Collection
Clinical tasks
Specializing in General Medicine
PEDIATRICS WITH CHILDHOOD INFECTIONS
Problem-situational tasks
Task No. 1.
The boy is 8 months old. Complaints about the child's lethargy, loss of appetite, unstable stool. A child from the 5th pregnancy, which proceeded favorably, 2 term births (weight - 3700 g, length - 50 cm). The neonatal period is without any peculiarities. Breastfeeding up to 2 months, from 3 months. introduced semolina without the advice of a doctor, unadapted mixtures were used. The child did not take vitamin D and rarely received juices. There were not walks every day. The weight gain was uneven. I suffered from acute respiratory infections 2 times. Material and living conditions are satisfactory.
Objectively: general state satisfactory, but the child is lethargic, pale, and sweating. Sits with support on his hands, his back is round. Muscle tone is diffusely reduced. The head is square in shape, with prominent frontal and occipital protuberances. Large fontanel 2.5x3.0 cm, pliable edges. The back of the head is flattened and bald. No teeth. The chest is compressed from the sides, the lower edges are unfolded, there are small “rosary beads” on the ribs, and pronounced “bracelets” on the arms. There is kyphosis in lumbar region spine, which disappears when the child is positioned on his stomach. Palpation, percussion and auscultation did not reveal any changes in the respiratory and cardiac organs. The liver protrudes 2 cm from under the edge of the costal arch. The spleen is not enlarged. The stool is unstable, urination is not impaired.
Blood test: Hb 102 g/l, Er-3.98x10 12 /l, L-4x10 9 /l, ESR 5 mm / hour. Urinalysis is unremarkable. Biochemical data: serum phosphorus 0:034 g/l, calcium 0.09 g/l.
Tasks
3. Write a prescription for vitamin D
4. Demonstrate techniques for measuring the height of children of different ages.
Sample answers
1. The child has rickets of the second degree, the peak stage. Iron deficiency anemia, mild. The conclusion is based on medical history: breastfeeding only up to 2 months, early introduction of complementary foods, lack of vegetables and fruit juices in the diet, did not receive vitamin D for preventive purposes.
Objective examination: sweating, pale skin, decreased muscle tone, severe deformation of the skull bones, chest, spine, limbs.
Laboratory tests: a slight decrease in hemoglobin in the blood, a decrease in phosphorus and calcium in the blood serum.
2. An additional symptom of this form of the disease is craniotabes softening of individual areas occipital bone, which is determined by palpation. At the level of attachment of the diaphragm, a retraction occurs, a “Harrison groove”, and the timing and order of teeth eruption are disrupted.
3. B in this case the child does not need urgent hospitalization in a hospital, and if the material and living conditions are satisfactory, treatment can be carried out at home.
4. In a hospital setting, to confirm the diagnosis, it is necessary to take an x-ray of the distal bones of the forearm and determine the level of the enzyme alkaline phosphatase in the blood serum, which plays an important role in the processes of bone calcification. First of all, you need to assign proper nutrition with daily inclusion in the diet vegetable puree, cow's milk, kefir, grated apple, yolk, cottage cheese, low-fat meat broth, meatballs, liver. Within 30-45 days the child should receive specific treatment rickets with vitamin D in the form of calciferol 1600 IU per day. Considering the presence of anemia in the child, iron supplements (aloe syrup with iron) should be prescribed. ascorbic acid, vitamin B 1. Massage required, daily physiotherapy, pine baths, walks in the fresh air.
5. Technique for measuring height in children of different ages according to the algorithm for performing manipulations.
Task No. 2.
A mother with a 2.5-year-old girl consulted a local doctor about frequent and painful urination in the child, abdominal pain and an increase in temperature to 37.5º C. She was examined by a surgeon, surgical pathology was excluded. These symptoms were observed twice during the year, and after examination a diagnosis of cystitis was made. Treatment was carried out on an outpatient basis. History of frequent colds (7 acute respiratory infections per Last year). The parents are healthy, but the grandmother on my mother’s side has kidney disease.
Objectively: weight 11.5 kg, length 85 cm. Condition is satisfactory. Asthenic physique. The skin and visible mucous membranes are clean. Lymph nodes: tonsillar painless, up to 0.8 cm in size, not fused with surrounding tissue. The subcutaneous fat layer is developed satisfactorily. Above the lungs there is a percussion sound of pulmonary, puerile breathing is heard. The boundaries of the heart correspond to age. The tones are clear and rhythmic. The abdomen is soft, painful above the womb. The liver and spleen are not enlarged. Pasternatsky's symptom is positive on both sides. Urination is painful, 15 times a day.
In general urine analysis, the reaction is alkaline, relative density of urine is 1012, cloudy, leukocytes 20-25, squamous epithelium 3-5 in sight. Blood test: ESR-25 mm per hour, L-12x10 9 /l, Hb-108 g/l. Zimnitsky test: daytime diuresis 300 ml, nighttime diuresis 500 ml, fluctuations in specific gravity 1005-1012.
Ultrasound of the kidneys: the size corresponds to age, the position and mobility are normal, there is compaction of the pyelocaliceal system on both sides, doubling of the kidney on the right.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms To clarify the diagnosis, tell us about the method of identifying them.
3. Tell me about the volume first aid and rules of transportation to destination.
4. Make a plan diagnostic studies in the hospital, tell us about the patient’s preparation for them and the principles of treatment.
5. Demonstrate the technique for collecting a general urine test in children infancy.
Sample answers
1. The patient has a disease urinary system - chronic pyelonephritis on the background congenital pathology kidney
The conclusion is based on the history and complaints typical for this disease:
Frequent and painful urination;
Abdominal pain, increased body temperature;
Symptoms continued for a year.
She has a life history of frequent colds, and her maternal grandmother has kidney disease.
Objective examination data: the child has an asthenic build, his weight is below the norm, the abdomen is painful on palpation above the womb, positive Pasternatsky’s sign on both sides; increased frequency of urination up to 15 times;
Laboratory data in urine tests: (general, Zimnitsky test), low specific gravity, leukocyturia; nocturia. In the blood, the ESR is increased to 25 mm/hour, there is slight leukocytosis, and hemoglobin is decreased.
An ultrasound examination reveals thickening of the pyelocaliceal system on both sides and doubling of the kidney on the right.
2. To clarify the diagnosis, it is necessary to check for the presence of edema (swelling of the eyelids, legs), and monitor A/D.
3. If a child has kidney disease, he or she must be hospitalized in a hospital.
4. In the hospital it is necessary to carry out: urine tests according to Nechiporenko, Addis-Kakovsky to study urine sediment and count shaped elements; functional test according to Zimnitsky, reflecting the reduced ability of the kidneys to concentrate urine. X-ray urological examination methods are informative - excretory urography, voiding cystourography, revealing the size, contours and location of the kidneys, uneven damage to their parenchyma, reflux and other obstacles to the outflow of urine. It is necessary to carry out bacteriological examination urine, sensitivity to antibiotics; Constantly monitor your blood pressure and the amount of fluid you drink and excrete.
Treatment program in hospital:
Bed rest throughout the febrile period;
Diet during the acute period, table No. 7, then table No. 5 (dairy-vegetable) with a limitation of spicy and salty foods. Additional amount of liquid due to watermelon, juices, cranberry and lingonberry fruit drinks, alkaline mineral waters;
Antibacterial therapy 10-15 days: semisynthetic penicillins, aminoglycosides, cephalosporins, nitrofuran drugs (furadonin, furazolidone; nevigramon, 5-NOK);
Vitamins C, group B
Upon achieving remission after inpatient treatment herbal medicine (medicinal herbal infusions) is prescribed according to the scheme.
5. Technique for collecting a general urine test in infants according to the manipulation algorithm.
Task No. 3.
During the next patronage visit to a 1-year-old child, the paramedic drew attention to the sharp pallor of the skin and mucous membranes. The mother reported that the child gets tired quickly, is irritable, inactive, and noted a loss of appetite. When questioning the mother, it was possible to establish that the child’s diet was monotonous, milk porridge twice a day. He prefers not to give fruits and vegetables for fear of indigestion. On this diet, the child gains weight, which makes the mother happy. They live in a hostel and rarely go out.
Upon examination: the baby’s condition is satisfactory. Pronounced pallor of the skin and mucous discharge, peripheral lymph nodes are not enlarged. From the side of the heart: a systolic murmur is heard. The abdomen is soft, the liver protrudes 2 cm from the hypochondrium. From the anamnesis it was revealed that the child was born full-term, on mixed feeding from 1 month, and often suffered from ARVI.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms to clarify the diagnosis, tell us about the method for identifying them.
4. How to prepare vegetable puree.
Sample answers
1. The child may have iron deficiency anemia. The main symptoms of the disease are: pale skin, fatigue, irritability, loss of appetite, lethargy. A systolic murmur is heard in the child's heart, and the liver is enlarged. Reasons: one-sided milk nutrition, frequent illnesses, poor care and poor living conditions.
2. To clarify the diagnosis, it is necessary to conduct a general blood test, where you can detect a decrease in the amount of Er less than 3.5x10 12 l, hemoglobin below 100 g/l, color index below 0.8. Er smears are pale in color, decrease in size, and exhibit moderate leukocytosis and reticulocytosis.
Patients may have additional symptoms of the disease: seizures in the corners of the mouth, waxy color ears, dry skin, dull brittle hair, muscle hypotonia.
3. Treatment of the child should be comprehensive; with moderate and severe forms of anemia, children are hospitalized, with mild degree treated at home. We need to organize correct mode nutrition. Give foods containing iron and other microelements: meat products, liver, cottage cheese, yolk, fruits, vegetables. You need to be in the fresh air more.
A child of the first year is prescribed aloe syrup with iron, ferrocal 0.3 gx3 times a day after meals, feramide, ferospan, vitamin C, B vitamins. It is necessary to establish the correct daily routine for the child. The child should walk in the fresh air, he needs massage and gymnastics, daily bathing.
When hardening, children are less likely to suffer from colds and anemia.
4. To prepare vegetable puree, take a combination of 2-3 vegetables, wash, cut and then boil them for 20 minutes, then cool and rub through a sieve, add a decoction of vegetables and a salt solution, butter, mix everything.
Task No. 4.
A 13-year-old boy was admitted to the hospital with complaints of pain in the epigastric region. There was vomiting before entering the hospital" coffee grounds", after which the pain subsided, but weakness, palpitations, dizziness, and tinnitus appeared.
On examination: pallor of the skin, decreased A/D, PS 110 per minute, palpation of the abdomen - muscle tension in the epigastric region.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Tell us about the scope of first aid and the rules of transportation to the destination.
3. Draw up a plan for diagnostic tests in the hospital, tell us about the principles of treatment.
4. Tell us about further medical examination.
5. Demonstrate the technique of intravenous administration of 10% calcium chloride solution.
Sample answers
1. Diagnosis: gastric ulcer, complicated by bleeding. The conclusion was given on the basis of complaints and objective examination: vomiting “coffee grounds”, dizziness, weakness, pale skin, tachycardia, decreased A/D, pain, muscle tension in the epigastric region.
2. First aid – lay the patient down, apply cold to the stomach area, swallow pieces of ice, urgent hospitalization, consultation with a surgeon.
3. Plan of diagnostic examination in the hospital:
a) general blood and urine analysis;
b) fibrogastroscopy of the stomach - to determine the nature of ulcerative defect gastric mucosa.
Treatment: diet - table No. 1a, No. 1b, No. 1. From medicines drugs that suppress Helicobacter pylori infection are needed: denol, de-nol + oxacillin, de-nol + trichopolum. Antisecretory agents: pepsin, cholinomimetics, atropine, platiphylline, selective M1-cholinomimetics-gastrocetin, antacids and adsorbents, almagel. Maolox, Vikalin. Gastrocytoprotectors: cytotec, smecta, agents that normalize gastric motility: cerucal, No-shpa, papaverine. Sedatives: elenium, diazepam, valerian. Repartees: sea buckthorn oil, rosehip oil.
4. After discharge from the hospital, patients are registered with a gastroenterologist and surgeon. The course of anti-relapse treatment includes diet therapy, drug treatment and physiotherapeutic procedures. The diet is mechanically and chemically gentle: foods with coarse fiber, such as mushrooms, are excluded from the diet. To ensure chemical sparing, foods that increase juice secretion (meat broth, fried foods) are excluded from the diet.
5. Technique for intravenous administration of calcium chloride solution according to the manipulation algorithm.
Task No. 5.
A mother with a 5-year-old girl came to the children's clinic for an appointment. The child has weakness, abdominal pain, decreased appetite, and in the evenings the temperature rises to 37.9º C. The mother noticed that the girl urinates often and her urine is cloudy. The tongue is dry, covered with a white coating. In the lungs, breathing is vesicular, heart sounds are muffled. The abdomen is soft and painless. The liver and spleen are not enlarged.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms to clarify the diagnosis and methods for studying this disease.
3. Tell us about the principles of treating the disease.
4. Demonstrate the technique of collecting urine samples according to Zimnitsky.
Sample answers
1. Acute pyelonephritis.
The diagnosis is based on medical history and complaints: the child has weakness, abdominal pain, fever in the evenings, frequent urination, cloudy urine.
2. Additional symptoms of the disease are symptoms of intoxication: fatigue, loss of appetite, pallor of the skin, pain in the lumbar region, the presence of edema.
3. Treatment of pyelonephritis is complex. The child is prescribed a regimen and diet appropriate to his condition, as well as antibacterial and stimulant medications. Strict bed rest during the acute period of the disease until the condition and well-being improve, body temperature normalizes, urine and blood tests.
A sick child must urinate frequently. To do this, you should strictly follow the eating and drinking regime.
Antibiotics are prescribed. Phytotherapy is carried out. Lysozyme, prodigiosan, methyluracil, pentoxyl, and sodium nucleinate are used as immunocorrective agents.
When increasing blood pressure antihypertensive drugs are prescribed.
Medical nutrition is based on the principles of a dairy-vegetable diet with moderate amount protein and salt. Fried foods and meat broths are not allowed. As the manifestations of pyelonephritis subside, the child is transferred to table No. 5. In the presence of metabolic disorders, limit the use of fish and meat to 2 times a week, mainly in boiled, stewed form using a potato and cabbage diet. Shown drinking plenty of fluids.
4. Urine analysis according to Zimnitsky should be collected according to the manipulation algorithm.
Task No. 6.
A 4-year-old girl has been sick for 2 days. Complains of weakness, lethargy, minor sore throat. On examination: temperature 37.9º С, condition moderate severity, the child is lethargic. Hyperemia of the pharynx is noted. On enlarged tonsils there are shiny grayish-white plaques (not removed with tampons). Sickly sweetish odor from the mouth. In the lungs there is vesicular breathing, no wheezing. Cardiovascular system without pathological changes. Stool and urination are normal. Not vaccinated for medical reasons.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Is hospitalization necessary in this case?
3. List possible complications.
4. Tell us about the principles of treatment.
5. Demonstrate the technique of taking a throat swab using a Loeffler stick.
Sample answers
1. A 4-year-old girl has a localized form of diphtheria of the pharynx. The diagnosis was made according to the anamnesis, complaints, objective examination: weakness, slight sore throat, t-37.9º C, hyperemia of the pharynx, grayish-white plaques on the enlarged tonsils (cannot be removed with tampons). Epidemic history: lack of vaccination for medical reasons.
2. The child is isolated in an infectious diseases hospital; to clarify the diagnosis, swabs are taken from the throat for Loeffler’s diphtheria bacillus. Bed rest, treatment with antitoxic diphtheria serum.
3. Possible complications: infectious-toxic shock, myocarditis, polyradiculoneuritis, acute glomerulonephritis.
4. Bed rest, nutritious, fortified diet.
The main thing in the treatment of all forms of diphtheria is the neutralization of diphtheria toxin with antitoxic diphtheria serum. The dose of serum depends on the form and severity of the disease. Before administering a therapeutic dose, a test is carried out according to the Bezredka method using 0.1 ml of serum diluted 1:100, injected intradermally; in 30 min. 0.2 ml of undiluted serum is administered subcutaneously and after 1.5 hours the remaining amount of serum is administered intramuscularly. For localized forms of diphtheria, serum is usually administered once.
5. The technique of taking a smear from the throat and nose on the BL is carried out according to the algorithm for performing the manipulations.
Task No. 7.
A paramedic was asked for help with a one-year-old child. I've been sick for three days, complaining of a cough, severe runny nose, bad dream, decreased appetite, lethargy.
Objectively: the child’s condition is moderate, t - 38.9º C, restless, catarrhal symptoms are expressed, profuse serous discharge from the nose, conjunctivitis, hemorrhage in the sclera, diffuse hyperemia in the pharynx, granularity of the posterior pharyngeal wall, enlarged submandibular lymph nodes. Skin clean. In the lungs, breathing is puerile, wheezing is not heard. Heart sounds are sonorous, tachycardia. The stool is normal.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. List the methods for diagnosing the disease.
3. Tell us about the principles of treatment.
4. Demonstrate the Nechiporenko urine collection technique.
Sample answers
1. Clinical diagnosis: " Adenovirus infection" is placed on the basis of:
History: complaints of cough, severe runny nose, poor sleep, decreased appetite, lethargy;
Objective examination: condition of moderate severity, temperature 38.9º C, catarrhal phenomena are expressed: profuse serous discharge from the nose, conjunctivitis, hemorrhages in the sclera, diffuse hyperemia in the pharynx, granularity of the posterior pharyngeal wall, enlargement of the submandibular lymph nodes.
2. Laboratory diagnostics:
a) serological testing for viruses of paired blood sera is carried out at intervals of
7-14 days;
b) culture of mucus from the nasopharynx for viruses 2 times;
c) immunofluorescent rapid detection method respiratory viruses in the columnar epithelium of the nasal passages. The answer can be obtained 3-4 hours after taking mucus from the nose.
Clarification of the epidemiological situation helps in making the correct diagnosis.
3. Children with ARVI can be treated at home, but the child must be isolated and kept in bed during the febrile period. A high-calorie diet with limited fat, meat products, and a predominance of fermented milk and fruit and vegetable dishes is necessary. Drinking plenty of fluids and symptomatic treatment are necessary.
Prescribe desensitizing drugs (diphenhydramine, suprastin, tavegil), antipyretics (paracetamol, panadol), multivitamins, alkaline inhalations, gargling (decoctions of chamomile, sage, eucalyptus, calendula), mustard plasters. The nasal mucosa is lubricated with oxaline ointment (0.25%).
When treating conjunctivitis, instill 6-8 times a day antiviral drugs– interferon, 0.25% oxolinic or florenal ointment is placed in the nose 1-2 times a day.
The conjunctival sac is often washed with solutions of furatsilin (1:5000), rivanol (1:5000).
At severe forms placental immunoglobulin is used. For bacterial complications, antibiotics are prescribed.
At heavy discharge Mucus is sucked out of the nose using a rubber bulb. The nose is cleaned with turunda, vasoconstrictor drops are used (galazolin, sanorin, naphthyzin).
Specific prevention: Influenza vaccines, but they are ineffective.
4. Urine collection technique according to Nechiporenko according to the manipulation algorithm.
Task No. 8.
A 3-year-old child lives with his parents in a dormitory and attends kindergarten. I fell acutely ill: temperature - 38.5º C, abdominal pain, vomiting once, frequent loose stools mixed with mucus, streaks of blood, the child is straining, restless. On examination: the child is pale, lethargic, muffled heart sounds, tachycardia, the abdomen is soft, the sigmoid is contracted, painful, the anus is pliable.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms to clarify the diagnosis,
3. Make a plan for diagnostic tests in the hospital.
4. List possible complications.
5. Tell us about treatment methods.
6. Prevention of dysentery.
7. Demonstrate gastric lavage techniques.
Sample answers
1. Dysentery. The diagnosis is based on the history and complaints typical for this disease: t - 38.5º C, abdominal pain, vomiting once, frequent loose stools mixed with mucus, streaks of blood, the child is straining, restless; as well as objective examination data: the boy is pale, lethargic, heart sounds are muffled, tachycardia, the abdomen is soft, the sigmoid is contracted, painful, the anus is pliable.
2. Additionally, there may be symptoms of intoxication (headaches, weakness, decreased or lack of appetite). Symptoms of distal colitis develop: spasm and soreness of the lower colon, painful nagging pain, false urges (tenesmus).
3. A child with any intestinal infection should be hospitalized in a children's infectious diseases hospital.
Diagnostic program in the hospital:
Laboratory and instrumental research methods;
Bacterial sowing on intestinal group;
Coprogram;
Sigmoidoscopy;
Indirect hemagglutination reaction. Bacterial culture for dysentery group.
4. Complications are possible with dysentery, especially in children early age: pneumonia, gingivitis, stomatitis, otitis, anemia, dysbacteriosis. In severe dysentery, rectal prolapse is sometimes observed.
5. Treatment should be carried out taking into account the patient’s age, severity infectious process and period of illness. On the first day, reduce the amount of food by 25%, prescribe fermented milk mixtures, liquid cereals, slimy soups, cottage cheese.
Etiotropic therapy: antibiotics, chemotherapy drugs and specific dysentery bacteriophage. Furazolidone, polymyxin, chloramphenicol are prescribed. IN severe cases prescribe gentamicin. The course of treatment with etiotropic drugs is 5-7 days. Along with etiotropic treatment in the acute period, it is advisable to prescribe vitamin C, groups B, A, E, and nonspecific immune stimulants: methyluracil, pentoxyl, sodium nucleinate.
To relieve intoxication, administer intravenous drips of saline and colloidal solutions; 10% albumin solution, concentrated plasma, rheopolyglucin, 10% glucose solution. Infusion therapy prescribe at the rate of 130-150 ml/kg body weight per day. For hyperthermia, prescribe the following medications: 50% analgin solution intramuscularly, paracetamol, aspirin.
6. Prevention. An important role in the fight against dysentery is played by: sanitary education of the population, universal implementation of sanitary and hygienic requirements, strict sanitary supervision of food enterprises and water supply. Hospitalization of patients with dysentery who work in the food industry is required.
Current disinfection is carried out at the patient's bedside, and final disinfection is carried out after hospitalization. At the same time, a bacteriological examination of contact persons in the outbreak is prescribed. The child communicating with the patient is monitored for 7 days. When cases of the disease appear in the children's team, a one-time bacteriological examination of children and staff is carried out.
7. Gastric lavage technique according to the manipulation algorithm.
Task No. 9.
While providing patronage to a newborn child, the mother turned to a paramedic for advice due to the fact that her eldest daughter, 5 years old, had become capricious, irritable, had worsened sleep and appetite, complained of periodic abdominal pain, itching in the anus, nausea. The girl began to experience bedwetting.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms to clarify the diagnosis.
3. Tell us about the treatment of this disease.
4. List methods of prevention.
5. Demonstrate the technique of scraping pinworm eggs.
Sample answers
1. Enterobiosis. The diagnosis is made on the basis of anamnesis, complaints typical for this disease: the child is capricious, irritable, sleep and appetite have worsened, complains of periodic abdominal pain, itching in the anus, nausea, and bedwetting is noted.
2. Pinworms can be detected on the surface of feces, and their eggs can also be removed from the perianal area with sticky, transparent plastic film, followed by microscopy.
3. Treatment. Pyrantel is effective in a single dose of 10 mg/kg, or piperazine adipate in an age-specific dosage for 5 days. If necessary, the course of treatment is repeated after 5 days. When treating enterobiasis, strict adherence to a hygienic regime is necessary. The prognosis is favorable. Control analysis - scraping for pinworm eggs is carried out after 1 month.
4. Prevention. Maintaining hygiene of body, clothing, home, simultaneous treatment of all family members. Parents are advised to monitor the child’s hygiene, wash vegetables, fruits, toys and household items, boil and iron and change bedding frequently. Carry out wet cleaning and ventilation of the room daily.
5. Technique for taking scrapings for enterobiasis according to the algorithm for performing the manipulation.
Task No. 10.
IN medical office kindergarten came with a 5 year old child. Today the mother discovered rashes all over the child's body due to... normal temperature. Almost all the children in the group got sick; no quarantine was announced.
Objectively: the girl’s condition is satisfactory, she is playing. On the skin of the face, torso and limbs there is a small papular rash of pink color against a normal skin background. The pharynx is hyperemic. The occipital lymph nodes are palpated to the size of a bean, elastic, painless. The heart and lungs are normal, the abdomen is soft, stool and urination are normal.
Tasks
1. Formulate and justify the presumptive diagnosis.
2. Name additional symptoms to clarify the diagnosis, tell us about the method for identifying them.
1. In a child 5 months of CINE with symptoms of toxicosis and exicosis.
2. Prescribe a water-tea diet for 4-6 hours with oral rehydration (Rehydron, glucosolan) 1-2 teaspoons
after 3-4 minutes and intravenous administration plasma, rheopolyglucin, 5% glucose solution, vitamins. After
water-tea diet can be given breast milk or acidic mixtures: acidophilus milk or kefir, antibacterial drugs- polymyxin, etc.
Problem No. 36
Calling an ambulance to a 9 month old child's home. The day before I had a runny nose and a temperature of 37.2° C. At night I suddenly woke up and became restless. Appeared barking cough, began to choke. The temperature became 38° C.
Tasks
2. What urgent measures should be taken?
Sample answers
1. A 9-month-old child developed false croup due to ARVI.
2. Provide emergency assistance:
distraction therapy ( hot bath, soda inhalation), - drug treatment: hormones (prednisolone); desensitizing agents (suprastin, diazolin, pipolfen).
Problem No. 37
The child is 7 years old and attends school. The teacher notes that during last week the child has become whiny, grimaces in class, and his handwriting has changed.
Tasks
1. Formulate a presumptive diagnosis.
2. What disease can cause similar symptoms and which specialist should be referred to
child for consultation? Tell us about the principles of treatment of this disease.
Sample answers
1. A 7-year-old child has an active rheumatic attack and minor chorea.
2. It is necessary to consult a rheumatologist. Treat in a hospital. Antirheumatic treatment:
penicillin, aspirin, prednisolone, vitamins, suprastin, phenobarbital.
Problem No. 38
Child, 2.5 years old, suffering congenital defect heart, was admitted to the hospital with complaints of shortness of breath at rest and swelling in the legs.
Tasks
1. Formulate a presumptive diagnosis.
2. What diet does the child need?
Sample answers
1. A 2.5-year-old child suffering from a heart defect developed symptoms of heart failure.
2. The child should be hospitalized in a hospital, prescribed bed rest, a dairy-vegetable diet with
restriction of salt, liquid (up to 1 liter), from medications - cardiac glycosides, vitamins.
Problem No. 39
A 10-year-old child was admitted to a children's hospital with complaints of headache and pain in the lumbar region. Upon examination, the boy is pale, the face is puffy, and there is swelling under the eyes. Daily diuresis is 600 ml.
Tasks
1. Formulate a presumptive diagnosis.
2. What examinations need to be carried out for the child?
Sample answers
1. A 10-year-old child admitted to the hospital may have glomerulonephritis.
2. In a hospital setting, it is necessary to conduct an examination (test according to Zimnitsky, Nechiporenko, general blood and urine analysis,
biochemical analysis blood, kidney ultrasound, excretory urography).
Problem No. 40
The child was observed bloody discharge from umbilical wound. Within one day, the child’s condition changed: he became lethargic, lethargic, and his skin acquired a gray-sallow hue. T=37.3°C. There is a zone of hyperemia around the umbilical wound. The vessels of the anterior and abdominal wall sharply contoured. Purulent discharge appeared from the umbilical wound.
Tasks
1. Formulate a presumptive diagnosis.
2. What can such a condition lead to?
Sample answers
1. The child may have omphalitis, complicated by phlebitis.
2. It can lead to umbilical sepsis.
Problem No. 41
A 4-month-old child suffers from rickets. She is being treated on an outpatient basis. Receives vitamin O and calcium gluconate. Suddenly in the morning, while eating, twitching of the limbs appeared, the child screamed, but the voice suddenly stopped, the child turned blue. After 30 sec. the skin turned pink, the convulsions stopped.
Tasks
1. Formulate a presumptive diagnosis.
2. What needs to be done?
Sample answers
1. The child may have spasmophilia (laryngospasm).
2. The child must be provided with urgent assistance: in case of laryngospasm, give access to fresh air, irritate the root of the tongue,
sprinkle the skin with cold water, perform a heart massage, artificial respiration. During an attack of convulsions intramuscularly
introduce a 25% solution of magnesium sulfate or a 0.5% solution of seduxen, a 20% solution of Tomk.
Problem No. 42
In a 15-day-old child, staphyloderma suddenly appeared heat 38.9° C, grayish-cyanotic skin color, weak pulse and tension, bloating. Breathing is frequent, with fluttering of the wings of the nose. Examination of the lungs revealed no pathology. On the 5th day of illness, a clear shortening appeared above the lungs percussion sound diffusely over the entire surface, moist, fine-bubbling rales. On the radiograph, there is an infiltrate on the right in the middle lobe of the lung and the parietal pleura is constructed. Leukocytosis in the blood is 12,000 per ml, ESR is 22 ml/hour.
Tasks
1. Formulate a presumptive diagnosis.
2. What could be the nature of this disease?
Sample answers
1. A 15-day-old child has pneumonia.
2. Possibly staphylococcal in nature.
Problem No. 43
During the next visit to the clinic by a 1-year-old child, the doctor noticed a sharp pallor of the skin and mucous membranes. The mother reported that the child gets tired quickly, is irritable, inactive, and has lost his appetite. When questioning the mother, it was possible to establish that the child’s diet was monotonous - dairy food (the mother breastfeeds the child twice a day), and the mother prefers not to give fruits and vegetables, for fear of digestive disorders. On this diet, the child gained weight well, which pleased the mother.
Tasks
1. Formulate a presumptive diagnosis.
2. What additional examination can clarify the diagnosis?
Sample answers
1. A 1-year-old child developed symptoms of anemia due to poor nutrition.
2. A blood test (decrease in hemoglobin and red blood cells) will help clarify the diagnosis.
Problem No. 44
Sasha M., 15 years old, became acutely ill: the temperature rose -38° C, pain when chewing, radiating to the left ear. There is swelling in the left parotid area, the skin over it is of normal color.
Tasks
1. Formulate a presumptive diagnosis.
2. Tactics in relation to the patient.
Sample answers
1. A 15-year-old child has mumps.
2. Isolate the child for periods of severe clinical manifestations, per area parotid gland left
put dry heat.
Problem No. 45
Serezha K., 3 years old, fell ill acutely with a rise in temperature to 38.8 ° C, single vomiting was noted, headache, pain when swallowing, by the end of the day a rash appeared. On examination: the condition is moderate, temperature 39.9° C. There is an abundant pinpoint rash on the skin on a hyperemic background. White dermographism, tongue coated. The pharynx is clearly hyperemic.
Tasks
1. Formulate a presumptive diagnosis.
2. What complications are possible from this infection?
Sample answers
1. A 3-year-old child has scarlet fever.
2. Possible complications - synovitis, purulent lymphadenitis, glomerulonephritis.
Problem No. 46
On the 3rd day of stay, an 11-month-old child in the hospital with a diagnosis of acute respiratory viral infection developed changes in the color of urine and stool: urine became dark, stool (stool) became light.
Tasks
1. Formulate a presumptive diagnosis.
2. What is your tactics in relation to the patient?
Sample answers
1. The child is 11 months old. phenomena of epidemic hepatitis, obviously "B".
2. Isolate the patient in the infectious diseases department. Prescribe bed rest, physiological nutrition
fortified, 5% glucose, vitamins, methionine, lipocaine. In severe cases, hormonal treatment.
Sample answers
1. The needs are violated: to breathe, sleep, rest, play, be healthy, communicate.
Patient problems
real:
Ineffective cleansing respiratory tract;
Sleep disturbance;
Concern about the outcome of the disease;
potential:
High risk of suffocation;
Deterioration of the patient's condition associated with the development of complications
2. The patient’s priority problem is ineffective airway clearance.
Short-term goal: The patient will notice improvement in sputum production by the end of the week.
Long-term goal: The patient will have no complaints of difficulty breathing by the time of discharge.
| Plan | Motivation |
| Nurse: | |
| 1. Call a doctor immediately. | 1. To provide emergency medical care. |
| 2. Provide the patient with bronchodilators as prescribed by the doctor. | 2. To dilate the bronchi |
| 3. Provides monitoring of the patient’s condition (RR, PS, BP). | 3. For early diagnosis and timely provision of emergency care in case of complications. |
| 4. Gives the patient a semi-sitting position. | 4. To make breathing easier. |
| 5. Use a pocket inhaler. | 5. To relieve and prevent asthma attacks. |
| 6. Complete the doctor’s orders. | 6. For effective treatment. |
| 7. Conduct a conversation about the prevention of asthma attacks. | 7. To prevent asthma attacks. |
Assessment: the patient will note improvement in condition, elimination of suffocation, and demonstrate knowledge about the prevention of suffocation attacks. The goals will be achieved.
Problem No. 59
Calling a paramedic to a 4-year-old child. Complaints of repeated vomiting and loose stools for 2 days. According to the mother, the vomiting began after the child drank the milk. Vomiting is observed up to 3 times a day. After each act of defecation there is increasing weakness. Objectively: consciousness is clear, the child is adynamic, the skin is pale and dry, facial features are pointed. Subfebrile body temperature = 37.1º C, C, PS = 52 beats per minute. weak filling, A/D 78/40.
Medical diagnosis: CINE ( intestinal infection unclear form).
Tasks
1. The needs are violated: to be healthy, to eat, to drink, to excrete, to maintain body temperature.
Patient problems:
real:
Repeated vomiting
Dehydration,
Weakness,
Body temperature is low-grade;
potential:
The risk of deterioration of the condition associated with the development of complications, heart failure, dehydration.
2. Priority problems: diarrhea, dehydration.
Short-term goals: prevent the child from aspiration of vomit and further dehydration, stop diarrhea. Protect contacts from infection.
Long-term goals: The baby will be healthy at the time of discharge.
| Plan | Motivation |
| Nurse: will provide | |
| 1. Correct position: child (lying on his back, head turned to the side), use a functional bed. | 1. To avoid aspiration of vomit. |
| 2. Control the volume of excrement and vomit. | 2. To prevent exicosis. |
| 3. Hygienic child care. Frequent change of linen. | 3. To prevent diaper rash, skin irritation, and purulent complications. |
| 4. Constant monitoring of the child’s condition (A/D, PS, t). | 4. For early diagnosis and timely provision of emergency care in case of complications. |
| 5. Following the doctor’s medication prescriptions. | 5. To ensure the effectiveness of treatment. |
| 6. At the outbreak, he will provide isolation of contacts, monitoring of contacts for 7 days, and a biological examination. Preventative treatment contact. | 6. To avoid the spread of infections. |
| 7. Sanitary clearance. work on the prevention of intestinal and especially dangerous infections. | 7. To avoid the spread of infections. |
| 8. Dachu emergency notice in SES. | 8. To avoid the spread of infections. |
Assessment: the patient will note an improvement in condition, absence of diarrhea and vomiting. The goals will be achieved.
Problem No. 60
During a regular visit to the clinic by a 1-year-old child weighing 10,700 grams, the nurse noticed a sharp pallor of the skin and mucous membranes. The mother reported that the child gets tired quickly, is irritable, inactive, and noted a loss of appetite. When questioning the mother, it was possible to establish that the child’s diet was monotonous: dairy foods, dairy products. The mother prefers not to give fruits and vegetables for fear of digestive problems. A child under 1 year old had ARVI 3 times. Blood history: Hb-100 g/l, Er-3.0x10 12, c.p. - 0.8
Medical diagnosis: Iron deficiency anemia.
Tasks
1. Identify the needs whose satisfaction is disrupted; formulate and justify the patient’s problems.
2. Identify goals and create a motivational nursing intervention plan.
During your next visit to the children's clinic, did your pediatrician hear a heart murmur in your child? The worst thing parents can do in this case is to start panicking. You can do a lot of stupid things out of fear, but in this situation you need to pull yourself together and act. It is advisable to first consult with pediatric cardiologist and understand not only the intricacies of terms that will be replete with the baby’s card, but also try to figure out how to deal with this problem.
Heart murmurs in a child: what you need to know
To reassure parents, it is worth saying that, in general, heart murmurs in a child do not indicate any serious problems. Strictly speaking, they are divided into three main types: functional (they are also called “innocent”), acquired and congenital.
As for functional heart murmurs in children, their causes may be rheumatism or disruption of the heart muscle. This type of pathology occurs in many young children. As you grow older, the noise goes away, and when you reach adolescence you can completely forget about them. The diagnosis is made by a cardiologist for the sole purpose: during subsequent examinations, parents should inform the doctor that similar disorders have already been detected previously.
Functional noises do not lead to disturbances in the functioning of the circulatory system, and therefore do not have any effect on the heart and other organs. Most often, they indicate changes occurring in the baby’s body (and mainly such noises occur in newborns), and are the result of adaptation of the cardiovascular system. vascular system to life outside the womb. It does happen, but much less frequently, that this kind of problem is found in adults, but this is rather an exception to the rule. According to statistics, up to 50% of all diagnosed heart murmurs are of this “safe” nature.
The cause of pathological murmurs is considered to be congenital anomalies of the heart, which lead to circulatory disorders. Usually the diagnosis is made very early (in the first months of the child’s life), because the face has quite expressive symptoms: bluish skin, shortness of breath, developmental delay, etc. But sometimes nothing other than noise indicates abnormalities in the work of a small heart, and not only parents , but doctors themselves may overlook a rather dangerous violation. Even worse, heart murmurs may not even be heard, but are detected only when the blood circulation has already been reorganized in a certain way. If heart murmurs increase over time, this is a very unfavorable symptom.
As for acquired heart murmurs in a child, they are most often caused by rheumatic attacks, which provoke inflammation of the heart valves. As a result, they are left with scars that negatively affect normal blood flow. The detection of murmurs in the heart that have not previously been observed clearly signals an active rheumatic process. But in this case, other signs will appear in parallel: changes in blood counts, increased temperature, etc. If these symptoms are not observed, perhaps the heart murmur is caused by old scars after a previous attack of rheumatism.
Congenital noises, as the name suggests, are most often heard in the first months of a child’s life (extremely rarely – after several years). They signal heart disease not related to inflammatory process. In this case, it is not the noise itself that should be alarming, but how the congenital defect will affect the functioning of the small heart. In a child, the disease may be accompanied by slow growth, bluish skin, and breathing problems. Children with congenital heart murmurs require constant monitoring by specialists, and in especially severe cases they may need surgery. If a child has a congenital heart murmur, parents should try to protect him from the slightest infection. Even when visiting a dentist, you need to inform the doctor about the illness of a small patient, since the risk of infection also exists during dental treatment.
Necessary research
If a heart murmur is detected in a child, it would be advisable to carry out a series of additional research in order to accurately determine the cause and develop the correct treatment strategy.
One of the main diagnostic methods is ultrasound (echocardiography, or Echo-CG). This is an absolutely safe and painless way to determine any disturbances in the functioning of the heart, which is also highly informative. Thanks to modern technologies, you can obtain an image of the heart in both two-dimensional and three-dimensional projections. In addition, the method allows you to learn about the speed of blood flow and pressure in individual parts of the vascular system. Making the correct diagnosis depends on the qualifications of the specialist who will interpret the results.
In addition to Echo-CG, problems in the heart are diagnosed using computed tomography or magnetic resonance imaging. Such research methods are very useful when it is necessary to simultaneously monitor the state of several body systems, for example, cardiovascular and respiratory. The complexity of these techniques lies in the fact that for their correct implementation the patient must be completely immobile, and this can be achieved from small child pretty hard. Therefore, if necessary, for a correct diagnosis, the examination can be carried out under anesthesia. The high cost of these procedures can also be considered a not very pleasant nuance.
If it is necessary to determine the oxygen content and pressure in the cavities of the heart, the doctor may prescribe catheterization. In this case, it is injected into the vein contrast agent in order to visualize the cavities of the heart and blood vessels (angiocardiography). Due to the complexity of the study, such a study may require a small patient to stay in the hospital.
Text: Tatyana Okonevskaya
4.88 4.9 out of 5 (25 votes)
Failure of a patient to appear without good reason at the appointed time for a medical examination is grounds for reducing the amount of disability benefits from the date of failure to appear. In addition, in certain cases, your absence from work may be regarded as absenteeism, last resort the punishment for which is dismissal (clause “a”, clause 6, part 1, article 81, article 192 of the Labor Code of the Russian Federation; clause 2, part 1, clause 1, part 2, article 8 of the Law of December 29, 2006 N 255 -FZ).
1. Notation of late attendance at a doctor’s appointment
The attending physician must record the fact of late attendance for an appointment on the certificate of incapacity for work. To do this, in the line “Notes on violation of the regime,” he indicates the code of the type of violation (- late attendance at a doctor’s appointment), the date of late attendance and puts his signature.
2.2.2. Calculation of benefits if you came to the doctor late while still sick
If you missed the date of your appointment with the doctor and came to him later, while continuing to be sick, your sick leave may be extended. It should be taken into account that the extension of a certificate of incapacity for work for the past time can be carried out in exceptional cases by decision medical commission when you contact medical organization or visiting you medical worker at home (clause 14 of the Procedure).
Benefit for the period following the date you missed an appointment until the date of recovery, if good reason paid in full. If the reason for not showing up for an appointment with a doctor is not valid, the benefit for these days can be calculated based on the minimum wage (Part 1, 8, Article 6, Part 2, Article 8 of Law No. 255-FZ).
At the same time arbitrage practice proceeds from the fact that the legislation does not contain a requirement that failure to appear on time for a medical examination entails a reduction in the amount of benefits from the date of failure to appear for the entire period of incapacity. In addition, this measure must be proportionate to the violation (Resolution of the Presidium of the Supreme Arbitration Court of the Russian Federation dated February 14, 2012 N 14379/11).
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