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

120 per min, RR – 45 per min. Percussion – box sound, auscultation-impaired breathing, dry wheezing over the entire surface of the lungs. Up to the age of 1 year the child had signs of food allergy, drug allergy, and then allergic rhinitis appeared. The state described above appeared for the first time. From anamnesis it was revealed that 2 weeks before there appeared a kitten in the apartment. Heredity burdened anamnesisfather suffers from neurodermatitis.

Questions:

1.Your preliminary diagnosis. Justify.

2.With which diseases should we make differential diagnosis?

3.Which additional investigations should be carried out to confirm the diagnosis?

4.Which treatment is necessary for this girl at the moment?

5.Which prevention methods are indicated to this patient?

Case 3

Boy M., 5 years old, was examined by the allergist due to complaints of runny nose and sneezing.

Medical record: the child fell ill two years ago, in April; there was severe itching, burning eyes, tearing, photophobia, hyperemia of conjunctive. Later, itching of the nose and nasopharynx, nasal congestion, shortness of breath appeared. Antihistamines,

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hormone drops topically brought some relief. In midJune symptoms ceased.

From family anamnesis: mother of the child is suffering from eczema. The patient himself suffered from infant eczema up to 3 years.

On examination: the boy with asthenic body build. Skin is clean and dry. Breathing through the nose is difficult, often scratched his nose, sneezing. Profuse watery discharge from the nose. Swollen eyelids, hyperemia of conjunctiva, tearing. RR 22 per minute. Auscultation: puerile respiration. Heart sounds are rhythmic, loud. The abdomen is soft and painless. Stool and urine are within the norm.

Hemogram: hemoglobin 112 g/l, RBC З,0х1012/l, WBC 7,0х109/l, Stab neutrophil 3%, segment neutrophil 34%, eosinophil 12%, lymphocyte 50%, monocyte 1%, ESR 5 mm/hour.

In winter scarification tests were conducted: strongly positive (+ + +) with pollen allergens of alder, hazel, allergy to pollen of artemisia, which clinically didn’t appear.

Questions:

1.Put a preliminary diagnosis

2.Evaluate the results of additional investiga-

tions

3.Differential diagnosis.

4.Name mediators of early and late phases of allergic response in this disease.

5.Classification of the disease according to ARIA.

6.The basic principles of treatment.

7.Additional investigation to confirm the diagnosis.

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the emergency doctor. Complaints of paroxysmal cough and wheezing.

The girl was born in term from first physiological pregnancy. Birth weight 3,400 g, length 52 cm. Neonatal period – without any pecularities. From the age of 2 months on artificial feeding. Up to the age of 1 year suffered from infantile eczema. Food allergies: chocolate, strawberry, egg (skin rash). Family anamnesis: mother – recurrent urticaria, father – asthma. At the age of 3 and 4 years, in May, in the country (in the country house), appeared asthma attacks that stopped on their own when she moved to the city. The present attack appeared during a performance at the circus, after performing of horses. Cough and shortness of breath were noticed. The doctor performed first aid. The asthma attack ceased. The emergency physician called the family doctor.

On examination: the state is moderate. Pale skin, cyanosis under the eyes. On the cheeks, behind the ears, in natural folds of the arms and legs – dryness, exfoliation and scratches. “Geographic” tongue. Noisy breathing and wheezing were heard from distance. Exhalation extended. RR – 28 per min. Percus- sion-box sound. Auscultation: loud dry wheezing over the surface of the lungs. Heart borders: right – 1 cm medially from the right edge of the sternum, left – 1 cm medially from the left mid-clavicular line. Muffled heart tones. HR – 110 per min. The abdomen is

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soft and painless. Liver +2 cm. The spleen is not palpable. Stools daily, shaped.

Hemogram: hemoglobin 118 g/l, RBC 4,3х1012/l, WBC 5,8х109/l, Stab neutrophil 1%, segment neutrophil 48%, eosinophil 14%, lymphocyte 29%, monocyte 8%, ESR 3 mm/hour.

General urine test: amount 100.0 ml, relative density 1016, mucus – abs, leukocytes 1-2, red blood cells – abs.

Chest radiograph: lung fields of enhanced transparency, increased bronchopulmonary drawing in root zone, no focal shadows.

Questions:

1.Put the diagnosis and justify it.

2.Classification of this disease.

3.Make a plan for further investigation.

4.Does this child need further therapy after the asthma attack was ceased? If yes, which treatment should be appointed?

5.Which urgent first aid should the emergency doctor carry out? In which cases does the patient require hospitalization?

6.What factors cause severity of condition of this child?

7.Plan dispensary observation for this patient.

8.Risk factors for this child.

Case 5

Patient Viktor, 2 years 8 months old. Hospitalized to admission department with complaints of

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cough, fever up to 37.5oC , dyspnea. The child was born prematurely from first pregnancy which was occurring with toxicosis in the second half. Early artificial feeding. Food allergy to cow milk. Since the first year of life has suffered from atopic dermatitis. At the age of 2 years the child started to attend kindergarten. Vaccination carried out on schedule. At the age of 10 months suffered bronchial obstruction, received inhaled Berodual. Family anamnesis is not burdened.

Medical record: sick for three days, temperature 37.8oC, dry cough and runny nose. The mother was treating the child alone (antipyretics and expectorant herb). Two days later, his condition worsened, there was expiratory dyspnea, wheezing, anxiety, and therefore the parents visited the doctor. Such a state has occurred the third time in his life, with upper respiratory virus infection. The child received inhalation of Berodual without significant effect.

On examination: moderate, the child is nervous. Skin is clean, body temperature 37.2oC. Cyanosis of nasal-labial triangle, hyperemia of pharynx. The chest is of usual shape, significantly involved in breathing auxiliary muscles, retraction of intercostal spaces and jugular fossa. Wheezing breath, exhale extended, percussion box sound, RR 42 per minute. Auscultation: diffuse dry expiratory wheezing on both sides, various sizes (medium and large bubbling), wheezing in all fields. The borders of the heart are not enlarged, rhythmic tones, muffled, HR 130 per minute. The abdomen is soft and painless. Liver 1.5 cm. Stool is regular, diuresis is normal.

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Hemogram: hemoglobin 118 g/l, RBC 4,1х1012/l, WBC 3,8х109/l, Stab neutrophil 2%, segment neutrophil 29%, eosinophils 2%, lymphocyte 51%, monocyte 5%, ESR 15 mm/hour.

Radiographs of the chest: there is an increase in transparency of lung tissue.

Questions:

1.Put a preliminary diagnosis. Which additional investigation do you need to exclude asthma?

2.Evaluate the results of additional investigation methods.

3.The differential diagnosis.

4.Assign treatment.

5.Explain the pathogenesis of the syndrome in this patient.

6.Which anatomical and physiological features in infants predispose to appearance of bronchial obstruction and disease progression?

Case 6

Olga K., 7 months old. Admitted to the hospital with complaints of itching, soaking of facial skin, rash on the trunk and extremities, anxiety and sleepiness.

From anamnesis we know that the child was born in term from the first pregnancy with toxicosis in 2nd half. Birth weight 3,600 gr. BCG vaccination is done in the hospital. Mother works as a nurse, has allergy (rash) from vitamin B6. Father – no allergic

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diseases. Grandmother – arthritis, allergic rhinitis and asthma.

The baby is on artificial feeding from the age of 2 months. When they started to feed the child with milk formula Malyutka, there appeared hyperemia, rash on skin and cheeks, thin stool. Currently receives cow milk. The girl received topical treatment with ointments and lotions without effect. Skin lesions increased. The child was admitted to hospital.

On examination: the child’s condition is moderate. The girl is thin. Dry skin on extremities, abdominal skin hyperemia. Vesicles – papular rash, scabs, and cracks on the extensor surfaces of the limbs. Palpable submandibular lymph nodes 1.5x0,5 cm. Mucous membranes are clean, "geographic" tounge. Percussion – lung sound. Puerile breathing. Cardiac sounds are rhythmic. Borders of relative heart dullness are normal. Abdomen is soft, moderately distended, liver +2 cm, spleen not palpable. Porridge-like stool, yellow with mucus. Urination is normal.

Hemogram: hemoglobin 110 g/l, RBC 3,5х1012/l, WBC 15,0х109/l, Stab neutrophil 3%, segment neutrophil 39%, eosinophil 15%, lymphocyte 57%, basophil 1%, ESR 12 mm/hour.

General urine test: protein neg., Epithelium 6-8 in sight, leukocytes 1-2 in sight, red blood cells 0-1 in sight, relative density 1012.

Coprology: undigested fiber + cells, white cells 15 in sight, mucus + +; helminth eggs were not found, fatty acids neg., Eosinophils 6-8 in sight, neutral fat neg.

Total IgE – 220 (N 20). IgE antibody titers to casein of cow's milk (4 +) by ELISA.

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Questions:

1.Put and justify clinical diagnosis.

2.Evaluate the results of the additional investi-

gation.

3.Differential diagnosis.

4.Treatment.

5.Prognosis.

Case 7

Girl P., 10 years old, was admitted to the hospital with a diagnosis of asthma, severe attack period.

The child was born in term from 1 pregnancy that occured with hypertension. Birth weight – 2,630 g, length – 47 cm, diagnosis of intra-uterine growth retardation. Apgar score 6/8 points. She was on breast feeding up to 2 weeks, then on artificial feeding. Atopic dermatitis was observed. Family anamnesis: mother – eczema, hypertension, uncle – neurodermatitis, no information about the father, the marriage is not registered. Vaccinated by age. Since birth the child has been a passive smoker.

Previous diseases – repeated pneumonia (first time at the age of 1,5 years), frequent upper respiratory infections (more than 4 times yearly). Asthma was diagnosed at the age of 2 years and 6 months, hospitalized repeatedly to intensive care department (6 times) due to status asthmaticus. Basic therapy was not received.

The present illness began that evening; there were complaints of sore throat, fever, expiratory dyspnea.

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On examination: severe condition. Dyspnea expiratory with muscles involving in breathing, RR 28 per min. Severe dry cough. Auscultation: harsh breathing, a lot of wheezes. Cardiac ones are loud, tachycardia. Abdomen is soft, liver +2 cm. After inhalation Berodual and pulmicort 500 mcg, positive dynamics was observed. Parents refused to hospitalize the child. However, at 23 o’clock the child’s condition worsened, febrile fever, severe anxiety. Expiratory dyspnea, nonproductive severe cough. On admission to the department the child’s condition was very severe. Orthopnea. In the lungs, breathing in some zones weakened, dry wheezing.

On radiographs of the chest – decreased lungs pattern, focal shadows due to perivascular changes, pneumothorax on the left side.

ABB: pO2 45 mm Hg, pCO2 60 mm Hg. Sat O2 74%, Ht 0,55, pH 7,2.

On admission to the intensive care department – unconscious, atony, areflexia, hypotension, total cyanosis, single breaths. In the lungs – no breathing, muffled heart sounds. Reanimation started.

Questions:

1.Put the complete diagnosis.

2.Why is the child’s condition very severe?

3.Which complications occurred during the course of status asthmaticus? Which emergency first aid should be carried out?

4.Assess the blood gas levels.

5.What are the causes of this deterioration?

6.Why is asthma severe in this child?

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7. Which reanimation procedure was done to the patient?

Case 8

Child of 4 years old was admitted to the hospital at 8:00 am with severe dyspnea. Have had asthma for 1 year; the child is receiving basic therapy, antiinflammatory therapy (Singular 4 mg daily). Daytime attacks of difficulty in breathing are rare, after running, not more than 1 time weekly. Night waking 1- 2 times weekly, associated with cough and stopped by itself or after inhalation Berodual.

2 months ago their apartment was flooded by neighbours. The last attack developed this morning at 5 am. Mother called the ambulance, gave the child inhalation with Berodual, ⅓ aminophylline tablets per recommendations . The ambulance brought the baby to the hospital.

On examination: orthopnea. HR – 122 per min, RR – 32 per minute, peak expiratory flow rate in the evaluation using a peakflowmeter less than 80% of the best individual performance. Thorax inflated emphysematous, with percussion defined box sound, auscultation – dry and bubbling different-sized and scattered wheezing, harsh breathing. Non-productive cough.

Questions:

1.Assess the severity of asthma.

2.Assess severity of asthma attack.

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