Download Case 1 -The boy from mother 26 years old, with a complicated

Case 1
-The boy from mother 26 years old, with a complicated history of somatic disease (diabetes),
from first multiple pregnancies that occured with the threat of interruption in the I and III-rd
trimesters, first operative delivery by caesarean section at 29 weeks due to vaginal bleeding .
This child was the second of twins.
-At birth: weight - 1300 g, height - 37 cm, Apgar score 4/5 points. After 15 minutes of birth the
appearance of tachypnea 85 per minute was noted, sternal retraction when inspiration, barely
noticeable blowing of the nose, while breathing room air, noticed cyanosis of naso-labial
triangle, auscultation - expiratory noise, impaired breathing. The child was transferred to the
intensive care department.
-At examination : the child is 1.5 days. OBJECTIVE: In the neurological status: expressed
depression syndrome. The skin is clean, light pink. Auscultation of the lungs-breathing is
weakened, crepitation wheezing. Muffled heart sounds, systolic noise over the area of the heart.
Abdomen correct shape, soft, accessible to palpation, 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, pCO2 = 70 mmHg, pO2 = 35 mm. Hg.
The X-ray: diffuse decrease transparency of lung fields, air bronhogramma.
Express blood: WBC = 18h109 / l
Questions
1. Place and justify preliminary diagnosis for this child?
2. Which scale 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 you know?
7. How is the antenatal prevention of this disease?
Case 2
-A boy from first pregnancy. Toxemia 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 MV
for 20 days " stringent" parameters. In two weeks operated for hemodynamically significant
patent ductus arteriosus (clipping). Mechanical ventilation was complicated by pneumonia. At
the age of 45 days, the child was extubated.
-On examination: 2 months old. He spent 7 days at the department of pathology of newborn in
severe condition. Perioral and periorbital cyanosis noticed. The child is oxygen dependent ,
SaO2 - 90-92% when applying humidified oxygen through oxygen tent (FiO2 above 30%).
When weaning from oxygen, observed anxiety and SaO2 decreased to 84 - 85%. In breath
involved supporting musculature. Auscultation: respiratory depression, bubbling wheezing of
various sizes, scattered dry wheezing.
-Chest X-ray: focal and infiltrative changes. Lung fields of enhanced transparency, there is an
alternation of band-shaped seal with areas of lung tissue swelling. Vascular pattern is not
observed in the periphery. Heart is in middle position. CTI 0.65 (norm - to 0.6), contour is fuzzy.
Echocardiogram: CHM data is not received. Systolic pulmonary artery pressure 40 mm Hg. Art.
Questions
1. Put the diagnosis, justify it.
2. Which form of this disease can be in this case and why?
3. Which risk factors are present in this child?
4. Which criteria are used to assess the severity of the disease? Assess the severity of the disease
in this patient?
5. The development of any complications should be suspected in this child? Justify.
6. Which medications with proven efficacy are used for the treatment of this disease?
7. Which damage of eye is typical for these patients?
Case 3
-A girl was born from 20 years old woman, first pregnancy, during pregnancy, recurrent acute
pyelonephritis. At hospital, in the mother’s vaginal smears discovered streptococcus group B
(Streptococcus agalactiae). Term birth at 39 - 40 weeks, long anhydrous period (26 hours). Birth
weight 3300 g, height 52 cm Apgar score 8/9.
- Impairment observed at the age of 18, cyanosis of naso-labial triangle, tachypnea to 50 per
minute, the appearance of regurgitation. In the lungs, breathing is weakened, absent in the lower
divisions, crepitation wheezing. In the neurological status - moderate depression. Muffled heart
sounds, tachycardia 167 per min. Abdomen is soft, available deep palpation, liver +3.5 cm, the
spleen – at the edge costal arch. Decreased urine output - 0.3 - 0.5 ml/kg/h, urine is transparent.
-CBC: Hb - 180 g/l, erythrocyte 5 x1012 / l, leukocytes - 35 x 109 / l, stab - 21%, segment - 50%,
lymphocytes - 20%, monocytes 9%.
Throat swab (preliminary results) - Gram-positive cocci arranged in chains, 5 × 105.
-At 20 hours of life in severe condition, cyanosis, on supplemental oxygen in an oxygen tent,
retraction of the subcostal, respiratory rate 80 per minute, no breathing in the lungs, the analysis
of acid-base balance: pH - 7,10, pCO2 - 69 mmHg , pO2 - 40 mmHg, BE-7mmol / l.
Questions:
1. Formulate a preliminary diagnosis.?
2. What are the diagnostic criteria for this disease?
3. Evaluate the results of laboratory tests. Which criteria indicate the presence of bacterial
infection in children according to the blood count?
4. Which other methods are helpful for clinical diagnosis?
5. What is presumably the etiology of the disease? Which is most likely the source of the
pathogen?
6. Make a plan of treatment
Case 4
-Boy 5.5 months old, was sick URI after contact with his older sister (four years old). The
disease developed gradually with nasal breathing difficulties, cough. Temperature 37.2 ° C. On
the third day of illness mother noticed frequent occurrence of breathing difficulties while
feeding. Examination - the state is moderate, health suffers a little, cheerful. Pale skin, perioral
cyanosis during exercise. Respiration rate - 56 min., HR - 148 min. Nasal breathing is
moderately difficult. The chest inflated; there is expiratory wheezing with retractions of
intercostal spaces, aggravated by physical effort. Auscultation: dry wheezing. Liver +3 cm.
Anamnesis - child from second physiological pregnancy. On mixed feeding. Family and personal
history for atopic diseases is not burdened. Radiographs of the chest - no focal infiltrative
shadow, lung fields of enhanced transparency. SatO2 - 96%
1. Which disease most likely the patient has?
2. Which agent most commonly causes this disease?
3. What is the mechanism of the development of bronchial obstruction in this disease?
4. Evaluate the results of additional methods of examination?
5. Assess the severity of the disease. Is this child needs to be hospitalized?
6. Which treatment should be assigned to the patient?
Case 5
The boy at the age of 2.5 months, hospitalized due to URI. From history we know that the boy
was from a woman with complicated gynecological (salpingo-oophoritis , erosion of the cervix),
and somatic (gastritis, peptic ulcer 12-p) history, from third pregnancy (1st – medical abortion,
2nd - term delivery ) occurs with a viral respiratory infections in the I trimester (receiving
palliative care), toxemia, the threat of interruption in the II trimester. Second independent
delivery at 32 weeks, birth weight - 1600 g, length - 38 cm, Apgar score 6/7 points. Condition at
birth was severe due to severe respiratory distress syndrome, depression. From birth for 5 days
was on mechanical ventilation. At the age of 28 days of life was independent of oxygen. He was
discharged home at the age of 1.5 months in good condition with a weight of 2030. He was ill 1
day before admission to the hospital, loss of appetite, shortness of breath, dry cough and
vomiting. At home he had contact with his brother(7 years old) who had URI. When admission,
severe condition. T 37.5 C. Pale skin with marble pattern, perioral cyanosis. Nasal breathing is
difficult, mucous discharge. Frequent unproductive cough. Retraction of the intercostal spaces in
breathing, respiratory rate to 76 per minute. In light percussion - sound box. Auscultation in the
lungs - harsh breathing, exhale extended, on both sides dry and wet wheezing. Heart sounds
mildly muffled, rhythmic. HR 150 per minute. Abdomen is soft, liver +4.5 cm.
On radiographs of the chest, swelling of the lung tissue, focal-infiltrative changes are not
detected. Segmental atelectasis at S2 to the right, pulmonary pattern is not strengthened, the
shadow of the heart is not enlarged, visible small shadow of thymus gland. Ttest for RSV positive.
Complete blood count: Hb - 141 g / l, RBC - 5.13 x1012/l, WBC - 11.62x109 / l, stab - 2%,
segment - 35% lymphocytes. - 51%, monocytes - 12%, ESR - 2 mm/h. Sat O2 - 87%
Questions:
1. Diagnose.
2. Rate the severity of the disease
3. What are the risk factors for the severe flow of this infection does you know?
4. What are the signs of respiratory failure are detected in this child? Which investigation
determines the degree of respiratory failure?
5. Is this child needs oxygen therapy, and why?
6. Which kind of therapy can be assigned to the child? Which medicines have proven efficacy in
this disease?
7. How to carry out the prevention of the infection in the children who are in group of risk?
Case 6
Girl, M., 3 years 10 months, Pediatrician examined on the third day of the disease, mother of the
child noted lethargy, subfebrile fever, runny nose, infrequent cough. Pediatrician diagnosed
URVI, assigned symptomatic treatment with a positive effect. However, on the 5th day of the
disease the child's temperature rose again to 38.6 ° C, cough increased. Mother called the doctor
again.
When re-examination - capricious. Skin is pale, clean. Wet unproductive cough. RR 48/minutu.
No dyspnea. Auscultation-harsh breathing, weakened in the interscapular region on the right, wet
bubble wheezing. Heart sounds loud, rhythmic. Heart rate: 100 per minute. The abdomen is soft
and painless. Liver +1.0 cm. The spleen is not palpable. Stool and urine output are normal. The
girl was hospitalized.
Complete blood count: hemoglobin - 124 g/l, erythrocytes 4.2 x1012/l, platelets 223 x109/l,
leukocytes - 15.3 x109/l, Stab neutrophil - 3%, segment neutrophil- 62 %, lymphocytes - 34%,
monocytes 1%, ESR - 16 mm / h
X-rays of the chest: reduced pneumatization by inflammatory infiltration in the projection of the
right upper lobe with distinct concave contours. Pulmonary drawing enriched, deformed to the
right. The median shadow heart is not displaced. The sinuses are free.
1. Put a diagnosis according to the classification.
2. What is the most important agent in the development of diseases in normal conditions (at
home) in this age?
3. What is the treatment of this patient.
4. Does this patient need oxygen? What additional research is necessary to the determination of
the indications for oxygen therapy?
5. What determines the rational choice of antibiotic?
6. Name the time and criteria to evaluate of the effectiveness of antibiotic therapy.
Case 7
Boy 10 months old, Hospitalized with a suspicion of pneumonia. From history we know that the
child from the 2nd pregnancy (1st med. Abortion), birth weight 3250g, height 51 cm, Apgar
score 4/6. 2 weeks ago for the first time suffered URI, acute purulent otitis media, received
amoxicillin. Three days before admission to the hospital, temperature increases to febrile digits,
cough, difficulty in nasal breathing. In the hospital - T-38, 7C. Skin is pale with marble pattern,
hyperthermia. Perioral cyanosis. Frequent unproductive cough. Retraction of the lower parts of
the chest when breathing, swelling of the nose, wheezing breathing, respiratory rate 56 per
minute. In the lungs - breathing is harsh, weakened in the lower right part, there are wet
wheezing, palpation – trembling sound. Heart yones are rhythmic. HR 128 in 1 minute. Liver
+1.5 cm Urine output is adequate.
CBC: RBC 4.76 x1012/l, platelets - 319 l - 18.4 x109/l, Stab neutrophil - 2%, segment neutrophil69%, lymphocytes - 22%, Monocytes - 7%; ESR - 25 mm/h
Biochemical analysis of blood: CRP - 12 g/l (normal 6 g/l)
Chest X-ray - pneumatization reduced at right lung fields in the projection of the middle lobe,
repeating its outlines, by inflammatory infiltration. Right contour of heart on the background of
infiltration is not clearly observed. The sinuses are free.
Questions:
1. Put a diagnosis according to the classification.
2. Assess the severity of the disease.
3. What is the etiology of this disease?
4. Which risk factors are unfavorable course of pneumonia can be identified in this child? What
else do you know?
5. Is this child needs oxygen therapy? Why?
6. Evaluate the results of the general and biochemical blood.
7. Assign treatment, explained the choice of antibiotic.
Case 8
Girl, 7 months old was born in term from second physiological pregnancy. Apgar score 8/9
points.
Sudden onset, there was difficulty in nasal breathing, profuse mucus-purulent discharge from
the nose, temperature 37.4 C. At home he had contact with ill URVI older brother. Pediatrician
was diagnosed URVI, assigned symptomatic treatment. After 2 days, the condition has
worsened; temperature rose to 38.6 ° C, was restless, and refused the breast, vomiting, dyspnea.
Was hospitalized.
On examination - severe condition, inhibited. Skin is pale with a grayish tinge, central
cyanosis. Feeding dramatically was difficult. Respiratory rate - 68 per minute, there is swelling
of the nose, compliant places retraction of the chest while breathing, shaking his head during
breathing. The chest inflated. In the angle of the back to the right - a shortening of percussion,
respiratory depression, there is wet wheezing, percussion box sound, harsh breathing on
auscultation. Muffled heart sounds, pulse 160 per minute. Distended abdomen, liver +3 cm,
spleen + 1 cm.
Complete blood count: Hb - 174 g / l, er. - 5.2 x 1012 / L, LA - 20.1 h109 / l, Stab neutrophil 10%, segment neutrophil - 61%, eoz. - 1%, lymph.- 19%, M - 9%, ESR 34 mm / hour.
Oxygen saturation - 88%.
Chest radiograph: the projection of the upper and middle lobe of the right lung homogeneous
inflammatory infiltration of lung tissue, on the background the right loop of the heart has been
observed.
Questions:
1) Put diagnosis according to the classification.
2) List the symptoms of respiratory failure in children. Estimate the severity of this disease.
3) Which pathogenic variants of respiratory failure do you know? Which of them has the leading
role in pneumonia?
4) Suppose the etiology of this disease.
5) Assign treatment.
Case 9
Girl, 2 months., Sudden onset - noted the rise in body temperature to 39.2 ° C, there were dry
cough, runny nose. Received amoxicillin, symptomatic treatment without any effect. On third
day of the disease, the condition has worsened, lethargy, refuses to eat, dyspnea, increased
cough, T 39oS. Was hospitalized.
From history we know that the girl is on the breastfeeding, the mother has recently been
diagnosed with mastitis, staphilodermia.
In hospital, severe condition. Loss of appetite, refuses to eat. Severe shortness of breath with
involvement of accessory muscles of the chest. Skin grayish with "marble" pattern, perioral
cyanosis, acrocyanosis, elements of staphilodermia. Respiratory rate - 64 per minute.
Auscultation: breath to right weakened in the upper right lung with bubbling wheezing,
crepitation, deadened sound. Muffled heart sounds, tachycardia up to160 per minute. Distended
abdomen, bloating, rumbling palpation along the intestine. liver +4 cm, spleen +2 cm. Stool with
green mixture & mucus.
Complete blood count: Hb - 104 g/l, RBC - 3.8 x1012 /l, WBC - 22.1x109 /l, myeloma. - 4%,
Stab neutrophil - 10%, segment neutrophil - 69%, lymph.- 15%, moncytes - 2%, ESR 44
mm/hour. Saturation O2 - 88%.
Sputum culture - numerous gram-positive cocci.
Chest radiograph: the projection of the upper lobe of the right lung on the background of
inflammatory infiltration revealed a cavity with a horizontal fluid level, the response of the
pleura, increase transparency of lung fields on the left. The sinuses are free.
Questions:
1)Put a diagnosis according to the classification.
2)What is the complications of this disease?
2) Suppose the etiology of the disease, specify the characteristics of this form of the disease.
3) The consultation of which specialists needs this child?
4) Assign the treatment.
5) Justify antibiotics treatment.
Case 10
Boy 7 years old, was hospitalized with suspected pneumonia.
From history we know that to date the disease was growing and developing normally. Two
months ago, he went to school. Three weeks after the beginning of school attendance for the first
time suffered obstructive laryngitis, complicated by mild obstructive bronchitis without fever,
was treated by broncholytics, received expectorants. Since that time remains haunting pertussislike dry non-productive cough. Three days before hospitalization cough dramatically increased,
dyspnoea on exertion.
On admission - state of 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 light
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 - 3.8 x 1012 /l, WBC - 10.1x109/l, Stab neutrophil 2%, segment neutrophil-25%, Eoz. - 2%, lymph. - 63%, monocytes - 8%, ESR 27 mm/hour.
Biochemical analysis of blood - C-reactive protein - 2 g / l.
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 pneumoniae
in diagnostic titre (1/3200).
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 you know? Which infiltration
determined in this patient?
4) What are the characteristics of the course of respiratory tract injuries?
5) Describe the CBC.
6) Which antibiotics are for mycoplasma? Which antibiotics can be assigned to this patient?
Why we must pay attention to the age restrictions?
7) What should be the duration of treatment?