Total information

1F.I.OO.: Chukanov Maxim Sergeevich

3Weight at birth: 3200 g.

4Height at birth: 50 cm.

Anamnesis of life

1 Child from the first pregnancy.

2 The pregnancy proceeded with symptoms of mild anemia and nephropathy in the second half of pregnancy. There was a threat of premature birth.

3During pregnancy, the mother ate well: fruits, vegetables, cottage cheese, meat products, excluding specific allergens.

Mom followed a regimen of rest, nutrition, sleep, and work during pregnancy.

Mom has a bad habit - smoking, which she continued during pregnancy.

4During the pregnancy, the mother studied.

5 Stimulation was performed during labor labor activity. The duration of labor was 12 hours.

6No aids were used during childbirth.

7The birth proceeded without complications.

8After birth, the child screamed immediately, the cry was active and loud.

9The body weight at birth of the child was 3200 g; height at birth – 50 cm.

10 The baby was put to the breast 4 hours after birth and actively took the breast.

11The baby was put to the breast after 3 hours.

12The umbilical cord fell off on the 4th day of the child’s life. Umbilical wound healed on the 15th day.

13Physiological weight loss was 100 g. and recovered by the time the child was discharged from the hospital.

14The child sleeps peacefully.

15After feeding, the child regurgitates (no more than twice a day).

16Reflexes to suck, swallow, breathe are well developed.

17Nervous mental development the child corresponds to his age: briefly fixes his gaze on shiny objects and follows them, flinches at sharp sounds, tries to keep his head lying on his stomach.

18No teeth.

19The edges of the large fontanelle are pliable, size – 2.5-2 cm.

20Diseases infancy the child did not have one.

21There is a mild allergic reaction per row food products.

22The child was vaccinated according to age.

23Vaccinations were carried out: V hepatitis B (No. 1), V BCG.

24At the time of patronage, he did not suffer from childhood infectious diseases.

25The child exhibits the following newborn reflexes: Babkin reflex, Robinson reflex, Babingsky reflex, support reflex, Bauer crawling reflex.

Family history

1 The mother’s age at the time of birth was 19 years, the father’s age was 25 years. Mother – Chukanova Ekaterina Vladimirovna. Father – Chukanov Sergey Grigorievich

2 State of health of parents and immediate relatives: father suffers chronic gastritis; mother - varicose veins; grandmother: rheumatism, myocardial dystrophy, pancreatitis, pyelonephritis, anemia, suffered a stroke leading to paresis of the lower extremities, underwent surgery - cholecystectomy. Grandmother is a disabled person of the first group. Among hereditary diseases– various heart defects.

3 Material and living conditions are satisfactory: wages exceed living wage(from the father), the grandmother receives a pension as a disabled person of the first group.

4 The mother and grandmother are primarily involved in caring for the child.

5 The child is provided with linen, toys, and a separate crib.

6 The child follows a daily routine (sleeps up to 20 hours a day, walks outside for 1-1.5 hours, feeding every 3 hours).

Objective examination data.

1 General state child is satisfactory.

2 The baby’s position in the crib is active.

3 Consciousness is clear.

4 Constitutional type – normasthenic.

5 Head volume – 35 cm, chest – 36 cm.

The sclera is jaundiced, skin slightly icteric.

6 Visible mucous membranes are bright pink. The skin feels dry to the touch. The skin and visible mucous membranes are clean. There is no pigmentation, petechiae, or rashes. The thickness of the skin fold on the anterior abdominal wall is 1.5 cm. Skin turgor is within normal limits. Dermagrophysm – red. There is fluff on the head. The nails are dense, the nail plates are completely covered nail beds. There is no swelling on the face, lower extremities, or anterior abdominal wall.

7 Inert system: no curvature of the limbs, dilation hip joints normal, uniform chest The normal muscular system is developed according to age.

8 Subcutaneous fat tissue is distributed evenly.

9 Examination of the pharynx: no teeth, pink mucous membranes, tongue of normal size and shade, tonsils and palatine arches without pathology

10 Peripheral lymph nodes (occipital, anterior and posterior cervical, submandibular, supraclavicular, axillary, inguinal, popliteal) are not palpable.

11 Respiratory system:

NPV – 46/min. There is no cough, tension of the wings of the nose is noted, auxiliary muscles are not involved in the act of breathing.

On percussion, the pulmonary sound on the left and right is homogeneous. Topagrographic boundaries of the lung by age. Auscultatory picture of the lungs: breathing is puerile, there is no wheezing or crepitation.

12 Cardiovascular system:

Borders of relative cardiac dullness: upper - second rib, left - 1.5 cm outward from the left midclavicular line, right - right parasternal line. Blood pressure is within normal limits and is 60/30 mm. Hg pillar Auscultation: heart sounds, heart rate – 136/min., no murmurs are heard. There is no pulsation of large vessels. Pulse rhythmic, symmetrical, satisfactory filling.

13Digestive system:

Appetite is good, breastfeeding, regurgitation up to 2 times a day. No vomiting. The abdomen is soft, painless on palpation, regular form. The liver protrudes from the submargin of the costal arch by 1.5 cm at the midclavicular line. The spleen is not palpable. The anus is without pathology. Stool up to 7 times a day, mushy, golden yellow.

14Moche – reproductive system: daily amount of urine up to 300 ml. Frequency of urination – up to 15 times a day. No swelling was noted. Pasternatsky syndrome is negative.

15The testicles are descended into the scrotum.

Tips given:

1 Hygienic care: daily baths with potassium spermangate 1:10000, with chamomile, string. Pour 50 grams (1 glass) of herbs into 3 liters of boiling water, boil for 5 minutes, strain, add to the bath. The umbilical wound is treated with a 3 percent solution of hydrogen peroxide or furacilin alcohol 1:1500, the crust is removed, and cauterized with a 5 percent solution of potassium permanganate.

2 Daily routine: sleep up to 18 hours. Duration of sleep from 50 minutes. up to 2 hours, wakefulness 10-30 minutes.

3 Hardening – room temperature 22 degrees, sleeping in the air at temperatures from -15 to +30 degrees, during swaddling air baths 5-6 min., wash at temp. water - 28 degrees, general bath at temp. water 36-37 degrees, duration 5-6 minutes, completion of the bath - pouring water 1-2 degrees lower.

4 A conversation was held about the benefits of breastfeeding.

COMPLETED: SUKHOV ANTON, Kaluga, 2002.

Approximately 10% of newborns worldwide are born early due date. A baby is considered premature if it is born earlier than 37 weeks of pregnancy and weighs less than 2.5 kg at birth. Of course, such children require special treatment and care. So, medical history: premature baby- the topic of this article.

Stress at birth.

The process of childbirth itself premature baby is an extremely difficult test, so doctors different countries if it is impossible to stop premature birth tend to insist on caesarean section. However, there is not always time or practical opportunity for this. In this case, they try to receive the newborn baby as carefully and carefully as possible. Immediately after birth, the premature baby falls into the hands of a neonatologist for timely identification of possible congenital anomalies and other problems. If upon examination the need for resuscitation measures is not identified and intensive care is not required, the child is swaddled and placed in a special incubator. He supports optimal temperature and air humidity.

After the maternity hospital.

After discharge from maternity hospital a premature baby still needs special care. Everyone understands that breast-feeding- most the best option for a newborn. In case of premature babies it is simply vital. Mother's milk increases the child's immunity, supplies his body with a number of optimal composition nutrients, essential vitamins and microelements. Physical contact is also important when breastfeeding - it relieves many neurological problems. Therefore, children who were born prematurely must be breastfed upon request. In cases where the baby does not have enough strength to suckle, you need to express the milk and give it from a bottle.

Basics about care.

A premature baby is much more at risk infectious diseases. That's why you need to pay more attention to hygiene when caring for it. All children's clothing and diapers must be ironed with a hot iron. Pacifiers and bottles must be boiled. Be sure to bathe your child in warm boiled water. In the room where the child is located, the temperature should be maintained at 22-23 degrees. It is extremely important to avoid sudden temperature changes and drafts.

Massage.

The baby really needs physical contact with his mother, especially if he only receives milk from a bottle. You need to try to pick up the child in your arms more often, caress him, hold him close to you. The baby can also benefit from a light massage. For children born weighing less than 1.5 kg, massage should begin no earlier than six months after birth. If the child weighed more than 2 kg at birth, then massage can be performed from the second month of life. The massage session should not be long (1-2 minutes), and the movements should be made lighter than for ordinary children.

From the first days of life, if there is no serious illness, premature baby needs regular placement on the tummy. This stimulates his emotional and physical development, strengthening the main muscle groups (abdomen, back, limbs). It should be placed on the baby’s tummy only before feeding and for no more than 2-3 minutes. To begin with, it is enough to carry out this procedure once a day.

Despite the fact that the medical history of a premature baby is not easy, in no case should you perceive him as inferior. Increased anxiety for the baby's future is understandable, but not very justified. Extra complexes will not be good for the baby, because children very sensitively feel the mood of their parents. Their preoccupation and constant worry can negatively affect psychological attitude baby. By simply following the pediatrician's recommendations, attention, love and caring parental attitude a child born prematurely grows and develops normally. By the age of 2-3 years, a premature child with proper care no different from their peers.

History of child development

FULL NAME. – Dvornichenko_.

Floor. – female

Date of birth: December 20, 2000

Obstetric history

1. Second pregnancy.

2. The end of the previous pregnancy (first) – miscarriage.

6. There were no toxicoses in the first and second half of pregnancy; she was hospitalized twice for premature detachment placenta.

7. Gestation period – 39 weeks.

8. The duration of the first stage of labor is 5 hours. Upon admission to maternity hospital amniocentesis was performed, and 20 minutes later the second stage of labor began, lasting 25 minutes. The third stage of labor lasted 40 minutes. No obstetric interventions were performed.

9. Normal duration of the water-free period.

10. Without complications, no benefits were carried out.

11. Apgar score – 7 – 8 points.

12. After birth, the child is in satisfactory condition, without any special features.

Objective examination (second day of life)

Body weight – 2900 g.

Height – 51 cm.

Chest circumference 36 cm.

head circumference – 38 cm (normal).

General condition is satisfactory.

The degree of maturity of the child corresponds to age indicators.

Nervous system. Available excessive sweating. Tendon reflexes are symmetrical and lively. The following reflexes are determined: search, orbiculo-palpebral, Moro reflex, upper Landau. There are no meningeal symptoms. Dermographism pink.

Muscle tone with a predominance of flexor tone, muscle strength of the upper and lower extremities is normal.

Motor activity is slightly increased.

There are no pathological reflexes.

The skin is pale pink. Visible mucous membranes are pale pink, clean, there is injection of the conjunctiva of the eye, with pinpoint hemorrhages. Subcutaneous tissue expressed moderately. Tissue turgor is satisfactory. There is no swelling. The lymph nodes not enlarged, painless on palpation.

The skull has a dolichocephalic shape. Great fontanel 2.0/2.0 at the level of the skull bones, does not pulsate. The edges are tight. The shape of the joints is not changed, there is no pain, swelling, or hyperemia, the range of motion in all joints is symmetrical and normal. Hip abduction is normal.

Circulatory organs. On the carotid arteries the pulse is synchronous, satisfactory filling, rhythmic. Pulse rate 125 beats/min. On examination, the cardiac region is unchanged. There is no heartbeat. The apical impulse is palpated in the 5th intercostal space 1 cm outward from the left midclavicular line, localized, of moderate height and strength, resistant. There is no cat purring.

On auscultation, heart sounds are clear and rhythmic.

Respiratory system. Breathing freely through the nose. There is no discharge.

The chest is cylindrical in shape. The number of respiratory movements is 34 per minute, breathing is rhythmic. The auxiliary muscles and wings of the nose do not participate in the act of breathing; both halves of the chest participate equally in the act of breathing. There is no shortness of breath.

On palpation, the chest is elastic and painless.

During percussion - the percussion sound is clear, pulmonary.

Auscultation of the lungs reveals puerile breathing.

Digestive organs and abdominal cavity. Satisfactory appetite. The mucous membrane of the oral cavity is pink, moist, without pathological plaques or rashes. Zev without pathology. The language has not been changed.

The tonsils do not protrude from the palatine arches and are not changed. Stomach round shape, soft, painless, accessible to deep palpation in all parts.

The liver is palpable 1.5 cm below the costal arch, painless, the edge is even and smooth. The spleen is not palpable.

Genitourinary system. Urination is free and painless. There is no swelling or hyperemia of the skin in the lumbar region. There is no pain when pressing on the lower back. The kidneys are not palpable. The external genitalia are formed according to female type, no developmental defects, no signs of inflammation.

Laboratory and instrumental research data

1. General analysis blood from 12/21/00

Er. – 7.69 t/l

Нb – 215g/l

Lake. – 11.0g/l

Segm. - 18%

Lymph. – 73%

ESR – 30mm/h

General urine test dated 12/21/00.

Color – salt yellow

The reaction is acidic.

Specific gravity – 1000

Protein – zero.

Lake. – unit

Flat – unit.

Urinalysis from 12/21/00.

Bile – neg.

Urobilin – neg.

Scatological research.

Cons. – mushy

Color – greenish

Approximately 10% of newborns worldwide are born prematurely. A baby is considered premature if it is born earlier than 37 weeks of pregnancy and weighs less than 2.5 kg at birth. Of course, such children require special treatment and care. So, the medical history: a premature baby is the topic of this article.

Stress at birth.

The process of childbirth itself is an extremely difficult ordeal for a premature baby, so doctors in different countries, if it is impossible to stop premature birth, tend to insist on a caesarean section. However, there is not always time or practical opportunity for this. In this case, they try to receive the newborn baby as carefully and carefully as possible. Immediately after birth, the premature baby falls into the hands of a neonatologist for the timely detection of possible congenital anomalies and other problems. If upon examination the need for resuscitation measures is not identified and intensive care is not required, the child is swaddled and placed in a special incubator. It maintains optimal temperature and humidity.

After the maternity hospital.

After discharge from the maternity hospital, a premature baby still needs special care. Everyone understands that breastfeeding is the best option for a newborn. In the case of premature babies, it is simply vital. Mother's milk increases the child's immunity, supplies his body with a number of optimal nutrients, essential vitamins and microelements. Physical contact is also important when breastfeeding - it relieves many neurological problems. Therefore, children who were born prematurely must be breastfed upon request. In cases where the baby does not have enough strength to suckle, you need to express the milk and give it from a bottle.

Basics about care.

A premature baby is much more at risk of infectious diseases. That's why you need to pay more attention to hygiene when caring for it. All children's clothing and diapers must be ironed with a hot iron. Pacifiers and bottles must be boiled. Be sure to bathe your child in warm boiled water. In the room where the child is located, the temperature should be maintained at 22-23 degrees. It is extremely important to avoid sudden temperature changes and drafts.

Massage.

The baby really needs physical contact with his mother, especially if he only receives milk from a bottle. You need to try to pick up the child in your arms more often, caress him, hold him close to you. The baby can also benefit from a light massage. For children born weighing less than 1.5 kg, massage should begin no earlier than six months after birth. If the child weighed more than 2 kg at birth, then massage can be performed from the second month of life. The massage session should not be long (1-2 minutes), and the movements should be made lighter than for ordinary children.

From the first days of life, if there is no serious illness, a premature baby needs regular tummy time. This stimulates his emotional and physical development, strengthening the main muscle groups (abdomen, back, limbs). It should be placed on the baby’s tummy only before feeding and for no more than 2-3 minutes. To begin with, it is enough to carry out this procedure once a day.

Despite the fact that the medical history of a premature baby is not easy, in no case should you perceive him as inferior. Increased anxiety for the baby's future is understandable, but not very justified. Extra complexes will not be good for the baby, because children very sensitively feel the mood of their parents. Their preoccupation and constant anxiety can negatively affect the baby’s psychological state. With simple adherence to the pediatrician's recommendations, attention, love and caring parental attitude, a child born prematurely grows and develops normally. By the age of 2-3 years, a premature child with proper care is no different from his peers.

BASHKIR STATE

MEDICAL UNIVERSITY.

DEPARTMENT OF CHILDREN'S DISEASES FOR MEDICAL

AND DENTAL FACULTIES

Head department - prof. Etkina E.I.

Teacher - Babenkova L.I.

DISEASE HISTORY

Curator: Afanasyev I.A.

Ufa 2003

PASSPORT PART.

1. Buryachenko Anastasia Dmitrievna

2. Age – 5 months, date of birth – 09/08/02

3. Gender - female

4. Date of admission – 02/10/03

5. Home address - Ufa, B. Ibragimov St. 37/2, apt. 13

6. The main diagnosis is ARVI

7. Complications of the main diagnosis – acute obstructive bronchitis medium degree severity, respiratory failure of 1st degree.

8. Concomitant – paratrophy 3rd degree, perinatal encephalopathy, hyperexcitability syndrome.

PATIENT'S COMPLAINTS.

Upon admission to the clinic: fever up to 37.5 C, cough, runny nose, hoarseness.

At the time of supervision: redness of the skin in the area of ​​the intergluteal fold, moisture in the back of the head.

HISTORY OF THE PRESENT DISEASE.

According to the mother, the child has been sick for two weeks. The illness began with fever and cough. They were treated with cefazolin. After 8 days the condition improved. The deterioration with a severe cough began 4 days ago, and was treated with amoxiclav. On the fifth day – 02/10/03 they were sent to the hospital.

LIFE HISTORY OF THE PATIENT.

1. Information about the development and past illnesses of the child.

The child was born from the first pregnancy. Childbirth at 37 weeks. The period from the onset of contractions to the onset of labor is 12 hours. Labor was stimulated. During pregnancy, the mother has anemia, threat of miscarriage, gestosis of the 2 halves (dropsy).

Condition of the newborn.

Weight – 3350 g.

Height – 51 cm.

Head circumference – 36 cm

Chest circumference – 34 cm

First breastfeeding after 40 minutes

The umbilical cord fell off on day 6

BCG vaccination was performed on day 4

Discharged from the maternity hospital on the 6th day.

The condition of the newborn on the Apgar scale: 1 min – 6-7, 5 min – 6-7

Feeding a child.

The child is on mixed feeding.

From two months gets apple juice. From the age of five months he receives Baby formula, milk porridge, vegetable puree, and applesauce.

Physical and neuropsychic development.

Smiling since 2 months

Holds head from 2.5 months

Gulling since 2 months

Tries to sit and crawl.

Past illnesses

Pneumonia (2 months), PEP, hyperexcitability syndrome

Preventive vaccinations

BCG – 4 days

DPT – 3 months, 4 months.

OPV-1 – 3 months

OPV-2 – 4 months.

Allergological history.

No intolerance to certain foods was noted. At 2 months he received amoxiclav and cefazolin. The parents and relatives had no allergy history. Housing conditions - dry, warm apartment.

FAMILY HISTORY

Father's age is 28 years, mother's age is 23 years. The mother has chronic pyelonephritis. Heredity is not burdened. The father’s bad habits are smoking, moderate alcohol consumption, the mother’s are smoking.

Family tree diagram

The father works, the mother is on maternity leave. Parents' education is secondary vocational. Living conditions are satisfactory, the child is provided with separate linen, a bed, and toys.

PATIENT STATUS.

General condition of the child.

While awake, he is animated, walks for a long time, and waves toys.

Weight – 9800g.

Height – 67cm.

Head circumference – 44.5 cm

Chest circumference – 47cm

Skin: the skin is pale, there is hyperemia in the area of ​​the intergluteal fold, moderate humidity. Elasticity is normal, soft tissue turgor is reduced. The pinch sign and the hammer sign are negative. Dermographism is white, unblemished. The hair on the head is long and coarse. There is no vellus hair on the back.

Subcutaneous fat: overdeveloped, unevenly distributed, more pronounced on the abdomen and thighs. Consistency – soft, “loose”.

Muscles: muscle relief is poorly expressed due to the excess subcutaneous fat layer. The belly is saggy. Reduced muscle tone.

Range of passive movements: extension in the elbow joint up to 180 degrees.

In the wrist flexion up to 150 degrees.

Hip extension – 75 degrees in each direction.

Extension of the shin in knee joint– 130g

Flexion of feet – 120 gr.

The head may touch the acromion process with the chin.

When moving the hand to the opposite shoulder, the fingers reach the acromion process.

The volume of active movements in muscle groups and joints is not less than the volume of passive movements.

Skeletal system: the shape of the head is round, the circumference is 44.5 cm. The saree-shaped, coronal, occipital sutures, lateral and posterior fontanelles are closed. Anterior fontanelle – 2.5*2.5 cm.

Standards physical development girls are 5 months old, according to the city of Ufa.

Excess body weight – grade 3 paratrophy.

Physical development is disharmonious.

RESPIRATORY SYSTEM.

Examination: The chest is cylindrical in shape, without asymmetries or deformations. The epigastric angle is straight. Harrison's groove is present. Breathing through the nose is difficult, the type of breathing is abdominal. RR – 36 per minute, breathing is shallow, irregular (34-48 per minute). Mucous discharge from the nose. Dry cough, severe inspiratory shortness of breath.

Palpation: The chest is moderately pliable and elastic. Voice tremors are weakened over the entire surface of the chest.

Percussion: over symmetrical areas of the chest, the percussion sound is pulmonary, with a boxy tint.

Topographic percussion: Upper border of the lungs. Both apexes lag behind the collarbones by 2 cm upward. Posteriorly, the apexes are located at the level of the spinous vertebra. The width of the Krenig margins on the right and left is 3 cm.

Lower border of the lungs

Auscultation: breathing is harsh, increased. Dry whistling rales over all lung fields.

CIRCULATORY SYSTEM.

Inspection: The heart area is without protrusions. The apical and cardiac impulses are not visible.

Palpation: The heartbeat is not detected. The apex impulse is palpated in the 4th intercostal space 1 cm outward from the left midclavicular line, the impulse is low in height, normal strength, limited. Heart rate 128/min.

Percussion: Limits of relative cardiac dullness. Upper - 3rd rib, left - between the left midclavicular and parasternal, closer to the midclavicular line. Right - left edge of the sternum. The diameter of the blunting area is 3 cm. The width of the vascular bundle is 3 cm.

Auscultation: Heart sounds are rhythmic, clear, sonorous. There are no noises. A weak pulsation is visualized medially from the sternocleidomastoid muscle carotid arteries. Outside the same muscles, a negative venous pulse is palpated in the jugular veins. The pulse of the temporal arteries is palpated in the temporal fossa. The femoral artery pulse is at the level of the middle of the inguinal ligament. The pulsation of the epigastric region is not visualized.

Auscultation of blood vessels: sounds and noises over the carotid arteries are not heard. The “spinning top noise” is not detected above the jugular veins. Over the femoral arteries, systolic sound, double Traube sound and Vinogradov sound are not heard.

SYSTEM OF DIGESTIVE ORGANS, ABDOMINAL ORGANS AND RETROPERITONEAL SPACE.

The lips are red, moderately moist, without rashes, ulcerations, or cracks. The oral mucosa is red and shiny. The pharynx is moderately hyperemic. The tonsils do not extend beyond the arches. The tongue is clean and moist. Gums of physiological color. The pharyngeal mucosa is without any features; there are no protrusions or lymphoid follicles on the posterolateral walls.

Abdomen: The right and left abdominal areas are symmetrical. The anterior abdominal wall extends beyond the plane, which is a continuation of the abdominal wall by 2 cm.

Percussion and effleurage: The percussion sound over the stomach is low, tympanic, over the intestines is higher, tympanic. Shchetkin-Blumberg and Mendel's symptoms are negative. The abdomen is soft and painless.

There is no separation of the rectus abdominis muscles. There are no swellings in the area of ​​the inguinal rings and navel.

Deep palpation: The sigmoid colon is palpated in the left iliac and left lateral regions in the form of a displaceable cylinder. The cecum is palpated on the right iliac region in the form of a displaceable cylinder with a pear-shaped extension. The terminal ileum is palpated as a rumbling and peristalting cylinder with a smooth surface. The ascending, descending and transverse colon are palpated as soft cylinders, painless and rumbling.

Auscultation: Intermittent bowel sounds are heard. There is no abdominal wall friction noise.

LIVER AND GALL BLADDER.

Examination: visual enlargement of the liver and liver pulsation are not detected.

Percussion: The upper border of the liver along the right anterior axillary line is the 7th rib.

Along the right midclavicular line is the 6th rib. The anterior midline is not determined.

The lower border of the liver along the right anterior axillary line is 1 cm below the right costal arch. Along the right midclavicular line - 2 cm below the right costal arch. Along the anterior midline 2 cm down from the xiphoid process. Ortner's sign is negative.

Palpation: the liver protrudes from under the edge of the costal arch along the midclavicular line by 2 cm. The edge of the liver is sharp, smooth, soft, painless. The surface is smooth. The symptoms of Kera, Murphy and Mussi are negative.

SPLEEN.

No apparent increase is detected. It is not palpable on the back and right side.

GINOROGENITAL ORGANS.

There are no protrusions above the pubis, in the area of ​​the kidneys. Tapping and palpation above the pubis is painless. The pain in the hypogastric region is painless. The kidneys are not palpable.

NERVOUS SYSTEM.

Daytime sleep – 3-4 times for 1.5-2 hours. Night sleep 8 ocloc'k. Neuropsychic development corresponds to age.

Visual and auditory functions without impairment.

Pain, temperature and tactile sensitivity are detected.

General hand movements are age appropriate. There is no hyperkinesis. Dermographism white. Tendon reflexes are lively, uneven, and have a wide area. There are no meningeal symptoms.

PRELIMINARY DIAGNOSIS.

Based:

3. Information about the child’s diseases – paratrophy, PEP

We exhibit preliminary diagnosis:

Associated Note: stage 3 paratrophy, PEP, hyperexcitability syndrome.

Obstructive bronchitis must be differentiated from pneumonia, bronchial asthma(asthmatic bronchitis), whooping cough.

SURVEY PLAN

3. Examination of stool for scatology, dysbacteriosis.

4. Chest X-ray. Fluorography of the mother's chest organs.

6. Consultation with an otolaryngologist.

ADDITIONAL RESEARCH

1. General blood test dated 02/12/03.

Hb – 133 g/l.

Er - 3.86x1012/l

Lake. 6.9x109/l

ESR – 29 mm/hour

Lymph. – 66%

Mon. - 7%

2. General urine test dated 02/12/03

Yellow color

Alkaline reaction

Transparent

Protein - negative

Sugar - negative

Epithelial cells are polymorphic - 0-1 in the field of view

Leukocytes - 2-0-0 in the field of view

Red blood cells - 1-0-0 in the field of view

Scatology from 02.13.03

No helminth eggs were found.

Neutral fats +

Undigested muscle fibers +

Bacteria +

ECG dated 02/10/03.

The rhythm is sinus. Heart rate 130 beats per minute. Email the axis is tilted to the right.

X-ray of the chest organs from 02/10/03

The pulmonary pattern is enhanced. Sinuses are free. The diaphragm dome is smooth. The cardiac shadow is without features.

DIFFERENTIAL DIAGNOSIS

1. In acute pneumonia, typical for children 2-6 months old, there is an incubation period of up to 4-8 weeks, a nonspecific onset of the disease (decreased appetite, lethargy, pallor, dyspepsia), tympanic percussion sound, shortness of breath, painful, paroxysmal cough, hard breathing, on the radiograph - emphysema, abundant focal shadows with blurred contours, leukocytosis in the blood, increased ESR, eosinophilia, pneumocystis in the bronchial secretions.

2. With asthmatic bronchitis, there is an allergic history, low-grade fever, persistent cough with viscous sputum, mixed shortness of breath, a boxy percussion sound over the lung fields and weakened breathing, fine and medium-bubble moist rales, moderate leukocytosis and eosinophilia in the blood. ESR is within normal limits.

3. Foreign bodies respiratory tract cause the sudden development of an attack of convulsive cough against the background of complete health, shortness of breath, which increases when the child is restless and disappears completely during sleep. X-ray changes in the form of unilateral emphysema or atelectasis, absence of hematological changes, the appearance of granulations in the larynx or bronchial tree

4. With whooping cough, the onset is subtle, paroxysmal painful cough, the face is puffy, the eyelids are swollen, the percussion sound is boxy, in the lungs there are intermittent dry and wet rales, viscous sputum, on the radiograph there is an increase in the transparency of the pulmonary fields, flattening of the domes of the diaphragm, increased pulmonary pattern, expansion of the roots in in the form of radial lines, leukocytosis in the blood, predominance of lymphocytes.

CLINICAL DIAGNOSIS

Based

1. Complaints from the child’s mother – increased body temperature to 37.5 C, cough, runny nose, hoarseness.

2. Objective data: - dry cough

Percussion sound with box tone

Hard breathing, dry wheezing.

3. Instrumental examination data - increased pulmonary pattern, succulence of roots, marginal emphysema

4. Laboratory data - increased ESR, decreased number of red blood cells, lymphocytosis

5. Physical development assessments – 33.5% excess body weight

6. Assessment of general condition – pallor, pastiness, decreased tissue turgor

7. Information about other diseases - PEP

The clinical diagnosis was made:

Main: ARVI, moderate obstructive bronchitis

Associated Note: stage 3 paratrophy, PEP, hyperexcitability syndrome

ETIOLOGY.

Etiology of the underlying disease.

Bronchitis is a complication of ARVI

The causative agent of ARVI can be

Influenza viruses (serotypes A and B)

Parainfluenza viruses serotype 4

Adenoviruses (more than 30 serotypes)

Rhinoviruses

Enteroviruses

Respiratory syncytial viruses.

Virus associations

Etiology of concomitant disease.

In this child, paratrophy has a mixed etiology and is postnatal dystrophy, which is caused by exogenous factors:

Nutritional – unbalanced diet

Infectious – intestinal infection

Dysbacteriosis

Anemia and gestosis of the 2nd half of pregnancy in the mother of the child are of certain importance.

PATHOGENESIS

Pathogenesis of the underlying disease:

Reproduction of viruses in sensitive cells Viremia Damage to the respiratory system Reverse development of the pathological process

Pathogen of concomitant disease:

PEP Changes in the central nervous system Unstable secretion of the gastrointestinal tract Disruption of humoral and endocrine regulation of metabolic processes Metabolic acidosis Decreased body resistance

TREATMENT

1. Individual mode

2. Nutrition.

Calculation of milk requirements for a five month old baby:

1) 1/7 body weight (9800g) = 1400 ml

2) according to Shkarin’s formula: = 800+5*(N-2), where N – month = 950ml

3) according to nutritional standards - for five months - 900-1000 ml

Thus daily requirement baby in milk ~ 1l

The child is on mixed feeding

Sample menu:

06.00 – breast milk or mixture 200 g.

10.00 – milk buckwheat or any “gray” porridge 200 g.

14.00 – vegetable puree 200 g.

18.00 – breast milk/formula 200 g, fruit juice– 50 g.

22.00 – breast milk/formula 200 g.

3. Etiotropic therapy

Rp: Cephazolini 0.25

D.t.d. N 10 in amp

S. IM 2 times a day for 5 days

Rp: Oxacillini 300000 ME

D.t.d. N30 in amp

S. Dissolve the contents of the ampoule in sterile water for injection, administer intramuscularly 3 times a day, 300,000 IU each.

4. Pathogenetic therapy

Rp: Sol. Euphyllini 1%-50ml

D.S take 1 tsp orally. 3 times a day

Rp: Sol Suprastini 2%-0.3ml

D.S. i/m 1 day/day

Rp: “Berodualum” 20?0 ml

D.S. inhalation: 10 drops 3 times a day

Rp: Massage on the chest area No. 2 for 10 minutes daily

4. Symptomatic therapy

Rp. M-rae Paracetamol 200.0 ml

Rp. M-rae Bromhexini 200.0 ml

D.S. Inside, 1 tsp. 3 times a day

TEMPERATURE SHEET.

02/14/03 Complaints of cough, runny nose, loose stool. Breathing through the nose is free. There are isolated dry rales over the lungs. RR 40/min. Heart tones are rhythmic and clear. Pulse 130 per minute. The stomach is soft. painless. t –

02/17/03 Complaints of cough, runny nose. Breathing through the nose is free. There are isolated dry rales over the lungs. RR 36/min. Heart tones are rhythmic and clear. Pulse 130 per minute. The stomach is soft. painless. t – Stool has returned to normal and is receiving treatment.

02/19/03 Complaints of cough, runny nose. Breathing through the nose is free. There are isolated dry rales over the lungs. RR 38/min. Heart tones are rhythmic and clear. Pulse 125 per minute. The stomach is soft. painless. t – Receives treatment.

DISCHARGE EPICRISIS.

Buryachenko Anastasia Dmitrievna entered the 3rd children's department clinics of BSMU on 02/10/03 with complaints of fever, runny nose, cough.

An examination was carried out - physical, laboratory, instrumental and a diagnosis was made: Main: ARVI, moderate obstructive bronchitis

Associated Note: stage 3 paratrophy, PEP, hyperexcitability syndrome

Antiviral, pathogenetic and symptomatic therapy was carried out. Physiotherapeutic procedures. Nutrition according to age with correction for vitamins and microelements.

He was discharged on February 21, 2003 in a state of improvement under the supervision of a local pediatrician.

The prognosis for life and recovery is favorable.

1. Balanced nutrition

2. Air baths at 20 C, ventilation 4-5 times for 10-15 minutes in the presence of a child.

Walking at a temperature not lower than –12 C from 15 minutes to 2 hours, 2 times a day.

3. Sunbathing

4. Water procedures.

5. Massage

Used Books:

1. Propaedeutics of childhood diseases, A.V. Mazurin, Moscow, “Medicine”, 1985

2. Childhood diseases, A.A. Isaeva, Moscow, “Medicine”, 1986