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

3.Which additional tests must be assigned?

4.In what order should emergency treatment be assigned?

5.What are presumed causes of asthma exacerbations?

Case 9

Girl of 5 years old was admitted with a diagnosis of right-sided pneumonia. She was born prematurely at 36 weeks with the weight of 2,300 g, length 43 cm, was bottle-fed from birth. Up to one year of age – food allergy, atopic dermatitis. Often ill, upper respiratory infections – 8 times a year, during the last year – 2 episodes of bronchoobstruction. Allegro-anamnesis: mother-drug allergies, father-pollinosis. The girl at the age of 2 years had allergic reaction to the injection of penicillin. In the emergency room, after the examination and x-ray, diagnosis of pneumonia was confirmed and treatment was appointed: Ampicillin 500x2 times daily. 2 minutes after administration of the drug weakness appeared, as well as dizziness, shortness of breath, maculopapular rash on the buttocks and abdomen, itchy skin. Then appeared acrocyanosis, blood pressure 70/40 mm Hg, tachycardia, HR 130 per min, loss of consciousness. The nurse called the physician on duty and made the injection of Suprastin 2% solution.

Questions:

1. Diagnose.

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2.Which medication should be administrated immediately in this case?

3.Which actions should be taken after that?

4.Which type of hypersensitivity reaction causes this disease?

5.Which reasons have led to this situation?

Case 10

A boy, 2 years old, was born from III pregnancy, followed by physiological labour. Was born in term, birth weight 3,400 g, length 53 cm, breast-fed up to 1 month, then artificial. In the hospital vaccination against tuberculosis and hepatitis was carried out. Then vaccination against DTP was done twice. After the second vaccination there was an increase in temperature and local allergic reaction. During the first year of life – manifestations of atopic dermatitis. The patient got sick, was taken to hospital by ambulance due to acute development of diffused rash on the face, trunk, extremities, accompanied by severe itching. 2 hours before, the baby ate strawberries and chocolates at the feast. The child's mother gave antihistamine with no effect.

On examination: lethargy, reacts negatively. On the skin – urticaria, pink color, ranging in size from a few millimeters to centimeters, surrounded by areas of congestion, rising above the surface of the skin, turns white when pressed. Expressed traces of scratches all over his body. After intravenous administration of 30 mg of prednisone rash completely disappeared.

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Questions:

1.Diagnose.

2.Differential diagnosis.

3.Which is the mechanism of development of this rash?

4.Prescribe treatment.

5.Prevention of these conditions.

Diagnostic keys

1.Uncontrolled severe hormone-dependent asthma, severe attack.

2.Atopic asthma, attack of moderate severity, allergic rhinitis.

3.Allergic rhino-conjunctivitis, persistent, mild

course.

4.Atopic asthma initially identified, attack of moderate severity. Atopic dermatitis.

5.Repeated obstructive bronchitis.

6.Atopic dermatitis. Allergy to cow's milk protein. Allergic enteropathy.

7.Uncontrolled asthma, severe course. Status asthmaticus III degree. Pneumothorax.

8.Mild persistent asthma. Attack of moderate severity

9.Anaphylactic shock to the injection of ampicil-

lin.

10.Acute urticaria.

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Ultrasound of kidneys: no pathology. Ultrasound of urinary bladder: walls are thick-

ened, internal layer is rough, small amount of sediment inside. After urination – significant amount of urine left.

Questions:

1.Rate changes in the urinalysis.

2.Put diagnosis and justify it.

3.Is there enuresis in this child? Which reasons lead to enuresis in children?

4.Differential diagnosis of this clinical case.

5.Which instrumental methods will allow us to decide whether this disease has organic or functional nature? Is there a necessity for them?

6.Assign treatment.

Case 2

2-year old girl was admitted to the hospital with complaints of pains in lumbar area and urination up to 15 times a day. Anamnesis: birth weight – 3,400 g, length 51 cm. Neonatal period-no pathology. She recently had acute respiratory infection. On the second day appeared headache, weakness and abdominal pains with irradiation to the left lumbar area. Temperature raised up to 38,5°С. No catarrhal symptoms developed. During next 4 days she had high temperature up to 38,5°С, pollakiuria and cloudy urine.

At admission her condition is moderate. Multiple dysembriogenetic stigmas are noticed.

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Skin is pale, no edemas, body temperature are 38°С. Left ureter palpation is painful.

CBC: Нb – 140 g/l, RBC – 4,5х1012/l, WBC – 11х109/l, stab – 10%, segment – 60%, lymphocytes – 22%, monocytes – 8%, ESR – 23 mm/h.

Biochemistry blood test: protein – 72,0 g/l, СRP – ++, seromucoid – 0.3, urea – 4,3 mm/l, creatinine 50 mkm/l, high values of γ- and α2-globulins.

Urinalysis: ph – neutral, density – 1014; protein – 0,09%, WBC – all over, RBC – 2, salts – oxalates, bac- teria-multiple, epithelial cells present.

Nechiporenko's test: WBC – 12 000, RBC – 150. Amburge urine test: more than 10 000 leuc/min,

70 erythr/min.

Addis-Kаkovskii urine test: WBC – 15 mill., RBC – 2.000 per 1 ml3.

Day urine volume – 750 ml. Day protein loss – 250 mg/l.

Zimnitskiy's test: day volume = 430 ml, night volume = 230 ml, urine density 1006-1019.

Urine culture: E.coli growth 500 000 bodies/ml3. Sediment in urine – neutrophils are prevalent. Ultrasound of kidneys: kidneys are placed cor-

rectly, left one is enlarged. Echo-signal from collecting system is changed, mainly from the left side, dilated. Doubling of the left kidney is suspected.

Cystoscopia: ureteral orifice is not enlarged.

Questions:

1.Put diagnosis and justify it.

2.Evaluate filtration and concentration functions of this child’s kidneys.

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3.How E.coli penetrate into the urinary system? What are the predisposing factors?

4.What are the main reasons for chronic inflammation of urinary tract?

5.What are age differences in the pattern of the disease in children?

6.Enter the child's plan of investigation.

7.Assign treatment.

Case 3

A boy of 10 years old was admitted to the hospital with complaints of loss of appetite, pain in the abdomen. 1 week before admission to hospital he felt sudden pain in the right lumbar region, increase in body temperature up to 38,5°C, and vomiting.

Anamnesis: neonatal period proceeded without any specific features. After the age of 1 year he often had upper respiratory virus infections (URVI). At the age of 5 years, urinalysis revealed 5-7 white blood cells, 6 red blood cells. At the age of 7 years, he had URVI which was accompanied with a long period of subfebrile temperature, calcium oxalate crystalluria and leukocyturia. The doctor's recommendations were not followed; the child’s state was not monitored after that. Family history: his grandfather has urolithiasis, his uncle – recurrent hematuria, hypertension, cholelithiasis.

On examination: The child's condition on admission is moderate. Skin is clean, no edema, cyanosis under the eyes. In the lungs, vesicular breathing, no wheezing. RR – 24 per min. Heart sounds are loud,

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rhythmic, HR – 82 per min, blood pressure 105/65. The abdomen is soft, palpation points of ureters are painful. Stool is normal, no dysuria. Height is 137 cm. Diuresis for last day was 1,000 ml.

CBC: Hb – 110 g/l, RBC – 4,5х1012/l, WBC – 13х109/l, stab – 6%, segment – 70%, eosinophil – 1%, lymphocytes – 18%, monocytes – 5%, ESR – 21 mm/hr.

Urinalysis: protein – 0.2‰, WBC – 25-30, RBC 6, relative density – 1029, mucus.

Nechiporenko's test: WBC – 13000, RBC – 1000. Bacteriuria: E.Coli 250,000 microbial bodies/ml3. Zimnitskiy's test: daytime diuresis = 450 ml,

nocturnal diuresis = 550 ml, 1015-1025. Biochemical test of blood: total protein – 71 g/l,

albumin – 57%, α1-globulin – 3%, α2-globulin – 1%, β2-globulin – 10%, γ-globulin – 18%; urea – 5,3 mmol/l; creatinine – 55 mmol/l, potassium – 3,8 mmol/l, sodium – 137 mmol/l, glomerular filtration rate 91 ml/min/1,73 m2.

Biochemical test of urine: decrease of anti crystalforming ability of urine, phosphorus 30 mmol/day (norm – 19-32), oxalate – 265 mkmol/day (norm – 90135), uric acid – 6,1 mmol/day (norm – 0,48-6,0), calcium – 11 mmol/day (norm – 1,5-4).

Renal ultrasound: central echo complex of kidney is compact, irregular contour of kidney.

Questions:

1.Formulate detailed clinical diagnosis.

2.Rate the changes in urinalysis and renal func-

tion.

3. What causes this disease?

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4.Describe the pathogenesis of this disease.

5.Assign etiotropic, pathogenic and symptomatic treatment.

6.At which age does the disease usually begin and which early signs are typical of it?

7.Which disease can develop in this child in adulthood?

Case 4

Girl 9 years old was admitted to the hospital with complaints of pain in the lumbar region and weakness.

Anamnesis: birth weight 2,400 g, length 48 cm, often had respiratory viral infection. At the age of 2 years she had high titers of IgG CMV, further was not tested.

She fell ill for the first time at the age of two months, when there was an increase in the temperature of the body up to 38-39°C, in urinalysis – leukocyturia (all over). She received antibiotics due to pyelonephritis. At the age of 1 year bilateral vesicoureteral reflux IV degree was diagnosed and then operated. Later repeatedly identified leukocyturia, bacteriuria, body’s temperature often raised, and periodically appeared pain in the abdomen, with infrequent urination. Since the age of 8.5 years, increase in blood pressure has been marked, proteinuria to 1.5 g/day.

On examination: slight retardation in physical development, disembriogenetic stigmata. Pale skin, dry. No edema. In the lungs, vesicular breathing, no wheezing. Heart sounds are loud, systolic murmur at

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the apex. Blood pressure 140/90 mm Hg. Art. A positive sign of a beating on the left.

CBC: Hb – 98 g/l, RBC – 3,4х1012/l, WBC – 9х109/l, stab – 5%, segment – 54%, eosinophil – 1%, lymphocytes – 35%, monocytes – 5%, ESR – 38 mm/hr.

Urinalysis: yellow color, transparent, pH – 6,0; glucose absent, protein – 0,39%, WBC – 30-60, RBC 5-10.

Nechiporenko's test: WBC – 45000, RBC – 1500, cylinder – 0.

Bacteriuria: 900000 microbial bodies/ml3.

Urine culture: growth of Proteus spp., Enterococcus faecalis, Candida.

Zimnitskiy's test: daytime diuresis = 420 ml, nocturnal diuresis = 1300 ml, variations in relative density 1003-1012.

Biochemical test of blood: total protein – 68 g/l, cholesterol – 5, urea – 12 mmol/l; creatinine – 170 mmol/l, potassium – 4.6 mmol/l, glomerular filtration rate 50 (moderate reduction).

Ultrasound of the kidneys: irregular contour of the left kidney, the size is increased; thickness of parenchyma 9-10 mm, dense, differentiation of layers is violated. The contour of the right kidney is nonsmooth, the size is increased, parenchyma thickness is 12 mm, dense, differentiation of layers is violated. Renal pelvis is moderately dilatated. The ureters are traced in the upper third, thickened.

Voiding cystic cystography: revealed a throw of radiographic contrast substance.

Questions:

1. Formulate a preliminary diagnosis.

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