds loud, heart rate – 120 min., II tone in the pulmonary artery is weakened, rough systolic murmur along the left sternal border, the epicenter of II-III intercostal space on the left. Liver +1.0 cm.

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Questions:

1.Put a preliminary diagnosis.

2.Describe the hemodynamics of this disease.

3.What caused the attacks of increased dyspnea and cyanosis?

4.What clinical symptoms allow to put a diagno-

sis?

5.What ECG and radiographic changes are specific to this disease?

6.The treatment plan.

7.Treatment of dyspnea-cyanotic attacks (anoxic

spells).

Case 4

Child of 3 years old. From the first physiological pregnancy, the first term birth. Birth weight 3,200 g, length – 50 cm; in the first year of life suffered acute respiratory infection 3 times, 1 time – pneumonia. When he was examined, systolic murmur was heard.

On admission to the examination: weight 12 kg, height 84 cm, moderately pale skin, cyanosis is absent. RR – 28 per minute, heart rate – 110 per minute (on activity RR – 34 per minute, heart rate – 124 per min). In the lungs, hard breathing, wheezing not heard. Border of the relative cardiac dullness: left – 1.5 cm outside of the left mid-clavicular line, right – right parasternal line, upper – the upper edge of the second rib. Heart tones loud, extrasystoles (3- 6 min.), systolic murmur in the II-III intercostal space on the left (without irradiation), the accent of second

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tone on the pulmonary artery. Liver +1.0 cm without swelling.

On ECG: electric cardiac axis deviation to the right, P «pulmonale», incomplete right bundle branch block, and deep S v4-v6, single supraventricular extrasystoles. On radiography of the chest: increased vascular pattern on the arterial type, CTI – 0.56, an increase of the right atrium and right ventricle.

Questions:

1.Put a preliminary diagnosis.

2.Describe the hemodynamics of this disease.

3.List the symptoms characteristic of this dise-

ase.

4.Give an opinion on the instrumental examinations (describe the changes).

5.What complications are most likely to occur at given disease?

6.Treatment tactic.

Case 5

Child of 6 years old. Early anamnesis is normal. In clinic examination noted BP = 120/60 mm Hg.

On examination: a disproportionate figure – welldeveloped shoulders and upper limbs, head circumference of 51 cm, reduced development of the lower extremities. Complains of fatigue in the legs when walking. Skin of normal color. BP on hand = 125/60 mm Hg, BP feet = 100/80 mm Hg. Femoral pulse hardly detectable. In the lungs, vesicular breathing, wheezing

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not listened. Area of the heart is not changed, palpationenhanced apical impulse, the borders of the relative cardiac dullness extended to the left. Heart sounds loud, rhythmic, noise is not heard. Auscultated rough systolic murmur in the interscapular region. Shortness of breath, tachycardia absent. Liver is not enlarged. On exertion – abdominal pain occasionally.

Questions:

1.Put a preliminary diagnosis.

2.Describe the hemodynamics of this disease.

3.List the symptoms of clinical diagnostic for this disease.

4.What changes in the ECG and chest X-ray are characteristic of this disease?

5.What are the most common complications of this disease?

6.Treatment tactic.

Case 6

Child of 5 years with CHD: tetralogy of Fallot. At the age of 9 months palliative surgery was performed because of frequent and heavy anoxic spells. Entered the office with complaints of recurrent epistaxis, lowgrade fever, recently increased dyspnea. 1 month ago he had adenotomy; before this operation there was no treatment.

On examination: the temperature of 37,4°C. Skin and mucous membranes cyanotic, rare petechiae on

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the extremities. In the lungs: breathing weakened, no wheezing. Heart sounds loud, systolic murmur p.max. II-III intercostal space on the left, a short diastolic murmur in the III intercostal space on the left. Heart rate 110 beats per minute, RR – 32 per minute. Liver +3 cm, spleen +2.5 cm. Edema is absent.

Complete blood count: Hb – 148 g/l, erythrocytes – 5,5 million, leukocytes – 8 thousand, band form – 5%, segmented – 72%, monocytes – 4%, lymphocytes – 19%, ESR – 15 mm per hour.

CRP – 0,08 mmol/l (normal < 0.005).

Questions:

1.What is the reason for worsening of the child’s

state?

2.List the symptoms of anoxic spells

3.What is palliative surgery for tetralogy of

Fallo?

4.List the symptoms on which the diagnosis of this complication of tetralogy of Fallot is based.

5.Evaluate the blood test.

6.What additional research is needed?

7.The treatment plan

8.What are the prevention measures of infective endocarditis?

Case 7

Child of 4 years old. Early anamnesis was normal. In the last year three times suffered purulent

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otitis. 2 months before admission operated on for superlative lymphadenitis.

On admission: complaints of febrile fever for 2 weeks, weakness, anorexia, weight loss, arthralgia, pronounced sweating.

On examination: the skin and visible mucous membranes pale, rare petechiae, no catarrhal symptoms, joints, apparently not changed and the temperature of 38,0°C, RR = 36 per minute, heart rate is 128 per minute. In the lungs: breathing hard, no wheezing. Area of the heart is not changed, the border of the relative cardiac dullness extended to the left, heart sounds are muffled, rhythmic, soft diastolic murmur auscultated, worse when standing, p.max. – III-IV intercostal space at the left. The abdomen is soft and painless. 3.5 cm liver, spleen 3 cm. Diuresis adequate.

Questions:

1.Put a preliminary diagnosis.

2.What symptoms allow to suspect this disease?

3.What are the causes of auscultative heart symptoms?

4.Does the patient have symptoms of the cardiac insufficiency and if so, to what degree?

5.With what diseases a differential diagnosis should be put?

6.What investigations should be conducted to confirm the diagnosis?

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Case 8

Child of 4 years old admitted to hospital with suspected infective endocarditis.

There are the following data: Hb = 100 g/l, white blood cells – 20.2 thousand, band shaped neutrophils 6%, segmented – 74%, lymphocytes – 16%, monocytes – 4%, ESR = 32 mm hour; α2-globulins – 12%, γ-globulins – 23%, seromucoid – 0.624, ASLO-1:250, RF – abs, CIC – 474 (normal 200), PCT – 5 pg/ml (N rate < 0.5).

In two of the three blood cultures obtained by growth of Staphylococcus aureus.

On the ECG shows sinus rhythm, deviation of EA to the left; QRS voltage is reduced, diffuse metabolic disturbances in the myocardium.

Echocardiogram: a moderate increase in the left ventricular cavity, separation of pericardium +6 mm, hypokinesis of ventricular septum, bicuspid aortic valve, valve thickened, on one of the cusp (leaflet) moving formation with a diameter of 2-3 mm is identified, the aortic valve regurgitation 2+.

Questions:

1.Formulate a diagnosis

2.What should be the differential diagnosis in this case?

3.List the diagnostic DUKE-criteria of infective endocarditis.

4.Assess the changes of the aortic valve.

5.What are the most common infectious agents etiologically associated with the disease?

6.Assign and justify treatment.

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