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

Questions:

1.Does the weight of the child correspond to the child’s calendar age? If not, then what is the deficit in body weight?

2.What is the presumptive diagnosis? Which reasons can cause disease?

3.What are your steps to confirm the presumptive diagnosis?

4.What should be the tactic of management?

5.Does this child need drugs?

6.Write nutrition recommendations for the mother.

Case 4

A boy, 6 months old, was born from a young healthy mother with birth weight 3,400 g, length 51 cm, Apgar score 9/10 points. On mixed feeding from 3 months of age. The appetite of the child was not affected. Fed 5 times daily with a 6-hour night break: 3 times got milk and 2 times formula "Nutrilon". He didn’t receive weaning food. Body weight in 6 months – 6,500 g, length – 57 cm

Examination: skin fold on the belly about 0.5 cm, the index Chulitsky is 8, lethargy, frequent negative emotions.

Questions:

1. Are reference values of the weight of the child normal or not? Put the diagnosis and justify.

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2.Does this child eat normally? What should be done to normalize the nutrition of this child? Does this child need drugs?

3.What should be the scheme of treatment for this child?

4.Write nutrition recommendations for the mother.

Case 5

A boy was 10 months old. He was born from the 1st of pregnancy, the 25-year-old mother in the first trimester of the pregnancy was suffering from iron deficiency anemia, moderate severity. Child birth – 41 week of gestation, physiological. Body weight at birth – 3,100 g, length – 50 cm. Apgar score at birth – 8/9 points. From the age of 1 month was on artificial feeding, dry-adapted formulas. Physical and psychological development was according to the age. It is known that at the age of 6 months the child's body weight was 7,900 g, length – 67 cm.

At the age of 9 months the child suffered upper respiratory infection, complicated by bilateral pneumonia, polysegmental. Loss of appetite, which was disrupted throughout the next month.

At the age of 10 months, his body weight was 8,000 g, length – 74 cm, he got adapted milk formula "Nutrilon", crackers, cookies, vegetable puree, meat, porridge, curd, apple juice. The child’s condition was satisfactory. The subcutaneous fat layer was reduced on the abdomen. Skin fold on belly 0.5 cm, Chulitsky

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index was 16. The boy was active, excitable. Locomotors and psychological development were according to the age.

Questions:

1.Does the weight of the child correspond to the child’s calendar age? Justify the diagnosis. Which reasons can cause disease?

2.Does this child eat rationally? What should be done to normalize the nutrition of this child? What are the ways to achieve the desired result?

3.Does this child need drugs?

4.Write nutrition recommendations for the mother.

Case 6

A 3-month-old girl was born from 2nd pregnancy (the first ended in abortion), from a healthy 20-year- old mother, the pregnancy was without complications. Childbirth – at 40th-week, childbirth physiological. Birth weight 3,500 g, length 51 cm, Apgar score 9/10 points. On breast feeding. From the age of 3-weeks the baby vomited after feeding. Vomiting was not regular, but frequent, sucks well. Developmental delays were observed. Body weight at 3 months – 6,500 g, the subcutaneous fat layer is well developed, skin fold on the belly is 2.5 cm, Chulitsky index was 36. Skin is pink, clean. Abnormalities of internal organs were not observed.

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Questions:

1.Does the weight of the child correspond to the child calendar age? Justify your assumption.

2.Does this child need to be hospitalized?

3.What should be the tactic of management?

4.Write nutrition recommendations for the mother.

5.Which consequences in adulthood can the disease have?

Case 7

Mother with her boy, who was 1 month old, went to the clinic with complaints about the child’s anxiety, poor weight gain.

From anamnesis we know that the child was from normal pregnancy, II in term delivery. Birth weight of 3,600 g., length 54 cm, on breast feeding up to 2 weeks – due to the sudden anxiety of the child during and after feeding (didn’t want to eat, shouting, strained legs pulled up to his stomach, "seething" belly) mother thought that she didn’t have enough milk to feed the baby, she stopped and transferred him to artificial milk formula “Nutrilon comfort”, according to the advice of the pediatrician. However, after receiving the formula, he continued to cry, shout, was nervous during and after feeding.

On examination: the child’s condition was of moderate severity, active. The child's weight was 3,500 g., length 57 cm. The skin was pale pink, clean, somewhat dry. Subcutaneous fat on the belly was 0.5 cm, 1.5 cm at the shoulder, on thigh 2 cm, tissue turgor slightly reduced. Increased of muscle

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tone in flexors. Mucous membrane was pink and clean. In the lungs, breath held in all departments, no wheezing. Heart sounds were loud, rhythmic. The abdomen was swollen, tense, slightly painful on palpation, hums, swollen bowel loops are also palpable. Liquid stool, yellow, white lumps of foam, "shoot" like, sour smell.

Questions:

1.Rate the physical development of this child.

2.Place a preliminary diagnosis. Justify. What caused the child's condition?

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

4.Did the mother behave correctly when she stopped breastfeeding ? Which advice should be given to the mother while breastfeeding was kept?

5.Differential diagnosis.

6.Assign treatment. What is the duration of therapy? What are the criteria for the effectiveness of therapy?

Case 8

A 1-year-old girl was admitted to the hospital for treatment and examination regarding the expressed edema syndrome. The mother is a young healthy student of the technical college; she lived in the central zone of the European part of Russia. The girl was

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born from the first pregnancy; delivery proceeded physiologically at 40th week of gestation. Birth weight 3,000 g, from the age of 2 months – bottle-fed. Up to 6 months of age, the girl grew and developed normally, was raised by her mother and lived in Moscow. When the child was 6 months old, her mother decided to return to the college, so she sent the girl to her grandmother, who lived in the village, and had a goat on the farm. Since the child was bottle-fed, the grandmother decided to feed the baby with goat milk. The child received milk in the form of unadapted mixture which composition was the following: ⅓ of goat milk with ⅔ cereal decoction (usually rice) until the age of 1 year. The mother returned back and noticed negative changes in the child’s health.

The body weight of the child on admission to the hospital was 10.5 kg, height – 70 cm, expressed edema syndrome (anasarca). The skin was pale, clean and thin. The hair was of medium thickness. Expression of pain on her face, lethargy.

Urine test was within norm.

Biochemical test of blood: total serum protein 2.8 g/l, albumin – 32%.

Questions:

1.Which diagnosis can be in this baby?

2.Which reasons caused this disease?

3.Did this child need to be hospitalized?

4.What should be the tactic of management?

5.Write nutrition recommendations for the mother.

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Case 9

A boy at the age of 5 days was admitted to emergency department at Children's Hospital with complaints of fever, lethargy, drowsiness, refusal to eat.

From anamnesis we know that the baby was from first pregnancy, which occurred with the threat of interruption in the 1st trimester. The mother smoked during pregnancy, at women's clinic was observed from 28 weeks, infections were not found. The mother’s blood group II (Two), Rh-positive. Delivery in term, weight 2,480 g, length 49 cm, cried directly. The baby was discharged from maternity clinic on the third day. Breast feeding from birth.

On examination: the child’s condition was severe. Temperature 38,5oC, lethargy. The weight was 2,500 g. Skin was icterus, dry and clean. Subcutaneous fat layer was thinned on the trunk and extremities. Tissue turgor was decreased. Sclera and conjunctiva were icteric. Mucous membranes of the mouth were dry. Auscultationbreathing normally, no wheezing. Heart sounds were loud, rhythmic. Abdomen was swollen, soft and painless. Liver +3 cm, spleen was not enlarged.

Value of bilirubin by bilitest was – 230-

240mmol/l.

Questions:

1.Write preliminary diagnosis and justify it.

2.Why was the child’s condition severe?

3.What was the reason of fever?

4.Make a plan of investigation.

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5.Assign treatment.

6.Which consequences in adulthood can the disease have?

Case 10

A girl of 1 year and 3 months old, admitted to the hospital with complaints of anxiety, loss of appetite, weight loss, soft stool 4 times a day.

From anamnesis we know that the child was born in term by Caesarean section. Birth weight 4,200 g, length 54 cm. Apgar score 8/9 points. On breast feeding up to 4 months, then adapted artificial milk formula "Nutrilak". Allergic reactions were not noted. Stool was normal. The girl grew up and developed according to her age: held her head from 2.5 months. She began to turn over on her belly from 4 months, on her back from 5 months, sat down on her own at 6.5 months, stood up with support at 8.5 months. Body weight at 6 months 8,200 g, length 68 cm. Received weaning food from 5 months, vegetable puree from 6 months, rice porridge, and then buckwheat, oatmeal, curd, from 7 months, mashed potatoes. Juices and fruit puree she got from 4 months. From 8 months received multi-cereals and wheat porridge. Stool was a child mushy. At 9 months the girl suffered URI, with loose stools. Received Creon, Bifidobakterin, but the stool remained liquid and became frothy, foul-smelling, and light, with an unpleasant smell, to 7 times a day. The girl began to lose weight.

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On examination: the child's condition was severe, lethargy, tearful, irritable. Body weight of 7,500 g, height 71 cm. Could sit, lean forward, but couldn’t sit down or stand up. Skin was pale, marble, dry, pigmentation on the chest. Skin folds returned back slowly. Tissue turgor drastically reduced. Subcutaneous fat layer was absent on the trunk, abdomen and extremities. Swelling of the feet, pastosity of legs and back. Ribs, rib rosary were seen. Head with enlarged frontal and parietal hillocks, on the hands and feet bone deformation (bracelets). Muscle tone was reduced. Mucous membranes were pale and dry. Cracks in the corners of the mouth. Tongue with flattened papillae. Teeth 2/2. In the lungs, harsh breathing, no wheezing. Heart sounds were muffled, systolic murmur at the apex. Belly increased in volume, dramatically swollen ("spider" like), moderately painful on palpation in all parts. Liver +3.5 cm, difficult while palpating.

CBC: Hb 98 g/l, RBCs 3.5х1012/l, Color index- 0.84, WBC 10.3x109/l, ESR 15 mm/hr.

General test of urine: reaction is acid, relative density – 1.006, protein – abs, glucose – abs, WBC – 1-2 in vision

Coprogram: unformed, mushy, yellow, connective tissue – abs, muscle fibers – little, neutral fat – single, fatty acids – a lot, undigested fiber – small amount, starch – a lot, leukocytes, red blood cells, epithelium – abs, no eggs of worms and protozoa, – are not found.

Questions:

1. Rate the physical development of this child.

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2.Place a preliminary diagnosis. Jusify. What is the cause of the child's condition?

3.What is the cause of the edema syndrome in this child?

4.Rate the blood, urine, coprogram.

5.Which additional examination should be carried out to confirm the diagnosis?

6.Differential diagnosis.

7.Assign treatment plan for this child.

8.What is the prognosis of this disease?

Case 11

A child of 5 years old was sent for examination to the hospital with suspected malabsorption syndrome, chronic gastroenterocolitis.

From anamnesis we know that the child was born in term from second pregnancy that occurred with toxicosis and anemia at the first half. Birth weight 3,100 g, length 49 cm, Apgar score 8/9 points. In the neonatal period – surgery of meconium ileus, prolonged jaundice. In the first year-poor weight gain (weight 8600 g) suffered anemia, rickets II degree subacute phase, 2 times upper respiratory infection with prolonged course. After the age of 1 year the child often had respiratory diseases (monthly). Did not attend pre-school facilities. From the age of 4 years, adenoiditis, recurrent sinusitis. Porr weight gain. Appetite was good. Bulky stool 2-3 times a day. It is known that the child’s cousin of 1.5 years old had persistent malnutrition of II degree.

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