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

On examination: body weight 13,5 kg, length 106 cm, skin is pale, cyanosis around the eyes, dry cracks in the corners of the mouth. Subcutaneous fat layer is weak on the trunk and extremities. Tongue is bright, dry. Muco-purulent discharge on the back of the throat. Nasal breathing is difficult. Submandibular lymph nodes are enlarged up to 1 cm, in the lungs breathing is harsh, no wheezing. Heart sounds are loud, rhythmic. The abdomen is slightly swollen, moderately painful in the right upper quadrant. Liver +2.5 cm, edge is smooth, sharp. Ortner symptom is positive, Kerr. The spleen is not enlarged. Urination is not changed.

Blood test: 105 g Hb/l, WBC 7.4x109/l, ESR 20 mm/hr.

Coprogram: myofibers +, neutral fat +++, fatty acid ++, starch intracellular +, starch extracellular +.

Questions:

1.Rate the physical development of this child.

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

3.Rate the blood, urine, coprogram.

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

5.Differential diagnosis.

6.Assign treatment plan for this child.

7.What is the prognosis of this disease?

Diagnostic keys

1. Hypotrophy I degree. Deficit 12.5%.

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2.Congenital pyloric stenosis. Deficit 20%.

3.Hypotrophy I degree. Pylorospasm. Deficit

11.8%.

4.Hypotrophy I degree. Deficit 14.5%

5.Hypotrophy I degree.

6.Vomiting associated with overfeeding. Paratrophy.

7.Primary congenital lactase deficiency? Hypotrophy I degree. Deficit 16.7%.

8.Hypotrophy III degree, protein-free nutritional edema etiology.

9.Intrauterine growth retardation, by hypotrophic type, I degree. Hyperbilirubinemia. Hyperthermic syndrome early neonatal period. Pathological loss of body weight. Exsicosis I degree.

10.Celiac disease, an active period. Hypotrophy III degree. Anemia, hypochromic, mild. Rickets II degree, subacute. Polyhypovitaminosis (A, B, C, PP, D, E). Delayed of motor development. The deficit of 31.8%.

11.Cystic fibrosis, intestinal form. Macular II severity. Mild anemia. Polyhypovitaminosis (A, B, C). Adenoids. Recurrent sinusitis. Biliary dyskinesia. deficit 25%

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Questions:

1.Place a preliminary diagnosis. Set the severity and period of the course of the disease.

2.Which factors could cause the disease?

3.Rate the physical development of the child.

4.Which additional examination should be carried out?

5.Assign treatment.

Case 2

A girl two months old was admitted to the hospital. The mother said that the child was recently flinch, restless, slept anxiously, often screamed and woke up. After sleeping on the pillow, it became wet with sour smell of sweat. On skin small intertrigo in the inguinal folds, balding at on the occipital region, edges of fontanelle were slightly large. The child wsa on breast feeding. Weight 4,800 g. From records we know that the child from normally proceeding pregnancy, healthy parents, birth weight 3,300 g, length 50 cm. She hasn’t been ill.

Questions:

1.Your clinical diagnosis.

2.What is the cause of neurological symptoms?

3.What is the scheme of investigation?

4.Assign treatment.

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Case 3

A child 4 months old was born from young, healthy parents, born in term, in spring. Birth weight 3,850 g, length 50 cm. He was on breast feeding up to 1.5 months, then artificial. In the last two months, the child was anxious, increased in sweating. On examination, baldness of occipital flattening of the skull bones, softening along the sagittal suture, soft focus of the parietal bone 0.8-0.9 cm in diameter. Muscle tone is sharply reduced. Hyperesthesia. Sportiness on the legs is missing. Abdomen is flattened. Tissue turgor decreased. RR 28 per min, cardiac tones clear, rhythmic. Liver +3.5 cm, stool with a tendency to constipation.

Questions:

1.Place a preliminary diagnosis.

2.What causes it?

3.Which biochemical parameters can confirm the diagnosis?

4.Assign treatment.

5.Which laboratory values can be used to monitor the effectiveness of treatment?

Case 4

A child 12 months old was admitted in serious condition with a cough, shortness of breath, severe weakness and muscle hypotonia. He was born in term from first pregnancy occurred with nephropa-

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thy. Breast feeding from birth. Started to get supplementary food from 10 months – mainly semolina porridge. In Moscow lives illegally, so the child has not been observed in the children's clinic, rarely has been outdoors.

On examination, temperature 37.4oC. The child couldn’t sit by himself or stand. When sitting, he tilts his body forward, touching his legs with forehead. Body weight 8,200 g, length 71 cm. The skin is dry, pale mucous membranes of the mouth. Teeth – 0/2, are broken off at the level of its necks, with enamel defects. Head with expressed deformities – taper neck, flattening in the parietal-temporal areas, more on the right. "Chicken chest". The lower thoracic deployed. Ribs are palpable. Thickening in the wrist and ankle areas. Sprawled abdomen. Noisy breathing with prolonged exhalation. Auscultation dry wheezing. The borders of the heart are not enlarged. Heart sounds are rhythmic, systolic murmur at the apex. Liver +4 cm, spleen +2 cm. “Sheep dung” stools 1 time every 2 days,. The child is not interested in others, speech delay.

CBC: Hb. 100 g/l, RBC 3.5, WBC 7.5, stab 2%, segment 31%, eosinophil 1%, lymphocytes – 63%, monocytes – 3%, ESR – 10 mm/hour.

Urine test without pathology.

Biochemical test of blood: Protein 65 g/l, Cholesterol 4.6 mg/l, calcium – 1.8 mmol/l, phosphorus – 1.1 mmol/l, alkaline phosphatase 950 U/l (normal 600), serum iron 5.6 mmol/l, TIBC 79 mmol/l.

Radiographs of long bones: osteoporosis, blurring and lack of clarity zones prior calcification, lack of ossification nuclei in the humeral head.

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Chest X-ray: focal and infiltrative changes in the lungs are not defined. Increasing of vascular pattern. The shadow of the heart is not enlarged.

Questions:

1.Place a preliminary diagnosis. Justify it.

2.Which factors contributed to the development of the disease?

3.Evaluate the results of additional testing.

4.Assign treatment. Does this child need antibiotic therapy?

Case 5

A girl 8 months old, in March was admitted to the neonatal department with severe tonic convulsions. From anamnesis we know that the girl was born from first pregnancy which occurred with toxicosis, hypotension, anemia, and cramps in the calf muscles. Delivery in term, weight 3,800 g, length 53 cm, from birth on artificial feeding. Complementary food from the fourth month. Currently gets porridge, vegetable purees, yogurt. From 5 months, diagnosed with rickets. Prescribed treatment was oily solution of vit D2.

On examination, the girl of high power, hydrocephalic head shape, expressed frontal and occipital protuberance. Craniotabes. Fontanel 2x2 cm, the edges malleable. Keeled form chest, the lower aperture deployed. Tissue turgor drastically reduced. Calf muscles are strain, "obstetrician’s hand" symptom.

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HR 150 per min. In the lungs bubbling rale. Sprawled abdomen. Liver +3 cm. Can sit only with support, can’t stand, periodically tonic convulsions.

Questions:

1.Formulate a preliminary diagnosis.

2.Which investigation should be carried out to confirm the diagnosis?

3.Which changes of calcium and phosphorus in the biochemical test of blood should be expected in this child?

4.Differential diagnosis?

5.Assign treatment

Case 6

A girl 8.5 months admitted to the hospital due to the sudden onset o of convulsions with apnea and cyanosis.

From anamnesis we know that the child was treated for 5 days from bronchitis. The night before that, monotonous cry observed, and then convulsions, which lasted 3 minutes.

On examination, actively resisted, suddenly shouted, after that apnea, respiratory arrest, there was a diffuse cyanosis, unconsciousness, tonic convulsions occurred, frowning face, stretching of lips, hands and legs. Tonic seizures were replaced to clonic, there was a snorting breath. After 3 minutes seizures stopped, the child regained consciousness and fell asleep. Temperature 36,0oC, pale skin. Fon-

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tanel does not pulsate, not burgling. Frontal bossing. Barrel-shaped chest, the sides are compressed, expressed Harrison's groove. Percussion of lungs-box sound. Breathing hard, dry rales are heard from both sides. Meningeal symptoms were detected.

CBC: Hb – 120 g/l, RBC 3.8, WBC 4.6, stab 2%, segment – 20%, eosinophil – 4%, lymphocytes – 64%, monocytes – 10%, ESR – 8 mm/h.

Urine test – no pathology.

Biochemical blood test: Protein 72 g/l, Cholesterol 3.3 mg/l, ionized calcium 0.6 mmol/l (normal 1.8-2.1), total calcium – 1.6 mmol/l (normal 1.8-2.1), phosphorus – 0.6 mmol/l (normal 0.6-1.6), alkaline phosphatase 920 U/l (normal up to 644 U/l).

Liquor: implies frequent drops, transparent, protein – 160 g/l, cytosis 2 in 3 μm, neutrophils – 0%, lymphocytes – 2%.

Questions:

1.Formulate a preliminary diagnosis.

2.Differential diagnosis.

3.Evaluate the results of the laboratory exami-

nation.

4.Which treatment should be appointed?

5.What is the prognosis for this child?

Case 7

A boy 7 months old admitted to the hospital from home with complaints of repeated vomiting, loss of appetite, constipation, fatigue, weakness.

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From anamnesis we know that the child was born in term from middle-aged mother, third pregnancy that occurred with nephropathy. Birth weight

6 months he has rickets II, received treatment (vitamin D). The mother by mistake, during the month gave the child 10 drops of vitamin D per day in combination with 1 teaspoon of fish oil 2 times daily.

On examination, the state is moderate, lethargic, and whiny. Repeated vomiting which has no relation to meals. Body weight 7,000 g, skin is pale, with expressed mottled, cyanosis under the eyes, "white spots" symptom. The skin and mucous membranes are dry. Subcutaneous fat layer is thinned on the trunk. Tension and muscle tissue is reduced. The skull is deformed, flattened parietal-occipital region more to the left. Fontanel 0,5x0,5 cm, thick edge. The chest is pressed from sides, rosary, Harrison's groove. Joint laxity, the child can’t sit or stand by himself. No teeth. Distended abdomen, liver +5 cm, the edge of the spleen is palpated. Liquid stool. Urination is rare, with the smell of acetone. In the investigation of urine for Sulkovich reaction is positive.

Questions:

1.Place a preliminary diagnosis and justify it.

2.Explain the development of the main symptoms of this disease.

3.Assign an examination plan.

4.What is the treatment plan?

5.What is the prognosis of this disease?

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