Практикум по педиатрии. Practicum in Pediatrics. Учебное пособие для студентов 5-го курса
.pdf6. How often we should monitor the level of Ca in the blood?
Case 8
A girl 5 years old was born from II in term pregnancy, birth weight – 3,600 g. The child’s mother and her cousins up to the age of 3 years had deformation of the lower extremities. No investigations were carried out. According to the parents, deformation of the lower extremities in this child appeared from the age of 1 year 3 months, after she began to walk independently. Adequate prevention of rickets was not carried out (received vitamin D2 in the first year for a total of 1 month.). First orthopedic examination at 1.5 years, diagnosed post rachitic Varus deformity of the lower extremities, appointed physical therapy, massage, heat treatment, multi-vitamins, UVR.
On examination, there is flattening of the neck, chest deformity, funnel-shaped, with the expanded aperture edges, "rachitic rosary", "bracelets". Humeral and forearm bones have saber form. Severe varus deformity of the hips, legs, more right limb, valgus ankle. Walking is difficult. Intelligence is not affected.
Biochemical test of blood: Ca = 2.2 mmol/l, P = 0,3 mmol/l, alkaline phosphatase = 1485 IU, in the analysis of urine increased of the amount of phosphates. On radiographs: varus deformity of the bones of the hips and legs, the growth zone expanded loosened. Moderate diffuse osteoporosis.
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Questions:
1.Place a preliminary diagnosis and justify it.
2.What are the causes and the mechanism of this disease?
3.Which additional investigation does this child
need?
4.Which specialists should be consulted and observe the child in the future?
5.Differential diagnosis.
6.What are the principles of treatment of this disease?
Case 9
A girl 4 days old was admitted to the neonatal pathology unit with a diagnosis of "intestinal bleeding". The child was born from I pregnancy which occurred with preeclampsia at second half of pregnancy, the mother was treated in a hospital. Birth at 37 weeks, anhydrous period 5 hours. Birth weight 2,400 g, length 45 cm, Apgar score 7/8 points. The state at birth was moderate. Breast-feeding from the first day. On the third day of life dark tar stool appeared, and therefore, 0.3 ml of 1% solution Vicasolum and epsilon-aminocaproic acid was administrated. On the 4th day of life coffee-ground vomit was observed, melena persisted, in this connection, the child was transferred from to the hospital.
On examination: the girl's condition was moderate, lethargy. Newborn reflexes are depressed. Sucks weakly, quickly falls asleep. Skin is icterus, marble pattern, clean. Morphological and functional signs of
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immaturity: a low positioned umbilical ring, lanugo, gaping genital slit. Muscle tone quickly exhausted, tremor of the hands. In the lungs there is no wheezing. Heart tones are rhythmic. Abdomen is soft and painless liver +2 cm, spleen was not palpable. Melena, urine is transparency.
CBC: Hb 180 g/l, RBC 5.2х1012/l, thrombocytes 320x109/l, WBC 17.4x109/l, stab 3%, segment 42% segmented, 46% lymphocytes, 9% monocytes, ESR 3mm/hour.
The clotting time by Bürker – start – 3.5 minutes, end – 7 min (normal clotting time by Bürker: Start – 2.5 min, end – 5 minutes). Bleeding time by Duque – 2 minutes (normal 2-3 min).
Questions:
1.Place a preliminary diagnosis and justify it.
2.Which factors could lead to the development of this disease?
3.Evaluate the results of CBC.
4.Which investigation does this child need?
5.The consultations of what specialists does the child need?
6.Differential diagnosis.
7.Assign treatment.
Diagnostic keys
1.Rickets II degree, acute course.
2.Rickets I degree, initial period, acute course.
3.Rickets II degree.
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4.Rickets III degree, iron deficiency anemia, acute respiratory viral infections, obstructive bronchitis.
5.Spasmophilia, rickets III degree, delayed of psychomotor development.
6.Viral respiratory infections, acute bronchitis. Rickets I-II degree. Spasmophilia.
7.Hypervitaminosis D. Rickets II degree, convalescence. Hypotrophy I degree.
8.Phosphate diabetes.
9.Hemorrhagic disease of the newborn. Morphofunctional immaturity. Hypoxic damage of CNS II degree, depression syndrome. Jaundice. Intrauterine growth retardation II degree.
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4. ANEMIA
Case 1
A girl 10 months old admitted to the hospital with complaints, from the words of her mother, of being pale, loss of appetite, lethargy. She was born at term (weight 3,300 g, length 49 cm), 1 pregnancy, occurring with toxicosis. From 3.5 months on artificial feeding, fruit and berry juices, but she didn’t get vegetables and meat. From 5 months, mainly fed with porridge, in her diet semolina porridge dominated. She could hold her head from 3 months, sit from 9 months. First teeth erupted at 8 months, she had only 2 teeth.
On examination: tearfulness, lethargy. Skin is pale, a bit dry. Pale mucous membranes, cracks in the corners of the mouth, pharynx is pink. Muscular hypotonia. Hair-thin, dull. RR 44 per min. Cardiac sounds rhythmical, moderately muffled heart tones, HR 142 per min, at the apex of heart – systolic murmur. Liver + 3 cm, the edge is smooth. Spleen is not palpable.
Complete blood count:
RBC – 2,8x1012/l |
RDV > 17 % |
(normal 3.80-4.90x1012/l), |
(normal 11.6-14.8%), |
Hb – 76 g/l |
Reticulocytes – 2.8%, |
(normal 115-145 g/l), |
Stab neutrophils – 2%, |
|
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WBC – 13.2 x109/l,
Ht 21% (normal 33.0-41.0%), MCV – 75
(normal 75.0-87.0), MCH – 27
(normal 27.0-31.0), MCHC – 10.3 (normal 32.0-37.0).
Segmented neutrophils – 29%,
Lymphocytes – 57%, Monocytes – 8%, Eosinophils – 1%, ESR 20 mm/hour.
Questions:
1.Formulate a preliminary diagnosis and justify it.
2.What are the possible causes of the disease and the risk factors?
3.Suggest a plan of further investigation.
4.Assign diet, drug therapy.
5.What is the duration of drug therapy?
6.How to conduct monitoring of the effectiveness of treatment?
7.Should we continue the treatment after the normalization of HB?
8.How to carry out prevention of this disease?
Case 2
A girl 14 years old was admitted to the hospital with complaints of weakness, epigastric pain, loss of appetite, headache, dizziness, recurrent fainting, and burning sensation in the tongue, taste perversion, fragility of hair and nails, nocturnal enuresis.
From anamnesis: menstruation from 12 years prolonged, from 13.5 years dizziness, fainting, last 2 months menstruation was absent.
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Objectively: super-nutrition, skin alabaster pale, wet, expressed vascular pattern. HR 82 per min symmetric rhythmic, satisfactory filling. The upper border of relative heart dullness – III rib, left border – left mammary line, right border – midpoint between the right edge of the sternum and the parasternal line. Stomach was painless on palpation. Liver at costal arch, spleen is not palpable.
Complete blood count:
RBC – 3,2x1012/l |
Stab neutrophils – 2%, |
(normal 3.80-4.90x1012/l), |
Segmented neutrophils – |
Hb – 85 g/l |
58%, |
(normal 120-140 g/l), |
Lymphocytes – 30%, |
Color index – 0,79, |
Monocytes – 7%, |
WBC – 4,2x109/l, |
Eosinophils – 3%, |
|
ESR 12 mm/hour. |
anisocytosis, poikilocytosis, hypochromia.
Questions:
1.Formulate a preliminary diagnosis and justify it.
2.What are the possible causes of the disease and the risk factors?
3.Make a plan for further investigation.
4.Assign diet and treatment.
5.How to carry out prevention of this disease?
Case 3
A 3-year-old boy admitted with complaints of severe weakness, pale skin, loss of appetite. The boy was born in term from third, physiological pregnancy.
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Birth weight 3,500 g, length 50 cm. From birth was on artificial feeding. He holds his head from 4 months. At the first year he did not walk, did not have enough vocabulary, the first teeth erupted at 8 months.
On examination: body weight 12 kg, length 90 cm, pale skin, with earthy shade, head shape "tower skull", mongoloid face type (broad low nasal bridge, protruding cheekbones). HR 110 per min, satisfactory filling. Heart borders: upper – 2-nd rib, left – midclavicular line, right – 0.5 cm laterally from the right parasternal line. Cardiac sounds rhythmical, at the apex of heart – soft systolic murmur. Stomach increased in volume, liver +3, smooth, spleen +7 cm.
Complete blood count:
Hb – 30 g/l,
RBC – 1,5x1012/l, color index – 0,6, MCV – 73
(normal 75.0-87.0), MCH – 20
(normal 27.0-31.0), MCHC – 27 (normal 32.0-37.0), RDV > 18%
(normal 11.6-14.8%), WBC – 10,0 x109/l,
Stab neutrophils – 11%, Segmented neutrophils – 38%,
Eosinophils – 3%,
Monocytes 2 %, Lymphocytes – 40%, ESR 40 mm/hour, Ht – 11%, Reticulocytes – 4%, poikilocytosis + + +, anisocytosis + + +.
Minimum osmotic resistance of the erythrocytes – 0.56% solution of NaCl, maximum – 0.24% solution of NaCl. (The norm of minimum resistance of erythrocytes 0.45-0.50%, maximum – 0.35-0.40% solution of NaCl.)
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Questions:
1.Formulate a preliminary diagnosis and justify it.
2.Name the characteristic features of the disease and the mechanism of the pathological processes in the body of the child.
3.Make a plan for further investigation.
4.Which changes can you see in additional investigations?
5.What are the principles of treatment of this disease?
Case 4
A boy 6 months old, was admitted to the hospital with complaints of pale skin, asthenia, and loss of appetite. The child was born prematurely from first pregnancy which was with toxicosis in the second half. From 2 months was on artificial feeding (goat milk). At the age of 3 months had an acute intestinal infection, from 4 months. – dysbiosis. Pale skin with lemonyellow shade, subicterus sclera. On the tongue – bright red patches of inflammation that are sensitive to food intake. HR 100 per min, symmetric, satisfactory filling. Muffled heart tones, no murmur. The borders of the heart were normal. Liver +2, spleen is not palpable.
Complete blood count:
Hemoglobin – 105 g/l, |
Segmented neutrophils – |
Erythrocytes – 2.8x1012/l, |
32%, |
Color index – 1.1, |
Eosinophils – 3%, |
WBC – 5.6 x109/l, |
3% monocytes, |
|
Lymphocytes – 72%, |
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ESR 4 mm/hour, Reticulocytes – 6%, poikilocytosis + + +
Questions:
macrocytosis + + +, megaloblasts + +, Jolly cells.
1.Place a preliminary diagnosis and justify it.
2.What are the risk factors and mechanisms of disease?
3.Make a plan for further investigation.
4.Prescribe treatment and supportive therapy.
5.Name the remission hematologic criteria.
6.Differential diagnosis
Case 5
A 4-year-old girl was admitted to the hospital with complaints of severe weakness, a feeling of heaviness in the left hypochondrium, jaundice of the skin.
From anamnesis: the child was born from second physiological pregnancy, delivery in term. Birth weight 3,100 g, length 50 cm. From 2.5 months – recurring jaundice of varying severity, not accompanied by discoloration of feces or urine, and without skin itch. The mother has cholelithiasis in anamnesis with episodes of jaundice. Earlier, the girl hasn’t been exanimated.
On admission: girl’s condition is severe. Expressed abdominal pain. Skin has an intense yellow color, with icterus of scleral. Liver +3 cm, the edge is smooth, soft. Spleen +7 cm, painless on palpation.
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