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

Case 9

Child of 1 month old. Admitted in a serious condition, weight 3,200 g, gained 200 g during the first month. Restless, does not actively take breast, gets tired easily while feeding. Today the state has worsened: sluggish, regurgitates, pale skin, RR 52 per min, heart rate 164 per min. In the lungs: breathing hard, fine moist rales. Precordial area is not changed, percussion border within the age norms, sounds are rhythmic, tachycardia, mild systolic murmur auscultated at the left of the sternum, systolic murmur heard on the back in intrascapular area. Sharply weakened pulse on a.femoralis c on both sides, right arm blood pressure 115/70 mm Hg, the right leg 75/35 mm Hg.

ECG recorded on ST-T changes in the standard and the left chest leads.

Marked increase in the level of urea in the blood serum of 12 mmol/l.

Sat O2 – 74%.

Questions:

1.What is the most likely diagnosis?

2.Describe the features of hemodynamics of this disease.

3.What clinical symptoms are the most important for the diagnosis of this disease?

4.What can be the cause of sharp worsening of the child’s condition?

5.Which sign is the most unfavorable for prognosis in this patient?

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6.What is an urgent method of investigation?

7.What treatment should be appointed?

Case 10

Child of 5 days old, transferred to the department of pathology of newborns. Full-term, birth weight 3,500 g, length 50 cm, cried at once. A few hours after birth appeared pronounced cyanosis of the skin, mucous membranes, RR 60-66 per minute. Heart rate of 160-180 per minute. Currently sluggish, poorly keeps the temperature, heart murmur is not heard.

Oxygen saturation during the 5 minute test of oxygen therapy Sat O2 – 70% (positive dynamics is absent).

ABB: pH 7,24, BE = –8.5 mmol/l. ECG corresponds to the age norm.

Questions:

1.What is the most likely diagnosis?

2.Assess laboratory findings.

3.What examination should be carried out immediately?

4.Describe the hemodynamics of this heart dise-

ase.

5.The presence of what heart communication provides the survival of children with this disease?

6.What treatment should be appointed?

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Diagnostic keys

1.Ventricular septal defect. Cardiac failure IIA.

2.Open ductus arteriosus. Cardiac failure IIA.

3.Fallot's tetralogy.

4.Atrial septal defect. Cardiac failure I.

5.Coarctation of aorta.

6.Secondary infective endocarditis.

7.Infective endocarditis. Myocarditis.

8.Secondary bacterial endocarditis (gram-posi- tive, staphylococcus), circulatory failure IIA.

9.Coarctation of the aorta.

10.Transposition of the great arterias.

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The ECG – sinus tachycardia, the interval PR – 0,20 sec. Low voltage of complexes QRS.

On Doppler echocardiography – thickening and buckling anterior mitral valve cusp, reduced left ventricular systolic function (ejection fraction – 55%), mitral regurgitation.

Questions:

1.Formulate a detailed clinical diagnosis

2.What are the major and minor diagnostic criteria of the disease for this case?

3.Connection with which infection must be confirmed for this diagnosis?

4.Describe the signs of carditis and polyarthritis in this patient.

6.Prescribe treatment for the patient.

Case 2

Child of 8 years old suffered a sore throat. After 2 weeks, there appeared weakness, fatigue, headache, shortness of breath, palpitations, chest pain, abdominal pain, arthralgia, fever up to 39°C.

On examination in the hospital were revealed pallor, annular erythema on the legs, expanding of the relative cardiac dullness of 2 cm to the left from the mid-clavicular line, the muffeled heart sounds, blowing systolic murmur at the apex. In the II-III left intercostal space of the sternum is determined pericardial rubs. HR – 120 per min., BP – 90/50 mm Hg. RR – 28 per minute. The abdomen is distended.

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The liver is +2.5 cm below the costal margin, pain on palpation. Edematous legs.

The blood tests: leukocytes 12*10 , ESR – 48 mm/h. Contents seromucoid – 0,860 (N – 0,200), total protein, 85 g/l. Albumin 44,2%, α1-globulin – 8%, α2-globulins – 12,1%, γ-globulin – 24.4%. The titer of ASL-O is 1:2000 (N – 1:250) CRP + + +.

The ECG – low voltage QRS, PR – 0,22 s, sinus tachycardia, the inversion of the segment ST, a significant reduction in T wave.

On echocardiography – a thickening of mitral valve cusps, mitral regurgitation, reduced left ventricular systolic function (ejection fraction 54%), pericardial effusion up to 10 mm.

On radiography of the chest an increase in cardiac shadow was revealed, mainly to the left.

Questions:

1.Formulate a detailed diagnosis.

2.What are the criteria for the diagnosis in this

case?

3.List all the major and minor diagnostic criteria for this disease.

4.What are the causes of this disease?

5.What is the duration of the active period of this disease? Can one now speak of acquired heart mitral defects in this child? What should be duration of anti-inflammatory therapy?

6.Determine the range of therapeutic interventions for the patient.

7.What is the secondary prevention of this dise-

ase?

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Case 3

In pediatric department Alexander N., 11 years old, was received with complaints of weakness, shortness of breath on exertion. The boy often has tonsillitis, acute respiratory infections. The mother has rheumatic mitral heart disease. At 8 years of age Alexander became ill with scarlet fever. Then for the first time there apeared pains in the joints. There were tachycardia, muffled heart sounds, systolic murmur. The boy was diagnosed with acute rheumatic fever and was treated in hospital. Subsequent permanent medical monitoring was absent. At the age of 9 and 10 years old underwent two repeated attacks of rheumatic fever. In the last 3 weeks the boy’s state has deteriorated. There appeared shortness of breath, weakness, palpitations.

On examination, pallor of the skin is determined. Retardation of physical development. The left border of the heart is 1 cm outside from the left midclavicular line. Heart sounds are muffled moderately. At the apex is an intensive blowing systolic murmur, which is irradiated to the left.

In the blood tests: leukocytes 6.7х10 /l, ESR – 18 mm/h. Seromucoid – 0,220, ASL-O 1250.

Questions:

1.Put the diagnosis. Justify it.

2.What are the disadvantages of the previous management of the patient?

3.What is the secondary prevention of this dise-

ase?

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4.What medications are used for secondary prevention, the duration of administration of these drugs?

5.Develop a treatment plan.

Case 4

The girl of 12 years old has been under the supervision of doctor since the age of 7 for chronic rheumatic heart disease. There have been three repeated rheumatic fever attacks (last time – a year ago). Gets a monthly year-round prevention of longacting preparations of penicillin. Rarely gets sick.

On examination, the patient has signs of malnutrition. The skin is pale. There is a chronic tonsillitis. Multiple dental caries. The left border of relative cardiac dullness of 1.5 cm outside of the left midclavicular line. Heart sounds are somewhat muffled. In II intercostal space to the left of the sternum – accentuayed II tone. At the apex – blowing systolic murmur. In the V th point and on the aorta there is diastolic murmur. Heart rate of 90 per minute, RR 20 per minute (with a little exercise heart rate 130 per minute, RR is 28 per minute). BP 120/30 mm Hg.

Laboratory study revealed no pathology.

Questions:

1.Put a diagnosis

2.Determine and justify the level of Cardiac insufficiency.

3.Can we now talk about the active inflammatory process (rheumatic fever)?

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4.What are the causes of formation of this stage of the disease in the patient?

5.Determine the treatment tactics in this case.

Case 5

The girl of 13 years old is at the appointment of neurologist. A month before applied for medical help because of the acute respiratory disease. Antibiotic therapy was performed. The girl quickly gets tired, becomes irritable; pale skin; periorbital cyanosis. These symptoms were interpreted as a manifestation of post-infectious asthenia at the puberty. Treatment (vitamins, glycine) did not bring effect. There appeared involuntary excessive movements of facial muscles, then such movements of muscles appeared on legs and arms; unsteady gait, handwriting changed. Became concerned regarding shortness of breath, palpitations.

On examination: the skin is pale, a lot of hyperkinesis, the tendon reflexes are increased, muscular hypotonia and decreased muscle strength. Fingernose and knee-heel tests performs unstably. The speech is not clear. The heart borders on percussion within the normal range. The heart sounds are decreased. At the apex and V point auscultated soft systolic murmur, worse after exercise. HR 90 per minute. BP 105/65 mm Hg. Liver at the costal margin. There is a chronic tonsillitis.

In the blood tests: leukocytes 9.0х10 , erythrocyte sedimentation rate 18 mm/hour, 0,300 seromucoid, ASL-O 1:500, CRP +.

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Questions:

1.Put the diagnosis. On the basis of what criteria was it built?

2.What are the pathogenetic mechanisms of this form of the disease?

3.List the main symptoms of CNS involvement in this disease

4.Put differential diagnosis

5.What additional research is needed to confirm the diagnosis?

6.Develop a treatment plan

7.What types of prevention of this disease do you know?

Case 6

Boy, 10 years old, was hospitalized to the neurology department with complaints of involuntary jerking movements of the limbs; weakness, fatigue. At the age of 5, was treated in the neurology department from the hyperkinetic syndrome; there was the observed choreiform-like hyperkinesis, muscle weakness, hyperreflexia, emotional lability. In a blood test inflammatory activity was not found, ASL-O 1:250. Received penicillin V/m, a short course of prednisolone. After discharge was not under medical control. After previous episodes of acute respiratory infections weakly expressed manifestations of hyperkinesis were observed periodically.

On examination: height 128 cm, weight 26 kg, marked pallor. There are mild manifestations of hyperkinesis in the limbs, a moderate increase of ten-

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