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

Jaundice has acquired a greenish shade. Serum bilirubin is 240 mmol/l. Direct faction is prevailed. Stool has become discolored, urine – intensely yellow.

Questions:

1.What caused the deterioration of the child’s

state?

2.Diagnose.

3.Differential diagnosis.

4.Prescribe treatment

5.Prognosis.

Case 5

Newborn girl was admitted to the neonatal intensive care unit at the age of 4 days due to the deterioration of her state and the growth of neurological symptoms.

From anamnesis we know that the mother's first pregnancy ended by abortion, 2nd pregnancy proceeded with toxicosis, anemia in the 1st half. Delivery at 38 weeks, the boy died on the 2nd day after birth (generalized edema and respiratory failure). This third pregnancy proceeded with toxicosis in the 1st half. Mother was observed in the antenatal clinic. Delivery was at home. Birth weight 3,200 g, length 50 cm, screamed at once. Breast feeding was applied immediately, sucked well. During the first hours of life appeared yellowness of the skin, which quickly escalated. The mother continued to feed the baby with breast milk. On the third day of life, anxiousness ap-

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peared, twitching of facial muscles was noticed, began to regurgitate. Mother drew attention to the unusual high-pitched cry of the child. On the next day, the temperature rose to 39.0oC, generalized seizure attack, the child was hospitalized in the intensive care unit.

On examination: serious condition, restless, screams loudly, throws his head back, horizontal nystagmus. Expressed icterus of skin and sclera noted. Hypersensitivity. Muscle hypertension with dystonia D>S. In the lungs, no wheezing, RR 60 per min. Heart sounds are rhythmic, HR 170 per min. The abdomen is soft, painless, liver +4 cm, spleen 2 cm. Urine is light.

CBC: Hb – 120 g/l, RBC – 3,0x10¹², Color index 0.9, WBC – 16,3x109/l, neutrophils – stab 7%, segment – 64%, eosinophils – 1%, lymphocytes – 23%, monocytes 5%, ESR – 5 mm/h.

Biochemical analysis of blood: protein – 55 g/l (34% albumin), urea – 3.3 mmol/l, total bilirubin 379 mmol/l, indirect bilirubin 365 mmol/l, K+ – 5.5 mmol/l, Na+ – 142 mmol/l, ALT – 46 pcs., ACT – 54 units (norm – 40).

The mother's blood group is 0 (I) first Rhnegative, the child's blood group is 0 (I) Rh-positive.

Questions:

1.Diagnose.

2.Plan of investigation.

3.Which urgent measures should be carried

out?

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4.Which mistakes were made by the mother while taking care of this child?

5.Treatment plan, if the child was born in the hospital

6.Prognosis.

Case 6

Premature girl, 5-days-old, born with weight 1,420 g, was admitted to the department with a diagnosis of "conjugation jaundice". Serious condition, adynamic. Liver +2 cm, spleen at the costal margin. Stool and urine – normal color. Bilirubin in the blood 224 mmol/l, indirect fraction prevailed. The mother's blood group A (II), Rh-positive.

Questions:

1.What caused the jaundice in a child?

2.What is the diagnosis?

3.Which complication can occur in this child?

4.What is your tactic for the management of this

child?

5.Which medication will you need to provide immediate relief to the child?

Case 7

In a premature infant with birth weight 1,200 g icteric staining of the skin appeared on 4th day of life.

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On the 6th day sharp fatigue appeared, hypotension, hypodynamy, apnea attack, symptom of "setting sun", throwing the head back, opisthotonos, general tonic spasms, reflexes of sucking, swallowing and Babkin’s reflex disappeared. In the biochemical test of blood – total bilirubin – 250 mmol/l, indirect reaction.

Questions:

1.What can explain the condition of this child?

2.Diagnose.

3.Which measures should be taken?

4.Prognosis.

Case 8

A newborn boy from the third pregnancy, at the age of 24 days, in satisfactory condition, active, loud cry, breast feeding on demand, sucks well, does not regurgitate. Neonatal reflexes are positive. Skin is jaundiced, clean, icteric of sclera and mucous. Umbilical wound epithelized, umbilical vessels are not palpable. In the lungs no wheezing, RR 38 per min. Heart sounds are loud, rhythmic, heart rate 136 per min. The abdomen was soft, painless, liver +1.5 cm, spleen is not enlarged. Stool is porridge-like, yellow without impurities. Urination is normal, urine bright.

From anamnesis: the child was born from the second normal pregnancy, 2nd urgent delivery,

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Apgar score 9/9 points, breast-fed immediately, umbilical cord fell down on day 3, was discharged from the hospital on fourth day. Jaundice appeared on third day with a gradual increase. Early neonatal period was normal.

Questions:

1.What is the cause of prolonged jaundice in this newborn?

2.How to check your supposition?

3.Which additional investigation should be appointed?

4.What are your recommendations for treatment of jaundice?

5.What is the prognosis?

Case 9

A child at the age of 2.5 months was admitted due to prolonged jaundice.

On examination: serious condition. The child was lethargic, adynamic, rough and husky voice, broad nasal bridge, and large tongue. Skin is icteric, cold, dry. Icteric sclera. The discrepancy of rectus abdominis. In lungs, no wheezing, RR 34 per min. Cardiac sounds a bit muffled, heart rate 88 per min. Distended abdomen, soft and painless. Liver +3 cm, spleen is not enlarged. Tendency to constipation.

Indirect bilirubin – 250 mmol/l, hypoglycemia. Bile pigments in the urine were found.

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Questions:

1.Place a presumptive diagnosis.

2.Which additional investigation should be appointed to confirm the diagnosis?

3.What are the basic principles in the treatment of this disease?

Case 10

Girl, 8 days old, admitted to the hospital with complaints of “fountain” vomiting , diarrhea, and loss of weight. From anamnesis we know that the child was born from fourth pregnancy. 1st pregnancy ended by miscarriage, the 2 and 3 newborns died in the neonatal period; the cause of death is unknown. The present pregnancy was with toxicosis, birth in term. Birth weight 3,600 g, length 53 cm, Apgar score 8/9 points. Breast feeding was applied from the first day, sucks well. The patient was discharged on the third day in satisfactory condition. On the third day there was icteric staining of the skin, sclera and mucous membranes, jaundice continued to increase.

Examination – the child's condition is extremely serious. Weight 2,850 g, length 53 cm, lethargy, decreased of muscle tone. Newborn reflexes: sucking is weakened; crawling, supports, Bauer, hand-mouth, grasping, and Galant are absent. Kernig and Babinski reflexes are positive. Skin, sclera, mucous are intensely jaundiced, dry, acrocyanosis. Swelling of

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the feet and legs. Subcutaneous fat layer is reduced on the trunk and extremities. In the lungs, no wheezing, RR 46 per min. Heart sounds are loud, rhythmic, HR 160 per min. The abdomen is swollen, tense, and painless on palpation. Liver +3 cm, spleen at the costal margin. Liquid stool, green with white lumps.

Complete blood count: Hb – 136 g/l, RBC – 3,5x10¹², color index 0,9, WBC – 20,0x109/l, stab 8%, segment – 57%, Eosinophils – 1%, lymphocytes – 23%, monocytes 11%, ESR – 10 mm/h.

Biochemical analysis of blood: protein – 56 g/l (albumin 38%), urea – 3.3 mmol/l, total bilirubin 260 mmol/l, indirect bilirubin 174 umol/l, direct bilirubin – 86 pmol/l, alkaline phosphatase – 780 U/l, ALT – 125 units, AST – 148 units (norm – 40).

General urine analysis: protein – abs, glucose + + +, leukocytes 2-3, RBC 1-2 p/sp.

Fecal culture for intestinal group three times – negative.

Questions:

1.Place a preliminary diagnosis.

2.Explain the changes in the tests.

3.Differential diagnosis.

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

5.Which treatment should be assigned to the

child?

6.What is the prognosis?

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Case 11

Girl, 3 days old, was born from the first normal pregnancy in term. Mother is 23 years old, healthy. The child's blood group 0 (I), Rh (-), the mother's blood group (III), Rh (-). Birth weight 2,600 g, length 50 cm, Apgar score 7/8 points. Immediately at birth slight icterus of the skin, petechial hemorrhages on the skin of the face and body. On day 2, the condition worsened, jaundice increased, regurgitation appeared. The abdomen is swollen. Liver +3 cm. Spleen was not palpable. Stool is discolored, intensely colored urine.

The urine is determined by a large number of bile pigments. Biochemical analysis of blood: total bilirubin – 204 mmol/l (indirect 68 mmol/l, direct

136mmol/l).

Questions:

1.Put a preliminary diagnosis.

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

3.Which specialists should consult this child?

Case 12

Girl in the Department of Pathology of newborns is diagnosed with cholestasis syndrome, intrauterine

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infection (?). From anamnesis we know that the child was born from a healthy woman, from the first pregnancy which occurred with threat of termination in the first trimester. At 28 weeks was diagnosed with intrauterine growth retardation. Delivery in term, polyhydramnios. Apgar score 6/7 points. Birth weight 2,700 g, length 48 cm, head circumference 34 cm, chest circumference 32 cm. Jaundice appeared at the age of 3 days, from the 4th day jaundice began to increase; liver +3-4 cm, increase in bilirubin, mainly direct fraction. The child is transferred to the department of pathology of the newborn.

On examination: serious condition due to depression syndrome, toxicosis. Lethargy, screaming loudly. Skin is intensely jaundiced with a greenish tinge, icteric sclera and conjunctiva. In the lungs, no wheezing, RR 44 per min. Heart sounds are loud, rhythmic, systolic murmur over the area of the heart, HR 140 per min. Abdomen increased in volume, soft and painless. Liver +4 cm, spleen is not enlarged. Stool is porridge-like, light yellow. The urine is yellow.

CBC: Hb – 146 g/l, RBC – 4,87x10¹², WBC – 19,1x109/l, PLT – 343х109/l, neutrophils: stab 2%, segment – 46%, lymphocytes – 37%, monocytes 15%, ESR – 5 mm/h.

General analysis of urine: yellow color, transparent; protein, sugar – abs, white blood cells 3-4, red blood cells 0-1, cylinders – abs.

Biochemical test of blood in the dynamics:

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