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Keywords: a case history, a pedonosology, children's diseases, an obstructive bronchitis, respiratory failure, a polyvalent allergy, a case history on a pedonosology
THE CASE HISTORY ON THE PEDONOSOLOGY
The diagnosis: a respiratory catarrh, a chronic obstructive bronchitis, an exacerbation. Respiratory failure - I. A polyvalent allergy: alimentary, medicamental.1. The PASSPORT PART
- the Surname, a name, a patronymic: ************* ******** *************
- Age: 3 years
- Date of entering in clinic: 19.09.2003 years
- Age of parents: mother - 24 years, father - 44 years.
- the Child visits a kindergarten.
- the Home address: ***********************************
2. COMPLAINTS.
Complaints at entering in clinic on: a febricula, a headache, rise in temperature up to 38,8 With, a rhinitis, constant dry tussis, palpitation, a short wind.
Complaints at date of a curatio: on the general delicacy, bad appetite, an incorporation of a nose, fast fatigability, a giddiness, hysterical dry tussis.
3. An anamnesis of life.
(from words of mum).
1) the Hereditary anamnesis.
Mum - 24 years, the daddy - 44 years. Parents of the girl are able-bodied (from words of mum). Among diseases of relatives marks an ischemic disease, insults, gastritises. Informs, that among relatives it is a lot of long-livers. A bronchial asthma, allergic diseases, manifestative hereditary diseases, endocrine diseases, a tuberculosis, mental and venereal diseases at relatives denies. Presence in a stem of abortions and frailty of children, congenital teratisms, unusual flow of diseases also denies. Parentage families rather congenial.
2) the Social anamnesis.
In family - 3 persons: the daddy, mum and the child. In family parents sometimes use alcohol, mum smokes. A psychologic climate in family quiet. The grandmother helps to look after the child. Domestic conditions correspond to the standard norms. Sanitary-and-hygienic conditions (a regimen of dream, security clothes, furniture, toys) satisfactory. A feed: till 7 months the child was on natural feeding: with correction after the first month (juices) and introduction of a baition (vegetable mashed potatoes) from 5-th month, from 6-th month - 2-nd baition (porridges), and then went on an artifial alimentation. Full value and a diet after year are kept. Appetite good, likes sweet. The allergy on citrous shows an enanthesis of the person, a trunk and an itch. About 2 flying visits a feeding rack.
3) the Biological anamnesis.
The child from the third pregnancy, protekavshej it is quiet with keeping a regimen and references of the doctor; in an anamnesis 2 abortions; it was monthly observed in female consultation, used a maternity leave, school of pullet mother did not visit; labors the first in 40 weeks without complications, there was a grant. The child has cried at once. The evaluation on Apgar scale has made 7-8 points. Body height - 51 sm, mass of a body - 4130, a circle of a head - 35 sm, a circle of a breast - 33 see. On a breast have applied at once, the child awakely sucked a breast. A regimen of a feeding on the first cry neonatal. The pristine loss of mass of a body has made 680. For the first 6 months the child has typed 900ã. Otpadenie pupovinnogo the residual on 4 day, a umbilical wound has begun to live by 7 day. The icterus neonatal last 4 days, then has disappeared (a physiological icterus). Have written out for 7 day, mass of a body at an extract - 3680ã. A condition of a lactemia satisfactory. For year the girl has grown up on 17 sm, weight has made 11êã 630ã, a circle of a head - 45 see. Tooths began prorezyvatsja from 6 months, to year - all 8 incisors. To 2-nd years - all 20 tooths. Psychological development: in 3 months - fixed a look, smiled, babbled, well held the head, top reflex Landau has appeared; in 6 months - turned in bed, looked aside a note, sat, played with toys, learned familiar persons; in 7,5 months - has become to say separate syllables, to murmur; inferior reflex Landau has joined; in 9 months - perceived speech, carried out simple tasks, said separate words, quickly crept, stood at support; to 1,5 years - independently went, squated; in 3 years - studies world around with the help of questions, runs, the obstinacy has appeared. Prophylactic inoculations were carried out in time, tolerated them well. Results of Mantoux tests - negative.
An allergological anamnesis: a medicamental allergy on Penicillinum, an allergic response on citrous as an eruption on the person, a trunk and an itch.
From the transferred diseases: often anginas, a respiratory catarrh, in July 2003 years - a left-hand pneumonia, an exacerbation of an obstructive bronchitis, a left-hand otitis. Hemotransfusions, and also plasma transfusions and introduction of an immunoglobulin were not carried out.
An epidemiological anamnesis: 17.09.2003 was contact to the contagious patient in a kindergarten (the boy, 4 years, presumably a respiratory catarrh); in family, an apartment of contagions is not present.
A state of health before the present disease: the Obstructive bronchitis, a remission (3 group of health) - a condition of subindemnification.
4) the Anamnesis of disease.
The child is sick with 6-òè monthly age, since March 2001 years when the rhinitis for the first time has appeared, the temperature has appeared. As a result of inspection domiciliary the local pediatrist had been put the diagnosis: a respiratory catarrh. Treatment is appointed: a suspension of Ampicillinum, a drop in a nose, Paracetamolum. For 2-nd day the child has become covered by an eruption, has become restless, whimsical. The diagnosis has been put: a medicamental allergy on Ampicillinum; Dimedrolum is appointed and within day the eruption has disappeared, the child has become quiet. Mum marks often anginas and a respiratory catarrh at the child since autumn 2001 years which were accompanied by a febricula, rise in temperature, a rhinitis. In 2002 year the food allergy on citrous in the spring is marked. After method of orange juice the girl has become covered by a punctate rash, has become to be capricious. Uch. The doctor - the pediatrist appoints Suprastinum, the eruption has disappeared for 2 day. Since October 2001 years of a respiratory catarrh began to be accompanied by long dry tussis which disturbed the child within 1 month after transferred to a respiratory catarrh. In the spring and in the autumn 2002 years the girl has transferred an acute bronchitis. It was observed it is out-patient uch. The doctor the pediatrist; treatment as macrofoam in a suspension, a syrup linkas, ambroteksa and Suprastinum has been appointed. Since the autumn 2002 years tussis has become to disturb more long span (2 months from the moment of disease): has become to be characterized by excruciating dry tussis. In July 2003 years on a background of the febricula, the increased temperature, a rhinitis tussis and a short wind has appeared. The girl have hospitalized in pulmootdelenie children's hospital where as a result of inspection of the child and additional methods of inspection the diagnosis has been put: a left-hand focal pneumonia on a background of a chronic obstructive bronchitis, a left-hand otitis. Treatment by antibacterial, antihistamine preparations, bronholitikami and a vitamin therapy has been lead. But mum marks, that tussis and a short wind disturbed the child within 1 month from the moment of an extract from a hospital. 17.09.2003 years, having returned from det. A garden home, at it the rhinitis has appeared, eyes have reddened; next day - in the morning (18.09.2003) tussis has appeared, the girl was left with houses; and on Friday in the afternoon - the short wind, by the evening has risen temperature up to 38,8 With; parents have caused first aid to which the girl has been delivered in reception ODKB ¹2 at 23 o'clock 19.09.2003ã. where to it have intramuscularly entered: Sol. Analgini 50 % - 0,5 ml, Sol. Papaverini hydrochloridi 2 % - 0,5 ml, Sol. Dimedroli 1 % - 0,5 ml also have transferred in 3å branch of this hospital. At entering: 38,8î With, a strong short wind up to 40/mines, a tachycardia about one 120/minutes, the fauces brightly bloodshots. Above mild it is percussion a clear pulmonary note, auscultative - in subscapular ranges: changeable wet and infrequent dry rhonchuses. Cardiac sounds clear, rhythmical. A belly mild, a liver +1ñì, the lien is not enlarged. Meningialnyh signs are not present. Taking into account complaints of the child, an anamnesis of the disease, given objective inspection, rise in temperature, has been put the diagnosis: a chronic obstructive bronchitis, an exacerbation; DN-1, a bilaterial pneumonia (?) treatment also is appointed: antibiotics, bronholitiki, antihistamine and expectorants, inhalations with berodualom and UVCH on range of a chest.
A course of a disease during stay in clinic prior to the beginning of a curatio (a brief epicrisis).
Mum of the child marks, that by the moment of a curatio the condition of the girl has a little improved. On a background of the appointed treatment the temperature was normalized, headaches have disappeared, general delicacy, a short wind, tussis has decreased; has become to depart a sputum. Mum connects the cause of an exacerbation of disease to a respiratory catarrh.
4. The data of inspection at the moment of a curatio.
The general average condition: a short wind, the subfebrile temperature, the expressed delicacy, a headache, the reduced appetite. A position of the patient awake. A body build normosthenic, the patient of a normal feed. Physical development average, harmonious. Mass of a body - 13 kg, length of a body - 94 see. The child educes according to age norm. A stigma dizembriogeneza are not revealed.
Nervous system: consciousness clear, reaction to associates adequate, behaviour quiet, mood good, is sociable, mental development corresponds to age. Changes from side CHMN are not present. Dermal belly and tendon jerks alive, D=S.. Meningialnye signs (a stiff neck, with. Kerniga, with. Brudzinskogo, etc.) and signs of a tension of nerve cords (signs Lassega, Matskevich, Vassermana) are absent. Coordination assays: dactyl - nasal, pjatochno-patellar it are satisfactory, resistant in posture Romberga. Gait usual, without features. The dermographism blended, appears through 15-16 sek, proceeds about 5 minutes.
Integuments acyanotic, humidity is a little bit increased (strongly sweats during dream), a skin elastic, warm; the moderate cyanosis of labiums is marked. Cicatrixes, an eruption, hemorrhages, plots of a pigmentation and a depigmentation it is not observed.
Inspection of eyes: abjointed from eyes is not present, the conjunctiva of usual colour, an injection of vessels of scleras is not present, locomotions of eyeglobes painless, the photophobia, puffinesses of blepharons, is not present a lacrimation.
Inspection of ears: auricles of the usual form, pink, abjointed are not present, the skin of an outside acoustic duct does not bloodshot.
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: of 5-6 mm, painless are palpated podnizhnecheljustnye lymph nodes in the dimension, easily displaced; the others: mental, occipital, cervical lymphonoduses, above and subclavial, axillary, torakalnye, kubitalnye and inguinal are not palpated.
Muscles: are advanced symmetrically, a tonus normal, painless at a palpation and at locomotion, force of muscles is not reduced (5 points).
Osteal system: it is advanced proportionally, without attributes of deformation, the form of a chest barrel, symmetric, rachiocampsises visually is not observed, an epigastric angle of a straight line. Garrisonovoj sulcuses and thickenings of ribs on border of osteal and cartilaginous parts it is not revealed.
System of respiration: nasal respiration labored, from a nasal cavity - a mucous discharge. Phylum of respiration blended. The frequency of respiratory movements compounds 24 1 minute, respiration rhythmical, deep, is accompanied by singing, the expiration prolates. Both half of chest take part in the act of respiration, intercostal spaces are a little bit amplate, the strain of gear muscles in regular intervals from both sides is marked. A short wind of blended character with predominance ekspiratornogo a component. The chest at a palpation is painless. The voice tremor symmetric, is slightly weakened. At a relative percussion the clear pulmonary note above all pulmonary 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 the changeable dry whistling, buzzing and creaking rhonchuses better auscultated in range of 6 segments (D=S) at intensifying of respiration at height of an inspiration are auscultated.
System of a circulation. At inspection of cardiac range: the cardiac back hollow is not present. The cardiac impulse precisely is not palpated, apical is palpated in the fifth intercostal space on 1 sm knutri from SKL, localized. 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 knaruzhi 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 pulsation of vessels of a neck rhythmical, uchashchennaja, a satisfactory strain. Pulse on a radial arteria: frequency 110 1 minute, Ps (110): a frequency of respiratory movements (24)=4,5:1, rhythmical, often, average, a satisfactory strain and filling, synchronic on both arms.
System of digestion and organs of an abdominal cavity. Labiums of red colour with a mild cyanochroic shade, dry, slightly exposed to the wind. Rashes, ulcerations, are not present cracks. A mucosa of an oral cavity and a gingiva of pink colour, wet; hemorrhages, aphthas, jazvochek, spots Filatova it is not marked. Tongue: the tip pink, starting from an average third and further is impose with a quaggy belovato-yellowish raid. Cracks, ulcers, are not present impresses of tooths, papillas slightly flattened. Tooths milk. The mucosa of a pharynx bloodshots, the back wall of a pharynx also bloodshots, edematous, palatine tonsils are hypertrophied, support limens of palatal arculuses, bloodshot.
Sialadens are not enlarged, at a palpation, a mastication, opening of a mouth painless.
The belly of the usual form symmetric, is not ventricose, the seen pulsation, a phlebectasia of a forward abdominal wall are absent, cicatrixes are not present, a peristalsis satisfactory. A percussion note tympanic. At a palpation a belly mild, painless, 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. A stool daily, made out, brown colour, without pathological admixings.
Signs Georgievskogo-Mjussi, Ortnera-Grekova, Murphy - negative.
Genitourinary organs. Diverticulums above a pubis and in range of kidneys it is not determined. 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.
Taking into account the data of an anamnesis: often anginas, a respiratory catarrh from 6-monthly ages, smoking of mother; the given histories of development of disease: long tussis already after the sanction of the next respiratory catarrh, during last 2 flying; appearance of a short wind in 2003 years on a background of a bronchitis; a polyvalent allergy: medicamental (preparations of group of Penicillinums) and alimentary (citrous; on the establishment of the data of inspection of the patient at entering: ×ÄÄ=40 in one minute; a cyanosis nosogubnogo a triangle; integuments acyanotic, wet. At an auscultation - respiration rigid; a bronchospasm, absent-minded dry rhonchuses in subscapular range; at a tussiculation, it is possible to put change of amount of rhonchuses -
the Preliminary diagnosis:
- the Basic disease: a respiratory catarrh. A chronic obstructive bronchitis, an exacerbation.
- Concomitant diseases: the Polyvalent allergy: alimentary, medicamental.
- Complications: Respiratory failure - I.
the Plan of inspection of the patient:
- the General analysis of a blood, urine, the general analysis of a sputum, a biochemical blood analysis; research of a feces on eggs of helminths and an intestinal flora.
- Roentgenography of organs of a chest. Consultation otorinolaringologa.
- Research FVD (spirografija).
Results of laboratory, tool and other researches.
the General analysis of a bloodfrom 20.09.2003:
A haemoglobin 123 g/l
Erythrocytes 3,8*1012/ë
THE CENTRAL PROCESSING UNIT - 0,99
Leucocytes 9,6*109/ë
Relating to stab neutrophile 3 %
Segmentojadernye 54 %
Eosinocytes of 6 %
Lymphocytes of 33 %
Monocytes of 3 %
A sedimentation rate 18mm/hour
The conclusion: a leukocytosis, nejtrofilnyj alteration to the left, an eosinophilia, an acceleration of a sedimentation rate.
the General analysis of urinefrom 20.09.03
Colour - straw-coloured;
Transparent;
Relative density 1021 (1010 - 10-25);
Reaction acidic (weakly acidic, neutral)
Protein - is not present (N up to 0,033 g/l);
An epithelium flat 0 - 1 in p/zr, transition. A unit in p/zr.
Leucocytes - a unit in a field zr. (up to 3 in p/zr.);
The conclusion: OAM in limens of age norm.
Roentgenography of organs of a chestfrom 20.09.03:
On a roentgenogram of organs of a chest in the direct projection plump by rays of average rigidity intensifying a pulmonary drawing in rhizospheres is determined. Roots mild malostrukturny. Focal infiltrativnyh shades are not present. Sine are free. Heart - in limens of age norm.
The conclusion: a R-picture of a respiratory catarrh, a bronchitis.
The conclusion on all additional methods of research: results of additional methods of research specify presence of inflammatory process (a moderate leukocytosis, augmentation of a sedimentation rate) in mild (on a roentgenogram the amplified pulmonary drawing in rhizospheres is determined).
Inspection of the otolaryngologist:
Nasal respiration free, a discharge not abundant, mucous. A stomatopharynx: the hypertrophy of palatine tonsils of II item, a moderate hyperemia, is not present strikes. ÀD=AS - b/p grey, shining.
The diagnosis: î. A rhinitis.
It is recommended to instill in a nose Albucidum of 20 % - 2,03 times day.
the Diary.
22.09.03 t=36,9 ×Ä=26 mines in CHSS=110/MINUTES
The general average condition. The short wind is not present. Respiration through a nose free, abjections from a nose not abundant, mucous character. Tussis has ceased to be obsessional. The skin around of eyes has a bluish shade, a mild cyanosis nosogubnogo a triangle; integuments clean, acyanotic. The fauces moderately bloodshot. Auscultative in mild dry whistling and buzzing rhonchuses in subscapular range are auscultated. Cardiac sounds sonorous, rhythmical. A belly mild painless. The stool is not broken. An emiction normal.
23.09.03 t=36,7Ñ CHDD=24/MINES in CHSS=98/MINUTES
The general average condition. Expressed dynamics is not present. Slept well. Colour of integuments acyanotic. Tussis with a small amount of a sputum. In mild dry whistling and buzzing rhonchuses continue to be kept, but the amount of them has considerably decreased. The expiration continues to remain prolate. Cardiac sounds sonorous, rhythmical. A belly mild, painless. A stool, an emiction free, without features.
24.09.03 t=36,7 From CHD=22/MINES in CHSS=88/MINUTES
The general average condition is closer to satisfactory. Marks improvement of state of health, decrease of a short wind, it is easier
The sputum departs: has become more fluid, it is more easy expectorated. A stool regular. The emiction is not broken.
5. A substantiation of the clinical diagnosis.
The diagnosis: the respiratory catarrh, a chronic obstructive bronchitis, an exacerbation, ÄÍ-1 is put on the establishment:
- Complaints of the patient to a febricula, fast fatigability, a giddiness, a headache, rise in temperature, palpitation, a rhinitis, a short wind, dry tussis with difficultly abjointed sputum;
- the data of a history of development of the present disease: development of disease is acute within 3 days after contact to the contagious patient, an expressiveness intoksikatsionnogo a set of symptoms (a fervescence up to 38,8°Ñ, malaises, delicacies, losses of appetite); the rhinitis, tussis, a short wind has appeared.
- the objective data: change of the form of a chest (barrel), expansion of intercostal spaces; at an auscultation - respiration rigid, plural dry whistling and buzzing rhonchuses, ekspiratornaja a short wind, a tachycardia, a subfebrile condition;
- results of laboratory and tool methods of research: a small leukocytosis, nejtrofilnyj alteration to the left, accelerated by a sedimentation rate (attributes of inflammatory process); a moderate eosinophilia (for presence atopicheskogo a component in development of disease), definition on a roentgenogram mild an amplified pulmonary drawing in rhizospheres; about a vascular and peribronchial infiltration;
- dynamics of patological symptoms during observation: positive dynamics in the attitude of tussis - has become more wet, the sputum more easy departs; the number of rhonchuses has decreased; the heart rate from 120 has decreased up to 88 (N), a frequency of respiratory movements from 40 - up to 22 in one minutes, hyperthermias - is not observed;
- an epidemiological anamnesis: disease began is acute after contact to the sick child.
6. The differential diagnosis.
It is necessary to lead bacteriological research of a sputum for exception of a pulmonary tuberculosis.
Bronhoobstruktivnyj the set of symptoms usually educes at a chronic obstructive bronchitis and a bronchial asthma. At a bronchial asthma, it is especial at its initial stage, in mezhpristupnyj the season parameters of an external respiration usually are not changed or changes are substantially reversible by inhalation Â2-àäðåíîìèìåòè÷åñêîãî of an agent. At a chronic obstructive bronchitis attributes of bronchial obstruction are available constantly, in the season of an exacerbation they strengthen (but not as acute attacks), and after treatment gradually weaken (within several weeks or months), but seldom peter.
7. A substantiation of treatment.
- As disease has the virus nature, resulted to originating the expressed bronchial spastic set of symptoms, and also a set of symptoms of an intoxication, purpose of antiviral agents will be expedient: Remantadinum, interferons, specific immunoglobulins or immunokompleksnyh immunoglobulins.
- At apposition of microbic process the antibiotic therapy is recommended: amoksitsillin, sumamed, rulid, klaritromitsin, macrofoams; because presence of bronchial obstruction frames additional conditions for development of a bacterial infection (stagnation in bronchuses of a secret, infringement of work tsiliarnogo the apparatus of bronchuses). At purpose of antibiotics it is necessary to take into account an opportunity of development at children of a dysbacteriosis and a candidiasis. Therefore it is expedient to use simultaneously a complex of vitamins, bifidum bakterin or bifikol, and also antifungal preparations (Nistatinum).
- In connection with presence of obstructive changes in the bronchuses caused by an edema mucous and a clump of a secret appoint sekretoliticheskie (Bromhexinum), expectorating preparations (a root of a mallow, Mucaltinum).
- Bronholitiki: an Euphyllinum, berodual; For liquidation of an obstructive set of symptoms, improvement of outflow of a sputum, restoration tsiliarnogo the apparatus.
- b-agonists (berotek). It is possible to appoint application of steroids mestno it (is inhalation) for elimination of an aboriginal inflammation (pulmikort, Becotidum).
- massage Is necessary: draining exercises - for the prevention of diffusion of an infection. Massage on a ball, clapping.
- Desensitizing therapy: Pipolphenum, Dimedrolum, Suprastinum, Tavegilum, klaritidin; since there is a polyvalent allergy which is a source of a sensibilization of an organism.
- Immunostimuljatory since the organism of the child is weakened by an infection, apply nukleinat a sodium, a ginseng, eleuterokokk.
- the Vitamin therapy.
- the Physiotherapy (UVCH, a photoradiotherapy on reflexogenic zones, electrophoresis, soda inhalations).
- the Phytotherapy (a root of a mallow, termopsis, mint, mother and the stepmother, a cowberry, a thyme).
- the Regimen. A low allergenic diet.
- Purpose: a regimen stationary; a diet: a table ¹ 15 with exception of hyperallergenic products; nebulajzernaja therapy by b2-agonists, electrophoresis of 0,1 % r-ra an epinephrine ¹ 2, UVCH on a chest ¹ 6, inhalations with berotekom, v/m Prednisolonum on 30ìã 2 times day a short course (4-5 days). lazolvan on 1 ch. l. 3 times day, an Euphyllinum - on 1/4 t. 2 times day, Suprastinum on 1/3 t. 2 times day.
8. The forecast.
At keeping the patient of a correct regimen, performance of purposes - rather congenial. 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 (an exercise stress to enlarge gradually, on a measure of habituation to it), a cancellation of prophylactic inoculations the nearest 3 months. Rehabilitational treatment (sanatorium), occupations by sport (navigation), prophylaxis of virus infections (it is especial in the season of epidemies), medical gymnastics, massage is recommended.
the Literature:
- Children's diseases: the Textbook/under L.A.Isaevoj.-'s edition of M.:iNn?µ??a, 1997.-592 with.
- Mazurin A.V., Vorontsov I.M.propedeutics of children's diseases. - M.: Medicine, 1985. - 432 with.
- Nikitin A.V., Pereverzev B.M., Gusmans V.A.bas of diagnosis of diseases of an internals: the Manual. - Voronezh: Publishing house of the Voronezh state university, 1999. - 368 with.
- the Nosography. Diagnosis and therapy. Ò.1.: Under R.Berkou, E.Fletchera.-'s edition of M.: the World, 1997.-1045 with.
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Keywords: a case history, a pedonosology, children's diseases, an obstructive bronchitis, respiratory failure, a polyvalent allergy, a case history on a pedonosology
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