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Keywords: a case history, a pedonosology, children's diseases, a bronchitis, a respiratory catarrh, an acute respiratory virus infection, a case history on pedonosologies, an acute simple bronchitis
the CASE HISTORY
the Clinical diagnosis: an acute respiratory virus infection, an acute simple bronchitis (J20 on ÌÊÁ-10).
NAMEPLATE DATA
- the Surname, a name, a patronymic of the patient - *********** ******* ************.
- Age - 4 years 3 months (date of a birth: on June, 18 1999 years).
- Date and time of entering in clinic - on September, 17 2003 years in 640.
- Age and a trade of parents - ***************************************.
- the Child visits a kindergarten.
- the Address, phone - ***********************************************.
- the Clinical diagnosis - an acute respiratory virus infection, an acute simple bronchitis.
COMPLAINTS OF THE PATIENT
Complaints at entering in clinic - on a rhinitis, sense of an incorporation of a nose, tussis, a fervescence up to 38,9°Ñ, a febricula, downstroke of appetite.
Complaints at date of a curatio - on a rhinitis, sense of an incorporation of the nose, an abjointed mucous secret from a nose, tussis.
THE ANAMNESIS OF LIFE
Was born from 1-st pregnancy. Pregnancy proceeded with an early toxicosis and a gestosis (the edematous form). Labors proceeded without complications, the child has cried at once, an evaluation on Apgar - 6-7 points. Body height at a birth - 3300 sm, mass of a body - 56 see. The physiological icterus after a birth - is short. After a birth was not sick.
Further educed in conformity with the years. Tooths have started prorezyvatsja in 3 months. To hold the head has become in 2 months, to sit - in 5 months, to stand - in 8-9 months, to go - to 11-12 months, to speak - from 1 year.
On natural feeding - up to 1 year. After 1 year a feed high-grade, the regimen keeps. Appetite good.
About 3 flying of 3 months visits a kindergarten.
Prophylactic inoculations - in time, were tolerated by the child without complications. A Mantoux test - negative.
An allergological anamnesis: the allergic response (red, pruritic enanthesises) the ambassador method of chocolate is marked. Relatives allergic diseases do not suffer. Intolerances of medicinal preparations are not present.
The transferred diseases: a respiratory catarrh, a grippe.
Hemotransfusions, plasma, introductions of an immunoglobulin were not.
Structure of family: 6 person - the patient, his parents, parents of mother, the younger sister (5 months). Parents: mother - 30 flying, idle; father - 29 flying, the militiaman in the beat. Both suffer a peptic ulcer of a stomach, a chronic gastritis. The child is looked after by mum and the grandmother. Domestic and sanitary-and-hygienic conditions - satisfactory. Presence in a stem of a tuberculosis, venereal, mental, endocrine and manifestative hereditary diseases is denied. Abortions, frailty of children, congenital teratisms was not.
THE EPIDEMIC ANAMNESIS
On September, 13 2003 years were contact to the contagious patient (the boy, 4 years, presumably a respiratory catarrh). In a kindergarten of patients is not present.
THE STATE OF HEALTH BEFORE THE PRESENT DISEASE
Group of health - 2-ÿ. it is is conditional able-bodied. The allergic response (red, pruritic enanthesises) the ambassador method of chocolate is marked. Are regular (1-2 times in year) diseases of a respiratory catarrh, are especial in the seasons of epidemies.
THE ANAMNESIS OF DISEASE
Was ill on September, 15 2003 years 2 days prior to entering in hospital, 7 days prior to the present curatio. First attributes of disease were a febricula, delicacy, loss of appetite, a fervescence up to 38,2°Ñ. Parents gave the child a tablet of Aspirinum. Next day to the above-stated signs tussis was added, the temperature has raised up to 39°Ñ. At night with 16 for September, 17 the condition has worsened, the child did not sleep, the body temperature - 39,6°Ñ. has been caused first aid, the preliminary diagnosis is put: an acute respiratory virus infection, a bilaterial pneumonia (?). Are intramuscularly entered: Sol. Analgini 50 % - 0,5 ml, Sol. Papaverini hydrochloridi 2 % - 0,5 ml, Sol. Dimedroli 1 % - 0,5 ml. The child is hospitalized in the second children's municipal hospital.
In hospital the preliminary diagnosis of a respiratory catarrh, a bilaterial pneumonia is put. Prednisolonum, Aspirinum and amoksitsillin are appointed. Subsequently the diagnosis of a pneumonia has not been confirmed also Prednisolonum has been cancelled. Further downstroke of a body temperature, decrease of tussis, weakening of rhonchuses in mild was observed.
THE PRESENT CONDITION OF THE PATIENT
the General condition of the childaverage - the child complains of a rhinitis, sense of an incorporation of a nose, a respiratory embarrassment, wet tussis with branch of a mucous sputum.
Nervous system.the Consciousness clear, on environmental reacts adequately, mood good, the child is sociable, questions answers correctly. Mental development of the patient corresponds to age. Belly reflexes alive, patellar and ahillov reflexes are invoked easily, moderately expressed. Meningialnyh (the stiff neck, a Kernig's sign, top and inferior signs Brudzinskogo) is not present signs. Signs of a tension of nerve cords (signs Lassega, Matskevich, Vassermana) are not present.
External inspection of eyes.Eyes clean, oxycinesias of eyeglobes are not present, eyelids are not hydropic, photophobias and lacrimations is not observed.
External inspection of ears.Ears without features.
Physical development.Mass of a body - 20 kg, length of a body - 105 see. The child educes according to age norm. Stigm dizembriogeneza it is not revealed.
the Skinusual colour, moderately wet, is coated with a pappus hair, is elastic. Cicatrixes, an eruption, hemorrhages, plots of a pigmentation and a depigmentation it is not observed.
the Hair, dactyls, nails.the Hair shining. Trailer phalanxes of dactyls and nails of the usual form.
the Subcutaneously - fatty tissue.the Child of an average feed, the subcutaneously - fatty layer is moderately advanced, distributed in regular intervals. Edemas and are not present a pastosion.
Lymph nodes.individual cervical, occipital axillary, inguinal lymph nodes in size with a small pea not soldered among themselves and with subject tissues, moderately dense Are palpated. In submandibular range at the left it is palpated single enlarged (1 sm) a lymph node, moderately dense, not soldered with subject and integumentary tissues.
Musclesare advanced in conformity with the years, a tonus normal, at a palpation and at awake and passive locomotions are painless. Force of muscles in conformity with the years.
Osteal system.the Form of a head usual. Deformations of bones, morbidity at pressing, a beating it is not taped. The backbone is not curled. A chest of the usual form; deformations, asymmetries, are not present tortuosities.
System of a respiratory organs. Nasal respiration labored. Phylum of respiration blended, in the act of respiration both half of chest participate. The additional musculation does not participate in the act of respiration. Respiration rhythmical, deep. Frequency of respiratory locomotions=26 1 minute. The short wind is not present. At a palpation the chest is pliable, painless, intercostal spaces do not sink down. A voice tremor slightly strenuously.
At a relative percussion the clear pulmonary note in all fields is determined. At a topographical percussion the inferior border dextral mild is determined on a sredinno-clavicular line - the top edge of 5 ribs, on an average axillary line - 7 rib, on a scapular line - the top edge of 9 ribs. Motility of pulmonary edge - 3 see Sign Koranji - negative.
At an auscultation mild puerile respiration is auscultated, is large and srednepuzyrchatye the wet rhonchuses better auscultated in range of 2 segments (D=S) at intensifying of respiration at height of an inspiration.
System of a circulation.At inspection: in range of heart of a diverticulum (" the cardiac back hollow ") is not taped. The apical beat about 1 sm2 is palpated by the area in the fifth intercostal space on a sredinno-clavicular line at the left. The cardiac impulse is not determined. At a percussion: the top border of relative dullness of heart - in the second intercostal space, dextral - on 0,5 sm to the right from a right edge of a breast bone, left - on 1 sm outside from a sredinno-clavicular line.
At an auscultation of heart sonorous rhythmical tints in all points of an auscultation, short functional hum on an apex and in Botkin - Erba (?) point are auscultated.
A seen pulsation of vessels of a neck, extremities, temporal arterias it is not determined. Pulse of a radial arteria rhythmical, an average strain, frequency=102 1 minute, synchronic on both arms. Arterial pressure=90/70 mm of a mercurial pile.
System of digestionand organs of an abdominal cavity. Labiums of pink colour, moderately wet, a mucosa of an oral cavity and a gingiva of pink colour, wet; hemorrhages, aphthas, ulcers, spots Filatova it is not marked. Tongue of pink colour, wet, is marked a moderate hypertrophy of papillas. Tooths milk.
the Mucosapharynxes bloodshots, palatine tonsils are hypertrophied, support limens of palatal arculuses, bloodshot.
The belly is symmetric, slightly acts above a level of a chest, participates in the act of respiration; diverticulums, retractions it is not observed. Seen perestaltiki an intestine it is not observed. Vienna a forward wall of a belly are not amplate. At a palpation of intensity and morbidity of muscles is not present, the prelum abdominale is advanced moderately, the divarication of recti is absent, the umbilical ring is not enlarged, the sign of a fluctuation is absent. Signs SHCHetkina-Bljumberga and Mendel negative.
The inferior edge of a liver painless, mild, elastic, smooth, acts on 1 sm from under a rib arch. The dimensions of a liver on Kurlovu: 8 sm, 6 sm, 5 see. The lien palpatorno is not determined. Signs Georgievskogo-Mjussi, Ortnera-Grekova, Murphy - negative.
Genitourinary organs.Diverticulums above a pubis and in range of kidneys it is not determined. A sign of a beating on lumbar range negative. An emiction painlessly.
THE PRELIMINARY DIAGNOSIS
An acute respiratory virus infection, an acute simple bronchitis (J20.)
THE PLAN OF INSPECTION
For acknowledgement preliminary the diagnosis it is necessary to lead the following additional methods of research: the general analysis of a blood, the general analysis of urine, the analysis of a feces on an intestinal flora and eggs of helminths, roentgenography of a chest in a direct projection. Consultation of the LOR-DOCTOR is required.
ADDITIONAL METHODS OF RESEARCH
the General analysis of a blood (17.09): (the age norm is specified in brackets)
the Haemoglobin 124 g/l (120-140 g/l)
Leucocytes 9,6*109/ë (4-9*109/ë)
Eosinocytes 1% (1-2 %)
Relating to stab neutrophile neutrophils 2 % (1-2 %)
Segmentojadernye neutrophils 50 % (45-55 %)
Lymphocytes 45% (40-50 %)
Monocytes 2% (2-5 %)
the Blood sedimentation rate 14 mm / ch (2-10 mm / ch)
the General analysis of urine (17.09):
Protein Is not present (up to 0,033 g/l)
Colour Straw-coloured (Straw-coloured)
the Transparence Transparent (Transparent)
Reaction Acidic (Acescent)
Slime Is a lot of (No)
the Flat epithelium 1-2 in sight (1-2 in sight)
Leucocytes 4-5 in sight (1-2 in sight)
Erythrocytes 1-2 in sight (1-2 in sight)
the Analysis of a feces (19.09):
Pathogenic enterobakterii are not secured, eggs of helminths are absent.
Roentgenography (17.09):
On a roentgenogram of organs of a chest in the direct projection plump by rays of average rigidity the amplified pulmonary drawing in rhizospheres is determined. Focal infiltrativnyh shades are not present. Sine are free. Heart - in limens of age norm.
the Conclusion on all additional methods of research:results of additional methods of research specify presence of inflammatory process (the moderate leukocytosis, augmentation of a sedimentation rate, a leukocyturia, presence in is wetted slime) in mild (on a roentgenogram the amplified pulmonary drawing in rhizospheres is determined).
DIARIES
8-th day of disease
Date: 22.09.2003 The condition of the patient can be treated as srednetjazheloe. Slept quietly. Complaints to sensation of an incorporation of a nose, a respiratory embarrassment, abjection from a nose of a mucous secret, tussis. The hyperemia of a mucosa of a pharynx is marked. In mild are auscultative auscultated largly and srednepuzyrchatye wet rhonchuses, at intensifying respiration at height of an inspiration. Cardiac sounds sonorous, rhythmical.
Purposes: a confinement to bed, consumption of a plenty of a liquid (up to 1 l/sut), UVCH on a chest, inhalations with berodualom, an interferon, Pipolphenum, an Euphyllinum, a root of a mallow
T=36,4°C ×Ä=26 in 1 mines ×ÑÑ=102 in 1 mines
9-th day of disease
Date: 23.09.2003 A condition of the patient srednetjazheloe. Slept quietly. Complaints to an incorporation of a nose, a respiratory embarrassment, abjection from a nose of a mucous secret, podkashlivanija. The moderate hyperemia of a mucosa of a pharynx is marked. In mild at height of an inspiration are auscultated largly and srednepuzyrchatye wet rhonchuses. Cardiac sounds sonorous, rhythmical.
Purposes: a confinement to bed, consumption of a plenty of a liquid (up to 1 l/sut), UVCH on a chest, inhalations with berodualom, an interferon, Pipolphenum, an Euphyllinum, a root of a mallow
T=36,8°C ×Ä=26 in 1 mines ×ÑÑ=104 in 1 mines
12-th day of disease
Date: 26.09.2003 A condition of the patient satisfactory. Slept quietly. Complaints to a mucous discharge from a nose. In mild puerile respiration is auscultated. Cardiac sounds sonorous, rhythmical.
Purposes: an interferon, Pipolphenum, a root of a mallow
T=36,6°C ×Ä=24 in 1 mines ×ÑÑ=100 in 1 mines
THE SUBSTANTIATION OF THE CLINICAL DIAGNOSIS
The diagnosis is put on the establishment:
- complaints to a rhinitis, sense of an incorporation of a nose, a mucous discharge from a nose, tussis;
- the acute beginning of disease, a fervescence up to 39,6°Ñ, malaises, delicacies, losses of appetite for the second day of disease;
- auscultations in mild it is large and srednepuzyrchatyh the wet rhonchuses intensifyed at height of an inspiration;
- a moderate leukocytosis, augmentation of a sedimentation rate, a leukocyturia, presence in it is wetted slime, definition on a roentgenogram mild an amplified pulmonary drawing in rhizospheres;
- presence in an anamnesis of contact to the patient with an acute respiratory virus infection.
The form of disease - typical.
Accurate information of the basic diagnosis:an acute respiratory virus infection (respiratory catarrh), an acute simple bronchitis (J20.)
THE DIFFERENTIAL DIAGNOSIS
The acute simple bronchitis should be differentiated with an obstructive bronchitis, a bronchiolitis and an acute pneumonia.
At an obstructive bronchitis at the patient - ekspiratornaja a short wind with participation in the act of respiration of an auxiliary musculation, probably moderate inflation of a chest, at a percussion - a box shade of a note, at an auscultation - respiration with a prolate expiration, rigid, dry, whistling rhonchuses.
At a bronchiolitis in a clinical picture signs nejrotoksikoza, sometimes attacks of an asphyxia and apnoe, ekspiratornyj character of a short wind with participation in the act of respiration of an auxiliary musculation prevail. It is percussion - a box note, decrease of relative cardiac dullness, a ptosis of borders of a liver and a lien, at an auscultation - respiration with a prolate whistling expiration, crepitant microvesicular rhonchuses both on an inspiration, and on an expiration, on a roentgen atelectases are possible.
At an acute pneumonia - decrease of a ratio between pulse and frequency of respiratory locomotions, ukorochenie a percussion note according to the locus of a defeat, a box shade above other plots (a local symptomatology) is frequently long the retained fever, considerably expressed nutrient-deficiency symptoms, a set of symptoms of the respiratory failure, a blended short wind with participation of an auxiliary musculation. At an auscultation rhonchuses on the certain plot are audible. In a blood - the expressed inflammatory reaction (nejtrofilnyj a leukocytosis, a sedimentation rate>20 mm / ch). On a roentgenogram - focal infiltativnye shades.
THE SUBSTANTIATION OF TREATMENT
Principles of therapy of the given disease according to the literature are those:
- a confinement to bed;
- introduction of plenties of a liquid (per os);
- as disease has a virus nature expedient there will be a purpose of antiviral agents: Remantadinum, interferons, specific immunoglobulins or immunokompleksnyh immunoglobulins;
- at apposition of microbic process the antibiotic therapy is recommended: amoksitsillin, sumamed, rulid, klaritromitsin, macrofoams;
- desensitizing therapy: Pipolphenum, Dimedrolum, Suprastinum, Tavegilum, klaritidin;
- protivokashlevye and expectorating preparations: Bromhexinum, Libexinum, Mucaltinum, Codeinum;
- at a respiratory embarrassment - bronholitiki: berodual, b-agonists;
- a phytotherapy: termopsis, a root of a mallow, mint, Tussilago farfara, a thyme;
- a physiotherapy: UVCH on a chest, a photoradiotherapy on reflexogenic zones, soda ingalljatsii.
the Circuit of treatment:a confinement to bed, consumption of a plenty of a liquid (up to 1 l/sut), UVCH on a chest, inhalations with berodualom, an interferon, Pipolphenum on 1 tab. 2 of time in day, an Euphyllinum of 1 tab. 2 of time in day, a root of a mallow.
THE FORECAST
Congenial. Flow of disease as a rule comes to an end complete convalescence. Time of an extract from a hospital 12-14 day from the beginning of disease. An opportunity of visitation of children's collective - in 1 week, restriction of an exercise stress - within 2 weeks, a cancellation of prophylactic inoculations the nearest 3 months.
THE EPICRISIS
************* ******** *********** 4 flying of 3 months has acted in the second city children's hospital on September, 17 2003 years, with complaints to a rhinitis, sense of an incorporation of a nose, tussis, a fervescence up to 38,9°Ñ, a febricula, downstroke of appetite. On the establishment of complaints to a rhinitis, sense of an incorporation of a nose, a mucous discharge from a nose, tussis; the acute beginning of disease, a fervescence up to 39,6°Ñ, malaises, delicacies, losses of appetite for the second day of disease; auscultations in mild it is large and srednepuzyrchatyh the wet rhonchuses intensifyed at height of an inspiration; a moderate leukocytosis, augmentation of a sedimentation rate, a leukocyturia, presence in it is wetted slime, definition on a roentgenogram mild an amplified pulmonary drawing in rhizospheres; presence in an anamnesis of contact to the patient with an acute respiratory virus infection the diagnosis has been put: an acute respiratory virus infection (respiratory catarrh), an acute simple bronchitis (J20). Treatment: Confinement to bed, interferon, amoksitsillin, an Euphyllinum, Pipolphenum, inhalations with berodualom, UVCH on a chest. Treatment has brought effect as downstroke of temperature, decrease of the catarrhal phenomena, tussis, weakening of rhonchuses in mild. Further are recommended: time restriction of an exercise stress, a cancellation of prophylactic inoculations, physiotherapy exercises, a vitamin therapy, a tempering.
THE LITERATURE
- Children's diseases: the Textbook/under L.A.Isaevoj.-'s edition of M.:iNn?µ??a, 1997.-592 with.
- Lectures on a pedonosology.
- the Register of medical products of Russia. The RLS-ENCYCLOPEDIA of medicines. - 9 edition, pererabotonnoe and added/Ãë. red. J.F.Krylov.-of M.: ÐËÑ-2002.-1504 with.
- the Nosography. Diagnosis and therapy. Ò.1.: Translation with English/under R.Berkou, E.Fletchera.-'s edition of M.: the World, 1997. xxxiv + 1045 with.
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Keywords: a case history, a pedonosology, children's diseases, a bronchitis, a respiratory catarrh, an acute respiratory virus infection, a case history on pedonosologies, an acute simple bronchitis
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