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

amniotic waters. Weight 1,800 g., length 40 cm, head circumference 29 cm, chest circumference 26 cm. The child’s condition was severe due to respiratory distress syndrome, respiratory failure and CNS depression syndrome. On the 2nd day of life the condition worsened due to episodes of apnea (duration of each episode – about 15-20 seconds). On the 4th day – tonic seizures appeared. On the 5th day – feeding through tube, depressed reflexes, tendon reflexes on the left was normal, tremor of limbs, fontanel 2,5x2,5 cm, bulging, pulses, small fontanelle 1x1 cm, divergence of the sagittal suture 1.0 cm; on mechanical ventilation, pale skin. Heart sounds were muffled, heart rate 152 min. The abdomen was soft, moderately swollen. Liver +1.5 cm. Urination up to 5 times daily. Stool with green slime, 4-5 times daily.

CBC: Hb – 110 g/l, RBC 3.5x1012/l, WBC 10x109/l, stab – 3%, segment – 44%, lymphocytes – 47%, monocytes – 6%, ESR 10 mm/hr .

Neurosonography (on day 4) brain parenchyma poorly differentiated on the sulci and gyri. The left lateral ventricle enlarged in all departments, d = 11 mm, in cavity – echo-positive inclusions. The right ventricle is enlarged to 10 mm. Extended cavity of the large tanks, III ventricle. In the periventricular region identified areas of hyperechogenicity.

Cerebrospinal fluid: color – bloody, cell counts increased at the expense of RBC (cover the entire field of view).

Questions:

1. Diagnose.

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2.What are the mechanisms of this disease in preterm infants?

3.Rate prognosis of the disease.

4.List the laboratory markers of the severity of the central nervous system during the recovery period.

5.Assign treatment.

Case 8

A boy L., 6 days old, was born from I pregnancy which occurred with toxicosis during the I and II trimester, birth in term, stimulation of oxytocin due to uterine inertia, anhydrous period 10 h. during delivery was noted difficulty in removing the shoulders. Weight 4,200 g, length 54 cm. Apgar score – 7/8 points.

After the birth the child was anxious, unquiet, muscular dystonia, in an elevated position the right arm hangs down. In the horizontal position, on the back, the hand is separated from the trunk by small longitudinal fold ("doll’s hand" symptom), adduction to the body, straighten of all joints, forearm pronated, the hand in the position of palmar flexion, head tilted to the sore shoulder. A small number folds in the axilla. An oral automatism reflex is positive, but palmar – oral, Babkin, grasping, Moro reflexes on the right are reduced, biceps tendon reflex is absent. Pain and tactile sensitivity were reduced. When passive moved, "click" detected in his right shoulder (positive symptom Fink). Active movements are limited in the shoulder and elbow joints.

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Questions:

1.Your preliminary diagnosis?

2.Specify the topic nervous system disease in this case.

3.Is X-ray examination indicated to this child? Which changes can be detected?

4.Assign treatment.

5.Rate prognosis.

Case 9

A girl C. moved from the hospital to the neonatal pathology unit on the 6-th day of life. From I pregnancies occurred with blood pressure 150/100 mm Hg. and obesity. Weight gain during pregnancy – 18 kg. Delivery in term with uterine inertia and manual breeding of head and left shoulder of the fetus. Birth weight = 4,100 g., length = 52 cm, screamed after cleaning of upper respiratory tract. Apgar score 6/8 points. Breast feeding for 2 days, sucking weakly, with frequent interruptions. From birth, left arm in all joints lay along the trunk, pronated, the hand passively hanging, limited movement of the fingers, the form of the hand "clawed feet", head turned in the opposite direction. Grasping and hand-oral reflexes on the affected side are absent; Moro reflex on the left is significantly reduced.

Questions:

1.Diagnose.

2.On which level the lesion is located?

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3. Which complications can accompany this dise-

ase?

4.What is the most informative examination that can be appointed?

5.Assign treatment.

6.What is the prognosis of the disease?

Case10

A full-term boy was born from a 32-year-old woman, first spontaneous deliver, in cephalic presentation. Narrowed pelvis I degree. Stimulation of oxytocin due to secondary uterine inertia, first period – 12 hour, second period – 1 hour 10 minutes, forceps delivery. Weight 3,890 g., length 53 cm, Apgar score 7/8 points. After birth, there was a generic swelling and bruising of parietal-occipital region. 5 hours after the birth the child was anxious, unquiet, did not sleep, motor agitation, cephalhematoma of the right parietal bone. At the age of 11 hours, the condition was very severe due to neurological symptoms: repeated tonic-clonic seizures, hypotonia S < D, apnea, bradycardia. Pupils S < D. There was a progressive decrease in blood pressure that required cardiotonic support. The child was on mechanical ventilation, did not respond to any stimuli.

CBC: Hb – 150 g/l, RBC – 4.3x1012/l, WBC – 15x109/l, segment – 60%, stab – 4%, lymphocytes – 28%, eosinophils – 2%, monocytes – 6%, trombocytes – 260x109/l, ESR 3 mm/h.

ABB: pH 7, 29; pO2 48 mm Hg, pCO2 44 mm Hg, BE – 5.8, lactate level – 3.2, glucose – 2.3, ionized Ca – 0, 95.

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Questions:

1.Diagnose.

2.Define risk factors for this disease.

3.Does high-resolution computed tomography has diagnostic advantages compared with NCG (neurosonography) in this case?

4.Which changes in the cerebrospinal fluid are characteristic for this disease?

5.Which additional instrumental examinations are necessary for the diagnosis?

Case 11

A boy was born from a 32-year-old woman in term, spontaneous delivery in cephalic presentation. Stimulation of oxytocin due to secondary uterine inertia; 1st period 12 hours, 2 period – 30 minutes, anhydrous period 15 hours. Birth weight 3,890 g, lenght 53 cm, Apgar score 7/8 points. Satisfactory condition after birth, there was a generic swelling and bruising of parietal-occipital region. 1 day after birth, the baby was anxious, unquiet, sharp cry, greedily sucks, spits sucked milk, and sleeps poorly, motor agitation. At the age of 2 days – hypersensitivity, increased muscle tone, lively reflexes, T 38.9°C, weight 3,610 g. Subicterus skin, lungs breathing evenly, no wheezing, RR 58 per min, heart sounds were muffled, regular rhythm, HR 160 per min, the abdomen is soft, liver +1.5 cm, spleen at the costal margin, stool – transition, urine bright. During examination clonictonic seizures were noticed.

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In the clinical test of blood (Age 1 day) Hb 187 g/l, erythrocytes 4.8x10¹²/l, WBC 18x109/l, segment – 58%, stab – 10%, lymphocytes 24%, Eosinophils 2%, monocytes 6%, platelets 260x100/l, ESR mm 3/hour.

ABB: pH – 7.32, pO2 – 48 mm Hg, pCO2 – 44 mm Hg, BE – 2.8, SatO2 92%, lactate 1.2, glucose 4.3, ionized calcium – 1.05.

Analysis of the cerebrospinal fluid in the age two days of life: color-bloody, slightly cloudy, sugar 1.6 mmo/l, protein 2,2 g/l, cell count 300 (90% red blood cells).

Procalcitonin 1.2 ng/ml.

Questions:

1.Preliminary diagnosis.

2.Risk factors for this disease.

3.Which additional instrumental examinations are necessary for the diagnosis?

4.Describe the CBC.

5.Prognosis.

Diagnostic keys

1.Birth asphyxia, moderate. Cerebral ischemia (perinatal hypoxic brain injury) I degree, depression syndrome. Apgar 5/7 points.

2.Perinatal asphyxia, severe degree. Apgar 5/3

points.

3.Birth asphyxia, severe degree. Cerebral ischemia is severe, II stage, depression syndrome, convulsions, muscle dystonia syndrome, hypoxic nephropathy. Apgar 3/5 points.

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4.Hypoxic-traumatic CNS: hyperexcitability syndrome, moderate, acute period. Kefalogematomy of left parietal region, mild.

5.Cerebral ischemia II degree: hyperexcitability syndrome, muscular dystonia syndrome, syndrome of vegetative-visceral dysfunction. Pylorospasm. Intestinal colic. Prematurity 37 weeks.

6.Fetal hypoxia. Birth asphyxia, severe. III degree of cerebral ischemia, depression syndrome. Prematurity 36-37 weeks. Intrauterine growth retardation. Apgar 3/6 points.

7.Perinatal hypoxic-hemorrhagic damage of CNS III degree: periventricular hemorrhage; depression syndrome, convulsions, hypertension-hydrocephalic syndrome. Prematurity 32-33 weeks.

8.Traumatic of brachial plexus. Proximal (upper) palsy, Erb-Duchenne type, right, moderate; dislocation of the humeral head?

9.Hypoxic-traumatic damage of CNS I degree: depression syndrome, acute period. Traumatic of brachial plexus. Distal (lower) paresis of the left, Dejerine Klumpke's syndrome.

10.Traumatic lesions of the CNS, epidural hemorrhage, convulsions, depression syndrome unconditioned reflex activity, acute period. Kefalogematomy of right parietal region. Fracture of the right parietal bone?

11.Traumatic lesions of CNS, subarachnoid hemorrhage, convulsions, acute period.

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2.Which reasons can cause disease? How to confirm them?

3.What should be the tactic of treatment?

4.Does this child need hospitalization?

5.What is the amount of food this child should receive daily?

6.Write nutrition recommendations and feeding schedule

Case 2

A boy, 1.5 months old. He was born from the first pregnancy, healthy mother 24 years old, in the second trimester of pregnancy iron deficiency anemia (received iron drugs), in the third trimester suffered nephropathy. The baby was born at 39 weeks. Delivery occurred without complication. Birth weight 3,500 g, body length – 52 cm, Apgar score 8/9 points. Breast feeding on demand. From the age of 3 weeks, after feeding, the baby started vomiting (often "fountain"), it began by 1-2 times a day, then up to 2-3 times a day. Vomiting happened every day. Vomit with putrid smell, its amount was greater than the intakes of food. Body temperature with tendency to hypothermia, appetite is good, stool with tendency to constipation.

On admission: body weight – 3,800 g. The subcutaneous fat layer is practically absent on the abdomen, reduced on the chest, hips and shoulders. The weight curve is moderately flat, index Chulitsky – 5. Body length – 57 cm, skin was pale with a greyish

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tinge. Palpation of abdomen-formation of the pyloric region of the stomach, visible peristalsis.

Questions:

1.Does the weight of the child correspond to the child’s calendar age?

2.Which disease in the child can be assumed?

3.Does this child need hospitalization?

4.What are your steps to confirm the diagnosis?

5.What should be the tactic of management?

6.Recommendations for therapy and rehabilita-

tion.

Case 3

A girl is 2 months old. She was born from the first pregnancy, healthy mother 20 years old, at 39 weeks. Delivery occurred without complication. Duration of labor 3 hours. She was born with cord entanglement around his neck. Birth weight 3,500 g, length – 52cm, Apgar score 4/6 points. Breast feeding on demand. The child was restless, often screaming. From the birth of the girl regurgitation after feeding was observed, vomiting occurred periodically. Vomit had a sour smell, its amount was less than the intake quantity of milk. Vomiting was not regular, and there were days when regurgitation and vomiting did not occur. Body weight of the child in 2 months – 4,500 g, reduction in tissue turgor, Chulitsky index was 10. In previous 2 months, the child was not ill.

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