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

count 450 ml, neutrophils 82%, 18% lymphocytes, glucose 2.5 mmol/l.

Radiographs: expressed lung pattern, to the right above the diaphragm and to the left side at the level of the upper part – sealing. At the level of these seals are visible scalloped ring shadows (suspected cavity). The roots are structural. Heart: the outlines are visible not clearly. The sinuses are free.

Questions:

1.A presumptive diagnosis?

2.What are risk factors for this condition?

3.Etiology of the disease?

4.What are the clinical criteria for the diagnosis of the newborn?

5.What investigation should be carried out to confirm the diagnosis? Diagnostic value of procalcitonin for the diagnosis at this age?

6.Assign treatment

Case 7

Child at the age of 14 days was admitted to the hospital in serious condition with temperature up to 39.6°C, weight 2,600 g. The child was born from second pregnancy that occurred with toxicity in the first trimester, exacerbation of pyelonephritis in the last trimester. Birth weight 3,000 g, length 51 cm, umbilical wound healed poorly, there was purulent discharge in large amount.

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On examination: the state is severe, lethargy, sucks milk weakly. Pale skin, with an earthy shade, subicteric, periorbital and perioral cyanosis, marbleness. Abdomen is swollen, tense. Swelling of the abdominal wall, extended venous net in the upper abdomen. On the abdomen around the umbilicus extensive infiltration with clearly defined borders, with brown-cyanotic skin over it. When stroking from the liver to the umbilicus, pus squeezed in the umbilical wound. Liver +3 cm, spleen +1 cm. Periodically observed vomiting, watery stools with mucus.

Blood tests: Hb 115 g/l, RBC – 3.5x1012/l, color index – 0.9, WBC – 22.0 x109/l, stab – 12%, segment – 42%, eosinophils – 1%, lymph. – 44%, monocytes 2%, ESR 38 mm/hour.

Questions:

1.A presumptive diagnosis?

2.What are the risk factors and the most important causative agent of the disease, predisposing anatomic and physiological features of subcutaneous adipose tissue?

3.Describe the stages of development of the disease.

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

5.Assign treatment. Justify the choice of antibiotic therapy.

Case 8

Child at the age of 9 days was born in term from 1st normal pregnancy. Birth weight 3,100 g, length

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50 cm, umbilical residue was dropped on the 4th day, umbilical wound healed quickly. In the maternity hospital, observed physiological skin catarrh with profuse desquamation. The patient was discharged from the hospital on the 5th day with weight 2,950 g, breast-feeding.

On the 6th day of life, on the face appeared isolated pustules, size 01.-0.2 cm, filled with yellowish contents. After 3 days pediatrician noted the presence of multiple pustules on the head, feet, buttocks and legs. On the face dried up pustules with crusts. Body temperature did not rise. Stool 3-4 times daily without pathological impurities.

Questions:

1.Presumptive diagnosis?

2.Etiology of the disease?

3.Where is the inflammation localized?

4.Which other types of pyodermya occur in children in the neonatal period and infancy?

5.Assign treatment.

Case 9

Boy, 10 days old, from the 1st pregnancy, occurred with toxicosis in the 1st trimester, purulent sinusitis in the 3rd trimester. Term birth. Birth weight 3,400 g, length 53 cm, Apgar score 8/9 points. Sucked breast actively, umbilical residue was dropped on the third day, on day 5 was discharged home.

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On examination: satisfactory condition, weight 3,600. Breathing through the nose freely, no discharge, mouth is clean. Dermal patches with exfoliation, slight icterus. Umbilical wound with serous contents, the umbilical ring infiltrated. Liver 1.5 cm and spleen was not palpable. Stool up to 5 times daily, yellow, porridge-like. Regular urination.

Questions:

1.Presumptive diagnosis?

2.What are the possible causes of this condi-

tion?

3.How to treat umbilical wounds?

4.What are the possible complications?

5.Assign treatment.

Case 10

Child of 17 days old. Born in term, weighing 3,400 g, length 53 cm, breast-fed. There was lack of weight gain; the child was lethargic, capricious.

On examination: state is moderate, sucks weakly, gets tired quickly, body temperature 37.5oC. Breathing through the nose is free, no discharge, mouth clean. Skin pale and pink, with desquamation. In the groin, neck folds, back, abdomen, extremities there are flaccid blisters, size of a pea to hazelnut, single chamber. The bubble was bright with serous content, the other part – sero-purulent. Positive Nikolsky’s sign. At the zone of skin damage were open elements, weeping erosive surface observed, sur-

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rounded by peripheral shrunken bubbles. Umbilical wound clean. On the palms and soles of the child's there was no rash. Liver +1.5 cm, stool yellow, por- ridge-like.

Laboratory findings: blood – heme. 160 g/l, er. – 4.9x1012/l, CI – 0.9, WBC – 14.0x109/l, stab – 8%, segment – 40%, eosinophil – 4%, lymphocytes – 38%, ESR 10 mm/hour.

Questions:

1.Your diagnosis?

2.What are the possible causes of this condi-

tion?

3.Which factor often causes this disease?

4.Which additional investigation must be carried out to confirm the diagnosis?

5.What is Ritter’s exfoliative dermatitis? Name the features of the clinical picture of the disease.

6.Differential diagnosis?

7.Assign treatment.

Diagnostic keys

1.Congenital cytomegalovirus infection. Depression syndrome, convulsions, jaundice. Hepatitis, hemorrhagic syndrome

2.Congenital toxoplasmosis, meningoencephalitis, convulsions, hydrocephalic syndrome, depression, hepatosplenomegaly.

3.Congenital rubella, depression syndrome, microphthalmia.

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4.Early congenital syphilis, syphilitic pemphigus, rhinitis. IUGR

5.Congenital herpes infection, herpes meningoencephalitis.

6.Early neonatal sepsis, pyosepticemia (purulent meningitis, bilateral necrotizing pneumonia, purulent omphalitis). 35-36 weeks of prematurity, low birth weight.

7.Abscess of the anterior abdominal wall, sepsis

8.Stafilodermiya of newborns. Vesiculopustule-

sis.

9.Omphalitis. Complications: umbilical vein phlebitis, abdominal wall abscess.

10.Pemphigus.

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liver +1.5 cm, the spleen is not palpable. Urination independent, urine bright, diuresis = 2 ml/kg/hour.

Blood gases: pH = 7.27, BE = –6.2 mmol/l, pCO2 = 70 mm Hg, pO2 = 35 mm Hg. The X-ray of the chest: diffuse decrease transparency of lung fields, air bronhogramm. Express blood: WBC = 18x109/l.

Questions:

1.Put and justify preliminary diagnosis for this

child.

2.Which scale is used to assess the degree of respiratory failure in newborn infants with this disease?

3.What is the pathogenesis of this disease?

4.Specify the risk factors for the disease in this patient.

5.How do you interpret the data of laboratory examination?

6.What pathogenic therapy should be carried out? Which drugs in this group do you know?

7.What is the antenatal prevention of this dise-

ase?

Case 2

A boy of 7 years old was hospitalized with suspected pneumonia.

From anamnesis we know that before the disease the child was growing and developing normally. Two months ago he went to school. Three weeks after the beginning of the school year for the first time he

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suffered obstructive laryngitis, complicated by mild obstructive bronchitis without fever; was treated by broncholytics, received expectorants. Since that time persisting pertussis-like dry non-productive cough has continued. Three days before hospitalization cough dramatically increased, dyspnoea on exertion.

On admission – the child’s state is moderate severity. The body temperature is normal. Pale skin, erythematous individual elements with enlightenment in the center of the trunk. Hyperemia, follicles on back wall of pharynx. Respiratory rate at rest – 25 per minute. Over lung percussion boxed sound, dullness in the lower parts of both lungs, auscultation – whistling dry wheezing, few bubbling wheezing when breathing deeply, asymmetric areas local respiratory depression in the lower regions of the lungs in two ways.

Complete blood count: HB – 104 g/l, RBC – 3.8x1012/l, WBC – 10.1x109/l, Stab neutrophil – 2%, segment neutrophil – 25%, eosinophils – 2%, lymphocytes – 63%, monocytes – 8%, ESR 27 mm/hour. Biochemical test of blood – C-reactive protein – 2 g/l.

X-ray of the chest: chest inflated, pulmonary vascular pattern reinforced thickened, deformed in the lower divisions, marked diffuse interstitial changes as peribronchial infiltration, the roots expanded, little structural.

During the enzyme immunoassay blood were found IgM-antibodies to Mycoplasma pneumonia in diagnostic titer (1/3200).

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Questions:

1.Put a diagnosis according to the classification.

2.Specify the etiology of the disease, epidemiological factors of the etiology of pneumonia?

3.Which types of inflammatory infiltration of pneumonia do you know? Which infiltration is determined in this patient?

4.What are the characteristics of the course of respiratory tract injuries?

5.Describe the CBC.

6.Which antibiotics are active against Mycoplasma? Which antibiotics can be assigned to this patient? Why must we pay attention to the age restrictions?

7.What should be duration of treatment?

Case 3

A boy from first pregnancy. Toxicosis of pregnancy occurred in the I trimester, threat of interruption in the II trimester (eclampsia). Mother at the period of 17 weeks got treatment from ureaplasma. However, the vaginal smear at 24 weeks showed positive ureaplasma (PCR).

Birth at 28 weeks by Caesarean section. Fetus fluid was bright. Birth weight – 990 g, height – 33 cm. Apgar score 4/5. Severe RDS, the child was transferred to the MV. From birth, was on mechanical ventilation for 20 days "stringent" parameters. In two weeks operated for hemodynamically significant pa-

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