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

don reflexes muscular hypotonia. The left border of relative cardiac dullness of 1.5 cm outside of the left mid-clavicular line, moderately muffled heart sounds, loud blowing systolic murmur with punctum max. at the apex, worse with exercise, which irradiates to the left. Heart rate of 96 per minute, RR 25 per minute. Liver +1.5 cm from the costal margin, the spleen was not palpable.

In the blood test: WBC 8.6х10 , erythrocyte sedimentation rate 18 mm/hour, CRP +, 0.300 seromucoid, ASL-O – 1:500.

The ECG: mild sinus tachycardia, PR – 0,19.

On echocardiography: moderate enlargement of the left atrium, the ejection fraction – 57%, mitral valve thickened, marked mitral regurgitation.

Questions:

1.Formulate and justify a diagnosis

2.What reasons led to the development of this disease?

3.List the symptoms of this form of the disease.

4.Can this form of the disease proceed with normal laboratory parameters?

5.Map out a treatment plan

6.What types of prevention of this disease do you know? What is secondary prevention?

Case 7

Ira K. 12 years was received to the pediatric department with a diagnosis of reactive arthritis? Acute

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rheumatic fever? In the past two months there has been fatigue and weakness. During the last week there was a high fever. 3 days ago there was a pain in the right hip joint, today – pain in the ankle joints.

On examination: pale skin. Appetite is reduced. Temperature of 38,2°C. Palpable posterior and anterior cervical, submandibular, axillary, cubital, inguinal lymph nodes, multiple, painless, mobile, 0.5-1.0 cm in diameter. Joints apparently not changed, tenderness and limitation of movement in the hip and ankle joints, pain palpation of legs. The left border of the heart is 0.5 cm outwards from the mid-clavicular line, slightly decreased heart sounds, on the apex there is a mild systolic murmur. Liver +4 cm from the costal margin, the spleen +2 cm; heart rate is 104, RR 24 per minute.

In blood tests: leukocytes 25.4x10 , ESR 56 mm/hr, Hemoglobin 110 g/l, in a week – 93 g/l, platelets 180x10 /l, in a week – 120x10 /l. CRP + + + ASL-O 1:250.

The ECG: sinus tachycardia, T wave flattened. PR 0,14 s.

Questions:

1.Put a preliminary diagnosis

2.What diseases should be included in a differential diagnosis?

3.What additional tests are required?

4.What examinations can confirm the presumptive diagnosis?

5.What therapy is possible currently?

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6. Is it possible to assign glucocorticoids at this moment? If not, why?

Case 8

Alexander of 8 years old was admitted to the hospital on 01 October with complaints about pain in the joints, fever up to 37.5ºC.

Anamnesis: frequent viral respiratory infections in the pre-school years, chicken pox. Immunizations according to the age. 2 weeks ago suffered a disease with fever, abdominal pain, diarrhea for three days. 2 times vomited.

Anamnesis of the present illness: Acutely ill on 28 September. The temperature rose to 38ºC, there were severe pains and swelling in the left ankle joint. From 30 September the right knee became painful. Could not walk. Ambulance service was called, and he was sent to hospital.

On examination: the state of moderate severity. Proper constitution, satisfactory development. Pale skin clean, shadows under the eyes, chronic tonsillitis. Moderate limpho-poliadeniya.

Gait abruptly broken. Right knee joint increased in volume, swelling of soft tissues, determined little effusion, sharply painful, movements are limited. Swollen left ankle, limited movement, painful. Other joints are apparently not changed, the movements are not impaired. The borders of the heart within the age norm, rhythmic sounds, distinct. Pulse 92 beats per min. Blood pressure 105/65 mm Hg. In the lungs, vesicular breathing. The abdomen was soft and

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painless. The liver is palpable below the costal margin of 2 cm, the spleen was not palpable.

Blood test: Er. – 4500000, HB – 110 g/l, L – 8000, p – 4, C – 75, limf. – 15, E – 1, mon. – 5, an ESR of 35 mm/hour.

Urinalysis normal.

Biochemical studies: protein 75 g/l, liver enzymes are normal, CRP, 0.035, ASL-O 125 units.

ECG – sinus tachycardia.

Questions:

1.What disease preceded this disease?

2.Put the presumptive diagnosis. What research should be carried out to confirm the diagnosis?

3.Give characteristics of articular syndrome.

4.What abnormalities are observed in the internal organs? What abnormalities are revealed in laboratory data?

5.With what diseases it is necessary to make a differential diagnosis?

6.What treatment should be appointed?

7.What is your prognosis in this case?

Case 9

A girl Katya of 6 years old was admitted to the hospital with complaints of fever, joint pain, shortness of breath on exertion.

Early anamnesis without peculiarities. During the first year – exudative diathesis, vaccinations received in accordance with the vaccination schedule. Rarely sick.

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This disease started on 15 February. When the temperature rose to 38,5-39°C, the girl began to complain of pain in the legs. Alongside with the high temperature tender maculopapular rash appeared. Two days later, the condition worsened. There was shortness of breath, weakness, she could not stand up, walk.

On admission – a serious condition. High fever. Gets a forced position. Pale skin on the side of the chest with maculopapular rash linear character. She complains of pain in the wrist, knee, ankle joints. These joints deformed due to exudative-proliferative effects in the knee joint – effusion, in the wrist joints – bursitis. Movement in these joints is limited, painful. Expressed morning stiffness. Axillary lymph nodes, inguinal multiple, measuring up to 1,0 cm. Dilated left borders of the heart, muffled heart sounds, tachycardia to 104 HB per min. Systolic murmur at the apex, pericardial rub along the sternum. In the lungs, breathing hard. The abdomen was soft and painless. The liver is palpable 2.5 cm below the costal margin, the spleen palpable edge.

Blood tests: erythrocytes – 3200000, HB – 95 g/l, Leucocytes – 10000, bound neutrophyles – 3%,

CRP – 1,002 (normal 0,001), ASL-O 125 units. Urine test within norm.

Questions:

1. Give a description of the articular syndrome.

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2.List the changes in the internal organs

3.Are there any abnormal laboratory findings?

4.What diagnosis can be made in this case?

5.Differentiate the articular syndrome and changes in the heart in rheumatic fever, reactive arthritis and juvenile rheumatoid arthritis.

6.Principles of therapy in this patient.

Case 10

The boy of 5 years old complains about pains in the right hip joint and lameness.

The boy is of the second pregnancy that occurred with toxicosis in the 1st half. Delivery on time, the weight of 3,250 g, the length of 51 cm, cried at once. Early anamnesis without peculiarities: rare acute respiratory infections, an intestinal infection at the age of 3.5.

The boy has been sick for 3 months, when slight lameness appeared for the first time, there were severe pains in the right hip joint, which took place at the end of the day. Similar episodes occurred several times. In the last 1.5 months there appeared marked lameness, the boy began to get tired quickly.

On examination: the boy of proper constitution, satisfactory development. The skin is clean. Adenoids of 2 degrees. On the outer surface of the right hip joint there is soft tissue swelling. Abduction, internal and external rotation of the right hip is limited and slightly painful. Other joints are apparently not

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changed, the movement in them is normal. Pronounced atrophy of the muscles of the right thigh (circumference of 1.2 cm less than the circumference of the left thigh), atrophy of the gluteal muscles on the right. When walking, lames on the right foot. There is a violation of gait, flat feet. In the lungs, vesicular breathing, heart sounds distinct, systolic murmur in point 5 of a functional nature. The abdomen is soft, painless, liver and spleen are not palpable. Stool and urine output are normal.

Laboratory parameters within the age norms. The X-ray revealed the hip joints swelling of

soft tissue in the right hip joint, osteoporosis and hip fracture of upper-outer part of acetabulum, the heterogeneity structure of paraepiphysis area of the femoral neck, on the border between the epiphysis and the neck, flattening of the epiphysis, the widening of the joint space.

Questions:

1.Assess the data of the clinical picture and laboratory and instrumental examination.

2.What diseases should be included in the list of differential diagnosis? Give the analysis of the clinical picture of each disease, respectively.

3.Your diagnosis?

4.What should be the tactics of the doctor?

5.What treatment should be appointed?

6.What is the prognosis for this disease?

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Diagnostic keys

1.Acute rheumatic fever. Carditis: endomyocarditis with damage of the mitral valve. Polyarthritis. Cardiac failure I-IIA.

2.Acute rheumatic fever. Carditis (pancarditis with the damage of mitral valve). Polyarthritis. Annular erythema. Abdominal syndrome. Cardiac failure IIA-B.

3.Rheumatic fever with chronic rheumatic heart

disease with heart disease (mitral valve against the mitral insufficiency). Cardiac failure II.

4.Chronic rheumatic heart disease. Failure of mitral and aortic valves. Cardiac failure. Chronic tonsillitis. Dental caries.

5.Acute rheumatic fever. Myocarditis. Chorea. Cardiac failure 0-I.

6.Rheumatic fever with chronic rheumatic heart disease. Mitral valve against the mitral insufficiency), chorea. Cardiac failure IIA.

7.Acute leukemia.

8.Reactive arthritis.

9.Juvenile rheumatoid arthritis

10.Perthes disease – osteochondropathy. Stage I radiographic changes.

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surface of the chest, breath held mosaic, muffled heart sounds, accent of II sound of the pulmonary artery.

Questions:

1.Put the diagnosis and assess the severity of exacerbation of asthma.

2.Name the criteria of severity of asthma attack.

3.Which treatment must be carried out in hos-

pital?

4.What does the decrease in oxygen saturation

mean?

5.What are the typical complications during the asthmatic attack?

6.Which additional tests must be done after the asthma attack?

7.Why is the efficiency of treatment low and what can be done to improve it?

8.Which criteria do you know to control the basic therapy in patients with asthma? Name the steps which should be used to strengthen the basic therapy for the patient.

9.Is treatment with anti-IgE drugs Xolair (Omalizumab) indicated to this patient or not?

Case 2

5 year-old girl woke up at night due to difficulty in breathing, "whistling".

On examination: nervous, sitting on the bed with the support of her hands. Exhalation is difficult. HR –

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