Download Task 1. Baby of 2 months. Admitted to the hospital with presumptive

Task 1.
Baby of 2 months. Admitted to the hospital with presumptive (suggested) diagnosis: acute
pneumonia; CHD?
The child of the second pregnancy, with ARD at the 3d month. (Mothers '32 years old, burdened
obstetric history - I pregnancy - miscarriage, then - secondary infertility for 8 years).
Spontaneous delivery, at term, birth weight 2300 Height 44 cm ; 2 times the child suffered from
ARI with prolong cough. Condition worsened over 5 days prior to event: dyspnoea, became
restless, refuses to eat. On admission: t = 37,4 weight 2900 head does not hold. Pale skin, with
the cry moderate acrocyanosis, lungs breathing weakened, moist rales in the lower regions of
predominantly left, RR = 48-52 per minute.
Heart area changed: cardiac bulge (hump). Percussion border of relative cardiac dullness: upper II rib, the left – anterior left axillary line, right - right parasternal line. Heart sounds are muffled
significantly, rhythm 'gallop', long systolic murmur at the apex, HR - 148 min. Liver 6 cm, 2 cm
spleen, decreased urine output, swelling abdominal wall, the feet. Increased abdominal volume.
QUESTIONS:
1. What is a preliminary diagnosis? What diseases can be suspected?
2. Estimate the size of the heart percussion, RR, HR?
3. What clinical signs point to heart disease?
4. What signs indicate the nature of fetal cardiac disease?
5. List the signs of circulatory (cardiac) failure, estimate the stage of cardiac insufficiency.
6. Explain investigation plan for differential diagnosis.
7. What treatment should be started immediately?
Task 2.
The baby 2 months. After analysis of clinical and anamnestic data suspected intrauterine
carditis?, pale CHD? The following additional methods were used:
ECG: normal position of the electrical axis of the heart, the heart rate of 148-152, high QRS
voltage , left bundle branch block, left ventricular and left atrium overloading, signs of
subendocardial ischemia.
Chest X-ray: pulmonary venous vascular pattern marked enhanced, focal and infiltrative lesions
in the lung tissue are absent, aortic configuration of heart shadow , CTI - 0.71
Echocardiogram: myxomatous changes of the mitral valve, other valves, the atrial, ventricular
septum are intact, diastolic blood flow in the pulmonary artery is absent.The left atrium and left
ventricle increased, ejection fraction (EF) of the left ventricle of 38% (N> 60%). Dramatically
amplified echosignal of the endocardium of the left ventricle.
LDG1/LDG2, CPC, CPC MB, troponin I, anticardiac antibodies - in the normal range
Blood culture (the sterility) - three times - no growth. Peripheral blood analysis - without
inflammatory changes.
QUESTIONS:
1. Evaluate the results of the ECG.
2. Evaluate the results of chest radiography.
3. Evaluate the results of echocardiography.
4. Evaluate the results of laboratory tests.
5. Make out the diagnosis based on all investigations.
6. What treatment is indicated?
7. What is the prognosis of the disease?
Task3.
3 months old child was admitted to the hospital with a diagnosis of acute respiratory infections,
obstructive bronchitis. The child of Ist pregnancy with acute respiratory infection (ARI) at 7
months, late histosis. Term birth, birth weight 3200 g, height 51 cm Perinatal encephalopathy
was diagnosed in neonatal period: hypertension-hydrocephalic syndrome. There are no any
evidence of patient’s contact with ARI.
Complains on admission: obsessive cough, dyspnea. Appetite is not reduced. T = N m=4600 g,
the pale is skin, sweating. Mixed dyspnea with a predominance of expiratory component, RR =
44 per min. In the lungs: breathing is rough, percussion box note, whistling dry and moist rales.
Precordial area is not changed, the border of the relative cardiac dullness can not be determined
accurately because of emphysema. Heart sounds are muffled, tachycardia. CR = 152 per min, the
murmur is not listen. Liver +1 cm, spleen +1.5 cm Diuresis is not reduced. Edema is absent
QUESTIONS:
1. Evaluate clinical history (anamnesis) of the child.
2. What might indicate anamnesis vitae?
3. Evaluate changes in the heart.
4. Explain the degree of cardiac insufficiency. .
5. Make out the preliminary diagnosis. What diseases can be suspected?
6. What can be causes of respiratory changes?
7. Define the plan of inspection.
8. What treatment should be appointed immediately?
Task4.
Child of 3 months.was admitted at the department with a preliminary diagnosis of myocarditis
(prenatal?) CI IIA d., hypertension-hydrocephalic syndrome.
Were examined:
1. ECG: left deviation of cardiac axis, the left anterior bundle block , incomplete right bundle
block, prolonged QT interval for 0.12 seconds, heart rate - 152 per minute.
2. Rg chest - focal and infiltrative changes in the lung are absent, increased vascular and
bronchial pattern, CTI = 0.58
3. Echocardiography: heart valves, septal defects are absent, moderate left ventricular
hypertrophy , dilated left ventricular cavity, EF = 50%, pericardium is thickened up to 5 mm
4. A moderate increase in creatine phosphokinase MB, increased rate of anticardial antibodies
5. Cardiac MRI - indirect signs of predominantly septal cardiosclerosis
6. MRI of the brain - a moderate internal and external hydrocephalus, small cysts in the
periventricular region (effects of meningoencephalitis?)
7. In the epithelial cells of the urinary sediment of mother and child were found the Coxsackie
virus antigens.
QUESTIONS:
1. Evaluate the results of the ECG.
2. Evaluate the results of chest radiography.
3. Assess data echocardiography.
4. What data may indicate the nature of subacute heart disease (more than 3 months.)?
5. Formulate a complete diagnosis.
6. What data help to make the final diagnosis?
7. What caused changes in the central nervous system?
8. What pathogenetic treatment should be used ? (except the cardiac insufficiency treatment)
Task5.
Child of 2 years old was admitted to infectious disease clinic with a diagnosis of viral respiratory
infections, pneumonia? Intestinal infection? Anamnesis: antenatal period was normal, birth
weight and length are N, grew and developed normally. Acutely ill 10 days before the event:
febrile t, gerpangina, the third day- maculopapular rash, disappeared in 2 days. On the third day
of illness appeared diarrhea, abdominal pain. On the 10th day he became exited, dyspnea,
cyanosis of nasolabial triangle appeared. General condition is serious, low-grade fever, mottled
skin, acrocyanosis. RR 36 min. with participation of accessory muscles. In the lungs, breathing
is rough, moist finely rales in the lower part of the lungs. Heart: left border on t the left anterior
axillary line. Heart sounds are muffled significantly, pericardial rub, heart rate 136-140 per
minute., 6-10 extrasystoles per minute. Liver 5 cm, reduced diuresis, swelling of feet. Doubles
analyses of blood serum revealed increasing rate in 4 times of antibodies to Coxsackie B4 virus.
QUESTIONS:
1. Place a preliminary diagnosis.
2. Can we assume the etiology of the disease, what it may confirm?
3. List the main symptoms of the disease
4. Explain the degree of heart failure.
5. Make a plan for the examination.
Task6.
Child of 2 years old was admitted to infectious disease clinic with a diagnosis of viral respiratory
infections, pneumonia? Intestinal infection? Anamnesis: antenatal period was normal, birth
weight and length are N, grew and developed normally. Acutely ill: subfebrile fever, catarrhal
conditions, rash - a small red spots on the face, erythema on the cheeks, then a lacy rash on the
trunk and limbs, persists for several days. Three weeks after the acute illness the child became
restless, dyspnea, cyanosis of nasolabial triangle appeared. General condition is serious, lowgrade fever, mottled skin, acrocyanosis. RR 36 min. with participation of accessory muscles. In
the lungs, breathing is rough, moist finely rales in the lower part of the lungs. Heart: left border
on t the left anterior axillary line. Heart sounds are muffled significantly, pericardial rub, heart
rate 136-140 per min. Liver +4 cm, normal diuresis, swelling is absent.
QUESTIONS:
1. Make out a preliminary diagnosis
2. What are the cause of the changes in the lungs?
3. Explain the degree of cardiac insufficiency? .
4. What instrumental changes can characterized: myocarditis, myopericarditis? What laboratory
data can characterized acute course of myocarditis?
5. Imagine the etiology of the disease. How can you prove your hypothesis?
6. Prescribe treatment.
Task7.
Boy 9 years old was admitted to the department with a diagnosis of rheumatic fever. Antenatal
period, infancy period was normal. In 2 years suffered pneumonia, after 3-year ARI 7-8 times
per year, tonsillitis 2 times a year. For 8 months. before admission began to complain of fatigue,
poor exercise tolerance, for 1 month. before enrolling mother noticed an increase in the
abdomen, swelling in the legs and face. When he was receivied - a very serious general
condition, the skin is pale, with a cyanosis of nasolabial triangle on exertion, weight 25 kg,
height 125 cm. Dyspnea, RR – 32 per min. In the lungs - multiple different in size moist rales,
the borders of the relative cardiac dullness are greatly extended (enlarged), more to the
left. Muffled heart sounds, heart rate 100 per minute., AP-100/60 mmHg , on the cardiac apex systolic murmur, without left irradiation. Increased abdomen, ascites, liver +8 cm, swelling in
the legs, face. Echocardiography - marked dilatation of the left ventricle and the left atrium, the
EF-33%., Heart valves and ventricular and atrial septum is not changed.
QUESTIONS:
1. What diseases can be suspected?
2. Evaluate the physical development of the child.
3. Assess changes in the heart.
4. What is your plan of invastigations?
5. Explain the degree of heart failure.
6. What data can help to exclude chronic rheumatic heart disease?
7. What treatment should be started immediately?
8. What method of study (the gold standard) allows to differentiate inflammatory
cardiomyopathy (chronic myocarditis) and non-inflammatory cardiomyopathy (primary)?
Task8.
Boy 8 years old , hockey player for 3 years, was admitted for investigation with complaints of
fatigue, shortness of breath on exertion, cardialgia, dizziness, and fainting during physical stress
and emotional stress. There have been recent complaints of heart attacks and "disruption" in the
heart. On examination revealed: HR 84 min., The left border of the heart - 2 cm outside of the
left mid-clavicular line, diffuse apical impulse, loud heart sounds, arrhythmia (extrasystoles),
rough systolic murmur at the apex and along the left sternal border, increasing standing and at
the exertion. In the lungs - vesicular breathing, without wheezing and any rales , RR 18-20 per
minute. Liver +1 cm, there are not inflammatory changes in blood , CPK, creatinephosphate
kinase MB, troponin were normal. ECG: signs of left ventricular hypertrophy, and negative T
waves in the left precordial leads, deep pathologic Q wave in II, III, V4-V6, frequent ventricular
extrasystoles. Holter ECG: frequent ventricular extrasystoles, ventricular tachycardia.
Echocardiography: the hypertrophy of the ventricular septum and posterior wall of the left
ventricle, the peak gradient in the left ventricular outflow tract of 55 mm Hg, EF 72%
QUESTIONS:
1. Describe the changes in the heart, give their assessment.
2. What are the causes of syncope are most likely to have this baby?
3. What diseases can be suspected on the child?
4. Which method of research is the most impotent for the diagnosis?
5. What echocardiography data indicate ventricular outflow tract obstruction?
6. What types of HCM (hypertrophic cardiomyopathy) are distinguished?
7. Make out the diagnosis/
8. Assign treatment.
Task9.
Boy of 11 months., acutely ill (before the disease is almost healthy): 2 weeks febrile fever,
conjunctivitis, cheilitis, stomatitis. On the third day - polymorphic (maculopapular, annular) rash
on the trunk, limbs, after 2 weeks - lamellar desquamation of fingers and toes. In the first week an increase of cervical lymph nodes.to 2 cm. Dyspnea no, no rales in the lungs lungs. Muffled
heart sounds, tachycardia, systolic murmur at the apex. Liver +2 cm, spleen is not palpable. A
blood test: Hb = 100 g / l Leucocytes = 12000, neutrophils-54% lymphocytes-30% monocytes14% eosinophils-2%, platelets – 650,000; ESR = 56 mm / h ECG: tachycardia, T wave
flattening, reduced voltage QRS. Echocardiography: a moderate increase in diastolic LV size, EF
= 54% (N> 60%), mitral insufficiency +2, separation of the pericardium, the expansion of the
coronary arteries of 3-4 mm, thickening of their walls.
QUESTIONS:
1. Describe the clinical signs of heart disease
2. What changes of the heart structures are revealed by the instrumental investigations??
3. Select the most significant changes in blood analyses?
4. What diseases can be suspected?
5. What treatment should be appointed?
Task10.
Boy of 5 days old was transferred from the maternity hospital to the department of pathology of
newborn in serious condition. The boy of IIId pregnancy occurring with the threat of
miscarriage. Mother 36 years old, suffers from lupus erythematosus. Ist pregnancy - a healthy
boy 7 years old, II pregnancy - miscarriage at 16 weeks. This delivery at 34 weeks by caesarean
section. Birth weight 2300 g, length - 43 cm. Caesarean section performed by registered at the
beginning of labor fetal bradycardia, heart rate = 80-90 per minute. On examination, the skin is
pale, icteric , discoid rash; sucking slowly. RR 46-52 per minute. In lungs - puerile breathing,
moist rales. Border of the relative cardiac dullness extended to the left, the heart sounds are
muffled, bradycardia, heart rate 72-80 per minute., Apex systolic murmur of medium intensity.
Liver+4, spleen +1 cm Urine output is reduced.
In mother’blood serum during pregnancy were identified antinuclear autoantibodies Ro-52/SSA.
The child identified ANF 1/80, thrombocytopenia, ECG - atrio-ventricular block II-III degree.
On echocardiogram - an increase of left ventricular ejection fraction decrease. Signs of CHD
were not detected.
QUESTIONS:
1. What diagnosis can be assumed according to clinical examination?
2. What is the direct cause (mechanism) of heart failure?
3. What clinical history and laboratory tests indicate the cause of which developed a high degree
AV block?
4. Explain the degree of heart failure
5. Suggest the diagnosis.
6. What is the cause of cardiac pathology development?
7. What measures had to be used during pregnancy and what should be done now?