Практикум по педиатрии. Practicum in Pediatrics. Учебное пособие для студентов 5-го курса
.pdfUrine is straw-yellow color. Stool is brown. Noteworthy – heterochromia of irises, high standing of the gingival, narrow dental arches.
Complete blood count:
Hb – 68 g/l,
RBC – 2.04х1012/l, Ht – 14%,
MCV – 72
(normal 75.0-87.0), MCH – 33
(normal 25.0-31.0), MSHS – 37 (normal 32.0-37.0), RDV > 16%
(normal 11.6-14.8%),
Questions:
Color index – 1.0, WBC – 16x109/l, Stab neutrophils – 3%
Segmented neutrophils – 34%,
Eosinophils – 1%,
Monocytes 10%, Lymphocytes – 51%, ESR – 22 mm/hour microspherocytes +++
Reticulocytes – 8%.
1.Your diagnosis. Justify it.
2.What is the cause of severity of the child’s dis-
ease?
3.What is the genesis of the disease?
4.Make a plan for further investigation
5.Which medical actions are required for this patient?
Case 6
A 4-year-old boy admitted to the hospital with complaints of weakness, fatigue, yellow skin and sclera, change in urine color.
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Jaundice appeared the previous night, changing of urine color on the day of admission. From anamnesis: the child had follicularis angina, and therefore, received Biseptol (Sulfamethoxazole + Trimethoprim) 2 days.
Objectively: condition of the child severe, expressed lethargy and weakness. Skin, scleras are pale with jaundiced shade. Heart sounds are muffled, at the apex of heart – systolic murmur. Liver +2 cm, the edge is smooth, painless on palpation. Spleen +3 cm. Dark-red urine.
The boy was born in term, from physiological pregnancy, on artificial feeding from early age. Previously hasn’t been ill.
Complete blood count:
RBC– 2.27x1012/l |
RDV > 16% |
(normal 3.80-4.90h1012/l), |
(normal, 11.6-14.8%), |
Hb – 68 g/l |
Reticulocytes – 6%, |
(normal 120-145 g/l), |
Stab neutrophils – 1%, |
WBC – 8.0x109/l, |
Segmented neutrophils – |
Ht – 19% |
40%, |
(normal 33.0-41.0%), |
Lymphocytes – 55%, |
MCV – 84 |
Monocytes – 3%, |
(normal 75.0-87.0), |
Eosinophils – 1%, |
MCH – 30 |
ESR 10 mm/hour, |
(normal 25.0-31.0), |
anisocytosis + + +, |
MCHC – 35 |
poikilocytosis + + +, |
(normal 32.0-37.0), |
polychrome. |
Questions:
1.Formulate a preliminary diagnosis and justify it.
2.Name the causes of the disease.
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3.Make a plan for further investigation.
4.Prescribe treatment.
5.How to carry out prevention of this disease.
Case 7
A 6-year-old boy admitted to the hospital with complaints of skin pale, loss of appetite. The child was born in term from second pregnancy, occurring with toxicosis at II half. Birth weight 2,500 g, length 47 cm. The child’s mother and his older brother have anemia in anamnesis. Both children have stigmas: deformation of ears, microphthalmia, polydactyly, cryptorchidism.
From birth the child has had pale skin, continuous loss of appetite, recurrent dyspepsia. Up to 1 year the boy was breastfed, complementary feeding started on time. By 1 year, weight 7.5 kg, length 68 cm. The child often had URI. From birth in the peripheral blood – rates of erythrocytes and hemoglobin decreased.
Objective investigation: length 1m 10 cm, weight 16 kg. Skin and mucous membranes are pale, diffuse bronze-brown pigmentation on the skin, expressed in natural skin folds. The lymph nodes were not enlarged. HR 92 per min., satisfactory filling.
The borders of the heart are normal. Heart tones are muffled, systolic murmur at the apex. The liver and spleen were not enlarged.
Complete blood count:
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RBC – 2.7 x1012/l |
MCHC – 38 |
(normal 3.80-4.90x1012/l), |
(normal 32.0-37.0), |
Hb – 96 g/l |
RDV – 13% |
(normal 120-145 g / l), |
(normal 11.6-14.8%), |
WBC – 3.5 x109/l, |
Reticulocytes – 0,2 |
PLT – 100x109/l |
Stab neutrophils – 1%, |
(normal 150-450x109/l), |
Segmented neutrophils – |
Ht – 25% |
40%, |
(normal 33.0-41.0%), |
Lymphocytes – 55%, |
MCV – 92 |
Monocytes – 3%, |
(normal 75.0-87.0), |
Eosinophils – 1 %, |
MCH – 35 |
ESR 10 mm/hour. |
(normal 25.0-31.0), |
|
Questions:
1.Formulate a preliminary diagnosis and justify it.
2.What is the genesis of this disease?
3.Characterize the clinical test of blood
4.Make a plan for further investigation.
5.What are the principles of treatment of this disease?
6.What is the prognosis of this disease?
Case 8
A 38-day-old child was born premature at 32 weeks, from an 18-year-old woman who is suffering asthenic-neurotic syndrome with body weight deficiency, smoking during pregnancy. She had anemia at II-III trimesters. Birth weight 1,600 g, length 41 cm. Apgar score 6/7 points. At birth: state
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of moderate severity due to respiratory failure – shortness of breath, cyanosis, RR 70 per min. From the first hours of life, the child was on CPAP due to RDS, received infusion and antibiotic therapy. Enteral feeding started from the first day of life. RDS was stopped by the end of the early neonatal period, and the child was transferred to the II stage of nursing. At the age of 28 days, anemia was revealed, prescribed a course of iron supplements, folic acid, vitamin E, but there was no effect.
Complete blood count:
Hb – 80 g/l |
Segmented neutrophils 32% |
(N – 124-166 g /l), |
(N – 17-39%), |
RBC – 3.2x1012/l |
Stab neutrophils 1% |
(N – 4.1-5.3x1012/l), |
(N – 0.9-3.1%), |
Color index 0.8 |
Lymphocytes 55% |
Reticulocytes 2% |
(N – 46-70%), |
(N – 0.49-1.09%), |
Eosinophils 5% |
Ht – 35 |
(N – 1.8-6.2%), |
MCV – 90 (N – 80-94), |
Monocytes 7% |
MCH 32 (N – 27-31), |
(N – 4.2-11.8%), |
MCHC 33 (N – 32-36), |
Platelets 260x109/l |
Leukocytes 9.6x109/l |
(N – 214-366x109/l) |
(N – 7.6-12.4x109/l), |
ESR 5 mm/h |
|
(N – 3-7 mm/h). |
Questions:
1.Formulate a preliminary diagnosis.
2.What is the pathogenic mechanism of this disease.
3.Make a plan for further investigation.
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4.Which drugs are pathogenetically justified for this disease?
5.Is there any indication for transfusion of packed red blood cells? If yes, determine the volume of transfusion.
Diagnostic keys
1.Iron deficiency anemia.
2.Hypochromic iron deficiency anemia. Early juvenile chlorosis.
3.Thalassemia major.
4.B12, folic acid deficiency anemia
5.Severe hemolytic anemia, hereditary microspherocytic disease. Hemolytic crisis
6.Hemolytic anemia. Hemolytic crisis. Presumably the lack of glucose-6-phosphate dehydrogenase.
7.Hereditary aplastic anemia Fanconi.
8.Early anemia of prematurity.
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5. NEONATAL JAUNDICE
Case 1
A girl, 4 days of life, is in the neonatal department. From anamnesis we know that the child is from the first pregnancy which occurred with toxicosis during the first trimester. Childbirth was in term, went normally. Birth weight 3,200g, length 50 cm screamed at once. Apgar score 8/9 points. Breast feeding was applied immediately, sucked well. Icterus of the skin and mucous membranes appeared at the end of second day of life. She was vaccinated in the hospital against hepatitis B, BCG.
On examination: the child's condition is satisfactory, active. Screams loudly. Sucks well, rarely regurgitates. Flexion pose. Muscle tone is satisfactory. Neonatal reflexes are positive. Skin is clean, icteric, umbilical wound under hemorrhagic crust. Icteric of sclera, mucous of mouth and throat is noticed. In the lungs no wheezing, RR 38 per min. Heart sounds are rhythmic, HR 136 per min. The abdomen is soft and painless. Liver is +2 cm, painless. Spleen is not palpable. Stool is porridge-like, yellowish-green color. Urinating is normal.
The mother's blood is group A (II), Rh-positive. The child's blood group is 0 (I), Rh-negative. CBC: Hb 196 g/l, RBC 6x1012/l, WBC 16.5 x109/l,
PLT 286x109/l, stab – 1%, segment 45%, lymphocytes – 46%, monocytes – 6%, eosinophils – 2%, ESR 5 mm/hour.
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Biochemical analysis of blood: protein 68 g/l, total bilirubin 186 mmol/l, bilirubin direct – 9 mmol/l, ALT – 24 U/l, AST – 28/l, urea 5.6 mmol/l, Cholesterol 3.6 mmol/l.
Questions:
1.Diagnose.
2.Is development of hemolytic disease in this child due to the Rh factor or blood group?
3.Rate the laboratory tests.
4.Can you feed this child with his mother's milk?
5.Assign treatment.
6.What is the prognosis for this child?
Case 2
A boy, on the first day of life, was born from a 23-year-old mother, with second Rh-negative blood group. The first pregnancy ended in miscarriage at 13 weeks. This second pregnancy proceeded with toxicosis during the first trimester, threat of termination during the second trimester and preeclampsia at the third trimester. She attended the antenatal clinic regularly during pregnancy, general investigation was conducted. Childbirth was urgent, independent. First period – 7 hours, the second – 30 minutes, anhydrous period – 5 hours. Birth weight – 2,990 g, length – 50 cm, Apgar score 6/8 points. Immediately at birth was noted icteric staining of the skin, membranes, amniotic fluid, and umbilical cord, expressed signs of CNS depression syndrome, hepatosplenomegaly (3 cm
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liver, spleen 1.5 cm). Bilirubin in cord blood was 90 mmol/l. Hemoglobin level 120 g/l.
Questions:
1.About which diagnosis can we think?
2.What are the pathogenetic mechanisms of this condition?
3.What are the necessary urgent measures for treatment of this child?
4.Identify the indications for emergency treat-
ment.
5.Explain how to conduct therapy.
6.Which methods of examination should be carried out for differential diagnosis of this disease and future treatment strategies?
7.What can happen if the wrong treatment strategy is chosen; describe the clinical symptoms of this complication.
Case 3
A boy, 4 days old, admitted to the neonatal pathology department from the maternity hospital with severe jaundice. From anamnesis we know that the child was born from a 25-year-old woman having a first Rh-positive blood group. The first pregnancy ended with the birth of a healthy full-term boy. The second pregnancy proceeded with the threat of termination in the first trimester, preeclampsia in the second half. Childbirth was urgent, independent. Birth weight 3,300 g, length 50 cm, Apgar score 8/9
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points. 10 hours after birth – increase of icterus of the skin with a tendency to growth was noticed.
On examination: state of moderate severity, icterus of the skin and sclera. Liver +3 cm, spleen +1 cm, meconium stool, urine output is adequate.
Complete blood count:
Hb – 140 g/l, |
Lymphocytes – 32%, |
RBC – 3,5x1012, |
Monocytes – 7%, |
Color index 0.98, |
ESR – 2 mm/h, |
WBC – 10,1x109/l, |
Biochemical analysis |
Stab neutrophils – 8%, |
of blood: |
Segment neutrophils – |
Total protein 52.4 g/l, |
52%, |
Total bilirubin 260 mmol/l, |
Eosinophils – 1%, |
Conjugated bilirubin – |
|
3mmol/l. |
Questions:
1.Your presumptive diagnosis.
2.Which additional investigation should be carried out?
3.Differentiation diagnosis
4.Assign treatment for this child.
5.Prognosis
Case 4
Baby was born prematurely, weight 2,200 g. On the second day – blood transfusion was carried out due to hemolytic disease of the newborn by Rh incompatibility. Bilirubin decreased 2 times, to 171 mmol/l. On the 5th day, the intensity of jaundice increased again.
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