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Keywords: a case history, a pedonosology, a respiratory catarrh, children's diseases, a bronchitis, a hemorrhagic vasculitis, a case history on a pedonosology
the Author: Beloshevskaja T.V.
THE CASE HISTORY ON THE PEDONOSOLOGY
The diagnosis: a respiratory catarrh, a bronchitis, a hemorrhagic vasculitis.I. A passport part.
FIRST NAME, MIDDLE INITIAL, LAST NAME: ********** ******** **************.
Age: 5 flying.
Date of entering in clinic: 20.09.03
Age and a trade of parents: mother - 29 flying, the lawyer; father - 29 flying, the security guard
Visits a kindergarten.
The address: *********************************.
The clinical diagnosis: a respiratory catarrh, a bronchitis, a hemorrhagic vasculitis.
II. Complaints.
Complaints at entering in clinic: on a pain in sacrolumbar range, delicacy, sense of fever, appearance of an eruption on legs.
Complaints at date of a curatio: not strong tussis, presence of an eruption in range of anticnemions and talocrural joints, augmentation of cervical lymphonoduses.
III. An anamnesis of life.
(From words of the grandmother.)
A hereditary anamnesis: parents (from words of the grandmother) are able-bodied, presence in a stem of a tuberculosis, venereal, mental, endocrine, etc. diseases denies; manifestative hereditary diseases denies; presence in a stem of abortions and mertvorozhdennosti, frailty of children, congenital teratisms, unusual flow of diseases denies.
A social anamnesis: the family complete, at parents denies presence of harmful habits, a psychologic climate in family quiet, domestic conditions good, the child is looked after with parents and the grandmother; sanitary-and-hygienic conditions (a regimen of dream, security clothes, furniture, toys) satisfactory. A feed: a kind of feeding - natural: till 1 month, since 1 month - completely artificial. Introduction prikorma since 8 months, juices - with 3 ned. An acceptability of nutrition - reaction for phylum allergic on beer honey, citrous.
A biological anamnesis: the child from the first pregnancy, protekavshej without a pathology. Labors the first, lingering, there was a grant. Has cried at once. Mass of a body at a birth 3200, body height 53 see. On a breast have applied for the second day. Times of an extract from a maternity home - in 7 days.
The further development: psychological development according to age, speech is well advanced.
An allergological anamnesis: reaction to foodstuffs (first time appearance of an eruption on a breast in 2 years in reply to the use was marked in I peep comb honey), reaction on citrous.
A transfusion anamnesis: hemotransfusions was not.
An epidemiological anamnesis: presence in family, an apartment of contagions and for last 3 weeks denies contact to contagious patients.
A state of health before the present disease: marks often acute infections.
IV. An anamnesis of disease.
It is sick from 10.09.03 - the throat was ill, the rhinitis, tussis, subfebrile temperature has appeared (up to 37,5î Ñ), have addressed to the local therapist 17.09.03, the diagnosis of a respiratory catarrh, a bronchitis have been put, received macrofoams in suspensions, Ascorutinum, a syrup linkas, ambroteks. 18.09.03 the eruption on legs has appeared. The condition has worsened 19.09.03 pains in lumbar range and in legs have appeared, the eruption in range of ankle joints, anticnemions was kept, the temperature up to 39,50 With, a moderate short wind up to 26/mines, a tachycardia about one 110/minutes has raised. Has been sent on first aid in DGKB ¹1. The data of inspection in a reception: weakly (+) the Kernig's sign, dermal process is submitted by the punctulate rashes towering above a surface of a skin, pink, without increase for last day; tussis is kept till now. It is directed in ODKB ¹2 (a contagious hospital). At entering: 37,8î With, a moderate short wind up to 26/mines, a tachycardia about one 110/minutes., On a skin of the inferior extremities in range of autopodiums, anticnemions, hips - a hemorrhagic eruption, the various dimensions (up to 0,5 sm in diameter), posed symmetrically. The fauces brightly bloodshot. On the right cervical lymphonoduses up to 3 sm in diam enlarged., morbid to the touch, the skin above them is not changed. Above mild it is percussion a clear pulmonary note, respiration vesicular, clean. Cardiac sounds clear, rhythmical. A belly mild, a liver +1ñì, the lien is not enlarged. Meningialnyh signs are not present. The diagnosis has been put at entering: a respiratory catarrh, a bronchitis, a cervical lymphadenitis on the right, a hemorrhagic vasculitis.
V. The data of inspection at the moment of a curatio.
The general condition of the child satisfactory.
Nervous system: consciousness clear, reaction to associates adequate, behaviour quiet, mood good, it is sociable, mental development corresponds to age. Changes from side CHMN are not present. Dermal belly and tendon jerks alive. Meningialnye signs (a stiff neck, with. Kerniga, with. Brudzinskogo, etc.) and signs of a tension are absent. Coordination assays: dactyl - nasal, pjatochno-patellar it are satisfactory, resistant in posture Romberga.
A skin: colour of integuments natural, the skin sunburnt, elastic, warm and dry to the touch, in range of the inferior third of anticnemions, ankle joints and back of autopodiums is appreciable a punctulate remitting hemorrhagic eruption, acyanotic, it is more on a dextral leg.
A hair, dactyls, nails: a hair shining, able-bodied, dactyls and nails of the usual form.
A subcutaneously - fatty tissue: it is advanced weakly, in regular intervals distributed, edemas, are not present a pastosion, a turgor of tissues normal.
Lymph nodes: on the right the cervical lymphonodus about 3 sm in diameter, painless at a palpation, is swept up visually (deformation of a neck on the right due to a cervical lymphadenitis), at the left - 1,0 h 1,0 sm, mental and podnizhnechelljustnye lymphonoduses - up to 0,5 sm, occipital up to 0,3 - 0,4 sm, above and subclavial about 0,2 - 0,3 sm, axillary about 0,4 - 0,5 sm, torakalnye and kubitalnye are not palpated, inguinal - a little pieces from both sides (on 2-3) up to 0,8 see. Lymphonoduses mobile, painless.
Muscles: are advanced symmetrically, a tonus normal, painless at a palpation and at locomotion, force of muscles on is reduced (5 points).
Osteal system: it is advanced proportionally, without attributes of deformation, the form of a chest cylindrical, symmetric, rachiocampsises visually is not observed, an epigastric angle of a straight line.
System of respiration: nasal respiration is not labored, phylum of respiration blended, a respiration rate=20/minutes, rhythmical, both half of chest participate in the act of respiration symmetrically, the short wind is not present. The chest at a palpation is painless. A voice tremor symmetric, moderate. A percussion: at relative - a clear pulmonary note above all fields, at topographical - borders mild in limens of norm. The auscultation - respiration puerile, is not present rhonchuses.
System of a circulation: the apical beat is palpated in the fifth intercostal space on 1 sm from within from a mammilar line, is localized, percussion borders of relative cardiac dullness in limens of norm (dextral by a right edge of a breast bone, top - the top edge of 4 ribs, left - on 1 sm from within from the left mammilar line). Auscultative cardiac sounds sonorous, rhythmical, are not present hums. Pulse on a radial arteria in 87/minutes, rhythmical, satisfactory characteristics on both arms.
System of digestion and organs of an abdominal cavity: labiums pink, dry, with cracks. Colour seen mucous light pink, mucous wet, tongue is impose with a white raid, there are plots of a desquamation of an epithelium of the spherical form with equal precise contours. A pharynx: tonsils enlarged, without strikes, the hyperemia is absent, a back wall - acyanotic, without features. Sialadens are not enlarged. The belly symmetric, is not enlarged, a regular form, the hypodermic venous network is not expressed, the belly participates in the act of respiration, at a palpation mild painless, a peristalsis normal. A liver on edge of a rib arch, a palpation in a point of a projection of a gall bladder painless. The lien is not enlarged. The stool is not broken.
Genitourinary organs: a deep palpation in range of kidneys and projections of ureters painless, a sign of a beating in lumbar range (-). The dysuric phenomena are not present.
VI. The preliminary diagnosis.
A respiratory catarrh, a bronchitis, a hemorrhagic vasculitis.
VII. The plan of inspection.
The general analysis of a blood.
Communities the analysis of urine.
A biochemical analysis of a blood.
A roentgen of organs of a chest.
The analysis of a sputum.
Spirografija.
Consultation of the otolaryngologist.
VIII. Results of laboratory, tool and other researches.
the General analysis of urine:protein 0,066 g/l, leucocytes 3-4 in p/z, erythrocytes 2-3 in p/z.
On Nechiporenko:L=1,7 * 106/ë; Ayr.=0,5 * 106/ë.
the General analysis of a bloodfrom 20.09.03
A haemoglobin - 123 g/l
Erythrocytes - 3,7
A colour parameter - 0,99
Leucocytes - 20,0
P - 15, With - 65, Eo - 3, L - 14, M - 3
A sedimentation rate - 54 mm / ch.
The bleeding time - 0 ' 35 ", started coagulation - 6 ', the end - 8 ' 45 ".
the Conclusion:a leukocytosis, nejtrofilnyj alteration to the left, an acceleration of a sedimentation rate.
the General analysis of urine20.09.03
A transparence: weak - cloudy
Colour straw-coloured
Relative density 1021
pH acidic
Protein 0,066 %î
An epithelium flat 0-1 in p/zr, transitive individual in p/zr.
Slime +++
On Nechiporenko:L=1,7 * 106/ë, Ayr.=0,5 * 106/ë
Roentgenography:
The description: ochagovo-infiltrativnyh shades are not present, has lain. Fig. is amplified in rhizospheres, roots reaktivny, sine are free, domes of a diaphragm are not changed, heart without features.
the Conclusion:a R-picture of a respiratory catarrh, a bronchitis.
Consultation of an otolaryngologia:
Complaints to LOR-ORGANS are not present, cervical lymphonoduses, nasal respiration free, a discharge scanty enlarged. A stomatopharynx: the hypertrophy of palatine tonsils of II item, a moderate hyperemia, is not present strikes. ÀD=AS - b/p grey, shining.
IX. A diary.
22.09.03 t=36,7 Since one CHD=20/MINUTES. CHSS=87/MINUTES
The general condition satisfactory, mood equal, quiet. Complaints does not show. Colour of integuments usual. In range of the inferior third of anticnemions, ankle joints and back of autopodiums it is appreciable punctulate remitting (from words of the grandmother of the patient) the hemorrhagic eruption, acyanotic, is more on a dextral leg. The neck is deformed due to a cervical lymphadenitis. A cervical lymphonodus on the right 3,0*3,0, at the left 1,0*1,0ñì. Tonsils enlarged, the hyperemia and is not present strikes, tongue is impose with a white raid, there are plots of a desquamation of an epithelium of the spherical form with equal precise contours. Of tussis does not complain. The short wind, rhonchuses is not present. Cardiac sounds sonorous, rhythmical, are not present hums. A belly mild painless, the liver, a lien are not enlarged. The stool is not broken. An emiction normal.
23.09.03 t=36,6 Since one CHD=22/MINUTES. CHSS=84/MINUTES
The general condition satisfactory, mood equal, quiet. Expressed dynamics is not present. Colour of integuments usual. In range of ankle joints and back of autopodiums the punctulate hemorrhagic eruption more on the right, less expressed is appreciable in comparison with former. The ecdysis of palms has appeared. The neck is deformed due to a cervical lymphadenitis. A cervical lymphonodus on the right 3,0*3,0, at the left 1,0*1,0ñì. Tonsils enlarged, the hyperemia and is not present strikes, tongue is impose with a white raid, there are plots of a desquamation of an epithelium of the spherical form with equal precise contours. Of tussis does not complain. The short wind, rhonchuses is not present. Cardiac sounds sonorous, rhythmical, are not present hums. A belly mild painless, the liver, a lien are not enlarged. The stool is not broken. An emiction normal.
24.09.03 t=36,6 Since one CHD=20/MINUTES. CHSS=88/MINUTES
A condition satisfactory. Complaints are not present. On dextral autopodium some dying away elements of an eruption. An ecdysis of palms. Tongue is cleared. Cervical lymphonoduses began a little bit less in the dimensions. Tonsils enlarged. Strikes are not present. Of tussis does not complain. In mild rhonchuses is not present. Palpitation equal rhythmical. Hums are not present. A belly mild painless. A liver on edge of a rib arch. The lien is not enlarged. A stool regular, normal. The emiction is not broken.
X. A substantiation of the clinical diagnosis.
On the establishment of complaints of the patient on augmentation of cervical lymphonoduses, appearance of an eruption at legs, tussis.
On the establishment of an anamnesis: often acute infections, alimentary allergic responses, a biological anamnesis (artificial feeding since 1 month, delayed introduction prikorma, juices), dynamics of development of the present disease: complaints at entering (a fever, pains in lumbar range and in legs, appearance of a hemorrhagic eruption, tussis, delicacy, a febricula).
On the establishment of the objective data: in dynamics from an anamnesis and immediate observation: appearance of a hemorrhagic eruption in places typical for a hemorrhagic vasculitis, a cervical lymphadenitis, a hyperemia of fauces (from an anamnesis), gipertofija tonsils, oblozhennost and a local desquamation of an epithelium of tongue, a tachycardia and a short wind (from an anamnesis).
On the establishment of dynamics of patological symptoms: zatihanie eruptions, decrease of lymphonoduses, a discoloration of tonsils (decrease of a hyperemia),
On the establishment of results of laboratory and tool methods of research: an acceleration of a sedimentation rate till 54 mm / minutes and a leukocytosis, nejtrofilnyj alteration to the left - attributes of inflammatory reactions; according to roentgenography - intensifying of a pulmonary drawing in rhizospheres, a reactivity of roots.
It is possible to diagnose: a respiratory catarrh, a bronchitis, a hemorrhagic vasculitis.
XI. The differential diagnosis.
First, it is necessary to differentiate a hemorrhagic vasculitis with other diseases proceeding with an eruption: a scarlatina, to a bark, a rubella, a chicken pox, an allergy. For the benefit of a vasculitis speaks character typical for him and localization of an eruption, and also on an etiology: often previous respiratory catarrhs, the allergic constitution.
Second, the augmentation of lymphonoduses is possible for differentiating with augmentation of those at, limfogrenulematoze, a leukosis, but in this case, as against these diseases, lymphonoduses were morbid at a palpation, mobile, on commissured with environmental tissues, dynamics of the dimensions of lymphonoduses is traced.
XII. Treatment.
Sol. Penicillini 600*106 ED 3 r v/m within the first week
Dimedrolum 1/3 t 2 r./d.
Calcii gluconati 0,5 t 3 r/d.
Ascorutinum 1 t 3ð./ä.
Mucaltinum 1 t 3 r./d.
A low allergenic diet.
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Keywords: a case history, a pedonosology, a respiratory catarrh, children's diseases, a bronchitis, a hemorrhagic vasculitis, a case history on a pedonosology
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