Pediatric Final All Merged 2022

Task 1
The child is 9 months old. She was born full-term with a weight of 3200 g. She has
been on artificial feeding for 2 months. From 5 months he receives cow's milk, fruit and
vegetable juices. Meat and egg yolk are not included in the diet. Complaints of loss of
appetite, anxiety, lag in physical development. At objective examination: pallor of the
skin and mucous membranes, pasty tissue, dry and brittle hair, signs of rickets, audible
systolic murmur at the apex of the heart, there is an increase in the liver and spleen. In
the anamnesis several times a year she had SARS. In the clinical analysis of blood the
content of erythrocytes - 2,8 × 10 12 / l, hemoglobin - 74 g / l, KP - 0,66. There are signs
of anisocytosis (microcytes) and poikilocytosis.
1. Establish a preliminary diagnosis.

2. Determine the protocol of management of the patient, prescribe treatment,
listing the groups of drugs, representatives of each group, indicate the dose and
frequency of administration.
3. Interpret the results of a clinical blood test.
In response:
1. Moderate iron deficiency anemia.
2. Diagnosis:
1) Determination of serum iron level, total iron binding capacity of blood, transferrin
saturation, serum transferrin level, average erythrocyte volume, average hemoglobin
content in erythrocytes.
2) Therapy:
The last thing is for the child to be outdoors
R ational therapeutic nutrition: adapted milk formulas enriched with iron, the introduction
of complementary foods, meat, especially veal, offal, buckwheat and oatmeal, fruit and
vegetable purees, hard cheeses; reducing the intake of phytates, phosphates, tannins,
calcium, which impair the absorption of iron
P eroralne prescribing iron in the average daily dose of 5 mg / kg: Aktyferyn 10-15krap
drops 3-4 times a day before eating
The effectiveness of the prescribed dose is monitored by determining the rise in the
level of reticulocytes (reticulocyte crisis, indicating the restoration of erythropoiesis) on
day 7-10 of treatment.
P ryznachennya vitamins C, B1 , B6 , folic acid
3. In the analysis of blood decrease in the number of erythrocytes hemoglobin,

indicating signs of anemia, as well as signs of anisocytosis and poikilocytosis
Task 2
A 15-year-old girl went to the family doctor with complaints of lethargy, weakness,
and a feeling of ants crawling on her skin. During the examination there is pallor of the
skin, lacquered tongue, cheilitis. From the anamnesis: surgery was performed for
gastric ulcer. In the general analysis of blood: erythrocytes - 2,7 × 10 12 / l, hemoglobin -
79 g / l, KP - 1,2, reticulocytes - 5%, thrombocytes - 250 × 10 9 / l, poikilocytosis,
available megalocytes, normoblasts.

Answers:
1. Foliyevodefitsytna B12-deficiency anemia, Mr. iperreheneratorna ( reticulo.

5%)
2. D iyeta: rich meat products, liver, eggs, cheese, milk.

Vitamin B12 preparations: Cyanocobalamin in a dose of 100-200 mcg (0.1-
0.2 mg) intramuscularly. 2 times a day. The course of treatment is 3-4 weeks.
F oliyeva acid 0,001 enterally 1 per day rate 4-6 weeks
3. In the analysis of blood decrease in the number of erythrocytes, hemoglobin,

indicating signs of anemia, there are megalocytes, which are characteristic of B12
deficiency anemia, KP-1,2 - hyperchromic anemia
Task 3
A 16-year-old girl suffers from menorrhagia. Complains of flickering flies in front of

the eyes, dizziness, dry skin, brittle nails, hair loss. The examination revealed pallor of
the skin and mucous membranes. Pulse 100 beats / min., Rhythmic, systolic noise at
the apex. Vesicular respiration. The liver and spleen are not enlarged. ZAK:
erythrocytes - 3,3 × 1012 / l, hemoglobin - 90 g / l, KP - 0,7, leukocytes - 9 × 109 / l, e
2%, n 3%, with 70%, l 25%, m 10%, anisocytosis, microcytosis, serum iron 7.2 μmol / l.

Answers:
1. Chronic posthemorrhagic anemia
2. Treatment of pediatric gynecologist menorrhagia.
Preventive measures: diet enriched with iron, dishes of buckwheat, corn, millet, carrots,
beets, garlic, onions, celery. It is especially useful to eat walnuts, blueberries, black
currants, strawberries, strawberries, raspberries, cherries, plums, grapes.
P Reparate iron : Feroplekt a daily dose of 5 mg / kg 1-2 tablets 2 times a day for 3
months.
3. In the analysis of blood decrease in number of erythrocytes, hemoglobin, indicating

signs of anemia, as well as signs, KP indicates hypochromic anemia.
Task 4
A 15-year-old girl was admitted to the pediatric ward with complaints of petechial
rash and bruising on the skin of the lower extremities and the front surface of the torso,
which occur spontaneously or as a result of minor trauma. Menorrhagia, nosebleeds are
noted. From the history of the disease it is known that during the last month there were
three spontaneous nosebleeds and bruises on the skin after minor strokes. Three days
ago, after tooth extraction, bleeding began immediately, which was stopped only after
12 hours. In connection with this event, the patient decided to be examined in the
hospital. From the history of life it is known that she suffered from measles, SARS,
heredity is not burdened, denies bad habits. Objectively: the condition is relatively
satisfactory, on the skin of the lower extremities and the anterior surface of the torso
petechial rash, which does not protrude above the surface of the skin, painless when
pressed, and a small number of bruises of irregular shape. No pathology was detected
in other organs and systems. Data of laboratory methods of research: Hb - 120 g / l,
leukocytes - 6,5х10 9 / l, erythrocytes - 4,5х10 12 / l, thrombocytes - 50х10 9 /
l. Biochemical analysis of blood without pathology. TSK is the norm. APTT (activated
partial thromboplastin time) - norms a. Cheka (bleeding time) - 4.5 minutes

3. Interpret the results of blood tests.
Answers:
1. Acute thrombocytopenic purpura , moderate form.
2. Additionally: determination of antiplatelet antibodies . P lazmaferez (replacement

plasma) in the amount of 1-1.5 plasma volume per day, during the preparations for
plasma exchange transfusion MSP spend in a dose of 30 ml / kg / day. Treatment
should be continued for 2 days after achieving an increase in platelet count to> 150,000
/ μl.
+ GK. The initial dose of prednisolone is usually equal to 1 mg / kg body weight / day (in
the absence of effect, the dose is increased to 2-3 mg / kg body weight / day). In such
doses, prednisolone is prescribed for no longer than 2-3 weeks, after which the dose is
gradually reduced to a maintenance dose (10-15 mg / day), or until complete
withdrawal. Steroid hormones can be prescribed in short courses, in particular
dexamethasone 40 mg / day for 4 days, repeating the courses every 28 days, for a total
of 6 cycles. In refractory forms of ITP use methylprednisolone in high doses parenterally
(30 mg / kg / day - 3 days, 20 mg / kg / day - 4 days, later 5, 2 and 1 mg / kg / day for 1
week). When treated with steroid hormones, it is necessary to prescribe potassium
supplements, and with oral prednisolone - antacids. At patients who need longer
treatment, you can use a weakened androgen - danazol. The standard dose of the drug
is 10-15 mg / kg / day for 2-4 months. In case of ineffectiveness of conservative
treatment in 3-6 months from the beginning of a disease the splenectomy is
recommended. In patients refractory to corticosteroid hormones, who have
contraindications for splenectomy, as well as in the ineffectiveness of splenectomy,
immunosuppressive therapy is used: vincristine at a dose of 0.02 mg / kg (1-2 mg)
intravenously once a week for 1-2 months; azathioprine 1-4 mg / kg body weight / day
for 2 months or cyclophosphamide 1-2 mg / kg / day. For immunosuppression,
cyclosporine has recently been used at a dose of 5 mg / kg body weight / day for
several months, as well as monoclonal antibodies - anti CD20 (rituximab), anti CD52
(alemtuzumab) and others. In urgent cases, prescribe polyvalent immunoglobulins for
intravenous use. Immunoglobulin is administered intravenously in a dose of 0.4 g / kg
body weight / day for 5 days or at a dose of 1 g / kg body weight / day for 2 days. If
these treatments are ineffective in order to quickly stop the bleeding in urgent cases,
recombinant activated factor VII (VII a) is administered at a dose of 60-90 mg / kg
intravenously every 2 hours until the bleeding stops.
3. Data of laboratory methods of research:

thrombocytes - 50х10 9 / l. - reduced amount (rate of 180 x10 9 / L )
RC (bleeding time) - 4.5 minutes - extended second time (the rate to 3 minutes)
Task 5
Patient L., 17 years old, was admitted to an obstetric clinic due to heavy uterine
bleeding. Over the past year, noted bruising on the extremities. When brushing your
teeth, bleeding gums are noted. These phenomena have increased over the last
year. Clinical blood test: hemoglobin 90 g / l; erythrocytes 3,0x10 12 / l; color index
1.0; platelets 10x10 9 / l; leukocytes 5.0x10 9 / l; ESR 14 mm / year. The patient was
transferred to the hematology department. The condition is satisfactory. The skin is
pale. On the skin of the thighs and forearms superficial hemorrhages up to 3 cm in
diameter. Liver, spleen are not palpable, after their palpation on the skin of the
abdomen appeared bruises petechial type. From the cardiovascular system, respiratory
system and gastrointestinal tract without abnormalities. On the oral mucosa vesicles
with hemorrhagic content. Myelogram: normal erythropoiesis, the number of
megakaryocytes is normal. Establish a preliminary diagnosis.

Answers:
1. Acute thrombocytopenic purpura , severe form. Acute posthemorrhage and mild
anemia.
2 . Additional research: antiplatelet blood pressure, it is necessary to

conduct tests to determine hemostasis . Characteristic: increase in bleeding time,
decrease in degree of retraction of a blood clot.
Tera Pius:
Bed rest with its gradual expansion as the extinction of hemorrhagic phenomena.
P lazmaferez (replacement plasma) in the amount of 1-1.5 plasma volume per day,
during the preparations for plasma exchange transfusion MSP spend in a dose of 30
ml / kg / day. Treatment should be continued for 2 days after achieving an increase in
platelet count to> 150,000 / μl.
+ GCS: prednisolone 2 mg / kg / day for 2-3 weeks with subsequent dose

reduction and complete discontinuation. in higher doses (3 mg / kg / day) is
prescribed in short courses of 7 days with a break of 5 days (not more than three
courses).
With severe hemorrhagic syndrome, the threat of hemorrhage into the brain is
possible "pulse therapy" with methylprednisolone (30 mg / kg / day intravenously
for 3 days).
+ Immunoglobulins: administration of human Ig at a dose of 0.4 or 1 g / kg for 5 or

2 days, respectively (course dose of 2 g / kg) as monotherapy or in combination
with glucocorticoids.
Splenectomy or pulmonary embolism is performed in the absence or instability of

the effect of conservative treatment, recurrent profuse prolonged bleeding,
leading to severe posthemorrhagic anemia, severe bleeding, life-threatening
patient
P Reparate iron : Feroplekt a daily dose of 5 mg / kg 1-2 tablets 2 times a day for 3
months.
3. Syndromes: hemorrhagic syndrome (skin manifestations + hemorrhages,
bleeding) according to laboratory data:
thrombocytopenia (t = 10x109 / l, N = 170-380x109 / l);
ESR 14 mm / h - increased (norm 10 mm / h )
anemic syndrome (erythrocytes = 3,0x1012 / l; N for women = 3,7-4,7); (Hb = 90g /
l, N = 132-173 g / l) The
color index is normal (N = 0.8-1.15), anemia should most likely be regarded as
posthemorrhagic, but this must be proven.
Task 6
Alexey, 5 years old. Complaints: the appearance of a rash on the skin of the torso
and extremities, intermittent abdominal pain. The rash appeared 3 days ago, but his
parents did not give it due importance, did not consult a doctor, the boy continued to
attend school and sports section. Since yesterday, my mother noticed that the rash
became much more abundant, the night slept restlessly, woke up because of abdominal
pain. Two weeks ago he suffered from SARS and was treated on an outpatient
basis. Objectively: a state of moderate severity, severe abdominal pain, subfebrile
temperature, draws attention to the rash on the skin of the upper and lower extremities,
mainly on the extensor surface, in the buttocks, on the ears. The rash protrudes in relief
above the skin surface, does not disappear when pressed, is symmetrically located,
there are areas of draining rash with necrosis in the center, on the feet. The mucous
membranes of the mouth are clean. Joints are not deformed, active and passive
movements in full. In the lungs and heart without pathology, pulse 98 / min. Blood
pressure 110/70, the abdomen of the usual configuration, participates in the act of
breathing, on superficial palpation is soft, diffuse pain, symptoms of peritoneal irritation
are negative. The liver and spleen are not enlarged. The chair was black in the morning,
decorated. Urination is normal. Blood test: erythrocytes - 4.2x10 12 / l, platelets -
245x10 9 / l, Hb - 134 g / l, leukocytes - 10.8x10 9 / l, P - 8%, C - 60%, E - 4%, L - 22%,
M - 6%, ESR - 32 mm / h, duration of bleeding according to Duke 3 min, SPR +++, urine
analysis without pathology.

3. Interpret the results of the laboratory test.
Answers:
1. Hemorrhagic vasculitis, skin and abdominal form.
The conclusion is based on: rash on the skin of the torso and extremities, recurrent
abdominal pain. Provoking research: subfebrile temperature, pronounced abdominal
pain, rash on the extensor surface of the upper and lower extremities, buttocks, ear
canals, symmetrical, which does not disappear when pressed, there are drainage areas
with necrosis in the center. At a palpation of a stomach morbidity, a chair of black color
is noted.
2 . Diagnostic program: general blood test; biochemical analysis of blood
(dysproteinemia, positive reaction to CRP); urine analysis; fecal occult blood
analysis; coagulogram; immunogram; determination of plasma CEC
content; determination of indicators of adhesion and aggregation of thrombocytes.
Treatment program:
D iyeta exclusion obligate allergens and new products; bed rest (the whole active
period);
D aggregates (heparin, curantil, trental):
Heparin 200-500 IU / kg / day; the initial dose is 50 IU / kg (intravenous injection ), the

maintenance dose is 100 IU / kg every 4 hours
Duration of heparin administration (within 2-4 weeks)
And antihistamines (tavegil, suprastin, pipolfen);
Suprastin 25mg, take 1/2 tablet 2 times a day for a period of 2-4 weeks.
In vitamins C and P
In severe cases, glucocorticoids and plasmapheresis: Prednisolone at a dose of 1-2

mg / kg / day for a period of 2-4 weeks with gradual withdrawal
3. According to laboratory tests (leukocytosis, neutrophilia, eosinophilia, elevated ESR).
Task 7
A 7-year-old boy complains of physical and sexual retardation. From the second
normal birth. Toxicity of the first half was observed during pregnancy. He was born with
a weight of 3300 g, body length 50 cm. He keeps his head from 2 months, sits from 6,
started walking at 11 months, speaks from 14 m. He rarely gets sick. Growth lag has
been observed since 2 years. Over the past 2 years, the increase in growth is 1
cm. Height of mother - 165 cm, father 178 cm. Objectively: height - 85 cm, body weight -
16 kg. The structure of the body is proportional. The skin is pale with a yellow tinge,
dry. The voice is high. No pathology was detected on the part of the lungs and
heart. Blood pressure 80/50 mm Hg Pulse 92 beats / min. The genitals are formed
correctly, correspond to the age of 2-3 years. Intelligence is not impaired.

3. Interpret the results of the child's physical development.
Answers:
1. hypophyseal dwarfism
2.Diahnostychna program includes: determination was Evan I somatotropin,
assessment of thyroid, adrenal hormones gonadotropin levels.
Laboratory-instrumental criteria: reduction of basal levels of somatostatin in the blood
and reserves of somatotropic function of the pituitary gland during stimulation tests (with
intravenous administration of insulin, thyrioliberin, luliberin, somatoliberin, oral L-dofa,
etc.)
Decreased secretion of gonadotropins, possibly thyrotropin and corticotropin; androgen
deficiency, decreased levels of thyroxine, triiodothyronine, cortisol, aldosterone, 17-ACS
and 17-CS in the blood and their excretion in the urine. Hyperlipidemia, hypoglycemia or
tendency to it, decreased alkaline phosphatase activity and serum inorganic
phosphorus; lymphocytosis. Data of computer and NMR tomography of the brain,
ultrasound of internal organs, ECG and X-ray examination (skull, hand and wrist).
Expressed delay in the appearance of ossification nuclei.
An important component of treatment is a complete diet enriched with proteins and

vitamins.
The main pathogenetic method of treatment is lifelong therapy with human growth
hormone.
Prescribe drugs of recombinant genetically engineered somatropin in a daily dose of

0.026-0.035 mg / kg body weight (0.07-0.1 IU / kg) under the skin at night 6-7 times a
week.
When acceptable growth is achieved and the final fusion of the epiphyseal fissures -
continue treatment with somatoropin drugs in a daily dose of 0.05-0.1 mg / kg / week,
administered daily. The control of the effectiveness of treatment is the level of IPFR-I.
3. The child lags far behind in physical development, this is indicated by height, body
weight, sexual characteristics, it is characteristic that the delay began at 2 years of age.
Task 8
A 5-year-old boy lags behind in mental development. Birth weight - 3900 g, height -
52 cm. From the first months lags behind in development, began to hold his head in 1
year, sit - in 1.8 years. Some words began to speak at 3 years old. Objectively: height
80 cm, weight 11 kg. The face is swollen, amimic, pasty, the eye slits are narrow, the
lips are thick, the mouth is half open, the tongue is swollen. The skin is pale, dry, flaky,
hair dry, thin. The big temple is open. There are only 4 teeth. Stomach without
features. Ps - 84 / min., Blood pressure - 85/60 mm Hg. Heart tones are
weakened. General blood test: Hb - 105 g / l, erythrocytes - 3,4х10 12 / l, KP - 0,80,
leukocytes - 8,5х10 9 / l, n - 2%, s - 32%, e - 1%, l - 57%, m - 8%, ESR -7 mm /
year. General analysis of urine: color - yellow, transparent, relative density - 1,015,
reaction - acid, protein - no, acetone - no. Biochemical analysis of blood: glucose -3.5
mmol / l, total bilirubin - 17.5 μmol / l, sodium 132.0 mmol \ L, potassium - 5.0 mmol / l,
total protein 60.2 g / l, cholesterol 8.4 mmol / L. The level of TSH is 20 mOD / l, T4 90
nmol / l.
Answers:
1. Congenital hypothyroidism
2. The diagnostic program includes: to determine the level of TSH, T4, T3, blood
pressure to TPO and TG, Ca, serum calcitonin, ultrasound of the thyroid gland .
Treatment is carried out for life.

Replacement therapy with thyroid hormone drugs: L-thyroxine, triiodothyronine
• A full replacement dose is given immediately.
• TSH control: at the stage of dose selection - 1 time in 1 month, further, at
achievement of compensation (TSH 0,5-2,0 mOD / l) - 1 time in 6 months.
L-thyroxine 3-4 μg / kg daily dose, the daily dose of the drug to take in the morning on
an empty stomach, 30 minutes before eating, drinking a small amount of water.
3. Slight decrease in hemoglobin, increase in cholesterol
The increase in TSH, T4 is determined
Task 9
Girl R., 14 years old, complains of constant irritability, sleep disturbances,

palpitations, visual disturbances, tearing, weight loss of 10 kg in 4 months. Objectively,
the skin is warm, moist, light asymmetric exophthalmos (more on the left), conjunctival
hyperemia, positive symptoms of Grefe, Kocher, Moebius. The thyroid gland is
enlarged, painless on palpation. Pulse 108 / min (during sleep), art. pressure 140/66
mm Hg. Art. Small tremor of the fingers. General blood test: Hb - 106 g / l, erythrocytes -
3,4х10 12 / l, KP - 0,85, leukocytes - 7,5х10 9 / l, p-1%, s - 32%, e - 2%, l - 57%, m - 8%,
ESR - 9 mm / year. General analysis of urine: color - yellow, transparent, relative
density - 1,015, reaction - acid, protein - no, acetone - no. Biochemical analysis of
blood: glucose - 4.3 mmol / l, total bilirubin - 19.5 μmol / l, sodium 122.0 mmol \ L,
potassium - 5.0 mmol / l.

Answers:
1. Goiter II. with t and rheotoxicosis of moderate severity. Endocrine
ophthalmopathy.
2 . Determination of TSH, T4, T3, blood pressure to TPO and TG, Ca, serum
calcitonin, thyroid ultrasound.
Appointment of thyrostatics - mercazolyl at a dose of 20-30 mg per day,
beta-blockers (anaprilin, propranolol) - the first 4 weeks, simultaneously with
thyrostatics - 1-2 mg / kg / day in 3-4 doses,
for the treatment of ophthalmopathy - glucocorticoids - prednisolone short
course at an average dose of 0.2-0.3 mg / kg / day for 2-3 doses, with a gradual
decrease after 7-10 days by 2.5-5 mg every 5-7 days until complete abolition. TSH.
3. General blood test: minor erythrocytopenia; c- reduced number; l- increased

number;
Biochemical analysis of blood: total bilirubin -increased, sodium- reduced.
Task 10
The 5-month-old baby, born full-term with a weight of 3,000, was up to 4 months on
artificial feeding with cow's milk. At this time receives a mixture of "Baby", twice a day
semolina. At inspection are noted: pallor of skin, unilateral flattening of a nape, growth
of frontal mounds, 108 depression of a nose. On the ribs rickets, there is a slight
hypotension of the muscles. Liver - 2 cm, Blood test: er. - 3,6 * 10 12 / l Tl HB -118 g / l,
Ca blood-2,25 mmol / l, P-0,8 mmol / l, Sulkovich's test - negative.

Answers:
1. Rickets of the II degree , moderate, without significant deviations of the content of
calcium and phosphorus in the blood.
2. Observance of the daily routine and sanitary and hygienic regime
Natural breastfeeding, if impossible - adapted breast milk substitutes
In 2 weeks from the beginning of medical treatment - to appoint baths:
salt (for children sedentary, pasty),
conifers (mostly excited children),
herbal (for children with exudative-catarrhal diathesis), general massage,
exercise therapy
Vitamin D (Aquadetrim) 4,000 ME, 1 drop contains approximately 500 IU of vitamin D3 ,

daily for 4-5 days for 4-8 weeks, then 2000 IU for 30 days 2-3 times a year with intervals
of at least 3 months to 3 - 5 years of age .
3. Everything is fine.
Task 11
Nastya M., 8 months old, was admitted to the clinic with the mother's complaints
about the child's mental and physical retardation, fracture of the upper limb. The child
was born weighing 2,600 g, from the first day of birth on artificial feeding, received milk,
semolina, was often ill, was not cared for by a pediatrician, the mother did not notice
any signs of injury. The condition is severe, pale, lethargic, no longer sitting, no teeth,
square skull, chest in the form of a "chicken" sternum. The upper right limb in a plaster
cast is a fracture of the radial bone. Liver at the level of the navel, spleen + 4 cm.
General blood test: e - 2.9x10 12 / l, Hb - 85 g / l, blood Ca - 1.08 mmol / l, P - 0.6 mmol /
l.

Answers:
1. Rickets of the III century. severe, calcium penic variant.

2. Observance of the daily routine and sanitary and hygienic regime
Natural breastfeeding, if impossible, adapted breast milk substitutes
Diet high in calcium, walks in the fresh air are long.
Correction of hypocalcemia: 5 - 10% solution of calcium chloride - 1 teaspoon 3 times a

day or calcium gluconate - 0.5 g 3 times a day for 2 weeks.
Vitamin D (Akvadetrym) 5000 IU, Mr rotyahom 30 - 45 days. In the future, to prevent

exacerbations and recurrences of the disease at 2000 IU for 30 days 2-3 times a year
with intervals between them of at least 3 months to 3-5 years of age .
In 2 weeks from the beginning of medical treatment - to appoint baths:

salt (for children with sedentary, pasty), coniferous (mostly excited children),
herbal (children with exudative-catarrhal diathesis), general massage, exercise
therapy
3. General blood test: erythrocytopenia, Hb - reduced, blood Ca -

reduced, P - the lower limit of normal.
Task 1 2
A 12-year-old girl complains of dull abdominal pain, aching in nature, occurring 30-45
minutes after eating. The above complaints first appeared 6 months ago, but
examination and treatment were not performed. Mother - 40 years old, suffers from
duodenal ulcer. Father - 42 years old, chronic gastroduodenitis. Objectively: height 137
cm, weight 31 kg. The skin is pale, moderate humidity. The abdomen is not enlarged. At
superficial and deep palpation in the right hypochondrium muscle tension and soreness,
as well as soreness in the epigastrium are determined. The liver protrudes from the
edge of the costal arch by 1.5 cm, the edge is soft, elastic, painless. Ortner-Grekov
symptom (+). From the lungs and heart -without pathology. Stools are regular,
decorated, sometimes very light. General blood test: H - 130 g / l, KP - 0.93,
erythrocytes - 4.6x1012 / l, leukocytes - 7.0x 109 / l: n - 2%, c - 66%, e - 2%, l - 25%, m
- 5% ESR - 7 mm / year General analysis of urine: color - light yellow, transparent, pH -
5.7, relative density - 1,020, protein - no, sugar - no, epithelium - a small amount,
leukocytes - 1-2 in p / s, erythrocytes - 0- 1 in p / s, mucus, salts, bacteria -
no. Biochemical analysis of blood: total protein - 72 g / l, ALT - 19 U / l, ACT 24 U / l, LF
- 138 U / l (norm 70-140), amylase - 100 U / l (norm 0-120) , thymol test - 4 Units, total
bilirubin - 15 μmol / l, direct - 9 μmol / l. Coprogram: color - brown, decorated, pH - 7.3,
muscle fibers in small quantities, intracellular starch - a little, iodine flora - a small
amount, plant fiber - a moderate amount, mucus a little, leukocytes - 1-2 in p /
with. Ultrasound of the abdominal cavity: liver - the contours are smooth, the
parenchyma is homogeneous, echogenicity is enhanced, the vessels are not dilated,
the portal vein is not changed. Gallbladder 85x37 mm (norm 75x30), the walls are not
thickened, Choledochus - up to 3.5 mm (norm 4), the walls are not thickened. After a
choleretic breakfast, the gallbladder shrank by 10%.
2. Determine the protocol of the patient, prescribe treatment, listing the groups of
drugs, representatives of each group, indicate the dose and frequency of
administration.
Answers:
1. Dyskinesia of the biliary tract by hypotonic type.

2. Tonic drugs - tincture of ginseng, Chinese lemongrass, Eleutherococcus;
Ginseng tincture 1 drop for 1 year of life, so 12 drops, taken orally 30 minutes before
meals, 2-3 times a day for 1 month.
X oleretics: Cholenzyme taken orally 1 tablet 2 times a day after meals. Course
duration 2 - 3 weeks.
X olekinetics: artichoke leaf extract 1/4 - ½ tsp. 3 times a day, magnesium sulfate 25%
to 1 tbsp. 2 - 3 times a day; galsten, vegetable oils (sunflower, corn, olive), flax seeds;
Galsten 1 tablet 2 times a day.
P rokinetics: domperidone 10 mg 3 times a day for 15 - 30 minutes. before eating
T yubazhi 2 times a week № 5 - 7 at the hypotonic form with mineral water (average
mineralization) on 100 - 200 ml on reception, 25% solution of magnesium sulfate on 20 -
50 ml, 10-20% solution of sorbitol or xylitol on 50- 100 ml.
F izioterapevtychni procedure: electrophoresis magnesium sulfate in the right
hypochondrium, sinusoidal modulated currents with a solution of mud, electrical
gallbladder;
B alneotherapy: mineral waters of average mineralization and average gas saturation
(Luzhanskaya, Morshinskaya, Polyana Kvasova, etc.) on 3-5 ml on 1 kg of weight on
reception, 3 times a day within 1 month;
3. General blood test without pathological changes, biochemical: increase in bilirubin
direct fraction.
Task 13
A 9-year-old girl complains of weakness, fatigue, and sometimes heartburn. For 2.5
years, abdominal pain, localized in the epigastrium and appears mainly on an empty
stomach, disappears after eating. Episodes of pain for 2-3 weeks occur 3-4 times a
year, the child was not examined or treated, the pain passed on its own. Mother - 36
years old, suffering from gastritis, father - 38 years old, duodenal ulcer. The maternal
grandfather has peptic ulcer disease. Objectively: height - 151 cm, weight 40 kg. The
child is lethargic, apathetic, significant pallor of the skin and mucous membranes. Heart
rate - 116 / min., AT 85/50 110 mm Hg. Art. Heart and lungs - without pathological
changes. The abdomen is not enlarged, on superficial palpation it is soft, moderately
painful, and on deep palpation it is painful in the epigastrium and in the pyloroduodenal
area. The liver is not enlarged, slight pain at the point of De Jardin and Mayo-
Robson. General blood test: er. - 3,5х1012 / l, НЬ - 118 g / l, KP - 0,77, reticulocytes -
5%, anisocytosis, poikilocytosis, Ht - 29%, lake -8,7х10 9 / l, n - 6% , с - 50%, є - 2%, л -
34%, м - 8%, Ш0Е - 12 mm / h, thrombus - 390х10 9 / l. Duke's bleeding time is 60
seconds. Coagulation time: beginning - 1 minute, end - 2.5 minutes. General analysis of
urine: no changes. Biochemical analysis of blood: total protein - 72 g / l, albumin - 55%,
globulins: a, - 6%, a2 - 10%, C - 13%, y - 16%, ACT - 34 U / l, ALT - 29 U / l, LF - 80 U /
l (norm 70-142), bilirubin: total - 16 μmol / l, direct - With μmol / l, thymol test 4 U,
amylase - 68 U / l (norm 10-120) , iron - 7 μmol / l. FEGDS in a stomach a mucous
membrane motley with flat protrusions in a body and antral department, focal hyperemia
and hypostasis in an antrum. Bulb of medium size, severe edema and redness. On the
anterior wall there is a linear scar of 0.5 cm. On the posterior wall there is a round ulcer
of 1.5x1.7 cm with a deep bottom and a pronounced inflammatory shaft. A biopsy of the
antral mucosa was taken. HP biopsy test: positive (+++).

2. Determine the protocol of the patient, the prescribed treatment, listing the
groups of drugs, representatives of each group, indicate the dose and frequency of
administration.
3. . Interpret the results of the laboratory test.
Answers:
1. Ulcer of the duodenum, activity of the first degree. Duodental ulcer bleeding,
posthemorrhagic anemia of moderate severity. Reactive pancreatitis, bending of
the middle third of the gallbladder.
2. With HP-associated gastric and duodenal ulcers:
1. Table №5n for 5-7 days, then table №5 according to Pevzner.

2. Etiotropic therapy (minimum duration of treatment 14 days). Weekly triple therapy
with bismuth drugs - De-Nol 120-240 mg 3 times a day; Macrolides - clarithromycin 7.5
mg / kg / day Semi-synthetic penicillins (amoxicillin 250-500 mg 2 times a
day); Imidazole derivatives (metronidazole 250-500 mg 2 times a day) In the absence of
success from the appointment of first-line therapy - the presence of pain, persistence of
H. pylori, the appointment of second-line therapy (quadrotherapy) is indicated. Proton
pump inhibitors - De Nol 120-240 mg 3 times a day; Macrolides - clarithromycin 7.5 mg /
kg / day Semi-synthetic penicillins; (amoxicillin 250-500 mg 2 times a day); Imidazole
derivatives (metronidazole 250-500 mg 2 times a day)
Antisecretory therapy is prescribed (selective blockers of H2 -receptors of histamine

of 2-4 generations (groups of ranitidine, famotidine) or blockers of H + / K + -ATPase
(groups of omeprazole, pantoprazole, etc.) - Ranitidine - 150-300 mg / day for 2 doses
in the morning and evening before meals, famotidine - 20-40 mg / day, mostly once in
the evening, regardless of food intake (at 18-20 hours), omeprazole, etc. - 10-40 mg /
day once in the morning before breakfast, pantoprazole 20- 40 mg / day once in the
morning before breakfast Prescribe: complex antacids (aluminum phosphate, aluminum
compounds, magnesium, calcium, etc.) 5-15 ml (1 / 2-1 table.) 2-3 times a day after 1,
5 - 2 hours after a meal, alginic acid preparations for 2-4 weeks, cytoprotectors
(smectite, sucralfate, licorice root preparations, synthetic prostaglandin analogues,
dalargin), smectite 0.5-1 sachet 2-3 times a day for 30 minutes before meals,
sucralfate 0.5-1 g 4 times a day for 0.5-1 hours before meals, liquviriton (or other drugs
from licorice root) 0.05-0.1 g 3 times a day before meals; misoprostol 0.1 g 3-4 times a
day with food and at night; dalargin - intravenously (or nasal electrophoresis) 0.001 g (1
ml) 1-2 times a day for 10-14 days; reparants (sea buckthorn oil, tikveol, spirulina,
aecol, propolis preparations, aloe); immunocorrectors (of plant origin). With impaired
motility (reflux, duodenostasis) - prokinetics (domperidone) for 2 weeks or motility
regulators - trimebutine maleate - 5 mg / kg per day for 2-3 doses 30 minutes before
meals 10-14 days
Bleeding peptic ulcer: prolonged treatment of PPIs (possibly with an H 2 -

receptor blocker ) for complete ulcer healing.
To eliminate the pain syndrome used: analgesics (metamizole sodium (50% - 0.1 ml /
year of life) and its combinations), antispasmodics - drotaverine (2% -0.5 - 2 ml),
papaverine (2% - 1-2 ml), platyphylline (0.2% - 1 ml).
Regulatory peptides have a depressant effect on the function of the pancreas:

somatostatin, dalargin, glucagon. - Sandostatin 25-50 mcg 2-3 times a day
subcutaneously for 5 -7 days. Dalargin (synthetic analogue of opioid peptides) 1 mg 2
times a day or in the form of nasal electrophoresis.
For the purpose of detoxification and elimination of metabolic disorders in the first
days in severe cases, IV glucose-novocaine mixture, saline solutions, ascorbic acid, B
vitamins are administered intravenously.
After elimination of a pain syndrome (in 4 - 6 days) pancreatic enzymes -

mesyme forte - 500 UNITS of 1 t. , Pancreatin - 120 mg n at meal on 1 t.
3 .: er. - norm, H - slightly reduced, KP - reduced, reticulocytes - norm, anisocytosis

(pathological condition when cells of the bigger or smaller size appear, happens at
anemias, deficiency of vitamin B12), poikilocytosis (change of the form of erythrocytes,
vitamin deficiency B12), Ht - decreased, lake - increased, n - slightly increased, c -
norm, e - norm, l - norm, m - norm, Sh0E - norm., Thrombus - increased. Duke's
bleeding time is the norm. Coagulation time: normal, total protein - normal, albumin -
normal, globulins: a, - slightly elevated, a2 - elevated, B - normal, y - normal, ACT -
normal, ALT - normal, LF - normal (normal 70-142 ), bilirubin: total - normal, direct -
normal, thymol test - normal, amylase - normal (no rma 10-120), iron - reduced.
Task 14
A 2.5-year-old child became acutely ill, had a body temperature of 39 ° C, and had
oropharyngeal hyperemia. In 2 days there was a painful urination with blood in the
end. Upon admission to the hospital, the boy is pale, restless, Pasternatsky's symptom
is positive. In the analysis of blood - erythrocyte - 4,0 x 10 12 / l; lake. - 14.2 x 10 9 / l; pal. -
8%; segment. - 72% ;. lymph.-12; mon. - 6; ESR - 45 mm / year. PSA- +++, sialic to-
that-380 units. Urine: specific weight - 1020; protein - 0.66 mmol / l, Lake. - 50-60 in
sight.

administration.
Answers:
1. Acute pyelonephritis, active stage. Acute cystitis.
2. Treatment requires the appointment of cephalosporins of II-III generations,
protected aminopenicillins (amoxiclav, augmentin).
Antimicrobial therapy - 5 days (first choice drugs - furamag, sulfametaxol /

trimetroprim (biseptol), furagin, furadonin)
semi-synthetic penicillins in combination with β -lactomase inhibitors - amoxicillin and

clavulanic acid: AUGMENTIN - 25-50 mg / kg / day, orally - 10-14 days; amoxiclav - 20-
40 μ / kg / day, orally - 10-14 days;
2nd generation cephalosporins: cefuroxime (zinacef, ketocep, cefurabol),

cefamandole (mandol, cefamabol) - 80-160 mg / kg / day, intravenously, intramuscularly
- 4 times a day - 7-10 days;
3rd generation cephalosporins: cefotaxime (claforan, clafobrin), ceftazidime (fortum,

vicef), ceftizoxim (epocelin) - 75-200 mg / kg / day, intravenously, intramuscularly - 3-4
times a day - 7-10 days; cefoperazone (cefobid, cefoperabol), ceftriaxone (rocephin,
ceftriabol) - 50-100 mg / kg / day, intravenously, intramuscularly - 2 times a day - 7-10
days;
aminoglycosides: gentamicin (gentamicin sulfate) - 3.0-7.5 mg / kg / day,

intravenously, intramuscularly - 3 times a day - 5-7 days; amikacin (amicin, lycacin) -
15-30 mg / kg / day, intravenously, intramuscularly - 2 times a day - 5-7 days.
semisynthetic penicillins in combination with β-lactomase inhibitors: amoxicillin and

clavulanic acid (AUGMENTIN, amoxiclav);
cephalosporins of the 2nd generation: cefaclor (ceclor, vertsef) - 20-40 mg / kg / day;
3rd generation cephalosporins: ceftibuten (Cedex) - 9 mg / kg / day, once;
nitrofuran derivatives: nitrofurantoin (furadonin) - 5-7 mg / kg / day;
quinolone derivatives (non-fluorinated): nalidixic acid (Negro, Nevigramon) - 60 mg / kg /

day; pipemidic acid (Palin, pimidel) - 0.4-0.8 g / day; nitroxoline (5-NOC, 5-nitrox) - 10
mg / kg / day;
sulfamethoxazole and trimethoprim (cotrimoxazole, biseptol) - 4-6 mg / kg / day for

trimethoprim.
Treatment of dehydration is carried out by water loading, detoxification - the use of

detoxification drugs (reosorbilakt, xylate, lipin). At refusal of oral administration of liquid,
signs of dehydration, a significant intoxication syndrome infusion of 5% of solution of
glucose or physiological solution of sodium chloride is carried out.
At hyperthermia antipyretics - paracetamol, ibuprofen are applied .
If necessary - pro-, pre- and symbiotics (yogurt, biosporin, bifi-forms, fructose, lactose,
extralact, bifilact extra, symbiter 1, 2).
Phytotherapy is recommended with phytonutrients (eg canephron H 20 drops 3 times a

day) .
3. erythrocyte- norm ; lake. - increased ; pal. - increased ; segment. - increased ;. lym

ph.- reduced ; mon. - norm ; ESR is significantly increased . PSA rotein - +++ degree of
activity 3 , sialic to-and- increased . Urine: specific weight - increased ; protein- should
not be normal , Lake. - a significant number .
Task 15
The boy, 8 years old, 2 weeks after the sore throat developed volatile joint pain,
swelling and restriction of movement, fever. Objectively: tachycardia, dilation of cardiac
dullness, weakening of heart sounds, gallop rhythm, gentle systolic murmur at the apex
of the heart, enlarged liver. In the blood: leukocytes — 14.2 * 10 9 / l, ESR - 55 mm / h,
ASL-0 - 500 IU, CRP (+++).

Answers:
1. Diagnosis: rheumatism, activity of III degree. Primary rheumatoid arthritis,
polyarthritis, acute course. NK 2 A
2. TREATMENT 1st stage - hospital. - Etiotropic therapy - benzylpenicillin in a daily
dose of 600,000-1,000,000 IU for 10 - 14 days, followed by the transition to the use of
durable forms of drugs - bicillin-5 or benzathine benzylpenicillin. Bicillin -5 is
administered at a dose of 400,000 - 600,000 IU once every 2 weeks, and benzathine
benzylpenicillin 600,000 - 800,000 IU intramuscularly every 2 weeks. In cases of allergic
reactions to penicillin drugs, the appointment of macrolides is indicated. - Pathogenetic
treatment - nonsteroidal anti-inflammatory drugs (acetylsalicylic acid, indomethacin,
diclofenac sodium, nimesulide, etc.). Acetylsalicylic acid (aspirin) is prescribed in
medium doses (for children under 12 years 0.2 g / kg / day, not more than 1-2 g in 3-4
doses). In severe carditis - prednisolone 1-2 mg / kg / day in 3 reception 2-4 weeks with
gradual him from mine and subsequent transition to aspirin. The combined use of
glucocorticoids and nonsteroidal anti-inflammatory drugs is used. Sufficient for children
dose of prednisolone - 0.7-0.8 mg / kg per dose in the morning after meals to achieve
clinical effect (average 2-4 weeks ), chloroquinoline series drugs: delagil (5 mg / kg after
dinner), plakvenil (7-8 mg / kg after dinner). In congestive heart failure vykorystovu- tion
drugs such groups: • angiotensin-converting Fe was ment (captopril 0.2-0.3 mg / kg
every 8-12 hours of admission); • diuretics: furosemide (1 mg / kg in the morning),
spironolactone (verospirone 3 mg / kg 2-3 times a day); • cardiometabolic therapy:
panangin (magnesium asparagine, potassium asparagine),
mildronate (trimethylhydrazinium propionate), cardonate, ATP-long (adenosine
triphosphate), etc.
3. leukocytes - increased , ESR - significantly increased , ASL-0 (antistreptolysin

O) - significantly increased , CRP (+++) 3 degree of activity .
Task 16
Vitya V., at the end of April fell ill with sore throat. He was treated with acetylsalicylic
acid. On May 10, hemorrhagic rash appeared on the hands and feet in the form of
ecchymoses and petechiae, and on May 11 there was nosebleeds, which were stopped
after applying cold to the nose. He was sent to the hospital. Upon admission to the
clinic, the condition is moderate. Lethargic, pale, abundant rash all over the body in the
form of petechiae and ecchymoses. Positive symptoms of a pinch, a plait. Internal
organs without abnormalities. Blood test: er. - 4.6 x 10 * 12 / l, Hb.-110 g / l, Ts.p-0.9, L-
5x10 9 / l, e-1%, P.-1%, S.-73 %, L.-20%, M-5%, ESR - 10 mm / g, platelets - 46x10 9 / l
Retraction of a blood clot - 65%. The duration of bleeding according to Duke - 20
minutes. Lee-White meeting - 7 minutes. After a month of therapy, the child's condition
is satisfactory, platelets-180x10 9 / liter.

Answers:
1. Diagnosis: Heteroimmune thrombocytopenic purpura, acute.
1. Diet №5 with the exception of spices, vinegar, canned, allergenic
foods. Food should be mechanically sparing, but with enough mineral salts and
vitamins (fresh fruits, vegetables, berries). 2. Protective mode with the exception
of physical activity, procedures that cause mechanical irritation of the skin or
mucous membranes (compression clothing, brushing teeth, etc.). 3.
Etiopathogenetic therapy of ITP includes the following stages: In mild forms of ITP
use: drugs that increase platelet function, stabilize cell membranes and improve
metabolic processes. Intermittent courses of drugs that stimulate the adhesive-
aggregation function of platelets have a positive effect:
2. - lithium carbonate in a single dose of 0.025-0.3 mg 3 times a day orally

after meals (up to 7 days); - Adroxone 0.025% -1-2 ml x 2-4 times a day in \ m
(course - 1 week); - riboxin 0.05-0.2 mg x 2-3 times a day (2-3 weeks); - vitamin
B5 (calcium pantothenate) 0.025-0.2 mg x 3 times a day (course - 2
weeks); - dicynon (ethamsylate) 0.05-0.25-0.5 mg x 3 times a day or 12.5%
solution of 2-4 ml orally (5-14 days); - ε-aminocaproic acid 0.2 g / kg / day (course
of treatment up to 2 weeks). In moderate and severe disease, corticosteroids are
prescribed (in a starting dose of 1-2 mg / kg / day) for 3-4
weeks. Immunoglobulins are administered in doses of 0.4 - 1 g / kg per day,
depending on the severity of the course. Pulse therapy with glucocorticosteroids
and cytostatics. Pulse therapy with methylprednisolone (metipred, urbazan) is
carried out at a dose of 20 mg / kg / day intravenously for 3 consecutive
days. Preparations of monoclonal antibodies - anti-CD40, anti-CD20
(Rituximab). Rituximab at a dose of 375 mg / m 2 per week for 4 weeks , danazol,
which is an androgen that has an immunomodulatory effect and stimulates
megakaryocyte sprout (dose 10-20 mg / kg per day). The therapeutic effect of
autologous and allogeneic bone marrow or peripheral stem cell transplantation
has also been revealed. If no e fektyvnosti above treatment for 6 months nastu-
pnym step is splenectomy.
3. er. - 4.6 x 10 * 12 / l, Hb.-110 g / l, Ts.p-0.9, L-5x10 9 / l, e-1%, P.-1%, S.-73 %, L.-

20%, M-5%, ESR - 10 mm / g  norm, thrombocytes - thrombocytopenia. Retraction of
a blood clot is the norm. The duration of Duke's bleeding is a 20-minute prolonged
bleeding time . Lee-White meeting is the norm. After a month of therapy, the child's
condition is satisfactory, platelets are normal.
Task 17
Child M., a boy of 2 days, was born from the 5th pregnancy of 2 births. The mother's
first pregnancy ended in a normal birth, the baby was healthy: the 2nd and 3rd
pregnancies ended in medical abortions, the 4th pregnancy - a miscarriage in the 20th
week, the 5th pregnancy was accompanied by toxicosis in the first and anemia in the
second half of pregnancy. Delivery on time, without pathology, the child was born
weighing 3200 g, length 51 cm, with a score on the Apgar scale of 8-9 points. 14 hours
after delivery, jaundiced skin and sclera appeared. Bilirubin in umbilical cord blood 68.4
μmol / l, 14 hours after birth bilirubin in peripheral blood was 290.57 μmol / l (indirect),
the amount of hemoglobin 150 g / l, erythrocytes 4.65 x 10 * 9 / l. Maternal blood 0 (I)
group, Rh - negative, anti-Rhesus antibody titer 1:64. Blood of child 0 (I) group, Rh -
positive. By the end of the first day, the child's condition had deteriorated. The newborn
became lethargic, sucks poorly, vomits; skin with a pronounced yellowish
color. Physiological reflexes are reduced. Heart sounds are muffled, systolic murmur at
the apex. In the lungs - puerile respiration. The liver protrudes 2 cm from the edge of the
costal arch. Urine is intensely colored. Cal - meconium.

administration.
Answers:
1. G emolytic disease of the newborn by rhesus factor, jaundice, severe.

This disease was promoted by Rhesus-negative blood of the mother, previous
pregnancies, the unfavorable course of this pregnancy.
2. Additional research:
- Determination of the child's blood group and its rhesus affiliation (if it has not been
determined before)
- Determination of the level of total bilirubin in the serum
- Determination of hourly increase in bilirubin level
- Determination of the direct Coombs test
- General blood test with count of erythrocytes, hemoglobin, hematocrit, part of
reticulocytes
- General analysis of urine, examination for intrauterine infections, neurosonography,
ultrasound of the liver
In children with clinical manifestations of hemolytic disease of newborns, the main
goals of therapy are the following: prevention of central nervous system damage due
to toxic effects of bilirubin, prevention of severe hemolytic anemia.
Conservative treatment is used to reduce the formation of bilirubin, accelerate
metabolism and excretion of indirect bilirubin, reduce the toxicity of indirect
bilirubin. Conservative measures include phototherapy, infusion therapy, the use of
certain drugs.
The most common manifestation of hemolytic disease of newborns is the jaundiced
form, in which the starting method of treatment is phototherapy . The duration of
phototherapy is determined by its effectiveness - the rate of decrease in the level of
indirect bilirubin in the blood. It usually lasts 72-96 hours. Courses of 6 hours a day
with two-hour breaks, or 2 hours with 1-2-hour breaks are recommended.
Infusion therapy - stimulation of diuresis accelerates the excretion of water-soluble
isomers of bilirubin. The main infusion solution is a 5% glucose solution. The use
of hyperosmolar solutions (including 10% glucose) is unacceptable in the treatment
of children with hyperbilirubinemia. On the first day of life, as a rule, appoint a
volume of fluid at the rate of 50-60 ml / kg in full-term infants, 40-50 ml / kg in
premature infants weighing more than 1.5 kg and 30-40 ml / kg in premature infants
with a body weight of less than 1.5 kg. Then increase the volume daily by 20 ml /
kg. From the 4th day of life when calculating the volume of infusion therapy take into
account the volume of enteral nutrition and
dynamics of body weight for the previous day. From the 2nd day for every 100 ml of
5% glucose solution add 3 ml of 10% solution of calcium gluconate, 2 mmol of
sodium and chlorine (13 ml of isotonic sodium chloride solution), and 1 mmol of
potassium (1 ml of 7.5% potassium solution) chloride). The infusion rate is 3-4 drops
per minute. By the 5th day of a child's life, the volume of fluid is 150 ml / kg / day. At
the same time prescribe diuretics.
The inclusion of albumin solution is justified only in laboratory confirmation of
hypoproteinemia.
Phenobarbital is an agent that improves bilirubin conjugation. Phenobarbital is
a drug that can activate monoamine oxidase and
glucuronidase system of the liver. When prescribing phenobarbital to the newborn, it
should be borne in mind that from the gastrointestinal tract of the child this drug is
absorbed slowly and unstable, providing a therapeutic effect on the 4-5th day of
therapy (therapeutic level 15 mg / l and above). The appointment of phenobarbital
can be accelerated and enhanced parenterally or internally in the load-maintenance
mode. To do this, on the first day of therapy phenobarbital is prescribed at a dose of
20 mg / kg / day (divided into 3 doses) and then 3.5-4 mg / kg / day in the following
days.
A combination of phenobarbital and phototherapy for hyperbilirubinemia is
recommended. Prescribe phenobarbital to a child 5-8 mg every 8 hours, and
phototherapy for 6 hours every 2 hours from the 1st to the 8th day of life. With this
treatment, the effect is much better than with a single appointment.
If phototherapy is ineffective, taking into account the dynamics of the hourly increase
in bilirubin levels, it is necessary to consider the replacement transfusion.
OZPK (replacement blood transfusion) is indicated because the hourly increase
in bilirubin was greater than 6 mmol / l (290.57-68.4) / 14 = 15.87 mmol / l). It is
necessary to transfuse blood 0 (I) rhesus-negative in the volume of 160-170 ml /
kg. In full-term infants, the volume of circulating blood (BCC) is 80 ml / kg, in
premature infants - 90-95 ml / kg In whole blood transfusion, the volume of blood for
transfusion is calculated at the rate of 160 ml / kg for full-term infants and 180-190
ml / kg for premature infants).
3. Hyperbilirubinemia ( normal bilirubin level in umbilical cord blood - up to 50 μmol / l,

and indirect bilirubin is normal 6.5-15.4 μmol / l). An increase in bilirubin leads to the
development of symptoms of bilirubin intoxication: lethargy, drowsiness, suppression of
physiological reflexes, decreased muscle tone. Hemoglobin - reduced (normal for the
early neonatal period 180-220 g / l), erythrocytes - reduced (normal 5.4-7.2 10 12 / l)
(anemic syndrome). Calmeconium, the norm. Urine - intense color due to the presence
of bilirubin in it.
Task 18
The child is 21 days old, is in the hospital. From the anamnesis it is known that the
pregnancy in the mother proceeded with toxicosis in the first trimester, at 24 weeks of
gestation there was an increase in body temperature without catarrhal
manifestations. Not treated. 1 time passed inspection on VUI. The increased content of
Ig G to toxoplasmosis was found to be 290 IU / ml. Childbirth at 37 weeks. Birth weight
2450 g, body length 48 cm. Jaundice appeared at the end of the first day of life. On the
third day of life he was transferred to the neonatal pathology department due to the
deterioration of his general condition - the child became agitated, vomited, and sucked
poorly. Objectively: the skin is pale pink, dry. The subcutaneous fat layer is thin. The
head is hydrocephalic in shape, the sagittal suture is open to 0.8 cm, the large temple is
filled, pulsating, 3x3 cm, small 1x1 cm. Grefe's symptom is expressed, the tone of
extensors prevails. Spleen + 1 cm, liver +3 cm.

administration.
Answers:
Answers:
1. In congenital toxoplasmosis .
2. Additional research: analysis of blood of mother and child on TORCH
infection; biochemical blood analysis (ALS, AST, LF, CPK), neurosonography,
consultations with a neurologist, ophthalmologist.
Determination of specific antibodies and / or DNA of Toxoplasma by PCR in

cerebrospinal fluid. IgG antibodies are passively transmitted from mother to child, so
testing of maternal and infant sera collected at the same time should be performed to
interpret the antibody titer in the child. Examination of the serum of the newborn alone is
not reliable for the diagnosis of congenital infection. Maternal antibodies that are passed
on to the baby usually decrease in concentration and disappear at the age of 3-6
months. Antibodies that are directly produced by the newborn remain for a long period
of time. Therefore, antibody titers in children during the first month of life, which are
smaller or the same as in the mother, usually reflect the passive transmission of
maternal antibodies. Titers in children 4 times or more higher than maternal may
indicate an active infection. If specific antibodies of the class to Toxoplasma persist in a
child up to 10-12 months, it indicates a congenital infection. Determination of IgM
antibodies in children is important in the diagnosis of congenital toxoplasmosis. But it
should be remembered that the production of antibodies of the class may be absent in
congenital toxoplasmosis in 30-50% of cases, so an IgM-negative child can not
completely rule out a congenital infection. For postnatal diagnosis of congenital
toxoplasmosis, the determination of specific IgA and IgE antibodies can also be used, in
addition to testing for IgG and IgM antibodies.
Intradermal allergic test with toxoplasmin becomes positive 4-6 weeks after the onset of
the disease - at the injection site of 0.1 ml of toxoplasmin appear redness and infiltration
of the skin with a diameter of at least 10 mm; the reaction is taken into account after 48
and 72 hours A positive test indicates only infection, but a negative allergic test can
reliably rule out chronic toxoplasmosis.
Treatment includes: etiotropic therapy, immunomodulatory therapy, post-syndrome
therapy.
In acute toxoplasmosis, when parasites exist in the proliferative
phase, the main treatment is chemotherapeutic drugs . Most often
use a combination of chloridine (daraprim, pyrimethamine, tindurine) (
initial loading dose of 2 mg / kg orally 1 time / day for 2 days, then 1 mg / kg orally 1
time / day, maximum dose - 25 mg), delagil (0.5 g 2 times) or aminoquinol (0.15 g 3
times) with sulfonamides (biseptol, sulfalene, sulfadimesine in the usual therapeutic
dose of 100 mg / kg / day for up to a year) for 7-10 days. As a rule, appoint 3 courses
with an interval of 7-10 days. To prevent side effects, it is recommended to prescribe
them after a meal, washed down with a solution of sodium bicarbonate (4-5 ml per 1 kg
of body weight), additionally use vitamin C (50-100 mg 2-3 times a day). Calcium
folinate (leucovorin) 5-10 mg 3 times a week, if necessary - increase the dose in case of
pyrimethamine toxicity. To reduce intoxication, prevent allergies in severe cases,
glucocorticoids are indicated (prednisolone 1 mg / kg / day in children with changes in
cerebrospinal fluid and active chorioretinitis until normalization).
Task 19
D., a 15-year-old girl, was hospitalized with complaints of lumbar pain, nausea,
vomiting, frequent urination, and fever up to 39 ° C. Ill acutely after
hypothermia. Objectively: the abdomen is soft, painful on palpation in the lumbar
region. In the analysis of blood - erythrocyte - 3,0 x 10 * 12 / l; Hb 115 g / l lake. - 15.2
x 10 9 / l; pal. - 10%; segment. - 72% ;. lymph.-10; mon. - 6; ESR - 45 mm / year. PSA- ++
+, sialic to-that-380 units. Urine: specific weight - 1020; protein - 0.66 mmol / l, Lake. -
50-60 in p / zor.

2. Determine the tactics of treatment and list the groups of drugs, name the
representatives of drugs from each group, indicate the dose and frequency of use.
Answers:
1. D Island pyelonephritis.
2. Additional researches : biochemical research of blood: creatinine, urea,
electrolytes; urine analysis by Nechiporenko, Zimnytsky test, ultrasound of the kidneys
and urinary system, excretory urography, daily blood pressure monitoring.
Treatment is carried out in a hospital (in the nephrology department) and includes
mode, diet, appointment of etiotropic, pathogenetic, symptomatic drugs, normalization
of urodynamics, increase the body's defenses.
Therapeutic nutrition: table 5, in case of renal dysfunction - table 7a, 7.
Ø Salt restriction - in the presence of renal dysfunction and / or hypertension.
Ø Restriction of meat - at disturbance of function of kidneys.
Recommended water load at the rate of 25-50 ml / kg / day (adequacy of the drinking
regime is estimated by the amount of diuresis - 1.5-2 liters) under the control of timely
emptying of the bladder (at least 1 time in 2-3 hours).
Ø Fluid intake is limited in renal dysfunction, hypertension, obstructive uropathy.
Drinking regime includes tea, alkaline mineral water, pure water, compotes (from dried
fruits), dairy products, phytotherapy. An alkaline reaction of urine shows an increase in
acidic valencies - fruit drinks, cranberry drinks, cranberries, etc.
1) gradual antibacterial therapy (for example, cephalosporin 2-3 generations)
(ceftriaxone / sulbactam (sulbactomax) 100 mg / kg / day in 2 injections in / in 3 days,
then cefix 8 mg / kg / day in the mouth for 7 days);
2) rehydration through the mouth and detoxification intravenously (reosorbilact 5 ml /
kg / day in two injections);
3) antipyretic and anti-inflammatory (if necessary): paracetamol orally 5-10 mg with an
interval of 4-6 hours 3-4 days and nimesulide 1 tablet (100 mg) 2 times a day (daily
dose - 200 mg) for up to 10 days children over 12 years).
4) detoxification if necessary (for example, lipin before 10-20 mg / kg 2-4 days).
"+" - recurrence prevention: preventive treatment with furamag 25 mg at night for 3-6
months.
3. Anemic syndrome - Erythrocytes - 3,0 x 10 * 12 / l, reduced (norm 3,6- 5,1 x 10 * 12
/ l), hemoglobin - 115 g / l, reduced (norm 130-150 g / l), leukocytes - 15.2 x109 / l,
elevated (norm 4.3 - 9.5 x109 / l); rod-shaped - 10% (norm 0.5-6%), elevated, indicating
an inflammatory process; segmental - 72% (norm 40-65%), elevated, indicating an
acute disease of the urinary system, acute infectious disease; lymphocytes -10 (norm
22-50%) lymphocytopenia, indicating depletion of the immune system; monocytes - 6
(norm 2-10%); ESR - 45 mm / year. (norm 4-15 mm / h), increased, indicating an
inflammatory process in the body, CRP - +++ (increased, inflammatory process), sialic
to-and-380 units (norm 130-210 Units), elevated, inflammatory process. Urine: specific
weight - 1020 (norm); protein - 0.66 mmol / l, proteinuria, indicating kidney disease,
leukocytes - 50-60 in p / zor., leukocytosis, indicating an inflammatory process in the
kidneys and / or urinary tract.
Task 20
The mother of a 4-year-old girl complains of a rise in body temperature to 39 0C. The
child has abdominal pain, headache, weakness. Ill acutely after
hypothermia. Objectively: general condition of moderate severity, high fever,
restless. The skin is pale, clean, dry. BH - 37 per minute, heart rate - 134 per
minute. No pathological changes were found in the heart and lungs. The abdomen is
soft, painless on palpation. The liver and spleen are not enlarged. A positive symptom
of Pasternatsky on both sides. Blood test: Er-4.3 x 10 12 / l, HB-115 g / l, Lake-17.4 x
10 * 9 / l, e-2%, n-10%, c-58%, l- 26%, m4%, ESR-28 mm / year. Urine analysis: yellow,
cloudy, density - 1012, protein 0.066 g / l, Er-2-4 in p / s, Lake-70-80 in p / s, a lot of
mucus, bacteria.

Answers:
1. Acute pyelonephritis.
2. Additional researches : biochemical research of blood: creatinine, urea,
electrolytes; urine analysis by Nechiporenko, Zimnytsky test, ultrasound of the kidneys
and urinary system, excretory urography, daily blood pressure monitoring.
Treatment is carried out in a hospital (in the nephrology department) and includes
mode, diet, appointment of etiotropic, pathogenetic, symptomatic drugs, normalization
of urodynamics, increase the body's defenses.
Therapeutic nutrition: table 5, in case of renal dysfunction - table 7a, 7.
Ø Salt restriction - in the presence of renal dysfunction and / or hypertension.
Ø Restriction of meat - at disturbance of function of kidneys.
Recommended water load at the rate of 25-50 ml / kg / day (adequacy of the drinking
regime is estimated by the amount of diuresis - 1.5-2 liters) under the control of timely
emptying of the bladder (at least 1 time in 2-3 hours).
Ø Fluid intake is limited in renal dysfunction, hypertension, obstructive uropathy.
Drinking regime includes tea, alkaline mineral water, pure water, compotes (from dried
fruits), dairy products, phytotherapy. An alkaline reaction of urine shows an increase in
acidic valencies - fruit drinks, cranberry drinks, cranberries, etc.
1) gradual antibacterial therapy (for example, cephalosporin 2-3 generations)
(ceftriaxone / sulbactam (sulbactomax) 100 mg / kg / day in 2 injections in / in 3 days,
then cefix 8 mg / kg / day in the mouth for 7 days);
2) rehydration through the mouth and detoxification intravenously (reosorbilact 5 ml /
kg / day in two injections);
3) antipyretics and anti-inflammatory (if necessary): paracetamol orally 5-10 mg with an
interval of 4-6 hours 3-4 days and nimesulide 1 tablet (100 mg) 2 times a day (daily
dose - 200 mg). up to 10 days (children over 12 years).
4) detoxification if necessary (for example, lipin before 10-20 mg / kg 2-4 days).
"+" - recurrence prevention: preventive treatment with furamag 25 mg at night for 3-6
months.
3. Blood test : Erythrocytes-4.3 x 10 12 / l (normal), hemoglobin-115 g / l (slightly
reduced, normal 120-140 g / l), Leukocytes-17.4 x 10 * 9 / l ( leukocytosis, normal 5-12
x 10 * 9 / l, inflammatory process), eosinophils -2% (normal 1-4%), rod -10% (normal
0.5-6%), elevated, indicating an inflammatory process ; segmental-58% (norm 40-65%),
lymphocytes - 26% (norm 22-50%), monocytes - 4% (norm 2-10%); , ESR-28 mm /
year. (normal 4-15 mm / h), increased, indicating an inflammatory process in the body
Urine analysis: yellow, cloudy (normally transparent, kidney disease), density - 1012
(normal), protein 0.066 g / l (proteinuria, which indicates kidney disease), erythrocytes -
2-4 in p / s (norm 0-2 in p / s), hematuria, indicating kidney disease, inflammatory
process in the kidneys; Leukocytes -70-80 in p / s, leukocytosis, indicating an
inflammatory process in the kidneys and / or urinary tract; a lot of mucus, bacteria - an
inflammatory process in the urinary system, infectious diseases.
Task 21
Nikita L., 14 years old, went to a pediatrician with complaints of heartburn near the
center of the sternum, dryness and occasionally sour taste in the mouth. About 6
months ago, abdominal pain and heartburn appeared. At first, these symptoms occurred
periodically, mostly after overeating, but in the last month, heartburn began to feel like a
pronounced fever behind the chest, obsessive, caused considerable discomfort. The
boy began to get tired quickly, his performance deteriorated, there were attacks of
hypochondria. Eating with long breaks, abusing dry food. This year, sharply increased
by 5 cm, there was discomfort in the thoracic region and heartburn. The teenager was
examined and hospitalized in a specialized gastroenterological hospital. Upon
admission, the condition is moderate, height 180 cm, weight 65 kg. The skin is pale,
dry. In the axilla, inguinal region - local hyperhidrosis. Red diffuse dermographism. The
oral cavity is clean. The tongue is moist, densely covered with white and yellow plaque,
bad breath. The liver is not enlarged. Chair once a day, decorated. Urinates freely,
painlessly. Examination results: General blood test: Hb - 128 g / l, KP - 0.91, Er -
4.2x1012 / l; Lake -7.2x10 9 / l; p / ya - 3%, s / ya - 51%, e - 3%, l - 36%, m - 7%, ESR -
6 mm / year. Biochemical analysis of blood: total protein - 72 g / l, ALT - 19 U / l, ACT -
24 U / l, LF - 138 U / l, amylase - 100 U / l, thymol test - 4 U, bilirubin - 15 μmol /
l. Intracavitary pH-metry with 3 electrode probe - on an empty stomach - pH in n / 3 of
the esophagus 6.3; periodically short-term for 15-20 seconds decrease to 3.3-3.0; in the
body of the stomach 1.7, in the antrum 3.8; after stimulation with 0.1% solution of
histamine at a dose of 0.008 mg / kg - pH in the esophagus 6 6.5 with a decrease in pH
more often for 30-40 seconds to 2.8-3.3; in the body 1.3; in the antrum 3.6. EFGDS -
the mucous membrane of the esophagus in the lower third is hyperemic, swollen,
hyperemia of the type of "tongues of flame", on the posterior wall of a large erosion up
to 0.3 cm, cardio closes insufficiently, is below the esophageal orifice of the diaphragm.

administration.
3. Interpret the results of laboratory blood tests.
Answers:
1. Gastro-esophago-reflux disease (reflux esophagitis IIB-degree), moderate form.
2.Dodatkoko: an aliz feces at hovanu blood (reaction Gregersen) , X-ray study of the
esophagus and stomach . daily pH monitoring of the esophagus .
Treatment of GERD includes:
 recommendations to the patient to change a lifestyle,

 correction of the patient's diet,
 treatment with prokinetics that normalize esophageal and gastric motility .
 appointment of antisecretory drugs and antacids
the use of cytoprotectors to increase the protective properties of the mucous
membrane of the esophagus and stomach.
General recommendations from the mode:
 avoid horizontal position during sleep (raising the head end of the bed by 15 cm);
 limiting medication that lowers the tone of the NSO, calcium channel inhibitors,
beta-blockers, theophylline, prostahland and us, tranquilizers and others.
 weight loss;
 refusal to wear corsets, tight magnifying belts
 intra-abdominal pressure;
 exclusion of lifting more than 5 kg;
 restriction of works connected with an inclination of a trunk, with an overstrain
of abdominal muscles.
Dietary recommendations :
 4-5 regular meals in small portions are recommended;

 exclusion of overeating;
 eating at least 3 hours before bedtime, after eating it is desirable not to lie down
for at least 1.5 hours;
 refusal to "eat" at night, horizontal position immediately after eating;
 avoiding hasty eating;
 restriction of products that reduce the tone of the esophageal sphincter (coffee,
strong tea, chocolate, mint, milk, fatty meat and fish);
 avoidance of products that irritate the CO of the esophagus (citrus, onions, garlic,
tomatoes, fried foods);
 restriction of products that increase intragastric pressure, stimulate the acid-
forming function of the stomach (carbonated beverages, beans, beer);
 preferably increased protein intake, which, unlike fat, increases sphincter tone
Pathogenetic drug therapy is carried out taking into account the stage of
development of GERD:
Antisecretory drugs: omeprazole 20-40 mg per day, 30 minutes before meals, for 3-4
weeks.
Gaviscon 5-10 ml after meals and at bedtime for up to 3 weeks.
Prokinetic: Domryd to her Zhi . 10 mg up to 3 times a day for 2-3 weeks.
The next component of a comprehensive treatment program is the use of physiotherapy

techniques aimed at normalizing motor disorders by stimulating the smooth muscles of
the esophagus (SMT-phoresis with prokinetics) and autonomic imbalance by improving
cerebral and spinal hemodynamics (DMV per cell area, electrosleep). In the remission
stage, non-drug methods of treatment are used : phytotherapy, reflexology,
homeopathy, balneotherapy. In case of ineffectiveness of conservative
therapy, indications for surgical treatment are: -complicated course of GERD (3-4
degree of esophagitis),- hernia of the esophageal orifice of the diaphragm, -expressed
esophageal manifestations, Nissen fundoplication is used, sometimes according to Tal,
Toupe.
Duration of inpatient treatment : At 1-2 degrees of severity 10-14 days, at 3-4

degrees of severity - 3 weeks. With a favorable variant of GERD (1-2 degrees), the
main treatment should be carried out in an outpatient setting.
Dispensary supervision . The minimum term of supervision is 3 years.
3. All indicators are normal.
Task 22
Patient S., 16 years old, was admitted to the clinic with complaints of chest pain,
which appears during meals, especially after eating hot and cold food, pain in the
epigastric region on an empty stomach. Also worried about frequent heartburn, belching
air or food eaten, nausea. Vomiting is rare, mainly in severe epigastric pain. After
vomiting, the pain in the epigastrium disappears. There is a tendency to
constipation. On admission, the condition is moderate, the patient is malnourished, the
tongue is slightly covered with white plaque, the abdomen is painful on palpation in the
epigastrium. Blood tests Hb - 128 g / l, KP - 0.91, Er - 4.2x1012 / l; Lake -7.2x10 9 / l; p /
ya - 3%, s / ya - 51%, e - 3%, l - 36%, m - 7%, ESR - 6 mm / year. Biochemical analysis
of blood: total protein - 72 g / l, ALT - 19 U / l, ACT - 24 U / l, LF - 138 U / l, amylase -
100 U / l, thymol test - 4 U, bilirubin - 15 μmol / l. EFGDS - mucous membrane of the
esophagus in the lower third hyperemic, edematous, hyperemia of the lower third of the
esophagus.

administration.
Answers:
1. Gastro-esophago-reflux disease (reflux esophagitis IA - degree), moderate form.
2.Dodatkoko: analysis of feces at hovanu blood (reaction Gregersen) , X-ray study of

the esophagus and stomach . daily pH monitoring of the esophagus .
Treatment of GERD includes:
 recommendations to the patient to change a lifestyle,

 correction of the patient's diet,
 treatment with prokinetics that normalize esophageal and gastric motility .
 appointment of antisecretory drugs and antacids
the use of cytoprotectors to increase the protective properties of the mucous
membrane of the esophagus and stomach.
General recommendations from the mode:
 avoid horizontal position during sleep (raising the head end of the bed by 15 cm);
 limiting medication that lowers the tone of the NSO, calcium channel inhibitors,
beta-blockers, theophylline, prostahland and us, tranquilizers and others.
 weight loss;
 refusal to wear corsets, tight magnifying belts
 intra-abdominal pressure;
 exclusion of lifting more than 5 kg;
 restriction of works connected with an inclination of a trunk, with an overstrain
of abdominal muscles.
Dietary recommendations :
 4-5 regular meals in small portions are recommended;
 exclusion of overeating;
 eating at least 3 hours before bedtime, after eating it is desirable not to lie down
for at least 1.5 hours;
 refusal to "eat" at night, horizontal position immediately after eating;
 avoiding hasty eating;
 restriction of products that reduce the tone of the esophageal sphincter (coffee,
strong tea, chocolate, mint, milk, fatty meat and fish);
 avoidance of products that irritate the CO of the esophagus (citrus, onions, garlic,
tomatoes, fried foods);
 restriction of products that increase intragastric pressure, stimulate the acid-
forming function of the stomach (carbonated beverages, beans, beer);
 preferably increased protein intake, which, unlike fat, increases sphincter tone
Pathogenetic drug therapy is carried out taking into account the stage of
development of GERD:
- antacids mainly in the form of gel or suspension: aluminum phosphate (phospholugel),

maalox, almagel - 1 packet 3-4 times a day 1 hour after meals and at night for 2-3
weeks.
- Gaviscon 5-10 ml after meals and at bedtime for up to 3 weeks.
- prokinetic: Domryd to her Zhi . 10 mg up to 3 times a day for 2-3 weeks.
The next component of a comprehensive treatment program is the use of physiotherapy

techniques aimed at normalizing motor disorders by stimulating the smooth muscles of
the esophagus (SMT-phoresis with prokinetics) and autonomic imbalance by improving
cerebral and spinal hemodynamics (DMV per cell area, electrosleep). In the remission
stage, non-drug methods of treatment are used : phytotherapy, reflexology,
homeopathy, balneotherapy. In case of ineffectiveness of conservative
therapy, indications for surgical treatment are: -complicated course of GERD (3-4
degree of esophagitis),- hernia of the esophageal orifice of the diaphragm, -expressed
esophageal manifestations, Nissen fundoplication is used, sometimes according to Tal,
Toupe.
Duration of inpatient treatment : At 1-2 degrees of severity 10-14 days, at 3-4

degrees of severity - 3 weeks. With a favorable variant of GERD (1-2 degrees), the
main treatment should be carried out in an outpatient setting.
Dispensary supervision . The minimum term of supervision is 3 years.

3. All indicators are normal.
Task 23
Matthew is 11 years old, complains of pain in the umbilical region and epigastrium,
appearing 1.5-2 hours after eating, sometimes in the morning on an empty
stomach. Belching air, nausea. Complaints of abdominal pain have been troubling for 7
years, but examination and treatment have never been performed. The skin is pale pink,
periorbital cyanosis. The abdomen is not swollen, Mendel's symptom (+) in the
epigastrium, on superficial and deep palpation pain in the epigastrium and
pyloroduodenal region. Liver + 1 cm, the edge is soft-elastic, painless. The chair is
regular once a day or every other day. At examination: General blood test: Hb - 132 g /
l; Er - 4.4x10 12 / l; C.p. - 0.9; Lake -7.3x10 9 / l; p / ya - 3%, s / ya - 47%, l - 38%, e - 4%,
m - 8%; ESR - 5 mm / year. Biochemical analysis of blood: total protein - 75 g / l, ALT -
38 U / l, ALT - 32 U / l, total bilirubin - 18 μmol / l, of which the so-called. - 0; LF -140 U /
l (norm 70-142), amylase - 38 U / l (norm 10-120), thymol test - 3
units. Esophagogastroduodenofibroscopy: esophageal mucosa pink. Cardia closes. The
mucosa of the antrum of the stomach is hyperemic, swollen, contains mucus, the bulb
of the duodenum and postbulbar departments are not changed. Two fragments of
biopsy of the antral mucosa on HP were taken. HP biopsy test: (++). Respiratory urease
test: positive. Ultrasound of the abdominal cavity: the liver is not enlarged, its
parenchyma is homogeneous, echogenicity is normal, the periportal tract is not
compacted. Gallbladder pear-shaped 65x38 mm (norm 50x30) with a bend in the neck,
biliary sludge. The pancreas with smooth contours, normal echogenicity, is not
enlarged. Intracavitary pH-metry with 3 electrode probe - on an empty stomach - pH in n
/ 3 of the esophagus 6.3; periodically short-term for 15-20 seconds decrease to 3.3-
3.0; in the body of the stomach 1.7, in the antrum 3.8; after stimulation with 0.1%
solution of histamine at a dose of 0.008 mg / kg - pH in the esophagus 6 6.5 with a
decrease in pH more often for 30-40 seconds to 2.8-3.3; in the body 1.3; in the antrum
3.6.

administration.
Answers:
1. Chronic erythematous gastritis in the acute phase, normoacid. Housing and
communal services stage II .
2. With exacerbation:
Outpatient treatment.
The diet is gentle
In HG (HGD) associated with HP infection, with pronounced activity of the process, drug
therapy begins with the use of eradication (triple or quadro-) therapy according to one of
the common schemes. Preference is given to preparations of colloidal subcitrate
(subsalicylate) of bismuth as basic with parallel appointment of antisecretory
drugs. Start with a triple scheme of the first line.
Modern schemes of treatment of HP infection in children:
I) One-week triple therapy with bismuth drug mainly for children under 12 years):
1) Colloidal bismuth subcitrate + amoxicillin or clarithromycin (azithromycin)
+ omeprazole
All drugs are prescribed 2 times a day (morning and evening) for 7 days. Azithromycin -
once a day for the last three days of the weekly course.
Doses of drugs used in eradication anti-HP therapy in children:
 colloidal bismuth subcitrate - 4-8 mg / kg per day (maximum 480 mg per day);
 amoxicillin - 25 mg / kg (maximum - 1 g per day);
 clarithromycin - 7.5 mg / kg (maximum - 500 mg per day);
 azithromycin - 10 mg / kg (maximum - 1 g per day);
 omeprazole - 0.5-0.8 mg / kg (maximum - 40 mg per day);
In the second stage of treatment of HCG prescribe non- absorbable antacids (aluminum
phosphate, aluminum compounds, magnesium, calcium, etc.) - Almagel or Maalox 5-15
ml (or 0.5-1 tablet) after 1.5-2 hours after meals and at bedtime. The main course of
treatment - 2 weeks, then - taking antacids on demand. With antacids in motor disorders
prescribe prokinetics (domperidone, etc.) at 0.25 mg / kg / day 3 times a day before
meals for 10-14 days, then - on demand.
In parallel, if necessary, cytoprotectors and reparants are prescribed for a period of 2-3
weeks : smectite - 0.5-1 sachet 3 times daily before meals 1) For spasms and severe
pain - antispasmodics (mebeverine is prescribed to children over 6 years in a dose 2.5
mg / kg per day 2 times a day for 20 minutes before meals, papaverine 0.005-0.06 g 2
times a day, drotaverine 40-200 mg / day in 2-5 doses, prifinia bromide 1 mg / kg / day,
belladonna preparations for 7-14 days in age doses.
After the abolition of antisecretory drugs - metabolites - to improve the trophism of the
central nervous system, vitamin drugs, immunocorrectors for 3-4 weeks.
In all forms of HG during exacerbation, sedatives are prescribed (primarily of plant

origin) - for 7-10 days, twice a day.
In the stage of exacerbation of the disease, physical therapies are used. To normalize
the secretory and motor function of the stomach and duodenum, as well as to increase
the trophism of the central nervous system, one of the following methods is prescribed:
 high-frequency electrotherapy (HF) - inductothermy;

 ultra-high frequency therapy (microwave) or microwave therapy: centimeter or
decimeter; The course of treatment is 7-10 procedures daily.
When the exacerbation subsides . Widely used herbal medicine (courses of 2 weeks),
balneotherapy depending on the state of acid-forming function of the stomach (courses
of 2 weeks, alternating with phytotherapy), physiotherapy (to normalize the secretory
and motor function of the stomach, improve trophic SOS use induction therapy,
microwave therapy) magnetic therapy, electrosleep); It is possible to use laser and
magnetic laser therapy.
At the recovery stage, reflexology, homeopathy, microwave resonance therapy, etc. are
used. Alternatively, antihomotoxic treatment can be prescribed.
In the stage of clinical remission, phytotherapy, balneotherapy, physiotherapy, exercise
therapy complexes and other non-drug methods are widely used.
Treatment of biliary sludge: UDCA (Ukrliv suspension; 250 mg / 5 ml) at 10 mg / kg /

day.
3. Norm.
Task 24
Maria is 11 years old, sick for 1 year, complaints of "hungry" pain in the epigastrium,
appear in the morning on an empty stomach, 1.5-2 hours after eating, at night, stopped
by eating; belching sour. The first visit to the doctor a week ago, after an outpatient
FEGDS hospitalized. From the anamnesis: the mother of the child has peptic ulcer of
the duodenum, the father - gastritis, the grandmother through the mother - peptic ulcer
of the duodenum. Obstetric and early history without pathology. Review: height 148 cm,
weight 34 kg, pale pink skin, clean. Abdomen: Mendel's syndrome is positive in the
epigastrium, on superficial and deep palpation, small muscle tension and pain in the
epigastrium and pyloroduodenal region, pain at the point of Desjardins and Mayo-
Robson. The liver is not enlarged, painless. The chair is regular, decorated. For other
organs without pathology. At examination: General blood test: Hb - 128 g / l, Ts.P. -
0.91, Er - 4.2x10 12 / l; Lake - 7.2x10 9 ; p / ya - 3%, s / ya - 51%, e - 3%, l - 36%, m - 7%,
ESR - 6 mm / year. General analysis of urine: light yellow, transparent; pH -
6.0; density- 1017; protein - no; sugar - no; ep. class - 1-2-3 in p / z; leukocytes -2-3 in p
/ z. Biochemical analysis of blood: total protein - 72 g / l, ALT - 19 U / l, ALT - 24 U / l,
LF - 138 U / l (norm 7-140), amylase - 100 U / l (norm 10-120) ), thymol test - 4 units,
bilirubin - 15 μmol / l, of which the so-called. bilirubin - 3 μmol /
l. Esophagogastroduodenoscopy: the mucous membrane of the esophagus is pink, the
cardia closes. In the stomach turbid mucus, mucous with focal hyperemia, in the antrum
on the walls of multiple explosions of various calibers. The mucosa of the duodenal bulb
- focal hyperemic, swollen, on the posterior wall of the ulcer defect 0.8x0.6 cm, round
with a hyperemic roller, the bottom is covered with fibrin. A biopsy was taken. Biopsy
test for HP infection: positive (++). Ultrasound of the abdominal cavity: the liver is not
enlarged, the parenchyma is homogeneous, echogenicity is not changed, the vascular
network is not expanded. Gallbladder pear-shaped 55x21 mm with a bend in the
bottom, its content is homogeneous, the walls are 1 mm. The stomach has a large
amount of heterogeneous content, its walls are thickened. Pancreas: head 21 mm
(norm 18), body 15 mm (norm 15), tail 22 mm (norm 18), echogenicity of the head and
tail is reduced. Gastric acidometry: on an empty stomach - pH in the body 2.4; in the
antrum 4.2; 30 minutes after stimulation with 0.1% histamine solution at a dose of 0.008
mg / kg - body pH 1.4; in the antrum 2.8. Respiratory urease test: positive.

administration.
Answers:
1. Chronic gastritis, in the stage of incomplete clinical remission, hypoacid. Peptic ulcer
of the duodenum, I phase of exacerbation (fresh ulcer) .
Localization of the Clinical phase and endoscopic The severity

Complication
ulcer stage of the flow
In the stomach: Exacerbation Light Bleeding

mediagastric stage I (fresh ulcer) Perforation
pyloroantral stage II (beginning of Moderate Penetration
epithelialization) Severe Stenosis
In the duodenum: Beginning of remission Perivisceritis
- in the bulb stage III (ulcer healing)
- extra-bulbous - without scarring;
- with scar formation, scar-ulcer
In the stomach and deformation. Stage IV
duodenum remission
(no symptoms or persistent scar)
2.
Inpatient treatment, gentle diet.
In HP-associated IB, treatment begins with eradication of HP: one of the conventional
schemes (triple or quadrotherapy) is prescribed for 7 days, followed by confirmation of
the effectiveness of eradication (at least 4-6 weeks after the end of antihelicobacter
therapy) by any two methods of verification of HP.
Modern schemes of treatment of HP infection in children:
I) One-week triple therapy with bismuth drug mainly for children under 12 years):
1) Colloidal bismuth subcitrate + amoxicillin or clarithromycin (azithromycin)
+ omeprazole
All drugs are prescribed 2 times a day (morning and evening) for 7 days. Azithromycin -
once a day for the last three days of the weekly course.
Doses of drugs used in eradication anti-HP therapy in children:
 colloidal bismuth subcitrate - 4-8 mg / kg per day (maximum 480 mg per day);
 amoxicillin - 25 mg / kg (maximum - 1 g per day);
 clarithromycin - 7.5 mg / kg (maximum - 500 mg per day);
 azithromycin - 10 mg / kg (maximum - 1 g per day);
 omeprazole - 0.5-0.8 mg / kg (maximum - 40 mg per day);
In parallel, or immediately after eradication treatment is prescribed antisecretory

therapy omeprazole - 10-40 mg / day once in the morning before
breakfast; pantoprazole 20-40 mg / day once in the morning before breakfast. After
cancellation of antihelicobacter therapy and reduction of a dose of antisecretory drugs
for a period of 3-4 weeks appoint: complex antacids (aluminum phosphate, compounds
of aluminum, magnesium, calcium, etc.) Almagel, Maaloks on 5-15 ml (1 / 2-1 tab.) 2-3
times a day 1.5-2 hours after meals; cytoprotectors : smectite 0.5-1 sachet 2-3 times a
day 30 minutes before eating; sucralfate 0.5-1 g 4 times a day for 0.5-1 hours before
meals;
reparants (sea buckthorn oil, tikveol, spirulina, aecol, propolis preparations,

aloe); immunocorrectors (of plant origin). At disturbance of motility
- prokinetics (domperidone) on 0,25 mg \ kg \ days 3 times a day before food 10-14
days, further - on demand.
Symptomatic treatment : sedatives (Persen, Novo-Passit, Sedasen, etc.) 1 table. (1

tablespoon) 2-3 times a day for 2-3 weeks;
antispasmodics (mebeverine is prescribed to children over 6 years at a dose of 2.5 mg /

kg per day 2 times a day for 20 minutes before meals, papaverine 0.005-0.06 g 2 times
a day, drotaverine 40-200 mg / day in 2-5 receptions, prifinia bromide 1 mg / kg / day for
7-15 days - parenterally for 5-7 days, if necessary to continue per os, or by
electrophoresis for another 7-10 days.
The average course of medical treatment of exacerbation of duodenal ulcer - 4-6

weeks .
From non-drug methods of treatment in the exacerbation phase use: psychotherapy,

physiotherapy (induction therapy, microwave therapy, microwave therapy,
diadynamotherapy, electrophoresis with antispasmodics, novocaine). When
the exacerbation subsides (magnetic remission) - magnetic therapy, electrosleep, heat
treatment (paraffin and ozokerite applications, etc.), balneotherapy, phytotherapy, MRI,
reflexology. Contraindications for physiotherapy are severe disease, bleeding, individual
intolerance to physiotherapy.
The duration of inpatient treatment for IB - 25 - 28 days, in severe cases - up to 6-8

weeks. At ulcer repair (phase of incomplete remission) treatment is continued in out-
patient conditions. In the remission phase, spa treatment is indicated. 3. Norm.
Task 25
The boy is 2 years old. For 6 months, the child diluted with mucus stool up to 5-6
times a day, in the last 2 months in the stool appeared blood impurities, rarely -
coagulates, for the last 3 weeks, blood impurities in the stool is constant. Disturbing
abdominal pain, often before defecation, loss of appetite, weight loss, low-grade
fever. Outpatient treatment with courses of antibiotics, bacteriophages and probiotics
without a lasting effect. The baby is full-term, breastfed for up to 6 months. From 1 year
atopic dermatitis, food allergy to carrots, citrus fruits, cow's milk protein. Mother is 27
years old, healthy. Father 32 years old, healthy. Grandmother (mother) - gastritis, colitis,
lactase deficiency. Review: height 85 cm, weight 11.5 kg. Pale skin and mucous
membranes, on the skin of the face and legs areas of redness, itching, crusts. Heart
rate 116 per minute, sonorous tones, soft systolic murmur in Comrade Botkin. The
abdomen is swollen, painful on palpation of the colon, the loops of the sigma and cecum
are spasmed. Liver + 1.5; +2; c / 3, dense, symptoms of Murphy, Kera - (+). General
blood test: Hb - 96 g / l; C.p. - 0.8; Er -3,7x10 12 / l; reticulocytes - 18%; Lake -
12.0x10 9 / l, p / ya - 7%, s / ya - 43%, e- 5%; l - 36%, m -9%, ESR - 18 mm / year; clot. -
330x10 9 / l. General analysis of urine: color - light yellow, transparent; pH 5.5; density -
1018; protein - no, sugar - no; L - 2-3 in p / z, Er - no. Biochemical analysis of blood:
total protein - 68 g / l, albumin -53%, globulins: alpha 1 - 6%, alpha2 - 14%, beta - 13%,
gamma - 14%, ALT - 40 U / l, ALT - 36 Units / l, LF - 162 units / l (norm 70-140),
amylase - 45 units / l (norm 10-120), thymol test - 3 units, total bilirubin - 13 μmol / l, of
which the so-called. - 0 μmol / l, iron-7 μmol / l. Coprogram: feces of semi-liquid
consistency, brown with red spots, muscle fibers undigested in moderation, neutral fat -
no, fatty acids - a small amount, extracellular starch - quite a lot. Gregerson's reaction
was sharply positive. Colonofibroscopy: examined colon and 30 cm ileum. The mucous
membrane of the ileum is pale pink, hyperemic, swollen, with a smeared vascular
pattern, hemorrhage, linear ulcers up to 0.6 cm on the walls of the ascending and
transverse intestines, pronounced contact bleeding. The mucosa of the sigmoid and
rectum is hyperemic, contact bleeding. Histology of fragments of the colonic mucosa:
intense lymphoreticular and eosinophilic infiltration of the mucous membrane and
submucosal layer with leukostasis, a decrease in the epithelium of the crypt of goblet
cells, cryptogenic abscesses.
administration.
Answers:
1. Nonspecific ulcerative colitis, moderate, exacerbation phase. Chronic

posthemorrhagic anemia of mild degree.
2. Treatment of VC is a complex problem and includes:
Hospitalization.
D iyetoterapi I (gentle, hypoallergenic, rich in fiber foods)
Basic therapy:
According to international standards, to first-line anti-inflammatory drugs in the
treatment of inflammatory diseases of the colon include drugs are 5-aminosalicylic acid
(5-ASA).
1) Sulfasalazine 0.25 g 3-6 times a day, the maximum dose (up to 60-80 mg / kg)
is prescribed for 1-2 months with a gradual decrease in
remission. And munosuppressive therapy : Prednisolone is prescribed at a rate of 1-1.5
mg / kg / day, a maximum of 2 mg / kg body weight per day; 2-3 weeks, followed by a
decrease of 2.5 mg per week before withdrawal. The topical corticosteroid budesonide
is effective in VC. It is prescribed at a dose of 9 mg / day, not indicated for severe
extraintestinal manifestations. At a left colitis rectal forms of budesonide are
recommended: enemas and foam. Methotrexate , cyclosporine A , is also used in the
treatment of resistant forms of VC. Biological drugs: I nfliximab at a dose of 5-10-12
mg / kg body weight in the form of a single infusion Additional therapy includes - the use
of antibiotics (metronidazole, ciprofloxacin); metronidazole 250 mg, table. , Every 8
hours 7-10 mg of metronidazole / kg body weight, corresponding to a daily dose of 20-
30 mg metronidazole / kg body weight. - enterosorption I: enterosgel 5g (1 teaspoon), 2-
3 times a day between meals, lactulose 5 ml 1 time a day;
- Probiotic: Biogaia 5 k r apel 1 time per day. Can be mixed with milk, water, second
- Iron supplements. AKTYFERYN 25-35 drops , 3 times a day , take her directly to
the same nd or during her Zhi , with few ridy us (with water or fruit tea) , for 3 months.
- Vitamins of group B (Thiamine chloride 2,5% 0,5 ml ( 12.5 mg ) In / m . Course of 10-

30 injections. Pyridoxine hydrochloride 5% 1,0 , 1-2 mg / kg of body weight a day The
course of treatment - 2 weeks alpha-tocopherol in acetate capsules solution 5% 15
drops - 0.5 ml 1 time per day.
- Extracorporeal and detoksykats Exposure (hyperbaric and oksyhenatsi I ,

plasmapheresis, hemosorbtsi I ).
Dispensary supervision : Consultation of a pediatric gastroenterologist -

quarterly; then 1 time in 6 months.
Endoscopic and biochemical studies in patients r.Hrehersena s with mild VC

spend 1 time in 6 months.
3. Hb - 96 g / l - reduced, the rate of 120-140 g / l

Ts.p. - 0.8; - norm
Er -3,7 х10 12 / l; - reduced (norm 4.2-4.8 x10 12 / l .) reticulocytes - 18% - reticulocytosis
- compensatory reaction to anemia. Conclusion: Normochromic normoregenerative
anemia of mild degree.
Lake - 12.0x10 9 / l, - increased ESR - 18 mm / h; (norm 4-10 mm / h ) Biochemical

analysis of blood: LF - 162 units / l (norm 70-140) - increased (for lesions and tumors of
the intestine, liver, bones, heart).
iron-7 μmol / l - reduced (norm 8.95-21.48 μmol / l ) - an additional sign of

posthemorrhagic anemia.
Task 26
The boy is 4 years old. From the anamnesis: full-term baby, birth weight 4000 g,
height 53 cm, up to 1 year of breastfeeding. From birth, the mother noted the child's
loose stools up to 5-6 times a day. At 4 months in the stool found streaks of
blood. According to the results of coprology, no pathological changes were detected. Up
to 1 year of weight gain. From 9 months the weight gain stopped. At 1 year 8 months,
profuse nosebleeds. Observed in the ENT doctor. At 2 years 4 months in the blood test
showed signs of severe anemia. The recommended iron preparation. There was no
effect from treatment. The child was sent for examination to the gastroenterology
department with a diagnosis of malabsorption syndrome and maldigestion. Family
history: mother and father are healthy.
Review: height 151 cm, weight 30 kg. Paleness and dryness of the skin and mucous
membranes. Heart rate 116 per minute, heart sounds are sonorous, soft systolic
murmur in V t Botkin, not related to tone, extracardiac is not performed. The abdomen is
swollen, painful on palpation of the descending and colon, the loops of the sigmoid
colon are spasmed. Liver +1.5; +2; 3, dense, symptoms of Murphy, Kera - positive. For
6 months, the child diluted stool accelerated with mucus up to 5-6 times a day, in the
last 2 months in the stool there were streaks of blood, rarely blood clots, over the past 3
weeks, blood impurities in the stool became constant. Disturbing abdominal pain, often
before defecation, loss of appetite, weight loss, low-grade fever. Outpatient treatment
with courses of antibiotics, bacteriophages and probiotics without a lasting
effect. General blood test - hemoglobin 96 g / l; c.p. 0.8; erythrocytes 3.7 * 10 12 /
l; reticulocytes 18 ‰; leukocytes 12,0 * 10 9 / l, rod-nuclear 7%, segment-nuclear 43%,
eosinophils 5%; lymphocytes 36%, monocytes 9%, ESR - 28 mm / h; platelets 330 *
10 9 / l. Biochemical analysis of blood - total protein 58 g / l, ALT 40 U / l, ALT 36 U / l,
alkaline phosphatase 602 U / l (norm 70-140), amylase - 45 U / l (norm 10-120), total
bilirubin - 13 μmol / l, iron 5.7 μmol / l, OZHSS 89 μmol / l (norm 36-72), CRP 12 g / l
(norm 0-4). Coprogram - feces semi-liquid consistency, brown with red spots, muscle
fibers undigested in moderation, neutral fat - no, fatty acids - a little, extracellular starch
- a lot. Sharply positive Gregerson's reaction, leukocytes 12-15-30 in p / s, erythrocytes
30-40-50 in p / s, mucus in large quantities. Colonofibroscopy - examined the colon and
30 cm ileum. The mucous membrane of the ileum is pale pink, the mucosa of the colon
is sharply hyperemic, swollen, with a smeared vascular pattern, multiple hemorrhages,
multiple erosions of 0.2-0.4 mm, single ulcers up to 0.6 cm on the walls of the
descending and sigmoid colon. Expressed contact bleeding. Liquid blood in the sigmoid
colon. The mucous membrane of the rectum is hyperemic, pronounced contact
bleeding. A biopsy was taken. Histology of fragments of the mucous membrane of the
colon: intense lymphocytic infiltration of the mucous membrane and submucosal layer,
reduction in the epithelium of the crypts of goblet cells. Cryptogenic abscesses.

administration.
Answers:
1. Nonspecific ulcerative colitis, moderate, exacerbation phase. Chronic

posthemorrhagic anemia of mild degree.
2. Treatment of VC is a complex problem and includes: Hospitalization.
D iyetoterapi I (gentle, hypoallergenic, rich in fiber foods)
Basic therapy:
According to international standards, to first-line anti-inflammatory drugs in the
treatment of inflammatory diseases of the colon include drugs are 5-aminosalicylic acid
(5-ASA).
1) Sulfasalazine 0.25 g 3-6 times a day, the maximum dose (up to 60-80 mg / kg)
is prescribed for 1-2 months with a gradual decrease in
remission. And munosupressive therapy : Prednisolone is prescribed at a rate of 1-1.5
mg / kg / day, a maximum of 2 mg / kg body weight per day; 2-3 weeks, followed by a
decrease of 2.5 mg per week before withdrawal. The topical corticosteroid budesonide
is effective in VC. It is prescribed at a dose of 9 mg / day, not indicated for severe
extraintestinal manifestations. At a left colitis rectal forms of budesonide are
recommended: enemas and foam . Methotrexate , cyclosporine A , is also used in the
treatment of resistant forms of VC. Biological drugs: I nfliximab at a dose of 5-10-12
mg / kg body weight in the form of a single infusion Additional therapy includes - the use
of antibiotics (metronidazole, ciprofloxacin); metronidazole 250 mg, table. , Every 8
hours 7-10 mg of metronidazole / kg body weight, corresponding to a daily dose of 20-
30 mg metronidazole / kg body weight. - enterosorption I: enterosgel 5g (1 teaspoon), 2-
3 times a day between meals, lactulose 5 ml 1 time a day;
- Probiotic: Biogaya tablets 1 tablet per day regardless of food intake.
- Iron supplements : Ferroplect in a daily dose of 5 mg / kg, 1 tablet 3 times a day for 3
months.
- Vitamins of group B ( Thiamine chloride 2,5% 0,5 ml ( 12.5 mg ) In / m . Course of 10-

30 injections. Pyridoxine hydrochloride 5% 1,0 , 1-2 mg / kg of body weight a day . The
course of treatment - 2 weeks. alpha-tocopherol in acetate kapsulы solution 5% 15
drops - 0.5 ml 1 time per
day. - vitro and detoksykats Exposure (hyperbaric and oksyhenatsi I , plasmapheresis,
hemosorbtsi I ). Clinical supervision : Consultation children gastroenterologist -
quarterly, then once every 6 months.
Endoscopic and biochemical studies, Gregersen's disease in patients with mild VC is
performed - 1 time in 6 months.
3. General blood test :

hemoglobin 96 g / l - reduced, the rate of 120-140 g / l
tsp. 0.8 - normal erythrocytes 3.7 * 10 12 / l - reduced (normal 4.2-4.8 x10 12 /
l .) Reticulocytes 18 ‰ - reticulocytosis - compensatory reaction to anemia. Conclusion:
Normochromic normoregenerative anemia of mild degree.
leukocytes 12.0 * 10 9 / l, ESR - 28 mm / year; alkaline phosphatase 602 U / l (norm 70-

140) - increased (in lesions and tumors of the intestine, liver, bones, heart). iron 5.7
μmol / l - reduced (norm 8.95-21.48 μmol / l ) (total iron-binding property) OZhSS 89
μmol / l - (norm 36-72), - increased - a sign of iron deficiency anemia . CRP 12 g / l
(norm 0-4) - increased.
Task 27
Patient Masha N., 11 years old, applied to the district pediatrician in connection with
complaints of: paroxysmal unproductive cough, accompanied by pain in the sternum,
febrile body temperature for 4 days, hoarseness, general weakness, malaise. Ill acutely,
about a week ago, when the body temperature rose to 37.6oC, there were mucous
secretions from the nose, then joined the cough, hoarseness, in the last 4 days the
temperature rises to 38.50 C. Objectively: the voice is changed. The skin is pale,
clean. Lymph nodes zadnoy w yni to 1.0 cm., Moderately painful. In the throat
moderate, diffuse redness, there is granularity of the posterior wall. At auscultation in
the lungs: on the background of hard breathing, audible coarse large and medium-
bubble rales on both sides, BH 20 per minute, free exhalation. Heart tones are clear,
rhythmic, heart rate 80 per minute. Other organs and systems during physical
examination - without features. General blood test: Hb - 128 g / l, Ts.P. - 0.91, Er -
4.2x10 12 / l; Lake -10.2x10 9 ; p / ya - 8%, s / ya - 51%, e - 3%, l - 31%, m - 7%, ESR -
16 mm / year.

administration.
Answers:
1. SARS medium degree of severity, acute rhinitis, larynhofarynhit, bronchitis
2. Bed rest until normalization of body temperature; heavy drinking (tea, fruit juices)
M ucolytics: bromhexine, ambroxol 15 .
Bromhexine 24mg / day, 1 tablet 3 times a day for 5 days.
Antipyretics: paracetamol 200 mg, 10-15 mg / kg 2-3 times a day
M istsev and vasoconstrictor and Means and, Nazyvin 0.05% 1-2 drops in each nostril
2-3 times a day.
Preparations for the throat. Antiseptics: Septolete total single dose is 1 click. Repeat
every 2 hours 3-5 times a day for 7 days.
3. In the analysis of blood and there is an increase in ESR .
Task 28
At home, a pediatrician examined a boy, 8 years old, with complaints of dry

paroxysmal cough, which worsens at night, difficulty breathing, body temperature
37.5oC, general weakness, sleep disturbances. From the anamnesis: acutely ill 3 days
ago, after hypothermia body temperature up to 38.5 o C, nasal congestion,
rhinorrhea. The next day there was a dry cough. Treated at home: antipyretics,
mucolytics - the condition did not improve significantly. The boy is often ill - ARI up to 6-
7 times a year. Acute bronchitis from 4 to 6 years - 1-2 times a year. Obstructive
bronchitis from 6 years 2-3 times a year. The last episode of airway obstruction 2
months ago, was treated on an outpatient basis. There were no allergic reactions. The
maternal grandfather has bronchial asthma. There is a mold in the house, both parents
smoke. On examination: The condition of a child of moderate severity. Cough dry
paroxysmal. The skin is pale. Posterior lymph nodes up to 0.5 cm, painless, not fused
with tissues. Mucous secretions from the nose, redness in the throat, no
overlays. Above the lungs - a boxy shade of percussion sound. At auscultation
breathing is rigid, exhalations are prolonged, on an exhalation dry whistling rales are
heard, chd 20 a minute. Heart tones are sonorous, heart rate is 80 per minute. The
boundaries of the heart correspond to age. Other organs and systems during physical
examination - without features. General blood test: Hb - 128 g / l, Ts.P. - 0.91, Er -
4.2x10 12 / l; Lake -8.2x10 9 ; p / ya - 5%, s / ya - 51%, e - 3%, l - 34%, m - 7%, ESR - 11
mm / year.

administration.
In response:
1. X chronic obstructive bronchitis, exacerbation phase.

2. P rotykashlovi medications central action: Tedeyin 1tabletka 1 per day, 5 days
B ronholitykiv: b2-agonists short action - salbutamol, Atrovent, fenoterol.

Salbutamol for relief of bronchoobstructive syndrome 1 inhalation 100 mcg
P preparations of theophylline (methylxanthines): Theophylline daily dose of 150 mg

(1/2 tablet of 300 mg), 1 time per day, after 3 days, increase the dose to 300 mg.
M ucolytics - acetylcysteine, ambroxol hydrochloride.
Acetylcysteine 200mg, taken orally 2-3 times a day.
Antioxidants: Alpha-Tocopherol Acetate (Vitamin E). Internally, the drug is taken in the
form of 5% oil solutions (1 ml contains 0.05 g, respectively), once a day.
Breathing exercises include elements of training mechanisms or components of the

respiratory act. The gymnastics complex should include static breathing sound
exercises to train prolonged exhalation. In addition to static, the complex has dynamic
breathing exercises, when exercise is combined with breathing. Sputum removal is best
achieved in a drainage position with the upper body lowered, this is facilitated by
vibrating massage (manual or with a vibrating massager).
B ronchoscopic remediation .
3. In the clinical analysis of blood we observe an increase in ESR.
Task 29
A boy of 8 years, sick for 7 days, became acutely ill after hypothermia, there was a
rise in temperature to 39.0 ° C, there was a dry painful cough, headache. The first 2
days after the onset of the disease, the patient had a high fever, but the temperature
decreased after taking paracetamol. From the 3rd day shortness of breath increased,
there was abdominal pain, refusal to eat, lethargy, malaise. When examined at home:
complaints of headache, dry cough. The skin is pale, with a "marble" pattern. Mucous
membranes are clean, dry. The throat is hyperemic. The breath is
creaking. SaO 2 89%. BH 32 in 1 minute. Percussion: on the right, below the scapula,
the area of dull percussion sound is determined. Auscultatory: breathing is hard, over
the area of dull breathing is weakened, creaking rales. Heart tones are muffled, no
noise, BH 120 beats / min. The abdomen is soft, painless. Liver at the edge of the costal
arch, spleen is not palpable. General blood test: Hb - 115 g / l, Lake - 18.6x10 9 / l, p / I -
10%, c - 57%, e - 1%, l - 23%, m - 9%, ESR - 28 mm / hour. On the review
roentgenogram of thoracic organs in a direct projection intensive decrease in
pneumatization of the lower share of the right lung due to infiltrative changes.

administration.
Answers:
1. Diagnosis: community-acquired pneumonia of the lower lobe of the right lung, 3 cat.,
DN II 2. Hospitalization of the patient, bed rest, general blood test, general urine test,
sputum culture for microflora, chest radiography, antibiotic therapy and
cephalospores. (cefuroxime 200 mg / kg / day 3 times / day IV) + macrolides (dalacin
(clindamycin) 30 mg / kg / day 3 times / day), antipyretic drugs (paracetamol single dose
200 mg, daily 600 mg, expectorant) ambroxol 30 mg 3 times / day), oral
rehydration, physiotherapy (UHF №5, amplipulsophoresis, warm-wet inhalation,
exercise therapy) 3. Laboratory: leukocytosis, shift of leukocyte formula to the left,
increased ESR indicates inflammatory changes in the body.
Task 30
The woman is 25 years old. Pregnancy I. In the women's clinic, the pregnant woman
was observed from 9 weeks of gestation. The first half of the pregnancy went without
complications. At 35-36 weeks, the pregnant woman suffered from acute respiratory
disease with a temperature of 38 ° C and catarrhal manifestations. The woman was
treated on her own. Childbirth at 38 weeks, physiological. The girl was born in a
satisfactory condition, Apgar score 9/9 points. Body weight 3400 g. The baby was
placed in the breast in the delivery room. On the 3rd day after birth, the girl and her
mother were discharged home. On the 6th day, the umbilical cord fell off on its own. The
baby sucks actively. On the 8th day of life, the newborn developed a low-grade
fever. The child was examined by a doctor, who referred the girl to a neonatal
hospital. Clinical examination of the internal organs and nervous system revealed no
pathology. Body weight - 3520 g, T - 37.7. There was swelling and redness of the
umbilical ring, purulent discharge from the umbilical wound. Clinical blood test: Hb - 167
g / l, Er - 4,0 * 10 12 / l, Ts.P. - 0.99, thrombus - 240x10 9 / l. Lake - 14.4x10 9 / l, Eos - 5,
myelocytes - 4%, p / I - 10%, c / I - 41%, lymph - 34%, monocytes - 6%, ESR - 12 mm /
h.

2. Determine the protocol of the patient. Justify the treatment. Describe the drugs
needed by the patient. Indicate the dose and frequency of administration of drugs.
3. Interpret the results of laboratory tests.
Answers:
1. purulent ompha years

2. Treatment In its simple form - local. The umbilical wound is treated with a
3% solution of hydrogen peroxide, then a 5% solution of potassium
permanganate, or a 2% alcoholic solution of diamond green. You can use a
powder with bacitracin and neomycin (Baneocin), treat the umbilical wound with
solutions of antiseptics (chlorophyll, 10-15% solution of propolis, 1% solution of
eucalyptus ball leaf extract, etc.). Ultraviolet irradiation of the umbilical wound is
used.
3. Hb - 167 g / l, Er - 4.0 * 10 12 / l, C.P. - 0.99, thrombus - 240x10 9 / l. Lake -
14,4h10 9 / L EMU - 5  rule , mielots and you - 4% (purulent process) , p / I -
10% c / I - 41% of lymph - 34% monocytes - 6%  norm , ESR - increased.
Task 31
At the outpatient clinic, the mother of a 2-week-old child complains of constipation,

jaundice, lethargy and drowsiness. At physical examination: the child's health is
somewhat impaired, motor activity is reduced, the child is lethargic, head of normal size,
a small spring 0.5x0.5 cm, large 2.5x3.0 cm, increased tissue turgor, mild jaundice,
swelling of the face and torso, bloated stomach, moderate bradycardia in sleep. History:
registered with a woman from 10 weeks of pregnancy, a woman's age of 30
years; pregnancy 2, childbirth - 1, (1 pregnancy - artificial abortion). At the 8th week of
pregnancy, the mother had SARS. Childbirth at 41 weeks. Apgar score - 7/8 points,
condition at birth of moderate severity. The body weight of the child at birth is 4000 g,
length 55 cm. The results of the neonatal test conducted in the maternity hospital: TSH -
30 mOD / l, T 4 - 70 nmol / l.

1. congenital hypothyroidism
Treatment is
carried out for life.
Replacement therapy with thyroid hormones (L-thyroxine, triiodothyronine) is prescribed

regardless of the level of damage and the cause of hypothyroidism.
Levothyroxine is indicated immediately after diagnosis by complete replacement therapy
at a dose of 10–15 μg / kg / day.
 A full replacement dose is prescribed immediately.
Doses of L-thyroxine:
Age Daily dose, μg / kg

Premature 8 - 10
0-3 months 10 - 15
3-6 months 8 - 10
6-12 months 6-8
1-3 years 4-6
3-10 years 3-4
10-15 years 2-4
> 15 years 2-3
3. TSH - increased , T 4 - decreased .
Task 32
Newborn from 3 pregnancies, 2 births. Fetal distress. Childbirth by cesarean section

at 37 weeks of pregnancy. The mother suffers from chronic gastritis, from the beginning
of the 3rd trimester of pregnancy - gestosis. The boy was born with asphyxia, Apgar
score - 4/7 points. Body weight at birth - 2900 g, body length - 51 cm. On the 3rd day of
life there were vomiting with impurities of fresh blood, dark stools, cherry stains on the
diaper. The general condition of the child is closer to satisfactory. There are no
neurological disorders. At clinical inspection from internals infringements are not
revealed. There are no inflammatory changes in the clinical blood test. Hemoglobin -
160 g / l, platelets - 270 x 10 9 / l . Hemostatic tests: activated partial thromboplastin time
(APTT) - 74 sec. Prothrombin index (PI) - 9%. Other indicators are normal. There is no
evidence of prophylactic administration of vitamin K after birth in the stationary card.

Answers:
1. Hemorrhagic disease of newborns, asphyxia of moderate severity, prematurity (37
weeks).
I. L and forging:
a. 1) peace;
b. feeding chilled breast milk to room temperature at the request of the child.
c. vitamin K1 (1-2 mg);
d. mixture with thrombin 1 teaspoon ampoule of thrombin 3-4 times a day.
III. Interpretation of laboratory parameters
Hemoglobin - 160 g / l, (reduced)
Platelets - 270 x 109 / l. (normal)
Hemostatic tests:
activated partial thromboplastin time (APTT) - 74 sec. (elongate)
Prothrombin index (PI) - 90%. (normal)
Task 33
In the newborn girl on the 1st day of life, the neonatologist noted prolonged bleeding
from the umbilical cord. From the anamnesis it is established that the child from IV
pregnancy, II childbirth at 36 weeks of gestation. During pregnancy, a 28-year-old
woman at 30 weeks of gestation had signs of preeclampsia with a decrease in estrogen
levels in the urine less than 10 mg / day. Two weeks before delivery, the pregnant
woman suffered from SARS and acute bronchitis, for which she was treated with
ampicillin.
Childbirth without pathology. The body weight of the newborn at birth is 2150 g, body
length 45 cm, head circumference 32 cm, chest 28 cm. She cried at once. Apgar score
8/8 points. Attached to the chest in the delivery room.
1. On the 3rd day of life, the child had ecchymoses and petechiae, bloody
vomiting, black fecal masses. The skin is pale, the extremities are cold. Pulse of
weak filling. Blood pressure 45/20 mm Hg Respiration rate up to 80 / min, heart
rate 188 beats / min. Clinical blood test: Hb 120 g / l; Er. 2.1 x 10 12 / l; CPU -
0.85; reticulocytes - 8%. Platelets - 210 x 10 9 / l. Lake. 12.3 x 10 9 / l; eos. 1%,
segment-nuclei. neutr. 40%; pal.-nuclei. neutr. 6%; lymph. 44%; mon. 9%; clot. 24
0 x 10 9 / L; ESR 3 mm / year; Ht 0.35. Coagulogram: prothrombin index
9%; prothrombin time 26 sec; prothrombin consumption 95%; fibrinolysis 100
min; paracoagulation tests are negative.
2. Define the protocol of management of the patient. Justify the treatment. Describe the
drugs needed by the patient. Indicate the dose and frequency of administration of drugs.
Answer:
1. Classical hemorrhagic disease of newborns. Gastrointestinal bleeding

(ground). Bloody vomiting (hematemesis). Prematurity of the I degree. Intrauterine
growth retardation (IUD) of hypotrophic type I severity.
Complications: Acute posthemorrhagic anemia, severe. Hypovolemic
(posthemorrhagic) shock, the stage of centralization of blood circulation.
2. Additional studies: Complete coagulogram and consultation with a
hematologist Direct measurement of vitamin K levels. Initial examination The
coagulation examination of a newborn with hemorrhagic disorders should include
prothrombin time (PTC), activated partial thromboplastin time (aTCH) and
fibrinogen levels.
Treatment: Feeding is carried out with expressed breast milk dosed depending on
the intensity of bleeding from the gastrointestinal tract.
The newborn should be administered intramuscularly a solution of vikasol 1%
(vitamin K3) in a dose of 0.3 ml twice a day (with an interval of 12 hours), which
after 4 hours increases the level of vitamin K-dependent coagulation factors:
prothrombin (f .II), proconvertin (f.VII), antihemophilic globulin (f. IX) and Stuart-
Prauer factor (f.X).
Topical therapy for grinding: 0.5% sodium bicarbonate solution (blood substitute,
electrolyte solution) inside 1 teaspoon 3 times a day and a solution of thrombin in
epsilon-aminocaproic acid also inside 1 teaspoon 3 times a day (ampoule of dry
thrombin is dissolved in 50 ml of 5% solution of epsilon-aminocaproic acid and
add 1 ml of 0.025% solution of adroxone).
At massive or recurrent bleeding with the phenomena of posthemorrhagic
anemia intravenously transfuse fresh-frozen plasma at the rate of 10-15 ml / kg of
a body.
In hypovolemic shock after recovery of BCC by transfusion of albumin or plasma,
it is necessary to monitor the dynamics of blood pressure, heart rate and diuresis
every hour. Diuresis less than 0.5 ml / kg / h indicates the preservation of
centralization of blood circulation and the development of acute renal failure. In
this case it is necessary:
a) continue infusion therapy "Infucol" (plasma substitute) (the first bolus at a dose
of 5-10 ml / kg body weight, ie 21.5 ml, the second bolus at the same dose 30-60
min after the first injection), then for 3 4 h enter 5% glucose solution (5-10 ml /
kg / h, ie 21.5 ml / h · 3h = 64.5 ml for 3 h) until the stabilization of diuresis (0.8-1,
0 ml / kg / h), then connected to the crystalloid solutions of Sol. Natrii chloridi
0.9% based on the physiological need for sodium 3 mmol / kg / day, which in the
calculation corresponds to 3 (mmol) · 2.15 (kg): 0.15 (mmol / ml) = 43 ml / day
intravenous drip ; in total during the day the child will receive 21.5 + 21.5 + 64.5 +
43 = 150.5 ml of infusion fluid, ie 70 ml / kg / day.
b) Dopamine solution (cardiotonic agent) 10 μg / min intravenously and titrate its

dose according to blood pressure, heart rate, diuresis (until normalization).
Oxygen therapy. If hypotension is not eliminated within 1 h, the child is
transferred to mechanical ventilation with FiO2 (oxygen concentration at the
udder) = 0.5.
Blood transfusion of one group of patient erythrocyte mass in the amount of 25
ml, followed by control of hematocrit. Enter the entire volume of erythromass for
40 minutes. The calculation of the volume of erythromass can be performed by
the formula:
Volume = Mass erytromasy and body weight (kg) × BCC (ml / kg) ×
( Hct same - Hct b ) / Hcterytromasy
where Hctj is the desired hematocrit;
Hctb - hematocrit of the patient;
Hct erythromass - hematocrit erythromass is 0.7 (70%);
BCC - the volume of circulating blood is conventionally taken 80 ml / kg.
The volume of erythromass for the patient = 2.15 × 172 × (0.5-0.35): 0.7 = 79
(ml).
3. Anemic syndrome, internal bleeding: Hemoglobin - reduced (normal in the
early neonatal period - 180-220 g / l), erythrocytes - reduced (normal 5.4-7.2 10 12 /
l), CP - 0.85, slightly reduced (normal in the neonatal period 0.9-1.2), reticulocytes
- 8% (normal 5-10%), platelets - 210 x 109 /l.(norm 150-300 x 10 9 / l), leukocytes-
12.3 x 109 / l (normally 10-30 x 109 / l); eosinophils - 1% (normally 1-4%),
segment.-nuclei. neutr. - 40%, slightly reduced (norm 45-80%); pal.-nuclei. neutr. -
6%, slightly increased (norm 1-5%), which indicates an inflammatory
process; lymphocytes-. 44% ;, increased (norm 15-35%), which may indicate an
infectious lesion, malignant process or non-infectious (vitamin deficiency, in this
case vitamin K), monocytes -9%; (norm 6-10%), platelets - 240 x 109 / l
(norm); ESR - 3 mm / h (norm 2-4 mm / h), hematocrit - 0,35 reduced (norm -
0,45-0,67) at decrease in erythrocytes at a hemorrhagic illness. Coagulogram:
prothrombin index 9% - very low, the rate of 80-100%, indicates a deficiency of
vitamin K, low levels of fibrinogen in the blood, and leads to severe
hemorrhage. Prothrombin time 26 sec - increased (norm 11-18 sec), indicates a
tendency to hypocoagulation. Consumption of prothrombin 95% (normal 75-
125%), fibrinolysis 100 min (normal 5-10 min), reduced blood clotting time,
bleeding tendency; paracoagulation tests are negative (the norm indicates the
absence of DIC syndrome).
Task 34
Pregnancy I. Mother's age 27 years. Mild anemia was observed in the first half of
pregnancy. Childbirth within 40 weeks of gestation. The girl was born in the
buttocks. Withdrawal of the shoulders was difficult. Apgar score: 8/8 points. Newborn's
body weight is 4200 g. Length is 54 cm. Head circumference: 37 cm. Chest
circumference: 35 cm.
Examination revealed that the head was tilted to the right, the right arm was brought
to the torso unbent at the joints, rotated in the middle in the shoulder, prone in the
forearm. The brush is bent in the palm, movements in the palm and fingers are
preserved, but limited. Shoulder lowered. Spontaneous movements are absent in the
shoulder and elbow joints, Reflexes of oral automatism are caused. The right hand does
not participate in the Moreau reflex. In a horizontal position, if you lift the child, his hand
hangs.
In the internal organs on examination the pathology was not detected. Clinical blood
test. Hb - 185 g / l; Er. - 4.5 ∙ 10 12 / l; CP - 0.9; Clot. - 298.0 ∙ 10 9 / L. Reticulot -
5% 0. Lake. - 11 ∙ 10 9 / L; eos - 0%, p / I - 8%, s - 60%, l - 18%, m - 14%, ESR - 3 mm /
year.
2. Determine the tactics of the patient. Justify the treatment. Describe the drugs needed
by the patient. Indicate the dose and frequency of administration of drugs.
Answers:
1. Childbirth injury (upper paralysis of the Duchenne-Erb brachial plexus).
2. Additional studies : lumbar puncture, myelography, radiography of the

spine (neck), ultrasound of the shoulder joint, neurosonography, computed
tomography, consultation with a neurologist, orthopedist.
Treatment. Immobilization of the spinal cord (splinting, splints), in severe cases
of traction. If the myelogram shows spinal cord compression, laminectomy and
extradural clot removal are required.
Prescribe drugs that increase blood clotting : vikasol (vitamin K, hemostatic
agent) - 2-5 mg / day, intravenously, the dose is divided into 2 injections; epsilon-
aminocaproic acid (antihemorrhagic agent, fibrinolysis inhibitor) - at a dose of
0.05 g / kg body weight 1 time per day; and drugs that reduce vascular
permeability (rutin ;, ascorbic acid - 50 mg x 2 times a
day ,.). Neuroprotectors: Piracetam orally 50-100 mg / kg, 5% cerebrolysin 1 ml,
dose - 0.3-0.5 ml i / m (0.01 mg / kg). Pyriditol (ennfabol) 200.0 syrup, dose - 1 ml
* 2 g.
Exercise therapy, thermal and physiotherapeutic procedures. Electrophoresis with
lidase, proserine 0.05% -1ml, dose up to 6 months 0.01ml, resorbing agents -
injections of aloe 0.3-0.5 ml i / m 2 times a day; drugs that increase the
metabolism of nervous tissue - B vitamins (thiamine hydrochloride - in / m 12.5 -
25 mg 1 time per day; pyridoxine - 1-2 mg / kg body weight per day in / m).
3. Clinical blood test. hemoglobin - 185 g / l (normal in the early neonatal

period - 180-220 g / l); Erythrocytes. - 4.5 ∙ 1012 / l, reduced, anemia (normal 5.4-
7.2 1012 / l); KP - 0,9 (norm in the neonatal period 0,9 - 1,2); Platelets - 298.0 ∙
109 / L (norm 150-300 (109 / L). Reticulocytes - 5% 0 (norm 5-
10%). Leukocytes. - 11 ∙ 109 / l (normally 10-30 x 109 / l); ; eosinophils - 0%,
reduced (normally 1-4%) may indicate the onset of sepsis or the onset of an
infectious disease; rod - 8%, increased, inflammatory process (norm 1-5%),,
segmental - 60% (norm 45-80%), lymphocytes - 18% (norm 15-35%), monocytes
- 14%, increased (norm 6-10%), which may be due to traumatic injury, ESR - 3
mm / h. . (norm 2-4 mm / year).
Task 35
A boy from the 2nd pregnancy. History of medical abortion. Childbirth 1st, premature
at 28 weeks of gestation. Childbirth by emergency cesarean section due to premature
detachment of the placenta. Newborn's body weight - 1110 g, height - 38 cm, head
circumference - 28 cm, chest - 25 cm. Apgar score - 4/6 points. Evaluation on the
Silverman scale 10 minutes after birth - 5 points. After the initial resuscitation measures,
the child was transferred to the VITN. The baby receives a constant positive airway
pressure (CPAP) from the delivery room.
Examination of the newborn 15 minutes after birth. The condition is serious. There is
no shout. He moans softly. Grade for Silverman - 7 points. Hemodynamics is unstable:
heart rate 170 per minute, blood pressure 40/19 mm Hg. Art., blood pressure average -
31 mm Hg Symptom of "white spot" 4 sec. With O 2 - 88%. Clinical blood test: Hb 150 g /
l, Er. 4.2 ∙ 10 12 / l, KP 1.1. Ht - 0.50, Ret - 7% 0 . Clot. 290 ∙ 10 9 / L. L - 9.2 ∙ 10 9 / L, p / I
- 4%, c - 57%, l - 33%, m - 6%, ESR - 4 mm / h. Analysis of the gas composition of the
blood: RaO 2 46 mm Hg. Art., RaSO 2 60 mm Hg. st., pH 7.2.

2. Determine the protocol of management of the patient, prescribe
treatment, listing the groups of drugs, representatives of each group, indicate the dose
and frequency of administration.
Answer:
1. Respiratory distress syndrome of newborns.

2. Additional studies : general blood test, general urine test, biochemical
analysis of blood in the dynamics, the content of C-reactive protein in the serum
6-12 h after birth, X-ray examination of OGK (diffuse reticular-granular pattern
(stage 1), dilation of the proximal bronchi against the background of reduced
transparency of the pulmonary fields (visible air contours of the bronchial tree
("bronchogram") go beyond the shadow of the heart) (2-3 stages), fuzzy or
missing borders of the heart (3-4 stages), decrease in tidal volume 4 stages);
"white" lungs (4 stages)). determination of blood glucose; determination of gas
composition and acid-base status of blood (arterial or capillary
blood); bacteriological examination (culture) of blood before the appointment of
antibiotics.
Treatment : Treatment measures during the provision of medical care
but for newborns with RDS include: non-invasive respiratory support (DP) or
artificial lung ventilation (ventilation), surfactant therapy, use of additional oxygen
as needed, monitoring and supportive measures, correction of hypotension,
etc. The optimal strategy to help newborns with RDS is to create a constant
positive airway pressure (CPAP) with early treatment of surfactant as soon as
possible .
Surfactants of natural origin should be used for the prevention and treatment of
RDS. To increase the likelihood of success of noninvasive DP and reduce the duration
of mechanical ventilation, prescribe methylxanthines and steroids, as well as use
acceptable hypercapnia.
Surfactant therapy in newborns with gestational age <32 weeks. - for optimal
treatment of RDS, it is recommended to use paractant alfa in an initial dose of 200 mg /
kg, as this dose is more effective than 100 mg / kg of paractant alpha or beractant. At
an initial dose of 200 mg / kg, only Poractant alpha is used. Preference should be given
to the early therapeutic administration of the surfactant after the initial administration of
CPAP with a pressure of at least 6 cm H2O. The first therapeutic dose of the drug
should be administered as soon as possible (optimally - in the first 2 hours of life). It is
not recommended to start RDS treatment with surfactant after 15 hours of life. The
repeated dose of paractant alpha is 100 mg / kg; doses of other surfactant drugs in case
of repeated administration do not change.
Oxygen therapy - in case of additional oxygen administration to a premature baby it is

necessary to maintain the level of SpO2 in the range of 90-94%. To do this, set the
alarm limits of the pulse oximeter at 89% and 95%, respectively.
Non-invasive respiratory support - It is important to use short binazal cannulas or

nasal masks, as well as an initial pressure of 6-8 cm H2O.
If non-invasive respiratory support methods are ineffective, standard endotracheal

ventilation should be used in infants with RDS . The initial tidal volume should be 4-5
ml / kg, followed by its correction in accordance with the level of PaCO2 and the
effectiveness of independent respiratory efforts of the child. During weaning from
ventilation, it is advisable to tolerate moderate hypercapnia (up to 55 mm Hg), provided
that the blood pH is above 7.22.
Caffeine citrate (methylxanthine) (psychoanaleptic) should be prescribed from the

first hour of life to all infants weighing up to 1250 g at birth, who receive non-invasive
respiratory support and have a high risk of subsequent mechanical ventilation. The dose
of caffeine citrate saturation is - 20 mg / kg (intravenously or internally), the
maintenance dose is 5 mg / kg (intravenously or internally).
If a premature baby has a significant risk of developing bronchopulmonary dysplasia,

requiring mechanical ventilation longer than 1-2 weeks to facilitate extubation, it is
advisable to prescribe a short course of dexamethasone . The initial dose of 0.15-0.2
mg / kg per day is gradually reduced over 7-10 days, with the aim of extubation of the
trachea during this period.
Antibiotic therapy : As a starting regimen of empirical antibiotic therapy use a
combination of semi-synthetic aminopenicillin (amoxicillin - 0.02 g / kg body weight
orally) and aminoglycoside (gentamicin - w / m 2-5mg / kg body weight or amikavacin
dose - w / m kg per day followed by the introduction of a daily dose of 15 mg / kg,
divided into 2 injections for 7-10 days.).
Treat arterial hypotension, the presence of which is evidenced by signs of insufficient

tissue perfusion (oliguria, acidosis, insufficient capillary filling - a symptom of "white
spot"> 3 s, etc.), and not just low blood pressure: 0.9% sodium chloride solution 10 ml /
kg , Dopamine (cardiotonic and hypertensive agent) 2-10 mcg / kg / min IV drip,
Epinephrine (hypertensive drug) IV drip 0,01-0,05 μg / kg / min, Hydrocortisone
(glucocorticosteroid) IV 1 mg / kg every 8 hours.
3. Clinical analysis of blood: anemic syndrome - Hb - 150 g / l, reduced

(normal in the early neonatal period - 180-220 g / l), erythrocytes. 4.2 ∙ 1012 / l,
reduced (normal 5.4-7.2 1012 / l), KP-1.1 (normal in the neonatal period 0.9-
1.2). hematocrit - 0.50 (normal - 0.45-0.67), reticulocytes - 7% (normal 5-
10%). Platelets-. 290 ∙ 109 / L. (Norm 150-300 (109 / L). Leukocytes - 9.2 ∙ 109 /
L (normally 8.5-24.5 x 109 / l); , rod - 4% (norm 1-5%), segmental - 57% (norm
45-80%), lymphocytes - 33% (norm 15-35%), monocytes - 6% (norm 6-10%),,
ESR - 4 mm / year (norm 2-4 mm / year).
Analysis of the gas composition of the blood: PaO2 46 mm Hg. Art. (norm 75–
100 mm Hg), PaCO2 60 mm Hg (norm 32–45 mm Hg), pH 7.2 (norm 7.35–7.45)
- decompensated respiratory acidosis. Sa O2 - 88% (norm 95–98%) - insufficient
oxygen saturation of arterial blood hemoglobin.
Task 36
A 10-month-old boy was admitted to the clinic with complaints of severe bleeding
from the tongue, a large hematoma of the left thigh. From the anamnesis: according to
the mother, the child fell out of the crib, bit his tongue when struck, there was a slight
bleeding, which intensified after a few hours. My grandfather and brother suffered from
increased bleeding. On examination, the skin, mucous membranes are clean, pale pink,
a large hematoma on the left thigh, continued bleeding from the mouth. KLA: er.-
3,4х10 9 / l, hemoglobin - 113 g / l, leukocytes - 5,4х10 12 / l, thrombocytes - 248х10 9 / l,
ESR-12 mm / h. ЧЗК-19 мин. The level of factor VIII in blood plasma is 1.5%.

Answers:
1. Hemophilia A severe form. Acute bleeding from the mouth. Acute hematoma of the
left thigh.
At a factor level < 2.0 %, a severe form of hemophilia is diagnosed , 2.1-5.0 % -

moderate,> 5.1 % - a mild form of hemophilia.
2. Hospitalization of the patient to the hematology department, bed rest, radiography of

the left femur, ultrasound of the left thigh;
In the lead cryoprecipitate in the dose required to raise the factor VIII to 50% of normal
(25 U / kg) and support at  5% for 48- 72 hours.
According to the definition, 1 ml of normal plasma contains 1 UNIT of antihemophilic
factor VIII.
Since the plasma volume is approximately 45 ml / kg, it is necessary to enter 45 IU / kg
of factor VIII to increase its concentration from 0 to 100% of normal.
In most cases, the introduction of 25-50 IU / kg of factor VIII can increase its plasma
concentration from 50% to 100%. Concentrated factor VIII drugs (octanate) can be used
for replacement therapy.
If there is minor bleeding from the mucous membranes (mouth, nose), hematomas
without compression of the surrounding tissues, removal of one tooth (not a molar) -
enter cryoprecipitate 15-20 IU / kg / day.
A more accurate formula for calculating a single dose of cryoprecipitate: the patient's
weight x a given level of factor VIII (%): 1.3 . Antihemophilic drugs are administered
intravenously. Other blood substitutes should not be administered, as this dilutes the
existing factor VIII. If factor VIII and cryoprecipitate cannot be used , or desmopressin is
used to treat patients with mild to moderate hemophilia A. The recommended dose is
0.3 μg / kg intravenously slowly for 20-30 minutes, pre-dissolved in 50-100 ml of
saline. With increasing the content of antihemophilic factor by 25-50%. It is entered
once in 1-2 days .
fibrinolysis inhibitor (tranexamic acid 10 mg / kg / day intravenously).
3. According to laboratory tests, this patient has slightly elevated ESR, increased
bleeding time and decreased levels of factor VIII in blood plasma that meets the criteria
of hemophilia A.
Task 37
A 7-year-old patient was admitted to the hospital with complaints of the appearance
of a small rash on the body, swelling and pain in the ankle on the right, abdominal
pain. From the anamnesis: 7 days after the SARS there was pain in the right ankle joint,
its swelling, soreness and elements of maculopapular rash on the body. The next day
joined the abdominal pain, 2-fold vomiting, increased the number of elements of the
rash. Examined by a surgeon - no data for acute surgical pathology were
found. Condition of moderate severity, on the body elements of maculopapular rash,
with a predominant localization on the extensor surface of the arms, legs, buttocks and
around the joints. The right ankle joint is enlarged, painful on palpation, the range of
motion is limited. Vesicular breathing in the lungs, no wheezing. The limits of the heart
within the age norm. Tones are clear, rhythmic, heart rate 82 per minute, AT-100/50 mm
Hg. The abdomen is soft, moderately painful around the navel, liver, spleen are not
enlarged. General blood test: HB-110g / l, Er-3,5x10 12 / l, Ts.P. -0.9, Thrombus. -
435x10 9 / l, Lake. -12,5h 10 9 / L, Young -1% p / I - 5%, from - 57%, -2% e, l- 28% of -
7%, ESR - 25 mm / h.

Answers:
1. hemorrhagic vasculitis , active phase, mixed form, cutaneous
articular second and abdominal syndrome, moderate, acute course.
2. Research: determination of daily

proteinuria, urinary albumin / creatinine; coagulogram, blood alkaline
phosphatase, autoimmune profile: ANA, dsDNA, pANCA, cANCA; Determination of IgA
in the wall of the affected blood vessels method ohm direct
imunoflyuorestsensiyi). Instrumental studies are indicated for all patients : ECG, Echo-
CG, Doppler-CG , ultrasound examination of the ankle joint, ultrasound examination of
the abdominal cavity
GV therapy is based on the following components:
 Bed rest for the period of new rash, arthralgia or arthritis, abdominal
pain.
 Diet excluding irritating foods as well as foods that can cause allergic
reactions.
 Medicated:
direct-acting anticoagulant heparin is prescribed for abdominal, renal
syndromes, severe skin syndrome and in the presence of hypercoagulation
according to the coagulogram:
at an average degree - 200-500 IU / kg / day;
Heparin should not be administered twice or thrice a day, as it provokes the formation
of intravascular blood clots. Withdrawal of heparin should be gradual, by reducing the
dose, not reducing the number of injections.
The duration of heparin administration (within 2-4 weeks) depends on the form and
severity of the disease, the clinical response to therapy, indicators of the blood
coagulation system;
antiplatelets (dipyridamole 3-5 mg / kg / day, pentoxifylline 5-10 mg / kg / day for 4-6

weeks with gradual withdrawal);
antihistamines (fencarol, peritol, suprastin, tavegil, claritin, loratadine, cetrin in age
doses for a period of 2-4 weeks) with a mild course, itchy skin;
glucocorticoids (GC) are indicated for lightning, abdominal, renal and massive
hemorrhagic syndrome with a high degree of inflammatory activity. Prednisolone is
prescribed at a dose of 1-2 mg / kg / day for a period of 2-4 weeks with gradual
withdrawal. To reduce the hypercoagulant effect, HA is combined with anticoagulants
and disaggregants. At a high degree of inflammatory activity, a joint syndrome, but
without signs of defeat of kidneys reception of prednisolone by a short course for 5-7
days with the subsequent full cancellation for the purpose of prevention of nephrological
pathology is allowed;
aminoquinoline drugs in moderate severity, low activity and hematuric form of

Shenlein-Genoch glomerulonephritis (delagil 2.5-5 mg / kg body weight per day) in a
continuous course for 12-18 months;
immunosuppressive therapy is prescribed in case of chronic recurrence, high degree
of activity (azathioprine 1-2 mg / kg / day for 2-3 doses for 1-2 years under the control of
blood tests);
3. General blood test:

HB-110 g / l - reduced, the rate of 120-150 g / l . Er-3,5 х10 12 / l - reduced, norm - 4,2-
4,8 х10 12 / l Ts.P. -0.9, - Thrombus norm . - 435 x10 9 / l, - thrombocytosis, norm 150-
300 x10 9 / l Lake. -12,5h 10 9 / l, ESR - 25 mm / h.
Task 38
The boy is 3 years old. Complaints of intermittent abdominal pain, bloating. Ill for 2
months. He did not receive treatment. Objectively: body temperature 36.4 ° C. The skin
is clean, pale pink. The tongue is covered with a whitish-yellow layer at the root,
dry. The abdomen is the correct shape, sensitive in the left half. The liver and spleen
are not enlarged. Chair recently 1 time in 3-4 days. General blood test: Leukocytes 8.5 *
10 9 / l, Hb -120 g / l; erythrocytes - 3,3 * 10 12 T / l, KP - 0,95, neutrophils: rod-nuclear -
3%, segment-nuclear - 52%; eosinophils-3%; lymphocytes-38%; monocytes -
4%; SHZE - 9 mm / year. General analysis of urine - without pathological changes. ECG
- a variant of the norm.

Answers:
1. Functional constipation
The diagnosis is made on the basis of Roman criteria IV (Two or fewer bowel
movements per week, the presence of episodes of delayed defecation, the presence
of painful bowel movements or solid stools) . 2. Outpatient treatment , adherence to
the regime of day and rest, physiologically complete diet with high content of
products that enhance the motor function of the intestine; chemically, mechanically
and thermally irritating food with sufficient fluid and fiber. Small meals are
recommended, 5-6 times a day. It is not recommended to include in the diet foods
that delay bowel movements. It is recommended to take low-mineralized, slightly
alkaline mineral waters (heated). Water is taken at the rate of 3-5 mg per kg of body
weight per reception, 2-3 times a day, 40 minutes before eating. Pharmacotherapy:
myotropic antispasmodic trimebutin at the rate of 5 mg / kg in 2-3 doses for 30
minutes. before meals, short-term use of laxatives (castor oil, magnesium salts,
lactulose)
3. Laboratory blood test - a variant of the norm.
Task 39
A 4-year-old girl was hospitalized with complaints of vomiting and abdominal pain. Ill
with SARS with hyperthermia on the 2nd day. Vomiting is repeated, appeared 8 hours
ago. Objectively: the child is drowsy, pale, the skin and mucous membranes are dry,
tissue turgor is reduced, the eyeballs are soft, tachycardia, oliguria, photo- and
phonophobia. Clinical tests are normal, blood glucose - 3.8 mmol / l, acetone in urine
3+. Objectively: reduced weight, tongue covered with white plaque, dry. On palpation of
the abdomen - pain in the epigastrium and pyloroduodenal area. Stool - once liquid.

Answers:
1. Acetonemic crisis
2. At the initial symptoms of acetonemic crisis, clean and rinse the intestines
1-2% sodium bicarbonate solution (1 teaspoon of baking soda per glass of water)
Infusion therapy the first day: Xylate at the rate of 20 ml / kg per day
The main drug for further infusion therapy should be 5 or 10% glucose solution with
insulin
The total volume of injected fluid is 50-60 ml / kg / day.
If the child wants to drink and can drink enough fluids, parenteral infusion
solutions can be completely or partially replaced by oral rehydration, which is
carried out with combined drugs.
On the first day, it is desirable not to feed the child, and give her liquid every 10-15
minutes in the form of sweet tea with lemon, still alkaline mineral water ("Luzhanskaya",
"Borjomi", "Svalyava"), 1-2% solution of baking soda sodium bicarbonate), combined
solutions for oral rehydration (Rehydron, Gastrolit, etc.) with a volume of at least
100 ml / kg body weight per day;
From the second day, begin to carefully feed foods that contain easily digestible
carbohydrates and a minimum amount of fat - liquid semolina, oatmeal or rice porridge,
crackers, biscuits, mashed potatoes in water, vegetable soup, baked apple. Eating -
frequent and small portions. Later in the diet you can enter buckwheat or wheat
porridge, steamed meatballs, fish.
Drug therapy at this stage includes the appointment of:
 Antispasmodics: drotaverine 10-20 mg 2-3 times a day

 E nterosorbent and , Sorbentohel single dose of 5g, 15g daily dose, internally 3
times a day for 1.5-2 hours before or 2 hours after eating or taking drugs, drinking plenty
of water
3. Clinical analysis of normal blood and normal blood glucose.
Task 40
Vladislav T., 9 swarms, was admitted to the hospital with complaints of runny nose,
liquid unproductive cough, anxiety, poor appetite, fever up to 38.6 ° C. Sick on the 2nd
day. On examination, the skin is pink, no cyanosis. Breathing through the nose is
difficult, mucous secretions from the nose, respiratory rate 20 in 1 minute, auscultatory -
puerile breathing with a hard tinge, single wet rales on both sides. Rhythmic heart
tones. Defecation and urination without features. In the analysis of blood - Leukocytes
8,5 * 10 9 / l, Hb -120 g / l; erythrocytes - 3,3 * 10 12 T / l, KP - 0,95, neutrophils: rod-
nuclear - 3%, segment-nuclear - 32%; eosinophils-3%; lymphocytes-58%; monocytes -
4%; SHZE - 9 mm / year. Establish a preliminary diagnosis.
1. SARS. Acute bronchitis.
2. Bed rest to normalize body temperature; heavy drinking (fruit juice, tea, fruit juices,
mineral water).
There is no need for antibacterial therapy.
For the treatment of cough, the child must choose a drug from the group of mucolytics
(bromhexine, ambroxol 15 ).
And mbroxol 15 - syrup, 5 ml 2-3 times a day
Drug correction of fever is carried out: paracetamol 200 mg, 10-15 mg / kg 2-3 times a
day
M istsev and vasoconstrictor and Means and, Nazyvin 0.05% 1-2 drops in each nostril
2-3 times a day.
3. 3. In the blood test - lymphocytosis, moderate leukocytosis
Task 41
Boy B., 6 months old, was admitted to the hospital. Life history: a child from the
second pregnancy with toxicosis in the first half, the second urgent delivery. Body
weight at birth 2950 g, length - 50 cm. Score on the Apgar scale 7/8 points. Attached to
the breast in the delivery room, sucked satisfactorily. On breastfeeding for up to 2.5
months, then transferred to artificial feeding due to hypogalactia in the mother. History
of the disease: after switching to artificial feeding (a mixture of "Nutrilon 1") the boy had
areas of redness on the skin of the cheeks with elements of microvesicles, which were
subsequently exposed to wetting with the formation of itchy crusts. At the age of 3
months on the scalp appeared diffuse grayish-yellow scales. From 4 months of age
there was a frequent change of milk formulas ("Frisolak", "Nutrilak Soy", "Nutrilon HA",
"NAS sour milk"), against which the skin manifestations intensified, involving the upper
and lower extremities, the body. In the future, the skin of the extensor surfaces of the
arms and legs, the buttocks are involved in the process. At 5.5 months, introduced
supplementary food - oatmeal in cow's milk, after which there was marked concern,
there was a sparse stool with mucus and undigested lumps, sometimes with streaks of
blood. The child lately practically does not sleep, the expressed itch worries. The child
was sent to a hospital for examination and treatment. Family history: mother - 29 years
old, suffers from eczema; father - 31 years old, suffers from hay fever, older brother - 7
years old. Upon admission, the child is sharply concerned. Manifestations of seborrheic
peeling are expressed on the scalp. The skin is almost everywhere (except the back)
covered with soaking erythematous vesicles, in places covered with crusts. Behind
ears, in the field of cervical folds, in elbow and popliteal bends, on a scrotum and in a
perineum sites with wetting and large-plate peeling are noted. Peripheral lymph nodes
up to 0.5 cm in diameter are palpable, painless, not fused with the surrounding
tissues. Puerile breathing, no wheezing. Heart tones are rhythmic, clear, heart rate -
114 beats / min. The abdomen is slightly swollen, painless on palpation in all
departments; grunting along the bowels. Liver +3.0 cm from under the costal arch. The
spleen is not palpable. Stool sparse, yellow-green, with undigested lumps and
mucus. The general analysis of blood: N - 104 g / l, Er - 3,4х10 12 / l, Ts., - 0,8, Lake -
11,2х10 9 / l, p / I - 7%, with - 33%, e - 9%, l - 41%, m - 10%, ESR - 12 mm /
year. Biochemical analysis of blood: total protein - 68 g / l, urea - 3.6 mmol / l, total
bilirubin - 16.7 μmol / l, potassium - 4.2 mmol / l. sodium -139 mmol / l, serum iron - 8.1
μmol / l, serum iron - 87.9 μmol / l, IgE - 830 IU / l.

Answers:
1. Exudative-catarrhal diathesis
2. Treatment begins with the establishment of a balanced diet.
Artificial feeding, especially with a proven allergy to cow's milk, is transferred to feeding
mixtures based on soy or highly hydrolyzed proteins.
Porridge and vegetable puree should be prepared not on milk, but on vegetable
broth. Instead of milk it is better to give kefir, biolact, and other sour-milk products.
Porridge prefer buckwheat, millet, pearl barley, rice cereals; excluded oatmeal and
semolina, replacement of sugar added to food, fructose in a ratio of 1.0: 0.3
It is desirable to replace sugar with xylitol or sorbitol
Drug therapy:
Probiotics: bifidumbacterin 5 doses 3-4 times a day, 10 days, the contents of one bottle
or package solution ichi in boiled water at room temperature at the rate of one teaspoon
of water per dose preparatu.Pryyma you for 20-30 minutes. before meals. mixing the
required amount with baby food.
Enterosorbents: enterosgel 5g (1 teaspoon), 2-3 times a day
Vitamins (vitamin A, B5, B15, E)
Antihistamines: suprastin 1/4 ampoule 0.25 ml, intramuscularly.

Local therapy: includes baths with bran, chamomile, herd, oak bark;
lotions for soaking eczema - from a decoction of tannins, oak bark, nettle
C urs of general ultraviolet radiation.
3. General blood test: decrease in hemoglobin . Biochemical analysis of blood is

normal, except for IgE - increased
Task 42
Patient Z., 7 years old, was admitted to the department with complaints of severe
edema, red urine, headache. On examination: severe condition, cavitary edema. AT -
145/95 mm Hg. An.krovi: er. - 3,1х10 12 / l, Нв - 120 g / l, lake. - 13,8х10 9 / l, ESR - 42
mm / year. In an.sech: VSh - 1029; protein 1.5 g / l, erythr. - 1/2 field of view, lake. - 4-5
in the field of view, cylinders - 10-15 in the field of view. In the biochemical en. Blood:
general. Protein - 68 g / l, albumin - 46 g / l, cholesterol 4.2 mmol / l; creatinine - 82
μmol / l, urea - 5.8 mmol / l.

Answers:
1. Acute glomerulonephritis. Nephritic syndrome. Hypertension of the first

degree. Without renal dysfunction.
2. Adequate etiotropic therapy for streptococcal infection: penicillin up to 3 million IU /

day, semi-synthetic penicillins (oxacillin, ampicillin) up to 2 million IU / day, protected
penicillins (amoxicillin) 1 g / day. 10-14 days
Tocopherol 50 mg / day 5-12 months
Chloroquine, hydroxychloroquine 0.15 mg 2 times a day with a transition of 0.25 mg /

day 5-12 months
Ramipril 2.5 mg once daily for 4-6 weeks.
heparin is administered in a dose of 15-20 thousand IU p / w 2-4 times a day for at least
3 weeks under the control of APTT.
Prednisolone 1 mg / kg / day, followed by a decrease to 2 mg daily for 6-8 weeks.
3. HOW: Anemia 1 st, leukocytosis, increased. SHOE.
BH: hypoproteinemia
Task 43
Olena K., 6 years old, became acutely ill: her temperature rose to 38.2 o C, she
vomited twice and had abdominal pain. During the next two days, abdominal pain
worsened, vomiting was repeated up to 3 times a day. The child refuses to eat, body
temperature 38.5 o C. At hospitalization (for 3 days): moderate condition, temperature
38.5 o C, pale skin, on the hands and feet - spotty-papular rash, tongue covered with
gray plaque, in rotogorli - moderate redness. Heart rate attenuated volume, pulse - 90
per minute.
The abdomen is painful on palpation in the right iliac region and around the navel, there
are symptoms of peritoneal irritation. The liver is not enlarged. Urine light. Stools 3
times a day watery without pathological impurities. It is known that the child attends
kindergarten, where during the last 5 days 6 cases of similar diseases have been
registered, and there are mice in the utility rooms. In the clinical analysis of blood:
Hemoglobin - 125 g / l; Er. - 4.4x 10 9 / l; k.p. - 0.9; Leukocytes - 16.2x10 9 / l; e - 1%; n -
8%; c - 66%; l - 22%; m - 3%; Platelets - 230x10 9 / l; ESR - 16 mm / year.
1 Your clinical diagnosis.
2 What laboratory tests should be ordered to confirm the diagnosis?
3 Prescribe treatment.
4 Plan anti-epidemic measures in the center of the disease.
5 Interpret the results of the clinical blood test.
Answers:
Answers:
1. Yersiniosis, gastrointestinal form, moderate.

2. General blood test - leukocytosis, neutrophilia, rod-shaped shift,
accelerated ESR, eosinophilia;
General analysis of urine - protein in small quantities, leukocytes, cylinders -
single;
Coprogram - mucus, single erythrocytes, leukocytes;
Bacteriological method - detection of the pathogen in feces, urine, blood, pus,
mucus from the oropharynx, lymph nodes (if necessary);
Serological method - reaction of agglutination (RA) and indirect hemagglutination
(RNGA) with live or killed culture of yersinia in dynamics. Diagnostic titers in RA -
1:40 - 1: 160, and RNGA - 1: 200. The highest titers of agglutinins at children appear
at 2-4 weeks of an illness.
3. Hospitalization in the infectious department, bed rest. Diet therapy - table

№ 4 according to Pevzner . Causal therapy, antibiotic therapy
chloramphenicol 0.5 g 3 times / day w / p , cephalosporins III
generation ceftriaxone 0.5 g, 2 times / d / v p ,. The course of treatment is 7-10
days.
Detoxification therapy of glucose-saline solutions.
Desensitizing therapy (antihistamines ) suprastin 0.5 ml 2 times / day intravenously .
Stimulators of phagocytic activity of neutrophils (metacyl) - 0.2 x 3 times - 10-15
days. Multivitamins.
4. The epidemic centers carry out deratization and final disinfection, examine
workers who work with food, patients are hospitalized and discharged after
clinical recovery and a negative bacteriological examination of feces, contact
persons are observed for 21 days
5. According to the results of laboratory examination in the blood
leukocytosis, a slight increase in rod neutrophils and increased ESR, which
indicates an infectious inflammatory disease of bacterial etiology.
Task 44
Patient A., 9 years old, was admitted to the clinic on the 7th day of illness with
complaints of yellowing of the skin and sclera, dark urine, single vomiting, loss of
appetite, fever up to 38 o C for 2 days.
Objectively: flaccid, temperature 36.8 o C, yellow skin and sclera,

heart rate attenuated volume, 68 per minute, the liver protrudes from the ribs by 3 cm,
sensitive to palpation, soft-elastic, spleen palpable is not detected. Cutting is
dark. Acholic feces. In the analysis of blood -IgM to HAV (anti-HAV IgM) by ELISA - 1.9,
IgG to HAV (anti-HAV IgG) by ELISA - 0.7.
1 Formulate a preliminary diagnosis.
2 What basic laboratory tests should be performed to confirm the diagnosis?
3 Principles of treatment of this child.
4 Plan non-specific preventive measures to prevent this disease in others.
5 Interpret the results of the blood test.
Answers:
1. Viral hepatitis A, jaundice, moderate.
2. Clinical blood test, urine test for bile pigments and urobilin, thymol test, determination
of prothrombin index and fibrinogen, biochemical blood test (alkaline phosphatase,
bilirubin and its fractions, ALT, AST activity), determination of markers of hepatitis,
detection of virus RNA by PCR.
3. Hospitalization in the infectious department;

regime - bed to the disappearance of symptoms of intoxication, semi-bed - to the
normalization of health, the disappearance of jaundice and normalization of laboratory
parameters;
Gastric lavage and high cleansing enema;
Dezintoksikatsiyna therapy - intravenous drip centuries edennya solution in an amount
of 50-100 mL / kg to boo, 5% glucose solution, a solution Ri nheru-lactate, 0.9% sodium
chloride; enterosorbents 2-3 weeks (Atoxil 12 g / day pre-dissolved 1 sachet per 100 ml
of liquid, Enterosgel 5 g 3 times / day); Lactulose preparations - in the age dose of 10-
14 days; deoxycholic acid 10 g / kg; with the threat of the development of the fulminant
form of prednisolone in a daily dose of 1-2 mg / kg 4 times a day for 7-10 days.
4. Isolation of patients, to ensure proper sanitary and anti-epidemic regime in the

presumed center of infection, to carry out current and final disinfection in the center, to
establish observation of contact persons for 35 days, to follow the rules of personal
hygiene, to discharge patients after clinical recovery and normalization of laboratory
parameters.
5. Due to the level of anti - HAV IgM (> 1) and anti - HAV Ig G ( <20 mIU / ml) can be
suspected acute viral hepatitis A
Problem 45
The 12-year-old girl was in Uzbekistan with her relatives in the summer. A few days
after returning, the body temperature rose, he felt worse, then there were signs of
jaundice, anemia, brick-red urine.
In the analysis of blood -IgM to HEV (anti-HEV IgM) by ELISA - 1.9, IgG to HEV
(anti-HEV IgG) by ELISA - 0.7.
1 What is your previous diagnosis?
2 What modern methods are used for laboratory diagnosis of this disease?
3 Principles of treatment of this child.
4 Plan non-specific preventive measures to prevent this disease in others.
5 Interpret the results of the blood test.
Answers:
1. Acute viral hepatitis E. Jaundiced form. Moderate.

2. ELISA, X-ray diffraction and PCR are used for diagnosis (the most
sensitive method)
Regime - bed to the disappearance of symptoms of intoxication, semi-bed - to the

normalization of health, the disappearance of jaundice and normalization of laboratory
parameters;
Detoxification therapy - intravenous drip solutions in the amount of 50-100 ml / kg per
day, 5% glucose solution, Ringer's lactate solution, 0.9% sodium chloride
solution; enterosorbents 2-3 weeks (Atoxil 12 g / day pre-dissolved 1 sachet per 100 ml
of liquid, Enterosgel 5 g 3 times / day); Lactulose preparations - in the age dose of 10-
14 days; deoxycholic acid 10 g / kg; P ri threat of fulminant forms: Prednisolone daily
dose of 1.2 mg / kg 4 times daily cont 7-10 days.
3. As with other intestinal infections, it is important to assess the state of

natural and social conditions: water quality, food, sanitary and epidemiological
regime in children's, medical, educational and other institutions where infection
with GE can occur. The epidemic centers carry out current and final disinfection
using a 3% solution of chlorine-containing drugs and chamber disinfection.
4. Serreau logically confirmed hepatitis E .
Task 46
The child is 9 months old, fell ill with lethargy, vomiting, refusal to eat, on the 3rd day the
urine darkened. Objectively: on the 5th day of the disease the child is lethargic,
adynamic, decreased appetite, jaundiced skin and sclera. The liver protrudes 4 cm from
under the ribs, the spleen 1 cm below the ribs. Urine is dark, feces is acholic. From the
anamnesis it is known that at the age of 7 months the child had pneumonia, received
treatment, including blood transfusions. On the 3rd day of stay in the hospital, the child
vomited "coffee grounds", refused to eat, had convulsions, loss of consciousness. Blood
test for bilirubin: total - 216.6 μmol / l, direct - 80 μmol / l, indirect - 136 μmol / l, ALT -
1.2 mmol / l, prothrombin - 38%, sulem test - 1.2 ml.
1 Formulate a preliminary diagnosis?
2 What studies need to be conducted to establish the etiology of the disease.
3 Tactics of patient management.
4 What is the specific prevention of this disease, when and how is it carried out?
5 Evaluate the above biochemical blood test.
Answers:
1. Viral hepatitis B fulminant form. Acute liver failure.
2. Treatment in the intensive care unit:

- gastric lavage and high cleansing enema ;
- catheter and tion of the central vein, nasogastric tube;
- Infusion therapy: infusion volume for detoxification (including persperative and
pathological losses) 50-100 ml / kg with correction of electrolytes and CBS.
Restoration of energy processes, infusion of 10-20% glucose in a daily dose of 5-10 g
/ kg. + insulin 1 UNIT per 4 g of glucose
Ringer Locke's solution (5 ml / kg / h), 0.9% phys. Rn (20 ml \ kg \
day), Rheopolyglucin (10 ml \ kg \ day), rn KCl (under the control of level K),
glutamine to and 50 ml of 1% solution, hepasteril A (1, 5 ml / kg / hour), albumin 10 ml
/ kg .
Mandatory potassium subsidy, which depends on the level of potassium in the blood
and is calculated by the formula : Potassium deficiency - D (K) = (K mmol / l desirable - K
mmol / l patient ) x body weight x0.3.
Physiological need - AF (K) = 2 mmol / kg
During parenteral nutrition, AF (K) + D (K) mmol is administered, divided into 2-3
injections. Use a solution of 7.5% KCl (1 ml-1 mmol / l ).
During enteral nutrition, only D (K)
is administered - prednisolone 10 mg / kg per day in 4 hours in equal portions without a

night break;
- Lasix 1 mg \ kg;
- heparin 100 U \ kg;
- lactulose 5 ml 1 time per day;
- hemostatics: 12.5% solution etamsylate (dytsynonu) intramuscularly - anticonvulsant
therapy: diazepam 0.5-1.0 mg / kg a / a - f ryhnichennya intestinal flora -
antibiotics : kanamycin 0.1 g / day , ampicillin - 20–40 mg / kg every 4 hours , for 5
days.
4. Vaccination is carried out in children (1 day - 2 months - 6 months), as well as adults

after determining the level of antibodies to the hepatitis b virus. Vaccinated three times:
the second dose is administered 1 month after the first, the third - 6 months after the
first. If after the course of vaccination studies show that the level of antibodies below
100 MU \ l then enter another booster dose of the vaccine
5. BH blood: hyperbilirubinemia due to both fractions, increased ALT, decreased PTI
Task 47
The child is 3 months old, sick for 8 days. The disease began with a cough, body
temperature of 36.5 o C. 5 days after the onset of the disease examined by a doctor - a
diagnosis of SARS. The cough worsened at night. Prescribed treatment is not
effective. From the anamnesis it is known that the child's father coughs for a month.
On day 10-11, the child's cough became paroxysmal up to 15 times a day, with the face
reddening, the tongue was protruded during the cough, there was cyanosis of the
nasolabial triangle. The child took a forced position. There was tearing. After an attack
of cough, viscous sputum was released. In one of these attacks, the child turned blue
and stopped breathing. In the lungs hard breathing, no wheezing. Rhythmic heart tones,
tachycardia. In the clinical analysis of blood: Hemoglobin - 115 g / l; Er. - 4,0х 10 9 /
l; k.p. - 0.9; Leukocytes - 19.2x10 9 / l; e - 1%; n - 2%; c - 22%; l - 72%; m - 3%; Platelets
- 230x10 9 / l; ESR - 2 mm / year.
The patient has a 6-year-old brother who attends kindergarten. Vaccinated,

revaccinated. The neighbors have a five-month-old baby.
1 Give the patient a clinical diagnosis.
2 What additional research methods should be performed to confirm the diagnosis? 2

Name the criteria for a confirmed diagnosis of pertussis according to WHO and CDC
recommendations.
3 Assign the patient etiotropic treatment.
4 What anti-epidemic measures need to be taken?

Answers:
1 Pertussis is typical, a period of spasmodic cough, severe form, apnea.

2 General blood test - leukocytosis, lymphocytosis, normal SEE;
Bacteriological - secretion of B. pertussis from mucus from the nasopharynx;
Positive PCR for B. pertussis (material of nasopharyngeal mucus);
Serological method - detection of IgA and IgM antibodies to B.pertussis in the blood.
According to the WHO and CDC recommendations, pertussis is considered to be
confirmed in a typical clinical picture and with positive PCR results or in established
contact with a pertussis patient (who has a laboratory-confirmed case of the disease).
3. Etiotropic therapy : azithromycin - 10 mg / kg (not more than 500 mg) orally for 5
days or Clarithromycin 7.5 mg / kg (not more than 500 mg) orally every 12 hours for 7
days;
maximum aeration; to remove apnea, it is necessary to clean the oral cavity of mucus,
artificial respiration, humidified oxygen or oxygen tent, the appointment of neuroleptics -
aminazine 0.6% 0.2 ml 2 times a day before bedtime and night, antihistamines (tavegil
or diazoline), ATC.
4. Isolate patients for 31 days without laboratory confirmation or after two negative
bacteriological tests for 25 days; The brother of a sick child should be observed for 14
days. A neighbor's child should be given 1.5 ml of human immunoglobulin and observed
for 14 days (during the incubation period).
5. According to laboratory tests in the child's blood there is leukocytosis with

lymphocytosis on the background of normal SHO E, which is one of the signs of
whooping cough.
Task 48
Sasha M., 6 years old, became acutely ill with a rise in body temperature to 39.7 0 C,
sore throat and joints, headache, vomiting twice. The next day ' appeared rash on the
skin .
Rev. objectively, on the second day of the disease condition serious, conscious, pale
pronounced nasolabial triangle. On the skin of the forehead, cheeks, neck, inguinal
fossae, lower abdomen, elbow, popliteal fossae, a small bright pink rash located on a
hyperemic skin background, in some places a miliary rash. In the oropharynx -
demarcated bright red redness, swollen tonsils, loose, in the lacunae - pus. The tongue
is covered with a white plaque, submandibular lymph nodes are enlarged to 2.5 cm,
dense, painful. Rhythmic heart tones. Pulse is intense - 122 beats. for 1 minute On the
5th day of the disease - bradycardia, muffled tones, gentle systolic murmur at the apex
of the heart.
In the clinical analysis of blood: er. - 3,5х10 12 / l; Hb -110g / l;
L-16x10 9 / l, e-5%, n-5%, c-67%, l-20%, m-3%, ESR-20 mm / year.
1 Formulate a clinical diagnosis.

2 List the main criteria for diagnosis.
3 Prescribe etiotropic treatment to this patient
4 What preventive measures should be taken?
Answers:
1. Scarlet fever is a typical, moderate form. Infectious and toxic myocarditis.
2. Criteria for diagnosis for this patient:
• incubation period - from several hours to 7 days;

• the onset of the disease is acute;
• intoxication syndrome: fever up to 39.7 0 C, b Il in joints, Home ground would Ile ,
twice is vomiting.
• rash appeared on the 2nd day of illness;
• specific morphology of the rash: small bright pink rash located on a
hyperemic skin background ;
• places of predominant localization of the rash: on the skin of the forehead,
cheeks, neck, groin, lower abdomen, elbow, popliteal fossa
• no rash in the nasolabial triangle (Filatov's symptom);
• sore throat;
• sore throat and limited hyperemia of the soft palate ("burning throat") :
in the oropharynx - demarcated bright red hyperemia, swollen tonsils, loose, in
the lacunae - pus - lacunar sore throat;
• the tongue is covered with a white plaque, which from 2 to 4-5 days is
gradually cleared of plaque, becomes bright crimson, enlarged papillae
appear (crimson "tongue," papillary "tongue);
• regional submandibular or cervical lymphadenitis : submandibular lymph
nodes enlarged to 2.5 cm, dense, painful.
• of mine phases of the autonomic nervous system: the first 3-4 days
tachycardia, increased blood pressure, with 4-5 day bradykardi I lower
blood pressure : p uls stressful - 122 bpm. for 1 minute On the 5th day of illness
- bradycardia .
+ you can still find the following features that are not described in the problem:
• white dermographism;
• symptom of Pastia - accumulation of rash in places of natural and artificial
folds of skin and the appearance of linear hemorrhagic elements of the rash;
• peeling of the skin from the end of the first week: on the face, neck - bran,
on the torso, limbs - small-plate, on the hands and feet - large-plate;
3. Bed rest during the acute period;
1. Etiotropic therapy:
Amoxicillin 30-50 mg / kg / day for 4 injections, intramuscularly
2. Detoxification therapy: Isotonic sodium chloride solution (0.9%)

3. Antihistamines: suprastin 25 mg 1/2 tablet 2 times a day;
4. Drugs that strengthen the vascular wall : askorutin 50 mg, 1 tablet 2 times
a day
5. Antipyretic drugs: ibuprofen 7.5 ml of suspension (150 mg) every 8 hours,
but not more than 3 times a day
6. Means of local sanitation: gargling with disinfectant solutions (furacillin 20
mg -1 tablet dissolved in 100 ml of water)
4. Urgent notification to the SES. Isolation of the patient for 22 days. In kindergarten in
the group where the patient was quarantined for 7 days. Throughout the quarantine
period, daily inspection of contact with thermometry.
5. In the blood leukocytosis, decreased lymphocytes and increased segmental,

increased ESR
Task 49
A 3-year-old child became acutely ill with a rise in temperature to 38 0 C. The

temperature remained at this level for 3 days, then joined the malaise, nasal mucosa,
pain when swallowing, lack of movement in the left leg. The child was hospitalized on
day 7 of illness.
Objectively, there was a decrease in the tone and strength of the muscles of the left
leg, tendon reflexes on the left, when walking pulls the left leg. In a throat the catarrhal
phenomena, on a mucous membrane of a soft palate, a vesicle language in the size of
2х3 mm. A systolic murmur is heard at the apex of the heart. In the cerebrospinal fluid:
color - transparent, protein - 0.16 g / l, p-tion Panda - (-), sugar - 2, 7 mmol / l (in the
blood - 5,4 mmol / l), chlorides - 104 mmol / l, cirrhosis - 7 cells / mm 3 (99%
lymphocytes).
After the appointment of treatment, the child's condition gradually improved, the
temperature returned to normal. Complete recovery of muscle strength came on the
15th day.
1 What diseases should be considered?
2 What laboratory tests should be performed to resolve the diagnosis?
4 What is the specific prevention of this disease?
5 Interpret the results of the cerebrospinal fluid analysis.

Answers:
1 Polio, enterovirus COXACY, ECHO infection.
2. Laboratory diagnosis is performed using virological, serological examination of

patients;
- virological examination should be performed as soon as possible from the onset of

the disease - the virus is detected in nasopharyngeal lavage, feces, as well as in blood
and cerebrospinal fluid taken in the first week of illness. The virus is cultured on cells
from monkey kidneys or human embryos and amnions;
- serological examination - increase in antibody titer in the neutralization reaction

(rarely hemagglutination inhibition reaction) not less than 4 times in paired sera taken at
the beginning of the disease and after 4-5 weeks.
3. There are no etiotropic drugs for the treatment of patients with polio.
Complete calm, strict bed rest .
Pathogenetic and symptomatic treatment :
Oral or parenteral rehydration.
Severe muscle pain requires the appointment of analgesics: analginum 50% 0.1
mL / year of life 1-2 times a day / m or / in, but no more than 3 days, moist
warm compresses to the area hrilok affected muscles .
The warmer is left for no more than 15-20 minutes, the procedure can be repeated in 3-
4 hours. The correct position of the patient in bed significantly relieves muscle pain.
Important in the treatment is physiotherapy (UHF on the affected segments of the spinal
cord, transverse and longitudinal diathermy), exercise therapy, massage .
Stimulation therapy can be started only after the complete end of the active process in
the spinal cord (ie not earlier than 3-4 weeks), it should be easy for the patient, the
choice is individual. Not earlier than the 14th-20th day from the beginning of the disease
in the period of pain reduction and the appearance of movements, stimulants of
interneural and motoneural conduction are prescribed - proserine, dibazole. In the early
recovery period for 20-25 days, anabolic hormones (nerobol, retabolil) are prescribed,
but polypragmatism is unjustified, sequential therapy is appropriate.
4. The main way to prevent polio is routine immunization of all children from two
months of age, with periodic routine revaccination.
Polyvaccines registered in Ukraine include:
- live (OPV): - polio oral vaccine 1, 2, 3 types, Russia; - OPVERO, France;
- inactivated (IPV): - monovaccines (Imovax polio, Belgium); - as a part of combined:

"Pentaxim", France; "Infanrix IPV", "Infanrix Hexa", Belgium).
1st dose: 2 months - IPV
2nd dose: 4 months - IPV
3rd dose: 6 months - OPV;
4th dose: 18 months - OPV;
5th dose: 6 years - OPV;
6th dose: 14 years - OPV.
5. According to the results of analysis of cerebrospinal fluid within normal limits,

except for chlorides - their number is reduced.
Problem 50
A 6-year-old child was admitted to the clinic 18 hours after the onset of the
disease. Ill acutely, when the body temperature rose to 39.9 0 C, there was vomiting,
abdominal pain, cramps of clonic-tonic nature, lost consciousness. The child was taken
to the clinic by ambulance.
Objectively: the condition is serious. In consciousness, body temperature

39.5C 0 . The skin is pale, the tongue is covered with a gray plaque. Vesicular
respiration in the lungs. Heart tones attenuated volume, rhythmic. Pulse - 110 per
minute, rhythmic. Belly of which , with a na lei . The liver and spleen
are not palpable . The sigmoid colon is spasmodic , sensitive . Stools
are liquid with mucus and blood in small portions.
Blood test: er.-3,1x10 12 / l, hemoglobin 102 g / l, leukocytes - 7,6x10 9 / l,
e-2%, n-16%, c-24%, l-50%, m-8%, ESR-4 mm / year.
Coprogram - undigested fiber, mucus, leukocytes - 10-15 in p / z.
The family has another child - a 5th grade student.
1 Your previous diagnosis.
2 What is the purpose of coprologic examination?
3 Urgent therapy for convulsive syndrome.
4 Can an older child attend school during quarantine?

5 Interpret the results of the clinical blood test and coprogram.
Answers:
1. Dysentery clinically, typical severe form, acute course. Degree of
dehydration III.
2. The coprogram allows to estimate functional activity of a stomach,

intestines, a liver and a pancreas, to reveal existence of inflammatory
processes and a dysbacteriosis. This analysis makes it possible to study
the effectiveness of the body's digestive processes, the process of
absorption of nutrients in the small, duodenum.
3. At the prehospital stage:
- relanium 2 ml intramuscularly or
lytic mixture (aminazine 1 ml - 2.5%, diphenhydramine 1 ml - 1.0%, novocaine 4 ml

- 0.5%) 0.1 ml of the mixture per 1 kg of body weight (2 ml).
In the hospital:
- detoxification therapy (10% glucose, saline NaCl , albumin or concentrated

plasma - 10 ml / kg);
- relanium 2 ml or sodium oxybutyrate 50-100 mg / kg (5-10 ml);
- osmodiuretics: mannitol 1-2 g / kg body weight;
- Euphyllin 1ml - 2.4% per year of life;
- furosemide 2-3 mg / kg;
At signs of a brain hypostasis prednisolone 3-5 mg / kg of weight or

dexamethasone.
4. No, it is not possible, because the supervision of contact persons is carried out for
7 days, with mandatory bacteriological examination of feces.
5. In the blood - anemia, rod shift. In the coprogram - signs of inflammation in the
colon.
Problem 51
The child is 5 months old. (weight-6 kg) fell ill 2 days ago, when it became worse to
suck, restless, t-38 ºC, there is difficulty breathing through the nose. This morning at 6
o'clock. Vomiting was noted 3 times in 30 minutes, t-39.3ºC, the child is
restless. Delivered to the hospital. The condition is serious. Sleepy, there is tremor of
the hands. The skin is pale, on the lower extremities single hemorrhagic elements of the
rash from 1 to 3 mm, asymmetrical, cherry color, irregular shape. Heart tones are
weakened, tachycardia, heart rate-180 per minute. Vesicular respiration in the
lungs. The abdomen is soft. Hyperesthesia. The child throws back his head, a large
spring explodes, a positive s-m Lesage. In the clinical analysis of blood: Hemoglobin -
122 g / l; Er. - 4.2x 10 9 / l; k.p. - 0.9; Leukocytes - 17.2x10 9 / l; e - 1%; n - 8%; c - 68%; l
- 21%; m - 3%; Platelets - 190x10 9 / l; ESR - 24 mm / year.
1 Formulate a diagnosis of a sick child.
2 What studies confirm this diagnosis?
3 What medical care is provided to children in the prehospital stage with this disease?
4 What anti-epidemic measures are carried out in the center of infection?
5 Interpret the results of a clinical blood test.
Answers:
1. Acute meningitis of unknown etiology, complicated by cerebral edema?
2 . If meningitis is suspected, blood and cerebrospinal fluid tests are
performed. The obtained samples are sent to the laboratory, where
specialists make a culture to identify a specific pathogen
3 . Prehospital stage of treatment
Providing venous access.
Antibacterial therapy - chloramphenicol sodium succinate 25 mg / kg (single
dose) intravenously.
Glucocorticoids 1-3 mg / kg on prednisolone.
Infusion therapy with saline and colloidal solutions.
Antipyretics. ( ibuprofen 5-10 mg / kg by mouth)
Furosemide - 1-2 mg / kg.
At spasms - diazepam in a dose of 0,3-0,5 mg / kg
body weight once (not more than 10 mg per injection).
Monitoring of the child's condition (observation) at the pre-hospital
stage
1. Assessment of the severity of the child's condition: the dynamics of
pathological symptoms -
skin and mucous membrane color, rash, consciousness.
2. Measurement of blood pressure.
3. Thermometry, heart rate, BH (characteristics of mechanics), pulse oximetry.
4. Control of airway patency.
4. In the epidemic center there are persons who have communicated with the
patient during the last 10 days. Their examination by an infectious disease doctor
and an ENT doctor is organized in order to identify patients with
nasopharyngitis. Contact persons are placed under medical supervision for 10
days (measurement of body temperature, examination of the nasopharyngeal
mucosa and skin). Contact persons must be bacteriologically examined once for
meningococcus, for this on an empty stomach or 2 hours after a meal, a swab is
taken from the nasopharynx.
5. increase in leukocytes and ESR - the presence of the pathogen + intoxication
Task 52
An 9-year-old child was examined by an ambulance doctor. Complaints of severe

headache, vomiting, fever up to 39.3 0 C. Sick on the fourth day, the disease began with
swelling in the parotid salivary glands, pain when chewing and opening the mouth. Not
treated. On examination, the child's condition is serious. The skin is pale. In the parotid
area there is swelling, the skin over the swelling is not changed, the rigidity of
the muscles of the back of the head , positive symptoms of Kernig , Brudzinsky . The
frequency of heart contractions -120 for 1 minute . On examination of the oropharynx,
the opening of the Stenon duct is hyperemic and. Belly of which is painless. Defecation
and urination without features. In the analysis of cerebrospinal fluid: color - transparent,
protein - 0,33 g / l, p-tion of Panda - (-), sugar - 2,7 mmol / l (in blood - 5,4 mmol / l),
chlorides - 104 mmol / l, cirrhosis - 1037 cells / mm 3 (99% lymphocytes).
2 What methods of specific diagnosis are used to confirm this disease?
3 What are the tactics of an ambulance doctor?
4 List the anti-epidemic measures that need to be taken.
5 Interpret the results of the cerebrospinal fluid.
Answers:
1 Mumps infection, typical combined (mumps, meningitis) severe form.
2. Virological method: examine saliva, blood;
- serological reactions: RGGA with paired sera in the range of 7-14 days detect
antibodies to increase the titer in 4 or more times;
- ELISA: specific IgM antibodies are detected, indicating an active process;
3. Hospitalization of the patient to the hospital. Submit an urgent notification to the

SES.
4. Isolate the patient, inform the SES, quarantine contact children in kindergarten for
21 days with daily contact examination and thermometry.
5. According to the results of analysis of cerebrospinal fluid, we can say that chlorides -
their number is reduced, lymphocytic (98%) pleocytosis (thousands of cells in 1 μl) .
Problem 53
The district doctor examined a 6-year-old sick child. Complaints of fever up to

38.2 0 C, loss of appetite, rash. Ill for 3 days. At inspection the child is weak. The skin is
pale, on the scalp, face, torso, extremities polymorphic rash: red spots, papules,
vesicles up to 3-5 mm in diameter, filled with a clear liquid. The vesicles are located on
an uninfiltered basis. No other pathological signs of the disease were detected. Before
the disease, the child attended kindergarten. When carried out 5 days after the onset of
ELISA: IgM antibodies to herpes virus type 1/2 - 0.4, to herpes virus type 3 - 1.12.
1 Formulate a diagnosis of a sick child.
2 Diagnostic criteria for chickenpox.
3 What drug is a means of etiotropic therapy, its dose.
4 What measures should be taken to prevent the spread of the disease?
5 Interpret the results of ELISA blood.
Answer:
1. Chickenpox (ELISA +), typical form, moderate.
2) DIAGNOSTIC CRITERIA:
CLINICAL:
Typical forms of chickenpox
The disease begins acutely with a rise in body temperature, the height of which is
determined by the severity of the disease, and with the appearance of a rash.
Sometimes 1-5 days before the appearance of the rash, prodromal phenomena in the
form of subfebrile fever, lethargy, loss of appetite and the appearance of "resh rash"
(scarlet fever, erythematous, crusty) are observed.
Chickenpox appears at the same time as the temperature rises or a few hours later. At
first, small spots are formed, which quickly turn into papules and vesicles. Vesicles are
usually single-chambered.
The rash is located on the skin of the torso, face, limbs, scalp, rarely on the mucous
membranes of the mouth, respiratory tract, eyes, external genitalia.
The rash may be accompanied by itching.
On the mucous membranes, the elements of the rash are quickly macerated with the
formation of surface erosions, which heal within 1-2 days.
On the skin, the blisters gradually fade, dry up and become crusty. After peeling of the
crusts in their place for a long time remains a slight pigmentation, in rare cases - scars.
The process of rash occurs in shocks, with an interval of 1-2 days, for 2-4 days, in rare
cases up to 7 days or more. Therefore, there is a false polymorphism of the rash.
The diagnosis of chickenpox can be made based only on clinical diagnostic criteria. In
cases of complex clinical diagnosis, additional examinations are used.
PARACLINICAL STUDIES:
General blood test: leukopenia, relative lymphocytosis, normal ESR.

X-ray diffraction allows to detect the antigen of the virus in smears - prints from the
contents of vesicles.
Paired sera are used for serological testing. An increase in titer of 4 or more times
within 10-14 days is considered diagnostic. Studies are performed using RZK, RNGA,
ELISA, RIA.
3) Acyclovir is administered intravenously at 10 mg / kg body weight 3 times a day. The

course lasts 7 days or 48 hours after the appearance of the last elements of the
rash. Immunocompetent children over 2 years of age and adolescents with severe
forms of acyclovir can be administered orally at a dose of 80 mg / kg per day.
4) Submit an urgent notification to the SES. Isolate the sick child for 5 days after the
appearance of the last element of the rash. Children who did not have chickenpox and
were in contact with the patient are subject to quarantine from 11 to 21 days after
isolation of the patient (in the first 10 days from the beginning of contact with the patient
the disease is not possible because the minimum incubation period is 11 days).
5) ELISA - herpes virus type 1 and 2 negative, type 3 (Varicella Zoster) positive
Problem 54
Boy M., 1 year and 4 months, was taken to the hospital by ambulance with
complaints of fever, hoarseness, frequent "barking" cough, shortness of breath. Ill
acutely at night, when in his sleep there was an attack of whooping cough,
hoarseness. Two hours later, an increase in body temperature to 38 0 C was detected ,
shortness of breath increased and the child was taken to the hospital.
On examination, the condition is serious. Body temperature 38.8 0 C. The skin is pale,
clean, significant periorbital and perioral cyanosis. Hyperemia in the throat. The voice is
hoarse, the cough is rough, "barking". Breathing is whistling, heard in the distance, the
act of breathing involves the accessory muscles, a pronounced retraction of the jugular
fossa. BH 60 for 1 min. Percussion over the lungs, the difference in percussion lung
sound is not determined. Auscultatory dry rales on both sides on the background of
evenly weakened breathing. Attenuated heart tones. Heart rate 140 per minute. When
conducting a clinical blood test, the following results were obtained: Hemoglobin - 127 g
/ l; Er. - 4.2x 10 9 / l; k.p. - 0.9. Leukocytes - 3.9x10 9 / l; e - 2%; n - 2%; c - 27; l - 66%; m
- 3%; Platelets - 219x10 9 / l; ESR - 5 mm / year.
1 Make a diagnosis.
2 What is the most informative method of diagnosing this infection?
3 What are the rules of hospitalization for this disease?
4 What anti-epidemic measures should be taken in the room where the patient is?

Answers:
1) SARS, stenotic laryngotracheitis II. (subcompensated).
2) Of particular importance is the use of rapid diagnosis of ARI, due to the emergence of
etiotropic treatments, which are most effective in the first 2 days of the disease. During
this period, the immunochromatography reaction is used, the advantage of which is
primarily in speed (the result is obtained in 15 - 20 minutes after the reaction, which can
be carried out directly at the patient's bedside, does not require laboratory staff and
special equipment - Cito-test), immunofluorescence reaction receive in 2 - 3 hours, is
carried out in the laboratory). When influenza is suspected, the method of
immunochromatography allows you to quickly establish the type and even subtype of
the virus that affects the patient.
3) Hospitalization in the infectious department. Isolation of patients in boxes or semi-

boxes, as a last resort, in small wards.
4)
- ventilate the room more often and carry out wet cleaning;
- follow the rules of personal hygiene: wash your hands often with soap;
- do not touch eyes, nose or mouth with unwashed hands;
-apply personal protective equipment (masks)
The room should be cleaned wet with disinfectants and ventilated 3-4 times a
day. Viruses are especially quickly disinfected with a solution of chlorine-containing and
other disinfectants registered in Ukraine, which can be purchased in
pharmacies. Disinfectants are prepared according to the instructions for use of the
manufacturer (as for drip viral infections) and are used once. For wet cleaning use
traditional, long-known tools that have proven themselves: 2.5% soap solution, 0.5%
soda solution, 0.2% citric acid solution and household chemicals that have disinfectant
properties ("Domestos" , “Linen”, etc.). One of these solutions should be wiped
windowsills, doors, bedside tables and other furniture in the room and wash the
floor. Cleaning should be done in rubber gloves
5) Leukopenia, lymphocytosis
Problem 55
The child is 5.5 years old, sick the first day. There is an increase in body temperature to
37.3C 0 , a small spotted rash of pale pink color on the face, torso, extensor surfaces of
the hands, palpated enlarged occipital and cervical lymph nodes. The mucous
membrane of the pharynx is moderately hyperemic. Avidity of IgG antibodies to rubella
20%.
1 What diagnosis is likely in this case?

2 What tests should be prescribed for this disease?
3 List the main directions in the treatment of the patient.
4 Schedule major anti-epidemic measures at the site of infection.
5 Interpret the blood test.
Answers:
1. Acquired rubella, typical form, moderate.
2. Serological tests: RGGA, RZK, RN (4-fold increase in antibody titer), ELISA -

detection of IgM antibodies, PCR (identification of virus RNA).
Virological examination: isolation of the pathogen from the blood, nasopharyngeal

lavage, urine in the first 5-7 days of the disease on cell cultures.
Clinical blood test: leukopenia, neutropenia, relative lymphocytosis, monocytosis, the

presence of plasma cells up to 10 - 15%, Turk cells 10 - 25%.
3. Symptomatic therapy: antipyretic drugs with fever (ibuprofen 5-10 mg / kg 3 times a

day, ie every 8 hours
or paracetamol 10-15 mg / kg every 6 hours.
Sufficient rehydration.
4. Urgent notification to the SES. Isolation of the patient for 5 days from the time of the
rash. For children who have been in contact with the patient, isolation is not required,
but the group of the children's institution is quarantined for 21 days.
5. Avidity of IgG antibodies to rubella 20%.

Antibody avidity is a laboratory indicator that shows the number of antibodies out of 100
that bind strongly to the rubella virus.
20% - low avidity, which indicates that less than 3 months have passed since the initial
infection .
Task 56
The baby was born in the 8th month of pregnancy. She was diagnosed with:
microcephaly, cataracts, heart disease. The mother of the child in the 2nd month of
pregnancy was ill: there was a short rise in temperature to 37.5 o C, swollen lymph
nodes and a small spot on the face, torso and extremities, which passed after 3 days
without residual effects. The child maintains high titers of IgG against rubella for 6
months.
1 What infection can cause such a clinical picture?

2 What paraclinical studies are performed to confirm this disease.
3 What is the treatment of patients with this disease?
4 What are the tactics of managing children whose mothers had this infection or were in
contact with the patient during pregnancy?
Answer:
1. Congenital rubella
2. I . COLLECTION OF HISTORY OF LIFE AND OBSTETRIC HISTORY OF THE

MOTHER: whether the woman had rubella before pregnancy, whether there were
skin rashes during pregnancy as so, at what time of pregnancy, whether she was
vaccinated against rubella, early childhood and rubella in early childhood whether
these vaccinations have been documented;
II . COLLECTION OF EPIDEMIOLOGICAL HISTORY OF PREGNANT WOMAN:
whether she was in contact with patients who would have a rash during pregnancy;
III . GENERAL CLINICAL EXAMINATION OF THE NEWBORN CHILD: detection of
typical for congenital rubella malformations - Greg's triad (deafness, blindness, heart
defects), or signs of intrauterine infection .
3. Today, congenital rubella cannot be completely cured. All measures are aimed at
improving the quality of life of the child. Drug therapy is based on the use of drugs
that increase antiviral immunity. Other methods include relief of symptoms and
elimination of concomitant diseases: critical heart defects are operated on, hearing
and vision disorders are eliminated if possible , intracranial pressure
is corrected . Because congenital rubella affects a child's mental development and
makes them disabled, in most cases, social adaptation and the help of a psychologist
are needed.
4. If a woman is infected in the 2-3rd trimester of pregnancy, she should be

monitored using, if possible, PCR, RNA hybridization in the chorionic villus biopsy or
virological examination of amniotic fluid, ultrasound, Doppler examination of fetal and
umbilical vessels, determination of fetoprotein. Direct determination of rubella antigen
and RNA in a sample of choroid villi biopsies or specific IgM in fetal blood obtained
from a percutaneous umbilical cord blood sample has been successfully performed.
Children born to mothers who had rubella during pregnancy or were in contact with a
rubella patient are subject to dispensary observation for at least 7 years with mandatory
regular examination by a pediatrician, ophthalmologist, otolaryngologist,
neurologist. Administration of immunoglobulin to prevent rubella is ineffective.
5. Determining the level of specific IgG blood antykrasnushnyh child - exploring

protykrasnushnyh levels of immunoglobulins M , G . Detection of IgM clearly
indicates intrauterine infection of the fetus ( IgM through the placenta to the fetus
does not enter and can not be of maternal origin, but the fetus is able to respond to
intrauterine infection to produce class M immunoglobulins). High IgG titers may also
indicate IV infection, as in the last months of pregnancy the fetal immune system is
already able to produce class G immunoglobulins , but given the possibility of
maternal origin, this result requires additional examination of the mother for
rubella IgG .
Problem 57
The child is 4 years old, attending kindergarten, body temperature rose to

39 0 C, ' appeared I cough, runny nose, con yunktyvit. The temperature remained
elevated for three days, catarrhal phenomena increased. On the 4th day of the disease
on examination, conjunctivitis, blepharospasm, enanthema on the oral mucosa, spots
Belsky-Filatov-Koplik. On the skin of the face, behind the ears spotted-papular
rash. The following results were obtained during a clinical blood test: Hemoglobin - 120
g / l; Er. - 4.1x 10 9 / l; k.p. - 0.9. Leukocytes - 3.9x10 9 / l; e - 2%; n - 3%; c - 29; l -
63%; m - 2%; Platelets - 228x10 9 / l; ESR - 4 mm / year.
1 Formulate a detailed clinical diagnosis.
2 What examinations should be scheduled?
4 Plan anti-epidemic measures in kindergarten?
Answers:
1. Measles, a typical moderate form.
2 Analysis of blood, urine, RPHA with measles antigen, determination of class M blood
pressure by ELISA.
3 . Extremely symptomatic - antipyretics (ibuprofen 5-10 mg / kg 3 times a day, ie every

8 hours or paracetamol 10-15 mg / kg every 6 hours). Sulfacil 20% 1 - 2 drops in the
eye 4 - 5 times a day. M ikstura cough, desensitization therapy (Tsentryn syrup 2.5 mg
(1/2 teaspoon) 1 per day ) , Nazyvin 0.05% 1-2 drops in each nostril 2-3 times a
day , vitamin.
At rest, a darkened room, proper hydration and nutrition of the patient Fr. At bacterial
complications - antibiotic therapy.
4. Children who have not had measles and have not been vaccinated may visit
children's institutions for the first 7 days with a single contact, and then be subject to
quarantine until the 17th day, and those who received immunoglobulin - until the 21st
day. In the center of an infection daily preventive inspection and thermometry,
regular airing of the room is carried out. Contact children who have not been previously
vaccinated in connection with contraindications, carry out urgent vaccination against
measles.
5. Leukopenia, lymphocytosis.
Problem 58
A 5-year-old boy fell ill 2 days ago when he began to complain of nasal congestion,
difficulty in nasal breathing without signs of a runny nose, headache, weakness,
increased sweating, sore throat. Objectively: a condition of average weight. Body
temperature 38.7 0 C. On palpation symmetrically enlarged submandibular, auricular,
cervical and occipital lymph nodes, not welded together and surrounding tissues. On
examination, the mucous membrane of the pharynx is hyperemic, there is swelling of
the tonsils, the posterior wall of the pharynx. On the tonsils yellowish-white plaque,
which is easily removed.
In the blood test: leukocytes 15x10 9 / l, erythrocytes 3x10 12 / l, eosinophils - 3%, rod-
shaped neutrophils - 2%, segmental neutrophils - 15%, lymphocytes - 45%, monocytes
- 15%, mononuclear cells - 20%, ESR - 18 mm per year.
2 Name the modern specific method of laboratory diagnosis of this disease.
3 Modern approaches to the treatment of this disease. Indications for the appointment
of antibacterial drugs in this disease. What antibacterial drugs are categorically
contraindicated in this disease?
4 Prevention of this disease.
Answers:
1. Infectious mononucleosis, typical form, acute course, moderate.
2. 1) Paul-Bunel-Davidson, Hoff-Bauer, Tomczyk, Lovrik-Wolner reactions
(heterohemagglutination reactions) and specific serological tests for antibodies
to Epstein-Barr virus (more often determine antibodies of class M or G to viral
capsid antigen)
Specific antibodies to EBV - appear in the 2nd week. disease (highest specificity
and sensitivity [ ELISA ]):
to capsid antigen: VCA IgM - appear the earliest, even in 95% with a fresh
infection, the titer increases rapidly within a few days from the beginning of the
acute phase of the infectious process; disappear within 2-3 months
2) detection of WEB DNA ( EBV ) (PCR; material: serum, blood [lymphocytes],
tissues): informative in patients with immunodeficiency (absence of specific
antibodies) or to detect WEB ( EBV ) infection in cancer, lymphoproliferative
diseases and CAEBV .
3) The diagnosis is made in the case of detection in the general analysis of blood
characteristic of infectious mononucleosis cells - atypical mononuclear cells.
3. Bed rest
Symptomatic therapy (ibuprofen syrup - 7.5 ml 3 years,
vasoconstrictor nasal drops-eukazolin + plus rinsing with saline solutions
adequate rehydration
GKK - prednisolone-1-2 mg / kg / days (at heavy lymphadenopathy)
The use of antibacterial drugs in this disease is impractical
4 . Prevention of infectious mononucleosis is to limit contact with

patients. Because the virus is not contagious , then the appearance of cases in
organized children's groups (in a manger, di tyachomu garden) any quarantine
measures is not made - just the usual wet cleaning.
Children who have been in contact with the patient are observed for 20 days. This
is the maximum incubation period for hvoryuvannya and if children are not ill
during that time - hence, infection was not.
There is currently no specific prevention of infectious mononucleosis (eg,

vaccinations).
5 . clinical blood test

Shoe - increased
Erythrocytes are reduced
Increase in leukocytes (segment-reduced neutrophils, elevated lymphocytes,
elevated monocytes)
With ' appeared atypical mononuclear cells
Task 59
An 11-year-old boy has a temperature of 39.2 ° C. Ill acutely. There is a hemorrhagic

asymmetric rash on the skin. Gram-negative diplococci were found in the blood. There
are signs of intoxication, in the coagulogram - signs of disseminated intravascular
coagulation syndrome. The following results were obtained during the clinical blood test:
Hemoglobin - 115 g / l; Er. - 4.1x 10 9 / l; k.p. - 0.9; Leukocytes - 3.2x10 9 / l; e - 0%; n -
8%; c - 68%; l - 20%; m - 4%; Platelets - 180x10 9 / l; ESR - 15 mm / year.
1. What is the most likely disease in a child?
2. Assign additional survey methods.
3 What anti-shock methods of therapy are carried out at the prehospital stage when this
diagnosis is made?
4 Prevention of this disease.
Answers:
1. Meningococcal infection, generalized form, meningococcemia, severe,
infectious-toxic shock III.
2 . Examination methods
 Bacteriological examination of mucus from the nasopharynx,

cerebrospinal fluid sediment, blood (meningococcal secretion).
 Bacterioscopy of blood smears and cerebrospinal fluid sediment.
 Serological tests: RNGA, RZK, coagglutination reaction, counter
immunoelectrophoresis (detection of meningococcal antigen), ELISA
(detection of IgM).
 Examination of cerebrospinal fluid: general clinical (pressure,
transparency, color, cell composition, amount of protein), bacterioscopic,
bacteriological, biochemical, immunological.
3. treatment (order 737)
At the prehospital stage, peripheral should be provided

venous access, initiated infusion therapy with salt or colloid
solutions, antibiotics, with suspected development of acute
adrenal insufficiency - administered intravenously
glucocorticosteroids, if necessary - antipyretics, anticonvulsants
therapy.
1. Oxygen therapy with humidified oxygen with FiO 2 0.35-0.4.
2. If indicated, ensure airway patency and
adequate respiration (introduction of an airway, oxygen therapy, auxiliary
ventilation with a mask, if possible - tracheal intubation and
Mechanical ventilation).
3. If there are signs of shock within 3-5 minutes with catheters
type "Vasofix" or "Venflon" to provide reliable venous access
and start infusion therapy with isotonic saline solutions (0.9%
sodium chloride solution or sodium chloride + potassium chloride + solution
calcium chloride dihydrate + sodium lactate) in the amount of 20 ml / kg body
weight per
20 minutes.
4. Antibacterial therapy - cefotaxime in a single dose of 75 mg / kg or
ceftriaxone in a single dose of 50 mg / kg intravenously. At
hypersensitivity to beta-lactam antibiotics - chloramphenicol
succinate in a single dose of 25 mg / kg intravenously.
At the prehospital stage, cefotaxime should be the first antibiotic
lines in cases where the hospital stage is expected
the use of solutions containing calcium (solution
Ringer, etc.). Ceftriaxone can be considered an antibiotic first
lines at the prehospital stage in the case when the introduction of drugs
calcium is not required for further therapy.
5. Glucocorticosteroids only intravenously (prednisolone,
hydrocortisone) at a dose of 10 mg / kg (calculation of the dose of prednisolone).
6. Antipyretic therapy (if necessary) - (paracetamol 10-15 mg / kg,
ibuprofen 5-10 mg / kg by mouth, metamizole sodium 50% IV 0.1 ml / year
life.
7. Anticonvulsant therapy (if necessary) - diazepam at a dose of 0.3-0.5 mg / kg
body weight once (not more than 10 mg per injection).
4 prevention
Timely medical treatment of patients with SARS for early detection and diagnosis
of meningococcal infection, as well as the provision of qualified medical care.
Reduce stays in poorly ventilated areas with large crowds, especially where there
are patients with SARS.
To lead a healthy lifestyle, especially in the winter-spring period to be in the fresh
air for at least 2-3 hours and eat enough calories and vitamins.
Use individual utensils, limit close communication among young people.
According to the Calendar of preventive vaccinations, meningococcal infection is
one of the recommended vaccinations. The population (children and adults) can
be vaccinated against this infection at their own expense
5. decrease in hemoglobin
Znazhennya a platelet-called ' connection DIC
In the coogulogram signs of DIC syndrome
Problem 60
At the child of 8 years the body temperature sharply rose to 39,6 ° C, there was an
intense sore throat, one-time vomiting, a bright red small-spot rash on a hyperemic
background of skin on the face, torso, extremities. The rash is more intense in the folds
of the skin. The nasolabial triangle is pale. On examination - bright redness of the
throat, enlargement of the tonsils, submandibular lymph nodes. Antistreptolysin "O"
(quantitative determination) 256 U / ml.
1 What is the most likely disease in a child?
2 Name the laboratory methods to confirm this infection.
3 Is there an etiotropic treatment?
4 What is the period of observation of contact in this disease?
5 Interpret the results of a blood test for antistreptolysin O.
Answers:
1 Scarlet fever, moderate, typical form, complicated by lymphadenitis
2. 1) General blood test is characterized by leukocytosis, neutrophilia and a significant
"shift to the left" of the leukocyte formula, -
2) General analysis of urine - against the background of a significant intoxication
syndrome may be leukocyturia and minor proteinuria as a manifestation of toxic kidney
disease, - 2) Swab from the oropharynx on B L (isolation of diphtheria pathogen -
Lefler's bacillus) should be performed before antibacterial therapy with the presence of
manifestations of sore throat,
3) Examination of the oropharyngeal smear for microflora is not appropriate due to the
high prevalence of hemolytic streptococcus among the population, - 4)
Electrocardiographic examination to establish the primary status of the cardiovascular
system of the child.
5) Examination by an otolaryngologist,
6) Examination of the level of antistreptolysin in the blood, if necessary, to exclude
Kawasaki syndrome, - In severe scarlet fever
7) study of liver samples, protein fractions, coagulogram to establish the functional state
of the liver and hemocoagulation system.
3 . Penicillin (or cephalosporins 1-2 generation -cefazolin, cefuroxime axetil, or
macrolides (azithromycin).
ceftriaxone in a single dose of 50 mg / kg intravenously. At
hypersensitivity to beta-lactam antibiotics - chloramphenicol
succinate in a single dose of 25 mg / kg intravenously
4 . 7 days.
5 . increase in this indicator indicates sensitization of the body to streptococcal
antigens. The level of ASL-O begins to increase at 1 week after the establishment of
streptococcal infection and reaches a maximum at 2-4 weeks. In the absence of
complications or recurrence of infection, the level of ASL-O normalizes after 6-12
months.
Task 61
The boy 10 years after visiting his grandmother had a mild sore throat, a feeling of
brokenness, severe headache. The third day the body temperature is 38.2-38.9 °
C. The skin is pale. Examination of the pharynx - hyperemia with a cyanotic tinge,
swelling of the tongue and mucous membrane of the pharynx, on the tonsils gray-white
coarse fibrinous film, which is difficult to remove. Submandibular lymph nodes are
enlarged, edema of subcutaneous fat extends to the middle of the neck. Bacterioscopy
of the oropharyngeal smear - large, straight, slightly curved polymorphic rod-shaped
bacteria. Metachromatic grains of volute are localized at the poles of the cells, giving the
cells a characteristic "mace" shape. The grains of volute are stained with methylene
blue according to Neisser. On micropreparations are located singly, or, due to the
peculiarities of cell division, are located in the form of the Latin letter V.
Despite treatment, after 2 weeks the child developed carditis.
2 What is the confirmed case of this disease
3 Who should be hospitalized with this disease?
4 At what age do vaccinations against this disease begin?
5 . Interpret the results of bacterioscopy of the oropharyngeal smear.
Answers:
1. Combined membranous diphtheria of the tonsils and oropharynx (clinically),
severe. Late infectious-toxic diphtheria carditis, severe form
2. What is the danger of an epidemic situation
There is a possibility that the child is not vaccinated .
3 . All patients with diphtheria, regardless of its clinical form and severity, are subject to
urgent mandatory hospitalization in an infectious hospital.
4 . Vaccination with AKDP (AAKDP) vaccine is carried out in: 2 months (first
vaccination), 4 months (second vaccination), 6 months (third
vaccination). Revaccination is carried out at 18 months.
5 . bacterioscopy of oral pharyngeal smear - diagnostically confirms the presence of
the pathogen Corynebacterium diphtheriae
Task 62
Olya K., 3 years old, became acutely ill. The disease began with a rise in body
temperature to 37.5 ° C, single vomiting, liquid watery yellow stools 5-7 times a
day. The first two days showed nasal discharge of a serous nature and coughing. The
following results were obtained during the clinical blood test: Hemoglobin - 128 g /
l; Er. - 4,5х 10 9 / l; k.p. - 0.9. Leukocytes - 3.5x10 9 / l; e - 2%; n - 3%; c - 27; l - 66%; m -
2%; Platelets - 219x10 9 / l; ESR - 5 mm / year.
2 What methods of specific diagnosis are used to confirm the diagnosis?
3 What should be the doctor's tactics?
4 Is there a specific prevention of this disease?
1. Rotavirus infection, gastroenteric form, moderate, acute

2. Enzyme-linked immunosorbent assay - detection of rotavirus antigen in fecal
samples
PCR - detection of double-stranded fragmented RNA
3. The most important link in the treatment of GCI is timely and adequate rehydration
therapy. Early and adequate use is the main condition for rapid and successful
treatment. Rehydration therapy is performed taking into account the severity of
dehydration of the child . Oral rehydration in GKI is the first and most effective treatment
at home when the first symptoms of the disease appear. Early administration of oral
solutions can effectively treat a significant number of children at home, reduce the
percentage of hospitalized, prevent the development of severe forms of exsiccosis
Oral rehydration should be performed without delay, as dehydration begins after the
appearance of the first liquid watery stools, long before the appearance of clinical signs
of dehydration. Complete rehydration therapy is carried out in 2 stages.
The first stage is rehydration therapy, which is carried out for 4-6 hours
recovery of lost fluid volume. At dehydration of easy severity it makes 30-50 ml / kg,
average weight - 60-100 ml / kg.
The rate of introduction of liquid orally makes 5 ml / kg / h.
The second stage is maintenance therapy, which is carried out depending on the
continuing fluid loss, with vomiting and bowel movements.
Supportive oral rehydration is that the child is given as much glucose-saline solution
every 6 hours as she has lost fluids in the previous six-hour period.
4. prevention of rotavirus infection, the only effective way - vaccination. Vaccination

should be at the age of 6 to 32 weeks from birth. The vaccine is administered orally
twice, at intervals of at least a month.
Also, to protect your child from encountering rotavirus, you should wash your hands
often, especially after walking and before eating.
5 Decrease in the number of segmental neutrophils due to decrease in the total number
of leukocytes on the background of viral infection
Increased lymphocytes - due to the immune response to a foreign antigen in the body,
but we must remember that in children under 4-6 years in the total number of leukocytes
is dominated by lymphocytes, ie they are characterized by absolute lymphocytosis; after
6 years there is a "crossing" and the total number of leukocytes is dominated by
neutrophils
Task 1
The boy is 6 months old. was admitted to the clinic with complaints of lethargy,
anorexia, weight loss, unstable stool with an unpleasant odor, light
color. Symptoms gradually increased against the background of normal body
temperature. Prior to this disease, the child developed normally. 3 weeks before
the onset of these symptoms, semolina was introduced into the child's
diet. Objectively: malnutrition of the II degree, dry skin, flabby, abdomen sharply
swollen. Stools a lot, they are foamy, slightly discolored, with a greasy sheen,
smelly, 1-2 times a day.
1. What is the most likely diagnosis?
2. Determine the daily amount of food for this child and the frequency of feeding.
3. Determine the one-time amount of food for this child
4. Principles of nutrition correction in children.
5. Tactics of patient management or correction of treatment of this pathology.
1 . C eliakiya typical form, the active period
2. The amount of food for children 6-12 months 5 times a day
The daily amount of breast milk for a child 6-9 months 1/8 of the child's body weight
+ from 6 months we enter supplementary food vegetable purees 50-100 grams, fruit
purees 40-50 grams, milk - cereals 50-100 grams
If the child is 6 months old weighing about 8 kg, the daily food requirement is about
1000 ml (breast milk + supplementation)
3. The single volume is approximately 200 ml
4. Among the baby foods to exclude from the diet - baby cereals based on wheat,
semolina, "mixed cereals", baby instant cookies, meat, fish, vegetables, canned fruits,
yogurt with wheat flour or semolina.
Patients with celiac disease can include in the diet of natural meat, fish, vegetables,
fruits, eggs, dairy and sour milk products (without fillers), marmalade, marshmallows,
some types of ice cream. In addition, special gluten-free products are recommended -
substitutes for bakery, confectionery and pasta. In the treatment of celiac disease it is
necessary to take into account the presence of secondary disorders of organs and
systems and deficient conditions.
Thus, in the period of manifestation of celiac disease in young children very often there
are multiple food intolerances. Secondary lactase deficiency and sensitization to cow's
milk proteins are the most common. Less often - to other foods (rice, bananas, chicken
egg white).
When organizing the diet of such patients, dairy products and mixtures should be
excluded from the diet and replaced with mixtures based on soy protein isolate or
mixtures based on protein hydrolysates with the addition of medium-chain
triglycerides. Alfare®, Nestle® is suitable for children under three years of age during
exacerbations, and Peptamen®, Nestle® for older children. During remission it is
necessary to prescribe mixtures that do not contain lactose: children under 1 year -
NAN® lactose-free, children from 1 to 10 years - Clinutren® Junior, Nestle®, from 10
years - Clinutren® Optimum, Nestle®.
5. The most important thing in treatment is a gluten-free diet
Drug treatment
Drug therapy of celiac disease is ancillary.
Violation of nutritional status during the manifestation of the disease (malnutrition of I-II
centuries) may require partial parenteral nutrition, correction of oncotic blood pressure
(intravenous administration of 5-10% albumin solution).
At the expressed diarrhea enterosorbents (Enterosgel, Smekta), astringents are
involved in a complex of therapy. Correction of digestive processes is carried out by
prescribing enzyme preparations. The use of probiotics, vitamin and mineral complex
preparations is shown.
Task 2
At the child of 1,5 years the expressed O -shaped deformation of the lower
extremities, muscular hypotension is revealed . He does not lag behind in
physical and mental development. In the blood: hypophosphatemia, increased
alkaline phosphatase. In urine: hyperphosphaturia.
1. Phosphate diabetes
2. Daily volume of 1200-1400 ml. The number of meals per day 3-4 times
3. A single volume of food is 350-400 ml
4. The diet should include dairy products, fruit, vegetable and berry juices, fruit and
berry puree , egg yolk, dill, parsley, cheese, milk porridge, meat,
5. Mode, diet therapy, walks in the fresh air, sun and air baths.
.Vitamin D, calcium and phosphorus preparations, vitamins A, E, B, surgical correction
Task 3
A 7-year-old boy complains of a headache, a feeling of heat, fever, shortness of
breath, a cough with a small amount of viscous sputum with blood, a dry, painful
cough, and sometimes nosebleeds. Physically: cyanosis, fingers in the form of
"drumsticks", shortening of the percussion sound paravertebral, hard
breathing. Radiologically signs of emphysema and retinal pattern of lung tissue.
5. Tactics of patient management or correction of treatment of this pathology ..
1. COPD, emphysema
2. Daily volume of 1600-1800 ml, the number of receptions 3-4 per day
3. The one- time volume makes 400-450 ml
4. A balanced diet enriched with vitamins
5 . Treatment of pulmonary emphysema is only symptomatic. Oxygen therapy, portable
breathing devices, respiratory analeptic olmitrin are appointed. It reduces suffocation,
stimulates peripheral hemoreceptors, increases the tension of oxygen in the arterial
blood .
Task 4
Baby 1 month. During the last 10 days. there is vomiting by the fountain, which
occurs after almost every feeding, the amount of milk that is boiled is greater
than the child ate at one feeding. Appetite is not disturbed. Constipation is
noted. However, body weight progressively decreases. The child has lethargy,
drowsiness, severe exhaustion.
5. Tactics of patient management or correction of treatment of this pathology ..
1) P ilorostenosis
2) M = 3 500 + 800 = 4300 g
Caloric method
Ed = 115 * 4.3tsf = 494.5 kcal
Daily amount of food
( 1000 * 494.5) : 650 = 760.8.5 ml
3) Determine the one-time amount of food for a given child
One-time volume
1000: 8 = 125 ml
4) Reduce the amount of milk per feeding and increase the frequency of feedings. In
order to relieve the spasm of the goalkeeper prescribe atropine, aminazine drops
orally 20-30 minutes before eating. Mustard seeds on the stomach (before
feeding).
5) Operational - pozaslyzova pilorotomiya by Fred - Ramshtedtu or Bairovu , with
the required ' necessarily preoperative preparation of 12 hours . up
to 2 days with adequate infusion therapy under the control of laboratory tests .
In the postoperative period, the tactics of feeding are as follows: after 2 hours for 7 -
10 ml of 5% glucose solution per. os. after 1 hour 10 ml of expressed breast milk,
and then every 2 hours for 10 ml of breast milk, followed by the addition of 100 ml of
breast milk per day.
After 7 days, apply to the breast for 7 feedings.
In parallel, the infusion therapy is continued, taking into account the volume of feeding
and daily fluid requirements
Task 5
The 10-month-old boy was found with enlarged frontal and parietal humps, a
large occiput 20x15 cm, dense edges, rib “rosaries ” on the wrists - thickening in
the form of “bracelets”, “O” similarly curved lower extremities, vitamin D no
received food with a predominance of milk and cereals. The child does not stand
alone, severe skeletal muscle hypotension, mental development does not
suffer. In the biochemical analysis of blood - Ca - 2.3 mmol / l, LF - 4000 IU, P - 1.1
mmol / l. Make a diagnosis.
5. Tactics of patient management or correction of treatment of this pathology .
1) Rah it, moderate, subacute period
2) Proper body weight
M = 3 500 + 800 * 6 + 400 * 4 = 9900 g
Caloric method
Ed = 115 * 9900 = 1138 .5 kcal
( 1000 * 1138 .5 ) : 650 = 1751.5 ml ~ 1000 ml
3) One-time volume
1000: 5 = 200 ml
4) In infants - natural feeding;
If the baby is on mixed or artificial feeding then - adapted milk formulas;
Timely introduction into the diet of fruit and vegetable juices, purees.
As the first supplement - vegetable puree, with a high content of calcium and
phosphorus, which is introduced from 4 to 5 months.
The second feeding 5 - 6 months. - porridge on
vegetable broth or with the addition of vegetables
and fruit, from 6 to 6.5 months. - minced meat.
When breastfeeding, in foods
the mother's diet should include foods
high in calcium and vitamin D.
5) Tactics of patient management or correction of treatment of this pathology.
For treatment use a solution of cholecalciferol aqueous 2000 IU for 30-45 days, then
to prevent exacerbations and recurrences of 2000 IU for 30 days 2-3 times a year at
intervals of 3 months to 3-5 years.
Task 6
The child of 9 months was admitted to the clinic with complaints of poor weight
gain, lethargy, loss of appetite, loss of interest in sharpening, The child has
frequent colic, bloating and rumbling. She was born with a weight of 2,800 g,
entered with a weight of 6,200 g. From the age of 1 month she is fed exclusively
with whole cow's milk. Chulytska index - 1, skin fold at the level of the navel - 0.4
cm. In the feces there is extracellular starch, neutral fat, fatty acids (+++), a lot of
mucus, leukocytes 1-2 in the field of view, protozoa and helminths are not
detected, liquid yellowish stool with foamy discharge and sour smell. Specify a
preliminary diagnosis.
1) Grade 2 malnutrition
M = 3350 + 800 * 6 + 400 * 3 = 9350 g
Caloric method
Ed = 110 * 9350 = kcal
( 1000 * 1028, 5 ) : 650 = 1582.3 ml ~ 1000 ml
3) One-time volume
1000: 5 = 200 ml
4) The basic principle of diet therapy for malnutrition is a three-phase diet:
1. period of clarification of food tolerance;
(duration 2-5 days)
The calculation of nutrition is based on the actual body weight;
The number of feedings increases by 1-2 per day;
Preferably the use of human milk, in its absence or
absence - adapted infant formulas enriched with probiotics,
oligosaccharides and nucleotides.
2. Transition:
begins with normal tolerability, when the amount of food gradually (over 5-7
days) increases; The calculation of nutrients is carried out on the desired body
weight; First, increase the carbohydrate and protein components of the diet, and
only last - fat.
The period of enhanced (optimal) nutrition.
The child receives a high-calorie diet (130-145 kcal / kg / day.) In combination with
drugs that improve digestion and assimilation of food.
Insufficient about ' is of food filled with liquid (tea, rose hips extract, glucose, fruit
juices, vegetables and fruit teas). When the child's condition improves, the amount
of food is gradually brought to the physiological norm.
5) • Identification and elimination of causes of eating disorders
 Eliminate the symptoms of malnutrition and ensure reparation processes
 Provide a rational, adequate diet
 Prevent the development of complications
 Exercise therapy
with malnutrition II and malnutrition III degree treatment is carried out in a hospital:
- parenteral nutrition (according to the indications - amino acid solutions, fat
emulsions)
- diet therapy with the use of specialized therapeutic milk and non-dairy mixtures,
therapeutic products based on soy protein isolate, protein hydrolyzate, etc.
- use of food additives: proteins and amino acids (methionine, arginine aspartate),
vitamins and vitamin-like preparations, macro- and microelements
- correction of dysbiosis (probiotics - Symbiter, bifidumbacterin, lactobacterin, etc. )
Task 7
A mother with a 2-month-old child complained to a pediatrician about the child's
anxiety and lack of weight gain. It is known that the child was born with a weight
of 3300 g During the control weighing it was found that the child eats 500 ml of
breast milk per day.
1. Insufficient milk supply due to improper feeding
2. Calculate the proper body weight
-mn = mo + 800 * 2
-mn = 3300 + 1600 = 4900g
Daily food requirement -Eg = 115 * 4.9 = 563.5
1000ml of women's milk -650kkld
X = ( 1000 * 563) / 650 = 866ml
For this child, the daily amount of food per day should not exceed 900 ml
Feeding frequency -6 times
3. The amount of food per feeding
866/6 = 144 ml
4. For this baby requires hourly feeding 6:00; 9:30; 13:00; 16:30; 20:00; 23:30
And monthly weight control
Task 8
A 2-year-old girl was referred by a district doctor to the hematology department
with a diagnosis of anemia. From the anamnesis it is known that the child during
the newborn was on artificial feeding and still in the diet is dominated by milk and
semolina. The child refuses meat, liver, vegetable dishes. Examined: pale, dry
skin, angular stomatitis. In the analysis of blood er.- 2,9 T / l, HB-62 g / l, KP-0,64,
lake.-6,0 G / l, s.-42 \%, e.-2 \%, l.-46 \%, m.-10 \%, reticulocytes-4 ‰, ESR-10 mm /
h.
1. Diagnosis: Iron deficiency anemia
2. Feeding a 2-year-old child should be carried out 4 times a day with an interval of 3.5-
4.5 hours
3. This child needs diet correction , proper nutrition and iron therapy
4. During the day you need to receive 3.5 g of protein, 3.0-3.5 fats, 13-14 g of
carbohydrates
Task 9
The child is 3 months old. Is on natural feeding, feels well, physical and
psychomotor development corresponds to the age of the child. No
complaints. From the 4th month of the child's life, the mother will be forced to be
absent 8 hours a day due to going to work .
Answer :
Proper body weight should be 5600 g
2.V daily volume -990ml
Multiplicity of food 6 times
3. One-time volume of food 165 ml
4. In the absence of the mother for 8 hours a day, she must express milk in special
containers
Task 10
At the doctor's appointment, a 7-month-old girl. Breastfed, the mother has a lot
of milk. The girl holds her head well, sits on her own, constantly
babbling. independently pulls a bottle to a mouth , repeats syllables (lip sounds)
for a long time. Plays with toys, knocks, translates. Crawls well.
1) The child is healthy
M = 3350 + 800 * 6 + 400 * 2 = 8950 g
Volumetric method
8950: 8 = 1119 g ~ 1000 g
Caloric method
110 * 8950 = 984.5 kcal
1000 * 984.5: 650 = 1515 ml ~ 1000 ml
3) One-time volume
1000: 5 = 200 ml
4)
Feedin Menu Volum B Ž IN Kcal
g time e
6.00 Breast 200 3 7 14 130
milk
10.00 Rice 200 5.5 11. 35 80
porridge 9
10%
Yolk ½ 1.1 - 25
This 50 - 2.2 12 48
-
14.00 Breast 200 3 7 14 130
milk
Warm 50 - - 5 20
apple
18.00 Vegetabl 200 3.5 9.7 27.9 220
e puree 8
Juice 20 - 4.8 19.2
-
22.00 Breast 200 3 7 14 130
milk
Total 19. 44. 126. 1002.
2 8 7 2
g / kg body weight 2.3 5.3 14.9 117.9
Recommended norms 3.0- 5.0- 12.0- 110-
3.5 5.5 14.0 115
The proposed menu is deficient in protein and excessive in carbohydrates. Daily
protein deficiency (3-2. 3) * 8.5 = 5.95 g ~ 6.0 g
In order to correct the protein part of the diet, it is necessary to include soft
cheese in the amount
100 g of cheese - 14.4 g of protein
X - 6 g of protein
X = ( 100 * 6) /14.4=41.6~40 g
In order to correct the carbohydrate part of the diet, it is necessary to give juice
without sugar. It is desirable to give soft cheese at 14.00, reducing the amount of
breast milk by 40 ml.
5) -
Task 11
The child is 4 months old. Natural feeding. In the last two weeks, the mother
noticed that the child had pale skin, increased sweating of the head, protruding
frontal bumps, restless sleep.
1) Rickets is mild
m = 3500 + 800 * 4 = 6700 g
Volumetric method
6700: 6 = 1117 ml ~ 1000 ml
Caloric method
120 * 6.700- 804 kcal
1000 * 804/650 = 1237 ml ~ 1000 ml
3) One-time volume
1000: 6 = 167 ml
4)
Feeding time Menu Volume B Ž IN Kcal
6.00 Breast milk 165.0 2.48 5.78 11.55 107.25
9.30 Breast milk 165.0 2.48 5.78 11.55 107.25
Yolk
Juice ¼ 0.55 1.1 - 12.5
25.0 - - 6.0 24.0
13.00 Breast milk 165.0 2.48 5.78 11.55 107.25
Juice
20.0 - - 4.8 19.2
16.30 Breast milk 165.0 2.48 5.78 11.55 107.25
Grated
apple 15.0 - - 1.5 6.0
20.00 Breast milk 165.0 2.48 5.78 11.55 107.25
Grated
apple 15.0 - - 1.5 6.0
23.30 Breast milk 165.0 2.48 5.78 11.55 107.25
Total 15.4 35.8 83.6 713.2
g / kg body weight 2.2 5.1 12.0 107.9
Recommended norms 2.0-2.5 6.5-6.0 12-14 115-120
The proposed menu does not meet the needs of the veins and therefore deficient
in energy.
Daily fat deficiency (6.0-5.1) -7-0.9-7-6.3 g
In order to correct the fatty part of the diet in the menu include oil in the amount
of 1 tsp. (3 g) per ½ tsp. 2 times a day (after meals).
The remainder of the fat deficiency 6.3-3-3.3. Cover with cream 10% fat
1000 cream - 10 g of fat
X - 3.3
X = 1000 * 3.3 / 10 = 33 ml ~ 35 ml
We give 1 tsp. before each feeding and use in the preparation of the yolk. After
correcting the fat part of the diet, the energy value of the diet will meet the needs
of the child.
6) For treatment use a solution of cholecalciferol aqueous 2000 IU for 30-45 days,
then to prevent exacerbations and recurrences of 2000 IU for 30 days 2-3 times
a year at intervals of 3 months to 3-5 years.
Task 12
At inspection of the child of 1 year it is established: Nv 68g / l, er. 3.6x1012 / l,
kp-0.6, reticulocytes -1 \%, three. - 230.0x109 / l. From the anamnesis of life it
became known that the child was fed artificially cow's milk and semolina. On
examination, the child's condition is moderate, the skin is pale, clean. Lymph
nodes are not enlarged. Liver, spleen of normal size.
1) Iron deficiency -> Severe iron deficiency anemia.
10.5 + 2 * 1 = 12.5 kg
The daily volume of food is 1200 ml
3) One-time amount of food
1200/4 = 300 ml
4) The basis of nutrition - should still be semi-liquid dishes , but not only mashed, but
also contain small pieces of food . It is not necessary to give too dry food to the kid yet
as he can have difficulties with swallowing. In a year the child already tries to eat
hands and it should be encouraged to it. You can give finely chopped, soft foods (eg,
small pieces of soft fruits, vegetables, cheese, well-cooked meat, pasta, etc.) and foods
that dissolve quickly (baby cookies, baby breads) - as food with the help of hands. It is
necessary to avoid products that can get into the respiratory tract and cause asphyxia
- sausages and other solid meat products, nuts (especially peanuts), grapes, raisins,
raw carrots, popcorn, round candy . Hold on to it for a while. In a year the share of
children appears without breast milk. But if your baby is still not weaned - do not rush, if
possible, give him a breast before bedtime. You can also breastfeed in between
meals. At this age, the child receives all the essential vitamins and minerals with food,
but a number of biologically active components he can get from breast milk.
Dairy products still play an important role in the child's diet, it is a source of calcium, B
vitamins, protein, milk sugar and fat. It is better to use special baby milk (it is marked
with three on the package), baby dairy products: yogurt, yogurt a total of 500-600 ml
per day. The child should be given cheese. The daily dose of cheese after 1 year can
be increased to 70 g per day. It can be given grated or combined with fruit puree,
pudding, casserole. This promotes the formation of chewing skills. Butter can be added
to cereals or spread on wheat bread, cookies at a dose of up to 12 g per day. After 1
year, you can give small amounts of low-fat sour cream and cream.
In a year the child must be given a variety of vegetables, combine them well with protein
foods, meat. Vegetable diet can now be varied with green peas, tomatoes, turnips,
beets, carrots, spinach in the form of puree. It is still better not to give beans.
After 1 year, you can gradually introduce your baby to new fruits
and berries : strawberries, cherries, sweet cherries, kiwi, currants, gooseberries,
chokeberry, sea buckthorn, raspberries, blackberries, cranberries, blueberries,
cranberries and even citrus. But do it gradually, watching the child's reaction. Berries
that have a dense skin (gooseberry), it is better to grind into a puree, while soft juicy
fruits (peaches, strawberries, apricots, kiwi) can be offered to baby pieces. The daily
dose of fruit - about 200 g per day, it can be supplemented with juice, 50-100 m
Meat products can be given in the form of steamed meatballs, meatballs, meatballs,
meat souffle and pudding in quantities up to 100 g daily - beef, veal, lean pork, rabbit,
turkey, chicken.
Fish can be given once or twice a week for 30-40 g per reception as a substitute for
meat dishes
Eggs (chicken, quail) give in boiled form or in the form of omelets in milk (you can try
with vegetables).
Porridge can be cooked from rice, oatmeal, buckwheat, corn, millet, semolina. At this
age, they should still have a uniform consistency, so it will be easier to swallow. You
can use ready-made industrial, children's instant porridge, such as various multigrain, to
which are already added fruits, crackers, cereals. Give once a day.
Be sure to give your child clean water (preferably bottled baby water) as much as he
wants. In addition, the baby can drink vegetable and fruit juices, dairy products,
compotes, weak tea.
The child at 1 year does not need to give confectionery and candy. From sweets at this
age you can sometimes give marmalade, dried fruits and cookies.
It is not necessary to give sausages and hot dogs, they are seldom prepared from high-
quality grades of meat, and they are rich in various food additives.
In total, the caloric content of food consumed per day should be about 1300 calories,
and its volume is about 1200 ml.
5) Iron supplements are prescribed
Iron sulfate or iron fumarate at a rate of 5 mg / kg / day, ie the child needs 62.5 mg / day
for 6 months.
Ascorbic acid 40 mg / day
In the future, the control is carried out quarterly for 3 years.
Task 13
In the anamnesis of a 6-month-old infant who is on artificial feeding - recurrent
diarrhea for one month, which was not accompanied by a violation of the general
condition. After several unsuccessful attempts to adjust the diet, the pediatrician
prescribed the child goat's milk. At the age of 12 months, the baby shows pale
and dry skin, lethargy, loss of appetite. The child gets tired quickly, can not walk
for a long time, often squats to rest. The mother also noticed the child's fragility
of nails and hair loss.
1 ) Anemia due to folic acid deficiency

2) Daily amount of food for a given child and the frequency of nutrition :
Proper body weight - 10.5 + 2 * 1 = 12.5 kg.
The daily volume is 1200 ml
3) One-time volume of food - 1200/4 = 300 ml
4) Breast milk (or a special milk formula) remains the most important food for a child at
this age, its amount in the daily diet should be about 500 ml. To get all the necessary
nutrients for the body, the nutrition of a 1-year-old child should be continued with breast
milk or an adapted mixture, gradually expanding the diet. Fruits and vegetables should
always be a mandatory component of the diet.
Feeding should be carried out with a frequency of 5 times a day. Keep in mind when
designing a 1-year-old's diet, the menu must include eggs, fish and meat dishes, soft
cheese and dairy products, fats, grains, vegetables and fruits. It is advisable to include
in the diet of vegetable oils and butter as a dressing for cereals, purees,
salads. Spreads and margarines are strictly forbidden!
A small amount in the diet should contain sugar (about 35 grams). Consider the
contents of the products to choose the right "sweets". For example, you can try to enter:
marmalade, dried fruits, natural honey, various cookies. Fast food is strictly forbidden,
because they contain many different flavors, dyes, preservatives and other harmful
substances that contribute to allergies. As a result, there is a problem of overweight and
various endocrine disorders.
The nutrition of a 1-year-old child should promote the formation of the correct behavior
of the baby during the meal. He should eat regularly, 4-5 times a day, without any
snacks. At this age, you should avoid strong tea, because the property of such drinks is
the leaching of iron from the body. The amount of food should be appropriate to the
child's weight and age.
A full (daily) menu for a child at this age should include products from 5 groups:
1 - meat, fish, eggs;

2 - milk and dairy products (cheese, yogurt, kefir, etc.);
3 - vegetables and fruits;
4 - products of grain processing;
5 - vegetable fats.
5) The need for folate depends on cellular metabolism. In general, the minimum daily
requirement is 65 to 400 mcg per day. The average content of folate in the body is from
5 to 10 mg, and half of all reserves are in the liver. Folate deficiency usually leads to
anemia within 6 months. Active absorption of folate that comes with food occurs mainly
in the proximal part of the small intestine. That amount of folic acid, which exceeds the
daily needs, is almost completely excreted by the kidneys as metabolites.
Folic acid treatment (2–5 mg / day) until hematological remission is achieved.
Task 14
A 5-month-old baby has frequent watery stools from the first days of life. Natural
feeding. The mother develops abdominal pain and loose stools after drinking
milk. The child is active. Weight deficit 24 \%. Stools 3-5 times a day, liquid,
watery with a sour smell. Examination: sweat chlorides - 20.4 mEq /
liter. Bacteriological fecal seeding is negative. Indicators of glycemia after lactose
loading: 4,6- 4,8 -4,3- 4,6 - 4,4 mm / l.
1) Congenital lactase deficiency

2) The weight of the child at 5 months - 7200g.
Volume method: 4-6 months. - 1/7 of body weight;
That is: 7200/7 = 1030 ml -daily volume
Multiplicity of food -5 times 6.00 10.00 14.00 18.00 22.00
Weight deficit of 24% - ie 1728
3) Single dose - 1030/5 = 205 ml.
4) C to shorten or increase the intervals between feedings, reduce the amount of single
feeding during overfeeding or supplementation, in the absence of breast milk .
5) The first stage: normalization of the mother's diet. Consumption of foods high in
lactose (whole milk) should be significantly reduced. Although there is evidence that the
lactose content in breast milk is stable and independent of maternal nutrition. You
should also limit the consumption of foods that increase gas in the intestines (cabbage,
spicy and smoked foods, onions, peas, beans, beans, corn, grapes, sodas, black bread,
salted and pickled vegetables, fatty foods, and a variety of condiments. ). The use of
fermented milk products is allowed. At artificial feeding mixes containing short-chain
triglycerides are recommended, at expressive colic mixes with partially hydrolyzed
protein are used.
The second stage - positional therapy: the mother should feed the child sitting, holding it
in a semi-vertical position (at an angle of 45-60 °), tummy down. After feeding, it is
necessary to keep the baby upright for 10-15 minutes to remove air swallowed while
eating. In the intervals between feedings and during the attack of colic, the child is
placed on the abdomen, passive bending of the legs in the knee joints with pressing
them to the anterior abdominal wall. Also use the massage of the anterior abdominal
wall in a clockwise direction. The tactile contact of the skin of the baby's abdomen and
the mother and the application of warm napkins or a warm warmer to the baby's
abdomen has a positive effect.
The third stage: to correct an acute attack of colic using drug therapy with simethicone.
The fourth stage: passage of gases and feces by means of a gas-removal tube or an
enema; possible introduction of a candle with glycerin. In children who have immaturity
or pathology of nervous regulation, this method of relieving colic is often used.
Fifth stage: if there is no positive effect, prescribe medications and probiotics:
antispasmodics, prokinetics, bifidobacteria and lactobacilli. The group of prokinetics
consists of drugs of synthetic origin only. Use drugs with antispasmodic action of
synthetic and herbal origin.
An effective alternative to diet therapy, especially in severe LN, may be
the appointment of drugs of the enzyme lactase . The enzyme lactase is prescribed
at the rate of 750 IU of lactase per 100 ml of milk. At each feeding, the enzyme is added
to 10-15 ml of expressed breast milk, left for 5-10 minutes for fermentation and given to
the child at the beginning of feeding, after which the child receives breastfeeding
Task 15
A screening study in a child of 1 month of age revealed a lack of reaction to the
environment, general lethargy, decreased muscle tone, often the child is
restless. The body and urine have a characteristic "mouse" odor, dry skin,
impaired motor function of all extremities, reduced skull size relative to other
parts of the body.
1) Phenylketonuria
2) For 1 month of life the child gains 600 gr. At birth, weight-3200. According to the
volumetric method, the daily requirement for food: 2 weeks - 2 months - 1/5 of the
proper body weight;
3800/5 = 760 ml (daily requirement)
3) Multiplicity of food 6 years: 760/6 = 125 ml (single meal)
4) The basis of the diet in PKU - the appointment of diets low in phenylalanine, the
source of which is protein foods. This diet is prescribed to all patients in the first year of
life .
Therapeutic diet in PKU is represented by three main components: medicinal products
(mixtures of amino acids without phenylalanine), natural foods (selected),
low- protein products based on starch.
Equivalent substitution for protein and phenylalanine is performed using the "portion"
method of calculation: 50 mg of phenylalanine is equated to 1 g of protein (for adequate
replacement of protein and phenylalanine products). Since phenylalanine is an essential
amino acid, to ensure the normal development of a child with PKU, the minimum need
for it must be met. During the first year of life, the permissible amount of phenylalanine
is from 90 to 35 mg / kg of the child
Control based on regular monitoring of phenylalanine in the blood (it should be in the
average range of 3-4 mg% or 180-240 μmol / l)
Task 16
A 15-year-old boy complains of increased appetite, fatigue, increased sweating,
headaches, shortness of breath with light exercise. The boy is malnourished, his
skin is pale pink, his subcutaneous fat is overly developed. The thickness of the
folds on the abdomen is 5 cm, the heart sounds are slightly weakened, heart rate
76 per 1 min, blood pressure 130/70 mm Hg.
1. Hypothalamic syndrome of puberty, obesity, progressive course.
2. The daily amount of food is about 2000 g, for this age you need 5 meals a day (3
main meals and 2 snacks)
3. One-time volume - 300-500 gr.
4. Daily need for products: milk - 600, cheese - 60, sour cream - 20, cheese - 20, meat -
220, fish - 70, egg - 1 piece, bread (rye - 150, wheat - 250), cereals , pasta - 60, sugar -
80, confectionery - 20, butter - 40, vegetable oil - 20, potatoes - 300, various vegetables
- 350, fresh fruits - 150-500, dried fruits - 25.
Example of diet per day:
Breakfast: boiled young potatoes with dill - 150g., Vegetable salad with sour cream
(sour cream 1 tbsp.) - 150g., Or omelet - 80-100g., Vegetable salad - 200g.
Snack: yogurt - 200g., Nuts - 30-40 gr., Dried apricots -3pcs.
Lunch: soup - 250g., Bread - 30g.
After 20 minutes: vegetable salad about stew - 150g., Meat - 100g.
Snack: fruit - 300g.
Dinner: baked meat or steamed meatballs - 100g., Buckwheat porridge - 100g.,
Vegetable salad -100g.
5. Modern methods of therapy of GSPP, first of all, provide correction of excess body
weight and metabolic and hormonal disorders.
The primary goal in the treatment of obesity is to stop weight gain and its gradual long-
term reduction. Achieving this goal is possible under the conditions of normalization of
eating behavior, the use of a low-calorie diet and a sufficient regimen of dosed
exercise. As eating behavior is more of a social and family problem, it is necessary to
involve not only the adolescent with GSPP, but also parents and members of the whole
family. It is necessary to explain the conditions of the diet, the correct stereotype of
eating, adjust the components and caloric content of foods. Fasting in such cases is
contraindicated. In the evening, it is desirable to take a walk or play sports
(recommended sports, sports or ballroom dancing) . A low-calorie diet should be quite
varied, with the mandatory inclusion of foods high in fiber and vitamins and balanced in
the ratio of protein, fat and carbohydrates (20% / less than 30% / 50% of the daily
diet). For obese adolescents, the caloric content of food should not exceed 1600-1800
kcal / day.
One of the problems in the treatment of obesity in patients with GSPP is the presence of
increased appetite, which is due to insulin and leptin resistance as factors in the
regulation of appetite and brain saturation centers. In pediatric practice, the use of drugs
that suppress appetite is contraindicated because they can cause unwanted psychotic
effects.
At increase of appetite against insulin resistance use of biguanides (metformin in an
initial dose of 500-750) is shown, and at increase of indicators of leptin and serotonin at
activation of CAC - sibutramine which is a selective inhibitor of reuptake of serotonin
and 10-noradrenaline days). After 3-5 weeks, the dose is increased to 15 mg, but
prescribed in courses of 3-6 months, under the control of the general condition,
glycemia and C-peptide and leptin. The course can be repeated in 2-3 months. Basic
drug therapy for all variants of GSPP involves dehydration therapy with saluretics
(diacarb, furosemide, torasemide (Trifas)), as well as aldosterone antagonists,
potassium-sparing agents (triamterene, spironolactone) and paraduraromo-combined
drugs potassium preparations (3-4-day courses for 3 weeks 3-4 times a year), and at
the raised hypertension - 25% solution of magnesium sulfate on 5-10 ml intramuscularly
10 injections .
Task 17
At the child of 8 months at external inspection the general weakness, dryness
of skin, quite often in places hyperpigmented is found, the child sits at support,
holds the head not confidently, is inactive, reflexes are weakened, eats
exclusively sour-milk mixes, sometimes mother notes liquid stool in large
quantity. The child is gaining weight poorly. Coprologic examination showed the
presence of extracellular starch, increased excretion of undigested nutrients in
the feces.
1. Celiac disease.
2. Daily volume of food - 1000 ml, multiplicity of food - 5 times.
3. A single volume of food 20 0 ml.
4. The principle of nutrition correction is to exclude products that contain explicit and
implicit gluten: cereals - rye, wheat, barley, oats and products of their processing; other
products that contain 1 mg of gluten per 100 g of product. It is allowed to eat rice,
buckwheat, corn, millet, fresh vegetables and
fruits, fresh meat, fish, eggs, dairy products, specialized gluten-free foods for celiac
patients
5. Treatment of this pathology:
- pancreatic enzymes (preference is given to pancreatic enzymes in the form of
gastroresis of stent granules and microspheres) - the dose is determined individually,
depending on the severity of the malabsorption syndrome;
- loperamide (0.2 mg / 10 kg of body weight 2-3 times a day);
- vitamins (A, B, C, D, E, according to the indications - K) in age dosages;
- with severe clinical manifestations of hypocalcemia, hypokalemia, hypomagnesemia -
parenteral administration of drugs Ca, K, Mg;
- correction of dysbiosis;
- anabolic hormones, in severe cases - steroid hormones;
- post-syndrome therapy depending on the severity of clinical manifestations
Task 18
The child is 9 months old, is breastfed. The mother complains that the child's
stool is not observed every day. The child is active, the general condition is
satisfactory. Feces in the form of "sausage", sometimes in the form of "balls",
dense.

1. Inadequate nutrition.
2. Daily volume of food - 1000 ml, multiplicity of food - 5 times.
3. A single volume of food 200 ml.
4. For the specified age of the child in addition to breastfeeding it is necessary to
introduce complementary foods.
5. In the diet of a 9-month-old child, for the proper functioning of the gastrointestinal
tract should already be the following dishes: vegetable puree (you can use mashed
potatoes, carrots, cabbage, zucchini, beets), milk porridge (rice, buckwheat, corn), non-
fat meat broth, which is later replaced by soup, from 7 months the child should have
received bread in the diet and minced meat, from 8-9 months should start eating minced
fish.
Task 19
The child is 11 months old, is on artificial feeding. Neuropsychological
development corresponds to age, reflexes are lively. A screening study in the
clinical analysis of urine revealed large amounts of oxalate salts.

4. Principles of correction of feeding in a child.
1. Disorders of Ca or oxalate metabolism (increased intake of oxalates from
food). 2. V daily = 1000 ml (approximately), the frequency of feeding 5 times.
3. V single 100/5 = 200 ml
4. Restriction of products containing vitamin C, oxalic acid, oxalates in excess,
replacement of artificial mixture.
5. Restriction of products containing vitamin C, oxalic acid, oxalates in excess,
replacement of artificial mixture.
Task 20
The child 5.5 months has lethargy, refusal to feed, there is a prolonged time of
breastfeeding (more than 20 minutes), unmotivated crying, increased sweating,
weight gain, in particular, crossing the curve of the graph of the body mass index
line lower than previous figures z-deviation. During feeding on the skin there will
be cyanosis of the nasolabial triangle, shortness of breath of a mixed nature,
sometimes convulsions, tachypnea.
1. Congenital heart disease

2. The proper weight of the child should be approximately 7450 g. V daily = 930 ml
(approximately) Multiplicity of food 5 times.
3. V single 185 ml. (Calculated for the norm!)
4. Nutrition should be age-appropriate.
5. Additional research to determine what kind of heart defect in a child and surgical
treatment.
Task 21
The patient is 5 years old, complains of runny nose, dry paroxysmal cough,
expiratory dyspnea, fever up to 38 ° C. Percussion - above the lungs box sound,
auscultatory - hard breathing, dry whistling and wet mid-bubble rales. In the
hemogram - moderate leukopenia.
1. What system of defeat can be thought of? Make a preliminary diagnosis and
identify the main clinical syndromes.
2. What characteristic changes at inspection can be found at this
disease? Demonstrate knowledge of the semiotics of changes in the nature of
respiration when examining the respiratory system.
3. Indicate the changes on palpation of the chest, which are characteristic of this
disease. Demonstrate the technique of palpation of the chest (determination of
resistance, pain) and knowledge of the semiotics of lesions.
4. Indicate the changes in chest percussion that are characteristic of this
disease. To define percussion, its types, to characterize methods, the general
principles of carrying out depending on age of the child, to carry out comparative
percussion of lungs.
5. Indicate the changes in lung auscultation that are characteristic of this
disease. Demonstrate lung auscultation technique.
1. Impressions of the respiratory system. Preliminary diagnosis: acute respiratory viral

disease. Acute obstructive bronchitis. Main syndromes: intoxication, catarrhal,
bronchoobstructive.
2. On examination: possibly swollen chest (horizontal placement of the ribs),
participation in the act of breathing auxiliary muscles, retraction of the intercostal
spaces.
3. At a palpation changes in lungs are absent.
4. Percussion determines the box shade of the lung sound.
5. Hard breathing. Exhalation is prolonged, rales are symmetrical, diffuse, change when
coughing; many whistling rattles. There may be dry and moist medium- and small-
bubble rales.
Task 22
A 3-year-old girl was taken to a doctor with a spotty rash on the skin, mainly on
the back and extensor surfaces of the limbs. History of purulent meningitis in the
first year of life; vaccination, except for BCG was not performed. Objectively -
palpated enlarged occipital lymph nodes, fever up to 37.5, moderate mucous
discharge from the nasal passages, a slight reddening of the conjunctiva.
1. Establish a preliminary diagnosis and identify the main clinical syndromes.
2. What characteristic changes of skin at inspection can be found at this
disease? Demonstrate the method of survey and review of this system, and
knowledge of the semiotics of lesions.
3. Demonstrate knowledge of the semiotics of skin rashes.
4. Demonstrate the technique of skin palpation and knowledge of the semiotics of
lesions.
5. Demonstrate the method of assessing the condition of skin capillaries.
1. Measles. The first sign of measles is usually a significant rise in

temperature about 10-12 days after infection, which lasts 4-7 days. At this initial
stage, rhinitis, cough, redness of the eyes and tearing, as well as small white
spots on the inner surface of the cheeks may occur. In a few days, a rash appears
- first, usually on the face and upper neck. After about three days, the rash
spreads throughout the body, including the arms and legs. It lasts 5-6 days and
then disappears. On average, the rash appears 14 days (7 to 18 days) after
exposure to the virus.
2. The main symptoms of measles increase gradually and are characterized

by the appearance and attenuation of the characteristic rash:
-1-2 days - spots on the cheek mucosa against the molars;
-2-3 days - abundant rashes on the skin of a papular nature,
-at first rashes appear on the head (behind the ears, on the lateral surfaces of the
neck, have different size and shape, do not contain fluid inside, merge with each
other,
parts of the head), by the end of the day the rash becomes darker and spreads to
the face and upper chest
-on the 2nd day the rash spreads to the whole body, except for the lower
extremities, and on the 3rd day - spreads to the legs;
-after the attenuation of rashes on the skin are pigmentation and peeling.
-The rash period usually lasts up to 3 days. The high temperature at this time still
persists.
-Increased runny nose, cough, deteriorating general condition of the patient.
-The period of pigmentation lasts from 1.5 to 3 weeks and is characterized by a
gradual "attenuation" of measles symptoms: the rash turns into brown spots, the
skin peels, body temperature drops to normal, inflammatory processes in the
upper respiratory tract subside.
3. SEMIOTICS OF RASH. Rash on the skin and mucous membranes can be
not only in viral and bacterial infections, but also in diseases of non-infectious
nature.
Elements of rashes. There are primary and secondary elements of
rashes. Primary elements are classified as roseola, spot, papule,
nodule , blister , hemorrhage. Secondary morphological elements include
pigmentation and depigmentation, scale, crust, erosion, crack, abrasion, ulcer,
scar.
1. Roseola (roseola) - a spot of pale pink, red in size from 1 to 5 mm. The shape
is round or irregular, the edges are clear or blurred, does not protrude above the
level of the skin, disappears when pressed and stretched the skin. Roseola is
found in many infectious diseases, especially typhoid fever.
2. The spot (makula) has the same color as roseola, size - from 5 to 20 mm,
does not protrude above the level of the skin. The shape is often incorrect. The
stain disappears when pressed on the skin and reappears after the pressure
ceases. Multiple spots 5 to 10 mm in size are described as a small spot rash (eg,
rubella). Spots 10-20 mm in size form a large spotted rash (for example, with
measles, allergies).
3. Erythema (erythema) - large areas of hyperemic skin of red, purple-red or
purple color. Occurs as a result of the fusion of large spots formed by
vasodilation not only of the papillary layer of the skin, but also of the sub-papillary
vascular plexus. Spots larger than 20 mm that tend to merge should be
considered erythema. Erythema is most typical for erysipelas, thermal, ultraviolet
burns.
4. Hemorrhage (haemorrhagia) - hemorrhage into the skin as a result of
destruction of skin vessels. It has the appearance of dots or spots of various
sizes and
shapes. 5. A papule is an element of a rash that rises above the level of the skin,
which is often determined by touch. It has a flat or domed surface, size - from
1 to 20 mm. The shape and color are the same as those of roseola and
spots. Papules often leave behind pigmentation and peeling of the skin.
6. Node (nodus) - a cavityless, limited, deep-sealing seal, often protruding above
the skin. The size of the nodes - from hazelnut to chicken egg and more. 7.
Blister (urtica) - islet inflammatory, slightly rising above the level of the skin
acavity element in size from 2-3 to 10-15 cm and more, has a round or oval
shape, often accompanied by itching. or brown crust. Secondary morphological
elements are formed as a result of the evolution of the primary elements of the
rash. 1. Hyperpigmentation (hyperpigmentatio) - a change in skin color as a
result of an increase in melanin or deposition of hemosiderin primary
elements. 2. Depigmentation (depigmentatio) occurs as a result of a decrease in
the content of melanin in the skin, is observed after the disappearance of the
nodule, tubercle - the resolution of spotty-scaly (bran herpes, eczematoids) and
papular (psoriasis) elements. 3. Scales (sguama) - a cluster of rejected cells of
the stratum corneum, sometimes subject to the layers of the epidermis. Bыvayut
scales on pervychnыh morphological element - papules (psoriasis, syphilis)
buhorkah, after permission puzыrkov (эkzema) and so on. D. 4.Эrozyya (erosio)
- kozhy defect in the epidermis as a result Limit vskrыtyya puzыrka, bubbles,
pustules, povtoryayuschyy s shape and size. 5. Abrasion (excoriatio) - a violation
of the integrity of the skin, arising from scratches, scratches and other
damage. Abrasions can be superficial - within the epidermis, sometimes involving
the papillary layer of the dermis, and heal without scarring. Deeper abrasions,
involving the deeper layers of the dermis, leave a scar. Abrasions are
characterized by a tendency to become infected. 6. Ulcer (ulcus) - a deep defect
of the skin, reaching the dermis, subcutaneous fat, fascia, muscles,
bones. Occurs as a result of the decay of the tissue of the primary element
(tubercle, node, ecthyma). Its size - from 1 mm to the size of a coin or palm and
more than 7. Cracks, tears (fissura, rhagades) - linear damage to the skin in the
form of its rupture, resulting from excessive dryness due to loss of elasticity
during inflammatory infiltration or overstretching of the skin. Cracks can be
located within the epidermis and dermis. They are usually localized in the corners
of the mouth, interdigital folds, on the palms, soles, above the joints, in the
anus. The surface crack after healing leaves no traces. After healing of deep
cracks, linear scars remain. 8. Crust (crusla) is formed on the skin as a result of
drying of the separated wetting surface (blister, blister, pustule, ulcer, erosion 9.
Scar (cicatrix) - the formation of connective tissue at the site of a deep
defect.Accurs after healing of deep skin defects at the site of ulcerated
bumps , deep pustules, nodules, deep burns, wounds
4. The process of palpation
Palpation is based on the tactile sensation of the hand , which occurs when
moving and pressing the fingers and palms . Palpation determines the properties
of tissues and organs : their condition, size, shape, consistency, mobility,
topographic relationships, as well as the pain of the studied organ . Types of
palpation There are superficial and deep palpation. Superficial palpation is
performed with one or both palms placed flat on the examined area
of skin , joints , heart , etc. Vessels (their filling, wall condition) are
felt with fingertips at the place of their passage. Deep palpation is performed by
special techniques, different in the study of the stomach , intestines (sliding
palpation, according
to Obraztsov ), liver , spleen and kidneys , rectum , vagina and other
internal organs .
5. PIPE TEST
To perform a pinch test, the skin without a subcutaneous base (in the area of the
supra- or subclavian fossa) should be grasped in the fold with the thumb and
forefinger of both hands. The distance between the fingers of the left and right
hand on the skin fold should be 2-3 mm, parts of the fold should be shifted in
opposite directions across the length of the fold, or connect the fingers along its
length, and then stretch the fold in opposite directions along its length. The
appearance of more than 4-5 petechiae at the site of the pinch indicates a positive
pinch symptom (PV Kozhevnikov's symptom). Increased fragility of skin vessels is
observed in patients with scarlet fever, hemorrhagic vasculitis, leukemia, sepsis,
chronic hepatitis and the like.
Task 23
A 13-year-old girl was taken to a doctor with complaints of enlarged posterior
cervical lymph nodes, low-grade fever, general weakness, and decreased
appetite. On examination, the cervical lymph nodes on the right are enlarged to
the size of beans, painless, sealed together (look like a bag of potatoes ). There is
a moderate increase in the liver and spleen.
1. Establish a preliminary diagnosis, indicate the system of lesions and identify
the main clinical syndromes.
2. Demonstrate the method of examination of lymph nodes and knowledge of the
semiotics of lesions.
3. Demonstrate the technique of lymph node palpation and knowledge of the
4. Demonstrate the technique of percussion of intrathoracic lymph nodes and
5. Demonstrate the method of auscultation of intrathoracic lymph nodes and
1. LYMPHOGRANULEMATOSIS
Clinical manifestations of lymphogranulomatosis are local and general signs. The
first include enlargement of lymph nodes of dense-elastic consistency, welded
together (they form a package), and not welded to the skin. In the localized
cervical variant, these enlarged nodes are often mistaken for
tuberculous lymphadenitis , and without any diagnostic measures, the patient is
treated with anti-TB drugs, while the disease continues to progress and spread,
capturing other groups of lymph nodes and internal organs. Among the general
symptoms typical for lymphogranulomatosis are: periodic fever, itchy skin,
sweating, increasing weakness, specific changes in the blood .
2. I. Ensuring proper conditions during the examination of the patient:

1. The room has a good shine vatysya.
The room temperature is in the range of 18-22 ° C.
Absence of strangers.
II. Preparing the patient for lymph node examination:
Inform the patient about the purpose and course of the manipulation
III. Visual assessment of lymph nodes - examination technique:
1. Gradually exposing the patient's body, see the section placing peripheral
lymph tation nodes ( occipital - BTE - chin,
submandibular, perednoshyyni , zadnesheynyh , supraclavicular, subclavian,
axillary, thoracic , elbow, inguinal, femoral) the direct side daylight.
2. Pay attention to skin color, presence, size of enlarged lymph
nodes. Identify defects, identify and assess their nature .
3. -Ensure effective ness palpation.

Conduct surface palpa tion should palmar surface of the fingers and deep - the
tip we stop.
- Ensuring PLAYBACK ness palpation .
Palpation of lymph nodes Provo DTIS as follows: cervical, submandibular,
supraclavicular and subclavian, axillary, elbow, inguinal, popliteal. - Provide
informa ciency palpation With palpation examination determine: assemblies value,
texture, tenderness, mobility, skin cohesion, together
with downstream fabric we nature of surface fluctuations, the presence of
scarring. - For differential diagnosis limfadenopatiy Rate character enlarged lymph
nodes, common, common process - increase in several of lymph nodes is
observed in limfohranulomatozi, leukemia, particularly chronic lymphocytic
leukemia, the syndrome of acquired immune deficiency (AIDS); local process - a
local increase in peripheral lymph tation nodes, there is the presence of cancer
metastases in these sites (eg metastasis Virchow is a characteristic symptom
of IOM in gastric cancer. This schil tion enlarged lymph node palpated between
the legs hrudnynno-clavicular-mastoid muscle and the upper edge of the
clavicle).
4. Arkavin's symptom
- Percussion on the front under the muscle lines from the bottom up towards the
axillary cavities.
- Normally, there is no shortening of the sound (negative symptom).
- dulling of a sound - a sign of increase in bronchopulmonary nodes.
Symptom of the Philosopher's Bowl
- Loud percussion in the 1st and 2nd intercostal spaces on both sides from the
outside to the inside towards the sternum (the finger-plessimeter is located
parallel to the sternum).
-Normal dulling of the sound - on the sternum (negative symptom).
- If blunting occurs before reaching the edge of the sternum - it is possible to
increase the nodes of the anterior mediastinum.
5. On examination of the skin of the chest in some patients, you can see the
expansion of the erythematous venous network. Listening (auscultation) of the
patient allows to recognize the symptom of D * Espin, sometimes appearing at
increase in intrathoracic nodes.
Symptom D * Espin increased bronchophonia

over the spinous processes below 7 cervical vertebrae in young children, below 2
thoracic vertebrae in children 8-10 years and below 3 thoracic vertebrae at a later
age, a cause of tuberculous bronchoadenitis.
Task 24
The patient is 8 years old. A month ago I fell ill with scarlet fever. Over the past
week, he became weak, his appetite worsened, and his face became
swollen. Objectively: pale skin, pasty face. Heart rate - 108 / min, blood pressure -
130/80 mm Hg. Art. Urination is not disturbed. Urine analysis: relative density
1028, protein level - 2.6 g / l, lake. - 5-8 in sight, er. - 40-50 in the field of view,
changed. Zymnytsky test: fluctuations in relative density - 1006-1024,
nocturia. What disease should you think about? What are its main symptoms?
2. Demonstrate the method of collecting medical history, examination of the
urinary organs and knowledge of the semiotics of lesions.
3. Demonstrate the technique of palpation of the kidneys and knowledge of the
4. Demonstrate the technique of percussion of the urinary system (bladder,
Pasternak's symptom, etc.) and knowledge of the semiotics of lesions.
5. Demonstrate the method of auscultation of the urinary system and knowledge
of the semiotics of lesions.
1. GLOMERULONEPHRITIS (URINARY SYSTEM) The signs and symptoms
of glomerulonephritis depend on the form (acute or chronic) and the cause, but
they can be generalized. These include: Pink or brown urine due to the presence
of blood cells in the urine ( hematuria ) . Foamy urine due to the presence of
proteins ( proteinuria ) . High blood pressure ( hypertension ) . Fluid retention
( edema ) with marked swelling of the face, arms, legs and abdomen . Fatigue
due to anemia or renal failure .
2.
In the presence of pain specify the localization (in the lumbar region, right, left, on
both sides, etc.), its nature (acute - cutting, burning, convulsive; dull - aching,
pressing, viscous), intensity (strong, insignificant), as it begins (suddenly, acutely,
gradually) and under what conditions (physical exertion, change of body position,
at rest, etc.), duration, irradiation (along the ureters, to the bladder, into the
urethra, genitals, perineum, groin area, in the thigh).
It is necessary to clarify the nature of urination (arbitrary, free; frequent and
painful), frequency (day, night), uncontrollable urge to urinate, pain, tingling or
itching in the urethra during urination ( at the beginning , during, at the
end). The child and his / her parents are asked if there are any changes in the
urine flow (thin, weak, intermittent), if there are no drops, the amount of urine
after each urination and the daily amount. The presence of urinary incontinence
(day, night, constantly) or its delay.
Attention is paid to extrarenal complaints, in particular, such as headache,
dizziness, fatigue, thirst, palpitations, heart pain, shortness of breath, nausea,
vomiting, impaired vision. Be sure to specify when these complaints appeared,
which preceded them, the presence of diseases.
3.
Palpation of the kidney is performed bimanually in the position of the patient on
his back, side or standing.
The doctor sits down on the side of the kidney to be palpated and pushes the
palm of his hand under the patient's waist (left - for palpation of the right kidney,
right - palpating the left kidney). The fingertips rest on the corner formed by the
XII rib and the long muscles of the back. Half-bent fingers of the second hand
penetrate the front into the hypochondrium parallel to the edge of the rectus
abdominis and outside it. Palpation is performed by bringing both hands together
at the height of inspiration and during exhalation, thus assessing the respiratory
mobility of the kidney.
Renal colic, acute inflammatory processes, traumatic kidney damage on
palpation of the affected organ are characterized by increased pain and muscle
tension of the anterior abdominal wall and lower back.
At pyonephrosis, hydronephrosis, nephroptosis or a tumor of a kidney the last
often manages to be palpated, to define character of its surface, a consistence,
mobility, running, painfulness.
Palpation of the ureters is usually almost impossible, even with a significant

increase, because they are located in the depth of the retroperitoneal space.
Of particular importance for the diagnosis of diseases of the ureter are the three
pain points of Tournai, pressing which causes increased pain. The upper point of
Tournai is at the level of the navel 4-6 cm lateral to it and corresponds to the first
narrowing of the ureter - the pelvic-ureteral segment. The second point is at the
intersection of the biiliaca line with the line drawn from the upper point of Tournai
to the tuberculum pubicum, and corresponds to the second narrowing of the
ureter - the place of its intersection with the iliac vessels. The third point
corresponds to the third narrowing of the ureter - the place of its confluence with
the bladder - and is determined bimanually by vaginal or rectal examination. The
bladder is palpated through the anterior abdominal wall or bimanually: in women
- through the vagina, in men - through the rectum. The empty bladder is not
normally palpable, painless. In acute and chronic urinary retention, the bladder
on palpation over the pubis is defined as a stationary, painful tumor-like formation
of elastic consistency, which disappears after the evacuation of its contents, such
as a catheter. On palpation in the suprapubic region can also be found
inflammatory infiltrates in the peribladder tissue, cancerous infiltrate of the upper
part of the bladder wall with the germination of the tumor in the peribladder
tissue. In such cases, the dense infiltrate over the pubis does not disappear after
emptying the bladder. Palpation will be painful in the inflammatory process of the
bladder and peri-bladder tissue, and in the case of suppuration of the latter
(paracystitis) can also detect fluctuations in the depth of the tissues.
4
Percussion of the kidneys is not performed due to the fact that they are
topographically deep. But to diagnose inflammatory processes in the kidneys use
the method of tapping in the projection of the kidneys. To do this, make short,
light blows with the fingers of the right (or left) hand or the side (elbow) edge of
the right hand (with the fingers folded together) on the back of the fingers of the
left hand, placed on the lumbar region. In the presence of inflammation
(pyelonephritis, paranephritis, etc.) the patient experiences acute pain. This
symptom is described by FI Pasternatsky and bears his name. But you should
know that the symptom of FI Pasternatsky can be positive in myositis, radiculitis
and it reduces its diagnostic value. In addition, in young children it is difficult to
assess the subjective feelings that arise when determining this symptom.
In young children, percussion of the bladder can be performed. It is carried out

along the midline from the level of the navel towards the pubis. The finger-
plesimeter is placed parallel to the pubis. If the bladder is stretched with urine,
when tapping there is dullness over the pubis, if it is emptied - a boxy sound.
5.
Auscultation. In all forms of arterial hypertension, auscultation of the patient is
mandatory: in front - in the upper quadrants of the abdomen, behind - at the level
of the costal-vertebral angles. Depending on the cause of the renovascular form
of hypertension, the noises are of different nature. Mild systolic murmur is
characteristic of renal artery stenosis . Rough and prolonged systolic murmur is
characteristic of arteriovenous fistula, atheromatosis of the abdominal aorta. At
fibrous and fibromuscular stenosis of a renal artery in the upper part of a
stomach the long high-frequency noise with late systolic strengthening is
defined.
Task 25
A 4-year-old child has complaints of weakness, fatigue, shortness of breath after
exercise. Ill for a week. On palpation of the pulse - heart rate 120 for 1 minute, for
percussion - the left border of the heart 2.5 cm outside the left midclavicular
line. At auscultation - tones of heart are weakened, on top the gentle systolic
noise which disappears in standing position is listened.
2. Demonstrate the method of collecting anamnesis in the study of this system
and knowledge of the semiotics of lesions.
3. Demonstrate the method of palpation (determination of pulse and its
characteristics) in the study of this system.
4. Demonstrate the technique of percussion of this system.
5. Demonstrate knowledge of the algorithm for analyzing the auscultatory picture
of the heart during the examination of this system and show the ability to assess
heart tones, their characteristics depending on the age of the child
1. Diagnosis: Sinus tachycardia. Asthenic syndrome. Functional systolic
murmur. Affected Cardiovascular system.
Asthenic syndrome.
2. Typical complaints include: pain or discomfort in the heart, exercise
fatigue, palpitations and heart rhythm disorders, shortness of breath, discoloration
of the skin, delayed physical development. Clarify the time of occurrence of
complaints, the presence of CCC diseases in the family. In young children,
especially infants, pay attention to sudden crying, anxiety of the child, violation of
the act of sucking, sweating, shortness of breath and cyanotic attacks, and so on.
Objective examination of the child begins with a general examination and

successive examination of the face, neck, heart, abdomen and limbs. Assess the
general condition of the child, position in bed, consciousness.
A healthy child has no complaints, the general condition is satisfactory, she is

active, her consciousness is not disturbed, physical development corresponds to
age, skin color and mucous membranes are pink.
3. Pulse studies are performed during sleep or at rest of the child. Pulse is
determined on the superficial arteries: arteria radialis, a. Carotis, a. Temporalis,
a. Femoralis, a. Dorsalis pedis; most often - on the radial artery.
4. Rules of pulse research. Pulse determination is performed in a sitting or

lying position at rest. First, the pulse is palpated on both hands
simultaneously. The second and third fingers of both hands cover the child's
hands on the back side in the area of the radial wrist joint, the thumb is placed on
the back of the forearm, and the index, middle and ring fingers - on the radial
artery. The child's hands are relaxed and located at the level of the
heart. Evaluate the synchronicity of the pulse by comparing the magnitude and
frequency of pulse waves on both radial arteries. At the same indicators the pulse
is synchronous. In the future, determine the state of the pulse on only one hand
and evaluate its characteristics: frequency, rhythm, filling, tension.
5.
There are relative and absolute cardiac dullness. Absolute cardiac dullness covers a
small area of the anterior surface of the heart that is directly adjacent to the chest. At
percussion in this site find a dull sound. Most of the heart is covered by the edges of
the lungs - relative dullness, its boundaries correspond to the actual boundaries of
the heart. Percussion in the area of relative dullness has a shortened sound.
Rules and methods of percussion:
Carried out in the vertical and horizontal position of the child, depending on his
condition and age. The size of cardiac dullness in the vertical position is 10-15%
smaller than in the horizontal;
Preferably direct percussion is used; indirect percussion is performed in
adolescents and children with significant development of muscles and
subcutaneous tissue;
The relative boundaries of the heart are determined by quiet percussion, and the
absolute - the quietest;
Percussion is performed on the intercostal spaces in the direction from the lung
tissue to the heart (from clear lung to dull or dull sound); the finger is placed
parallel to the border of the heart;
The relative boundary of the heart is determined by the outer edge of the finger.
Percussion procedure: definition of 1) right, 2) upper, 3) left border of relative and
absolute dullness of the heart.
6. 1) listen to the child's heart in a vertical, horizontal position, on the left
side, at rest;
2) compare the data of auscultation on inhalation, exhalation and respiratory
arrest;
3) auscultation is performed in a certain sequence
And the tone corresponds to a pulse beat on the carotid artery or apical
shock. The pause between I and II tones is shorter than between II and I. The
apical shock coincides with the I tone.
Auscultatory determine: heart rate, sonority, clarity of tones, the presence of

noise. Determine the characteristics of noise: timbre, strength, in which phase of
the heart they are heard (systolic or diastolic); what part of systole or diastole
they cover; connection with the tones of the heart (along with the tone, slightly
deviates from the tone), as well as the connection with a change in body position
or exercise.
In a healthy child, heart sounds are rhythmic, sonorous, clear. Moderately

weakened tones in children in the first days of life, as well as exhaustion,
obesity. In the case of pathology, there is an increase or decrease at various
points.
Task 26
A 5-year-old boy developed a punctate hemorrhagic rash symmetrically on the
legs (feet, legs), swelling of the ankle joints, weakness, there are rises in
temperature to febrile figures. The spleen is not palpable, the liver is palpated and
cm below the edge of the costal arch.
2. To demonstrate the method of collecting anamnesis, examination of this
system and knowledge of the semiotics of lesions, to provide a description of
hemorrhagic rash in hemorrhagic syndrome.
3. Demonstrate the technique of palpation of the spleen system and knowledge of
the semiotics of lesions.
4. Demonstrate the technique of percussion of the spleen, bones and knowledge
5. Demonstrate knowledge of interpretation of changes in clinical blood analysis
and semiotics of lesions.
1, Diagnosis Hemorrhagic vasculitis.
2. The onset of the disease is observed in the form of skin lesions, which manifests
itself in the form of purpura on the feet, legs, buttocks, upper extremities, torso,
head. The rash has a hemorrhagic nature, rises above the surface of the skin, does not
disappear during pressure, may be accompanied by slight itching, necrosis may be
observed in the center of the element. Rash To make an accurate diagnosis, the doctor
collects a medical history, interviews the patient or his parents. Be sure to study the
history of all diseases (both chronic and transferred). Next, the doctor will examine the
skin, assess the extent and type of rash. Assign other research methods.
3. I moment of palpation : the doctor places the left hand on the left half of a thorax
and presses on it. The half-bent fingers of the right hand are set in the area of the left
hypochondrium so that the middle finger of the examining hand was as if a continuation
of the X rib of the patient.
II moment of palpation : during inhalation the skin moves down.
III moment of palpation : during exhalation, the fingers are immersed deep in the
abdominal cavity.
IV moment of palpation : the patient is asked to take a deep breath, and the spleen, if
it is enlarged, descending down under the pressure of the diaphragm, its lower pole hits
the doctor's fingertips, rests on them and then slips under them.
4. The spleen is located in the abdominal cavity, in the left hypochondrium, at the level
of IX to XI ribs. The spleen has an elongated oval shape, its long axis coincides with the
course of the X rib.
Percussion of the spleen is performed to determine its size. Apply quiet percussion. The
patient occupies a supine position on the right side.
The finger-plessimeter is installed near the edge of the left costal arch perpendicular to
the X rib. Percussion of weak force is carried out directly on the X rib, first from the left
costal arch towards the spine, and then from the posterior axillary line in the forward
direction. With the appearance of dull percussion sound, two boundaries of the long axis
of the spleen are noted.
From its middle draw perpendiculars to X edges and percusse on them, making quiet
blows and thus defining borders of diameter of a spleen.
Remember: Normally, the length of the axis of the spleen, which is located on the X rib,
is 6-8 cm, and the diameter is 4-6 cm.
5. Features of laboratory blood tests: the presence of anemia, signs of inflammatory
reactions (increased ESR, thrombocytosis, PSA, neutrophilic leukocytosis). Changes in
biochemical parameters are usually nonspecific and depend on the organs and systems
involved in the pathological process. In the general analysis of urine it is necessary to
control proteinuria, leukocyturia, erythrocyturia therefore periodically appoint definition
of daily quantity of protein, the analysis of urine according to Nechiporenko, Zemnitsky's
tests, the uroleukogram are appointed.
Task 27
In a 3- year - old child there is an intense headache, high body temperature (39 °
C), vomiting, which does not bring relief, short-term clonic-tonic convulsions. The
symptom of Kernig and the upper Brudzinski is positive.
1. Establish a preliminary diagnosis and identify the main clinical syndromes.
2. Demonstrate knowledge of the evaluation scheme of this system.
3. Demonstrate the method of review of this system and knowledge of the
4. Demonstrate methods of studying the function of cranial nerves and
5. Demonstrate the method of detecting pathological reflexes (meningeal
symptoms).
1. Meningococcal meningitis.
2. 1. General assessment of the child's behavior, the correspondence of its
neuropsychological development to age, the level of its consciousness.
General examination (posture, examination of the head, face, etc.).
Study of cranial nerve function
. Research of superficial and tendon reflexes.
Sensitivity study.
Tests for coordination of movements.
Investigation of the functions of the autonomic nervous system.
Detection of pathological reflexes.
3. is usually done in a supine position on the patient's back or, more conveniently, on
the right side .... The doctor puts his left hand with a splash on the left half of the chest
in the area of UII-X ribs and presses a little; thus it achieves, fixing the left half of a
thorax, increase in respiratory excursions of the left diaphragmatic dome. Slightly bent
in the last phalangeal joint of the fingers of the right hand, placed perpendicular to the
costal margin in the X rib, just near the costal margin and pressed slightly into the
abdominal cavity, we feel the lower end of the spleen, which moves during deep
breathing excursions. No movements of the fingertips towards the spleen, which falls
when inhaling, should not be done by probing, because then in cases of small
enlargement of the spleen, you can easily miss the moving edge of it and not feel it. The
spleen itself with deep breathing of the patient approaches the fingers.
4. Research of the function of CHMN.
• I. Olfactory nerve - low diagnostic value
• II. Optic nerve - a study of visual acuity using diagnostic tables.
• III. Oculomotor nerve - study the movements of the eyeballs upward, inward,
downward and functions akkomodatsiyi
• And V . Block nerve - a study of the movements of the eyeballs down and sideways.
• V . Trigeminal nerve - a study of sensitivity on the face alternately in each of the zones
of innervation of individual branches of the trigeminal nerve and the function of the
masticatory muscles.
• VI . The afferent nerve is the study of the movements of the eyeballs outward.
• VII . Facial nerve - a study of facial function
muscles, taste on the front two thirds of the tongue, hearing, mucous membranes
of the eyes and mouth ..
• VIII . Vestibular - auditory nerve - study of hearing and balance. • IX . The
lingual-pharyngeal nerve is a study of phonation, swallowing, and taste in the
posterior third of the tongue. • X . The vagus nerve is a study of phonation and
swallowing. • XI . Additional nerve - the study of turning the head to the side and
the ability to raise the shoulders. • XII . Sublingual nerve - a study of the
motor function of the tongue during extension.
5. MENINGEAL SIGNS, REFLEXES

Occipital muscle rigidity - pain or inability to bring the head to the chest.
Vabinsky's reflex - stroke irritation of the sole on the outer edge of the foot from the heel
to the base of the big toe causes dorsiflexion of the big toe and plantar flexion of the
other toes (physiological reflex up to 2 years of age).
Kernig's reflex - an attempt to unbend the leg, bent at the knee and hip at right angles,
in a child lying on his back, fails (physiological reflex to 4-6 months of age).
Brudzinski's reflex (physiological up to 3-4 months of life):
- upper: with passive bending of the head in a child there is a rapid bending of the legs
in the knee and hip joints;
- medium: when pressing the edge of the palm on the pubic joint in a sick child, the legs
are bent;
- lower: with passive bending of one leg in the knee and hip joints, the other leg is also
bent.
Lasega reflex - the inability to bend a straightened leg in the hip joint by more than 60-
70s.
In newborns for the diagnosis of meningitis use Flat syndrome (dilation of the pupils with
a rapid tilt of the head forward) and Lessage (pulling the child's legs to the abdomen in
a suspended position) in combination with the clinical picture.
Task 28
The mother of a 3-month-old boy complains that the child has sweating of the
head, baldness of the nape of the neck, frequent tremors, lethargy, a tendency to
constipation, enlarged "frog" belly.
1. Which system disease is most likely? What is the most likely
diagnosis? Highlight the main clinical syndromes.
2. Demonstrate the method of examination of the muscular system and
3. Demonstrate the technique of palpation of the muscular system and knowledge
4. Demonstrate methods of assessing muscle strength and knowledge of the
5. Demonstrate methods of diagnosis of increased mechanical excitability of
muscles and knowledge of semiotics of lesions.
1. Rickets - a disease of infants and young children, is a violation of mineral
metabolism, especially phosphorus-calcium, which leads to a disorder of the proper
formation of the skeleton and the functions of internal organs and systems.
Rickets of moderate severity, subacute course, initial period
Syndromes: malabsortsiyi, hyperexcitability, allopetsiyi, myaz is howling
Ki potonyy
2. Examining different muscle groups (limbs, torso, etc.), pay attention to their functional
ability, ie the ability to perform certain movements. When examining a child, you can get
an approximate idea of the state of muscle tone. Muscle tone is a slight physiological
and constant tension of the skeletal muscles at rest, which ensures the readiness of the
muscles to perform movements.
3. Muscle trophism, which characterizes the level of metabolic processes, is assessed
by the degree and symmetry of development of individual muscle groups. The
assessment is performed at rest and during muscle tension. There are three stages of
muscle development: weak, medium and good. With a weak degree of development of
the muscles of the torso and limbs at rest are not enough, when stressed, their volume
changes quite a bit, the lower abdomen sags, the lower corners of the shoulder blades
lag behind the chest. At an average stage of development, the mass of the muscles of
the torso at rest is moderate, and the limbs - well, when the muscles are tense, their
shape and volume change. At a good degree of development muscles of a trunk and
extremities are well developed, and at tension there is a clear increase in a relief of
muscles.
4. Assessment of muscle strength in children is carried out on a special scale on a five-

point system: 0 points - no movement; 1 - active movements are absent, but muscle
tension is palpated; 2 - passive movements are possible at overcoming of insignificant
resistance; 4 - passive movements are possible when overcoming moderate
resistance; 5 - muscle strength within normal limits.
5. To diagnose the increased mechanical excitability of muscles which can be observed

at patients with a spasmophilia, and also at a hypocalcaemia use the following tests:
a) the phenomenon of the Tail - with a light knock with a neurological hammer on the
cheek in the middle between the corner of the mouth and ear (the place of exit of the
facial nerve) the patient has a lightning contraction of the upper lip, nasal wings, eyelid
muscles and even forehead;
b) Trusso phenomenon - the doctor squeezes the child's shoulder above the elbow and
due to mechanical irritation of the nerves passing into the sulcus bicipitalis , after 1-
2 minutes there is a spasm of the muscles of the hand, which accurately reproduces the
picture of the "obstetrician's hand";
c) Lust's symptom - muscle contraction and lifting of the outer edge of the foot when
struck by a neurological hammer on the head of the tibia (irritation of the n . peroneus );
d) Schlesinger's symptom - when lifting a straightened leg there is a carpopedal spasm.
Task 29
A 13-year-old girl complains of weakness, an increase in body T to 37.4 ° C in the
last 2 months. after SARS. On examination: thin, diffuse enlargement of the
thyroid gland of the first degree, its density on palpation, exophthalmos,
tachycardia.
2. Demonstrate the method of collecting anamnesis and examination of this
system and knowledge of the semiotics of lesions.
3. Demonstrate the technique of palpation in the study of this system.
4. What characteristics are determined by percussion during the study of
this system ?.
5. What characteristics are determined by auscultation during the study of this
system?
1. Diseases of the endocrine system
Thyrotoxicosis . Subacute thyroiditis
2. Patients with pathology of the endocrine glands may have complaints of irritability,
irritability, restless sleep, sweating, skin discoloration, hair and nail growth disorders,
thirst
3. Palpation of the isthmus with sliding movements of the thumb, index and middle
fingers. For palpation of the right and left lobes it is necessary to get the II- V bent
fingers of both hands for its back edge, and the thumb - for the front edges of the
sternum-nipple. meat
4. At percussion over the handle of a sternum it is possible to find shortening of a
percussion sound that can testify to existence of a retrosternal goiter.
5. Auscultatory you can hear the vascular noise above the surface of the gland
Task 30
The child is 10 years old, complains of weakness, nervousness, loss of appetite,
heartburn, pain in the umbilical region, which is dull in nature and occurs more
often in 2-3 hours after eating, in the morning - on an empty stomach. The pain
decreases after eating. Ill for three years. Objectively: pale skin. The abdomen is
soft, painful on deep palpation in the epigastric and pyloro-duodenal
areas. Mendel's positive symptom.
2. Demonstrate a method of reviewing this system and knowledge of the
3. Demonstrate the technique of palpation of the intestines (sigmoid, blind, colon)
in the study of this system and knowledge of the semiotics of lesions.
4. Demonstrate the technique of percussion in the study of this system and
5. Demonstrate the method of auscultation in the study of this system and
1. Peptic ulcer and duodenal
2. EXAMINATION of a child with suspected diseases of the digestive system
is carried out according to the generally accepted scheme, starting with the
examination of the face, primarily determining the color of the skin, mucous
membranes and sclera. Examination of the tongue and mouth is often unpleasant
for the child, so in children, especially at an early age, this procedure should be
performed at the end of the examination. Examination of the abdomen must be
performed in two positions of the sick child - vertical and horizontal, first vertically
and then horizontally.
3. . The sigmoid colon is palpated in the left ileal fossa. To do this, four
slightly bent, folded together fingers of the right hand are placed parallel to the
sigmoid colon, which has an oblique projection direction: top left and down
right. First, the doctor mixes the skin towards the navel and during exhalation,
when the abdominal press relaxes, gradually immerses the fingers in the
abdominal cavity and reaches its posterior wall. Then, without reducing the
pressure, the doctor makes a sliding movement of the hand together with the skin
in the direction perpendicular to the longitudinal axis of the intestine (towards the
pupal ligament), and rolls the hand over the surface of the intestine.
The cecum is palpated in the right ileal fossa. Its longitudinal axis is directed
slightly obliquely: to the right and from above - down to the left, therefore it is
necessary to palpate perpendicularly to an organ axis in the direction obliquely to
the left from top to right down along the right umbilical line or parallel to it. The
technique of deep methodical palpation of the cecum is the same as for palpation
of the sigmoid colon:
In most cases, the transverse colon is 3-4 cm below the border of the
stomach. On the right it has a horizontal position, but gradually from the middle
line begins to shoot I left obliquely. The transverse colon is palpated with both
hands - bilateral palpation
4. Mendel's symptom ("hammer" symptom) - pain that occurs when tapping
in the Shoffar area folded into a hammer with the index, middle and ring
fingers. This symptom is positive in duodenitis and exacerbation of duodenal
ulcers.
5. auscultatory percussion (auscultatory friction). This method determines the
position (boundaries) and size of the stomach. With auscultation, the child is in a
supine position. On the abdominal wall in the area of the projection of the stomach
(to the left of the midline 3-4 cm above the navel) the doctor puts a stethoscope
and at the same time with his finger performs light scraping movements on the
abdominal wall, gradually moving away from the stethoscope. As the finger moves
in the area corresponding to the location of the stomach, the stethoscope is heard
through the stethoscope, which immediately disappears as soon as the
finger goes beyond the stomach. The location of the finger during the
disappearance of sound phenomena corresponds to the boundaries of the
stomach.
Task 31
At the child of 7 months there is a rapid increase in head volume, divergence of cranial
sutures, pronounced venous network on the scalp, thinning of the skin on the temples,
enlargement and protrusion of the large temples, open small and lateral temples, Grefe's
symptom, convergent strabismus , horizontal nystagmus, exophthalmos, drowsiness and
lethargy.
1. 1. What system of defeat can be thought of? Make a preliminary diagnosis

and identify the main clinical syndromes.
2. 2. Demonstrate the method of examination of the head during the examination of the
skeletal system and knowledge of the semiotics of lesions and variants of the norm.
3. 3. Demonstrate the method of examination of the chest during the examination of
the skeletal system and knowledge of the semiotics of lesions and variants of the
norm.
4. 4. Demonstrate the method of examination of the lower extremities and pelvic bones
during the examination of the skeletal system and knowledge of the semiotics of
lesions and variants of the norm.
5. 5. Demonstrate the technique of palpation in the examination of the skeletal system
and knowledge of the semiotics of lesions and variants of the norm.
6. What system can you think of? Make a preliminary diagnosis and identify the
main clinical syndromes
DZ: HYDROCEPHALIA
Brain damage. Nervous System
Intracranial hypertension syndromeIn newborns, it is manifested by profuse belching, which

does not depend on food intake, frequent and long crying, developmental delay (later begin to sit
and crawl, unsteadily hold the head, etc.). Indirect signs are too convex forehead or exploding
spring in the baby. For children with high ICP is characterized by a symptom of "setting sun", in
which the eyeballs roll down to such an extent that the top shows a thin white strip of sclera.
In seniorsOffensiveness, tearfulness, drowsiness; Palpitation; High blood pressure; Flashes

before the eyes, strabismus; Cramps and nausea; Night and morning headache; Bruising under
the eyes, pain behind the eyes.
2. Demonstrate the method of examination of the head during the examination of the skeletal
system and knowledge of the semiotics of lesions and variants of the norm.
determine its size and shape. The circumference of the head in healthy children is directly
proportional to age. If you need to more accurately determine the size of the head, measure its
circumference with a tape measure. Decreased head size (microcephaly) An increase in head
size is called macrocephaly - hydrocephalus of the brain (hydrocephalus). Normally, the shape of
the head is rounded. Depending on the ratio of transverse and longitudinal diameters of the skull,
there are: narrow (dolichocephalic), medium (mesocephalic) and wide (brachycephalic) skull.
With pathology,
a) tower-like - sharply extended head upwards, high forehead, rising steeply, vertically lowered
parietal bones, closed arrow-shaped seam; b) buttock - significantly enlarged frontal and parietal
humps, the skull is flattened, the sagittal suture is deepened; c) saddle-shaped - significantly
enlarged frontal and parietal humps, seams (arrow-shaped and coronal) are significantly
deepened, especially pronounced depression in the place of the large umbilicus; d)
scaphocephaly occurs with premature closure and arrow (sagittal) suture and is characterized by
an elongated or narrow shape of the head; e) oxycephaly develops with premature closure of the
coronal suture and is characterized by severe deformation of the skull, face and eye sockets. with
rickets there is a flattened nape, which is a consequence of the pressure of the pillow on the soft,
pliable occipital bone. assessment of the development of the upper and lower jaw, the features of
the bite, the number of teeth, their nature (milk, permanent) and condition (shape, integrity,
developmental abnormalities, etc.). Underdeveloped lower jaw (micrognathia) due to
underdevelopment of the bones of the facial skull and lesions of the temporomandibular joint in
rheumatoid arthritis ("bird's face"). An increase in the size of the lower jaw (macrognathia) is
observed in chondrodystophy, osteomyelitis. Absence of teeth (all or some) is noted in
congenital ectodermal dysplasia and Marfan's syndrome (arachnodactyly). Violation of the
formation of tooth enamel in the form of depressions, cracks, irregularities occurs in rickets,
hypoparathyroidism, chronic diseases of the digestive system, syphilis. their different color is
revealed. Opalescent dentin - with congenital bone fragility; pink or reddish-brown hue - with
chronic porphyria; dark green color - in disorders of mineral metabolism, and dark - in lead
poisoning.
3. Demonstrate the method of examination of the chest during the examination of the skeletal
system and knowledge of the semiotics of lesions and variants of the norm.
examine the chest. shape, looking at the profile and full face, taking into account the direction of
the ribs, the magnitude of the epigastric angle (the angle between the right and left costal arches)
and anteroposterior and transverse dimensions. In healthy children - three forms of the chest: a)
conical - anteroposterior and transverse breast size are the same, the epigastric angle is obtuse,
the ribs depart from the spine at right angles almost horizontally; b) cylindrical - anteroposterior
and transverse dimensions of the chest are almost the same, the epigastric angle is straight, the
ribs are directed obliquely, from top to bottom; c) flat - GC flattened by reducing the
anteroposterior size, the epigastric angle is sharp, the direction of the ribs oblique and they are
attached to the spine at an acute angle. "Rickets" - These rib, brush-shaped thickenings are
clearly visible in the form of a chain, directed arcuately from top to bottom and out at the level of V-
VIII ribs. ask the child to raise his hands up and examine her chest in oblique projection. These
rib thickenings are an indisputable sign of rickets. Often with rickets, the sternum protrudes
sharply, forming a keel-like but "chicken" chest. Funnel-shaped breast (pectus fusiforme). This
form of chest ("shoemaker's GC") is an anomaly of development, the result of rickets or
respiratory disease. The bar-shaped form (wide and short) of a thorax which is characterized by
expansion of all thorax, increase in its anteroposterior transverse sizes, is observed at children at
an emphysema of lungs, bronchial asthma, asthmatic and obstructive bronchitis. Paralytic - in
chronic bronchopulmonary processes, tuberculosis. Other chest deformities in children include: a)
"heart hump" - limited protrusion of the chest in the heart - is observed in congenital and acquired
heart defects, left ventricular hypertrophy, and sometimes in exudative pericarditis; b) flattening of
one half of the chest develops due to a chronic fibrous process in the lungs, which leads to its
shrinkage. c) unilateral protrusion of the chest indicates the accumulation of exudate in the
pleural cavity. Along with the protrusion of one half of the breast also show smoothing or even
protrusion of the intercostal spaces and the absence or reduction of their retraction during
inspiration. and sometimes with exudative pericarditis; b) flattening of one half of the chest
develops due to a chronic fibrous process in the lungs, which leads to its shrinkage. c) unilateral
protrusion of the chest indicates the accumulation of exudate in the pleural cavity. Along with the
protrusion of one half of the breast also show smoothing or even protrusion of the intercostal
spaces and the absence or reduction of their retraction during inspiration. and sometimes with
exudative pericarditis; b) flattening of one half of the chest develops due to a chronic fibrous
process in the lungs, which leads to its shrinkage. c) unilateral protrusion of the chest indicates
the accumulation of exudate in the pleural cavity. Along with the protrusion of one half of the
breast also show smoothing or even protrusion of the intercostal spaces and the absence or
reduction of their retraction during inspiration.
4. Demonstrate the method of examination of NC and pelvic bones during the examination of the
skeletal system and knowledge of the semiotics of lesions and variants of the norm.
Examining the child's pelvis, pay attention to the presence of flat-rickets pelvis, aplasia (agenesis)
of the pelvic bones and pelvic deformity, which is characterized by pathologically deep
acetabulum (so-called "Otto's pelvis") and may at puberty be manifested by lameness and pain in
knee joints.
The child's limbs should be examined in a supine and standing position. First inspect the top and
then the bottom. evaluate their length as a whole and the length of the forearm and shoulder,
proportionality to each other and to the total length of the body, the presence of distortions,
deformations, thickenings and developmental abnormalities. Long-handedness with thin and long
fingers is characteristic of arachnodactyly (Marfan's syndrome), while shortened upper
extremities are observed in patients with pituitary dwarfism, thyroid dwarfism, chondrodystrophy. in
dwarfism both limbs are proportionally shorter in relation to the torso, and in chondrodystrophy the
proximal extremities are significantly shortened ... Significantly enlarged hands are found in
children with pituitary gigantism (acromegaly) due to increased growth of soft tissues and bones.
Wide and short brushes with fingers resembling cancer claws, characteristic of children with
mucopolysaccharidosis type I (Pfaundler-Gurler disease). Thickened palm with short fingers
(brachydactyly) in the form of stumps is characteristic of Marquezani syndrome. In
chondrodystrophy of the hands of a square shape, all the fingers are almost the same length
and significantly expanded interdigital spaces, which gives the hands a peculiar shape in the
form of a trident. Fingers in the form of "drumsticks" (deformation of the end phalanges) and
nails as "watch glasses" - with congenital and acquired heart defects and with chronic
bronchopulmonary diseases. absence of one limb or its part), phocomelia (significant reduction
in the size of the proximal parts of the limbs), acheria (absence of hands), adactyly (absence of
fingers), aphalangia (absence of phalanges). Changes in the fingers and toes can also be in the
form of polydactyly (extra fingers), syndactyly (finger fusion) and macrodactyly (enlargement of
one or more fingers)
When examining the NC in children pay attention to their length, shape, the presence of
thickenings, deformations and anomalies of bone development, the symmetry of the skin folds
on the thighs, the presence of additional skin folds, clubfoot and flat foot. Shortening of both NCs
in children occurs in chondrodystrophy, and one of the extremities - in congenital dislocation of
the hip joint, Perthes' disease (aseptic subchondral necrosis of the femoral head), congenital
shortening of the thigh, tuberculous lesion of the hip joint. If the thighs and lower legs are affected
with the formation of a bulge directed outwards, the lower extremities form the letter "O"
- O-shaped legs. When the muscles and ligaments are weak, the rickets can be curved inward,
and then the lower extremities are curved in the shape of the letter "X" - these are the so-called
X- shaped legs. In children with congenital syphilis, the shins, curved forward, resemble a sword
- saber-shaped legs. It is necessary to pay attention to one more form of curvature of NC -
congenital varus deformation of hips. Coxa vara is characterized by the position of the thighs in
the state of abduction, high standing of the trochanters and a special gait by the carrier ("duck
gait"). Medial curvature of the knee joint occurs in rickets, Pfaundler-Gurler, Morkio, polio and
traumatic bone injuries. Examining the foot, first of all determine the shape of its arch (normal,
flattened, elevated) .: a) the child is placed on his knees on a chair facing his back with free-
hanging feet; b) the child stands so that the arch of the foot is clearly visible. Plantography is
used for more accurate diagnosis of flat feet. Flat feet (flat feet) are quite common in childhood.
And up to 3 years it is a physiological phenomenon, because their vault is filled with
subcutaneous fat. In the future, this deformity should be remembered, because in the future it
often causes pain in the lower extremities. Various inflammatory, dystrophic and traumatic
lesions of the foot bones can cause its deformation. Thickening of the bones in the form of
swelling may indicate the presence of malignant (osteosarcoma, Ewing's sarcoma,
chondrosarcoma) or benign (osteoma) "bone tumors. Changes in the configuration of the bones
in the form of a spindle-shaped swelling, as well as local reddening of the skin may be a sign
and consequence of an acute inflammatory process in them - osteomyelitis, which particularly
often affects the femur and tibia. And up to 3 years it is a physiological phenomenon, because
their vault is filled with subcutaneous fat. In the future, this deformity should be remembered,
because in the future it often causes pain in the lower extremities. Various inflammatory,
dystrophic and traumatic lesions of the foot bones can cause its deformation. Thickening of the
bones in the form of swelling may indicate the presence of malignant (osteosarcoma, Ewing's
sarcoma, chondrosarcoma) or benign (osteoma) "bone tumors. Changes in the configuration of
the bones in the form of a spindle-shaped swelling, as well as local reddening of the skin may be
a sign and consequence of an acute inflammatory process in them - osteomyelitis, which
particularly often affects the femur and tibia. And up to 3 years it is a physiological phenomenon,
because their vault is filled with subcutaneous fat. In the future, this deformity should be
remembered, because in the future it often causes pain in the lower extremities. Various
inflammatory, dystrophic and traumatic lesions of the foot bones can cause its deformation.
Thickening of the bones in the form of swelling may indicate the presence of malignant
(osteosarcoma, Ewing's sarcoma, chondrosarcoma) or benign (osteoma) "bone tumors.
Changes in the configuration of the bones in the form of a spindle-shaped swelling, as well as
local reddening of the skin may be a sign and consequence of an acute inflammatory process in
them - osteomyelitis, which particularly often affects the femur and tibia. In the future, this
deformity should be remembered, because in the future it often causes pain in the lower
extremities. Various inflammatory, dystrophic and traumatic lesions of the foot bones can cause
its deformation. Thickening of the bones in the form of swelling may indicate the presence of
malignant (osteosarcoma, Ewing's sarcoma, chondrosarcoma) or benign (osteoma) "bone
tumors. Changes in the configuration of the bones in the form of a spindle-shaped swelling, as
well as local reddening of the skin may be a sign and consequence of an acute inflammatory
process in them - osteomyelitis, which particularly often affects the femur and tibia. In the future,
this deformity should be remembered, because in the future it often causes pain in the lower
extremities. Various inflammatory, dystrophic and traumatic lesions of the foot bones can cause
its deformation. Thickening of the bones in the form of swelling may indicate the presence of
malignant (osteosarcoma, Ewing's sarcoma, chondrosarcoma) or benign (osteoma) "bone
tumors. Changes in the configuration of the bones in the form of a spindle-shaped swelling, as
well as local reddening of the skin may be a sign and consequence of an acute inflammatory
process in them - osteomyelitis, which particularly often affects the femur and tibia. Thickening of
the bones in the form of swelling may indicate the presence of malignant (osteosarcoma,
Ewing's sarcoma, chondrosarcoma) or benign (osteoma) "bone tumors. Changes in the
configuration of the bones in the form of a spindle-shaped swelling, as well as local reddening of
the skin may be a sign and consequence of an acute inflammatory process in them -
osteomyelitis, which particularly often affects the femur and tibia. Thickening of the bones in the
form of swelling may indicate the presence of malignant (osteosarcoma, Ewing's sarcoma,
chondrosarcoma) or benign (osteoma) "bone tumors. Changes in the configuration of the bones
in the form of a spindle-shaped swelling, as well as local reddening of the skin may be a sign and
consequence of an acute inflammatory process in them - osteomyelitis, which particularly often
affects the femur and tibia.
5. Demonstrate the technique of palpation in the examination of the skeletal system and
knowledge of the semiotics of lesions and variants of the norm.
Palpation is performed sequentially, feeling the bones of the skull, chest, spine, upper and NC, as
well as joints. Palpating the bones of the skull, determine their density, the condition of the sutures
and temples. The study is performed with both hands as follows: the thumbs are placed on the
forehead, palms on the temples, and the middle and index fingers carefully examine the parietal
bones, nape, sutures and temples, ie the entire surface. A common softening of the skull bones -
craniotabes - is most common in the scales of the occipital and parietal bones. In these areas,
the bone is pliable, bends very easily when pressed, often gives the feeling of parchment, and
then returns to its previous position. the edges of the bone seem to rise- "felt hat" -RACHIT.
Palpating the temples - determine its size, condition of the edges, tension and pulsation. The size
of the umbilicus (in centimeters) is determined by measuring the distance between the midpoints
of the edges of the two opposite sides. Tension and protrusion of the large (anterior) umbilicus -
in healthy infants during a loud cry. That the umbilicus is bulging and tense with increasing
intracranial pressure. This occurs in meningitis, meningoencephalitis, brain tumors and some
other diseases and pathological conditions. --pulsation of the temples. An inflamed temple is an
important symptom of dehydration (or exsiccosis) of the body. The condition of the sutures
between the skull bones should also be palpated and assessed. On the head of the newborn
there are the following sutures: frontal, coronal, arrow, or sagittal, lambdoid and parieto-nipple. At
children with an active stage of an acute rickets edges of seams are soft, pliable, and at
overgrowth of seams in the period of convalescence edges become dense and quite often dense
bone rolls are formed. At a hydrocephalus seams between skull bones Can differ considerably.
Palpation of the chest in children allows you to specify the type of constitution, the presence of
deformities (thickenings, fractures of the ribs, etc.), to identify pain and elasticity, as well as to
determine vocal tremors. The magnitude of the epigastric angle: the doctor places the palms of
both hands with the ribs on the right and left arches formed by the ribs of the chest. At a
normosthenic constitution the epigastric angle makes 90 degrees, at a hypersthenic it is dull, and
at an asthenic constitution sharp------deformities and fractures of the ribs and clavicle. Palpation
is performed with the tips of the index and middle fingers, running along the rib in the direction from
the anterior axillary line forward to the sternum. At the junction of the bony part of the ribs in the
cartilage may be brush-shaped thickenings ("rickets"). On palpation of the spine - the size, nature
and level of scoliosis. This requires that the child is slightly bent forward and to spend an index
finger from top to bottom on odd processes of vertebrae. Palpation of the upper extremities in
children who have suffered from rickets can identify symmetrical thickenings of the epiphyses of
the radial bones of the forearm ("rickets bracelets") and thickening of the diaphysis of the
phalanges of the fingers ("pearl threads"). Palpation of "rickets" is better to spend the index and
middle fingers on the back surface, slightly bending the child's arm at the wrist. "Pearl threads"
are detected by palpating the lateral surfaces of the phalanges of the child's fingers with the
thumb and forefinger. Palpation of the joints is performed carefully so as not to cause or
aggravate pain, with maximum muscle relaxation. Be sure to examine symmetrical joints.
Palpation of the joints allows you to roughly determine the temperature of the skin above the
joints, soreness, the presence of edema and exudate in the joint cavity, as well as various
formations in the joint. Often on palpation of the joints are found nodes. Heberden's nodes are
found on palpation of the distal, and Bouchard's nodes - proximal interphalangeal joints.
Inflammatory processes in the joints are accompanied by exudation into their cavity and
periarticular tissues. A characteristic sign of inflammation and edema of the periarticular tissues
is a thickening of the folds of the skin and subcutaneous tissue, which is detected by palpation in
the affected joint (a positive symptom of Alexandrov). Inflammatory processes in the joints are
accompanied by exudation into their cavity and periarticular tissues. A characteristic sign of
inflammation and edema of periarticular tissues is a thickening of the folds of the skin and
subcutaneous tissue, which is detected by palpation in the affected joint (a positive symptom of
Alexandrov). Inflammatory processes in the joints are accompanied by exudation into their cavity
and periarticular tissues. A characteristic sign of inflammation and edema of periarticular tissues
is a thickening of the folds of the skin and subcutaneous tissue, which is detected by palpation in
the affected joint (a positive symptom of Alexandrov).
The symptom of "floating patella" is detected as follows: squeeze the palms of the hands
straightened knee joint on both sides, slightly displace the soft periarticular tissue up and at the
same time make a push-like pressure with your fingers on the patella. In cases of exudate in the
cavity of the knee joint, the patella oscillates freely in the free fluid. At the end of the examination
of the joints, you need to assess the amplitude of passive movements, determining its limitations,
the presence of contractures and ankylosis. Lameness when walking or walking patient - "duck
gait", shortened lower limb, asymmetry of skin folds on the thighs, additional skin folds on the
medial surface of one of the thighs, lordosis of the lumbar region, external rotation of the lower
limb), special tests are used to diagnose the disease: a) to limit the removal of the thigh in the hip
joint on the side of the lesion - a child lying on his back with legs bent at the knees and hips, the
thighs are spread as much as possible. In healthy children, the legs should be completely parted
with the formation of an angle of about 180 degrees, while in the presence of dislocation (or
dysplasia), the breeding of the thighs is limited. Abduction less than 60-70 degrees, indicates
pathology; b) Ortholani - bent at the hip joint, brought and rotated inward, the femur is turned
outward and at the same time withdraw the leg. The head of the femur suddenly enters the
acetabulum and there is a click (a positive symptom of Ortholani); c) Barlow - in a child lying on
his back with bent at the knees and hips and moderately withdrawn lower extremities, the doctor
places the middle finger over the big swivel, thumb - medially and below average. And then,
pressing laterally with the thumb, the index finger rotates the knee joint medially and the head of
the femur is removed from the acetabulum. At the same time there is a click (a positive symptom
of Barlow). To detect the symptom of Allis, the child should be placed on his back and compare
the position of the knee joints of the NC, which are bent and brought to the abdomen. In the
presence of congenital dislocation, there is a shortening of the thigh and knee joints are located at
different levels. Examination of a child standing with his back to the doctor, in the presence of
congenital dislocation of the hip joint, reveals pubescence of one half of the pelvis - a symptom of
Trendelenburg the knee joint is turned medially with the index finger and the head of the femur is
removed from the acetabulum. At the same time there is a click (a positive symptom of Barlow).
To detect the symptom of Allis, the child should be placed on his back and compare the position
of the knee joints of the NC, which are bent and brought to the abdomen. In the presence of
congenital dislocation, there is a shortening of the thigh and knee joints are located at different
levels. Examination of a child standing with his back to the doctor, in the presence of congenital
dislocation of the hip joint, reveals pubescence of one half of the pelvis - a symptom of
Trendelenburg the knee joint is turned medially with the index finger and the head of the femur is
removed from the acetabulum. At the same time there is a click (a positive symptom of Barlow).
To detect the symptom of Allis, the child should be placed on his back and compare the position
of the knee joints of the NC, which are bent and brought to the abdomen. In the presence of
congenital dislocation, there is a shortening of the thigh and knee joints are located at different
levels. Examination of a child standing with his back to the doctor, in the presence of congenital
dislocation of the hip joint, reveals pubescence of one half of the pelvis - a symptom of
Trendelenburg In the presence of congenital dislocation, there is a shortening of the thigh and
knee joints are located at different levels. Examination of a child standing with his back to the
doctor, in the presence of congenital dislocation of the hip joint, reveals pubescence of one half of
the pelvis - a symptom of Trendelenburg In the presence of congenital dislocation, there is a
shortening of the thigh and knee joints are located at different levels. Examination of a child
standing with his back to the doctor, in the presence of congenital dislocation of the hip joint,
reveals pubescence of one half of the pelvis - a symptom of Trendelenburg
Task 32
A 6-year-old child has a body temperature of 38.5 ° C, shortness of breath, whooping

cough, pale skin, tachycardia. Percussion - shortening of the lung sound, auscultation -
crepitating rales in the lower right. Ill at home, sick for 5 days. Beginning with catarrhal
manifestations.
1. Which system disease is most likely? What is the most likely diagnosis?
Highlight the main clinical syndromes.
1. 2. Demonstrate the method of examination of the upper respiratory tract in the study
of the respiratory system and knowledge of the semiotics of lesions.
2. 3. Demonstrate knowledge of cough semiotics.
3. 4. Demonstrate knowledge of the semiotics of changes in percussion sound during
comparative percussion of the lungs.
4. 5. Demonstrate knowledge of the semiotics of lesions of auscultatory changes in the
study of the respiratory system (characteristics of normal breathing and pathology)
Lower lobe right-sided pneumonia
Pathological
Indicators Version Characteristic
conditions
Chronic laryngitis,
tracheitis, bronchitis,
Rhythm Constant Giggling in the form of initial stage of
individual coughing fits tuberculosis, heart
failure, vaginal
compression,
neurosis
Exacerbation of chronic
Periodic A series of coughing bronchopulmonary pathology
(bronchole- fits that are (bronchitis, bronchiectasis,
genetic) repeated at short tuberculosis, emphysema,
intervals pneumosclerosis); breath of
cold air
Unexpected start of
Foreign body in the
a series of coughing
Assault-like respiratory tract, whooping
fits, which are
cough, cavernous form of
interrupted by a loud pulmonary tuberculosis, lung
exhalation abscess
Short gentle coughing with a Dry pleurisy, the initial
Timbre Careful
grimace of pain stage of pneumonia
Loud, intermittent, Laryngitis, tracheal
Barking
dry cough compression,
hysteria
Raucous Silent, quiet cough Laryngitis
Cancer, tuberculosis,
Soundless No sound
laryngeal syphilis, in some
patients
Nature Dry (unproductive) Cough without sputum Bronchitis, early
pneumonia, pulmonary
infarction, pleurisy, at
the beginning of an
asthma attack
Acute stage of bacterial and
Wet
Cough with sputum viral infection, cavities in the
(productive)
lungs
Chronic inflammatory
Time of "Cough when washing", at 5- process of the upper
appearanc Morning 7 o'clock in the morning respiratory tract,
e cavities in the lungs,
smoking
Intensifies in the
Night Bronchitis, pneumonia
afternoon
Enlargement of intrapulmonary
Night Appears or lymph nodes (tuberculosis,
intensifies at night bronchogenic cancer, blood
diseases)
Continuation of table 2.3
Chronic bronchitis,
Conditions of
No reason tuberculosis,
occurrence
bronchogenic cancer
Appearance or Cavity formations in the
Changing intensification of cough in lungs (bronchiectasis,
body position a certain position (often on abscesses, cancer in the
the healthy side) decay stage)
Dry cough during a meal Cancer of the insured with
Meal or cough with mucus and a breakthrough in the
pieces of food in the respiratory tract;
sputum diaphragmatic hernia
Pertussis,
Concomitant During coughing or after an
Vomit tuberculosis, chronic
phenomena attack
pharyngitis
Laryngitis, laryngeal tumor,
Voice Hoarse voice compression of the
change recurrent nerve
Pain Behind the sternum in the Mediastinal, dry or
syndrome lower and lateral parts metastatic pleurisy
Expressed
shortness of Alveolitis
breath
Shorteningpercussion sound is noted:
 at decrease in airiness of fabric of a lung: a) at an inflammation of lungs (infiltration

and hypostasis of alveoluses and interalveolar partitions); b) with hemorrhages into
the lung tissue; c) with significant pulmonary edema (usually in the lower parts); d)
when scarring the lungs; e) at decline of a pulmonary takni - atelectasis, compression
of pulmonary fabric by the pleural liquid, strongly expanded heart, a tumor in a
thoracic cavity;
 in the formation of other airless tissue in the lung cavity: a) in tumors, b) in the
formation of a cavity in the lungs and accumulation of fluid in it (sputum, pus,
echinococcal cyst), provided that this cavity is more or less filled with fluid;
 when filling the pleural space: a) exudate (exudative pleurisy) or transudate; b)
fibrinous overlays on pleural leaves.
Tympanichuesound appears:
 in the formation of air-containing cavities: a) in the destruction of lung tissue due to

inflammation (cavity in pulmonary tuberculosis, abscess), tumors (decay), cysts; b)
with diaphragmatic hernia and pneumatization of cysts; c) in the pleura in the form of
accumulation in its cavity of gas, air - pneumothorax (spontaneous pneumothorax,
artificial);
 at some relaxation of pulmonary fabric owing to decrease in its elastic properties
(emphysema), at compression of lungs above a location of liquid (exudative pleurisy
and at other forms of atelectasis);
 with a certain degree of filling of the alveoli with air with the simultaneous presence
of fluid in them - pulmonary edema, at the beginning of inflammation, with the
liquefaction of inflammatory exudate in the alveoli.
Boxsound- loud percussion sound with a tympanic tinge appears when the elasticity of the
lung tissue is weakened and its airiness is increased (emphysema of the lungs).
Thenoiseofa"crackedpot"- a peculiar, intermittent rattling sound, similar to the sound of

tapping on a cracked pot. The sound becomes clearer when the patient opens his mouth.
It is obtained by percussion of the chest during screaming in children. In a number of
diseases, it occurs in cavities that communicate with the bronchi through a narrow slit.
2Hard breathing: compared to vesicular breathing, it is breathing with a change of

timbre (louder and coarser) and with equal length of inhalation and exhalation. In children of
younger age groups, hard breathing differs from washing only in increased volume. In older
children, in addition to this sign, an additional auscultatory indicator may be listening to the
entire exhalation; it occurs in simple bronchitis, because it is based on a narrowing of the
lumen of the small bronchi, and on the inflamed swollen wall accumulates aesculapius.
Weakened breathing usually occurs due to obstruction of the small bronchi, infiltration
of lung tissue, high diaphragm location or insufficiency of lung excursion, insufficiency of
respiratory movements of the lungs, mainly associated with pain (obstructive syndrome,
foreign body in the bronchi, tumor bronchial edema, exudative pleurisy, hemo- and
pneumothorax, high location of the diaphragm, atelectasis, emphysema, pain - myositis,
intercostal neuralgia, dry pleurisy).
Bronchial breathing - loud breathing with a predominance of exhalation noise.
Observed over the site of inflammation
Lungs at the beginning of pneumonia and tuberculosis with significant infiltration of lung
tissue.
Amphoric breathing - loud breathing with a sharp hard with a musical tinge breath.
Appears above the site of the bone, were, abscess, cavity.
Saccaded - with uneven contraction of the diaphragm and manifested by intermittent
breathing. Normally, such breathing may be when the child cools, trembling, crying.
It is necessary to assess how evenly breathing is heard in all parts of the
lungs. Additional pathological respiratory noises (rales).
Wheezing can be diffuse (bronchitis, bronchial asthma, alveoli, acute bronchioles)
and local (pneumonia, bronchiectasis, local pulmonary fibrosis, chronic bronchiolitis with
obliteration), wet and dry.
Wet ralesarise at accumulation in respiratory tracts or in cavities which are
connected with them, bronchial secretion, exudate, transudate. They are heard mainly on the
breath. The "size" of wheezing depends on the caliber of the bronchi. The volume of wet
rales depends on the nature of the inflammation (the density of the airway cell), as well as
the depth of the location of the source of inflammation relative to the chest. Sounding wet
rales are characteristic of infiltrative lesions of the lungs of an inflammatory nature
(pneumonia), also occur in the presence of a cavity with smooth walls (cavity,
bronchiectasis); inaudible - occur in bronchitis, bronchiolitis, congestive and edematous
lung lesions.
There are small-, medium- and large-bubble wet rales. Small-bubble wet rales occur in
the small bronchi and bronchioles (bronchitis, bronchioles, pneumonia), while the mucous
membrane accumulates exudate (mucus of inflammatory origin). In the case of pulmonary
edema in the airways from the vascular bed sweats transudate - blood (plasma, non-
inflammatory elements). After coughing, the number of small blisters may decrease or
increase.
Medium-bubble wet rales occur in the bronchi of medium caliber, are heard during
inhalation and exhalation. In terms of sound size, they are larger than small-bubble, in
number they are always smaller.
Large-bubble rales occur in the large bronchi, in the trachea with a productive cough,
when the inflammatory fluid moves up. As a rule, they are single.
Dry wheezing occurs when the accumulation in the airways of dense, viscous
sputum hanging from the walls of the bronchial mucosa in the form of films or threads that
are stretched between the walls. The movement of air causes them to tremble. Uneven
swelling of the bronchial mucosa, along which the air passes on top, also contributes to the
occurrence of dry rales. Dry rales are formed in the bronchi and differ in timbre. They are
heard mainly on the inhale, because on the exhale the bronchial lumen increases in
proportion to the expansion of the lung volume. Depending on the timbre, dry rales are
divided into those that buzz and buzz, which are formed in the bronchi of large and medium
caliber (acute recurrent and chronic bronchitis, bronchiectasis) and whistling, which occur in
the small bronchi (bronchial asthma).
Crepitationresembles the sound of rubbing a tuft of hair near the ear, they are listened
to only at the height of inspiration (the result of sticking alveoli) in the phase of
resorption of exudate in acute pneumonia, alveolitis.
Pleuralfrictionnoise- a sound that is heard during auscultation on exhalation and at the
beginning of inspiration and resembles the crunch of snow underfoot (dry pleurisy, initial
and final stages of exudative pleurisy, tuberculosis, significant dehydration). In these
diseases there is swelling and fibrinous layers on the leaves of the pleura, and with
dehydration they become dry. Sometimes it is difficult to tell the difference between
crepitation and pleural friction noise
1. Problem 33
2. At the 3-month-old child against subfebrile body temperature and rhinitis pallor,
cyanosis of a nasolabial triangle, the expressed short wind of expiratory character, the
swollen thorax, dry cough, participation of auxiliary muscles in breath is observed.
Percussion box sound above the lungs, during auscultation - on the background of
prolonged exhalation - scattered dry and small-bubble wet rales on both sides. In the
blood: H - 112 g / l, Er - 3,2x1012 / l, L - 15,4x109 / l, lymph.- 72%.
3. 1. Which system disease is most likely? What is the most likely diagnosis?
1. 2. Demonstrate the method of examination of the neck, chest, extremities in the

study of the respiratory system and knowledge of the semiotics of lesions.
2. 3. Demonstrate
knowledge of the
semiotics of respiratory
changes during the
examination of the
respiratory system
(rhythm, depth).
3. 4. Demonstrate
the technique of topographic percussion of the lungs.
4. 5. Demonstrate knowledge of the semiotics of lesions of auscultatory changes in the
study of the respiratory system (characteristics of extraneous respiratory noises
(wheezing, crepitation, noise of friction of the pleura) and semiotics of lesions)
1. Which system disease is most likely? What is the most likely diagnosis?
Respiratory system. Acute bronchiolitis.
Bronchoobstructive syndrome
Respiratory distress
intoxication syndrome
2. Demonstrate the method of examination of the neck, chest, extremities in the

study of the respiratory system and knowledge of the semiotics of lesions.
Diagnostic criteria
- At observation there is a significant violation of the general condition, there

are symptoms of rhinitis, nasopharyngitis, catarrhal symptoms;
- body temperature is often normal, sometimes subfebrile, very rarely -

hyperthermia;
- severe respiratory failure: expiratory dyspnea, participation in the act of breathing

auxiliary muscles, swelling of the wings of the nose, retraction of the intercostal
spaces, cyanosis of the nasolabial triangle;
- signs of impaired bronchial patency (enlarged anterior-posterior size of the chest,

horizontal position of the ribs, lowering of the diaphragm);
- at percussion the box percussion sound is noted;
- on auscultation hard breathing is heard, exhalations are prolonged, damp

low- sounding small-bubble rales, on an exhalation dry, whistling rales;
- there is a pronounced tachycardia, heart sounds are weakened;
- on the chest radiograph there is an increase in vascular pattern, increased

lung transparency due to obstructive emphysema, increased pattern of bronchi.
- manifested by hypersecretion, edema and necrosis of epithelial cells
- lesions of the upper and obstruction of the lower respiratory tract
Method of examination of the neck Review. The neck is examined from all sides in direct
and lateral light. Pay attention to its shape, contours, skin changes, edema, thickening of the
veins, visible pulsation of the arteries, as well as the position of the larynx and trachea.
When examining the anterior surface of the neck sternoclavicular-mammary the muscle is
defined in the form of the platen which begins behind a mandible and goes obliquely,
medially downwards and is fixed to a clavicle and sternoclavicular connection of a pulsation
of a carotid artery. Sharply visible pulsation of carotid arteries is a characteristic sign of
insufficiency of aortic valves. Examination reveals a sharp uniform increase in the size of
the neck with a sudden compression of the chest and an increase in intra-thoracic pressure
(traumatic asphyxia), with compression of the mediastinum by tumors with impaired blood
and lymph circulation (clamp-like neck) - uneven increase in the submandibular region and
lateral parts of the neck as a result of the pathological process of lymph nodes (tuberculous
lymphadenitis, lymphogranulomatosis, leukemia, leukemia, leukemia, leukemia).
Examinations can reveal fistulas of various origins due to tuberculous lymphadenitis,
purulent osteomyelitis, actinomycosis, foreign bodies and congenital. Enlargement of the
anterior surface of the neck below the thyroid cartilage usually indicates pathology of the
thyroid gland. Oxus, tumors, inflammatory processes lead to the expansion of its
boundaries, the isthmus can spread beyond the sternum and to the top of the
thyroid cartilage. In the presence of a tumor on the anterior surface of the neck relative to
the location of the thyroid gland check the symptom of swallowing water. At the moment of
swallowing by the patient of the liquid the tumor connected with a thyroid gland moves
together with a larynx at first upwards, and then downwards.
Palpation .Palpation should determine the extent of swelling, consistency (soft, dense,
nodular), the location of the trachea relative to the midline, the displacement of the
formation in the vertical and horizontal directions. The upper poles of the gland are palpated
well, and the lower ones can go beyond the sternum and should be palpated when
swallowing. Palpation of the thyroid gland is performed by the following method. First, the
doctor stands in front of the patient and fixes the neck with his left hand, and puts the palm
of his right hand along, fingers up, on the front of the neck. Palpates the thyroid 6 cartilage,
asks the patient to slightly raise his head up. After that, slides your fingers down the surface
of the thyroid and then along the arch of the annular cartilage. Directly below it is a
horizontally located roller of the isthmus of the thyroid gland. Palpating the isthmus,
determine its width, consistency, mobility when swallowing. After that, between the inner
edge of the oscillating muscle and the trachea directly above the upper edge of the isthmus
palpate the lateral lobes. The described method of palpation of the thyroid gland should be
supplemented by the following technique: the patient sits on a chair, the doctor stands
behind the patient and covers the neck with both hands so that the thumbs are behind and
the others lie on the front surface. After that, the middle fingers of both hands find the thyroid
cartilage, the isthmus of the thyroid gland. Palpate the tissues that are above the trachea.
Place the fingers on the sides of the trachea to the inner edges of the oscillating muscles.
Palpation by this method, it is necessary that the patient slightly lowered his head to relax
the oscillating muscle. To determine the motility of the thyroid gland, the patient is asked to
take a sip. Normally, the lobes of the thyroid gland are not palpable,
Chest examination technique ReviewAt inspection the form and symmetry of a thorax is
visually defined. Pay attention to isolated or diffuse protrusions or depressions, respiration
rate, rhythm, depth and uniformity of participation of both halves of the chest. The thorax is
examined in direct and lateral illumination and in a certain sequence - the area of the
clavicle, sternum, sternoclavicular joints, supraclavicular and subclavian cavities,
Morenheim pit (between the deltoid and pectoralis major muscles), compare the front and
back of both halves of the chest cells, intercostal spaces (width, degree of fulfillment), the
shape of the epigastric angle (acute, obtuse - in degrees). Men are more likely than women
to have a duller epigastric angle and a flatter angle of Louis. When measuring the
surrounding size of the chest, it is advisable to compare on both sides the distance from
the middle of the sternum to the spinous processes. Normally, the chest is correct,
symmetrical in shape. Changes in shape may be due to pathology of the chest or improper
formation of the skeleton during development.
Palpation .Palpation determines the ribs, intercostal spaces, pectoral muscles, the degree
of resistance of the chest, the phenomenon of vocal tremors. The patient is
examined standing or sitting. Normally, the chest is elastic, pliable, especially in the
lateral parts. Chest resistance is determined by the resistance when pressed in different
directions. Increased chest rigidity is observed in pleural effusion, large lung tumors,
emphysema, ossification of costal cartilage in old age. Determination of retrosternal
pulsation When the patient's head is tilted, a finger is placed in the jugular fossa. There may
be a pulsation of the aorta, indicating its expansion. Palpation of the clavicle The clavicle is
grasped with the thumb and forefinger and palpated along its entire length. If a clavicle
fracture is suspected, palpation is performed with great caution due to the sharp pain and
the possibility of damage to the subclavian vessels by bone fragments. You can find a
typical displacement of the inner fragment up and back, and the outer - down and
forward. Palpation of the supraclavicular fossa Carry out a comparative determination of
lymph nodes on both sides. This is important in tumors of the breast, lungs.
Sometimes you can find a flat bone
formation, which depends on the presence of an additional cervical rib. Pain when pressing
on the inner part of the supraclavicular fossa (placement of the humeral plexus) may
indicate plexitis. Palpation of the ribs and intercostal spaces On palpation, the chest is not
painful, the surface of the intact ribs is smooth. It is necessary to remember that it is
necessary to palpate each rib from a sternum to a backbone. Pay attention to the junction of
ribs and cartilage (rickets), bone thickening, localized pain. Gentle crepitation is defined as a
consequence of subcutaneous emphysema in rib fracture with damage to the pleura and
lungs. Coarser crepitation during respiratory movements indicates a fracture of the ribs
(bone crepitation). Determination of bone crepitation is best performed after novocaine
blockade of the fracture site. To determine which rib is damaged, the count is performed
from above, in front, starting from the clavicle. The calculation can be performed at the back,
bottom, starting from the XII rib. Isolated swelling and soreness of the intercostal spaces
may indicate the presence of an inflammatory process (purulent focus) in the pleural cavity.
Definition of vocal tremor Vocal tremor occurs during conversation and palpation of chest
vibrations, which are transmitted from vibrating vocal cords. The patient repeats in a low
voice words that contain the letter "P", such as "thirty-three". Determination is performed
using tightly attached palms symmetrically to both sides of the chest. Increased vocal tremor
occurs in infiltrative processes of lung tissue (pneumonia, over the cavities and
bronchiectasis). Weakening of vocal tremor, or its absence is observed in the presence of
fluid in the pleural cavity, pleural tumors, obstruction of the bronchial lumen. over caverns
and bronchiectasis). Weakening of vocal tremor, or its absence is observed in the presence
of fluid in the pleural cavity, pleural tumors, obstruction of the bronchial lumen. over caverns
and bronchiectasis). Weakening of vocal tremor, or its absence is observed in the presence
of fluid in the pleural cavity, pleural tumors, obstruction of the bronchial lumen.
Percussion .Percussion of the chest makes it possible to determine the boundaries of the
lungs and heart. Comparative percussion is performed sequentially on the anterior, lateral
and posterior surfaces of the chest symmetrically on both sides along topographic lines, as
well as topographic - sequential determination of boundaries, mobility of the lower edges,
the height of the lungs. Chest percussion, first of all, determine the boundaries of the lungs
and heart. To determine the limits of absolute dullness of the heart inflict weak beats, to
detect 8 relative dullness - stronger beats. Percussion of the lower chest during inhalation
and exhalation determine the mobility of the lung edges. Distinguish a clear lung sound at
normal lung fabric; box - with emphysema; high tympanitis - with pneumothorax; dull or dull
sound - when compacting lung tissue, the presence of fluid in the pleural cavities, tumors.
The presence of fluid and air in the pleural cavity gives the limit of blunting in the form of a
horizontal level. In the presence of only liquid without air, the limit of blunting will be along
the line of Damuazo, oblique line with the highest point - along the posterior axillary line.
3. Demonstrate knowledge of the semiotics of respiratory changes when

examining the respiratory system (rhythm, depth).
- Apnea may occur during treatment
-Increased respiratory rate
-Simpressed respiratory failure: expiratory dyspnea, participation in the act of

breathing auxiliary muscles, swelling of the wings of the nose, retraction of the
intercostal spaces, cyanosis of the nasolabial triangle;
- Signs of impaired bronchial patency (enlarged anterior-posterior size of the

chest, horizontal location of the ribs, lowering the diaphragm).
- -on the chest radiograph there is an increase in vascular pattern, increased
lung transparency due to obstructive emphysema, increased bronchial pattern
Depthofbreathing.The depth of respiration is determined by the volume of inhaled and exhaled

air at rest. In a healthy person under physiological conditions, the volume of respiratory air
is 500 ml. Depending on the change in the depth of respiratory movements, there are
superficial and deep breathing.
Superficial respiration (hypopnea) is observed at pathological increase in respiration due to

shortening of both phases of respiration (inhalation and exhalation). Deep breathing
(hyperpnea) is more often combined with pathologically affected breathing. For example,
"Kussmaul's great breath" or "air starvation" - liquid, deep, loud breathing caused by the
development of metabolic acidosis, followed by irritation with acidic products of the
respiratory center; observed in patients with diabetic, uremic and hepatic coma.
Rhythmofbreathing. The breath of a healthy person is rhythmic, with the same depth,
duration and alternation of phases of inhalation and exhalation. With the defeat of the
central nervous system, respiration becomes arrhythmic: individual respiratory movements
of varying depth occur more often or less frequently. Sometimes with arrhythmic breathing
due to a certain number of respiratory movements there is a prolonged pause or shortness
of breath (apnea). Such breathing is called periodic. The following pathological types of
respiration belong to it: Cheyne-Stokes respiration, Grock's wavy respiration and Biot's
respiration.
Cheyne-Stokesbreathing- periodic pathological breathing, characterized by a long (from a

few seconds to 1 minute) respiratory pause (apnea), after which silent shallow breathing
increases rapidly in depth, becomes loud and reaches a maximum of 5-7 breaths, then in
the same sequence of breathing decreases and ends with the next short pause (apnea).
During the pause, the patient is poorly oriented in the environment or completely
unconscious, which is restored when resuming respiratory movements. Cheyne-Stokes
respiration is caused by decreased excitability of the respiratory center, acute or chronic
cerebral insufficiency, cerebral hypoxia, severe intoxication and is a prognostically
unfavorable sign.
Grock's"Wave-likeBreath"or dissociated respiration,characterized by a wavy change in the

depth of respiration and differs from Cheyne-Stokes respiration in the absence of periods of
apnea. Grock's respiration is caused by the defeat of the respiratory coordination center,
caused by a chronic violation of cerebral circulation. It is more often observed at a brain
abscess, meningitis, a brain tumor.
Biot'sbreath-periodic pathological breathing, characterized by rhythmic but deep

respiratory movements, alternating at regular intervals with a long (from a few seconds to
half a minute) breathing pause. Biot's respiration is caused by a deep disorder of cerebral
circulation and is observed in patients with meningitis and in the agonizing state.
4. Demonstrate the technique of topographic percussion of the lungs.
- at percussion the box percussion sound is noted
Topographicpercussion.
used for:
1) determination of boundaries between bodies;
2) the height of the tops;
3) the width of the Krenig fields;
4) the lower edge of the lungs;
5) mobility of the lower edge of the lungs (excursions);
6) the magnitude of the crescent space Traube;
7) the magnitude and location of the pathological process.
Landmarks on the chest.In order to determine the localization of normal or pathological

data within the chest use certain landmarks vertically (ordinates) and horizontally
(abscissas). The role of the abscissa is played by the edges, and the role of the ordinates
is played by imaginary vertical lines:
1. Anterior midline (linea mediana anterior)
2. Right and left sternum lines (lineaе sternales dextra et sinistra)
3. Right and left thoracic lines (lineae parasternales dextra et sinistra
4. Right and left midclavicular lines (lineae medioclaviculares dextra et sinistra)
5. Right and left anterior axillary lines (lineae axillaris anteriores dextra et sinistra)
6. Right and left middle axillary lines (lineae axillaris mediae dextra et sinistra)
7. Right and left posterior axillary lines (lineae axillaries posteriores dextra et sinistra)
8. Right and left scapular lines (lineae scapulares dextra et sinistra)
9. Right and left vertebral lines (lineae paravertebrales dextra et sinistra)
10. Posterior midline (linea mediana posterior)
If certain changes are not detected at the point of intersection of the rib or intercostal space
with one of the mentioned lines, then determine the distance in centimeters to the nearest
line. For example, it is recorded that blunting is determined in the seventh intercostal space
2 cm to the right of the right scapular line.
In addition to the ribs and lines, the landmarks are the clavicle, sternum, its handle, Louis's
angle, supra- and subclavian fossae, VII rib (the last of the cartilage directly attached to the
sternum). Behind the landmarks are the spinous process of the VII cervical vertebra, the
scapular spines (corresponding to the III rib), the lower corners of the scapulae
(corresponding to the VII rib).
Determiningtheheightofstandingthetopsofthelungsinfront. The finger-plesimeter is

placed over the clavicle (parallel to it) and a quiet percussion is performed from the middle
of the clavicle up to the change of the percussion sound, a mark is made on the lower edge
of the finger facing the clear pulmonary sound. Normally, the tips protrude above the
collarbone by 3-4 cm.
Determining the height of the tops behindspend from the scapular spine in the direction
close to the spinous sprout VII of the cervical vertebra. The patient tilts his head down. The
apices of the lungs behind are at the level of VII cervical vertebra.
To determine the width of the Krenig fields,,representing the projection of the tops of the
lungs on the upper arm, the finger-plesimeter is placed in the middle of the trapezius
muscle perpendicular to its anterior edge and percussed first medially and then laterally
until a dull sound. The distance between the points of transition of clear lung sound to dull is
measured in centimeters. Normally, it is 5-6 cm, but can reach from 3 to 8 cm. It should also
be noted that normally the height of the top on the right is 1 cm lower, and the width of the
Krenig field is narrower by 1-1.5 cm than on the left.
Todeterminethelowerlimitsofthelungspercussion is performed from top to bottom along conditionally

drawn topographic lines. First on the right and then on the left. The lower border of the left
lung is determined from the left side (anterior, middle and posterior axillary lines) and
posteriorly (scapular and vertebral lines), because the heart is located in front of the left. The
finger-plesimeter is placed along the intercostal spaces and inflicted on it weak and uniform
blows. Chest percussion is performed from the right anterior surface of the chest at the level
of II-III intercostal spaces (in the horizontal and vertical position of the patient). On the lateral
surface - from the axillary fossa, behind - from the lower corner of the scapula, which
corresponds to the VII rib
The lower border of the right lung is usually at the junction of a clear lung sound to a dull
(pulmonary-hepatic border) or sometimes tympanic, as discussed below. The location of
the lower limits of the lungs is normal.
Place of percussion Right lung Left lung
Sweep line V - intercostal space -
Mid-clavicular line VI - rib -
Front wing wing line VII - rib VII - rib
Middle wing line VIII - rib VIII - rib

Rear wing line IX - rib IX - rib
Scapular line X - rib X - rib
spinous sprout of the XI spinous sprout of the XI

The vertebral line
thoracic vertebra thoracic vertebra
5. Demonstrate knowledge of semiotics of lesions of auscultatory changes in the

study of the respiratory system (characteristics of extraneous respiratory noises
(wheezing, crepitation, noise of friction of the pleura) and semiotics of
lesions)
- at auscultation hard breathing is heard, exhalations are prolonged, damp low-

sounding small-bubble rales, on an exhalation dry, whistling rales
Auscultation. Listening to the heart determines the heart tones, which are enhanced
or weakened. I and II tones are heard on the apex of the heart, aorta, pulmonary artery.
Intracardiac noises (systolic, diastolic) and pericardial friction noise may be heard.
Auscultation of the lungs is performed at symmetrical points in front and behind, from top to
bottom. Normally listen to the main respiratory noises (vesicular respiration). At pathological
processes - additional, or side respiratory noises. Vesicular respiration occurs due to
oscillations of the walls of the alveoli. It can change in the direction of strengthening or
weakening. These changes are physiological and pathological. Physiological enhancement
of vesicular respiration is observed in children, and weakening - with thickening of the
chest wall. Pathological weakening of vesicular respiration occurs in inflammation,
Bronchial respiration is a respiratory murmur that occurs in the larynx and trachea. Normal
bronchial breathing is well listened to over the larynx, trachea, bifurcation of the trachea.
Pathological bronchial respiration is heard when the lung tissue is compacted and the
alveoli are filled with inflammatory exudate.
Adverse respiratory noises - wheezing, occur during the development of a

pathological process in the trachea, bronchi, lung parenchyma.
Dry wheezing - the main condition for their occurrence is a total or focal narrowing of the
bronchial lumen. Wet wheezing occurs as a result of accumulation in the lumen of the
bronchi of liquid secretion. Crepitation is a crack that, unlike wheezing, occurs in the alveoli.
Noise of friction of the pleura - listened to in pathological conditions that lead to changes in
the properties of the leaves of the pleura, resulting in their movements there is an additional
noise - "noise of friction of the pleura."
1. Task 34
2. A 3-year-old child who is underweight has a persistent wet cough. In the anamnesis
of several transferred pneumonias proceeding with the phenomena of bronchial
obstruction. Objectively: shortness of breath of an expiratory nature at rest, the chest
is swollen, above the lungs shortening of the percussion sound in the lower parts,
auscultation - a lot of wet rales of various calibers. The level of sweat chlorides is 80
mmol / l. Nails in the form of drumsticks.
3. 1. Which system disease is most likely? What is the most likely diagnosis?
1. 2. Demonstrate knowledge of the semiotics of respiratory changes during the

examination of the respiratory system (type, frequency).
2. 3. Demonstrate the method of palpation (determination of vocal tremor, noise of
friction of the pleura, subcutaneous emphysema) in the study of the respiratory
3. 4. Demonstrate the method of determining the mobility of the lower edges of the
lungs and knowledge of the semiotics of lesions.
4. 5. Demonstrate knowledge of methods for determining bronchophonia and semiotics
of lesions.
Cystic fibrosis(also Cystic fibrosis / CF) - autosomal, recessive, hereditary

diseaseexocrine gland. It's impressivelungs,, sweat glandsand digestive system, causing
chronic respiratory and digestive problems.
Cystic fibrosis is manifested by a variety of clinical symptoms. There are 4 clinical forms of
cystic fibrosis.
Meconium ileus - in infants due to lack of trypsin meconium becomes very thick, viscous
and accumulates in the ileocecal area. Intestinal obstruction develops.
The intestinal form is associated with digestive disorders and intestinal function.
Dysfunction of the pancreas leads to the assimilation of fats in the body. The consequence
of the latter is osteoporosis and muscular hypotension. Often in patients with cystic fibrosis
there is a peptic ulcer of the stomach and duodenum. Increased bile viscosity causes the
development of cholestatic hepatitis, gallstone disease, biliary cirrhosis.
Bronchopulmonary form of cystic fibrosis is manifested by recurrent and prolonged
bronchitis, bilateral focal pneumonia, which results in the development of atelectasis,
bronchiectasis and pneumosclerosis. There is constant shortness of breath and cyanosis.
The thorax is barrel-shaped, the nail phalanges are in the shape of drumsticks. Chronic
hypertension of the small circle of blood circulation, caused by a chronic inflammatory
process in the lungs, leads to the formation of pulmonary heart and heart failure.
Atelectasis often occurs with the development of chronic pneumonia and bronchiectasis.
At the mixed pulmonary-intestinal form there is a combined defeat of respiratory and
digestive tract.
Demonstrate knowledge of the semiotics of respiratory changes

during the examination of the respiratory system (type, frequency).
The rate of respiration per minute in children depends on age:
at the newborn - 40-60
in 6 months. - 35-40
in 1 year - 30-35
at the age of 5 - 25
in 10 years - 20
over 10 years - 18-16.
Types of breathing:
 Pectoral
 Abdominal
 mixed
Demonstrate the method of palpation (determination of voice tremor, pleural friction noise,
subcutaneous emphysema) in the study of the respiratory system and knowledge of
the semiotics of lesions.
Palpation is performed by lightly pressing the palms and end phalanges of the fingers of
both hands on symmetrical areas of the child's chest. Thus, first determine the presence of
hypersensitivity of the skin, pain on palpation of the clavicle, ribs, intercostal spaces, sternum.
By means of a palpation it is possible to reveal painful points of a thorax, to specify their
localization. At healthy children the thorax at a palpation is painless. Chest pain can be
associated with both lung or pleural diseases and extrapulmonary lesions.
Confirmation of pleural pain will be its intensification when coughing, tilting the torso in a
healthy direction, as well as its weakening (or even disappearance) when immobilizing the
chest by squeezing it with his hands on both sides (symptom FG Yanovsky). A typical pain
point for diaphragmatic pleurisy is the Mussey point, located between the legs of the
sternoclavicular-nipple muscles. At an abscess of lungs the localized pain at pressing on an
edge or an intercostal space according to localization of an abscess is noted. Pain on
palpation of the intercostal spaces occurs in cases of neuralgia of the intercostal nerves,
myositis of the intercostal muscles. At an intercostal neuralgia painful points in three places
are defined: a) near a backbone - in a place of an exit of the corresponding intercostal nerve
(so-called vertebral point); b) along the axillary line (lateral point) and c) near the edge of the
sternum (anterior point) - at the exit to the surface of the lateral and anterior cutaneous
branches of the corresponding intercostal nerve. It should be noted that the pain associated
with intercostal neuralgia is significantly exacerbated by tilting the torso to the patient's side.
When the intercostal muscles are affected, the pain is manifested throughout them and is
associated with respiratory movements. Pain in the ribs is observed in leukemia, trauma,
tumor metastases.
Palpation signs of subcutaneous emphysema and edema of the skin fold are determined
under the shoulder blades and along the posterior axillary line in the lower chest. Capture
the skin and subcutaneous tissue in the fold with two fingers (thumb and forefinger, which
is on top) on symmetrical areas and subjectively note its thickness, and then feel the fold
for the presence of crunch. Normally, the thickness of the folds should be the same in
symmetrical areas, and there will be no crunch. In massive inflammatory diseases of the
chest (lobar pneumonia, exudative pleurisy, hemothorax), the skin fold on the affected side
is thicker due to edema. At a pneumothorax air will saturate surrounding fabrics and
promote development of hypodermic emphysema - under fingers there is a characteristic
crunch which reminds a snow crunch.
Demonstrate the method of determining the mobility of the lower edges of the lungs
and knowledge of the semiotics of lesions.
Determination of the mobility of the lower edges of the lungs (the amplitude of their
displacement) is impossible in young children and is limited in children up to 7-8 years. This
information has practical value only after 10 years. Normally, the displacement of the lower
edges of the lungs is 2-6 cm
In conditions of pathology, the lower limits of the lungs can change, in particular to shift
downward when the lungs expand, ie in the presence of a large amount of air. Enlargement
of the lungs is observed in emphysema, bronchial asthma (especially at the height of the
attack), chronic blood stasis in the small circle of blood circulation (loss of lung tissue of its
elasticity). In addition, the displacement of the lower limits down is observed in the lowering
of the lungs, which is very rare, but may be in cases of general enteroptosis and
low standing of the diaphragm. The lower limits of the lungs fall down also in paralysis of
the phrenic nerve.
False unilateral downward displacement of the border is observed in pneumothorax

(false because in the percussion of the common tympani due to the presence of air in the
lower pleural sinus, create the impression of an enlarged lung).
Upward displacement of the lower lungs may occur with a decrease in the mass of the
lungs due to shrinkage and scarring of the lower lobes (tuberculosis, pneumonia,
destructive processes), fluid accumulation in the pleural cavity, high standing of the
diaphragm due to increased intra-abdominal pressure (ascites, meteorrhea) , hepato- and
splenomegaly).
At emphysema of lungs disturbance and front borders (expansion of lungs) is observed.

The result is a reduction in the limits of absolute cardiac dullness. Displacement of the
anterior boundaries of the lungs is manifested externally by scarring in the lungs and their
removal by an enlarged heart in cardiomegaly of any origin. Similar changes in the anterior
edges of the lungs occur in mediastinal tumors, exudate pleurisy (increased intracellular
pressure, which causes some decline in lung tissue).
Arkavin's symptom is determined by loud percussion on the anterior axillary line from
the bottom up on one side and then on the other. The patient is in an upright position with
arms raised and folded at the nape of the neck. The percussion finger is located parallel to
the ribs. Percussion should be applied to the intercostal spaces. In healthy children, the
shortening of the percussion sound is detected at the level of the II rib in the axilla
(Arkavin's symptom is negative) and is associated with m.pectoralis major. With an
increase in bronchopulmonary lymph nodes and lung root nodes, the shortening will be
below this level, and Arkavin's symptom is considered positive.
Demonstrate knowledge of methods for determining bronchophonia and

semiotics of lesions
Problem35
1. A 6-month-old baby has cyanosis of the lips, nose, fingers, shortness of breath
during feeding and crying. Objectively: the left half of a thorax protrudes a little, the
apical push is strengthened, in 3-4 intercostal spaces on the left systolic tremor is
defined. At auscultation - a rough systolic noise with the epicenter to the left of a
sternum which is made under a shovel. On the radiograph: the heart is normal in size,
resembling the shape of a "shoe", the pulmonary pattern is depleted, the aorta is
located on the right. On the ECG - right ventricular hypertrophy, deviation of the axis
of the heart to the right.
2. 1. Establish a preliminary diagnosis, indicate the system of lesions and identify the
main clinical syndromes.
3. 2. Demonstrate the method of examination of the torso, abdomen, extremities in the
study of this system and knowledge of the semiotics of lesions.
4. 3. Demonstrate the method of palpation in the study of this system (determination of
apical (age-dependent limits, characteristics) and heartbeat, the symptom of "cat
purr", edema) and knowledge of the semiotics of lesions.
5. 4. Demonstrate knowledge of the general principles of percussion of the heart.
6. 5. Demonstrate knowledge of differential diagnosis of systolic and diagnostic heart
murmurs and semiotics of lesions.
1. Aortic valve insufficiency. Affected cardiovascular system.

2. Examination of the heart: the presence or absence (apical shock, heartbeat, heart hump,
the phenomenon of feline purring, pulsation of the carotid arteries, Musset's symptom).
Examination of the epigastric region: the presence or absence of epigastric pulsation (may
be caused by hypertrophy or dilatation of the right ventricle, pulsation of the gingival aorta, as
well as pulsation of the liver). Examination of the extremities: color (presence or absence of
cyanotic changes), the presence or absence of edema.
3. On palpation of the apical shock (heartbeat), the doctor places the palm of the right hand
on the left half of the chest at the base of the sternum at the level of IV-V intercostal space
to the axillary area (linea axillaris anterior) and observes the approximate location of the
apical shock.
The location of the apical shock depends on the age of the child. In young children, the
apical shock is normally localized in the IV intercostal space, in middle and older age - in the
V intercostal space.
Prevalence(area)ofapicalshock:normally the apical shock is localized. In young children,

its area is approximately 1 × 1 cm, in older - 2 × 2 cm. With increasing area - the shock is
diffuse.
Theheight(magnitude)oftheapicalshock estimated by the amplitude of oscillations of
the intercostal spaces during systole.
Resistance- is the pressure that the doctor's finger feels during palpation.
Normally, the apical shock is localized, moderate height and strength.
To detect heartbeat(heart ventricle) the palm of the right hand is placed on the surface of the
projection of the heart on the sternum, and the fingers - along the intercostal spaces to the
axillary area. In healthy children, heart rate is not determined.
"Cat purr" palpated with the palm or fingers of the right hand over the area of the II intercostal
space to the right and left of the sternum, as well as in the projection of the apex of the heart.
Palpation reveals "hidden" cardiac edema.To do this, press your finger on the skin in the
area of the anterior surface of the leg and release it and run your fingertip along the skin of
the leg from top to bottom. Preservation of the depression (pit) is a sign of edema. Normally,
the skin is instantly smoothed - no swelling.
4. Limitsofrelativecardiacdullnessinolderchildren
Age of
The right limit Upper border Left border
the child
Up to 2 2 cm outward from 2 cm outward from l.

II rib
years l. sternalis dextra medioclavicularis sinistra
1 cm outward from II intercostal 1 cm outward from l.
2-7 years
l. sternalis dextra space medioclavicularis sinistra
0.5 cm outwards
7-12 The upper edge 0.5 cm outwards from l.
from l. sternalis
years of the III rib medioclavicularis sinistra
dextra
12-15 l. medioclavicularis sinistra or 0.5

l. sternalis dextra III rib
years cm to the middle of it
5. There are systolic and diastolic murmurs. Systolic is listened to during systole (relatively
short pause between I and II tones). Diastolic is listened to during diastole (relatively long
pause between II and I tones).
Organic noise loud, constant, long, carried out outside the heart, persist when changing
body position and exercise, do not change when breathing.
Functionalnoisenot constant, not carried out outside the heart, change during exercise and
body position, when breathing.
Extracardiac noises include pericardial friction noise. It does not coincide with heart tones, is
listened in both phases (systole and diastole), amplifies at pressing by a stethoscope, at a
respiratory arrest on a background of a deep exhalation (leaves of a pericardium approach),
at vertical position of the patient, at an inclination forward.
1. Task 36
2. Parents of a 3-year-old boy complain of weakness, fatigue, shortness of breath at
rest, note that the child periodically has dyspnea-cyanotic attacks. On examination,
the child lags behind in physical development, cyanosis of the nasolabial triangle,
moderate heart hump. On palpation of the pulse - heart rate 130 for 1 minute, for
percussion - the left border of the heart by 3.0 cm outside the left midclavicular line.
At auscultation - tones of heart are weakened, on systolic noise in all points. The
liver and spleen are not palpable.
4. 2. Demonstrate the method of examination of the head, neck in the study of this
5. 3. Demonstrate knowledge of the semiotics of changes in the properties of the pulse.
6. 4. Demonstrate the method of auscultation of this system.
7. 5. Demonstrate knowledge of the analysis of the general characteristics of heart
murmurs.
Task 37
An 11-year-old boy who suffered from sore throat 2 weeks ago was diagnosed with
arthritis of the elbow and ankle joints, involuntary movements of facial muscles, ring-shaped
rash on the abdomen and thighs, deafness of heart sounds, low-grade fever, general
weakness, shortness of breath during exercise. History of positive rheumatic history.
2. 2. Demonstrate the method of general review in the study of this system and
3. 3. Demonstrate the method of examination of joints and knowledge of semiotics of
lesions.
4. 4. Demonstrate the method of determining blood pressure.
5. 5. Demonstrate knowledge of differential diagnosis of organic and functional heart
murmurs.
1. Acute rheumatic fever. II degree of activity, rheumatic carditis. Affected:

nervous system, cardiovascular system, musculoskeletal system, skin.
Syndromes: arthralgic, chorea, carditis, exanthema (rash), fever
2. Assess the general condition of the child (satisfactory, moderate, severe, very
severe). The patient's position in bed (active, passive, forced).
Consciousness of the child. Reaction to the review. Anthropometric indicators: body

weight and length, head and chest circumference, Chulytska (up to 8 years) and
Erisman indices (in all age groups), assessment by centile tables with conclusion.
Build: constitutional type (asthenic, normastenic, hypertensive). Body temperature.
Appearance of the patient: face, expression, puffiness.
Neuropsychological sphere: Mental development, intelligence, memory. Sense

organs: Nervous system. Correspondence of mental development is passive,
restless.
Convulsive readiness, convulsions Gait: normal, shaky, ataxic, paralytic. Stability in
the Romberg position (complicated outside the Romberg position). Nystagmus
(horizontal, 12 vertical, rotatory, large or shallow, right-handed, left-handed). Deviation of
the tongue. Eyelid tremor with eyes closed. Tremor of the tip of the tongue. Finger-
nose test.
. Reflexes: tendon, abdominal, conjunctival, pharyngeal, cutaneous. The presence of

pathological reflexes. The presence of paresis and paralysis (their location and type).
Dermographism. Skin sensitivity: decreased, increased (tactile, painful, thermal).
Meningeal symptoms
Skin, subcutaneous fat, mucous membranes, salivary glands, lymph nodes.

Skin: color and its disorders (pallor, jaundice, redness, marbling, cyanosis),
elasticity, moisture (increased, dry skin), rashes, hemorrhages, pigmentation,
(number, size, location), itching, scarring, itching, hemorrhage, vascular asterisks.
Moisture and turgor of the skin.
Lymph nodes, if palpated:
Musculoskeletal system. General muscle development: good, moderate, weak.

Muscle tone, pain on palpation or movement. The presence of atrophy, hypertrophy
and seals. Bone and joint system. Symmetry of bones, limbs. Determination of the
size and shape of the head, craniotabes, large umbilicus (its size, condition of bone
edges and soft tissues, protrusion, depression). Chest shape (conical, cylindrical
flat), "rickets", Garrison furrow, "bracelets", "pearl threads", curvature of the spine
(lordosis, kyphosis, scoliosis) and curvature of the limbs (O-shaped, X-shaped,
saber-shaped) , "Drumsticks", flat feet. Deformation of bones, soreness when
pressed, tapped.
The presence of deformities of the pelvic bones.
Configuration of 13 joints, edema, contractures, ankylosis. The volume of active and

passive movements (in full, limited, the degree of restriction), pain during movements.
3. Methods of examination of joints include: examination, palpation,

measurement of limbs and joints, determining the degree of mobility of the joints.
The examination of the joints actually begins from the moment the doctor first sees
the patient. Observation of the gait, posture, movements of the patient gives a
general idea of the changes and functional capabilities of the musculoskeletal
system, and sometimes helps to establish the diagnosis. Noticeable limping - duck
gait, appears in coxarthrosis.
Examination of the joints of the patient is carried out, if the condition of the
musculoskeletal system, in a standing position, lying down and during movement. If
the patient is examined in a supine position, he should lie comfortably on a firm
couch so that his muscles are relaxed.
Review
During the examination of the joints pay attention to:
- symmetry of the body;
- the length of the limb and its parts relative to the other:
- change in the shape and contours of the joints, the shape of the bones of
the extremities;
- change of contours in the locations of tendons and synovial bags;
- the condition of the muscles of the extremities;
- the condition of the skin in the joint, the condition of the nails.
Great importance should be given to the study of changes in the configuration of the
joints. An increase in the volume of the joint - swelling - is one of the main signs of its
defeat.
Swelling of the joint may be diffuse or limited. Uniform diffuse swelling is

characterized by smoothing of the contours of the joint, in particular the
disappearance of bone protrusions, which is often due to acute arthritis, but can also
occur with significant swelling of the synovial membrane, extraarticular cavities and
soft tissues. joint.
Different numbers of joints can be involved in the pathological process. Monoarthritis
- inflammation of one joint, oligoarthritis - several, polyarthritis - pain of the sixth. The
lesion can be symmetrical or asymmetrical. The presence of symmetrical polyarthritis
of the wrist joints is most characteristic of rheumatoid arthritis; monoarthritis,
asymmetric oligoarthritis of the lower extremities are characteristic of seronegative
spondyloarthritis (ankylosing spondylitis, Reiter's disease), and inflammation of the
joint of the 1st toe is more common in gout.
Palpation
With the help of palpation it is possible to detect an increase in local body

temperature, to establish the nature of changes in the shape of the joint, the
presence of effusion in the joint, joint noise, pain points, etc. Palpation is performed in
a comfortable position of the joints when the muscles are relaxed. The technique of
palpation involves the following actions:
- the back of the palm determines the temperature of the skin in the area of the joint;
- local increase in temperature indicates an inflammatory process in the joint;
- show pain, mainly in the area of the articular surfaces of the bones, which can be
superficial and deep.
Signs of joint damage
Joint pain, joint deformity and deformation, hyperthermia of the skin over the
affected joints, restriction of movement in the joints, changes in the tendon-
ligamentous apparatus of the joints, changes in the muscles
Research methods for rheumatic diseases
Functional methods
Measurement
Measurement of joints and extremities aims to determine the length of the

extremities, the circumference of the extremities and joints, which allows to detect
pathological changes, to assess the dynamics of the disease. Centimeter tapes
and special rulers are used for measurement.
Investigation of the volume and amplitude of movements in the joints
In the study of the degree of mobility in the joint determine the extremes of active
and passive movements in all possible directions for this joint, as well as identify
pathological forms of movement. The study begins with a study of the volume of
active and then passive movements. The study is performed using a protractor
(goniometer). Restriction of joint mobility can be reversible and permanent.
Goniometry
Indications: study of the functional state of the joints of patients with joint diseases.
There are no contraindications.
Equipment: goniometer, centimeter tape.
Goniometry is the determination of the amplitude of joint movements. Carried out

using a goniometer. One branch of the protractor is installed on the axis of the
proximal part of the joint, the other - parallel to its distal part. The axis of the joint
must coincide with the axis of the hinge. The amount of mobility in the joint is taken
into account from the initial position, known as anatomical or neutral. For most joints
in the initial position along the axis of the limb segments form a straight longitudinal
line to the vertical free position of the body.
Description of the study
1. The measurement is performed by a spring sphygmomanometer, auscultatory

method or an electronic device, the reliability of which is confirmed (list →
www.dableducational.org). Use a cuff of the appropriate size - with a rubber bag,
which covers 80-100% of the circumference of the shoulder and has the
appropriate width (wider - on a rough shoulder; 1/2 the length of the cuff).
2. If the patient's blood pressure has never been measured, the measurement
method should be explained to the patient to prevent agitation that may cause an
increase in blood pressure. Before the examination, the patient should sit quietly
for a few minutes. The area of the shoulder where the blood pressure will be
measured should be at the level of the patient's heart, and the arm should be
supported. The
patient should sit comfortably, leaning on his back and feet, without crossing his legs.
3. The first time blood pressure is measured on two hands, subsequent

measurements are performed on the hand on which blood pressure was
higher.
4. The cuff should be placed on the shoulder so that its lower edge is ≈3 cm above
the elbow flexion → apply the stethoscope to the place where the pulse is best felt →
inject air into the cuff to a pressure of ≈30 mm Hg. Art. above the one at which the
pulse on the radial artery disappeared → let the air out at a rate of 2-3 mm Hg. Art.
for one heartbeat (especially important in arrhythmias) or for a second → note the
systolic pressure together with the first tone heard (Phase I Korotkov), and diastolic
when the tones disappear completely (Phase V). In some clinical conditions with
hyperkinetic circulation (eg, hyperthyroidism, fever, significant physical activity), the V
-phase may not be (tones are heard to zero mercury), in which case the value of
diastolic pressure is taken as ,,
5. Measure blood pressure twice on one hand with an interval of 1 min, and then
additionally, if the results of the first two measurements differ significantly. The
result is defined as the average value of the measurement indicators. In the
elderly, patients with diabetes mellitus, and other conditions that increase the
likelihood of orthostatic hypotension, additional BP measurements should be
performed in the standing position 1 to 3 minutes after the patient gets up.
5. Organic noise is mainly observed in the presence of acquired valve defects and
congenital heart defects. All types of heart defects are caused by the same
mechanism of noise, in particular the passage of blood through a narrowed hole. In
this case, there are two types of changes in the area of the openings that connect the
cavities of the heart with each other or with large vessels: 1) narrowing of the
opening, which makes it difficult for blood to flow to the adjacent department - stenosis
of the opening; 2) inability of the valve apparatus to completely close the hole to
prevent backflow of blood - failure of the valves. In the presence of stenosis of the
orifice, noise occurs during the passage of blood through it in the usual direction, in
case of valve insufficiency - during the return flow of blood through damaged and not
completely closed valves (regurgitation noise).
Functional noises appear in the presence of thyrotoxicosis, anemia, infectious

diseases, nervous excitement. Most often their occurrence is due to the acceleration
of blood flow. Functional noises heard in the pulmonary artery are often observed in
young people for no apparent reason. It is believed that functional noise can be
periodically detected in 5-15% of healthy people, and in children even more often in
25-50% of cases.
Problem38
A 10-month-old child developed recurrent clonic seizures with mild SARS. Examination
revealed clear manifestations of rickets of moderate severity. The level of blood calcium is
1.6 mmol / l, the QT interval on the ECG is extended to 0.33 s. There are no data on
perinatal CNS damage. Cerebrospinal fluid is intact, leaking under pressure. Artificial
feeding, without vegetable dishes.
1. 1. What system of defeat can be thought of? Make a preliminary diagnosis

and identify the main clinical syndromes.
2. 2. Demonstrate the method of history taking and general examination during the
examination of the skeletal system and knowledge of the semiotics of lesions and
variants of the norm.
3. 3. Demonstrate the technique of examination of the spine during the examination of
the skeletal system and knowledge of the semiotics of lesions and variants of the
norm.
4. 4. Demonstrate the method of examination of the upper extremities during the
examination of the skeletal system and knowledge of the semiotics of lesions and
variants of the norm.
5. 5. Demonstrate the technique of palpation of joints in the examination of the skeletal
system, knowledge of the semiotics of lesions and the ability to diagnose congenital
dislocation of the hip joint.
1. Spasmophilia. Lesions of the musculoskeletal system. Bronchospastic syndromes

2. The examination is performed in a standing position, at rest, lying down and in motion,
from top to bottom.
At inspection define conformity of growth of the child of his age, proportions of a body
(the ratio of the size of the head and the whole body, head and length of the limbs, torso and
limbs, frontal and cerebral parts of the skull). At the newborn the head makes 1/4
body length, 2-year-old-1/5, 6-year-old - 1/6, 12-year-old child - 1/7, adult -
1/8
3. At inspection of a thorax, first of all, estimate its form (cylindrical,
cone-shaped, barrel-shaped). Pay attention to the deformation of the chest: chicken
chest, the presence of a peripneumotic furrow Filatov-Harrison (depression in place
attachment of the diaphragm), heart hump, cobbler's chest or funnel-shaped chest
cells.
Also pay attention to posture disorders (deviation of the spine in the sagittal
or frontal plane, which is determined by the state of muscle tone and habitually altered
child posture). Expressiveness of physiological curves of the spine: lordosis,
kyphosis; availability
scoliosis, ie lateral curvatures of the spine, indirect signs of which are: asymmetry
chest, uneven location of the shoulders and shoulders, different levels of standing
nipples, smoothing the waist triangles. Often kyphosis is combined with scoliosis
- kyphoscoliosis. Suspicion of scoliosis should be confirmed
radiologically. Simultaneously with the examination of the spine it is necessary to check its
mobility
by the amount of inclinations and turns of the neck and torso,
4. The child's limbs should be examined standing and lying down: evaluate their
shape, the ratio of the length of the limbs, the presence of deformations.
Anomalies in the development of the extremities include: polyphagous, brachydactyly,
excessively long fingers, syndactyly, complete absence of limbs, hands, fingers.
With rickets, there may be curvature of the legs in the form of O-shaped or X-
figurative, local enlargement of the distal extremities - "bracelets", as well as
thickening on the phalanges of the fingers - "threads of pearls".
The presence and severity of flat feet are determined by the development of bone and
muscular "skeleton" of the foot. Accordingly, in young children it is possible to speak
conditionally
about physiological flat feet. In the presence of systemic connective tissue dysplasia
or general muscular hypotension, neurological pathology of muscle tone or regulation
movements, the frequency of flat feet increases significantly at any age.
5. It is also necessary to state valgus (pronation) or varus (supination)
foot position. Valgus position is characterized by pronation of the foot with
raising its outer edge. The angle between the midline of the shin and the vertical
the axis of the heel in the frontal plane is open to the outside.
Varus position is characterized by supination of the foot or rotation
plantar surface inward with lowering the outer edge of the foot. The angle between
the midline of the shin and the vertical axis of the heel open inward.
At inspection of joints the form, existence of deformations is found out, pay
attention to skin color in the joints, limited mobility or hypermobility,
which is a sign of some hereditary connective tissue dysplasias.
At the end of the examination, the child is asked to go around the office to identify possible
gait disorders.
Symptoms of congenital hip dislocation.
When examining lameness when walking or walking the patient by the carrier - "duck
walking",
shortened lower limb, asymmetry of skin folds on the thighs, additional skin folds on
medial surface of one of the thighs, lumbar lordosis, external rotation
lower extremity. When examining a child standing with his back to the doctor, if any
congenital dislocation of the hip joint, there is a lowering of one half of the pelvis -
symptom of Trendelenburg.
Symptoms:
a) to limit the removal of the hip in the hip joint on the affected side - the child,
lying on his back with legs bent at the knees and hips, as much as possible
dilute the thighs. In healthy children, the legs should be completely parted with the formation
of an angle
about 180 deg. (ie dilution reaches 90 deg.), whereas in the presence of dislocation (or
dysplasia) hip breeding is limited. Abduction less than 60-70 degrees. indicates pathology;
b) Ortholani - bent at the hip, reduced and rotated inward thigh
the bone is turned outwards and at the same time the leg is removed. The head of the
femur
suddenly enters the acetabulum and a click is felt (positive symptom
Ortholani);
c) Barlow - in a child lying on his back with bent at the knee and hip
joints and moderately detached lower extremities, the middle finger of the doctor places
over the thumb, thumb - medially and below average. And,
pressing the thumb laterally, the index finger rotates the knee joint
medially and the head of the femur is removed from the acetabulum. It is felt
click (positive Barlow's symptom).
d) to detect the symptom of Allis should put the child on his back and compare positions
knee joints of the lower extremities, which are bent and brought to the abdomen. In the
presence of
congenital dislocation is observed shortening of the thighs and knee joints located on
different levels.
1. Problem39
2. A 10-year-old boy complains of weakness, dizziness, tinnitus. During the last 2
weeks there was an exacerbation, three times there was vomiting of "coffee
grounds", tar- like bowel movements. Objectively: the skin and mucous membranes
are pale, clean. Pulse - rhythmic, 108 / min. AT - 80/50 mm Hg. Art. The abdomen is
tense and painful on palpation in the epigastrium. Blood test: Er - 2,3х1012 / l, НЬ-
60г / л, КП - 0,7, Л - 1,0х109 / л, е-3%, п / я - 4%, с / я - 58%, l - 27%, m -8%, ESR -
12 mm / year. Blood clotting: onset - 2 minutes 30 s, end - 5 min., Duration of
bleeding - 4 min. Gregersen's reaction is sharply positive.
4. 2. Demonstrate the methodology of the survey and knowledge of the semiotics of
complaints when examining this system.
5. 3. Demonstrate knowledge of methods and general principles of palpation in the
examination of this system.
6. 4. Demonstrate the method of determining the palpatory-percussion symptoms of
digestive lesions.
1. 5Gastric ulcer. Active bleeding. Syndromes: pain, asthenic, dyspeptic and

laboratory changes.
2. Pain or not associated with food intake, the nature of the pain, the irradiation of pain.
3. Superficial and deep palpation, palpated in a circle from a less painful area.
4. Pain, compaction, inclusion, mobility, cohesion.
5. Ultrasound
7. . Demonstrate knowledge of pancreatic examination.
1. Task 40
2. A 12-year-old child complains of dull aching pain in the right hypochondrium, which
after exercise and after eating, is sometimes accompanied by nausea. Emotionally
labile. Abdominal pain in the right hypochondrium, positive "bladder" symptoms. Liver
+1 cm, slightly painful on palpation. Defecation without features. Er - 5,5хЮ12 / l, НЬ -
120 g / l, Л - 7,1х109 / l, ESR - 6 mm / h, АСАТ - 0,52 mmol / l, АЛАТ - 0,6 mmol / l,
total bilirubin - 22 μmol / l (direct - 14 μmol / l), ultrasound examination: in the lumen
of the gallbladder sediment.
3. 1. What system of defeat can be thought of? Highlight the main clinical syndromes.
4. 2. Demonstrate a method of reviewing this system and knowledge of the semiotics
of lesions.
5. 3. Demonstrate the technique of superficial palpation in the study of this system and
6. 4. Demonstrate knowledge of the method of liver examination.
7. 5. Demonstrate the method of auscultation in the study of the boundaries of the
stomach and knowledge of the semiotics of lesions.
8. 1. What system of defeat can be thought of? Highlight the main clinical syndromes.
9. Lesions of the digestive system. Dyskinesia of the biliary tract, hypertensive-
hyperkinetic form. The main clinical syndromes: dyspeptic, painful, astheno-
vegetative, cholestatic
10. 2. Demonstrate a method of reviewing this system and knowledge of the
11. During the examination, in a horizontal position, the doctor should sit to the right of
the patient. The abdomen is examined from the xiphoid process to the pubic
symphysis, paying attention to its shape, size, symmetry, participation in the act of
breathing, position of the navel The shape of the abdomen is normal (oval, flattened,
round), in pathologies of the gastrointestinal tract can be observed spherical, frog
belly, protrusion. Normally, the abdomen has the appropriate size to the human
constitution, symmetrical. adipose tissue. The anterior abdominal wall is involved in
the act of breathing normally, with pathologies may involve the entire surface of the
abdomen. Protrusions are present in hernias, lipomas, tumors. Abdominal skin is
normally clean, not moist, without inflammation.At pathologies expressiveness of
hypodermic veins, telangiectasia, hemorrhages, petechiae, scars come to light.
12. 3. Demonstrate the technique of superficial palpation in the study of this
system and knowledge of the semiotics of lesions.Before palpation, the doctor
must follow the general rules of palpation (clean, warm hands). right iliac, peri-umbilical,
peri- pubic. If the patient complains of pain in the left iliac region, then start palpation
from the least painful area.
13.At a superficial palpation the abdomen is soft and not painful. Abdominal wall
tension is absent. Botkin-Blumberg's peritoneal irritation symptom is negative.
14.Swelling, seals, nodules, tumors and enlarged organs and pathological formations
of the abdominal cavity, as well as differences in the rectus abdominis, dilation of
the umbilical ring were not detected.
15.Deep methodical sliding topographic palpation according to the method of VP
Obraztsov-MD Strazhesko and other physical methods of examination of abdominal
organs
16. Intestinal palpation:
17.Sigmoid colonfelt in the left iliac fossa in the form of a smooth, elastic cylinder,
painless, 2 cm thick, moderately dense, has a smooth surface, mobile, does not
growl. The cecum is felt in the right iliac region as a smooth slightly mobile (1 - 2
cm) cylinder with a slight expansion downwards (there is a growl), 4 cm
thick,
elastic, no pain on palpation. The final part of the ileum is not palpable, the
appendix is not palpated, the pain at the point of Lanz and McBurney is absent. The
ascending intestine is palpated in the form of a strand of medium density with a
diameter of about 4 cm in the right flank, the surface is smooth, elastic, does not
growl, is not painful, no seals. The transverse colon is palpated in the form of a
movable, slightly bent in the middle of an elastic cylinder with a thickness of 4 cm of
moderately dense consistency, on palpation painless, does not grumble. The
descending intestine is palpated in the form of a strand of medium density with a
diameter of about 4 cm in the left flank, the surface is smooth, elastic, does not
growl, is not painful, no seals.
18.Palpation of the stomach:at an approximate palpation the area over a stomach
and a duodenum is not painful. There is no splash noise. At a deep methodical
sliding palpation by the Obraztsov-Strazhesko method the big curvature of a
stomach could not be palpated. The goalkeeper is palpated as a short strand with a
diameter of 2 cm, which changes its shape and consistency. Mendel's,
Obraztsov- Strazhesko's symptom I, II is negative. The lower limit of the stomach,
determined by succussion, auscultation is located along the midline 3 centimeters
above the navel. Technique for determining the lower limit of the stomach: the
stethoscope is placed under the left costal arch, at the same time the finger makes
light dashed movements along the abdominal wall. When the finger goes outside
the stomach area, no movements are heard.
19.Theloweredgeoftheliveron palpation soft, slightly pointed, smooth, painless; does
not come out from under the edge of the right costal arch .:
20. DeterminationofliverboundariesbyVHVasylenko(percussion):
21.top:поl.Medianaanterior(definedconditionally)-thebasisofthexiphoid
22.appendix;
23.onl.Parasternalisdextra-ontheupperedgeoftheVIrib,
24.onl.Medioclavicularisdextra-attheleveloftheVIrib,
25.onl.medianaanteriordextra-attheleveloftheVIIrib,
26.bottom:onl.Medianaanterior-3cmbelowtheloweredgeofthexiphoid
27.appendix;
28.onl.Parasternalisdextra-1.5cmbelowtherightcostalarch,
29.onl.Medioclavicularisdextra-attheleveloftherightcostalarch,
30.onl.medianaanteriordextra-atlevelXoftherightcostalarch;
31.ontheleftcostalarch-atthelevelofVII-VIIIribs.
32.ThesizeoftheliveraccordingtoKurlov:
33.-rightmiddleclavicle9cm; 34.-
middle8cm;
35.-leftoblique(ontheleftcostalarch)7cm.
36. Gallbladder not palpable. Symptoms of Ortner, Vasilenko, Zakhar'in, Murphy,
Georgievsky - Mussey, Kerr, Courvoisier - are negative.
37. Pancreas: not palpable, pain in the area of Shofar, Gubergritz - Skulsky, Desjardins
and Mayo - Robson point is absent. Symptoms of Mayo-Robson, Melle-Guy,
Kerte- Rufanov are negative.
38. Rectum:at inspection of changes it is not revealed, at finger research the sphincter in a
satisfactory tone, mucous is smooth, on a glove the stool is invariable.
39. External hemorrhoids, cracks, fistulas, warts, tumors, prolapse of the intestinal
mucosa were not detected.
40. Semiotics: Normally, on superficial palpation, the fingers do not meet any
resistance from the abdominal wall, soft, pliable and painless. Resistance of the
abdominal wall is observed in the local inflammatory process of the abdominal
cavity without inflammation of the peritoneum. Muscle tension is observed where
the peritoneum is involved in the inflammatory process. There is a symptom of
Shchetkin-Blumberg in inflammation of the peritoneum. At pathologies of intestines
it is possible to palpate pathological peristalsis, hernias, tumors.
41. 4. Demonstrate knowledge of the method of liver examination.
42. For palpation of the patient's liver is placed on his back, legs outstretched, arms
folded across his chest. First, it is necessary to perform percussion of the abdomen
in the direction of the costal arch along the right midclavicular line in order to roughly
determine the location of the lower edge of the liver. It is better to search for the
edge of the liver near the edge of the rectus abdominis, because through the
muscles in many cases, palpation of the liver is difficult or impossible. If we
percussion reached the costal arch and did not find a shortening of the percussion
sound, then palpation is performed below the costal arch. 4 fingers of the right hand
gradually on exhalation deepen on 5 - 6 cm, and then advance a little upwards,
creating, according to VP Exemplary, a kind of "pocket". Then ask the patient to take
a deep breath "in the abdomen", and at this time we relax our fingers. The abdominal
wall during inhalation pushes the fingers out of the abdomen and at this point the
fingers meet with the edge of the liver, which at the height of inspiration inhales as
much as possible from under the edge of the costal arch. In most healthy people at
the height of inspiration, the liver emerges from under the edge of the costal arch
along the midclavicular line by 1 - 2 cm. Percussion of the liver When determining
the upper limit of absolute hepatic dullness, quiet percussion is used. In practice,
often use and determine the size of hepatic dullness according to Kurlov. The first
size of hepatic dullness according to Kurlov completely corresponds to the height of
hepatic dullness along the right midclavicular line and its definition is not particularly
difficult. However, it can be specified differently, for example: 9 (1). A mark in
parentheses means at what distance below the edge of the costal arch in cm (in this
case 1 cm) is the limit of hepatic dullness along the right midclavicular line. The
second size of hepatic dullness according to Kurlov is determined by the anterior
midline and is the distance between the upper and lower limits of hepatic dullness
along this line. Immediately a reasonable question arises: what is the upper limit of
hepatic dullness in the anterior midline can be discussed, if here, as we know, is the
absolute dullness of the heart? However, in this case we are not talking about the
real, but about the conditional limit of absolute hepatic dullness, which is believed to be
at the same level as the upper limit of absolute hepatic dullness (already valid) on the
right midclavicular line. Omitting in mind the perpendicular from this point to the front
midline, we thus find the conditional upper limit of hepatic dullness we need along
the anterior midline. Connecting the upper and lower limits along this line and
measuring the resulting segment, we find the second size of hepatic dullness
according to Kurlov, which is
normally 7-9 cm. Finally, connecting the points that characterize the left border of
hepatic dullness along the edge of the costal arch and all the same conditional upper
limit of hepatic dullness along the anterior midline, we find the third size of hepatic
dullness according to Kurlov, which is normally 6-8 cm. It is also called oblique size.
An increase in the size of hepatic dullness can occur in diseases such as hepatitis,
fatty infiltration of the liver, heart failure, etc., a decrease in some (atrophic) forms of liver
cirrhosis, acute liver dystrophy. Significant reduction, and sometimes complete
disappearance of hepatic dullness,
43. 5. Demonstrate the method of auscultation in the study of the boundaries
of the stomach and knowledge of the semiotics of lesions.
44.The mixed method of research - auscultation and percussion - auscultatory
percussion (auscultation friction) has some clinical value. Using this method to
determine the position (boundaries) and size of the stomach. At auscultation, the
child is in a supine position. On the abdominal wall in the area of the projection of
the stomach (to the left of the midline 3-4 cm above the navel) the doctor puts a
stethoscope and at the same time with his finger performs light scraping movements
on the abdominal wall, gradually moving away from the stethoscope. As the finger
moves in the area corresponding to the location of the stomach, a rustle is heard
through the stethoscope endoscope, which immediately disappears as soon as the
finger extends beyond the stomach. The location of the finger, when sound
phenomena disappear, corresponds to the boundaries of the stomach. The position
of the lower limit of the stomach in healthy children depends on many factors
(degree of filling, level of intra-abdominal pressure, body structure, etc.), so the shift of
the limit has diagnostic value only in cases where it is quite pronounced. Low
standing of the border of the stomach indicates lowering (gastroptosis), expansion
or sharp atony of its muscles.
45.
Task 41
Boy, 2 months
Anthropometric data: weight - 4200 g, body length - 55 cm, head circumference - 37 cm,
chest circumference - 37 cm. On examination: the child's condition is satisfactory, pale skin,
slightly reduced tissue turgor and dry skin to the touch, subcutaneous fat layer reduced in
the abdomen. The neuropsychological development of the child is within the age norm.
Data at birth - weight - 3600 g, body length - 48 cm, head circumference - 35 cm, chest
circumference - 34 cm.

2. Assess the child's physical development.
3. Calculate the child's body mass index.
4. Tactics of this patient.
5. Explain the method of weighing children under one year.

DZ: malnutrition of the first century
3600 + 600 + 800 = 5000 - lags behind in weight (about 16%)
48 + 3 + 3 = 54 cm longer than
35 + 1.5 + 1.5 = 38 cm head - exceeds the norm
34cm 45-2 (6-2) = 45-8 = 37cm - norm
Disharmonious development
BMI is calculated by dividing body weight (in kilograms) by the square of height (in square
meters)
BMI = 4.2: (0.55 * 0.55) = 13.88
4. Tactics of this patient. Basic principles of treatment: Depending on the degree of eating
disorders and the presence of complications or concomitant conditions
Goal
1. Identifying and eliminating the causes of eating disorders

2. Eliminate the symptoms of malnutrition and ensure reparation processes
3. Provide a rational, adequate diet
4. Prevent the development of complications
o at a malnutrition of the I degree of treatment out-patient nutrition according to
age, vitamins, enzyme preparations (a course of 1 month), probiotics and
prebiotics, massage is carried out;
o with malnutrition II and malnutrition III degree treatment is carried out in a
hospital
WEIGHING TECHNIQUES FOR CHILDREN. up to 3 g on special cup scales with a maximum

allowable load of up to 20 kg. Cup scales consist of a tray and a rocker arm with two scales of
divisions: the bottom - in kilograms, the top - in grams. The accuracy of the scales is up to 10 g.
The scales are balanced, then a diaper is placed on the tray so that its edges do not hang from it,
and it is weighed. The naked child is placed on a diaper with the scales closed. The head and
shoulders are placed on the wide part of the tray, the legs - on the narrow. Then open the rocker
and weigh. From the readings of the scales subtract the weight of the diaper.
senior 3 g is carried out on lever scales. Their accuracy is up to 50 g. An undressed child is
placed in the middle of the plane of pre-balanced scales. The readings of the scales are taken in
the same way as when weighing on cup scales.
Task 42
Girl, 6 months
chest circumference - 45 cm. On examination: the baby's skin is pale, slightly reduced
tissue turgor and skin is dry to the touch, subcutaneous fat is reduced on the abdomen ,
torso and limbs. The child lags behind in neuropsychological development by 1.5 months.

3. Estimate the ratio of weight to body length of this girl according to the
schedule of standard deviations of the WHO.
1. Grade 1 malnutrition.
2. Weight reduced, norm 7100, weight deficit 22, 5%, length norm, og norm.
3. Body mass index 12.9 on the WHO scale -3, body weight on the WHO scale -2
4. Treatment 1. Elimination of factors that led to quantitative and qualitative starvation;
2. The organization of an adequate mode, care, education. 3. Organization of staged
feeding of patients. 4. Replacement therapy. 5. Correction of the body's defenses. 6.
Treatment of concomitant diseases. Optimal mode - room temperature - 24-25 ° C; -
ventilation; - wet cleaning - 2 times a day; - walks in the fresh air, in winter at a
temperature not higher than - 5 ° C; - at a hypotrophy of the I degree - treatment at
home; - at a hypotrophy of the II-III degree - in the conditions of a hospital Weekly or
every decade control of increase in body weight is carried out. Control and analysis
of actual nutrition once every 7-10 days. The calculation of nutrition is carried out - in
case of malnutrition in case of malnutrition of the II degree - proteins and
carbohydrates at the proper weight, and fat only at the actual weight.
Replacement therapy. Enzymes: gastric juice, hydrochloric acid with pepsin,
pancreatin, abomin,
mezim - forte, creon, pangrol.
Normalization of intestinal microflora: bifidumbacterin, lactobacterin, bifiform, linex,
acidophilus from 2 to 4 weeks. The drug Bifiform BABY, which has proved itself well
used to prevent functional disorders of nutrition, recovery and
normalization of intestinal microflora in children from the first days of life.
Normalization of metabolic processes: vitamins A, E, C, group B or complex drugs -
multitabs, picovit, etc. The course of treatment is 1 month.
Apilak in candles on 0,0025g 2-3 times a day to newborns and on 0,005g 3 times
a day to children
up to 1 year. The course of treatment is 14 days. Potassium orotate 20 mg / kg body
weight per day for 2 weeks.
- physiotherapy (electrophoresis, paraffin on the abdomen).
- general massage, №20
The average duration of inpatient treatment is 28-30
days. Dispensary supervision
Deregistered 6-8 weeks after reaching physical and neuropsychological
development according to the age of the child
Examination by a pediatrician - 1st month. 5 times (mandatory weight control and
other anthropometric
indicators), then once a month
1. Determination of body weight of children from birth to 3 years is carried out on cup
levers, with a permissible load of up to 20 kg. Infant weighing technique. First you
need to balance the scales, if they are mechanical. Next, weigh the diaper. It is placed
on the tray so that the edges of the diaper do not hang down. A variant of the
weighing procedure is to balance the scales together with the diaper. Then its weight
is not taken into account. The child is placed on the wide part of the tray with his
head and shoulder girdle, feet in the narrow part of the tray. You can also put the baby
on the wide part of the tray, and put your feet on the narrow part. It is possible to put
and remove the child from levers only at the closed rocker arm (arrest), standing
directly opposite to a rocker arm of levers. Weight readings are taken from the side
of the lever where there are notches (or notches) with numbers. The accuracy of
weighing is 5 grams (half the smallest interval of the upper scale). Before taking the
child, close the rocker arm 6 scales. Then the levers are set to zero. To determine
the weight of the child it is necessary to subtract the weight of the diaper from the
indicators of the levers. Determination of body weight of a child older than 3 years is
carried out on medical mechanical scales of intensive use with an arrester or medical
electronic scales. When weighing, the undressed child should stand still in the
middle of the lever area. The rocker arm of levers consists of two scales, the
smallest interval - 50 grams, accuracy - 25 grams. Weighing should be performed in
the morning on an empty stomach, preferably after urination and defecation. To
determine the weight of the child it is necessary to subtract the weight of the diaper
from the indicators of the levers. Determination of body weight of a child older than 3
years is carried out on medical mechanical scales of intensive use with an arrester or
medical electronic scales. When weighing, the undressed
child should stand still in the middle of the lever area. The rocker arm of levers
consists of two scales, the smallest interval - 50 grams, accuracy - 25 grams.
Weighing should be performed in the morning on an empty stomach, preferably after
urination and defecation. To determine the weight of the child it is necessary to
subtract the weight of the diaper from the indicators of the levers. Determination of
body weight of a child older than 3 years is carried out on medical mechanical scales
of intensive use with an arrester or medical electronic scales. When weighing, the
undressed child should stand still in the middle of the lever area. The rocker arm of
levers consists of two scales, the smallest interval - 50 grams, accuracy - 25 grams.
urination and defecation. accuracy - 25 grams. Weighing should be performed in the
morning on an empty stomach, preferably after urination and defecation. accuracy -
25 grams. Weighing should be performed in the morning on an empty stomach,
preferably after urination and defecation.
Task 43
Boy, 9 months
chest circumference - 46 cm. On examination: significant exhaustion of the child, pale gray
skin, reduced tissue turgor and skin is very dry to the touch, the subcutaneous fat layer is
reduced on the face, abdomen, torso and limbs. The child lags behind in
neuropsychological development by 3 months.

5. Explain the methods of weighing children.
Malnutrition of the 3rd century

Initial mass= body weight at birth + (800 x 6 (allowance for the first six months) + 400 (N-6),
where N is the number
of months (from 6 to 12)

Body BMI is determined by the formula: Body weight (kg) / (Height / m) ² = 5650 /
0.70 = 8

5. Treatment
6. 1. Elimination of factors that led to quantitative and qualitative starvation;
7. 2. The organization of an adequate mode, care, education.
8. 3. Organization of staged feeding of patients.
9. 4. Replacement therapy.
10. 5. Correction of the body's defenses.
11. 6. Treatment of concomitant diseases.
12.Optimal mode - room temperature - 24-25 ° C; - ventilation; - wet cleaning - 2 times
a day; - walks in the fresh air, in winter at a temperature not higher than - 5 ° C; - at
a hypotrophy of the I degree - treatment at home; - at a hypotrophy of the II-III
degree - in the conditions of a hospital Weekly or every decade control of increase
in body weight is carried out. Control and analysis of actual nutrition once every 7-
10 days. The calculation of nutrition is carried out - in case of malnutrition of the I
degree - for proper weight - in case of malnutrition of the 2nd degree - proteins and
carbohydrates for proper weight, and fat only for actual weight - in case of
malnutrition of III degree - proteins and carbohydrates for approximately proper
weight (actual weight + 20% from it), and fat only on actual weight.
13.
14. Replacement therapy

15.Enzymes: gastric juice, hydrochloric acid with pepsin, pancreatin, abomin, mesyme -
forte, creon, pangrol. Normalization of intestinal microflora: bifidumbacterin,
lactobacterin, bifiform, linex, acidophilus from 2 to 4 weeks. The drug Bifiform BABY,
which is used to prevent functional eating disorders, restore and normalize the
intestinal microflora in children from the first days of life, has proven itself well.
Normalization of metabolic processes: vitamins A, E, C, group B or complex drugs -
multitabs, picovit or others. The course of treatment is 1 month. Apilak in candles
0.0025 g 2-3 times a day for newborns and 0.005 g 3 times a day for children under
1 year. The course of treatment is 14 days. Potassium orotate 20 mg / kg body
weight per day for 2 weeks. - physiotherapy (electrophoresis, paraffin on the
abdomen). - General massage №20 The average duration of inpatient treatment is
28-30 days. Dispensary supervision: deregistered 6-8 weeks after reaching physical
and neuropsychological development according to the age of the child. Examination
by a pediatrician - 1st month. 5 times (mandatory control of weight and other
anthropometric indicators), then 1 time per month. Examination by specialists
(neurologist, surgeon, orthopedist) once a year and according to the indications.
16.
17. Prevention
18. 1. Antenatal prophylaxis (prevention of pathological course of pregnancy and
childbirth).
19. 2. Early detection of hypogalactia in the mother of a sick child.
20. 3. Preservation of natural feeding.
21. 4. Organization of proper care and treatment of infants. 5. Prevention of rickets,
anemia.
5 Explain the methods of weighing children.
From birth to 2-3 years, children are weighed on electronic or cup scales with a maximum
allowable load of up to 20 kg. Before weighing the baby, the scales are balanced, then a
diaper is placed on the tray so that its edges do not hang from it, and it is weighed. The
naked child is placed on a diaper with the scales closed. The head and shoulders are
placed on the wide part of the tray, the legs - on the narrow. From the readings of the
scales subtract the weight of the diaper. Electronic scales show more accurate weighing
results, so it is better to use them for weighing children. Weighing of children older than 3
years is carried out on lever scales. Their accuracy is up to 50 g. An undressed child is
placed in the middle of the plane of pre-balanced scales. The readings of the scales are
taken in the same way as when weighing on cup scales. The child should be weighed
before breakfast,
On average, weight gain for each month of the first half is:
 - for the 1st month. - 500-600 g;

 - 2nd month - 800-900 g;
 - 3rd month - 800 g and for each following month - 50 g less than the previous one.
According to the formula, in the first half of the child's body weight is equal to:
birth weight + (800 x n), where n is the number of months, 800 is the average monthly
weight gain during the first half of the year.
For the second half of life, the baby's body weight is equal to:
birth weight + 800 • 6 + 400 (n-6), where n is the age in months.
The average monthly weight gain in the second half of the year is 400
Task 44
Girl, 7 months
chest circumference - 44 cm.
On external examination, the explosion of a large spring, the discrepancy of the cranial
sutures, the tension of the subcutaneous venous network of the head, the sparse growth of
hair on the head. Periodically, the child develops nystagmus, symmetrical spastic
paraplegia of the lower extremities, convulsive syndrome. There is also exophthalmos,
ptosis of the eyelids and a positive symptom of Grefe. The child lags behind in psycho-
motor development.

3. Calculate the Erisman index.
5. Explain the method of measuring the head circumference in children.
1 Acquired closed hypertensive hydrocephalus
2 Physical development is disharmonious:
 Weight is the norm

 Body length is the norm
 Chest circumference is the norm
 Head circumference - increased
3 Calculate the Erisman index.

IE = chest circumference - 1/2 height IE = 44-66 / 2 = 11 cm norm
4 Bypass
Treatment occlusivehydrocephalus by shunting is quite effective, however, according to

various sources, complications after this operation account for 40-60% of cases.
However, depending on the cause of the dysfunction, all or part of the shunt must be
replaced.
Experience has shown that the most common complications requiring shunt revision occur
between six months and one year after surgery. Most patients who underwent shunting
have to undergo several surgeries throughout their lives. In any case, at least two or more
revisions should be expected - because the child is growing. After shunting, the patient
becomes "shunt-dependent", ie, his entire subsequent life will depend on the operation of
the shunt.
5. Thus from:
Problem 45
Boy, 3 months.
chest circumference - 38 cm. On examination: pale skin, disproportionate size of the head,
compared to the body, the child's head looks very small, forehead is beveled outlines, ears
protruding, superciliary arches strongly protrude beyond the lateral parts of the forehead.
The patient has reduced muscle tone, tonic-clonic seizures, which are sometimes
accompanied by loss of consciousness by the child. There is also emotional instability of
the child, he is too irritable, on the contrary - apathetic and lethargic.

1. Microcephaly.
2. Physical development is disharmonious: Weight - norm. Body length - norm.

Chest circumference - norm
Head circumference-microcephaly
3. BMI = body weight (kg) / height (m2) = 5.25 / (0.6x0.6) = 14.58 (below normal weight)
4. There is no special treatment. First-line drugs for the treatment of seizures in children are
benzodiazepines (diazepam [seduxen, sibazone, relanium, valium.
Seduxen is administered intravenously (iv), rarely intramuscularly (i / m) as a 0.5%

solution in a single dose of 0.20-0.35-0.50- (0.70) mg / kg body weight (one ampoule of
seduxen contains 10 mg in 2 ml).
Nutrition according to age, vitamins, enzyme preparations (1 month course), probiotics and
prebiotics, massage.
5. Thus from:
Task 46
Girl, 10 months
chest circumference - 46 cm. On examination: the skin is moderately pale, reduced elasticity,
dry to the touch, subcutaneous fat is reduced on the abdomen, slightly on the torso. The
child lags behind in neuropsychological development by 2 months.
From the anamnesis it is known that the girl's mother developed hypogalactia at 1.5
months, so she began to feed the child boiled cow's milk and liquid semolina, no
complementary foods were introduced to the child.

1. 3. Calculate the Erisman index.

2. 4. Tactics of this patient.
3. 5. Explain the method of measuring body length in children under one year.
1. Task 47
2. Boy, 2 years old.
3. Anthropometric data: weight - 17.3 kg, height - 85 cm, head circumference - 49 cm,
chest circumference - 51 cm. On examination: pink skin, an increase in the layer of
subcutaneous fat, especially on the face and abdomen. The boy has only 4 teeth.
The boy is lethargic, apathetic, hypodynamic.

5. Explain the method of weighing children older than one year.
2. Diagnosis: obesity of the first degree.

3. Weight above normal, should be 14 kg, height is normal, up to 2 years should be
20 teeth.
4. Body mass index is calculated by dividing body weight (in kilograms) by the
square of height (in square meters).
17.3: 0.85 * 0.85 = 17.3 6: 0.7225 = 23.9
For the age of 2 years, this figure indicates obesity
5. Principles of treatment of childhood obesity:
correction of eating behavior and lifestyle;
gradual weight loss;
creating motivation and goals for the child;
encouraging every achievement.
The first step in restoring normal body weight is diet therapy. The classic version of
the correction of the diet of an obese child involves a low-calorie diet with a balanced
content of fats, proteins, carbohydrates, vitamins and minerals. The child's diet
significantly limits the amount of simple carbohydrates (flour and confectionery, sugar)
and animal fats.
Portions should be small and contain all the necessary nutrients that the growing
body needs.
Active lifestyle - is an important component of the treatment program for childhood
obesity. Increasing energy expenditure due to dosed exercise can reduce the
amount of deposited fat, restore the balance between synthesis and hydrolysis of
lipids, strengthen the cardiovascular system.
Drug treatment of obesity in pediatrics is very limited and is prescribed only in the
presence of endocrine causes. Surgical treatment of obesity in children can be
performed only in the case of diagnosed hormone-producing brain tumor. Surgery to
remove excess adipose tissue in children is prohibited.
6. Determination of body weight of children from birth to 3 years is carried out on cup
levers, with a permissible load of up to 20 kg. Infant weighing technique. First you
need to balance the scales, if they are mechanical. Next, weigh the diaper. It is placed
on the tray so that the edges of the diaper do not hang down. A variant of the
weighing procedure is to balance the scales together with the diaper. Then its weight
is not taken into account. The child is placed on the wide part of the tray with his
head and shoulder girdle, feet in the narrow part of the tray. You can also put the
baby on the wide part of the tray, and put your feet on the narrow part. It is possible
to put and remove the child from levers only at the closed rocker arm (arrest),
standing directly opposite to a rocker arm of levers. Weight readings are taken from
the side of the lever where there are notches (or notches) with numbers. The
accuracy of weighing is 5 grams (half the smallest interval of the upper scale).
Before taking the child, close the rocker arm 6 scales. Then the levers are set to
zero. To determine the weight of the child it is necessary to subtract the weight of the
diaper from the indicators of the levers. Determination of body weight of a child older
than 3 years is carried out on medical mechanical scales of intensive use with an
arrester or medical electronic scales. When weighing, the undressed child should
stand still in the middle of the lever area. The rocker arm of levers consists of two
scales, the smallest interval - 50 grams, accuracy - 25 grams. Weighing should be
performed in the morning on an empty stomach, preferably after urination and
defecation. To determine the weight of the child it is necessary to subtract the weight
of the diaper from the indicators of the levers. Determination of body weight of a
child older than 3 years is carried out on medical mechanical scales of intensive use
with an arrester or medical electronic scales. When weighing, the undressed child
should stand still in the middle of the lever area. The rocker arm of levers consists
of two scales, the smallest interval - 50 grams, accuracy - 25 grams.
urination and defecation. To determine the weight of the child it is necessary to
subtract the weight of the diaper from the indicators of the levers. Determination of
body weight of a child older than 3 years is carried out on medical mechanical scales
of intensive use with an arrester or medical electronic scales. When weighing, the
undressed child should stand still in the middle of the lever area. The rocker arm of
levers consists of two scales, the smallest interval - 50 grams, accuracy - 25 grams.
urination and defecation. accuracy - 25 grams. Weighing should be performed in the
morning on an empty stomach, preferably after urination and defecation. accuracy -
25 grams. Weighing should be performed in the morning on an empty stomach,
preferably after urination and defecation.
Task 48
Girl, 6 years old.
Anthropometric data: weight - 31 kg, height - 110 cm, head circumference - 51 cm, chest
circumference - 56 cm. On examination: the skin is pink, oily, there are excess fat in the
abdomen, pelvis, thighs, face. There are stretch marks on the skin of the thighs and
abdomen. The girl is determined by shortness of breath during exercise.
1. Obesity
2. Body mass index
Imt = body weight in kilograms ÷ height in meters
48) 2)
Imt = 31 ÷ 1.1
= 28.18
3. height and weight less than normal
4. Consultation of an endocrinologist
Appointment of a diet
Gradual weight loss
Active lifestyle
Drug treatment only in the presence of an endocrine cause!
5. TECHNIQUE OF WEIGHING CHILDREN. Weighing of children under 3 years is carried
out on special cup scales with a maximum allowable load of up to 20 kg. Cup scales consist
of a tray and a rocker arm with two scales of divisions: the bottom - in kilograms, the top - in
grams. Accuracy of scales to 10 g. Scales before weighing of the child balance, then on a
tray put a diaper so that its edges did not hang down from it, and weigh it. The naked child
is placed on a diaper with the scales closed. The head and shoulders are placed on the
wide part of the tray, the legs - on the narrow. Then open the rocker and weigh. From the
readings of the scales subtract the weight of the diaper.
Weighing of children older than 3 years is carried out on lever scales. Their accuracy is up
to 50 g. An undressed child is placed in the middle of the plane of pre-balanced scales. The
readings of the scales are taken in the same way as when weighing on cup scales.
Task 49
Boy, 10 years old.
circumference - 66 cm. On examination: the skin is pale pink, there are excess fat in the
abdomen, pelvis, thighs, face, upper extremities . The boy is determined by shortness of
breath, decreased tolerance to exercise.
From the anamnesis it is known that the boy at the age of 7 had a craniocerebral trauma
which he received in road accident.

1. Congenital hypothyroidism
2. Height within 0- + 1 sigma, weight +3 sigma
3. Mass index 29
4. Endocrinologist consultation
5. Weighing technique for children From birth to 2-3 years, children are weighed on
electronic or cup scales with a maximum allowable load of up to 20 kg. Before
weighing the baby, the scales are balanced, then a diaper is placed on the tray so
that its edges do not hang from it, and it is weighed. The naked child is placed on a
diaper with the scales closed. The head and shoulders are placed on the wide part of
the tray, the legs - on the narrow. From the readings of the scales subtract the
weight of the diaper. Electronic scales show more accurate weighing results, so it is
better to use them for weighing children. Weighing of children older than 3 years is
carried out on lever scales. Their accuracy is up to 50 g. An undressed child is
placed in the middle of the plane of pre-balanced scales. The readings of the scales
are taken in the same way as when weighing on cup scales.
Problem 50
Girl, 12 years old.
circumference - 72 cm. On examination: the skin is pink, there are excess fat in the
abdomen, pelvis, thighs, chest, back, face, upper extremities. The girl has shortness of
breath, decreased tolerance to exercise, high blood pressure. The patient also complains of
fatigue, weakness, drowsiness, decreased school performance, dry skin and stretch marks
on the skin of the hands, feet, abdomen, back. The girl has oily skin, acne, excessive hair
growth.


Second degree obesity, secondary,
endocrine
n- age of child weight = 30 + 4 (n-10) = 38 kg; (+3 and above) obesity height = 100 +
6 (n-4) = 148 cm; (0; +1) norm OG = 50 + 0.6 (n-5) = 54.2 cm; (0; +1) norm OOGK = 63 + 3
(n-10)
= 69cm; (0; +1) norm
IM = 85 / 1.5 * 1.5 = 37.7
Body weight by centiles (non-parametric indicators) is more than 97- is a high
physical development. The physical development of the child does not correspond to the
norm and age. Sharply disharmonious development.
IM = 85 / 1.5 * 1.5 = 37.7 Obesity of the II
degree
Diagnosis of the cause of obesity: - Determination of fasting blood glucose
followed by oral glucose tolerance test (OGTT) (glucose - 1.75 g / kg body weight, but not
more than 75 g), glycosylated hemoglobin - Insulin level in the blood, calculation of the index
HOMA-IR, CARO - Blood lipid spectrum (total cholesterol (CH) and triglycerides (TG), low
density lipoprotein (LDL), very low density (LDL) and high density (HDL), atherogenic factor)
- Thyroid hormones (TSH, with an increase in TSH - blood pressure on T3v., T4v.,
BP to TG, BP to TPO). - At signs of sexual dysfunction - sex hormones: in men - the level
of testosterone in the blood, in women - estradiol and blood progesterone. FSH, LH, blood
prolactin - in both women and men.
Ultrasound of the thyroid gland, adrenal glands, abdominal organs, women if
necessary - ultrasound of the pelvic organs
Prescribing treatment depending on the diagnosed cause of obesity,
Energy balanced, low calorie diet.
Regular exercises of low and medium intensity
From birth to 2-3 years, children are weighed on electronic or cup scales with a
maximum allowable load of up to 20 kg. Before weighing the baby, the scales are balanced,
then a diaper is placed on the tray so that its edges do not hang from it, and it is weighed.
The naked child is placed on a diaper with the scales closed. The head and shoulders are
placed on the wide part of the tray, the legs - on the narrow. From the readings of the
scales subtract the weight of the diaper. Electronic scales show more accurate weighing
results, so it is better to use them for weighing children.
Weighing of children older than 3 years is carried out on lever scales. Their accuracy
is up to 50 g. An undressed child is placed in the middle of the plane of pre-balanced
scales. The readings of the scales are taken in the same way as when weighing on cup
scales. The child should be weighed before breakfast, during the measurement it is
undressed.
Problem 51
Boy, 9 years old.
circumference - 64 cm. On examination: the skin is pale pink, clean, moist.
Neuropsychological development of the child corresponds to age.

3. Calculate the Tour index.
5. Explain the method of measuring the circumference of the breast in children.
1. Establish a preliminary diagnosis. Development corresponds to age. Harmonious

physical development corresponds to age. According to signal tables and centiles - norm
2. Evaluate the physical development of the child.
Weight 10 + 2 * 9 = 28 kg Height 100 + 6 * (9-4) = 130 cm
Chapter 50 + 0.6 * (9-5) = 52.4 GK 63-1.5 (10-9) = 61.5
3. Calculate the Tour index. the difference between the indicators of the circumference of the head
and the circumference of the chest; Norm: from 1 to 7 years, the circumference of the chest exceeds
the circumference of the head by as many cm as the age of the child.
53-64 = -9 norm
4. Tactics of management of the given patient. Treatment does not demand. Recommendations for
daily and rest. Exercise. Follow a diet
5. Tell us about the method of measuring breast circumference in children.
Measurements of the perimeter of the chest are performed in infants in a supine position, in older
children - in a standing position. The child should be at rest, hands down. The beginning of the
centimeter tape is in the left hand on the side of the armpit. Behind the tape is held at an angle to
the blades, and in front - on the lower edge of the areola. In girls with developed breasts in front, the
tape is held along the fourth rib above the breasts at the junction of the skin from the chest to the
gland.
Task 52
Girl, 16 years old.
circumference - 80 cm. On examination: the skin is pale pink, moderately dry, the
subcutaneous fat layer is developed normally. The girl is diagnosed with epicanthus, high
(gothic) palate, short thick neck, low hair growth on the back of the head, pterygoid folds of
the neck, scoliosis, a significant number of pigmented nevi on the skin, hypertrichosis.
From the anamnesis and examination it was found that there is a delay in sexual
development - the absence of mammary glands, agenesis of the uterus and ovaries.

5. Explain the method of measuring growth in children older than one year.
Shershevsky Turner Syndrome
Erisman index - determines the proportionality of chest development
According to the formula:
 IE = Q - L / 2;
Where:
 IE - Erisman index (cm)

 Q is the circumference of the chest in the pause (cm)
 L - height (cm).
Norm:
 ≈ + 5.8 cm for men

 ≈ + 3.3 cm for women
Index = 4.50 Good chest development

Treatment
There is no specific treatment for the syndrome, but symptomatic therapy is possible:
treatment of growth retardation with growth hormone drugs, hormone replacement
therapy, correction of congenital anomalies and cosmetic defects, prevention of
osteoporosis and cardiovascular disease in patients with Shereshevsky-Turner syndrome.
Techniqueofanthropometricmeasurementsinchildren
Anthropometric studies in children include measurements of body weight and length,

perimeters of the chest and head, as well as a number of other measurements needed to
calculate additional indicators of physical development.
In the first year of life, the child's body weight is determined in the clinic on the days of
monthly admission (closer to the date of birth of the child 2 ± 1 days), and body length -
once a quarter, if there are no indications for more frequent measurements. For children
from 1 to 3 years, body weight is determined once a quarter (± 3-5 days), body length - once
every six months. For children from 3 to 7 years of age, body weight is estimated once
every six months (± 5-10 days), body length - annually.
In preschool institutions, weight control is performed in children up to 6 months. life

every 10 days, from 6 months. up to 1 year - once every 15 days, from 1 to 3 years - once a
month, from 3 to 7 years - once a quarter.
In the hospital, children of the first year of life are weighed daily. Children who do not
suffer from acute and chronic eating or digestive disorders, from 1 to 3 years are weighed
every other day, aged 3 years and older - once a week. In the presence of certain
indications, children are weighed more often.
Anthropometry is recommended in the morning, because by evening the body length

increases, usually by 1-2 cm. Children should be undressed (if possible). Weighing
should be performed on an empty stomach and at the same time, preferably after
defecation and urination.
Problem 53
Boy, 17 years
old.
circumference - 92 cm. From the anamnesis it is known that the boy suffered at the age of 9
mumps meningitis. At inspection at the child the following changes are observed: high
growth; lengthening of the limbs, disproportionately small head size; reduced efficiency.
The boy complains of increased fatigue; weakness; decreased vision; frequent

headaches; dizziness; numbness of the extremities; arthralgia; painful sensations during
motor activity.

Giantism
Body weight: from 2 to 10 years M = 10 + 2n, where n is the age of the child in
years. Older 10 years: M = 30 + 4 (n - 10), where n is the age of the child in years.
Height: up to 4 years: L = 100 - 8 (4-n);
older than 4 years: L = 100 + 6 (n - 4), where n is the age of the child in
years. Head circumference: from 1 to 5 years OG = 50 - 1 (5-n);
after 5 years of CO = 50 + 0.6 (n - 5), where n is the age of the child in
years. Chest circumference: from 1 to 10 years: OGr = 63 - 1.5 (10-n);
older than 10 years: OGr = 63 + 3 (n - 10), where n is the age of the child in years.
Index FF Erisman (IE) characterizes the development of the child's chest and partly
its fatness:
IE = chest circumference (cm) - 1 \ 2 height (cm);
Norm: 1st year - 13.5 - 10 cm;
2-3 years - 9 - 6 cm;
6-7 years - 4-2 cm;
7-8 years - 0, but it is best when up to 15 years IE = 1-3
cm; adults - 5-6 cm
IE = 92-102 = -10cm
Surgical treatment
The method of choice is the removal of the tumor by transphenoidal access (after
preparation of the patient with the help of somatostatin analogues of prolonged
action); can lead to complete recovery.
Pharmacological treatment
1. Drugs: somatostatin analogues of prolonged action:

1) octreotide in an initial dose of 20 mg i / m 1 × per month .; if within 3 months. IGF-
1 level is not normalized → increase the dose to 30 or 40 mg i / m 1 × per month .;
or
2) lanreotide 60-120 mg every 4 weeks. deep n / w; with good efficacy n / w to

enter a dose of 120 mg every 6 or 8 weeks.
2. Impressions:
1) before surgical treatment of macroadenoma, in particular, if it infiltrates the

surrounding tissues; in most cases it is possible to achieve a reduction, and in
≈50% normalization of STG levels, as well as reduction of the tumor and changes
in its consistency, which facilitates total resection;
2) after removal of the macroadenoma, if the surgery was not effective;
3) in patients who have not undergone surgery - in case of contraindications

or refusal of the patient, as well as with a low probability of effectiveness of
the intervention - in order to reduce the intensity of symptoms.
3. If somatostatin analogues are ineffective → it is necessary to additionally

prescribe a dopaminergic drug, an antagonist of STG receptors (pegvisomant), to
perform repeated surgery or, as a last resort, to consider the possibility of radiation
therapy.
Radiation therapy
Stereotactic or conformal radiation therapy as adjuvant therapy, with ineffective

surgical and pharmacological treatment. Normalization of HGH levels occurs several
years after the end of radiation therapy; still requires treatment with somatostatin
analogues. The side effect is, first of all, hypofunction of the pituitary gland (perform
control examinations).
BODY LENGTH. Length means the size of the child from head to toe when
measured in a supine position, horizontally. Vertical measurement of the same size
standing is called height. Body length to some extent reflects the level of maturity of
the organism. Body length in children of the first 2 years is measured in the supine
position using a special height meter in the form of a board with a centimeter scale.
The top of the baby should fit snugly against the fixed height bar. The head is fixed
so that the lower edge of the orbit and the upper edge of the external auditory canal
are at the same level. The child's legs are straightened by light pressure on the
knee. The movable bar of the height meter is tightly pressed to the heels of the
child. In older children, height is measured using a vertical height meter with a folding
stool. The child stands on the platform of the height meter with his back to the scale.
The child touches the scale with the back of the head, between the shoulder blade,
sacrum and heels. The head is fixed in the same way - so that the lower edge of the
orbit and the upper edge of the external auditory canal are at the same level. The
movable bar is fixed at the apex of the head.
CALCULATION OF THE IDEAL GROWTH OF CHILDREN OF DIFFERENT AGES
The body length of a child in the first year of life can be calculated as follows:
for the first quarter. - 3 cm per month (9 cm for the quarter);
for the II quarter - 2.5 cm per month (7.5 cm per
quarter); for III quarter - 1.5 cm per month (4.5 cm per
quarter); for IU sq. - 1.0 cm per month (for a quarter of 3
cm).
The total increase in body length in the first year of life is 25 cm. The child's body
length doubles to 4, triples to 12 years.
After 1 year, use the following formulas:
up to 4 years L = 100 - 8 (4 - n)
after 4 years L = 100 + 6 (n - 4), where n - years
Problem 54
Girl, 13 years old.
circumference - 74 cm. On examination: pale skin, moisture to the touch, subcutaneous fat
layer is reduced on the face, abdomen, torso and limbs. Tremor of extremities is defined.
The patient complains of pain in the eyeballs, burning, tearing, decreased visual acuity, a
feeling of sand under the eyelids, photophobia, as well as sleep disturbances,
nervousness, diarrhea and intermittent heart failure. At objective inspection at girls
exophthalmos, hypostasis of eyelids and periorbital fabrics, conjunctival hyperemia and
restriction of mobility of eyeballs come to light.

3. Calculate the Tour index.
1 Diffuse toxic goiter
2Filanguage development is disharmonious:

 Weight - reduced
 Body length is the norm
 Chest circumference is the norm
 head circumference - the norm
3Tour Index. the difference between the indicators of the circumference of the head and the
circumference of the chest; Norm: from 1 to 7 years, the circumference of the chest exceeds
the circumference of the head by as many cm as the age of the child.
52-74 = -22 norm
4
5 CHILDREN'S WEIGHING TECHNIQUES. up to 3 g on special cup scales with a maximum
allowable load of up to 20 kg. Cup scales consist of a tray and a rocker arm with two scales of
divisions: the bottom - in kilograms, the top - in grams. The accuracy of the scales is up to 10 g.
The scales are balanced, then a diaper is placed on the tray so that its edges do not hang from it,
and it is weighed. The naked child is placed on a diaper with the scales closed. The head and
shoulders are placed on the wide part of the tray, the legs - on the narrow. Then open the rocker
and weigh. From the readings of the scales subtract the weight of the diaper.
senior 3 g is carried out on lever scales. Their accuracy is up to 50 g. An undressed child is

placed in the middle of the plane of pre-balanced scales. The readings of the scales are taken in
the same way as when weighing on cup scales.
Problem 55
Boy, 11 years old.
circumference - 67 cm. On examination: pale skin, slightly reduced turgor and tissue
elasticity and the skin is very dry to the touch, subcutaneous fat is reduced by face,
abdomen. The boy has increased thirst, frequent painless urination, heavy drinking (up to 5
liters of fluid), lethargy, weakness and drowsiness, constant restless hunger.

5. Explain the methods of weighing children older than one year.
1. Type 1 diabetes mellitus.
2. Body weight: M = 30 + 4 (age of the child-10) = 34 below
normal Height: L = 100 + 6 (age-4) = 142 norm
Head circumference: OG = 50 + 0.6 (age-5) = 53.6 below normal
Chest rim: 63 + 3 (age-10) = 66 below normal Development is disharmonious
3. BMI = body weight (kg) / height (m2) = 14.8 below normal
4. Consultation with an endocrinologist. Lifestyle modeling, insulin therapy 0.1 IU / kg
5. Weighing of children under 3 years is carried out on special cup scales with a
maximum allowable load of up to 20 kg. Cup scales consist of a tray and a rocker arm
with two scales of divisions: the bottom - in kilograms, the top - in grams. Accuracy of
scales to 10 g. Scales before weighing of the child balance, then on a tray put a diaper
so that its edges did not hang down from it, and weigh it. The naked child is placed on a
the tray, the legs - on the narrow. Then open the rocker and weigh. From the readings
of the scales subtract the weight of the diaper.
Task 56
Girl, 15 years old.
circumference - 76 cm. On examination: pale skin, dry to the touch, subcutaneous fat is
reduced on the face and abdomen. Determined shortness of breath during exercise,
cyanosis of the nasolabial triangle, the chest is slightly deformed. The girl complains of
fatigue, poor memory, frequent headaches, poor school performance.
From the anamnesis it is known that the girl suffers from chronic bronchopulmonary
pathology, often lying in the hospital.

Problem 57
Boy, 7 years old.
circumference - 56 cm. On examination: pale skin, moisture, sedentary child lags behind in
psycho-motor development, the child gets tired quickly, there is a "garrison" furrow
"curvature of the legs, wrists, as well as ribs, in places of transition of bone tissue to
cartilage are palpated so-called rickets bracelets and" rosaries "in the form of bumps.

1. Rickets. Moderate.
2. Weight - norm, Height - low, og norm, ogk norm
3. FF Erisman's index (characterizes the development of the child's chest and partly
its fatness) 1E = chest circumference (cm) - 1/2 height (cm). Norm:
- 1st year - 13.5-10 cm;
- 2-3 years - 9-6 cm;
- 6-7 years - 4-2 cm;
- 7-8 years - 0;
- optimal up to 15 years is IE = 1-3 cm;
- in adults the value of the index is about 5-6 cm;
- the value of IE should be positive up to 6-8 years, and the better the physically
developed child, the later her chest circumference is equal to half-life;
4. Treatment of rickets must be comprehensive - nonspecific (properly organized daily
routine, walking, prolonged breastfeeding, proper nutrition, dynamic lifestyle) and
specific (medication).
Mild degree - 2000 IU
Medium severity - 4000 IU
Heavy - 5000 IU
Within 30 - 45 days. In the future to prevent exacerbations and recurrences of the
disease by 2000 IU for 30 days 2-3 times a year with intervals of at least 3 months
5. The circumference of the chest is measured three times: at calm breathing, at the
height of inspiration and at the height of exhalation. The child should be in a
standing position with his hands down. The measuring tape is placed behind at the
lower corners of the blades with the arms set aside. Then the hands are lowered and
hold the tape in front of the middle chest point (lower edge - near the nipple circle).
In girls of pubertal age with well-developed mammary glands, the tape is applied over
the breast at the junction of skin and gland. First, measure the main anthropometric
indicator - the circumference of the chest with calm breathing. Then the
measurements are continued on the maximum inhalation and after the maximum
exhalation. All measurements are performed with one application of the tape.
Problem 58
Girl, 4 months
Anthropometric data: weight - 8000 g, body length - 62 cm, head circumference - 40.5 cm,
chest circumference - 40 cm. On examination: pink skin, soft tissue turgor is reduced, there
are soft rounded body shapes , round face, short neck, soft tissue pastosity, muscular
hypotension. The child has a short restless sleep, allergic rashes on the skin. From the
anamnesis it is known that the girl had Quincke's edema on the introduction of the DPT
vaccine, already had several SARS.

1. Itsenko-Cushing's syndrome
2. body mass index-12.9
3. body weight and height more than usual
4. Consultation of an endocrinologist
5. In the first year of life the child's body weight is determined in the clinic on the days of
monthly admission (closer to the date of birth of the child 2 ± 1 days).
Task 59
Boy, 5 months
Anthropometric data: weight - 10600 g, body length - 64 cm, head circumference - 41.5
cm, chest circumference - 41 cm. On examination: pink skin, soft tissue turgor is reduced,
there are soft rounded body shapes , round face, short neck, soft tissue pastosity, muscular
hypotension. The child has a short restless sleep. The child lags behind in
neuropsychological development for 1 month.

1. Itsenko-Cushing syndrome
2. Body mass index 25
3. Growth rate weight +3 obesity
4. Endocrinologist consultation
5. Weighing technique for children From birth to 2-3 years, children are weighed on
electronic or cup scales with a maximum allowable load of up to 20 kg. Before
weighing the baby, the scales are balanced, then a diaper is placed on the tray so
that its edges do not hang from it, and it is weighed. The naked child is placed on a
the tray, the legs - on the narrow. From the readings of the scales subtract the
weight of the diaper. Electronic scales show more accurate weighing results, so it is
better to use them for weighing children. Weighing of children older than 3 years is
carried out on lever scales. Their accuracy is up to 50 g. An undressed child is
placed in the middle of the plane of pre-balanced scales. The readings of the scales
are taken in the same way as when weighing on cup scales.
Problem 60
Girl, 15 years old.
circumference - 81 cm. On examination: the patient is tall, thin, has long, thin limbs, thin
wrists with long toes and feet ( arachnodactyly). Scoliosis, high flexibility of joints, highly
placed palate with deformed dentition and occlusion, flat feet, stooping and stretch marks
on the skin. The girl complains of pain in the joints, bones and muscles. The patient is
determined by subluxation (partial dislocation) of the lens, myopia.
The girl also complains of weakness, shortness of breath, palpitations, pain in the lower
back, legs, abdomen, other neurological symptoms in the lower extremities and even a
headache. These symptoms are more pronounced in the horizontal position of the patient.

1. Establish a preliminary
diagnosis. Marfan's syndrome
(arachnodactyly)
n- age of child weight = 30 + 4 (n-10) = 50 kg; (0; +1) normal height = 100 + 6 (n-4) = 166
cm; (+3 and above) very tall
OG = 50 + 0.6 (n-5) = 56 cm; (0; +1) norm OOGK = 63 + 3 (n-10) = 78 cm; (0; +1)
norm Body length by centiles (non-parametric indicators) is more than 97 - is a high
physical development.
BMI = 50 / 1,82 * 1,82 = 15,09 - exhaustionSo, sharply Disharmonious physical
development, tallness (gigantism)
IE = chest circumference - 1/2 heightIE = 81-182 / 2 = - 10 cm.indicates a narrow chest (low
development of the child's chest and low fatness)
1. Stop premature puberty: estrogen and progesterone
2. Prevention of cardiovascular complications: beta-blockers: atenolol, bisoprolol
3. Regular examination by a cardiologist to monitor the heart valves and
aorta, regular examination by a neurologist to prevent complications, consultation
with an ophthalmologist
4. Symptomatic treatment: diclofenac 50 mg 1t 1d,
5. Preventive surgery. If the diameter of the aorta exceeds the norm.
6. Limitation of physical activity
• Take a tape measure, Prepare your hands.
• Psychologically prepare the child for manipulation.
• Wash your hands, dry, warm.
• Lay the young child on the changing table on his back, and put the older child.
• Apply a centimeter tape circularly around the head, behind - at the level of the
occipital humps, in front - at the level of the superciliary arches.The beginning of the
centimeter tape should be in the left hand. The tape should not be stretched during
the measurement
Instrumental research methods
problem № 1
A child 4.5 years old for 3 days is bothered by cough, fever up to 37.6 degrees, nasal mucus. At
inspection the condition of the child is broken a little. The child is active, appetite is satisfactory. There are
no shortness of breath. Scattered dry and medium-bubble rales are heard in the lungs. Interpret the chest
X-ray №50.
problem № 2
During feeding 3 days ago, the child coughed for 1.5 months, then turned blue. The cough was
prolonged, to the point of vomiting. After that, the condition improved and the cough was infrequent, dry
with a satisfactory condition. Today the temperature has risen to febrile figures, appetite has worsened,
cough has intensified, shortness of breath has appeared. When percussion over the right lungs
dullness. At auscultation in this area of breath is not listened. Interpret the chest radiograph №3201.
problem № 3
A 1-month-old child is ill for 2 days, respiratory rate 68 per minute, heart rate 156, participation of
auxiliary muscles in respiration. Dry and scattered medium and small-bubble rales are heard above the
lungs. Liver +4 cm, spleen is not palpable.
Interpret the chest X-ray №480.
problem № 4
On the 8th day of the disease in a child 2 months body temperature 38.6 0 , unproductive cough,
signs of intoxication, respiratory rate 68 per minute. The child refuses to eat, weak. There is
cyanosis. Above the left lung shortening of percussion sound, at auscultation breath is
weakened. Interpret the chest radiograph №1461.
problem № 5
On the 10th day of illness, the child is 5 months old. body temperature 38.7 0 , unproductive cough,
signs of intoxication, respiratory rate 67 per minute Percussion on the upper lobe of the right lung
shortening of the percussion sound, immediately on the background of weakened breathing crepitation is
heard.
Interpret the chest radiograph №6682.
problem № 6
The child is 4 months old. complaints of unproductive infrequent cough for 3 weeks. Feeling
satisfactory. Interpret the chest radiograph №3196.
problem № 7
A 15-year-old boy complained of cough and fever on the 5th day of illness. There are symptoms of
severe intoxication. He did not receive treatment. Interpret the chest radiograph №327.
problem № 8
At the child of 8 months the 4th day of a febrile fever, unproductive cough, intoxication
syndrome. Above the right lung, on the background of weakened breathing, audible creaking rales are
heard. Interpret the chest radiograph №3572.
problem № 9
A 5-month-old child has frequent respiratory diseases. There is not a frequent cough, which lasts
for 7 days, with a normal state of health. Interpret the chest radiograph №3257.
problem № 10
On the 8th day of the disease in a child 3 years and 3 months high body temperature (38.8 0 ),
unproductive cough, signs of severe intoxication, respiratory rate 53 per minute. The right part of the chest
lags behind in the act of breathing. Interpret the chest radiograph №41.
problem № 11
The child is 6 months old. from the moment of a birth the increased fatigue at breast-feeding is
noted. The child's well-being is satisfactory. Some lag behind in physical development. Interpret the chest
X-ray №544.
problem № 12
A 3-year-old child fell ill 2 days ago. The disease began with fever up to 38.8 0 , cough, progressive
shortness of breath and lethargy. Objectively: body temperature 39.1 0 C, respiration 64 per minute, heart
rate 152 per minute. Severe condition: pale skin with a cyanotic tinge, lethargy, anorexia, cyanosis of the
central type (disappears by inhalation of 40% oxygen). Marble pattern on the distal extremities. Cough is
unproductive, annoying. Breathing is moaning, the wings of the nose are tense. Above the right lung in the
area of the upper lobe shortening of the percussion sound and weakened breathing. Heart tones are
muffled. The throat is slightly hyperemic, the mucous membrane of the mouth is dry. Stool and urination
without features. General blood test: Hb 97 g / l, erythrocytes 3.1 x 10 12 / l, leukocytes 28.2 x 10 9 / l,
eosinophils -0, rod-shaped neutrophils 24%, segmental 51%, lymphocytes 23%, monocytes 2%, SHLE -
36 mm / h, toxic granularity of leukocytes. Radiograph- №2258. Urine analysis and coprogram - without
features.
Answer the questions:
1. What is the previous diagnosis?
2. Give an interpretation of the chest radiograph.
3. Prescribe starting therapy.
problem № 13
A 3-year-old child fell ill 3 days ago. The disease began with fever up to 38.8 0 , cough, progressive
shortness of breath and lethargy. Interpret the chest radiograph №3968.
problem № 14
The child is 2 months old. Complaints of vomiting after each feeding. The disease began about 5
weeks ago, when vomiting began after breastfeeding once a day. Gradually, they became more
frequent. In vomit, in addition to sucked milk, there is coagulated. The child stopped gaining weight,
although he eats greedily. There were signs of malnutrition. Stools have the character of "hungry
stools". Interpret the radiograph №4951.
problem № 15
The child is 7 months old. Complaints of increased fatigue during feeding. In the Department of
Neonatal Pathology, where tinnitus was treated after birth, the presence of gross noise in the capital was
noted. A week ago, the condition worsened: the temperature rose to 38.7 degrees, the child refused to
eat, there was a cough, shortness of breath. Interpret the гра447 radiograph.
problem № 16
The 11-month-old boy is ill on the 6th day. The disease began with cough, rhinorrhea, low-grade
fever. On the 3rd day the temperature rose to 39 0 C, there was a moaning breath, a painful unproductive
cough, the child became weak. The mother treated at home, giving the child ampicillin 0.25 3 times a
day. Objectively: body temperature 37.4 0 C, respiration 48 per minute, heart rate 126 per minute The
general condition of the child is moderate: moderate cyanosis of the central type (disappears with
inhalation of 40% oxygen), the wings of the nose are tense. Involvement of pliable areas of the chest,
participation in the act of breathing auxiliary muscles. Above the left lungs shortening of the pulmonary
sound in the area of the upper part of the scapula. Breathing is hard, weakened in the area of shortening,
crepitation. The heart is enlarged in size. Tones are muted, clean. The big temple is closed. The chair is
urination without features. General blood test: Hemoglobin 112 g / l, erythrocytes 3.8x1012 / l, Leukocytes
14.6 x109 / leosinophils -0, rod-shaped neutrophils 21%, segmental -47%, lymphocytes 20%, monocytes
12%, SHE 28 mm / h . General analysis of urine and coprogram without features.
Answer the questions:
1. What is the preliminary diagnosis?
2. Give an interpretation of the chest radiograph №488.
3. Prescribe starting therapy.
problem № 17
A 3.5-year-old child with a prolonged cough (10 days) and subfebrile after SARS developed
shortness of breath, cyanosis of the nasolabial triangle, shortening of the percussion sound and
weakening of breathing in the upper right lung. The temperature rose to 38.7 0 degrees yesterday , the
child refuses to eat, became capricious.
Interpret the radiograph №272.
problem № 18
A 6-year-old child with a prolonged cough (8 days) and subfebrile after SARS developed shortness
of breath, cyanosis of the nasolabial triangle, shortening of the percussion sound and weakening of
breathing in the upper left lung. The temperature rose to 38.9 degrees yesterday, the child refuses to eat,
became capricious. Interpret the radiograph №113.
task № 19
A 3-month-old child is being treated in the pediatric department of the CDH. Received complaints of
fatigue during breastfeeding, almost daily vomiting after feeding. From the maternity hospital the child has
a rough systolic murmur over the heart, more than 3-4 intercostal spaces on the left, cyanosis of the
central type. There are signs of malnutrition of 1 degree. Interpret the chest radiograph №3116.
problem № 20
The mother of a 9-month-old child went to see a family doctor with complaints of fatigue when
breastfeeding and eating. From the maternity hospital the child has a rough systolic murmur over the
heart. There are signs of malnutrition of the 2nd degree, the child lags behind in physical development
(does not sit, there are 2 teeth). Interpret the chest X-ray №1940.
problem № 21
A mother with a 3-year-old child applied to the district pediatrician with complaints of low-grade
fever, runny nose, and cough. The child is ill for 3 days. The family also has an 8-year-old older sister with
SARS and rhinitis. The mother treated herself with a cough medicine, but today the condition has
worsened: the temperature has risen to 37.9 degrees, the cough has intensified, it has lasted long until
vomiting, the appetite has worsened.
Above the lungs is a clear percussion sound, heard on both sides scattered mid-bubble
rales. Interpret the №6681 radiograph.
problem № 22
While on duty at the hospital, you were called to a child who was hospitalized today under the
direction of a district pediatrician. A 6-month-old child is being treated in the pediatric department of the
CDH. Received complaints of breastfeeding fatigue. From the maternity hospital the child has a rough
systolic murmur over the heart. There are signs of malnutrition of 1 degree. Interpret the chest radiograph
№3118.
problem № 23
A 12-year-old child applied to the district pediatrician with complaints of periodic fever up to 39
degrees, enlargement of the cervical lymph nodes without changing the color of the skin above
them. There is weakness, the child sweats, loss of appetite. Interpret the №6507 radiograph.
problem № 24
A mother with a 1.5-month-old child applied to the reception with complaints of the child's
weakness, loss of appetite, and low-grade fever. A week ago, the child suffered from SARS. During
exercise, cyanosis appears. At inspection the heart is increased in the sizes, tones are muffled, the short
systolic noise is listened. Interpret the гра3309 radiograph.
problem № 25
A 3-month-old child often suffers from respiratory diseases. The mother turned to the district
pediatrician about vaccinations. The vaccination commission sent the child for an X-ray of the
chest. Interpret the но2049 radiograph.
problem № 26
A 1-year-4-month-old child went to see a family doctor with complaints of lethargy, unproductive
cough, shortness of breath during exercise, loss of appetite, fever up to 39.4 degrees. Percussion over the
left lung below the scapula shortening of the percussion sound, immediately upon auscultation weakening
of respiration. Interpret the №6669 radiograph.
problem № 27
The child is 1 year on the 5th day of the disease SARS fever to 39.4 degrees, from ' appeared
shortness of breath, increased coughing, the child refuses to eat. The child became sickly, with ' appeared
cyanosis, involving mizhreber ' ate for inspiration. Percussion over the right lung shortening of the sound,
breathing on auscultation over the right lung is weakened. Wheezing is not heard. Interpret the но8267
radiograph.
problem № 28
A mother with a child of 1 year and 8 months applied to the district pediatrician with complaints of a
child's cough, fever up to 39 degrees (4 days), refusal to eat, weakness, shortness of breath. Ill for 5 days,
did not see a doctor. Above the right lung percussion over the shoulder blade there is a shortening of the
sound, immediately weakened breathing. Small-bubble rales over the focus of shortening, there is a
retraction of the intercostal spaces on inspiration. The child is observed by a doctor for congenital heart
disease. Advised by a cardiac surgeon in February 2006. Surgical correction is planned for
September. Interpret the radiograph №3083.
problem № 29
A 2.5-year-old child was on outpatient treatment for bronchitis for 2 weeks. Received
comprehensive treatment, including cefazolin. The condition improved, but the temperature remained
subfebrile, persisted cough, loss of appetite. Above the left lung below the angle of the scapula shortening
the sound, immediately heard small-bubble rales, crepitation. Chest radiography was performed
(3142). Interpret the radiograph №3142.
problem № 30
During the active visit of a 2-month-old child who came to the polling station from Cherkasy region,
there were complaints of increased fatigue of the child during breastfeeding. The child is slightly behind in
physical development (in 2 months he gained 860 grams), does not hold his head. At percussion increase
in the sizes of heart is noted. At auscultation over area of heart the rough systolic noise which is
transferred outside of it is listened. Chest radiograph (№702). Interpret it.
task № 31
The child 8 years after SARS felt worse, there was a rapid fatigue. The skin is pale, the boundaries
of the heart are not expanded, a short systolic murmur at the apex. Interpret the obtained ECG (ECG
№1).
problem № 3 2
A 12-year-old boy has been suffering from SARS for 5 days. On examination, the district
pediatrician found an expansion of the heart to the left, on auscultation - a weakening of the first tone at
the apex, the rhythm of the gallop, a short systolic murmur at the V point. The boy had an ECG (ECG
№2). Interpret it.
problem № 33
A 6-year-old girl on the background of chronic decompensated tonsillitis periodically suddenly

appears short-term discomfort in the heart, chest tightness, epigastric pain, dizziness, vomiting. During the
attack, the child is pale, BH-40 / min., Pulsation of the jugular veins. Pulse -160 / min., Small filling. AT-
75/40 mm Hg Interpret the ECG (ECG №3).
problem № 3 4
The child is 14 years old. Two weeks ago he fell ill with sore throat. Complaints of poor appetite,
sleep disturbances, dizziness, discomfort in the heart. Interpret the ECG (ECG №4).
problem № 35
At inspection in a hospital at the child of 6 years the high defect of an interventricular membrane is
revealed. Evaluate the obtained ECG data (ECG №5).
problem № 3 6
A 13-year-old child was diagnosed with non-rheumatic myocarditis, acute, moderate severity, with NC I
st., Which arose 7 days after SARS. An ECG is recorded, interpret it (ECG №6).
problem № 3 7
The 10-year-old girl after SARS with ' appeared to complaints of pain in the heart and shortness of
breath on exertion. On examination: pale skin. The left border of the heart - 1 cm outside the mid-
clavicular line, weakening of heart sounds, gentle systolic murmur at the apex. Heart rate-124 / min, AT-
90/60 mm Hg In the blood: anemia of the I st., Moderate leukocytosis, increased ESR. Interpret the ECG
performed on this child (ECG №7).
problem № 3 8
A 6-year-old boy's body temperature rose to 37.5 ° C 2 days after SARS. Complains of shortness of
breath, pain in the heart. At inspection - pallor of integuments, tachycardia, weakening of the I tone, short
systolic noise in 3-4 intercostal spaces on the left edge of a sternum. The child has an ECG, evaluate the
changes (ECG №8).
problem № 3 9
At preventive inspection at the boy of 14 years of an asthenic structure of a body with a thin chest
wall in horizontal position at auscultation systolic noise is revealed. Complaints are not pre ' is. The
boundaries of the heart are not changed. The boy had an ECG (ECG №9). Interpret it.
problem № 40
Patient T., 14 years old, complains of shortness of breath during exercise, aching pain in the heart,
palpitations, heart failure, fever up to 37.5 ° C. Three weeks ago she had the flu with a high fever and
intoxication. Objectively: the limits of relative dullness of the heart are increased. Heart tones are
weakened, systolic murmur at the apex. Interpret the ECG (ECG №10).
problem № 41
An 7-year-old boy was taken to the hospital by ambulance. Complaints of discomfort in the heart,
epigastric pain, dizziness, vomiting. On examination: pronounced pallor of the skin, shortness of breath,
pulsation of the jugular veins. Arrhythmic pulse, small filling. AT-90/50 mm Hg ECG recording performed ,
interpret it (ECG №11).
problem № 42
Boy D., 12 years, complains that it had shortness of breath, Nav ' yazlyvoho cough. On examination:
severe condition, malnourished child, oral and acrocyanosis. BH 30 / min., Heart rate 90 / min. On the left
in the lower parts there are small-bubble wet rales, the left limit of relative dullness of the heart 3 cm
outside the left midclavicular line, the right 1 cm outside the right parasternal line, above all parts of the
heart there is a rough systolic murmur on the back, accent II tone over the pulmonary artery. The liver is
enlarged by 4 cm, not painful. Evaluate the changes in the ECG of this child (ECG №12).
problem № 4 3
E., a 11-year-old child, complains of frequent constipation. The disease began at the age of
three. The girl was observed at the place of residence of the district pediatrician, who recommended a diet
high in fiber. The condition was somehow stabilized, but the symptoms did not disappear completely. At
the age of 10, the condition worsened - there were cases when there were no bowel movements for 3-4
days. The child was sent for consultation to a gastroenterologist of the regional children's clinical
hospital. It was found that the child's condition is close to satisfactory. There was an increase in the
abdomen, enlarged sigmoid colon and sensitive to palpation. No pathological changes were detected on
the part of the cardiovascular and respiratory systems. There was a slight increase in the liver. At
laboratory inspection (clinical analysis of blood, urine, feces on worm eggs) - pathological changes are not
revealed. Irigography was performed (№54 dated March 12, 2002).
Analyze ir and gogram.
What diagnosis can you make in this patient?
problem № 4 4
Child 3, Miss was consulted by a pediatrician with complaints of vomiting, deterioration of weight
gain, which occurred 2 weeks ago. The girl was born with a body weight of 3200. Pregnancy and childbirth
had a physiological course, discharged from the hospital on the third day. The girl is breastfeeding. At
inspection weight 5000 (deficit 750 gr). Turgor and elasticity are not disturbed.
A similar pattern of vomiting and deterioration of weight gain was observed at one month of age,
but after treatment with atropine - vomiting disappeared and the child began to gain weight. In clinical
tests of blood, urine, feces for coprology - without pathology. After consultation with a pediatric surgeon,
the pediatrician ordered an X-ray examination of the stomach (№52, 54, 55 dated 12.04.2012) with
contrast (barium in breast milk). Analyze radiographs. What other studies will you order?
What diagnosis did you suspect in this case?
problem № 45
The boy was admitted to the intensive care unit for 30 days on the 3rd day of the disease with
complaints of vomiting and loose stools, shortness of breath, hyperthermia, exicosis. The disease began
after feeding the child semolina in cow's milk.
The child's condition is severe due to toxicosis and exsiccosis. Clinical tests of blood and urine,
bacteriological researches of excrements (excrements - 12 a day, watery, with a putrid smell) are
taken. The abdomen is bloated, peristalsis is not audible.
X-ray examinations of the thoracic and abdominal cavities were performed (radiograph №5379
dated 18.11.2000) . Analyze the radiograph. What disease do you think of the child?
INSTRUMENTAL METHODS OF RESEARCH
The answer to problem №1

Answer: radiograph №50, age 4.5 years.
On the review roentgenogram of bodies of a thorax in a direct projection pulmonary fields without
infiltrative changes. The pulmonary pattern is enriched, more to the left in the basal zones. The domes of
the diaphragm are clear. Diagnosis: Bronchitis.
The answer to the problem №2
Answer: Radiograph №3201, age 1.5 months.
On the review roentgenogram of bodies of a thorax in a direct projection intensive decrease in
pneumatization of the upper share of a right lung due to infiltrative changes is defined.
Right upper lobe aspiration pneumonia .
Radiograph №480, age 1 month.
On a review radiograph of the chest in a direct projection, the pulmonary pattern is enriched in
the basal areas due to hypervolemia and severity.
Obstructive bronchitis.
Radiograph №1461. Age 2 months
On the review roentgenogram of bodies of a thorax in a direct projection decrease in pneumatization of an
upper lobe of a left lung due to infiltrative changes is defined. The dome of the diaphragm on the left is not
differentiated. Right - without features.
Left-sided total pneumonia.
Radiograph №6682, age 5 months.
On the review roentgenogram of bodies of a thorax in a direct projection decrease in pneumatization of
the upper share of the right lung with a clear lower contour along an interlobular pleura is defined.
Right upper lobe bronchopneumonia.
X-ray № 3196, age of the child 4 months.
On the review roentgenogram of bodies of a thorax in a direct projection pulmonary fields without
infiltrative changes. The sinuses are free, the edges of the diaphragm are clear. In the area of the upper
mediastinum enlargement of the thymus gland. Thymomegaly.
Radiograph №327, age 15 years.
On the review roentgenogram of bodies of a thorax in a direct projection from the left the enriched
pulmonary drawing due to gravity is defined. The left root is expanded, homogenized.
Left lower lobe bronchopneumonia.
Radiograph №3572, age 8 months.
On the review roentgenogram of thoracic organs in a direct projection intensive decrease in
pneumatization of the upper lobe of the right lung due to infiltrative changes without clear lower contours.
Right right lobe bronchopneumonia.
Radiograph №3257, age of the child 5 months.
On the review roentgenogram of bodies of a thorax in a direct projection the slightly enriched pulmonary
drawing in basal zones due to a hypervolemia is noted. The sinuses are free, the edges of the diaphragm
are clear. The position of the heart is normal, has a mitral configuration. In the area of the 2nd arc of the
heart hemogenic shadow measuring 2x2.5 cm in diameter.
Ascending aortic aneurysm.

Radiograph №41, child age 3 years and 3 months.
On the review radiograph in a direct projection on the right there is an intensive homogeneous decrease in
pneumatization to level 2 of the intercostal space without clear upper contours due to the accumulation of
fluid in the pleural cavity. The dome of the diaphragm and the sinuses on the right are not
differentiated. The shadow of the mediastinum is slightly shifted to the left.
Right-sided exudative pleurisy.
Radiograph №544 child age 6 months.
On the review roentgenogram in a direct projection pulmonary fields without infiltrative changes. The
domes of the diaphragm are clear. Heart - aortic configuration, slightly increased in size due to the left
ventricle.
Aortic stenosis.
1. Acute out-of-hospital right-sided pneumonia, DN 2.
Right upper lobe segmental bronchopneumonia.
2. Radiograph- №2258. On the review roentgenogram in a direct projection on the right in the field of 2-3
segments intensive decrease in pneumatization of pulmonary fabric due to infiltrative changes. The
sinuses are free, the domes of the diaphragm are clear. Pulmonary pattern in the basal areas is heavy.
3. Oxygen therapy, penicillins or cephalosporins 1-2 generations, symptomatic drugs.
Radiograph №3968, child age 3 years.
On the review roentgenogram in a direct projection on the left in area 2 of segment intensive decrease in
pneumatization due to infiltrative changes is defined.
Left upper lobe pneumonia.
Contrast mass study (barium). At the 90th minute the satire of the passage was noted. Pylorostenosis.
Radiograph №447, child age 7 months.
On the review roentgenogram in a direct projection on the left paracostally intensive pleural layers. The
shadow of the mediastinum is normal. The dome of the diaphragm on the left is not differentiated. Right -
without features. The heart is a normal position, increased in size due to the right and left divisions, mitral
configuration. The vascular bundle is narrowed.
Left paracostal adhesive pleurisy. Mitral heart disease.
Correct answers:
1. Acute outpatient left lobe pneumonia during treatment.
2. On the review roentgenogram №488 in a direct projection on the left in the upper lobe of the 3rd
segment intensive decrease in pneumatization of a lung due to an infiltrate and pleural layers.
3. Oxygen therapy, penicillins or cephalosporins 1-2 generations, symptomatic drugs, physical methods.
X-ray №272, age of the child is 3.5 years.
On the review roentgenogram in a direct projection on the right intensive homogeneous On the right in the
field of the 3rd segment intensive decrease in pneumatization due to infiltrative changes. The pulmonary
pattern is heavy.
Right upper lobe pneumonia.

X-ray №113, age 6 years.
On the review roentgenogram in a direct projection on the left in basal segments of the upper lobe the
weight of a pulmonary drawing and decrease in pneumatization due to peribronchial infiltration is
defined. There was an increase in tracheobronchial lymph nodes.
Left ventricular bronchopneumonia.
X-ray № 3116, age 3 months.
No survey radiograph of the chest in the vertical position of the pulmonary fields without infiltrative
changes, the sinuses are free, the diaphragm is clear. Heart of aortic configuration, normal position. The
shadow of a thymus gland is noted. There is no free gas in the abdominal cavity. Gas bubble of the
stomach of large size 7x2.8 cm with clear contours.
Congenital aortic heart disease. Pylorostenosis? Additional X-ray examination with barium mixture is
required.
X-ray №1940, age of the child 9 months.
On the review roentgenogram in a direct projection the pulmonary drawing is strengthened, enriched in
basal zones due to a hypervolemia. The sinuses are free, the diaphragm is clear. The heart of the aortic
configuration is encircled in the pericardium due to the left ventricle.
Aortic heart disease.
Radiograph №6681.
On the review roentgenogram in a direct projection the pulmonary drawing is enriched in basal zones due
to a hypervolemia and gravity. Subcutaneous emphysema on the right. Acute bronchitis.
Radiograph №3118. Age 6 months
On the review roentgenogram in a direct projection of pulmonary fields without infiltrative changes, the
drawing is enriched at the expense of a hypervolemia. The heart is enlarged in diameter due to the right
and left divisions.
Congenital heart disease.
Radiograph №6507, age of the child 12 years.
On the review roentgenogram in a direct projection pulmonary fields without infiltrative changes. On the
right and left there are packets of enlarged tracheobronchial lymph nodes with clear contours. Sinuses
free diaphragm clear.
Lymphogranulomatosis.
Radiograph №3309, age of the child 1.5 months.
sinuses are free, the diaphragm is clear. The heart is a normal position, enlarged in the lumbar region and
size due to the right and left divisions. The vascular bundle is narrowed.
Non-rheumatic myocarditis .
On the review roentgenogram in a direct projection the pulmonary drawing is a little enriched at the
expense of a hypervolemia. The sinuses are free, the diaphragm is clear. The shadow of a thymus gland
in the field of an upper mediastinum is noted.
Thymomegaly.

Radiograph №6669, age of the child 1 year 4 months.
On the review roentgenogram in direct projection the decrease in pneumatization in the lower lobe of the
left lung without clear upper contours to the level of the 3rd intercostal space is noted.
Left lower lobe pneumonia.
Radiograph №8267, age 1 year.
On the review roentgenogram in a direct projection intensive decrease in pneumatization of the right lung
due to infiltrative changes is defined. The mediastinum is normal. The sinuses are free. The dome of the
diaphragm on the right is not differentiated.
Right-sided drain pneumonia.
Radiograph №3083, age 1 year 8 months.
On the review roentgenogram in a direct projection intensive homogeneous decrease in pneumatization of
an upper lobe of the right lung with a clear lower contour along an interlobar pleura is noted. Pulmonary
pattern is enriched, heavy. More on the root zones. The sinuses are free, the diaphragm is clear. Heart of
aortic configuration, increased in size due to the left ventricle. The shadow of a thymus gland is noted.
Right upper lobe pneumonia. Aortic heart disease.
Radiograph №3142, the child's age is 2.5 years.
On the review roentgenogram in a direct projection on the left intensive decrease in pneumatization due to
infiltrative changes without accurate upper contours is defined. The left dome of the diaphragm is not
differentiated. Paracardial pleural mooring.
Left lower lobe pneumonia during treatment.
sinuses are free, the diaphragm is clear. The heart of the aortic configuration (duck type), increased in
size due to the left ventricle and the ascending aortic arch.
Aortic heart disease.
ECG №1, age of the child 8 years, ECG recording speed 50 mm / s. Wolf-Parkinson-White syndrome .
The rhythm is sinus. P = 0.08 s, PQ = 0.006 c , QRS = 0.08 c , detected  -wave on the ascending part of
the ventricular complex in I, AVL , V 2 - V 6 , QT = 0, 42 c , RR = 0, 8 c , heart rate 75 for 1 min.

ECG №2, age of the child 12 years, clinical diagnosis - infectious-allergic myocarditis, ECG recording
speed 25 mm / s.
Alternation of sinus rhythm with group ventricular extrasystoles.
Heart rate of sinus rhythm 24 per 1 min. (tooth R before and after extrasystole), ventricular rate 150 per 1
min.

ECG №3, age of the child 6 years, ECG recording speed 25 mm / s.
Attack of atrial paroxysmal tachycardia with heart rate 158 / min., Tooth P is in front of each ventricular
complex, QRS complex is not deformed. After the attack - a compensatory pause, normal sinus rhythm
was restored with a heart rate of 83 / min.

Sinus rhythm, sinus bradycardia with a heart rate of 60 / min. P = 0.08 s, PQ = 0.16 c , QRS =
0.09 c , QT = 0.36 c , RR = 1.0 c .

The rhythm is sinusoidal. P = 0.08 s, PQ = 0.08 c , QRS = 0.10 c , QT = 0.28 c , RR = 0.8 c , heart rate 75
/ min.
Shortening of the PQ interval , incomplete blockade of the right leg of the His bundle (M-shaped
ventricular complexes in V 1 - V 2 ) .

ECG №6, age of the child 13 years ECG recording speed 50 mm / s.
Alternation of sinus rhythm with single ventricular extrasystoles, the ratio of normal rhythm to extrasystoles
1: 1, after extrasystoles - a complete compensatory pause.
Heart rate of sinus rhythm 40 per 1 min. ( R wave before and after extrasystole), extrasystole frequency
40 per 1 min.
The answer to the problem №3 7

ECG №7, age of the child 10 years ECG recording speed 50 mm / s.
1: 1, after extrasystoles - a complete compensatory pause.
Heart rate of sinus rhythm 75 per 1 min. ( R wave before and after extrasystole), extrasystole frequency
75 per 1 min.

2: 1, after extrasystoles.
Heart rate of sinus rhythm 60 per 1 min., Extrasystole frequency 30 per 1 min.

ECG №9, the child's age is 14 years.
The rhythm is sinus. The electrical axis of the heart is vertical. P = 0.08 s, PQ = 0.12 c , QRS =
0.08 c , QT = 0.34 c , RR = 0.94 c , heart rate 64 in 1 min. ECG - a variant of the age norm.

ECG №10, age of the child 14 years, ECG recording speed 25 mm / s. Clinical diagnosis - carditis with
arrhythmia.
On the ECG - atrioventricular block II. type Mobitz I with a frequency of 2: 1.
P = 0.09 s, PQ different, QRS = 0.08 c , QT = 0.40 c , RR = 1.36 c , ventricular rate 44 per 1 min, PP =
0.60 s, atrial rate 100 in 1 minute

ECG №11, child age 7 years.
Atrial fibrillation, tachysystolic form. The intervals R - R are different, in the lead V 1 clearly visualized f -
waves.

ECG №12, the child's age is 12 years.
Clinical diagnosis - congenital heart disease, ventricular septal defect.
ECG data: signs of atrophy of the atria, right and left ventricles, AV - blockade of the first degree.
P = 0.11 s, PQ = 0.20 c , QRS = 0.10 c , QT = 0.36 c , RR = 0.73 c , heart rate 82 in 1 min.

On the irigogram №54 dated March 12, 2002 . with tight filling of the distal parts of the colon is
determined by an elongated loop of the sigmoid colon (symptom of "triple"). Gaustration of the distal parts
of the descending intestine is preserved.
Diagnosis: Dolichosigma.

At X-ray examination of a child 3.5 months of stomach and duodenum (№52, 54, 55 from
12.04.2012) 15 minutes, 40 minutes and 3 hours after feeding a barium mixture in a volume of 60 ml on
the chest milk. On the visual radiograph №52-54 stomach of moderately pronounced cascading
shape. On an empty stomach it contains fluid and mucus, the folds of the mucosa are unevenly
expanded. Pyloroduodenal area is spasmodic - traces of contrast agent in the proximal small intestine.
On the radiograph №55 (3 hours after feeding) there is no free gas in the abdominal cavity. In the
stomach 2/3 of the barium mixture. The pyloroduodenal zone is spasmed. The proximal parts of the small
intestine (etc.) are continuously filled with barium mixture.
Diagnosis: Pylorospasm. It is advisable to make an X-ray in 6 hours and after 24 hours.

On the radiograph №5379 dated 18.11.2000 . chest and abdominal organs of a boy S. 30 days:
the chest is symmetrical. Pulmonary fields without infiltrative changes. Sinuses, domes of the diaphragm
are clear, normal shape.
The left dome of the diaphragm at the level of 8-9 intercostal space along the scapular line. Heart -
shape and position are normal, not increased in size. There is no free gas in the abdominal cavity. Gas
bubble of the stomach - the usual location, without features.
Intestinal paresis. Acute infectious toxicosis.
Task 46
Patient V., 13 l., Was admitted to the admission department with nosebleeds, fever 38.5 C, paleness,
shortness of breath. On the skin p and petechiae, purpura, gingival hyperplasia. Splenomegaly and
hepatomegaly.
9
In the clinical analysis of blood: erythrocytes 2,8 × 1012 / l. Hemoglobin 76 g / l. Color index 0.8.
Leukocytes 100 × 10 / l., In a blood smear:
monoblasts 59%.
Leukocyte formula
Neutrop
B Э hils L. M
M M/ P/ С/ n
M I Я
- 1 - - 6 10 1 6
8
2. Establish a preliminary diagnosis
Task 47
A 14-year-old patient was admitted to the hematology department due to a sudden deterioration in
the outpatient treatment of acute pneumonia. For two weeks she was treated with ampicillin,
antihistamines with positive dynamics.
Objectively: fever 38.0 o C , yellowing of the skin on a general pale background, icteric sclera.
Wheezing in the lungs. Tachycardia. The spleen is palpated. Bilirubinemia. Urobilinuria,
hemoglobinuria. Tests: osmotic century iykist red blood cells is not changed, Coombs test positive.
In the clinical analysis of blood: erythrocytes 2,1 × 10 12 / l. Hemoglobin 60 g / l. The color index is
0.86. Leukocytes 10.4 × 10 9 / l.
Leukocyte formula
Neutrop
B Э hils L. M
n
M M/ P/ С/
M I Я
- 2 - - 6 55 2 9
8
Task 48
A 7-month-old baby was hospitalized with whooping cough and shortness of breath. On
examination: lags behind in physical development ( body weight deficit - 24%), doll-like face, pale skin,
earthy hue, cyanosis of the nasolabial triangle. Often there is a paroxysmal cough. Sputum is heavy,
viscous
, purulent in nature. According to chest radiography, a diagnosis of pulmonary emphysema was
established, and fibrous incisions were found in the root zones. Analysis of sweat electrolytes: BMI
century sweat chloride - 65 mEq / L.
Correct answer: P idvyschennya sweat chloride at a concentration of more than 40 mEq / L - for
infants, causes probable diagnosis; more than 60 meq / l - probable. Cystic fibrosis.
Task 49
Patient A., 12 years old, entered the clinic with complaints of Mr idvyschenu fatigue, hair loss, brittle
nails, taste perversion, loss of appetite, epigastric pain, aggravated empty stomach. The patient for
10 years suffers from peptic ulcer disease with frequent
12 exacerbations. Repeatedly observed black
dohtepodibnyy century ilets. Blood test: Hb 70 g / l, erythrocytes 3.5 × 10 / l, reticulocytes 14%, platelets
9
380 × 10 / l, leukocytes 5.2 × 109 / l,

myelocytes - 0, metamyelocytes - 0, p / i - 2, s / i - 64, e - 2, b - 0, l - 27, mn - 5, plasma cells - 0%, ESR
16 mm / h, severe anisocytosis (microcytes), moderate poikilocytosis; erythrocytes with basophilic
granularity, single in the field of view polychromatophilia. Serum iron 5.2 μmol / l, indirect bilirubin 10
μmol / l, transferrin iron saturation 8%.
Problem 50
A child of 7 years periodically there is jaundice, Mr idvyschennya fever, enlarged liver and spleen.
12Laboratory indicators of blood: erythrocytes - 2,2 × 10
/ l, hemoglobin - 90 g / l, KP - 0,9, reticulocytes - 30 ‰, leukocytes - 6,2 × '10 9 / l, eosinophils - 2%,
rod-shaped neutrophils - 4%, segmental neutrophils
- 66%, lymphocytes - 22%, monocytes - 6%, ESR - 16 mm / h, microspherocytosis. Osmotic resistance:
min. / Max. - 0.46-0.24 - 0.48-0.26.
Problem 51
Vitya V., at the end of April fell ill with angina. Treated acetylsalicylic kislotoy.10 May in the hands
and feet appeared haemorrhagic rash as ecchymosis and petechiae, and May 11 there were
nosebleeds, which was suspended Mr donkey application of cold nose. He was sent to the hospital.
Upon admission to the clinic, the condition is moderate. Lethargic, pale, abundant rash all over the
body in the form of petechiae and ecchymoses. Positive 12
symptoms of a pinch, a plait. Internal organs without abnormalities. Blood test: er.- 4.6 x 10 / l, Hb -
9
110g / l, KP - 0.9, lake.-5x10 / l, EOS. 1%, item 1%,

segment.- 73%, lymph.-20%, mon.-5%, ESR - 10 mm / h, platelets - 46 x 10 9 / l. Retraction of a
blood clot - 65%. The duration of Duke's bleeding is 20 minutes. Coagulation by the method of L and
White - 7 minutes Because of isyats treatment of the child's condition is satisfactory, platelet-180h10
9 / L.
Task 52
The patient S. was diagnosed with bronchial asthma, persistent, third degree, moderate course,
partially controlled. Receives basic therapy. There are no complaints . At auscultation breath is rigid,
there are no rales. BH 20 per minute. An inhalation test with salbutamol was performed (results are
attached). Before inhalation of salbutamol: VEL - 92% FJEL - 85% FEV1 - 80% Typhoid index - 92%.
Q donkey salbutamol inhalation: VC - FVC of 94% - 92% FEV 1 - 97% Tyfno Index - 98%
1. Interpret the results of spirography
Problem 53
A 9-year-old girl complains of a dry cough and shortness of breath. He is ill for one year.
Intermittent asthma 1-2 times per m isyats. Objectively: the child is restless, pale skin, cyanosis of the
nasolabial triangle, shortness of breath of mixed type, BH - 48 / min. The chest is swollen. Above the
lungs percussion sound with a boxy tinge, auscultatory - breathing is weakened, dry wheezing on
both sides. On the radiograph of the chest - signs of swelling of the lung tissue. The assessment of
the functional state of external respiration was performed: VL - 62% FV - 55% FEV 1 - 49% Typhoid
index - 89%
Problem 54
A 10-year-old child has short-term attacks of asthma, which recur 2-3 times a year and are
eliminated in a few minutes. The child was bottle-fed early on, there were occasional manifestations
of atopic dermatitis, an allergic reaction to p itsylin. At the time of examination: dry cough, BH - 28 /
min. On auscultation breathing is hard, dry wheezing on both sides, exhalation is prolonged. Heart
tones are moderately muffled, rhythmic, pulse - 90 / min. No deviations were detected in other
systems. The child is not far behind in physical development . The assessment of the functional state
of external respiration was performed: VL - 92%; FZHEL - 70%; FEV1 - 68%; Index T ifno - 67%.
Problem 55
Biochemical analysis of blood: age - 5 years in . The department is nephrological. The child is ill for
1.5 years. Complaints of weakness, headache, pale skin, swelling on the face, legs. Total protein - 58
g / l, cholesterol - 8.68 mmol / l, urea - 18.4 mmol / l, creatinine - 130 μmol / l. General analysis of
urine:
specific gravity 1010, protein - 10.5 g / l, leukocytes - 4-5 in the field of view,
erythrocytes - 3-4 in the field of view. Zymnytsky test: specific gravity from 1006 to 1009,
nocturnal diuresis predominates.
Correct answer: a urine - proteinuria, Mr. ipoizostenuriya, the prevalence of nocturnal

diuresis. In the biochemical analysis - a decrease in the level of total protein, increased
levels of cholesterol, urea, creatinine. Chronic nephritis, nephrotic variant with impaired renal
function.
Task 56
Analysis of cerebrospinal he idyny, age 10 months. Department: infectious children under

one year. Ill acutely, fever, moderate catarrhal manifestations. The child is excited,
convulsive readiness. Liquor: amount of 3 ml. When p before centrifugation - colorless.
Pressure 320 mm of water Art. Transparency and to Mr donkey centrifugation - transparent.
Cytosis 10 3 . Protein 0.33 g / l. Blood sugar 5.2 mmol / l, p idyny 3.3 mmol / l. Chlorides
150 mmol / l.
Liquogram: 100% lymphocytes.
Correct answer: cytosis and Biochem m Ichnya parameters within normal limits.
Increased pressure indicates the presence of intracranial hypertension, which is typical
for neyrotoksykoziv and for meningitis in irusnoyi etiology.
Problem 57
Biochemical analysis of blood: age - 12 years in . Department - cardiorheumatology. Total
protein - 86.9 g / l, albumin - 44.5%, globulin - 55.5%, alpha-1
- 9.2%, alpha-2 - 13%, beta - 9.3%, gamma - 24 %, antihyaluronidase - 420 IU,
seromucoid - 760 IU, ASL-O - 480 IU, sialic acid - 360 IU, C-reactive protein + + +.
Correct answer marked Mr idvyschennya globulin levels by alpha-2 and gamma

fractions raising products disorganization of connective tissue. For rheumatism,
diffuse connective tissue diseases.
Problem 58
Biochemical analysis of blood: in IR - 4 days. Department - neonatal maternity hospital.

The boy observed persistent vomiting, frequent watery Art ilets, polyuria, weight loss of
14%, features eksykozu. At objective inspection - incorrectly formed external genitalia.
Biochem m ichnyy blood: sodium - 130 mg / dL., Potassium - 7.6 mmol / l, glucose - 2.8
mmol / L, pH - 6.7.
Correct answer: reduce , the ivnya sodium, glucose, blood pH, increased levels of
potassium. Self-losing form of adrenogenital syndrome.
Task 59
Biochemical blood test: a 9-year-old girl. The disease began with the appearance of
edema on the face and legs, waist, Mr idvyschennya fever, malaise, abdominal pain,
1 2
reduction of urine. Daily proteinuria 3.5 g / l. In the biochemical analysis of blood total
protein 54 g / l, albumin - 30%, globulin - 70%, α - 4%, α - 24%, β - 14%, γ - 28%, total
cholesterol - 12.6 mmol / l, urea of 5.4 mmol / l, creatinine .078 mmol / l, total ca n go - 8
mmol / l.
Correct answer: hypoproteinemia, dysproteinemia (increased alpha-2 and gamma

globulins), hypercholesterolemia, hyperlipidemia. The leading clinical syndrome is
nephrotic.
Problem 60
Biochemical analysis of blood: in IR - 8 days. Department - resuscitation of newborns.

The child indicated ikterychnist sclera, skin, mucous membranes periodic symptom "sun
goes down," Mr idvyscheni tendon reflexes, great Spring 3 x 3 cm., Tense. The level of
total bilirubin is 450 μmol / l, direct - 50 μmol / l, indirect - 400 μmol / l, increase in bilirubin
for the last 3 hours - 20 μmol / l.
Correct answer: hemolytic disease of the newborn, nuclear jaundice, tactics -

replacement blood transfusion.
Task 1
The girl is 6 years old. Complaints of polydipsia, weight loss, polyuria during the
week. Objectively: the child's condition is severe due to exsiccosis, acidosis, ketosis. The girl
is sleepy, lethargic, smells acetone in her mouth. The skin is pale, cool distal extremities,
"marble" pattern on the skin, on the cheeks - a pronounced rubeosis. The mucous
membranes are dry, tissue turgor is reduced. Breathing 35 per minute noisy, deep. Above the
lungs box sound, hard breathing. Peripheral rhythmic pulse, frequency 125 / min. The limits of
relative cardiac dullness are normal, heart tones are muted. Abdomen moderately bloated,
liver +2 cm from under the costal arch, the spleen is not palpable. There were no chairs
during the day. Urination is frequent, painless. General blood test: Hb - 126 g / l, erythrocytes
- 4.2 T / l, KP - 0.9, leukocytes - 7.9 G / l, eosinophils - 5%, rod-shaped neutrophils - 6%,
segmental - 40% , lymphocytes - 48%, monocytes - 1%, SHE - 3 mm / h. Blood glucose
profile 30.8 mmol / l; 14.6 mmol / L, 14.0 mmol / L, 12.1 mmol / L. General analysis of urine:
specific gravity 1032, acidic, acetone ++++, sugar - 3.1%.
1. Establish a preliminary diagnosis / emergency.
2. Determine the tactics of treatment and list the groups of drugs, representatives
of each group. Indicate the dose and frequency of application.
Answers:
1. Type I diabetes mellitus, severe form, first detected, state of
decompensation, ketoacidosis.
2. Urgent
therapy:
1) Infusion therapy of 0.9% NaCl : 1st hour 20 ml / kg 2nd hour: 10 ml / kg body

weight 3rd hour and further: 5 ml / kg body
weight
Q donkey lowering blood glucose to 12-15 mmol / l - in replacement solutions

containing 0,9% NaCl +5% glucose , the ratio of 1: 1,
From the first day, the volume of all infusions is not more than 4 l / m2 of body surface.
Infusion therapy is carried out gradually over 48 hours. It is stopped when recovery of
consciousness, absence of vomiting, possibility of independent reception of liquid.
Further oral fluid intake.
2) Diabetic ketoacidosis is always accompanied by hypokalemia

Potassium levels are monitored 1-2 hours after the start of the infusion.
Plasma potassium, Potassium chloride, mmol /

mmol / l kg body weight per hour
<3 0.5
3-4 0.4
4-5 0.3
5-6 0.2
>6 do not enter
Depending on the value, enter 7.5% KCl (1 ml-1 mmol / l ).
3 ) Insulin therapy.
Begin only after successful recovery from shock and rehydration and administration of
potassium-containing solutions (as the transfer of potassium from plasma to cells may cause
cardiac arrhythmia).
During the first 60-90 minutes after the start of rehydration, glycemia can be significantly
reduced even without insulin therapy .
Insulin (short-acting only) is administered in small doses, continuously intravenously or diluted
in 0.9% NaCl (1 U / ml) .
Insulin should be infused using a Y- shaped adapter, in parallel with other fluids (insulin
should not be added to injected fluids).
Before the introduction of insulin 50 IU is dissolved in 50 ml of 0.9% NaCl, and 1 ml of this
solution contains 1 IU of insulin.
The recommended starting dose is 0.1 IU / kg / h . During treatment, glycemia should be kept
in the range of 8-12 mmol / l. Switch to subcutaneous insulin only if the blood glucose is
reduced to <14 mmol / l and with normal CRR. When glycemia is reduced to 13-14 mmol / l,
the insulin dose is reduced by half (approximately 2-3 IU per hour). , can be administered
subcutaneously. Therefore, its first subcutaneous injection is administered in 30 minutes. until
the cessation of intravenous administration.
Task 2
The patient is 14 years old, has had diabetes for 3 years. Gets 48 units of insulin per
day. Against the background of influenza on the second day the condition worsened: fever
with low-grade fever, thirst, shortness of breath, abdominal pain, nausea, vomiting,
drowsiness. In the evening she lost consciousness. The smell of acetone from the
mouth. Pulse at 120 per minute, blood pressure 80/45 mm Hg. Breathing is noisy. The skin is
pale, cool distal extremities, "marble" pattern on the skin, on the cheeks - a pronounced
rubeosis. The mucous membranes are dry, tissue turgor is reduced. Breathing 42 per
minute noisy, deep. Above the lungs box sound, hard breathing. Peripheral rhythmic pulse,
frequency 130 / min. The limits of relative cardiac dullness are normal, heart tones are
muted. The abdomen is moderately swollen, the liver +3 cm from under the costal arch, the
spleen is not palpable. There were no chairs during the day. Urination is
frequent, painless. General blood test: Hb - 130 g / l, erythrocytes - 4.3 T / l, KP - 0.9,
leukocytes - 8.2 G / l, eosinophils - 3%, rod-shaped neutrophils - 6%, segmental - 42% ,
lymphocytes - 48%, monocytes - 1%, SHE - 5 mm / h. Blood glucose profile 31.8 mmol /
L. General analysis of urine: specific gravity 1033, acidic, acetone ++++, sugar - 3.1%.
Answers:
1. Tsu blood type I diabetes, severe form, decompensation, ketoacidosis.
2. Emergency therapy:
2) Infusion therapy of 0.9% NaCl : 1st hour 20 ml / kg 2nd hour: 10 ml / kg body
weight 3rd hour and further: 5 ml / kg body
weight
After lowering blood glucose to 12-15 mmol / l - replacement with solutions

containing 0.9% NaCl +5% glucose, a ratio of 1: 1,
From the first day, the volume of all infusions is not more than 4 l / m2 of body surface.
Infusion therapy is carried out gradually over 48 hours. It is stopped when recovery of
consciousness, absence of vomiting, possibility of independent reception of liquid.
Further oral fluid intake.
2) Diabetic ketoacidosis is always accompanied by hypokalemia

Potassium levels are monitored 1-2 hours after the start of the infusion.
Plasma potassium, Potassium chloride, mmol /

mmol / l kg body weight per hour
<3 0.5
3-4 0.4
4-5 0.3
5-6 0.2
>6 do not enter
Depending on the value, enter 7.5% KCl (1 ml-1 mmol / l ).
3) Insulin therapy.
Begin only after successful recovery from shock and rehydration and administration of
potassium-containing solutions (as the transfer of potassium from plasma to cells may cause
cardiac arrhythmia).
During the first 60-90 minutes after the start of rehydration, glycemia can be significantly
reduced even without insulin therapy .
Insulin (short-acting only) is administered in small doses, continuously intravenously or diluted
in 0.9% NaCl (1 U / ml) .
Insulin should be infused using a Y- shaped adapter, in parallel with other fluids (insulin
should not be added to injected fluids).
Before the introduction of insulin 50 IU is dissolved in 50 ml of 0.9% NaCl, and 1 ml of this
solution contains 1 IU of insulin.
The recommended starting dose is 0.1 IU / kg / h . In the absence of positive dynamics of
glycemia during the first 2-3 hours, the insulin dose is doubled. The rate of reduction of
glycemia should be slow - not faster than 4-5 mmol / l in 1 hour. During treatment, glycemia
should be kept in the range of 8-12 mmol / l. Switch to subcutaneous insulin only if the blood
glucose is reduced to <14 mmol / l and with normal CRR. When glycemia is reduced to 13-14
mmol / l, the insulin dose is reduced by half (approximately 2-3 IU per hour). Therefore, its
first subcutaneous injection is administered in 30 minutes. until the cessation of intravenous
administration.
Task 3
On a call to a 16-year-old teenager with diabetes from the age of 12, it was established
that after drinking alcohol in the company of peers, he developed a sharp weakness,
paleness, loss of consciousness. Objectively: no consciousness, pale skin, "marble", cyanotic
limbs, cold, sharply increased sweating. Periodically - convulsive twitching, shallow breathing,
frequent; tachycardia, pulse filamentous; from the mouth - the smell of alcohol.
Answers:
1. Type 1 diabetes, decompensation, hypoglycemia.
2. Outside the medical institution:
o 1.0 mg glucagon intramuscularly or subcutaneously or nasal spray
o If for 10-20 minutes no effect - check glycemia
 In a medical institution - intravenously bolus:
o 20% solution ch th goats (dextrose) 1 ml / kg body weight (or 2 ml / kg of 10%
solution) for 3 minutes, then - 10% glucose 2-4 ml / kg test glycemia, if no
recovery of consciousness - enter 10-20% glucose solution to maintain glycemia
in the range of 7-11 mmol / l, check glycemia every 30-60 minutes.
Task 4
A 15-year-old child is unconscious. He has been suffering from diabetes for 10 years. The
course of the disease is labile. For 2 years - proteinuria, hypertension. During the last week I
had enterocolitis, complained of weakness, polyuria. Today the child's condition has
significantly deteriorated, there were hallucinations, oliguria. The child's condition is serious,
unconscious. Convulsions are noted. The skin and mucous membranes are dry, pale. The
tongue is dry, covered with brown plaque. Tissue turgor is sharply reduced. Muscle
hypertonia, determined meningeal signs. The eyeballs are soft. There is no smell of
acetone. Breathing is frequent, shallow. Oliguria. Heart sounds are deaf, tachycardia up to
110 per minute. AT 80/40 mm Hg The abdomen is soft. Blood glucose 43 mmol / l, blood pH>
7.4, osmolarity 330 mOsm / l
Answers:
1. type 1 diabetes mellitus, severe form , labile, in a state of decompensation. Hyperosmolar
coma.
The first stage:

 Warming the patient - covering with a blanket.
 Inhalation of 100% humidified oxygen with an oxygen mask
 The introduction of nasogastric with NDU .
 Under games of infusion solutions to 37 , With 0 With before in conducting
Rehydration.
0.9% NaCl solution is administered: First hour: 15-30 ml / kg Second and third hours: 10 ml /
kg From the fourth hour onwards - 5 ml / kg / hour Infusion therapy is carried out gradually
over 48 hours. It is stopped when recovery of consciousness, absence of vomiting, possibility
of independent reception of liquid. Insulin therapy. Insulin (only short-acting) administered in
low doses mode, continuously inside shno tively drip. This mode of administration reduces the
risk of hypoglycemia, cerebral edema, it is easy to determine the amount of insulin
acting. First hour: inside shno tively jet - 0.15 U / kg body weight of the future - every hour
inside shno tively drip of 0.1 U / kg / h in the form of a mixture of 0.9% NaCl (per 100 ml of
0.9% NaCl add 10 UNITS of insulin) If there is no positive dynamics of glycemia during the
first 2-3 hours - the insulin dose is doubled. When glycemia is reduced to 13-14 mmol / l, the
insulin dose is reduced by half (approximately 2-3 IU per hour).
Task 5
A 13-year-old girl. Disturbing pain in the heart, palpitations, fever, dizziness,

weakness. The complaints appeared 2 months ago after a vacation on the coast. I lost 6 kg,
sleep deteriorated sharply. Appetite is increased. Sharp deterioration after a stressful situation
at school. Objectively: weight - 36 kg, height 155 cm. Skin of high humidity,
hyperpigmentation of skin folds, halo, periorbital pigmentation. Tissue turgor is reduced. Heart
tones are loud, tachycardia up to 140 beats / min. Vesicular respiration. The abdomen is soft,
painless. The liver and spleen are not palpable. Blood pressure 150/50 mm Hg Excited. Body
temperature 380C. Thyroid gland of the III degree, diffuse elastic, painless. Tremor of fingers.
Answers:
1. Diffuse toxic goiter of the III century, thyrotoxic crisis.
2. Determination of the level of TSH, vT4, vT3 in the serum, ultrasound of the thyroid
gland ( decrease in the level of TSH, increase in the level of vT4 and vT3 in the serum )
Treatment:
Thionamides (mercazolyl, etc.) - 1-2 mg / kg / day in 3-4 doses (orally, through a
nasogastric tube or rectally). To suppress the secretion of thyroid hormones, an hour
after administration of thionamides, a 1% Lugol's solution is administered, in which
potassium iodine is replaced by sodium iodine.
Glucocorticoids ( prednisolone short course in an average dose of 0.2-0.3 mg / kg / day
for 2-3 doses, with a gradual decrease after 7-10 days by 2.5-5 mg every 5-7 days until
complete withdrawal of 1 mg / kg per day on prednisolone ) intravenously in isotonic
sodium chloride solution.  - adrenoblockers (anaprilin) 2 mg / kg per day orally 3-6
times a day or intravenously slowly 1 mg per minute, the dose should be reduced
gradually. P ersh 4 weeks, Sedatives (diazepam 0.5-1.0 mg / kg). Oxygen therapy. To
prevent infection - broad-spectrum antibiotics in large doses.
Task 6
An ambulance was called to the 3-year-old boy. The child had complaints of anxiety,
severe headache, difficulty breathing, polymorphic rash all over the body with itching. It was
found that before the arrival of the ambulance crew, the patient was given the first injection of
0.5 ampicillin intramuscularly due to pneumonia. At the time of examination, the child is
retarded. On the skin of the face, torso, extremities urticarial rash on a pale background. Cold,
sticky sweat. Difficulty exhaling. Respiration rate - 56 per 1 minute. Auscultatory breathing is
performed evenly on both sides, diffuse rales and sub-strengthening rales. Percussion -
sound with a box tint. The boundaries of the heart are not expanded, the tones are
muted. Blood pressure - 60/20 mm Hg, pulse - 160 beats / min, filamentous. The abdomen is
palpable, there is moderate pain without a specific localization. Liver + 1 cm from under the
edge of the costal arch. There was no urination during the last hour.

Answers:
1. Drug anaphylactic shock, hemodynamic variant.
2. 1. Cessation of allergen (AH) to the patient's body.
In case of hypertension parenterally (drug ) apply ice to this place for 15
minutes; inject 0.3-0.5 ml of 0.1% adrenaline solution with 4.5 ml of isotonic sodium
chloride solution. 2. Measures aimed at restoring acute circulatory and respiratory
disorders.
1. Adrenergic drugs. Enter 0.15-0.3 ml of 0.1% adrenaline solution subcutaneously at

intervals of 5-10 minutes. The total dose of adrenaline should not exceed - 1 ml of
0.1% solution. It should be remembered that repeated administration of small doses of
adrenaline is more effective than a single injection of a large dose.
If blood pressure does not stabilize, it is necessary to immediately begin intravenous
administration of norepinephrine (or mezaton) 0.2-1.0-2.0 ml per 500.0 ml of 5%
glucose solution, as well as "flood" the patient with polyionic solutions.
2. Compensation for adrenocortical insufficiency . Intramuscular or intravenous
injection of glucocorticosteroids: prednisolone 40-100 mg once
3. Antihistamines. Intramuscularly inject 0.5-1.5 ml of a solution of tavegil 0.1% or suprastin

2.5% under control of blood pressure.
4. In case of bronchospasm, bronchodilators (2-8 ml of 2.4% euphylline solution in 0.9%
sodium chloride solution) or glucocorticoid dexamethasone (20-40 mg) are administered
intravenously.
5. Respiratory analeptics (Korglikon 0.2-0.5 ml per 10 ml of 0.9% sodium chloride solution
slowly 2 times a day, the interval between injections is 8-12 hours) is administered according
to the indications.
6. If necessary, the airways should be cleared of mucus, vomit and oxygen
therapy. 4. Neutralization and inhibition in the blood of mediators of allergic
reactions. For this purpose, conduct plasmapheresis, enterosorption.
Task 7
Call an ambulance to school for an 8-year-old boy. The child was bitten by a bee. A few
minutes later, the condition deteriorated sharply. There was rapid breathing with exhalation,
there was loose stools. Periodically convulsions. Pulse more than 150 in 1 minute, almost not
palpable, heart sounds are weakened. Blood pressure 60/0. Sharply slowed down.
Answers:
1. Anaphylactic shock.
2. Emergency care
1 . Put the child on his back , with raised legs - helps to treat hypotension . P overnuty
head facing sideways, push the lower jaw, tongue lock. Provide fresh air or oxygen
inhalation.
2.Adrenalin / m to enter with vnishnyu thighs 0.15 mg, max. 0.3 g, a solution of
0.1 % - 1 mg / ml . You can repeat the administration every ≈5–15 min, in the absence
of improvement or low blood pressure (in most patients the general condition improves
after the introduction of 1-2 doses).
3. Oxygen should be supplied through a face mask (usually 6-8 l / min) .
4 . Provide intravenous access with two large diameter peripheral catheters .
5 . Infuse infusions of solutions - in patients with a significant drop in blood pressure

who do not respond to the introduction of adrenaline in / m, pour 1-2 liters of 0.9% NaCl
as quickly as possible (10 ml / kg body weight during the first 5– 10 min ).
6 . Monitor blood pressure as well as, depending on the patient's condition, ECG,
pulse oximetry or arterial blood gasometry.
7 . In a patient with a drop in blood pressure, without a reaction to repeated

intravenous administration of adrenaline and intravenous infusion of solutions →
consider the appointment of adrenaline 0.1-0.3 mg in 10 ml of 0.9%
NaCl intravenously for several minutes or with constant IV infusion of 1–10 μg / min
(solution of 1 mg in 10 ml of 0.9% NaCl [0.1 mg / ml, 1: 10000]).
8. Additional drugs
If blood pressure remains low - enter alpha-adrenomimetics daily every 10-15

minutes. to improve the condition:
- 0.2% solution of norepinephrine - 1-5 mg / kg
In the absence of effect - pre-titrated administration of dopamine at a dose of 8-10 μg /
kg per minute. under the control of blood pressure and heart rate.
9. Then in the lead GC in / in for max. 3 days (eg, methylprednisolone 1-2 mg / kg, then
1 mg / kg / day, or hydrocortisone 200-400 mg, then 100 mg every 6 hours) or p / o.
1 0 . Follow-up after elimination of symptoms of anaphylaxis
Observe patients for 8-24 hours, given the possibility of the second phase of the
reaction or prolonged anaphylaxis.
Task 8
The girl is 6 years old. Treated for acute glomerulonephritis. Objectively: body temperature
37.0 ° C, respiratory rate 24 / min, heart rate 104 / min, blood pressure 145/105 mm Hg. The
girl's condition is severe, moderate edema. Heart tones are deaf, rhythmic. Above the lungs
percussion - clear lung sound, auscultatory - vesicular respiration. Abdomen soft, there is pain
during percussion in the lumbar region on both sides. Did not cut for 12 years. General blood
test: Hb - 110 g / l, erythrocytes - 3.5 T / l, leukocytes -8.2 G / l, eosinophils -4%, rod-shaped
neutrophils - 5%, segmental - 42%, lymphocytes -40%, monocytes - 9%, ESR - 10 mm /
year. General analysis of urine: cloudy, the color of "meat slops", specific gravity 1038,
protein 1.2 g / l, no sugar found, bile pigments - negative, erythrocytes cover the entire field of
view. Granular and erythrocyte cylinders, leukocytes 8-10 in the field of view. Serum
potassium 9.0 mmol / L. Diagnosed with oligoanuric stage of acute renal failure. During the
transfer to the intensive care unit, the child lost consciousness, mydriasis was noted, there
was no peripheral pulse, superficial bradypnea, ECG -
Click and drag for comments
Answers:
1 Ventricular fibrillation.
2. Against the background of primary resuscitation measures (airway clearance, tracheal

intubation, mechanical ventilation, closed heart massage), the patient should be urgently
defibrillated.
The initial energy of the discharge is 2 J / kg. In the absence of effect - the energy of the next
discharge can be increased to 4 J / kg.
All subsequent ECT must be combined with / in the introduction of epinephrine (0.01 mg / kg)
and at intervals of not less is 2-3 minutes. Maximum discharge energy - 360 J.
- In the absence of effect is prescribed novocainamide 10% solution intravenously in a dose

of 1.0-3.0 ml depending on age or lidocaine 1% solution intravenously slowly at a dose of 1
mg / kg.
After drug administration - repeated defibrillation.

- After stopping the attack and improving the child's condition, a diet enriched with foods
containing vitamins, potassium and magnesium is prescribed. Sodium chloride and liquid are
limited. Mode - depending on the underlying disease.
- Mandatory treatment of the underlying disease.
Task 9
Girl 6 months. The mother's complaints about the child's anxiety, shortness of breath,
fever, refusal to eat. Objectively: the general condition of the child of moderate severity, due
to moderate intoxication syndrome on the background of catarrh of the upper respiratory tract
and significant tachycardia. Body temperature 38.5 ° C, the child is restless, lethargic. Large
temple 2x2 cm, at the level of the skull bones. The skin and visible mucous membranes are
pale pink, clean, the pharyngeal mucosa is moderately hyperemic. Pulse 210 / min, fast,
shallow, weakened. The boundaries of relative cardiac dullness within the age norm, at
auscultation tones are clear, pure. Nasal breathing is difficult due to mucous
secretions. Above the lungs - a clear percussion sound, hard breathing on auscultation,
respiratory rate - 50 / min. The abdomen is soft on palpation, not painful, the liver is 3 cm
below the costal arch along the midclavicular line, the edge is elastic, the spleen is not
palpable. There was no chair in the morning, I urinated. General blood test: Hb - 122 g / l, er. -
3.9 T / l, leukocytes - 8.0 G / l, neutrophils: rod - 2%, segmental - 35%, eosinophils - 3%,
lymphocytes - 53%, monocytes - 7%, SEE - 11 mm / h . ECG:
Click and drag for comments
. (Heart rate - 260 / min, vertical position of the EMU).

Answers:
1. Supraventricular paroxysmal tachycardia .
2. Lower body temperature (paracetamol 10 mg / kg),
Vagus tests : - apply a bubble of ice on the nose and cheeks for 20-30 seconds
- In young children, irritation of the anal area and sphincter with the tip of the enema;
- Infants may re Revert child head down and hold in that th provisions position 25-30
seconds.
- Carotid sinus massage

- Ashner test (pressing on the eyeballs)
Sedatives: corvalol, valocordin, valerian (1 drop per year of life), asparkam (panangin)
1/3 - 1 table. depending on age.
- In the absence of effect from reflexes and sedatives antiarrhythmic drugs are used in
the following sequence:
- verapamil 0.25% solution iv slowly (without dissolution) under the control of blood
pressure and heart rate at a dose: up to 1 year 0.4-0.8 ml,
- ATP 1% solution in / in jet, 0.1 mg / kg max. first doses of 6 mg . Can be repeated a second
and third time at a dose of 0.2 mg / kg max. 12 mg and 20 mg, respectively .
- Aimalin (giluritmal) 2.5% IV slowly for 10.0-20.0 ml of 0.9% NaCl solution at a dose of
1 mg / kg.
- Digoxin 0.025% v / m or v / v. The saturation dose is 0.03-0.05 mg / kg. Saturation

rate 3 days. Maintenance dose - 1 / 5-1 / 6 saturation dose. Digoxin is contraindicated
in supraventricular form of PT with aberrant ventricular complexes.
- In the absence of effect from antiarrhythmic therapy - transfer of the patient to the
ICU or cardiorheumatology center.
Amiodarone 5% solution iv very slowly in 10.0-20.0 ml of 5% glucose solution at a
dose of 5 mg / kg.
In the absence of effect - consultation of the cardiac surgeon concerning need of
carrying out esophageal electrocardiostimulation or electropulse therapy.
Task 10
The child is 2 weeks old. Maternal complaints of repeated vomiting, sometimes fountain,
not associated with food intake, severe lethargy, poor sucking and loose stools. The child
from 2 pregnancies without pathological manifestations, was born weighing 3100 g, from birth
on breastfeeding. The first child, a boy, died at the age of 1 month. In the maternity hospital
the child was diagnosed with bilateral cryptorchidism. The child's weight at admission 2950 g,
on examination the skin and mucous membranes are clean, pale pink, dry, soft tissue turgor
and skin elasticity are reduced, the reflexes of the neonatal period are significantly
suppressed. Large forehead 3x2.5 cm, slightly sunken. The subcutaneous fat layer is
thinned. Heart tones are moderately weakened, rhythmic, heart rate 154 / min., Respiratory
rate 42 / min., Percussion over lungs box shade of percussion sound, auscultatory - hard
breathing. Severe hypotension. The abdomen is enlarged, the lower edge of the liver is 2 cm
below the costal arch, the spleen is not palpable. On examination, the chair without
pathological impurities, slightly diluted. Urine is concentrated. The doctor had doubts about
the sex of the child: the testicles in the scrotum are missing, the penis is shortened, the
urethra opens on its inner surface, which was regarded as virilization of the external genitalia
of the girl. General blood test: Hb 108 g / l, erythrocytes 3.3 T / l, CP 0.98; leukocytes 8 G / l,
rod-shaped 7%, segmental neutrophils 34%, eosinophils 1%, lymphocytes 52%, monocytes
6%, SHE 15 mm / h. Ionogram of blood: Na + - 120 mmol / l, K + - 6,3 mmol / l, Ca 2+ - 2,4 mmol
/ l, SI - - 95 mmol / l. Ultrasound revealed a neonatal uterus. Karyotype of the child - 46 XX.
Answers:
1. Adrenogenital syndrome (congenital hyperplasia of the kidneys), loss-making form,
state of decompensation.
2. Control of concentration of sodium, potassium, plasma glucose every 2 hours;

1) In order to rehydrate appoint a 5% solution of glucose in 0.9% sodium chloride solution (1:
1) , but the glucose solution is administered only after a bolus dose of sodium chloride : 50
ml / kg for 1-2 hours, 25 ml / kg - for 3-4 hours, then, depending on the patient's condition -
20-25 ml / kg body weight. At the expressed hypoglycemia use 10% solutions of glucose.
2) intravenous hydrocortisone 10-20 mg / kg (or prednisolone 2-4 mg / kg), then during the
day, until the condition stabilizes, every 4 hours.
intravenous hydrocortisone - 2-4 mg / kg. After stabilization of the patient's condition, the dose
of glucocorticoids is gradually reduced, usually over 5 days (1/3 of the daily dose) - to
maintenance. After achieving a stable state, normalization of blood pressure and correction of
electrolyte disturbances, the patient is transferred to oral hydrocortisone with the addition of
fludrocortisone (cortineff) 0.1-0.2 mg per day , ie 1 tablet of 0.1 mg at 7.00 and 1 tablet in
between from 15.00 to 18.00 . 3) Correction of hyperkalemia:
o usually substituted intravenous fluid reduces or eliminates hyperkalemia;

o ifon an ECG - increase of a tooth of T, prolongation of an interval R-R, 1 degree
of heart block with loss of a tooth P or there are ventricular arrhythmias - for
stabilization of membranes enter 10% of calcium gluconate of 0,5 ml / kg in / in
within 2-5 minutes; with bradycardia less than 60 beats per minute, calcium
administration is stopped, and if the heart rate drops below 100 beats per minute,
the calcium infusion can be continued, but only if absolutely necessary.
o Sodium bicarbonate 7.5% is prescribed at a dose of 2-3 ml / kg for 30-60 minutes to
improve the entry of potassium into the cells and reduce it in the serum.
4) Metabolic drugs: cocarboxylase 100 μg / kg intravenously.
Task 11
The girl is 6 years old. Complaints of polymorphic generalized rash, fever, dysphagia,
salivation, photophobia, which appeared acutely on the third day of taking biseptol for sore
throat. Objectively: the condition is extremely severe, body temperature 38.7 ° C, on the skin
of the torso and extremities maculopapular and vesicular-bullous elements, rash elements are
also present on the conjunctiva, oral mucosa, genitals. The rash worsens significantly within
hours. Pulse 128 / min, weakened, the limit of relative cardiac dullness within the age
norm; tones are muted, rhythmic. Above the lungs - a clear percussion sound, hard
breathing. The abdomen is soft on palpation, moderately painful in the umbilical region, the
liver is 2 cm below the costal arch along the midclavicular line, the spleen is not
palpable. There was no chair. General blood test: Hb - 112 g / l, er. -3.5 T / l, CP - 0.94,
reticulocytes - 0.5%, platelets -100 G / l, leukocytes -24.5 G / l, neutrophils: rod-nuclear -
30%, segment-nuclear - 51%, eosinophils - 3%, lymphocytes - 14%, monocytes - 2%, ESR -
38 mm / h. C-reactive protein - (+++).
Answers:
1. Stevens-Johnson syndrome.
2. Cancellation of biseptol.
Basic principles of care and treatment:
1. Sterile box, with Mr ostiyny of control room temperature;

Either the intensive care unit or the intensive care unit in the burn unit (mandatory
presence of bactericidal lamps, laminar flow of sterile heated air). Room temperature
30–32 ° C. Solutions for patient care must be heated to 37.3 ° C.
Timely intubation and mechanical ventilation.
Stable access to the peripheral vein outside the affected area.
2. The organization of early enteral nutrition through a nasogastric catheter with the
subsequent transition to independent food intake .
Daily caloric intake is 30-35 kcal / kg. But to prevent a negative nitrogen balance, protein
intake should be at least 1.5 g / kg per day. Hypoallergenic diet.
3. Infusion therapy 6 ml / kg / h, on average up to 3000 liters per day.

Crystalloids ( 5% glucose solution and 0.9% sodium chloride solution , in a ratio of 2: 1)
and colloids (rheopolyglucin, if necessary, albumin), in a ratio of 1: 2.
4. Pathogenetic therapy: systemic HA, intravenous immunoglobulins, immunosuppressants,

plasmapheresis.
The only opinion is which drug to start with.
Systemic HAs are less expensive, but they prolong the onset of epithelialization of
damaged skin.
Dexamethasone from 4-32 mg per day intravenously.
Also effective use of pulse therapy with methylprednisolone at a dose of 125 - 1000 mg /
day (10-30 mg / kg per day) for 3 days. Then before on the supporting.
And up to 12-14 days the dose is reduced to the minimum necessary.
In case of inefficiency of systemic HA, pulse therapy is interrupted immediately

and intravenous immunoglobulins are administered , the average daily dose is 0.5 g / kg
for 4 days.
But also note the effectiveness of the primary appointment of intravenous
immunoglobulins.
You can also start with immunosuppressive therapy, cyclosporin A , administered orally
in doses and 3 mg / kg / day for the first 10 days along , then - 2 mg / kg / day - 10
day s and 1 mg / kg / day - for 10 days along .
Plasmapheresis or a combination of the above drugs is also effective.
5. For the treatment of erosions on the skin, lesions of the oral mucosa - external therapy
with solutions of antiseptic drugs: a solution of hydrogen peroxide 1% 2 times a day or a
solution of chlorhexidine 0.05% 2 times a day.
Be sure to clean the wound from necrotic tissue, but not extensive and not aggressive.
Refusal of all adhesive materials in the care of skin and mucous membranes during the
heat.
For eye treatment 0.05% cyclosporine solution 2 times a day. If erosions appear, then
aqueous solutions of aniline dyes - an aqueous solution of diamond green.
6. Drug control of pain and anxiety. Diazepam 0.3 mg / kg intravenously once daily.
Task 12
The child is 6.5 months old. The third day of the disease, which began with low-grade
fever, rhinorrhea, cough. Objectively: body temperature 37.8 ° C, pulse 176 / min.,
Respiration 64 / min. The general condition of the child is severe: restless, cyanosis of the
central type (disappears with inhalation of 60% oxygen), expiratory distress syndrome. Cough
is unproductive, painful, chest in the inhalation position. Percussion over the pulmonary fields
is determined by the box sound. Numerous small-bubble rales without clear localization are
listened over lungs. Distant noisy wheezing is determined. The limits of relative cardiac
dullness are slightly shifted inward, heart tones are loud, clean, pulse of satisfactory
properties. The abdomen is slightly tense, the liver +3 cm from under the costal arch, its edge
is sharp, soft. Stool and urination without features, pharynx clean, moderately
hyperemic. There are no meningeal signs. General blood test: Hb - 106 g / l, erythrocytes -3.8
T / l, leukocytes - 11.6 T / l, eosinophils 2%, rod-shaped neutrophils - 8%, segmental - 34%,
lymphocytes 52%, monocytes - 4%, SHE 16 mm / year. OGK radiography: pulmonary pattern
is enhanced, the diaphragm at the level of the anterior end of the 8 ribs ("tent" syndrome), the
ribs are horizontal. PaCO 2 - 58 mm Hg. Art., SaO 2 - 76%, pH of venous blood -7,21,
deficiency of buffer bases (BE) (-) 7 mmol / l. Urine analysis and coprogram without features.
Answers:
1. Acute bronchiolitis t , severe , DN W art.
2. Treatment:
1. Hospitalization .
2. Adequate nutritional support and re hydration.
2. Since the child has respiratory failure III. , she can not tolerate oral feeding, you need to
start intravenous fluids.
The drugs of choice for nutritional support of children with acute bronchiolitis are 2.5%
glucose solution and 0.45% saline .
Calculation of the volume of the entered liquid V general = FP + PV
FP = 4 ml / kg / h
PV = 30 ml / kg a day for each 10 respiratory movements above norm + 10 ml / kg a day for
each degree above 37 0 C.
Approximately V total genus = AF (770 ml) + PV (240-320 ml) = 1000-1100 ml per day
Mandatory potassium subsidy, which depends on the level of potassium in the blood and is
calculated by the formula :
Potassium deficiency - D (K) = (K mmol / l is desirable - K mmol / l of the patient ) x body weight
x0,3. Physiological need - AF (K) = 2 mmol / kg During parenteral nutrition , AF (K) + D (K)
mmol is administered, divided into 2-3 injections. Use a solution of 7.5% KCl (1 ml-1 mmol /
l ).
An early return to oral nutrition is optimal. Stage: nasogastric tube - oral nutrition with a
reduced volume of up to 50% , and then gradually increase to normal age values
3. Rehabilitation of the upper respiratory tract
- electric suction
- drainages: postural, vibrating
4. Oxygen : Breathing and support a continuous positive airway pressure (CPAP). In the
absence of effect from these measures , the beginning of non-invasive ventilation is
recommended. Invasive ventilation should be avoided.
5. Bacterial infection is probable at body temperature> 38 ° С, in the presence of changes in

the clinical analysis of blood (leukocytosis, neutrophilia) and is possible at hospitalization in
the intensive care unit. In these cases, the appointment of antibacterial therapy is
appropriate.
6. Beta-agonists - trial treatment of salbutamol 2.5 mg through a nebulizer with monitoring of

the response. 1 - 2 inhalations, which were performed with an interval of 30 - 60 minutes.
If no improvement is observed, then administered HA (dexamethasone 0.6 mg / kg at a rate
of 1-1.2 mg / kg / day or prednisolone 6 mg / kg at a rate of 10-12 mg / kg /
day) intravenously .
7. With astosuvannya mucolytic drugs is not advisable as secret bronchioles not

tight and groove dkyy, and may even be harmful by increasing its content, resulting in
enhanced respiratory failure.
Subsequently, after improving the condition - DII-DAY, you can use and inhalation of 3%
NaCl . The duration of treatment is three days.
8. Antiviral drugs :
Specific RSV therapy is in clinical trials and is not yet used in routine practice . But you can try
ribavirin intravenously.
8. Physiotherapeutic procedures: microwave therapy, UHF therapy, electrophoresis with

euphyllin, MgSO4, phytotherapy with the use of hypoallergenic plants (licorice, mint, thyme,
bagulnik).
Task 13
The child is 7 months old. Against the background of well-being there were tonic-clonic
convulsions, which disappeared without treatment before the ambulance arrived, the child
was sent to the hospital. The mother notes increased sweating of the child, poor appetite,
lethargy. A child from 3 pregnancies, who had anemia, was born weighing 3100 g, from birth
on breastfeeding, as a supplement receives only semolina. Psychomotor development
corresponds to age. The boy is vaccinated according to the calendar. The weight of the child
at receipt of 8900 g, sits with support, rests badly on legs, there are no teeth. When
examining the child, the skin is pale, soft tissue turgor is satisfactory, muscle tone is reduced,
subcutaneous fat is well defined, large forehead 3x3.5 cm, occiput slightly flattened,
expanded lower aperture of the chest, palpable thickening of cartilage in the area of
attachment ribs to the sternum and distal forearm bones. Positive symptoms of Rabbit, Tail,
during the examination of the child appeared carpopedal spasm. Heart rate 140 / min, BH 34 /
min, percussion over the lungs clear lung sound, auscultatory - hard breathing. The abdomen
is slightly enlarged, the lower edge of the liver +1 cm below the costal arch, the spleen - near
the edge. Stool 2 times a day, without pathological impurities. Clinical blood test: Hb 90 g / l,
er.- 3.3 T / l, KP 0.8; lake.- 9 T / l, p / i -7%, s / i -34%, e. -1%, l. -52%, m.- 6%. Biochemical
analysis of blood: Ca 2+ total - 1.6 mmol / l, Ca 2+ ionized - 0.5 mmol / l; P - 1.1 mmol / l,
alkaline phosphatase - 1200 Units. Neurosonography - without pathology.
Answers:
1. Rickets, subacute course, period of exacerbation, severity II. Explicit
spasmophilia. Deficient hypochromic anemia of the first degree.
2. The scheme of therapy.

Mandatory measures: relief of hypocalcemia, post-syndrome therapy of spasmophilia,
treatment of rickets.
Auxiliary methods of treatment: regime, diet, vitamin therapy.
Mode: limit as much as possible or very carefully perform unpleasant procedures for the
child.
Diet: exclusion of cow's milk for 3-5 days, carbohydrate food, a gradual transition to a
balanced, age-appropriate food.
For convulsions: calcium chloride or gluconate 10% solution, 2-3 ml, intravenously
microjet. Sodium oxybutyrate 50-100 mg / kg intravenously slowly or seduxen 0.5%
solution, 0.15 mg / kg, or GHB - 20% solution (0.5 ml / kg) intramuscularly , or
magnesium sulfate 25% solution, 0.8 ml / kg intramuscularly, but not more than 8.0 ml.
After first aid: 10% solution of calcium chloride - 1 teaspoon 3 times a day or calcium
gluconate - 0.5 g 3 times a day for 2 weeks.
Vitamin D (Aquadetrim) 3000 ME, 1 drop contains approximately 500 IU of vitamin D3 , daily
for 4-5 days, for 4-8 weeks .
In the future, to prevent exacerbations and recurrences of the disease at 2000 IU for 30 days
2-3 times a year with intervals between them of at least 3 months to 3-5 years of age .
Task 14
The child is 7 months old. The mother's complaints about the child's anxiety, increased
sweating, muscle twitching. A child from the first pregnancy without pathological
manifestations, born with a weight of 3000 g, from birth on natural feeding, receives food in
the form of semolina. Wit. Dz, juices and fruit and vegetable dishes did not receive. The
child's weight on admission is 8200 g, when the skin and mucous membranes are clean; pale,
soft tissue turgor is satisfactory, but muscle tone is significantly reduced, the child does not sit
on his own, leans poorly on his legs. Large forehead 3x2.5 cm, thickened edges. Pronounced
frontal and parietal humps, rib "rosaries", visible "bracelets", "threads of pearls". The lower
aperture of the chest is deployed. Teeth are missing. The subcutaneous fat layer is developed
satisfactorily. Heart tones are moderately weakened, rhythmic, heart rate 154 / min,
respiratory rate 42 / min., Percussion over the lungs clear lung sound, auscultatory - hard
breathing. The abdomen is slightly enlarged, the lower edge of the liver is 5 cm below the
costal arch, the spleen is +1 cm. Positive symptoms are Truso and Erba. On examination, the
chair without pathological impurities, prone to constipation. Urine is concentrated. General
blood test: Hb 100 g / l, erythrocytes 3.4 T / l, KP 0.88; leukocytes 8 T / l, rod-shaped 7%,
segmental neutrophils 34%, eosinophils 1%, lymphocytes 52%, monocytes 6%, SHE 7 mm /
h. Ionogram of blood: Na + - 137 mmol / l, K + - 4.2 mmol / l, Ca 2+ -1.9 mmol / l, P - - 1.1 mmol /
l. Increased alkaline phosphatase activity in the blood.
Answers:
1. Rickets, subacute course, feathers from the heat, severity II . Latent
spasmophilia. Deficient hypochromic anemia of the first degree.
2. Treatment:
Mandatory measures: relief of hypocalcemia, post-syndrome therapy of spasmophilia,
treatment of rickets.
child.
After first aid: 5 - 10% solution of calcium chloride - 1 teaspoon 3 times a day or calcium
Vitamin D (Aquadetrim) 3000 ME, 1 drop contains approximately 500 IU of vitamin D3 , daily
for 4-5 days. In the future, to prevent exacerbations and recurrences of the disease at 2000
IU for 30 days 2-3 times a year with intervals between them of at least 3 months to 3-5 years
of age .
Task 15
The child is 6 months old. The mother complains of coughing, sneezing, difficulty
breathing, fever up to 38.5 ° C. The child is ill for 3 days, did not receive
treatment. Objectively: general condition of moderate severity, inguinal temperature 39.2 ° C,
pale skin, perioral cyanosis, "marble" pattern of the skin, limbs cold to the touch, a symptom
of "goosebumps". The child became lethargic, crying unemotional, constantly moaning, body
temperature, despite giving paracetamol. continues to rise. Large forehead 2x2 cm,
moderately exploding, not tense. The mucous membrane of the throat is hyperemic, breathing
through the nose is difficult, from the nose - mucous secretions. The conjunctiva of both eyes
is hyperemic, membranous layers, there are mucopurulent secretions. Percussion above the
lungs clear sound, on auscultation - dry conductive rales, respiratory rate 48 / min. Rhythmic
pulse, frequency 150 / min, heart tones are clean, slightly muffled. The abdomen is soft, not
painful on palpation. The liver protrudes from the costal arch by 3 cm, the spleen - by 1 cm.
General blood test: Hb - 126 g / l , erythrocytes - 3.8 T / l, leukocytes - 8.2 T / l, rod
neutrophils - 8%, segmental - 19%, eosinophils - 6%. lymphocytes - 61%, monocytes - 6%
SHE - 5 mm / h. General urine analysis and coprogram: no pathological abnormalities.
Answers:
1. SARS, clinical - adenoviral, rhinopharyngoconjunctival fever, hyperthermic
syndrome.
2. Tactics of treatment - relief of "pale fever": the same antipyretic + vasodilator and
Papaverine 2% 1 ml / kg i / m or Dibazol 1% 0.02 ml / kg + analgin 50% 0.01 ml / kg i / m.
Or in / m enters ting analginum 50% 0.01 ml / kg / m , and a

1% ozchynu  Mr. ikotynovoyi acid and 0.05 ml / kg.
Away, ibuprofen suppository uu rektal or 60 mg 3 times a day , ie every 8 hours.
However, if there are signs of centralization of blood circulation (the difference between
axillary and rectal temperature is more than 1 ° C) in / m 0.25% solution of droperidol in 0.1 ml
/ kg (0.05 mg / kg) + analgin 50% 0.01 ml / kg v / m.
But after droperidol side effects are possible: extra pyramidal disorders with a convulsive
component (tonic contractions of the face and neck).
In the presence of seizures 0.5% solution of diazepam 0.1 ml / kg body weight, but not more
than 2 ml once.
Sulfacil 20% 1 - 2 drops in each eye 4 - 5 times a day.

Nazivin 0.01%, 1-2 drops in each nasal passage 2-3 times a day. Before instillation, rinse
overnight with saline.
For throat treatment: Chlorophyll oil solution 2% solution. The drug is instilled 3-10 drops in
the mouth 3-4 times a day. In between meals.
Task 16
The boy is 14 years old. Complaints of swelling and pain in the left elbow and knee joints
that occurred after the injury, limitation of active movements of the affected extremities. From
the anamnesis it is known that intermuscular hematomas were noted in a child for the first
time at the age of 1 year. Uncle proband on the mother's side suffers from increased
bleeding. Objectively: pale skin and visible mucous membranes, swelling and tension of the
skin over the left elbow and knee joints. Single small submandibular and cervical lymph nodes
are palpated. Blood pressure - 105/65 mm Hg, pulse 110 / min, weak filling and not tense. No
pathological abnormalities were detected from other organs and systems. General blood test:
Hb - 90 g / l, er. - 3,0 T / l, KP-0,9, reticulocytes - 0,5%, thrombocytes - 220 T / l, leukocytes -
8 T / l, neutrophils: rod-nuclear - 7%, segment-nuclear - 62%; eosinophils - 1%, lymphocytes -
24%, monocytes - 6%, SEE - 13 mm / h. Coagulogram: blood clotting time (according to Lee-
White) - 60 min, prothrombin time - 28s, prothrombin index - 60%, thrombin time - 17 s,
activated partial (cephalin-kaolin) thromboplastin time - 3 min (normal 45-55 c), fibrinogen -
3.4 g / l, hematocrit - 0.38.

Answers:
1. Hemophilia A, hemarthrosis of the left elbow and knee joints, posthemorrhagic
anemia.
2. Additionally: determining the amount of factor VIII
With normal hemarthrosis, ice is 15-20 minutes, every 4-6 hours; the limb is immobilized for
up to 48 hours (then passive movements to prevent contractures and sclerosis),
cryoprecipitate is administered in the dose required to raise factor VIII to 50% of normal (25
IU / kg) and maintenance at  5% for 48-72 hours.
According to the definition, 1 ml of normal plasma contains 1 UNIT of antihemophilic factor
VIII.
Since the plasma volume is approximately 45 ml / kg, it is necessary to enter 45 IU / kg of
factor VIII to increase its concentration from 0 to 100% of normal.
In most cases, the introduction of 25-50 IU / kg of factor VIII can increase its plasma
concentration from 50% to 100%. Concentrated factor VIII drugs (octanate) can be used for
replacement therapy.
If after 24 hours of bleeding, joint pain is not relieved, or local temperature increases (a sign
of infection) , then perform a puncture of the joint.
If there is minor bleeding from the mucous membranes (mouth, nose), hematomas without
compression of the surrounding tissues, removal of one tooth (not a molar) - enter
cryoprecipitate 15-20 IU / kg / day.
A more accurate formula for calculating a single dose of cryoprecipitate: the patient's weight x
a given level of factor VIII (%): 1.3 . Antihemophilic drugs are administered
intravenously. Other blood substitutes should not be administered, as this dilutes the existing
factor VIII. If factor VIII and cryoprecipitate cannot be used , or desmopressin is used to treat
patients with mild to moderate hemophilia A. The recommended dose is 0.3 μg /
kg intravenously slowly for 20-30 minutes, pre-dissolved in 50-100 ml of
saline. With increasing the content of antihemophilic factor by 25-5 0%. It is entered once in
1-2 days .
Task 17
The boy is 9 years old. Complaints of pain in the epigastric region, at night the child
sometimes woke up from the pain, and the boy had hypersalivation, periodically - nausea,
bloating, accompanied by a feeling of discomfort in the epigastric region. Ill for 2 months, fell
ill in the spring. He did not receive treatment. Objectively: body temperature 36.2 ° C,
respiratory rate 44 / min, pulse 138 / min, blood pressure 70/40 mm Hg. Art. The skin is clean,
pale. The tongue is covered with a whitish-yellow layer at the root, dry. The abdomen is the
right shape, soft. At a palpation of a pyloroduodenal zone the painful reaction is
observed. The liver and spleen are not enlarged. The chair is unstable, and recently dark in
color. During the examination -defecation, defecation in the form of melena. General blood
test: Hb -70 g / l; erythrocytes - 1.83 T / l, CP - 0.95, reticulocytes -3%, neutrophils: rod - 7%,
segment - 49%; eosinophils-3%; lymphocytes-38%; monocytes - 3%; SHZE - 12 mm /
year. General analysis of urine - without pathological abnormalities. ECG - a variant of the
norm. In the coprogram - leukocytes 5-6 in the field of view, a positive Gregersen reaction.
Answers:
1. Acute gastrointestinal bleeding from the upper parts, hemorrhagic shock degree
II. Acute posthemorrhagic anemia .
Gastric or peptic ulcer:
2. Additionally: endoscopic examination, X-ray contrast examination of the

stomach.
Assessment of hemorrhagic shock, immediate emergency care, consultation with a
surgeon.
Treatment includes : 1. General measures (bed rest, cold on the epigastric region, a tube in
the stomach to control hemostasis and hemostatics, catheterization of the central vein for
effective infusion and transfusion therapy). Refrain from taking food for 1-2 days . 2. Infusion-
transfusion therapy (for the restoration of BCC, correction of water- electrolyte disorders,
elimination of metabolic acidosis, restoration of colloid-osmotic pressure and rheological
properties of blood, elimination of anemia). And nfuziya solutions crystalloid and colloid. To
achieve a hemodynamic effect, the corrective volume of colloids should be higher than the
volume of blood loss by 20%, and crystalloid solutions - by 300-400 %
Total blood loss of approximately 20% of BCC = 400 ml.

It is necessary to enter colloids approximately 500 ml. Crystalloids 1600 ml
Crystalloids: 0.9% NaCl solution, Ringer's solution, Ringer's lactate solution .

Colloids: hydroxyethylated starch 6% solution, gelofusine 4% solution .
Speed b input colloids dose is approximately 5.6 ml / kg at a speed 0,75-1,2 ml / (kg · min) to
the relative stabilization of blood pressure, then - 0.1-0.5 ml / (kg · min) .
Currently, when conducting infusion-transfusion therapy, the issues of indications for blood
transfusion in different medical institutions are considered ambiguously. In this regard, it
should be noted that with adequate plasma replacement therapy, even a significant
decrease in hemoglobin concentration (does not pose a direct threat to the patient's life.
Therefore, at the first stage of treatment of SCC does not involve the
use of blood products .
3. Hemostatic therapy.
P odribnenu hemostatic sponge inside of 1 tablespoon every 1-2 hours,
maintaining 5-10% solution of calcium chloride (0.5 ml per year of life) with ascorbic
acid 1.3 ml of 5% solution intravenously; 12.5% solution of ethamsylate (dicynon) 2
ml intramuscularly. 4. Antiulcer therapy; Ranitidine 25 mg / ml intravenously: 25 mg ( 1 ml)
every 6-8 hours. The contents of the ampoule ( 25 mg) are diluted with 0.9% sodium
chloride solution or 5% dextrose solution for injection to obtain a total volume of 20 ml and
injected within 5 minutes 5. Therapeutic and diagnostic endoscopy (aims to diagnose the
source of bleeding and its stop, monitoring the effectiveness of hemostasis and prognosis
of bleeding recurrence);
Task 18
The child is 8 years old. Complaints of coughing, shortness of breath with wheezing and
wheezing that can be heard in the distance. From the anamnesis it is known that such
respiratory episodes are observed from 5 years, especially in the autumn-spring period of
unstable weather. Signs of dermatitis were observed in girls from 3 months to 2
years. Objectively: respiration 32 / min, pulse 126 / min, blood pressure 100/80 mm Hg Chest
in the inhale position. The girl is sitting, leaning her hands on the bed, with her head pulled
between her shoulders, there are retractions of the pliable areas of the chest. Above the
pulmonary fields is a box shade of percussion sound, during auscultation - noisy
wheezing. Cough is unproductive, with discharge of viscous, transparent sputum. The
boundaries of the heart are evenly and slightly shifted inward. Heart tones are clean,
clear. Pulse of satisfactory properties. The liver protrudes 1 cm from the edge of the costal
arch, not painful. General blood test: Hb -124 g / l. erythrocytes - 4.2 T / l, leukocytes -8.0 T /
l, rod-nuclear - 12%, segment-nuclear - 45%, lymphocytes - 29%, monocytes - 2%,
eosinophils - 12%. SaO 2 = 87%, the maximum air flow rate on the exhale - 56% of normal,
forced expiratory volume in the first second - 62% of normal. Radiologically: signs of
increased transparency of the pulmonary fields. In the analysis of sputum - accumulation of
eosinophils. In the general analysis of urine - without pathological changes.
Answers:
1. Bronchial asthma, atopic form, persistent, paroxysmal period, DN II.
2. Urgent therapy:
1. Inhalation of oxygen, to achieve CaO 2 > 95%
2. Short-acting beta-2-agonist (salbutamol 100 mcg, GAI, AVI 2.5 / 2 mcg ) dosed spray
2 inhalations every 20 minutes for 1 hour.
3.Pri no immediate response - System CC: Prednisolone 1.2 mg / kg / day in / at.
4. Repeat the assessment of severity after 1 hour: SEW, CaO 2 .
If the VASH is 60-80%, the symptoms are moderate, it is considered a moderate attack.
And therapy is continued:
Beta-2-agonist short-acting inhalation +
cholinolytic: Fenoterol / ipratropium bromide (Berodual) 50/2 0 mcg , every hour.
System CC: Prednisolone 1.2 mg / kg / day in / at. 3-5 days.
In case of improvement, continue treatment for 1-3 hours.
If VASV <60%, symptoms are sharply expressed at rest, there is no improvement after initial
therapy, it is regarded as a severe attack
and therapy is continued:
Oxygen therapy: to achieve CaO 2 > 95%
Short-acting beta-2 agonist inhalation + cholinolytic: Fenoterol /
ipratropium bromide (Berodual) 50/20 mcg , every hour.
Possibility ve a / a xanthine short steps eufillina 2% 2 mg / kg of fully upheld at daily doses -
24 mg / kg .
5. Assessment of response to treatment after 1-2 hours
1) Improvement persists for 60 minutes after the last administration of drugs. Objectively - the
norm, SEV> 70%, SaO 2 > 95% - continuation of treatment and preparation for discharge.
2) Objectively - symptoms from mild to moderate, STI <60%, CaO 2 does not improve -
continuation of treatment:
System CC: Prednisolone 1.2 mg / kg / day in / in or tablets 5 mg, 1.2 mg / kg / day.
Monitoring of SEV, CaO 2 , pulse.
3) Objectively - the symptoms are pronounced, confused consciousness, SEW <30%,

P and C O 2 > 45 mm Hg. , P aO 2 <60 mm Hg - continuation of treatment:
Oxygen therapy: until SaO 2 > 95% is reached Beta-2-agonist short-acting inhalation +
cholinolytic: Fenoterol / ipratropium bromide (Berodual) 50/20 mcg , every hour.
System CC: Prednisolone 1.2 mg / kg / day in / at.
Perhaps a / a xanthine short steps eufillina 2% 2 mg / kg of fully upheld at daily doses - 24 mg
/ kg .
Incubation and mechanical ventilation are possible.
Task 19
The boy is 12 years old. Admitted 8 hours after the onset of the disease, manifested by
cough, shortness of breath, shortness of breath and wheezing distant rales. Such episodes of
respiratory disorders occur from the age of 9, usually at night, and are well treated by
inhalation of beta-2 agonists. Despite 3 times in 20 minutes. inhalation of Albuteroli and
Irgatropium bgomidi, shortness of breath continues to increase. Objectively: respiration 38 /
min, pulse 144 / min, blood pressure 110/85 mm Hg, body temperature 36.2 ° C. The general
condition of the child is severe: expiratory dyspnea, moderate cyanosis (which disappears
with inhalation of 40% oxygen), drowsiness. The thorax is in the inhaled position, the auxiliary
muscles take part in the act of breathing, the pliable parts of the thorax are involved. Above
the pulmonary fields noisy wheezing, box percussion sound. The limits of relative cardiac
dullness are moderately displaced inward. Heart tones are pure, muted. The abdomen is
painful on palpation in the upper parts, the liver protrudes 2 cm from the costal arch, not
painful. General blood test: Hb - 142 g / l, erythrocytes - 4.6 T / l, leukocytes - 5.8 T / l,
eosinophils - 6%, rod neutrophils - 12%, segmental - 59%, lymphocytes - 20%, monocytes -
3%, ESR - 8 mm / year. OGK radiography - signs of increased lung transparency, scattered
linear atelectasis. The maximum expiratory rate is 28% of normal, PaCO 2 - 63 mm Hg,
CaO 2 - 76%, venous blood pH - 7.2, deficiency of buffer bases (BE) - (-) 9 mmol / l.
Answers:
1. Bronchial asthma, persistent, in a severe course, asthmatic stage I (relative

compensation).
2. Urgent therapy:
40–50 mg of prednisolone intravenously + 100 mg of hydrocortisone;
P hydration (introduction of physiological solution, Ringer's solution to 1,5–2,0 l / days);
In case of ineffective treatment, the patient is hospitalized in the intensive care unit.
Then, when the condition improves, re- assessment of severity: SEW, SaO 2 .
If the VASH is 60-80%, the symptoms are moderate, it is considered a moderate attack.
And therapy is continued:
Beta-2-agonist short-acting inhalation + cholinolytic: Fenoterol /
In case of improvement, continue treatment for 1-3 hours.
If VASV <60%, symptoms are sharply expressed at rest, there is no improvement after initial
therapy, it is regarded as a severe attack
and therapy is continued:
/ kg .
5. Assessment of response to treatment after 1-2 hours
1) Improvement persists for 60 minutes after the last administration of drugs. Objectively - the
norm, SEV> 70%, SaO 2 > 95% - continuation of treatment and preparation for discharge.
2) Objectively - symptoms from mild to moderate, STI <60%, CaO 2 does not improve -
continuation of treatment:
System CC: Prednisolone 1.2 mg / kg / day in / in or tablets 5 mg, 1.2 mg / kg / day.
Monitoring of SEV, CaO 2 , pulse.
3) Objectively - the symptoms are pronounced, confused consciousness, SEW <30%,

P and C O 2 > 45 mm Hg. , P aO 2 <60 mm Hg - continuation of treatment:
Oxygen therapy: until SaO 2 > 95% is reached Beta-2-agonist short-acting inhalation +
cholinolytic: Fenoterol / ipratropium bromide (Berodual) 50/20 mcg , every hour.
System CC: Prednisolone 1.2 mg / kg / day in / at.
/ kg .
Incubation and mechanical ventilation are possible.
Task 20
A 10-year-old girl went to the clinic with complaints of nosebleeds and bloody
vomiting. Suffers from bleeding from 4 years. Exacerbations occur 4-5 times a year in the
form of nosebleeds and hemorrhages on the skin. Repeatedly treated in hospital, last
received inpatient treatment 3 months ago, discharged with improvement. The girl from 1
physiological pregnancy, was born in term with a weight of 3200 g. From one month of age on
artificial feeding. I was not ill for a year. After a year of frequent ARI. Allergic history is not
burdened. Mother and father are 34 years old. The father suffers from hay fever. Objectively:
the condition of a girl of moderate severity. The pallor of integuments and presence on skin of
a trunk and extremities of various color of "bruises", the size from 0,5х1,0 cm to 3х4 cm, and
also a petechial rash on the face and neck draws attention. Ecchymoses are located
asymmetrically. Single petechial elements on the oral mucosa, on the posterior wall of the
pharynx - blood. Tonsils do not protrude because of the brackets. Lymph nodes are not
enlarged. Vesicular respiration in the lungs. Heart tones are clear, rhythmic, pulse 95 beats
per minute. The liver and spleen are not enlarged. Urination is not disturbed, the chair is
decorated, dark in color. In the blood test: Er. - 3.3x10 12 / l, HB 85 g / l, platelets 24.6x10 9 / l,
lake.-8.0x10 9 / l. The duration of bleeding according to Duke 15 minutes Gregersen's reaction
is positive. Urine analysis without pathology.

administration.
Answers:
1. Idiopathic thrombocytopenic purpura.
2. Pre-medical care is to provide emergency care : creating a calm atmosphere ,

transportation in the position of the patient with his head raised, mechanical hemorrhage: cold
on the area of the nose, anterior not tight nasal tamponade, local hemostatic
agents ( hemostatic sponge ) . Diagnostic program in the hospital: general blood test to
determine the number and morphology of platelets and the duration of
bleeding; coagulogram; bone marrow puncture myelogram; general analysis of
urine; determination of the number of platelets in the dynamics; immunological
examination; biochemical analysis of blood (protein, proteinogram); identification of foci of
chronic infection; consultation with a hematologist, dentist, ophthalmologist; Ultrasound of the
abdominal cavity to rule out hemorrhages in the liver and spleen.
Treatment program:
fight against hemorrhagic syndrome:
parenterally :
intravenous epsilonaminokapronov and acid and 5% 100-200 ml / drip in, etc. and tsynon
12.5% 2.4 ml / m)
In case of nasal bleeding, instill a solution of thrombin (20 mg in an ampoule) and adroxone
0.025% -2 ml, dissolved in 50 ml of 5% solution of ε-aminocaproic acid, 3-5 drops in each
nostril every 3-5 minutes.
Tampons with the specified solution in an anterior nasal passage alternate a hemostatic
sponge .
In case of gastrointestinal bleeding, cooling of mechanically and chemically sparing food is
recommended - table 5a; cooled solution of ε-aminocaproic acid with adroxone, thrombin 1
teaspoon 4-6 times a day, vinyl (antiseptic drug with regenerative properties) 1 teaspoon 3-4
times a day, lanzap (proton pump blocker) 30 mg day.
GC: prednisolone is prescribed for 7 days at a dose of 2 mg / kg / day with the cessation of
the entire dose; repeat the course in 5 days at a dose of 3 mg / kg / day.
In the absence of persistent effect after 3 courses
predn and zolonoterapiyi - splenektomi me .
In the treatment of ITP use larger doses of methylprednisolone - pulse therapy with
methylprednisolone (metipred, urbazan) at a dose of 20 mg / kg / day intravenously for 3
consecutive days. Prednisolone is administered taking into account the circadian rhythm of
secretion of pituitary adrenocorticotropic hormone and adrenal corticosteroids in the morning
with an interval of 3 hours, the last administration no later than 16 hours.
After discharge from the hospital recommended diet table №5, with the exception of obligate
allergens, anti-relapse treatment 2 times a year, vitamins P, A, C, herbal medicine,
remediation of foci of chronic infection.
3. In laboratory data: in the analysis of blood decrease in number of erythrocytes, decrease in

hemoglobin, decrease in thrombocytes; increase in duration of bleeding according to Duke to
15 min - prolongation of duration of capillary bleeding (norm of 2-4 min) . Positive Gregersen's
reaction = positive reaction to occult blood, ie gastrointestinal bleeding.
Task 21
A 15-year-old girl, 3 months ago after suffering from lacunar sore throat, had pain in the
heart, palpitations, a feeling of heat, dizziness, weakness. I lost 4 kg, my school performance
and sleep deteriorated. Appetite is not disturbed. Objectively: weight - 36 kg, height 152 cm.
Tearful, irritable. Skin of high humidity, hyperpigmentation of skin folds, halo, periorbital
pigmentation. Tissue turgor is reduced. Heart tones are loud, tachycardia up to 120 beats /
min. Vesicular respiration. The abdomen is soft, painless. The liver and spleen are not
palpable. Blood pressure 140/50 mm Hg Thyroid gland of the III degree, diffuse-elastic,
12
painless. Tremor of fingers. General blood test: Hb - 106 g / l, erythrocytes - 3,4х10 / l, KP -
0,85, leukocytes - 7,5х10 9 / l, p-1%, s-32%, e-2%, l-57%, m-8%, ESR -9 mm / year.
administration.
1. Diffuse toxic goiter of the third degree. with severe thyrotoxicosis.

2. Determination of the level of TSH, vT4, vT3 in the serum, ultrasound of the thyroid
gland.
Therapy:
1. Thyrostatic drugs - thionamides: (mercazolyl, thiamazole, metizol, tyrosol, etc.).
- The initial dose is 0.3-0.5 mg / kg / day - depending on the severity of thyrotoxicosis. The
dose is divided into 2-3 doses.
At clinical improvement of a condition (normal pulse, absence of clinical manifestations of a
thyrotoxicosis) - on the average in 14 - 21 days - further every 10-16 days the dose is reduced
by 2,5-5 mg to maintenance.
- The average maintenance dose is 2.5-7.5 mg / day (approximately 50% of the initial) - once
a day.
- Against the background of taking thiamazole drugs, side effects may occur:
allergic reactions in the form of skin rash, accompanied by itching; nausea; blood changes:
leukopenia up to agranulocytosis, the symptoms of which are fever, sore throat, diarrhea,
thrombocytopenia.
- In case of allergy to thiamazole drugs or their side effects - lithium carbonate drugs at a
dose of 30-50 mg / kg / day
2. Beta-blockers (anaprilin, propranolol) - the first 4 weeks, simultaneously with thyrostatics -

1-2 mg / kg / day in 3-4 receptions. With normalization of the pulse - a gradual decrease in
dose until complete withdrawal of the drug (abrupt cessation of the drug can cause a
"withdrawal syndrome", with worsening of the condition).
3. When euthyroidism is achieved (on average 6-8 weeks after the start of treatment) -
combination therapy: thionamides (mercazolyl, etc.) 5-10 mg / day and L-thyroxine 25-50 μg /
day.
4. Glucocorticoids:
- In severe thyrotoxicosis, combined with endocrine ophthalmopathy
- When signs of adrenal insufficiency (NNZ)
- If bad blood indices (leukopenia, thrombocytopenia)
- When connecting comorbidity, the stress - to prevent acute NNZ
- Prednisolone is prescribed in a short course at an average dose of 0.2-0.3 mg / kg / day for
2-3 doses, with a gradual decrease after 7-10 days by 2.5-5 mg every 5-7 days until complete
cancellation.
Task 22
The child, 8 months old, was admitted to the clinic with the mother's complaints of fever up
to 38.0 C, convulsions that occurred after eating mustard. The child had pneumonia. At
inspection the condition of the child is heavy, signs of pneumonia, rickets of the II degree are
revealed. During the examination in the hospital, the condition worsened again, the child
turned pale, numb, there were twitching of the facial muscles, breathing became intermittent,
sobbing. The child turned blue, there were clonic-tonic convulsions with loss of
consciousness. The attack lasted 3 minutes, after which the child fell asleep. After sleep there
were no signs of convulsions, but there were symptoms of Tail, Trusso. In the clinical analysis
12
of blood the content of erythrocytes - 2,8 × 10 / l, hemoglobin - 74 g / l, KP - 0,66. There are
signs of anisocytosis (microcytes) and poikilocytosis.
administration.
Answers:
1. Rickets, subacute course, period of exacerbation, severity II. Explicit

spasmophilia. Deficient hypochromic anemia of the II century.
2. Additionally, screening for iron deficiency anemia (ferritin and free iron in the
blood) , the number of reticulocytes.
Therapy scheme.
Compulsory measures: arresting hypocalcemia, posyndromna therapy manifestations
spazmofilii treatment of rickets.
child.
For convulsions: calcium chloride or gluconate 10% solution, 2-3 ml, intravenously
microjet. Sodium oxybutyrate 50-100 mg / kg intravenously slowly or seduxen 0.5%
solution, 0.15 mg / kg, or GHB - 20% solution (0.5 ml / kg) intramuscularly , or
magnesium sulfate 25% solution, 0.8 ml / kg intramuscularly, but not more than 8.0 ml.
After first aid: 10% solution of calcium chloride - 1 teaspoon 3 times a day or calcium
In itamin D (Akvadetrym) 3 000 ME , 1 drop contains approximately 500m vitamin D3 , day 4-
5 day within 4-8 weeks. In the future, to prevent exacerbations and recurrences of the disease
at 2000 IU for 30 days 2-3 times a year with intervals between them of at least 3 months to 3-
5 years of age .
3. In the clinical analysis of blood

erythrocyte content - 2.8 × 10 12 / l, anemia rate 3.6-4.9 x 10 12 / l hemoglobin - 74 g /
l, reduced, rate 110.0-135.0 g / l CP - 0.66. (0.83 - 0.92) - hypochromic anemia. There are
signs of anisocytosis (microcytes) and poikilocytosis. Microcytosis is a pathology in which the
average erythrocyte volume is less than 80 μm 3 . POYKYLOCYTOSIS - change in the shape
of erythrocytes of varying severity compared to disc . Moderate hypochromic anemia is a
frequent concomitant clinical symptom of rickets. If screening for iron deficiency anemia is
negative and the anemia does not resolve after the administration of Vitamin D, a
differentiated diagnosis should be made and the need for erythrocyte transfusion should
be considered .
Task 23
The mother of a 7-year-old boy turned to the district pediatrician, complaining that the child
had a fever of 38˚-39˚, cough, headache, loss of appetite, and sleep disturbance for 6
days. The general condition of the child of moderate severity: moderate cyanosis of the
central type SaO 2 87%. At objective inspection: percussion - shortening of percussion sound
under the right shoulder blade, auscultatory - hard breathing, crepitation. Heart tones are
muffled. General blood test: hemoglobin 112 g / l, erythrocytes 3.8 * 10 12 / l, leukocytes 14.6
* 10 9 / l, e 0 p21 s 47l 20 m12 SHZE 30 mm / h.
administration.
Answer:
1. Nosocomial pneumonia of the lower lobe of the right lung, group 4, severe DN II.
2. Hospitalization, bed rest, diet therapy with a predominance of proteins.
Antibacterial therapy:
Cephalosporins III pok. Ceftriaxone 0.5 g iv per 10 ml of 0.9% sodium chloride solution
2 times / day for 10 days + macrolides azithromycin, which is used 0.5 g per day on
the 1st day, and from the 2nd to 5th day - 0.25 g 1 time per day .
Oxygen therapy: additional oxygen through the nasal cannula, using a pulmonary
machine, a dome for oxygen therapy or a mask to maintain oxygen saturation> 92%
Rehydration: in this situation there is no significant fluid loss in pneumonia (except for
loss of perspiration), so oral rehydration is preferred for this purpose, it is
recommended to use glucose-saline solutions, in particular rehydration and rehydration
optim in daily need.
Antipyretic pr.-ti (nonsteroidal anti-inflammatory pr.-ti) Anapirone 15 mg / kg iv drops
(1.5 ml of the drug) with fever, daily dose not more than 2 g / day.
Mucolytic etc. Ambroxol 15 mg 3 times / day
3. According to the laboratory examination: in the blood leukocytosis, an increase
in young forms of granulocytes - "shift of the leukocyte formula to the left", an increase
in SEE, which indicates inflammatory changes in the body of bacterial etiology.
Task 24
The girl, 9 years old, is in serious condition. Body temperature 39, lethargic, adynamic,
appetite is sharply reduced. Ill for 7 days. The skin is pale, respiratory rate 40 per 1 min, pulse
130 per 1 min, deaf heart sounds, gallop rhythm, edema in the lower extremities. The
radiograph shows cardiomegaly. On the echocardiogram: decrease in contractility of a
myocardium, dilatation of ventricles. On the ECG: violation of the repolarization of the left
12
ventricular myocardium. In the analysis of blood - erythrocyte - 4,0 x 10 / l; lake. - 14.2 x 10 9 /
l; pal. - 8%; segment. - 72% ;. lymph.-12; mon. - 6; ESR - 45 mm / year. PSA- +++
administration.
Answers:
1. Acute infectious diffuse myocarditis. Severe course with impaired repolarization

of the left ventricular myocardium , CH IIB, III FC.
2. Strict bed rest to eliminate the phenomena of heart failure, bed - to normalize
the ECG. Diet - restriction of salt, increase the content of vitamins. Fluid restriction.
Antibiotic therapy: cephalosporins III pok. Cefatoxime 0.5 mg iv p 2 times / day 14 days
+ aminoglycoside gentamicin 3 mg / kg / day divided into 3 doses iv p 14 days
Glucocorticoids are important in the treatment of patients with myocarditis because
they have an immunosuppressive and anti-inflammatory effect. Prednisolone is
administered orally at a rate of 1 mg / kg for 10-12 days, followed by a gradual dose
reduction.
Cardiac glycosides Digoxin saturation dose 0.03 mg / kg / day divided into 2 doses for
the first 5 days, then maintenance therapy 1/5 daily dose 1 time /
day per os . Diuretics. verospirone (2 mg / kg) + furosemide (1 mg / kg) 1 time / day in
the morning.
Therapy of arrhythmia anti-arthritic pr.-amiodarone 5 mg / kg per day pre-dissolved in

250 ml of 5% glucose solution in / in drops. 1 time / day.
Inhibitors of angiotensin converting enzyme (ACE) inhibitors. Drugs in this group and
reduce post to the load, reduce congestion in the pulmonary circulation and increased
cardiac output (captopril - 0,5-1-2 mg / kg of 3 g / day)
Cardiometabolic therapy phosphocreatine 1 g / day after dissolution in 200 ml of saline

or 5% glucose, the total course dose of 5-8 g .
After myocarditis, the child is under the supervision of a pediatrician and pediatric
cardiorheumatologist: for 4 months after discharge from the hospital examination is
performed once a month, then during the year - once a quarter, after that - 1 time in 6
months (according to indications - more often). An ECG is mandatory at each
examination. ECHO-CG is performed once a year (according to the indications - more
often).
3. Laboratory: leukocytosis, blood count - normocytosis, elevated ESR and PSA

levels may probably indicate infectious myocarditis.
Task 25
Mother 25 years old, healthy, laboratory assistant. My father is 26 years old, healthy, a
miner. Pregnancy 2, 1 - 2 years ago ended in childbirth on time, the child died in the hospital,
the disclosure was not carried out. The second pregnancy in the first half was without
features, in the second half the mother suffered from SARS in a mild form, was not
treated. Childbirth on time, water left 2 days before childbirth, 1 period - 30 hours, 2 period -
30 minutes. Birth weight 3800 g, length 53 cm. Shouted immediately, the condition after birth
was regarded as satisfactory. On the third day of life there was a purulent conjunctivitis, on
the 4th - small single abscesses on the face and neck. The general condition remained
satisfactory; local treatment. On the 8th day, the child's condition deteriorated sharply: weight
loss per day 180 g, began to vomit with bile, the skin is gray- cyanotic, dry. On the 15th day -
an abscess on the scalp. The chair is liquid, green. In the general analysis of blood - Er.-3.2 x
1012 / l, HB-100 g / l, CPU-0.9, lake.- 14.0 x 109 / l, n-15%, e3%, c- 60%, l-28%, m-4%, ESR-
20 mm / hour. Blood culture for sterility - isolated Staphylococcus aureus, plasma-
coagulating.
administration.
Answers:
1. Early neonatal epsis caused by Staphylococcus aureus . C epitopeemic

form: purulent conjunctivitis, vesiculopustulosis, scalp abscess, enterocolitis. Acute
course. Degree of dehydration II.
(because the symptoms appeared from the 3rd day, and this corresponds
to early neonatal sepsis)
2 . Biochemical analysis to determine total protein, liver samples, electrolyte

composition of blood; chest radiography .
1. Transfer to the intensive care unit.
2. Respiratory support - oxygen therapy, it is necessary to maintain SaO 2 > 90%,
3 . Antibacterial therapy:
Vankomits Ying at an initial dose of 15 mg / kg, following infusion - 10 mg / kg every 8 hours ,

in / in drip slowly from 0.9% sodium chloride , sodium or 5% glucose solution .
Ceftriaxone 20-80 mg / kg 1 time a day , in / in drip slowly from 9% sodium chloride or 5%

glucose solution .
If after 3 days of treatment the condition has not improved or worsened, then change the
antibiotic from the group of aminoglycosides and carbopenems.
If the condition has improved, continue for another 4 days or more. 4 . Infusion therapy and
nutrition Nutrition in Nor mi child should receive 1/5 part from its birth weight = 760 ml. But
during sepsis, energy needs are doubled, so the baby should receive 760 ml / day of breast
milk + glucose infusion to increase calories.
Shown is nteralne eating low-dose 24 ml / kg / day = 90 ml / day , feeding through a tube
while applying to the chest.
Amino acids : 2 g / kg / day = 7.2 g / day 10% Am and noven and nfant ( 100 mg / ml), you
need 72 ml.
Carbohydrates 60 ml / kg / day = 250 ml = 90 kcal , 10 % p glucose solution .
Glucose, electrolytes and amino acids are mixed in one vial and administered
intravenously. But do not add medication.
Lipids are prescribed only from the 3rd day of parenteral nutrition: 20%
"B and tal and n and d" 0.5-1.0 g / kg / day
Total food = 412 ml / day
Infusion therapy:
V (infusion) = V (liquid) - V (food)
V (s.liquid) = FP + DR + PV
DR-fluid deficiency = 216 ml of

Art. dehydration 6% = 60 ml / kg
PV - pathological costs = 25 ml / kg (diarrhea) + 10 ml / kg (for each degree over 37 o C) = 35
ml / kg = 126 ml
FP = 120 ml / kg = 450 ml
V (liquid) = 450 ml + 216 ml + 126 ml = 800 ml
V (infusion) = V (liquid) - V (nutrition) = 800 ml - 412 ml = 400 ml
1: 3 = colloids: crystalloids
130 ml - rheopolyglucin
270 ml - 0.9% NaCl
First, the colloids for the first 5-10 minutes, then the crystalloids.
calculated by the formula :
Potassium deficiency - D (K) = (K mmol / l desirable - K mmol / l patient ) x body weight x0.3.
5. Imunokoryhuyucha therapy - Pentahlobin 50 mg / ml, 1 ml / kg, can and enter 2-3

at Yoma with and interval of 24 hours . The next entry is not healing ishe , than at 1
m isyats only in / m.
You can use interferon drugs: B and ferron, K and pferon).
6. Restoration of normal microbiocenosis: Lactial GG 1 drop of solution per day with meals.
Surgical treatment of abscess.
Problem № 26
The child is 6 months old. sick on the third day: there is difficulty in nasal breathing,
loose mucous secretions from the nose, rare dry cough, body temperature 37.5 o C.
From the third day of the disease the condition worsened: the cough became spastic
appeared and rapidly increased shortness of breath to 80 in 1 min . The child became
restless, there was a single vomiting. Body temperature 37, 3 o C. According to the
mother: this is the first time a child has this condition. In the anamnesis - an acute
respiratory viral infection in a mild form 3 weeks ago. On examination, the child's
condition is serious. The skin, mucous membranes of the lips and mouth are
bluish. Breathing is noisy, "puffing", superficial, with difficulty exhaling and
participating in the act of breathing auxiliary muscles (wings of the nose, shoulder
girdle), retraction of the intercostal spaces. The chest is swollen, above the lungs - a
boxy shade of percussion sound, the limits of cardiac dullness are reduced, the upper
limit of the liver and spleen are shifted down to one intercostal space. At auscultation
breath is rigid, exhalations are sharply extended, on inhalation and an exhalation on all
fields the weight of small-bubble and crepitating rales is listened. Heart tones are
sonorous, heart rate is 172 in 1 min, accent I tone over the pulmonary artery. The
boundaries of the heart correspond to age. Other organs and systems during physical
examination - without features. Blood test: Er-4.3 x 10 12 / l, HB-115 g / l, Lake-17.4 x 10
* 9 / l, e-2%, n-10%, c-58%, l- 26%, m4%, ESR-28 mm / year. Chest radiograph -
diffusely enhanced pulmonary pattern due to the bronchovascular component, small
atelectasis.

Answers:
1. Acute bronchiolitis, severe, DN W art.
2. Treatment:
Hospitalization. Adequate nutritional support and rehydration.
Since the child has respiratory failure W. , she can not tolerate oral feeding, you need to start
intravenous fluids.
The drugs of choice for nutritional support of children with acute bronchiolitis are 2.5%
glucose solution and 0.45% saline.
Calculation of the volume of the entered liquid V total = FP + PV
FP = 4 ml / kg / h
PV = 30 ml / kg a day for each 10 respiratory movements above norm + 10 ml / kg a day for
each degree above 37 0 C.
Approximately V total genus = AF (770 ml) + PV (240-320 ml) = 1000-1100 ml per day
calculated by the formula:
Potassium deficiency - D (K) = (K mmol / l is desirable - K mmol / l of the patient ) x body weight x0,3.
An early return to oral nutrition is optimal. Stage: nasogastric tube - oral nutrition with a
reduced volume of up to 50% , and then gradually increase to normal age values
Rehabilitation of the upper respiratory tract
- electric suction
- drainages: postural, vibrating
Oxygen : Breathing and support a continuous positive airway pressure (CPAP). In the
absence of effect from these measures, the beginning of non-invasive ventilation is
recommended. Invasive ventilation should be avoided.
Antibacterial therapy: Cephalosporins III pok. Ceftriaxone 0.5 g iv per 10 ml of 0.9% sodium
chloride solution 2 times / day for 10 days + macrolides azithromycin, which is used 0.5 g
per day on the 1st day, and from the 2nd to 5th day - 0.25 g 1 time per day .
Beta-agonists - trial treatment of salbutamol 2.5 mg through a nebulizer with monitoring

response. 1-2 inhalations, which were performed with an interval of 30 - 60 minutes.
If no improvement is observed, then administered HA (dexamethasone 0.6 mg / kg at a rate
of 1-1.2 mg / kg / day or prednisolone 6 mg / kg at a rate of 10-12 mg / kg / day)
intravenously.
The use of mucolytic drugs is not appropriate, because the secretion in the bronchioles is not
dense but liquid, and may even be harmful by increasing its content, resulting in increased
respiratory failure.
Subsequently, after improving the condition - DII-DAY, you can use and inhalation of 3%
NaCl . The duration of treatment is three days.
8. Physiotherapeutic procedures: microwave therapy, UHF therapy, electrophoresis with

euphyllin, MgSO4, phytotherapy with the use of hypoallergenic plants (licorice, mint, thyme,
bagulnik).
Task 27
A 5-year-old boy was taken to the hospital. According to the mother, 2 days later there was
weakness, malaise, swelling of the face. About 3 weeks later, the child caught a cold during a
walk and had SARS. Objectively: pale skin, significant swelling on the face and legs. The
boundaries of the heart are expanded to the left. Systolic murmur. Blood pressure 110/80 mm
Hg Free fluid in the abdomen, disturbing abdominal pain, liver + 4 cm from under the costal
margin. In the blood test protein 37 g / l. In the urine - protein - 9.7 g / l, granular and hyaline
cylinders.
Answers:
1. Acute glomerulonephritis, nephrotic syndrome, the period of detailed
manifestations.
2. Bed rest - for the whole time of extrarenal manifestations and

improvement of urine tests ; Diet therapy: protein restriction to 2.0-2.5 g / kg for 1
month ; Drinking regime.
Volume of fluid consumed = volume of diuresis for the past day + volume for
perspiration (15 ml / kg / day or 300-400 ml / m 2 ). Exclusion from the diet of salt for 8
weeks. With its gradual increase.
Antibiotic therapy of cephalosporins III pok. Cefatoxime 0.5 mg iv 2 times / day for 14
days
Antihistamines for 4-6 weeks (block mediator reactions). In / m 1.5 ml of a solution of
tavegil or 0.1% or suprastin
Drugs that improve renal circulation (euphyllin 10 mg / kg, trental 10-15 mg / kg,
curantil 15 mg / kg)
Vitamins that have an antioxidant effect in age doses (vitamins A, E, C, P)
Infusion of B \ B dextran 10-40 ml / kg or reosorbilact, 20-50% solution of albumin .
Diuretics. verospirone (2 mg / kg) + furosemide (1 mg / kg) 1 time / day in the
morning
Pathogenetic therapy:
Glucocorticoids prednisolone 1.5-3 mg / kg (but not more than 40-60 mg / day) for 6-8
weeks. Then the dose is gradually reduced, at half the therapeutic dose is switched to
a cyclic appointment for 6-12 weeks (3 days the child receives prednisolone, 4 days - a
break). Every 6-8 weeks, the half dose is reduced by 2.5 mg to 5 mg / day, which is left
until the end of treatment.
Depending on the response to glucocorticoid therapy : Hormone-sensitive option -
achieving clinical and laboratory remission at 2-4 weeks of treatment with maximum
doses, Partially hormone-sensitive (late hormone sensitivity) - achieving partial
remission after 8 weeks. treatment on a maintenance dose of HA, hormone-resistant -
no remission on the background of treatment and after its completion, hormone-
negative - deterioration of clinical and laboratory parameters on the background of
treatment.
Cytostatics are prescribed for hormone resistance - chlorbutin, leukeran 0.2 mg / kg /
day, cyclosporine, cyclophosphamide 3 mg / kg, sandimun-oral 5-6 mg / kg - 8-12
weeks and maintenance - 8-10 months.
Anticoagulant and hypolipidemic therapy (heparin, lipidal, injection samples ,
lespenephril, hofitol) . Daily dose of 100-300 IU / kg p / w, iv for 4-6 injections. Duration
of application 4-6 weeks. Cancel gradually, by reducing the single dose (not the
number of injections!).
Improvement of renal circulation: curantil 1.5-3.0 mg / kg / day; trental 5.0 mg / kg /
day; ticlid - 2 weeks.
Membrane stabilizers : Dimefosfon 30-50 mg / kg 2-3 weeks, carnitine chloride 1
drop. per year of life 3 times a day.
3. Laboratory: low protein levels in the blood, proteinuria in the urine,
cylindruria, which indicates a violation of glomerular function of the kidneys.
Task 28
A 6-year-old child was admitted to the department with complaints of dry paroxysmal
cough, nasal congestion, nasal mucosa, fever up to 380. Lethargy. The mother noted a food
allergy in the first year of life, atopic dermatitis in the 2nd year of life. General condition of
moderate severity. The skin is clean, pale. The pharynx is hyperemic. Cyanosis of the
nasolabial triangle. Expiratory dyspnea involving the accessory muscles. Percussion over the
lungs shortening of the percussion tone, auscultatory -hard breathing, dry wheezing on both
sides, moist medium and small-bubble. Heart tones are rhythmic, sonorous. The abdomen is
soft accessible to palpation. Blood test: HB -126 g / l, L-10.2 × 10 9 g / l, L, e -5, n -10. s- 53, l-
24, m-8, ESR - 25 mm / year
Answers:
1. acute obstructive bronchitis
2.1. Hospitalization
2. The diet is hypoallergenic, complete, according to the age of the child
3. Antispasmodics enterally or parenterally (but-spa tablets 40mg 2r / d)
4. Broncholytics: bronchoadrenomimetics - salbutamol (suspension) - and 1 inhalation

(100 mcg). If necessary, the dose can be increased to 200 mcg (2 inhalations). ,
berodual 0.5–2.0 ml Berodual after dilution with physiological solution to a volume of
3–4 ml. -.
5. GKS - Pulmicort - was not 0,25 on 2,0 physical solution of 2 g / d
6. Mucolytics and expectorants of plant and synthetic origin (acetylcysteine, lasolvan,

bromhexine, prospan, trypsin, etc.).
7. Vibration massage and postural drainage.
8.Fizioterapevtychni procedure: electrophoresis with eufillinom, MgSO 4
9. Phytotherapy with the use of hypoallergenic plants (licorice, mint, thyme,

bagulnik). . At the stages of rehabilitation therapeutic breathing exercises,
speleotherapy, hardening, sanatorium treatment (Southern coast of Crimea).
10. Dispensary supervision at the allergist
Task 29
Boy, 3 years old. At the reception of the district pediatrician with complaints of: nasal
congestion, poor runny nose, rare dry cough, body temperature 37.6oC. From the anamnesis:
the patient for 4 days, became acutely ill, after attending kindergarten in the evening the body
temperature rose to 37.8 oC. Breathing through the nose became difficult, there were mucous
secretions from the nose. On day 3, a dry cough, shortness of breath appeared and quickly
increased. The child became restless, there was a single vomiting. I was not ill
before. Moderate manifestations of atopic dermatitis at 1 year of age associated with the
introduction of supplementary feeding. Family history is not burdened. On examination: the
child's condition is serious. The skin is pale, cyanosis of the nasolabial triangle, auricles,
fingertips. Breathing is noisy, shallow, with difficulty exhaling and participating in the act of
breathing auxiliary muscles (wings of the nose, shoulder girdle), retraction of the intercostal
spaces, BH up to 80 per 1 min. The thorax is swollen, above the lungs - a boxy shade of
percussion sound, during auscultation breathing is hard, exhalation is sharply prolonged, on
inhalation and exhalation the mass of small-bubble and dry whistling rales on all fields is
listened. Heart tones are sonorous, heart rate is 172 in 1 min. Other organs and systems
during physical examination - without features. The child is hospitalized. At examination in the
12
hospital: SaO 2 88%, blood test: HB 140 g / l, Er 4,3x10 ; L 8.4x10 9 / l; ESR 15mm /
year; E3%, P 1%, C 57%, L 33%, M 6%. Chest radiograph - There is a sharp swelling of the
apex. Diffusely enhanced pulmonary pattern, enhanced and low root shadows. The domes of
the diaphragm are clear. The middle shadow is usually located.
administration.
Answers:
1. False groats, DN1
2. All children with croup are subject to mandatory hospitalization, which is able to
provide conditions for intensive care.
Antibacterial therapy for uncomplicated cereals is contraindicated!
Non-specific means of therapy are to create a favorable microclimate for the child
(humid and cool air).
In the presence of fever above 38.5-39 ° C, the use of antipyretics is appropriate. The
drugs of choice in children are acetaminophen (paracetamol) 10-15 mg / kg per dose
up to 3-4 times a day (daily dose should not exceed 60 mg / kg ), ibuprofen 5–10–15 mg
/ kg per dose up to 3 times a day.
infulgan is 10% used in doses of 15 mg / kg, ie 1.5 ml / kg (single) and 60 mg / kg, ie 6
ml / kg body weight (maximum daily) as an infusion over 15 minutes in children aged 1
year or with a body weight over 10 kg. Its use is advisable in the presence of venous
access at the inpatient and outpatient stages of medical care.
Corticosteroids are administered intravenously or intramuscularly at a rate of 3-5 mg /

kg of prednisolone per day.
Dexamethasone is prescribed at a rate of 0.6 mg / kg per day once (for 6-24 hours, if
necessary, you can repeat the injection).
Inhalations of budesonide (2 mg) or fluticasone are performed using nebulizers.
In the presence of uncompensated respiratory failure, a drug is needed that provides a

faster action. This means is adrenaline, used by inhalation at the rate of 0.05-0.1 ml per
year of life of the child with the addition of 0.9% sodium chloride solution (4-5 ml)
using a nebulizer (in its absence - a steam inhaler). Inhalation should last 10-15
minutes. Repeat inhalation, if necessary.
In case of severe respiratory disorders and ineffectiveness of conservative therapy,

endotracheal intubation is performed, which lasts until the reverse development of
laryngeal mucosal edema.
To improve the rheological properties of sputum in complex therapy include

mucolytics in age-appropriate doses, this is also facilitated by oxygen and adequate
inhalation therapy (physiological or alkaline solutions).
3. Increased ESR.
Task 30
A 10-year-old boy was admitted to the pediatric pulmonology department with complaints
of a painful paroxysmal cough that worsens at night and in the morning. The patient for 1.5
months when, after working with magazines and books, there was a barking cough and
hoarseness. He was treated on an outpatient basis: bromhexine, ATC. Positive dynamics
from the therapy was not observed. Observed by an allergist for atopic dermatitis. From 8
years episodes of obstructive bronchitis 2-3 times a year. Mom suffers from hay fever (allergic
rhinoconjunctivitis). Objective examination: The condition of a child of moderate severity. The
skin is pale, nasal breathing is difficult. At physical inspection: in lungs hard breath is listened,
on the forced exhalation dry whistling rales from both parties are listened, exhalations are
extended, NPV 24 in min. Heart tones are clear rhythmic, heart rate 88 per minute. The
abdomen is palpable, soft. The chair is regularly decorated. Urination is free. Blood test: HB
110g / l Er 4,3x10 12 ; Lake 6.6x10 9 ; ESR 6 mm / year; E15 P2 C35 L50 M8 Cytological
analysis of the nasal mucosa: epithelium. - 2-4 in p / zr, EOZ - 10 in p / zr.
administration.
Answers:
1. Bronchial asthma, allergic etiology, moderate, persistent
2. Treatment protocol №868. The doctor should pay attention to whether the child is
obese, calculate the BMI, conduct a consultation on nutrition. Breathing exercises with
a physiotherapist.
Drug treatment.
B2 short-acting agonists-salbutamol 200 mcg (2 inhalations) 4 g / d
GCS-pulmicort-nebula 0.25 per 2.0 physical solution, 2 g / d
3. In the analysis we observe eosinophilia
Task 31
Girl from the 3rd pregnancy, 3rd childbirth by cesarean section. 1st pregnancy - a healthy
baby. 2nd pregnancy - the birth of a child with a swollen form of hemolytic disease of the
newborn. The child died on the 2nd day of life as a result of progressive multiple organ failure.
During the 3rd pregnancy, hemosorption and plasmaphoresis were performed to reduce
the increasing antibody titer. Surgical delivery at 37 weeks of gestation was due to a sharp
increase in antibody titer. The mother has blood group A (II) Rh (-). The baby was born with
an Apgar score of 6/7. Body weight at birth - 3000 g, body length - 48 cm. Blood group of girl
A (II) Rh (+). Mild jaundice was observed in the child an hour after
birth. Hepatosplenomegaly. The level of Hb in the umbilical cord blood - 130 g / l, Ht - 42% /
The level of bilirubin in the umbilical cord blood is 56 mmol / l, after 3 hours - 128 mmol / l.
Answers:
1. Hemolytic jaundice, moderate
2.
Treatment - phototherapy:
Standard treatment: radiation intensity of 25-30 mW per square centimeter to the nanometer
(mW / cm2 / nm, microW / cm2 / nm) ( 430- 490 nm)
light source:
- Use additional light source during DTIS tion for intensive phototherapy . It can be a fiber-
optic substrate, an LED mattress or a set of special blue lamps . • Distance: - Maximize
exposure by minimizing the distance between the baby and the light source • Usually 10-15
cm for full-term and "near-term" (near term) children Care during phototherapy :
1. If possible, do not separate mother and child during phototherapy •

2. On the child only under a button.
3. Use protective barrier creams on the buttocks if the child has loose stools . Use
eye protection - moisturizing eye drops may be indicated.
4. Monitoring of eye discharge and conjunctivitis .
5. Ensure constant monitoring of the child .
6. Monitoring the child's temperature:
- risk of hyperthermia if halogen lamps are used;
- the risk of hypothermia if the undress baby is in the crib for newborn / infant beds
using LED or fluorescent lamps at a cool temperature environment ; - Place the
premature baby in an incubator or under radiant heat .
7. Maintain a normal oral diet in full-term infants. The clinical effect of
phototherapy is obvious within 4-6 hours after initiation . The estimated
reduction of the BSA is 34 μmol / l .
Children undergoing phototherapy:

a. Measure the BSA after 4-6 hours until its level is taken under control, then measure once
every 12-24 hours.
b. Stop phototherapy if the BSA below the line is more than 50 μmol / l and check again in 12-
24 hours.
If the child's BSA level is above the threshold level and the BSA is not expected to be below
the threshold level after 6 hours of intensive phototherapy, an exchange transfusion is
indicated.
If there are signs of bilirubin encephalopathy, immediate exchange transfusion is

recommended.
Task 32
Newborn baby from I pregnancy. Childbirth in a row. Maternal blood - 0 (I) Rh (+). The
child's blood - A (II) Rh (+). The child was born with a body weight of 3200 g. There was a
birth tumor in the parietal bones. At the beginning of 2 days of life appeared jaundiced
skin. Phototherapy was performed. On day 5, the jaundice increased sharply. The child
became lethargic, muscle tone and tendon reflexes decreased. Blood bilirubin 342 μmol / l:
indirect - 320, direct - 22. Hemoglobin - 132 g / l, reticulocytes - 14%. On day 6, the child
became restless, there was hypertension of the lower and upper extremities, stiffness of the
occipital muscles, a symptom of "setting sun", convulsions.
3. Interpret the results of laboratory tests .

Answers:
1. Prolonged jaundice, severe, complicated by acute bilirubin encephalopathy
2. Treatment - non- rapid metabolic blood transfusion = Replacement transfusion . Use

plasma: O (I) RhD-negative or for children without anti-A, B- and D-antibodies - negative in
relation to the corresponding antigen; CMV negative (if available) Irradiated 4 ZTK is made by
volume of 2 BCC of the child (160 ml / kg) 4
• Continue intensive phototherapy

• Measure BSA for 2 hours after exchange transfusion
Intensive treatment: 30 μW / cm2 / nm (microW / cm2 / nm) or more (430–490 nm)
Light source:
- Use an additional light source under the child for intensive phototherapy . It can be a fiber-
optic substrate, an LED mattress or a set of special blue lamps . • Distance: - Maximize
exposure by minimizing the distance between the baby and the light source • Usually 10-15
cm for full-term and "near-term" (near term) children Care during phototherapy :
1. If possible, do not separate mother and child during phototherapy •

2. The baby has only a diaper.
3. Use protective barrier creams on the buttocks if the child has loose stools. Use
eye protection - moisturizing eye drops can be shown.
4. Monitoring of eye discharge and conjunctivitis.
5. Ensure constant monitoring of the child.
6. Monitoring the child's temperature:
- risk of hyperthermia if halogen lamps are used;
- risk of hypothermia if the undressed child is in a crib / crib when using LED or
fluorescent lamps at a cool ambient temperature;
- Place the premature baby in an incubator or under radiant heat.
7. Maintain a normal oral diet in full-term infants.
The clinical effect of phototherapy is obvious within 4-6 hours after

initiation . The estimated reduction of the BSA is 34 μmol / l .
Task 33
The boy was born at 36 weeks of gestation by caesarean section (premature detachment of
the normally located placenta, which led to bleeding in the mother). The child's body weight at
birth is 2800 g, body length 49 cm. Apgar score 3 \ 4 points. In the delivery room, according to
the Protocol, a full range of resuscitation measures was performed according to the severity
of asphyxia. During the examination in the intensive care unit, the child's condition is severe
due to cerebral, respiratory and cardiovascular insufficiency. Draws attention to muscular
hypotension, hypodynamics, pale skin and mucous membranes. Symptom of a pale spot for 4
seconds, tachycardia up to 180 beats per minute, blood pressure 50/35 mm Hg, muffled heart
sounds during auscultation and gentle systolic murmur. BH up to 70 per minute,
moaning. The liver and spleen are not enlarged. At research on cyto of peripheral blood the
level of Hb made 160 g \ l. Erythrocytes - 5.1 x 10 12 / l. SaO 2 = 78%.
2. Define the protocol of management of the patient. Justify the treatment. Describe the drugs
Answer:
1. RDS , severe degree
2. Additionally : radiography (frosted glass with increased transparency).

The Silverman scale is used to diagnose respiratory disorders in premature
infants. Assessment is performed every 2, 6, 12 and 24 hours of life );
Therapeutic measures during the provision of medical care to premature infants with RDS
include:
- non-invasive respiratory support (DP) or artificial lung ventilation (ALV), - surfactant therapy,
- use of additional oxygen as needed,
- condition monitoring and supportive measures,
- arterial correction hypotension.
The optimal strategy to help newborns with RDS is to create a constant positive airway
pressure (CPAP) as soon as possible with early therapeutic administration of surfactant. An
early sign of ineffective CPAP in a premature baby is the need for oxygen> 30% in the first 2
hours of life, which in turn justifies the feasibility of early administration of exogenous
surfactant using less invasive methods. Surfactant therapy: For optimal treatment of RDS, it is
recommended to use Poractant alpha in an initial dose of 200 mg / kg. The first therapeutic
dose of the drug should be administered as soon as possible (optimally - in the first 2 hours of
life). It is not recommended to start RDS treatment with surfactant after 15 hours of life. In
children who breathe independently and are on CPAP, but require the introduction of
surfactant (ineffective CPAP), the latter should be administered using the method of INSURE
(incubation of the trachea, bolus injection of surfactant, extubation and breathing through
nasal cannulas with constant positive pressure in the respiratory tract). The second and, if
necessary, the third dose of surfactant should be administered if after the first administration
of surfactant signs of RDS progress, in particular, there is a persistent need for oxygen or the
need for treatment with mechanical ventilation. The repeated dose of paractant alpha is 100
mg / kg. In the case of additional oxygen administration to a premature baby, it is necessary
to maintain the level of SpO2 within 90-94%. To do this, set the alarm limits of the pulse
oximeter at 89% and 95%, respectively.
After administration of the surfactant, it is necessary to avoid a hyperoxic peak (increasing the
level of SpO2 above these limits) by rapidly reducing FiO2.
The child's body temperature should be maintained in the range of 36.5-37.5 ° C, starting
from the delivery room and throughout the treatment period.
Most newborns with RDS who are in an incubator with the required level of humidity, the fluid
should be prescribed at a rate of 70-80 ml / kg / day. Change the daily amount of fluid should
be individually, depending on serum sodium and weight loss.
During the first few days of life it is necessary to limit the appointment of sodium until the
restoration of diuresis with careful monitoring of fluid balance and electrolyte levels.
Parenteral nutrition should be started immediately after birth. Protein is prescribed from the
first day of life in the amount of 2.0-2.5 g / kg / day.
The introduction of fats should also begin from the first day of life, rapidly increasing (if
tolerated) the daily amount to 3.0 g / kg / day.
Minimal enteral (trophic) breastfeeding (preferably) or formula should be started from the first
day of life if the baby's hemodynamics are stable.
Prescribing antibiotics:
Premature infants with persistent respiratory disorders should be prescribed antibiotics until
the diagnosis of "sepsis" or "pneumonia" is ruled out.
Use a combination of semisynthetic aminopenicillin and aminoglycoside as a starting point for

empirical antibiotic therapy.
Amoxiclav 30 mg / kg body weight at intervals of 8:00 + Gentamicin 5 mg / kg once daily,
a / c.
Antibiotic therapy should be stopped immediately after the diagnosis of "sepsis" or
"pneumonia".
Correction of arterial hypotension and ensuring adequate tissue perfusion Treat arterial
hypotension, the presence of which is evidenced by signs of
insufficient tissue perfusion (oliguria, acidosis, insufficient capillary filling - a symptom
of "white spot"> 3 s, etc.), and not just reduced arterial pressure. Drugs for the correction
of arterial hypotension are listed in the table: Maintain the appropriate concentration of
hemoglobin (Hb). The lower limit of Hb content in the blood of non- molluscs in need of
respiratory support in the first week of life is 115 g / l (hematocrit - 35%), in the second - 100 g
/ l (hematocrit - 30%) and 85 g / l (hematocrit - 25%) - at a later age. The concentration of Hb
below these indicators is an indication for erythromass transfusion.
3. SaO 2 = 78%. - hypoxia (96-98% )
Task 34
The girl, aged 4 weeks, was born weighing 1200 g. She received complex therapy in the
ICU for RDS. In the Department of Neonatal Pathology there was an increasing pallor of the
skin and mucous membranes, tachycardia up to 170 per minute, tachypnea at rest. Motor
activity is reduced, sucks poorly from the nipple, weight gain has stopped. No significant
pathology was detected in the internal organs. Clinical blood test on the 28th day of life: Hb-
80 g / l, er-2,5x10 12 / l, Ht 0,34; CP 1.0; Ret 2% 0 ; tr-450 x 10 9 / l. L-7.4 x 10 9 / l, n-3%, segm-
40%, lymph-51%, mon-6%, ESR-7mm / h. Macrocytosis of erythrocytes, hypersegmentation
of neutrophils, anisocytosis +++, poikilocytosis +++, thorny processes of erythrocytes.
2. Determine the tactics of the patient. Justify the treatment. Describe the drugs needed by
the patient. Indicate the dose and frequency of administration of drugs.
3. Interpret laboratory tests.
Answers:
1. Early anemia of prematurity, mild .

2. Additionally: the level of erythropoietin, folic acid, B12, ferritin, free iron in the blood?
The classic approach to the treatment of RAS is that in mild cases, anemia is carried out by
health measures ( air and hygienic baths, temperature regime, therapeutic gymnastics,
massage, etc.) and nutrition .
Prophylactic administration of vitamin E at a dose of 5 mg / day, and in its deficiency - at a

dose of 50 mg / day.
Folic acid is prescribed at a rate of 40 μg / day.
Some authors confirm the need for vitamins B6, B12, A, C and trace elements (zinc, copper,
manganese).
Therefore, against the background of a balanced diet, a vitamin-microelement complex

is prescribed . It includes multivitamins "Mu ltitabs" - 1-2 drops per day, iron "Actiferin" -
4 drops / kg / day in two doses, copper "Copper sulfate" and cobalt "Coamide" at the rate of
100 mcg of copper / kg and 2 mcg cobalt / kg 1 time per day, vitamin E-8.5 mg / day per dose.
The question of the validity of the appointment of iron supplements remains debatable . Given
the reduced fetal iron stores in preterm infants, the negative balance and increased
absorption of this trace element in the intestinal tract , as well as the progressive decrease in
serum iron in premature infants up to 2-3 months, it was recommended to use iron
supplements for RAS prevention .
In addition, it is not recommended to use milk formulas with an iron content of 10-12 mg / 0.14
l, as they can cause hemolysis, susceptibility to infectious diseases.
Subcutaneously erythropoietin 50 0-1000 IU / kg once a week. But more physiologically 150-

200 IU / kg 3 times a week.
3. Hb-80 g / l - reduced (120 g / l norm) 90-80- mild, up to 70 - moderate, up to 66 - severe

anemia. er-2,5х10 12 / l - reduced n and (4,2 -5,8 norm) Ht 0,34 - reduced (norm 0,4) KP
1,0; - Ret rate 2% - reduced (6-8% - in premature babies)
RI = number of reticulocytes (in percent) X (Ht of the patient / normal Ht of children of this
age).
2x0.34: 0.4 = 1.7 - normoregenerative anemia (2 <- hyperregenerative, <1 -

hyporegenerative, 1-2 - normogenerative.)
Erythrocyte macrocytosis, neutrophil hypersegmentation, +++ anisocytosis, +++

poikilocytosis, and erythrocyte - like processes are signs of megaloblastic anemia. (in 27% of
premature babies - the above symptoms are observed).
Conclusion: Normochromic, normoregenerative megaloblastic anemia, mild.
Task 35
Boy, age 1 day. The mother is 19 years old, she suffers from chronic
pyelonephritis. Pregnancy I, toxicosis of the first half of pregnancy. Exacerbation of chronic
pyelonephritis in the third trimester. Childbirth at 40 weeks of gestation. 1st period of childbirth
- 23 hours, 2nd - 35 minutes, waterless period - 22 hours. Amniotic fluid is greenish, with an
unpleasant odor. Apgar score 6/7 points. The body weight of the child at birth is 2700 g,
length 50 cm. Review. The child's condition is serious. Decreased motor activity. The cry is
weak, the reflexes are suppressed. T - 36.0 o C. The skin is pale, with a grayish tinge,
marbling, acrocyanosis, cyanosis of the nasolabial triangle. BH 68 / min. Retraction of
intercostal spaces. Breathing is shallow, with periods of apnea. Percussion over the lungs is
determined by the shortening of the sound, auscultation - breathing is weakened, on a deep
breath - crepitation on both sides. Heart tones are muffled, rhythmic, heart rate - 170 /
min. The abdomen is soft on palpation. The liver protrudes from under the costal arch by 2
cm, the spleen is not palpable. Clinical blood test: Hb - 180 g / l; Er. - 5.5 ∙ 10 12 / l; CPU -
0.9; Clot. - 208.0 ∙ 10 9 / L; Lake. - 25.1 ∙ 10 9 / L; myelocytes - 2%, metamyelocytes - 4%, e-
2%, p / I - 19%, c - 50%, l - 13%, m - 10%, ESR - 4 mm / h. Acid- base state of blood: pO 2 -
49 mm Hg, pCO 2 - 70 mm Hg, pH - 7.21, BE = - 18 mmol / l; BB = 19 mmol / L.
administration.
3. Interpret the results of laboratory tests .
Answers:
1. Meconium aspiration syndrome , severe form, moderate RDS.
2. Additionally: chest radiography , double pulse oximetry , echocardiography , cranial

ultrasound , EEG , blood cultures for sterility.
Treatment:
Resuscitation should be started immediately using artificial lung ventilation with a bag and
mask or breathing apparatus (Neonatal Resuscitation Protocol) if a newborn with
respiratory disorders, regardless of age:
1) has respiratory arrest (apnea) and the child does not respond to tactile stimulation, or
2) is detected breathing type "gasping" - single convulsive (terminal) respiratory movements,
or
3) is determined by bradypnea <20 breaths per 1 minute.
In the presence of moderate respiratory disorders (4-6 points) or severe (7 or more points):
1) as soon as possible to provide vascular venous access and begin infusion of 10% glucose
solution according to the age of the child ( 60-80 ml / kg per day) ), at least for the first 12
hours (Table 7);
2) insert the probe into the stomach to release it from the contents ; 3) Prescribing antibiotics:
Premature infants with persistent respiratory disorders should be prescribed antibiotics until
the diagnosis of "sepsis" or "pneumonia" is ruled out.
Use a combination of semisynthetic aminopenicillin and aminoglycoside as a starting point for
empirical antibiotic therapy.
Amoxiclav 30 mg / kg body weight at intervals of 8:00 + Gentamicin 5 mg / kg once daily,
a / c.
Antibiotic therapy should be stopped immediately after the diagnosis of "sepsis" or
"pneumonia".
4) Correction of metabolic disorders : Significant acidemia (pH of arterial / capillary blood

<7.2) . Regardless of the cause and age of the newborn at the time of metabolic acidosis
(arterial / capillary blood pH <7.2 and bicarbonate content less than 18 mmol / l), the latter is
corrected by slow infusion of 4.2% sodium bicarbonate solution provided effective ventilation
of the patient's lungs.
The required dose of sodium bicarbonate (mmol) is calculated by the formula:

Sodium bicarbonate (mmol) = deficiency of bases (mmol / l) x body weight of the child (kg) x
0.5 (age distribution ratio of anion bicarbonate).
Given that 1 ml of 4.2% sodium bicarbonate solution contains 0.5 mmol of sodium
bicarbonate, the required amount of solution (in milliliters) is determined by the product of the
amount of deficiency of bases and body weight of the child.
Half of the calculated amount of solution is injected very slowly (at least 2 minutes), and the
rest - for 8-12 hours.
Respiratory acidosis (blood pH <7.2 and PaCO2> 45 mm Hg) is corrected by artificial lung
ventilation (increase ventilation). Sodium bicarbonate solution is not prescribed in such cases,
as this may lead to a further increase in the value of PaCO2.
5) after stabilization of the child's condition and the appearance of signs of improvement on
the background of treatment (reducing the severity of respiratory disorders, reducing oxygen
dependence, increasing diuresis, increasing motor activity, etc.), it is advisable to start enteral
nutrition, prescribing expressed breast milk, and in its absence ;
I n case started enteral feeding, daily count necessary quantity of milk (mixture);
With alezhno of the child's condition gradually increase the amount of enteral nutrition and
simultaneously reduce the volume of the infusion in order to provide daily fluid volume under
age child's needs;
P Eid time enteral feeding should carefully monitor the general condition of the child:
respiratory rate, color of skin and mucous membranes, physical activity;
3. Clinical analysis of blood:

Acid-base state of blood:
pO 2 - 49 mm Hg - hypoxia (80-95) рСО 2 - 70 mm Hg - increased, hypercapnia (norm 35-
45) pH - 7,21 - decreased, acidosis (norm 7.35-7.45) BE = - 18 mmol / l; (norm -2.3 to +2.3
mEq / l ) - excess of alkalis BB = 19 mmol / l - reduced (Norm 42 - 52 mmol / l )
Task 36
The boy, aged 28 days, was admitted to the Department of Neonatal Pathology. From the
anamnesis: mother 24 years old, pregnancy 1-a, in 24-26 weeks of gestation there was an
increase in temperature without catarrhal phenomena, the pregnant woman was not
treated. Childbirth at 38 weeks of gestation, physiological. Body weight at birth 2800 g, length
- 48 cm, head circumference - 35 cm, chest - 32 cm. The child is attached to the breast in the
delivery room. Discharged home on the 3rd day. The early neonatal period, according to his
mother, went smoothly. From the age of 10 days the child became lethargic, sucked
unsatisfactorily. The weight gain for the month was 450 g. Review. The child's condition is
serious. The skin is pale pink, dry, insufficient nutrition. The head is hydrocephalic in shape,
the circumference of the head is 40 cm, the thorax is 34 cm. The discrepancy of the skull
bones along the sagittal and coronal sutures, the large crown is 4x4 cm. The Grephe's
symptom is pronounced, horizontal nystagmus. Liver + 2.5 cm; spleen + 1 cm protrudes from
the edge of the costal arch. Clinical blood test. Hb - 140 g / l; Er. - 4.1 ∙ 10 12 / l; CPU -
0.9; Thrombosis. - 208.0 ∙ 10 9 / l; Lake. - 10.1 ∙ 10 9 / l; e-5%, p / ya - 6%, s - 30%, l - 44%, m -
5%, ESR - 4 mm / year. Analysis of cerebrospinal fluid: transparency - cloudy, protein 1.66 g /
l, cytosis - 32.

2. Determine the protocol of management of the patient, prescribe
treatment, listing the groups of drugs, representatives of each group, indicate
the dose and frequency of administration.
1. Congenital toxoplasmosis. Acute encephalitis. Cerebrospinal fluid syndrome

(hydrocephalus).
2. Detection of toxoplasma DNA by PCR , ELISA.

Treatment:
1st option: The total duration of specific therapy 1 year: 4-6 weeks - a combination of
chloridine with sulfadimesine + folic acid 2 times a week;
during the year - 4 courses, divided into 1-1.5 monthly courses of Spiramycin.
Option 2: Chloridine and Sulfadimesine 6 months, then up to 1 year, monthly courses of
chloridine and sulfamedizine, alternating with spiramycin. + corticosteroids . Pyrimethamine
(daraprim, chloridine, tindurine in the first 2 days is given orally in the load up to 2 mg / kg /
day., Divided into two doses; then - at a dose of 1 mg / kg / day . (In 2 doses for oral
administration) once in 2 days, because the half-life of the drug from the body - about 100
hours.
Sulfadimesine is prescribed at a dose of 50-100 mg / kg / day. in 2 or 4 receptions inside.
To prevent hematological toxicity of chloridine and sulfadimesine three times a week give folic
acid orally or parenterally at a dose of 5 mg (Optimally 10 mg of leucovorin).
In second place in terms of efficiency are macrolides.

Spiramycin (rovami tsin) - 1-1.5 month course at a dose of 100 mg / kg / day ., Divided into 2
doses, in the middle.
Clindamycin 30mg / kg per day
Co-trimoxazole (in the absence of these drugs , as well as in the impossibility of their enteral
administration) - at the rate of 30 mg of sulfamethoxazole and 6 mg of trimethoprim per kg of
body weight per day intravenously in 2 doses (Duration - not more than 14 days,
under control number of erythrocytes, hemoglobin, leukocytes, platelets every other day);
Therapy of cerebrospinal fluid-hypertension syndrome :

 Diacarb 80-100 mg / kg / day orally, maintenance dose 30-50 mg / kg / day
 Furosemide 1 mg / kg / day intravenously
 Dexamethasone 0.1 mg / kg intravenously
 Isosorbit 2 mg / kg intravenously
 Lumbar puncture
Subsequently,
prednisolone at a dose of 1.0 mg / kg / day., Divided into two doses, inside (morning
and afternoon) is prescribed for a proven active inflammatory process (in the presence of
protein in the cerebrospinal fluid more than 1 g / dl and active chorionic retinitis, threatening
violations vision) until it subsides (to reduce the level of protein in the CSF to 1 g / l or to
regression of active chorioretin and).
The dose is gradually reduced before discontinuing the drug .
3. Analysis of cerebrospinal fluid: transparency - cloudy (normal - transparent)

protein 1.66 g / l - n and mobile (normal - 0,15-0,33)
cytosis - 32 - increased (normal 10-20)
Task 37
The boy, A., 11 years old, was admitted to the hospital under the direction of a district
pediatrician with complaints of cramp-like abdominal pain, pain in the right knee and ankle
joints, the appearance of a small red rash on the lower extremities. Two weeks ago, the boy
had a fever up to 38.50C, sore throat. Diagnosed with lacunar sore throat, prescribed
amoxicillin. After 7 days on the skin of the lower extremities appeared a small rash,
intermittent pain in the right knee joint. Upon admission, the child's condition is
serious. Sluggish, forced position with knees tucked up to the abdomen. On the extensor
surface of the lower extremities, buttocks, around the joints, earlobes small droplets,
sometimes draining, hemorrhagic rash, slightly protruding above the skin surface,
symmetrically located. The right knee and ankle joints are swollen, painful, limited in
movement, hot to the touch. The abdomen is painful on palpation. The liver and spleen are
not palpable. Chair in small portions, pasty, the color of "raspberry jelly". Urination is free,
12
urine is light. General blood test: HB-110g / l, Er-3,5x10 / l, Ts.P. -0.9, Thrombus. -
435x10 9 / l, Lake. -12,5h 10 9 / L, Young -1% p / I - 5%, from - 57%, -2% e, l- 28% of -7%,
ESR - 25 mm / h. Biochemical analysis of blood: total protein -71 g / l, urea - 3.7 mmol / l,
creatinine - 47 μmol / l, total bilirubin - 20.2 μmol / l, AST - 20 units, ALT - 20 units. General
analysis of urine: color - straw-yellow, relative density - 1012, no protein, epithelium - 0-1 in
p / s, leukocytes - 2 4 in p / s, erythrocytes, cylinders are absent.
Answers:
1. hemorrhagic vasculitis , active phase, mixed form, cutaneous articular second and
abdominal syndrome, moderate, acute course. Complications: Intussusception.
2. Research: coagulogram, alkaline blood phosphatase, autoimmune profile: ANA, dsDNA,

pANCA, cANCA; Determination of IgA in the wall of the affected blood
vessels method ohm direct imunoflyuorestsensiyi). Instrumental studies are indicated for all
patients : ECG, Echo-CG, Doppler-CG , ultrasound examination of the ankle joint, ultrasound
examination of the abdominal cavity
Emergency surgery.
- Bed rest for the period of new rash, arthralgia or arthritis, abdominal pain.
- Diet with the exception of irritating foods, as well as foods that can cause allergic reactions.
- Medicated:
direct-acting anticoagulant heparin is prescribed for abdominal, renal syndromes, severe
skin syndrome and in the presence of hypercoagulation according to the coagulogram:
at an average degree - 200-500 IU / kg / day;
Heparin should not be administered twice or thrice a day, as it provokes the formation of
intravascular blood clots. Withdrawal of heparin should be gradual, by reducing the dose, not
reducing the number of injections.
The duration of heparin administration (within 2-4 weeks) depends on the form and severity of
the disease, the clinical response to therapy, indicators of the blood coagulation system;
antiplatelets (dipyridamole 3-5 mg / kg / day, pentoxifylline 5-10 mg / kg / day for 4-6 weeks
with gradual withdrawal);
antihistamines (fencarol, peritol, suprastin, tavegil, claritin, loratadine, cetrin in age doses for
a period of 2-4 weeks) with a mild course, itchy skin;
glucocorticoids (GC) are indicated for lightning, abdominal, renal and massive hemorrhagic
syndrome with a high degree of inflammatory activity. Prednisolone is prescribed at a dose of
1-2 mg / kg / day for a period of 2-4 weeks with gradual withdrawal. To reduce the
hypercoagulant effect, HA is combined with anticoagulants and disaggregants. At a high
degree of inflammatory activity, a joint syndrome, but without signs of defeat of kidneys
reception of prednisolone by a short course for 5-7 days with the subsequent full cancellation
for the purpose of prevention of nephrological pathology is allowed;
aminoquinoline drugs in moderate severity, low activity and hematuric form of Shenlein-
Genoch glomerulonephritis (delagil 2.5-5 mg / kg body weight per day) in a continuous course
for 12-18 months;
immunosuppressive therapy is prescribed in case of chronic recurrence, high degree of
activity (azathioprine 1-2 mg / kg / day for 2-3 doses for 1-2 years under the control of blood
tests);
3. General blood test:

HB-110 g / l - reduced, the rate of 120-150 g / l . Er-3,5 х10 12 / l - reduced, norm - 4,2-
4,8 х10 12 / l Ts.P. -0.9, - Thrombus norm . - 435 x10 9 / l, - thrombocytosis, norm 150-
300 x10 9 / l Lake. -12,5h 10 9 / l, ESR - 25 mm / h.
Task 38
The patient is 7 years old, was admitted to the clinic on the 3rd day of illness with
complaints of headache, swelling of the face, legs, the appearance of urine the color of "meat
slops". The child from the first pregnancy which proceeded with toxicosis of the first half, the
first urgent childbirth. The real disease began 2 weeks after the sore throat. On admission,
the condition is moderate. The skin and visible mucous membranes are clean, there is
swelling of the face, legs and feet. In the pharynx tonsils are hypertrophied II-III degree, fluffy,
without overlays. Musculoskeletal, lymphatic system without features. Vesicular respiration,
no wheezing, BH 20 per minute, the boundaries of the heart are not expanded, rhythmic heart
sounds, heart rate 72 per minute, blood pressure 135/85 mm Hg. Abdomen of normal shape,
soft, painless. The liver and spleen are not palpable. Daily diuresis 400 ml, urine reddish-
brown. General blood test: Hb - 125 g / l. Er - 4,3x10 12 / l, Lake - 12,3х10 9 / l, p / i - 5%, z -
60%, e - 5%, l - 24%, m - 6%, ESR - 30 mm / an hour. General analysis of urine:
transparency - incomplete, reaction - alkaline, relative density - 1020, epithelium - 1-2 in p / s,
erythrocytes - 50-60 in p / s, leukocytes - 2-3 in p / s, cylinders - granular 3-4 in p / s, protein -
0.99 g / l. Biochemical analysis of blood: total protein - 65 g / l, albumin -53%, alpha 1 globulin
- 3%, alpha2-globulin - 17%, beta-globulin -12%, gamma globulin - 22%, urea - 4.2 mmol / l,
creatinine - 87 μmol / l, potassium - 5.21 mmol / l, sodium - 141.1 mmol / l, cholesterol - 6.0
mmol / l, beta-lipoproteins - 2.0 g / l. Daily protein loss: protein - 0.8 g / l, diuresis 1.2 liters.
In response:
1. Acute glomerulonephritis with nephritic syndrome, a period of detailed clinical
manifestations, acute renal failure. Chronic tonsillitis.
2.-Bed rest for at least 2 weeks
-diet: table №7a-7, water regime
-antibacterial therapy 2-4 weeks (cefuroxime 75 mg / kg / day, cefuroxime axetil 30 mg / kg /

day, amoxicillin 30 mg / kg / day)
-claritin 10 mg x 1p №10-14
-furosemide 2 mg / kg / day №3-5
-dibazole 0.005 x 2r / day №10-14
-enterosgel 1 dec. spoon x 3p / day №7-10
-further remediation of chronic foci of infection

Task 39
Patient E., 12 years old, was admitted to the clinic with complaints of fatigue, hair loss,
brittle nails, taste perversion, loss of appetite, epigastric pain, intensified on an empty
stomach. The patient for 10 years suffers from peptic ulcer disease with frequent
exacerbations. Black, tar-like chair was repeatedly noted. Blood test: Hb 70 g / l, erythrocytes
3.5 × 10 12 / l, reticulocytes 14%, platelets 380 × 10 9 / l, leukocytes 5.2 × 109 / l, myelocytes -
0, metamyelocytes - 0, p / I - 2, s / I - 64, e - 2, b - 0, l - 27, mn - 5, plasma cells - 0%, ESR 16
mm / h, severe anisocytosis (microcytes), moderate poikilocytosis; erythrocytes with
basophilic granularity, single in the field of view polychromatophilia. Serum iron 5.2 μmol / l,
indirect bilirubin 10 μmol / l, transferrin iron saturation 8%.
Answer:
1. Hypohemoglobinemia, hypoerythremia, increase in the number of reticulocytes (normal

0.5-2%) (hyperregenerative anemia), a slight increase in ESR, decreased serum halide
(normal 14-25), and iron saturation transferrin (normal 15-50%).
2. chronic posthemorrhagic anemia, severe
Task 40
A 7-year-old child periodically develops jaundice, fever, enlarged liver and

12
spleen. Laboratory indicators of blood: erythrocytes - 2,2 × 10 / l, hemoglobin - 90 g / l, KP -
0,9, reticulocytes - 30 ‰, leukocytes - 6,2 × '10 9 / l, eosinophils - 2%, rod-shaped neutrophils
- 4%, segmental neutrophils - 66%, lymphocytes - 22%, monocytes - 6%, ESR - 16 mm / h,
microspherocytosis. Osmotic resistance: min. / Max. - 0.46-0.24 - 0.48-0.26.
Answer:
1. Hb ↓, erythrocytes ↓, reticulocytes ↑ (N = 0.5 -2%), platelets, leukocytes - N,
eosinophils, rod-shaped neutrophils, segmental neutrophils, lymphocytes, monocytes -
N. ESR ↑, lower. Osmorezist. (0.54-0.34 N)
2. Hemolytic hereditary anemia Minkowski -Schoffar (microspherocytosis), severe,
hemolytic crisis
Task 41
Vitya V., at the end of April fell ill with angina. He was treated with acetylsalicylic acid. On
May 10, hemorrhagic rash appeared on the hands and feet in the form of ecchymosis and
petechiae, and on May 11 there was nosebleeds, which were stopped after applying cold to
the nose. He was sent to the hospital. Upon admission to the clinic, the condition is
moderate. Lethargic, pale, abundant rash all over the body in the form of petechiae and
ecchymoses. Positive symptoms of a pinch, a plait. Internal organs without
abnormalities. Blood test: er.- 4.6 x 10 12 / l, Hb -110g / l, KP - 0.9, lake.-5x10 9 / l, EOS. 1%,
item 1%, segment.- 73%, lymph.-20%, mon.-5%, ESR - 10 mm / h, platelets - 46 x 10 9 /
l. Retraction of a blood clot - 65%. The duration of Duke's bleeding is 20 minutes. Collapse by
the method of Lee-White - 7 minutes After a month of therapy, the child's condition is
satisfactory, platelets-180x10 9 / liter.
Answers:
1. Hypohemoglobinemia, thrombocytopenia, increased duration of bleeding according to
Duke (normal 2-4 minutes) and li-white (normal 4-6 minutes)
2. Heteroimmune thrombocytopenic purpura, acute course
Task 42
In a 7-month-old child on the background of runny nose, cough, redness of the mucous
membrane of the posterior wall of the pharynx is an increase in body temperature to 39.8 0 C,
agitation, clonic-tonic convulsions. At a lumbar puncture the cerebrospinal fluid flowed out
frequent drops, Pressure - 1,9kPa; cytosis - 5 cells / μl. Cytogram: lymphocytes - 97%,
neutrophils 3%. Protein - 0.22 g / l. Panda's reaction is negative. The Nonne-Apelt reaction is
negative. Sugar - 2,6 mmol / l (in blood - 5,2 mmol / l. Fibrin film is absent. Chlorides - 105
mmol / l.
2. Determine the tactics of treatment and list the groups of drugs.
3 Name the representatives of the drugs from each group.
4 Indicate the dose and frequency of administration.
5 Interpret the analysis of cerebrospinal fluid.
Answers:
1. Acute serous meningitis of moderate severity.

2. Strict bed rest until stable normalization of body temperature, disappearance of
meningeal syndrome and normalization of blood, cerebrospinal fluid, on average for 10-
14-21 days.
Diet therapy: children of the first year of life are prescribed breast milk or adapted milk
formulas in the first day with a volume of 1 / 2-1 / 3 of the age norm, followed by an
increase to full volume within 2-3 days.
Detoxification therapy is performed with 5% glucose solution in combination with 7.5%
potassium chloride solution, saline solutions (isotonic sodium chloride solution, Ringer's
solution), hydroxyethyl starches (refortan, stabizol, volekam).
The total daily volume is not more than 2/3 of physiological needs (with normal diuresis
and no initial dehydration). The volume of infusion should not exceed 1/2 of
physiological need (80 ml / kg).
From the second day maintain fluid deficiency in the mode of zero water balance. The
volume of infusion is 1/3 - 1/2 of physiological needs.
In case of oliguria or anuria, fluid administration is contraindicated until diuresis is
restored.
For dehydration use furosemide ( 1 mg / kg) , mannitol ( 0.25-1 g / kg body weight or
30 g per 1 m2 of body surface for 2-6 hours.) .
Dexamethasone is prescribed to prevent neurosensory deafness at a daily dose of
0.15 mg / kg every 4 hours for the first 2 days. The first dose of dexamethasone should
be given 10-30 minutes before the antibiotic is given.
In viral meningitis, angioprotectors (actovegin, trental, instenon, ceroxone) are
indicated together with infusion therapy to improve microcirculation.
Apply ribonuclease - a course of 2 weeks 6 times a day, children under 1 year - 3 mg,
2-3 years - 5-9 mg, 6-10 years - 14 mg, 11-15 years - 20 mg.
At herpesvirus meningitis - acyclovir (at a dose of 10-35 mg \ kg on 100 ml of physical
solution in \ 3 times a day), at cytomegalovirus - ganciclovir (in / in introduction the
daily dose makes 5-10 mg / kg.), groprinosin, tsimiven in age doses. The course of
treatment varies from 5 to 20 days
If meningitis is suspected, all children are prescribed empirical antibacterial therapy
(ceftriaxone (100 mg / kg / day) or cefotaxime (100 mg / kg / day)).
Anticonvulsant therapy (phenobarbital ( D and tyam 30-40 minutes before meals 2
times and on the day: single a dose of 10 mg) , diphenine, sibazon ( C erednya single
dose - 10 mg (2 ml of 0.5% r-ra )
3. In the analysis of lumbar puncture - High blood pressure and the relative number
of lymphocytes
Task 43
A 4-year-old child was admitted to the admission department on the first day of the disease
in a serious condition: body temperature - 39.5 0 C, marbling of the skin, acrocyanosis, on the
skin of the lower extremities, torso abundant hemorrhagic, "star" rash, blood pressure - 80/40
mm Hg, heart rate - 90 / min., oliguria. Positive meningeal symptoms.
At a lumbar puncture the cerebrospinal fluid flowed out frequent drops. The cerebrospinal
fluid is turbid, milky white. Pressure - 2.8 kPa; cytosis - 7000 cells / μl. Cytogram: lymphocytes
- 15%, neutrophils 85%. Protein - 1.6 g / l. Panda's reaction - (+++). Nonne-Apelta reaction -
(+++). Sugar - 2.6 mmol / l (in blood - 5.2 mmol / l. Fibrin film is absent. Chlorides - 105
mmol / l. Detected diplococci Gr (-), in pairs, extra- and intracellularly.
4 Indicate the doses and frequency of use of antibacterial drugs.
5 Interpret the analysis of cerebrospinal fluid.
Answers:
1. Meningococcal meningitis. Meningococcemia. ITS II degree
2. TREATMENT:
Pre-hospital stage of treatment:
1. Providing venous access.
2. Antibacterial therapy - chloramphenicol sodium succinate 25 mg / kg (single

3. Glucocorticoids - prednisolone, hydrocortisone or dexazone 2-3 mg / kg

prednisolone 10 mg / kg.
4. Infusion therapy with saline or rheopolyglucin to stabilize BCC. initiate

infusion therapy with isotonic saline ( 0.9% sodium chloride solution or sodium
chloride solution + potassium chloride + calcium chloride + sodium lactate) in the
amount of 20 ml / kg body weight in 20 min + hydroxyethyl starch III generation
10 ml / kg
5. Inotropics (D opamine) - to support hemodynamics. 8-10 μg / kg per

minute. under the control of blood pressure and heart rate.
Hospital stage of treatment:
1. Depending on the severity of hospitalization in the intensive care unit and

intensive care unit, or the neuroinfection department of an infectious hospital.
2. Ensuring airway patency and adequate respiration (oxygen therapy, auxiliary

ventilation with a mask, tracheal intubation and mechanical ventilation).
3. Antibacterial therapy: in the presence of ITS drug of choice - chloramphenicol

succinate at a dose of 100 mg / kg / day, when removing a patient with ITS prescribe
penicillin 200 mg / kg / day, or third-generation cephalosporins - cefatoxime 100-200
mg / kg / day, ceftriaxone kg / day.
In severe form and the need to protect against nosocomial infection additionally used
aminoglycosides of the 3rd generation - amikacin up to 20 mg / kg / day, netil mycin
1.5-2 mg / kg every 8 hours.
Treatment of hyperthermic syndrome (paracetamol, ibuprofen, metamizole sodium,

physical cooling methods) Pale fever: Papaverine 2% 0.1 ml / year in / m or Dibazol 1% 0.1-
0.2 ml / year of life + analgin 50% 0.1 ml / year of life. Or in / m enters ting analginum 50% 0.1
ml / per year of life , and a 1% ozchynu  Mr. ikotynovoyi acid and 0.05 ml / kg.
Red fever: ibuprofen 5-10 mg / kg 3 times a day, ie every 8 hours. or paracetamol 10-15 mg /
kg every 6 hours.
3. liquor turbid (normal - transparent),
milky white count oru (norm - a colorless )
pressure - 2.8 kPa - high (normal 1-1,78 kPa )
cytosis - 7000 cells / mm - high (normal - 3 10)
Cytogram: lymphocytes - 15%,
neutrophils 85% - cytosis due to neutrophils.
Protein - 1.6 g / l - increased (0.15-0.33)
Panda reaction - (+++) - moderate turbidity - a sign of purulent meningitis.

Detection of globulins by exfoliation ( Nonne-Apelt reaction ) - (+++) - significant turbidity - a
sign of purulent meningitis
Sugar - 2.6 mmol / l (in the blood - 5.2 mmol / l. - Chloride norm - 105 mmol / l . -
with Mr. yzheni (120-140) revealed diplococci Gr (-) pairwise roztashov or, extra- and
intracellular - meningococcus.
Task 44
A 3-year-old child complains of a cough that gradually worsens. On the 12th day
objectively: temperature 37.1ºC, pale skin. The mucous membrane of the oropharynx is pale
pink. There is a small ulcer on the bridle of the tongue. There are bouts of coughing up to 20
per day, which are characterized by a series of coughing fits, followed by wheezing, the attack
ends with the release of vitreous sputum. In the lungs, shortness of breath, dry wheezing,
sometimes wet. On the radiograph: horizontal position of the ribs, increased lung
transparency, expansion of the root pattern. In the blood: leukocytosis - 23x10 9 / l, e. -1%, p.-
3%, s.-23%, l. -70%, m. -3%, SHZE - 2 mm / year. During one of the bouts of coughing, the
child stopped breathing
4 Indicate the doses and frequency of use of antibacterial drugs.

Answer:
1. Whooping cough, typical form, period of spasmodic cough, severe severity.
2. Treatment:
Mode - maintaining the optimal air regime (frequent airing, wet cleaning). In mild and
moderate forms, a long stay in the fresh air is prescribed.
3. Diet - the daily amount of food is maintained, the number of feedings increases.
First-line drugs: macrolides; Second-line drugs (for macrolide intolerance) trimethoprim

sulfamethoxazole, synthetic penicillins (amoxicillin).
Children older than 6 months - azithromycin - 10 mg / kg (not more than 500 mg) orally on the
1st day, then 5 mg / kg (not more than 250 mg) in the next 4 days;
Clarithromycin - children older than 1 month: 7.5 mg / kg (maximum 500 mg) orally every 12
hours for 7 days;
Erythromycin - children older than 6 months 40-50 mg / kg body weight per day (not more
than 2 g per day) in 4 doses for 7 days.
In case of macrolide intolerance, co-trimoxazole and ampicillin are used, which are prescribed
for 14 days.
T rimethoprim sulfamethoxazole - 40 mg / kg per day 2 r / d, 14 days.
Hormone therapy is prescribed for severe disease: prednisolone 3‒5 mg / kg per day,
hydrocortisone 5‒7 mg / kg per day, dexazone 0.25 mg / kg per day after 6 hours at a rate of
3‒5 days.
Specific protykashlyukovyy γ-globulin complements the successful early treatment diseases

of r ryuvannya. It is administered intramuscularly in 3 ml 3 days in a row, then several times a
day. At clinically expressed symptoms of a hypoxemia and a hypoxia oxygen therapy is
shown.
Aspiration of mucus and sputum from the respiratory tract, oxy gene therapy, salt-
alkaline inhalations are performed. 2.4% solution of euphyllin 2-3 mg per kg of body weight
(0.15 ml per kg) in isotonic sodium chloride solution, sodium bicarbonate, treatment of
the disease that led to respiratory failure is shown. In the absence of effect from therapy and
beds of the last weight of respiratory insufficiency the rehabilitative bronchoscopy is shown, at
the III degree of respiratory insufficiency carry out IVL.
3. In the blood: leukocytosis - 23x10 9 / l
l. -70%,
Absolute lymphocytosis in the blood.
Problem 45
A 3-year-old boy gradually became ill. From the first days of the disease, the child's mother
complained of a dry, infrequent cough. Then the cough became paroxysmal, each attack of
cough lasted up to 10 minutes and consisted of a series of short coughing fits, which were
interrupted by a convulsive deep breath. There were up to 6-8 of them during one attack of
cough. The attack ended with vomiting. One of the bouts of coughing led to apnea.
When conducting a clinical blood test, the following results were obtained: Hemoglobin -
125 g / l; Er. - 4.4x 10 9 / l; k.p. - 0.9; Leukocytes - 19.2x10 9 / l; e - 1%; n - 2%; c - 22%; l -
Answers:
1. Whooping cough , typical form, period of spasmodic cough , severe.
2. Treatment:
Mode - maintaining the optimal air regime (frequent airing, wet cleaning). In mild and
moderate forms, a long stay in the fresh air is prescribed.
Diet - the daily amount of food is maintained, the number of feedings increases.
First-line drugs: macrolides; Second-line drugs (for macrolide intolerance) trimethoprim

sulfamethoxazole, synthetic penicillins (amoxicillin).
Children older than 6 months - azithromycin - 10 mg / kg (not more than 500 mg) orally on the
1st day, then 5 mg / kg (not more than 250 mg) in the next 4 days;
Clarithromycin - children older than 1 month: 7.5 mg / kg (maximum 500 mg) orally every 12
hours for 7 days;
Erythromycin - children older than 6 months 40-50 mg / kg body weight per day (not more
than 2 g per day) in 4 doses for 7 days.
In case of macrolide intolerance, co-trimoxazole and ampicillin are used, which are prescribed
for 14 days.
T rimethoprim sulfamethoxazole - 40 mg / kg per day 2 r / d, 14 days.
Hormone therapy is prescribed for severe disease: prednisolone 3‒5 mg / kg per day,
hydrocortisone 5‒7 mg / kg per day, dexazone 0.25 mg / kg per day after 6 hours at a rate of
3‒5 days.
Specific antitussive γ-globulin complements successful treatment in the early stages of the
disease. It is administered intramuscularly in 3 ml 3 days in a row, then several times a
day. At clinically expressed symptoms of a hypoxemia and a hypoxia oxygen therapy is
shown.
Aspiration of mucus and sputum from the respiratory tract, oxygen therapy, salt-alkaline
inhalation. Shown 2.4% solution of euphyllin 2-3 mg per kg of body weight (0.15 ml per kg) in
isotonic sodium chloride solution, sodium bicarbonate, treatment of the disease that led to
respiratory failure. In the absence of effect from therapy and increase in severity of respiratory
insufficiency the rehabilitative bronchoscopy is shown, at the III degree of respiratory
insufficiency carry out IVL.
3. In the blood: leukocytosis - 23x10 9 / l

l. -70%,
Absolute lymphocytosis in the blood.
Task 46
A 1-year-old child was hospitalized in the infectious department with complaints of

repeated unrestrained vomiting, profuse liquid watery stools. Objectively: facial features are
sharpened, eyes are inflamed, tissue turgor is sharply reduced, acrocyanosis, lethargy. Blood
pressure - 55/35 mm Hg Anury.
The following results were obtained during the clinical blood test: Hemoglobin - 115 g /
l; Er. - 4.1x 10 9 / l; k.p. - 0.9; Leukocytes - 4.1x10 9 / l; e - 1%; n - 3%; c - 21%; l - 72%; m -
3%; Platelets - 225x10 9 / l; ESR - 4 mm / year. Hematocrit- 41.

4 Specify the dose and method of rapid rehydration (bolus administration).
Answers:
1. Compensated hypovolemic shock III degree.
2. Hospitalization in the infectious department; Infusion therapy: 5% glucose, saline solutions

(saline, Ringer's solution, Trisol), KCl ; blood pressure correction Adrenergic and
dopaminergic drugs (Dopamine 2 - 8 μg / kg / min.) ; Membrane stabilizing therapy with
glucocorticoids (prednisolone 1-1.5 mg / kg / day for 3-5 days)
With the development of DIC syndrome, its correction (heparin 150 IU / kg , trental 5 mg / kg /
day )
Restoration of adequate diuresis, diuretics (euphylline 5-8 mg / kg / day, furosemide 1-3 mg /

kg / day)
Normalization of intestinal microflora (linex, hilak-forte)
Enterosorbents (enterosgel, smectite)
Restoration of normal digestion - proteolytic enzymes (pancreatin, mesylate, creon)
Vitamin therapy (ascorbic acid, B vitamins)
In the absence of laboratory control of infusion therapy and the need for rapid rehydration in
the first stage ( resuscitation) use the technique of rapid rehydration - bolus administration of
glucose-saline solutions in a ratio of 1: 1 at a rate of: in the first 30 minutes 30 ml / kg, for the
next 2.5 h 70 ml / kg, further . The child's condition is checked every 15-30 minutes until the
pulse on the radial artery is restored. After the entire volume of solutions is introduced, the
child's condition is assessed again :
if signs of severe dehydration persist, repeated intravenous fluid administration according to

the above scheme.
If the child's condition improves, but there are signs of moderate exsiccosis, switch to oral
administration of glucose-saline solutions
3. Laboratory: Hematocrit - the upper limit of normal, segmental granulocytes are reduced,
lymphocytes are elevated, other indicators are normal, these indicators may indicate a viral
infection, the so-called "shift of the formula to the right".
Task 47
The 4-month-old child was taken to the clinic in serious condition. Ill for 2 days, disturbed
by vomiting up to 10 times and loose stools up to 7 times a day. According to the mother,
there is a significant loss of body weight during the illness. Temperature - 36.1 o C. The skin is
pale, with a "marble" pattern, dry. She cries without tears. Mucous membranes are bright
pink, dry. The child does not want to drink. There are no active movements, bradycardia, low
blood pressure. In the lungs, breathing is evenly weakened. Urination once every 4-6
hours. Stool in small quantities, yellow-green, without pathological impurities.
When conducting the ionogram, the following results were obtained: sodium (Na + ): 125 mmol
/ l; potassium (K + ): 3.4 mmol / l; chlorides (Cl - ): 85 mmol / l; calcium (Ca 2 + ): 2.1 mmol /
l; (ionized 09 mmol / l, magnesium (Mg2 + ): 0.6 mmol / l,
4 Methods of parenteral rehydration, dose.
5 Interpret the results of the ionogram.
Answer:
1. Acute toxic dyspepsia, hypotonic type of dehydration, exicosis of the III century.
2. Hospitalization in the infectious department, cleansing enema, gastric

lavage.
Rehydration therapy is performed with glucose-saline solutions (5% glucose solution in
combination with 0.9% sodium chloride solution in a ratio of 1: 1).
Antibacterial therapy of cephalosporins of the third generation (Ceftriaxone 0.25 g iv
page 2 times / day for 5 days)
Membrane stabilizing therapy with glucocorticoids (prednisolone 1-1.5 mg / kg / day for
3-5 days)
With the development of DIC syndrome, its correction (heparin 150 IU / kg , trental 5
mg / kg / day )
Restoration of adequate diuresis, diuretics (euphylline 5-8 mg / kg / day, furosemide 1-
3 mg / kg / day)
Normalization of intestinal microflora (linex, hilak-forte)
Enterosorbents (enterosgel, smectite)
Restoration of normal digestion - proteolytic enzymes (pancreatin, mesylate, creon)
Vitamin therapy (ascorbic acid, B vitamins)
Stages of rehydration 1 stage - resuscitation of 20 ml / kg with 5% glucose solution in

combination with 0.9% sodium chloride solution in a ratio of 1: 1, if necessary, repeat
(20 ml / kg)
Stage 2 - recovery - lasting 8 hours, lead 5% glucose + 0.45% NaCl + 20-30 meq /
l KCl at the rate of ½ deficiency remaining after resuscitation + 1/3 of physiological
needs per day; Stage 3 - stabilization - lasts 16 hours, calculation (5% glucose + ½
deficiency remaining after resuscitation + 2/3 physiological needs )
3. Sodium ( Na + ): 125 mmol / l (norm 135-145); potassium ( K + ): 3.4 mmol / l (norm 3.4-
5.5); chlorides ( Cl - ): 85 mmol / l (norm 95-110); calcium ( Ca 2 + ): 2.1 mmol / l (norm 2.3-
2.5); (ionized 0.9 mmol / l (norm 1.03-1.37), magnesium ( Mg 2 + ): 0.6 mmol / l (norm 0.7-1).
Task 48
The 10-month-old child became acutely ill. The disease began with a rise in body
temperature to 38.8 o C, nasal congestion, coughing. The mucous membrane of the posterior
wall of the pharynx is hyperemic. On the 3rd day, the general condition of the child
deteriorated due to an increase in temperature to 39.9 o . The child is conscious. Pale skin,
acrocyanosis, cold extremities, a positive symptom of "white spot". Tachycardia, shortness of
breath, convulsive readiness.
When conducting a clinical blood test, the following results were obtained: Hemoglobin -
121 g / l; Er. - 4,3x 10 9 / l; k.p. - 0.9. Leukocytes - 3.9x10 9 / l; e - 1%; n - 3%; c - 27; l -
1 Establish a previous diagnosis / emergency.
2 Define treatment tactics and list groups of drugs.

Answers:
1. SARS, among its severity, acute pharyngitis. Hyperthermic syndrome.
2. Tactics of treatment - relief of "pale fever": the same antipyretic + vasodilator drugs and
Papaverine 2% 0.1 ml / year in / m or Dibazol 1% 0.1-0.2 ml / year of life + analgin 50% 0.1
ml / year of life.
Or in / m enters ting analginum 50% 0.1 ml / per year of life , and a

1% ozchynu  Mr. ikotynovoyi acid and 0.05 ml / kg.
Subsequently, ibuprofen 5-10 mg / kg 3 times a day, ie every 8 hours. or paracetamol 10-15

mg / kg every 6 hours.
However, if there are signs of centralization of blood circulation (the difference between
axillary and rectal temperature is more than 1 ° C) in / m 0.25% solution of droperidol in 0.1 ml
/ kg (0.05 mg / kg) + analgin 50% for up to 1 year 0.1 ml / year of life.
But after droperidol side effects are possible: extra pyramidal disorders with a convulsive
component (tonic contractions of the face and neck).
In the presence of seizures 0.5% solution of diazepam 0.1 ml / kg body weight, but not more
than 2 ml once.
Task 49
A 7-year-old patient on the 5th day from the onset of chickenpox had a headache, vomiting,
shaky gait. At objective examination: positive meningeal symptoms, disturbance of
consciousness by type of sopor, pathological reflexes on both legs, convulsions. When
performing ELISA: IgM antibodies to herpes virus type 1/2 - 0.8, to herpes virus type 3 - 1.08.
1 Establish a previous diagnosis / emergency.
2 Define treatment tactics and list groups of drugs.

Answers:
1. Acute viral encephalitis caused by herpes virus type 3, severe
2. Mandatory hospitalization in the neuroinfection department or intensive care unit.
Dairy-vegetable diet (table №5 according to Pevzner), 5-6 times a day with the transition to
table №2 in the recovery period; the drinking mode corresponds to age daily requirements for
liquid taking into account daily volume of solutions which are entered in / in;
Causal therapy: Mr rotyvirusni agents (acyclovir claim ryznachayetsya at 15 - 30 mg / kg 3

times a day w / drops. For 10-14 days, then continue taking the drug 200 - 400 mg 5 times a
day for 14 enterally days; )
Pathogenetic therapy:
- insufflation of oxygen through a nasal catheter or laryngeal mask

- treatment of cerebral edema ( increased position of the upper body at an angle of 30
°, which reduces intracranial pressure by 10 - 15 mm Hg;
diuretic (intravenous drip 20% mannitol solution for 10 - 20 minutes 1.5 - 2 g / kg / day
for 2 - 3 injections ), to increase the effect of mannitol - furosemide - 1 - 3 mg / kg 3
times a day.
Adrenergic and dopaminergic drugs (Dopamine 2 - 8 μg / kg / min.) Drug of choice. Dopamine

is a natural mediator of the brain);
Glucocorticoids ( Dexamethasone - 0.5 mg / kg after 6 hours for 3 days with a subsequent

decrease by extending the interval of administration after 8 - 12 - 24 hours for the next 6
days. )
Electrolyte solution ( Magnesium sulfate - 25% solution. Prescribed at a dose of 0.3 ml / kg 3-

4 times a day ) .
- at threat of accession of bacterial microflora it is necessary to use antibiotics from groups of

cephalosporins of the III generation (Ceftriaxone 0,5 g in / in page on 10 ml of 0,9% solution
of chloride of sodium 2 times / days 10 days) and aminoglycosides of the III generation
(amikacin 5 mg / kg every 8 hours in / in drip for 10 days);
- anticonvulsant therapy anticonvulsant derivatives of benzodiazepines (seduxen 0.5 mg / kg

iv), in case of ineffectiveness of seduxen barbiturates (thiopental sodium 8-10 mg / kg iv;
phenobarbital 10 mg / kg iv) .
At the stage of rehabilitation:
- nootropic drugs (cortexin 10 mg i / m 1 time / day for 10 days).
5. According to the ELISA results of IgM antibodies to the herpes virus type 1/2 - 0.8 , which
indicates a questionable result, to the herpes virus type 3 - 1.08 , indicate a positive result and
indicate an active course of infection caused by chickenpox or shingles herpes.
Problem 50
A 2-year-old child became acutely ill with a rise in temperature to 37.5 ° C, the appearance of
a runny nose with a slight discharge of mucus, a dry "barking" cough. On the 2nd day of the
illness, the child woke up at night with a rough cough, hoarseness quickly appeared, noisy
frequent breathing with difficulty breathing. Involvement of intercostal spaces was noted,
auxiliary muscles took part in the act of breathing. At auscultation of lungs - there are no
rales. When conducting a clinical blood test, the following results were obtained: Hemoglobin
- 127 g / l; Er. - 4.2x 10 9 / l; k.p. - 0.9. Leukocytes - 3.8x10 9 / l; e - 2%; n - 3%; c - 26; l -
3. Name the representatives of the drugs from each group.
4. Indicate the dose and frequency of application.
1. acute respiratory syndrome constrictive larynhotrahe yit , S tupin severity of stenosis II.
2. Treatment:
Hospitalization
Treatment should begin with the establishment of treatment and protection.
The room in which the child is, should be ventilated, with sufficient humidity.
Nutrition by age, dairy-vegetable sparing diet with the exception of spicy and irritating foods,
hot and carbonated beverages.
Bed rest - according to the indications.
The patient is prescribed vocal rest, even whispered speech is excluded.
Rehydration therapy.
Oxygen therapy with warm humidified oxygen.
GC in / in or / m 5.3 mg / kg prednisone per day. Dexamethasone 0.6 mg / kg once.
Fenoterol is inhaled at a dose of 200 mcg, again 100 mcg after 5 minutes.
Fenoterol solution for inhalation 1 mg / ml: children < 6 years - 50 μg / kg (10 drops =
0.5 ml Fenoterol 0.5 mg / ml and ipratropium bromide 0.25 mg / ml solution for inhalation:
children < 6 years - up to 50 μg / kg (up to 10 drops = 0.5 ml) per reception;
Fast action :
- at adrenaline - 0,18% of adrenaline hydrotartrate by inhalation at the rate of 0,05 - 0,1
ml / year of life. + 0.9% NaCl (4-5 ml) through a nebulizer or steam inhaler. 10-15 minutes
Repeat if necessary in 1-2 hours, no more than 6 times.
- Salbutamol orally at a dose of 3-8 mg / day in the form of an aerosol 1-2 doses 3-4 times a
day or inhalation through a nebulizer at 1.25-2.50 mg.
3. Leukocytes - 3.8x10 9 / l; e - 2%; n - 3%; c - 26; l - 67%; m - 2%;

Relative lymphocytosis is a sign of a viral infection.
Problem 51
The child is 8 months old, fell ill with lethargy, vomiting, refusal to eat, on the 3rd day the urine
darkened. Objectively: on the 5th day of the disease the child is lethargic, adynamic,
decreased appetite, jaundiced skin and sclera. The liver protrudes 4 cm from under the ribs,
the spleen 1 cm below the ribs. Urine is dark, feces is acholic. From the anamnesis it is
known that at the age of 7 months the child had pneumonia, received treatment, including
blood transfusions. On the 3rd day of stay in the hospital, the child vomited "coffee grounds",
refused to eat, had convulsions, loss of consciousness. Blood test for bilirubin: total - 216.6
μmol / l, direct - 80 μmol / l, indirect - 136 μmol / l, ALT - 1.2 mmol / l, prothrombin - 38%,
sulem test - 1.1 ml.
4. Specify the dose of infusion therapy.
5. Interpret the results of biochemical blood tests.

Answers:
1. Viral hepatitis B fulminant form. Acute liver failure.
2. Treatment in the intensive care unit:

- gastric lavage and high cleansing enema ;
- catheter and tion of the central vein, nasogastric tube;
- Infusion therapy: infusion volume for detoxification (including persperative and
pathological losses) 50-100 ml / kg with correction of electrolytes and CBS.
Restoration of energy processes, infusion of 10-20% glucose in a daily dose of 5-10 g /

kg. + insulin 1 UNIT per 4 g of glucose
Ringer Locke's solution (5 ml / kg / h), 0.9% phys. Rn (20 ml \ kg \ day), rn KCl (under the
control of level K), glutamine to and 50 ml of 1% solution, hepasteril A (1,5 ml \ kg \
h), albumin 10 ml \ kg .
calculated by the formula : Potassium deficiency - D (K) = (K mmol / l desirable - K mmol /
l patient ) x body weight x0.3.
During enteral nutrition, only D (K)
is administered - prednisolone 10 mg / kg per day in 4 hours in equal portions without a night

break;
- Lasix 1 mg \ kg;
- heparin 100 U \ kg;
- lactulose 5 ml 1 time per day;
- hemostatics: 12.5% solution etamsylate (dytsynonu) intramuscularly - anticonvulsant
therapy: diazepam 0.5-1.0 mg / kg a / a - f ryhnichennya intestinal flora -
antibiotics : kanamycin 0.1 g / day , ampicillin - 20–40 mg / kg every 4 hours , for 5 days.
Task 52
The child is 1.5 years old. I fell ill for the first time. Sick on the second day t - 37.6 o C. Dry
cough, respiratory rate 70 / min., Expiratory dyspnea. Above the lungs box percussion
sound. Auscultatory hard breathing, scattered dry wheezing. At hospitalization in the clinical
analysis of blood: Hemoglobin - 125 g / l; Er. - 4.4x 10 9 / l; k.p. - 0.9; Leukocytes - 4.0x10 9 /
l; e - 4%; n - 2%; c - 25%; l - 66%; m - 3%; Platelets - 210x10 9 / l; ESR - 2 mm / year.
Answer:
1. Acute obstructive bronchitis of moderate severity
Emergency care of obstructive bronchitis - 1-2 doses of one of the bronchospasmolytic

drugs using an aerosol inhaler through a suitable spacer with a face mask (children under 4
years) or with a mouthpiece (from 4 years):
 β 2 -agonist (salbutamol, fenoterol), used mainly in older children and
in the ineffectiveness of other inhaled bronchodilators, or
 M-cholinolytic (atrovent (ipratropium bromide)), used mainly in
young children, or
 combined bronchospasmolytic (β 2 -agonist in combination with M-
cholinolytic - berodual (ipratropium bromide + fenoterol)), is used as a universal drug
with a high safety profile.
The best option for the use of bronchospasmolytics may be inhalation through a nebulizer
using special solutions for inhalation in single doses with a face mask (children under 6 years)
or with a mouthpiece (older than 6 years):
 salbutamol at a dose of 0.1-0.15 mg / kg (not more than 5 mg
simultaneously) or
 berotek (fenoterol), children under 6 years - 5-10 drops, older than 6
years - 10-20 drops or
 atrovent (ipratropium bromide), children under 6 years - 10 drops,
older than 6 years - 20 drops or
 berodual (ipratropium bromide + fenoterol), for children under 6
years - 10 drops, from 6 years - 20 drops.
With the continued effectiveness of bronchial antispasmodic drug therapy starting using it
orally or inhaled every 4-6 hours, or administered methylxanthines (theophylline) short
(aminophylline) or long-acting (teopek, teotard etc.).
To improve the drainage function of the bronchial tree, it is possible to use ambroxol in the
form of a solution for inhalation through a nebulizer, ambroxol in the form of syrup or
bromhexine in age doses orally.
Vibration massage and postural drainage.
Physiotherapeutic procedures: electrophoresis with euphylline, MgSO 4.
Antiviral drugs.
Indications for the appointment of antibacterial drugs may be the following signs: prolonged
hyperthermia, no effect of therapy, the presence of stable areas of hypoventilation in the
lungs and / or asymmetry of physical data, increasing toxicosis, signs of cerebral hypoxia, the
appearance of purulent sputum, uneven strengthening of the lung in blood tests -
leukocytosis, neutrophilia, increased ESR, sensitization to previous frequent SARS or
transferred shortly before this episode of the disease.
At the stages of rehabilitation - therapeutic breathing exercises, speleotherapy, hardening,

sanatorium treatment (southern coast of Crimea).
Dispensary supervision by an allergist.
5. Changes in clinical analysis: the norm.
Problem 53
A 6-year-old child is ill for the second day. Complaints of fever up to 40 ° C, headache,
weakness, repeated vomiting, pain when swallowing. The condition is serious. On
examination, the subcutaneous fat of the neck was swollen to the middle. Above the surface
of the edema, the skin is not changed, when pressed, the pit does not remain, the edema has
the character of jelly. On the tonsils, palate, tongue dense, white-gray plaques, removed with
difficulty, and after removal the surface bleeds. The mucous membrane is swollen, hyperemic
with a cyanotic tinge. The following results were obtained during the clinical blood test:
Hemoglobin - 120 g / l; Er. - 4.2x 10 9 / l; k.p. - 0.9; Leukocytes - 16.4x10 9 / l; e - 1%; n - 7%; c
- 69%; l - 21%; m - 2%; Platelets - 218x10 9 / l; ESR - 24 mm / year.

1. Tonsil diphtheria is a toxic form of I degree.
2. TREATMENT :
1. I was hospitalized in the boxed intensive care unit of an infectious disease

hospital.
2. Diet - vitaminized, high-calorie, sparingly processed food.
3. Etiotropic therapy - administration of diphtheria serum (PDS), dose and

frequency of administration depends on the severity and clinical form of
diphtheria. After the diagnosis of diphtheria or probable suspicion of it, PDS is
introduced in the first two hours after hospitalization.
Toxic form - a severe form of diphtheria.
In severe diphtheria, the course dose of PDS is 90,000-120,000 IU - 120,000-150,000 IU. The
first dose should be 2/3 of the course. On the day of hospitalization, a course dose is
administered. The frequency of PDS is 12 hours, if the entire dose of serum was administered
intravenously, the interval is 8 hours. In very severe forms of the disease, intravenous drip of
serum is indicated. Half of the calculated dose is administered intravenously, the other half
intramuscularly.
Antibacterial therapy: parenterally semisynthetic antibiotics of the penicillin and cephalosporin

series. The duration of the course of antibacterial therapy is 10-14 days. The drugs are
prescribed in age doses.
Local sanitation of the oropharynx - rinsing and irrigation of the oropharynx with disinfectant
solutions.
Detoxification therapy with glucose-salt and colloidal solutions in moderate and severe forms,
taking into account the daily fluid requirements and pathological costs.
Glucocorticosteroids - at a dose of 10-20 mg / kg of prednisolone.
5. Leukocytosis due to increased neutrophils, increased ESR.
Problem 54
The child is 2 years old, sick for the third day. The disease began acutely with an increase in
body temperature to 39.6 0 C, frequent liquid stools up to 16 times a day with a green tinge,
without pathological impurities. Visible mucous membranes and dry skin. Tissue turgor is
somewhat reduced. When performing a blood test: Ht - 0.52. Biochemical parameters: K - 5.2
mmol / l, Na - 154 mmol / l. Urination is rare, in small portions.
5. Interpret the results of the blood test.
Answers:
1. Acute intestinal infection. Enteritis. Severe. Exicosis 2 tbsp.
2. Diet therapy . Reducing the daily volume of food by 40-50%, increasing the frequency of
feedings to 8-10 times a day. As a supplement for children with GKI use non-dairy cereals
(preferably rice), vegetable puree, whey-washed cheese, early introduction of meat puree.
In severe forms of the disease, the starting antibiotics for GKI are cephalosporins of 3-4
generations, often in combination with aminoglycosides, carbapenems. The daily dose of
CEFIXIM is 8 mg / kg of body weight, which is divided into 2 oral doses. Amoxicillin 50-100
mg / kg / day in \ in
Oral rehydration: 1st stage : With exsiccosis 2 tbsp. for 6 years - 60 - 100 ml / kg. At this
stage of rehydration it is necessary to use special solutions for oral rehydration. The rate of
fluid introduction through the mouth is - 5 ml / kg / h. After 4-6 hours, evaluate the
effectiveness: if the signs of dehydration have decreased, then proceed to the second stage
of rehydration, if the condition has not improved, then proceed to parenteral fluid
administration.
2nd stage: supportive rehydration : Duration - at 1 tbsp. - 20 years, at 2 tbsp. - 18

years Approximate volume of solution for maintenance rehydration: in children under 2 years -
from 50 to 100 ml / kg of body weight per day, in children older than 2 years - 100-200 ml / kg
or 10 ml / kg of body weight after each bowel movement. The effectiveness is assessed by
the disappearance or reduction of dehydration, ie by increasing body weight: on the 1st day
by 6-8%; in the following days - by 2-4% (but not more than 50-100 g per day.
Stage 3: This is the period of the next 24 hours or more - the liquid is given at the rate of: AF
+ food volume + 10 ml / kg for each watery stool.
Enterosorbents - White (silicon) - 1 ml / kg / day (enterosgel, sorbogel, enterocat, atoxil, silica)
Course - 5-7 days
Criteria for early withdrawal: normalization or delay of defecation for 2 days
Enzymes: Daily dose (DD): Up to 4 years - 1,000 IU per lipase 3-5 times a day Course: 2-3
weeks
In invasive diarrhea on the background of antibacterial therapy using self-eliminating

probiotics (containing saccharomycetes) or probiotics containing lactobacilli. The latter in the
vast majority are resistant or moderately resistant to antibiotics. Lactial GG 2 drops with
meals 1 time per day. The course of therapy lasts 5-10 days.
5. In the blood test: a slight increase in sodium, potassium and hematocrit.
Problem 55
An 8-year-old child fell ill suddenly: his body temperature rose to 39–40 ° C, he was
bothered by a diffuse headache, which was aggravated by turning his head, significant light
and sound stimuli, and vomiting without nausea. The child is sleepy, lying on his side with his
head tilted and his knees brought to his stomach. At a lumbar puncture the cerebrospinal fluid
flowed out frequent drops. The cerebrospinal fluid is cloudy, yellow-green. Pressure - 2.9
kPa; cytosis - 6200 cells / μl. Cytogram: lymphocytes -5%, neutrophils 95%. Protein - 2.6 g /
l. Panda's reaction - (+++). Nonne-Apelta reaction - (+++). Sugar - 1.8 mmol / l (in the blood -
5.2 mmol / l. Fibrin film is absent. Chlorides - 104 mmol / l.
5. Interpret the results of the analysis of cerebrospinal fluid.
Answers:
1. Acute purulent meningitis. Severe.
TREATMENT:
Prehospital stage of treatment:

3. Glucocorticoids 1-3 mg / kg on prednisolone.
4. Infusion therapy with saline and colloidal solutions.
5. Antipyretics.
6. Furosemide - 1-2 mg / kg.
7. At spasms - diazepam.
Inpatient treatment:
1. Antibacterial therapy: benzylpenicillin 300000 - 500000 IU / kg / day,

administration every 4 hours. Reserve antibiotics: ceftriaxone 100 mg / kg / day,
cefotaxime - 200 mg / kg / day. In the presence of ITS - chloramphenicol succinate 100
mg / kg / day.
2. Detoxification therapy in moderate forms with the use of glucose-saline

solutions.
3. Acetazolamide (diacarb) + asparkam. The dose is selected depending on the

severity of the hypertension syndrome.
4. In-syndrome therapy is carried out in accordance with the existing syndromes,

their treatment is carried out according to the appropriate treatment protocols.
5. In the period of convalescence: nootropic drugs, B vitamins.
5. Changes in the analysis: Pressure is increased, cytosis is increased, the relative

number of neutrophils is increased, protein is increased, reactions are positive, glucose is
reduced.
Task 56
The child 7 years after intramuscular injection of a solution of amoxicillin appeared

weakness, fever, dizziness, pale skin with urticarial rash on the buttocks. When examining
heart rate - 110 / min., Blood pressure - 70/55 mm Hg. Art. The level of tryptase is 18 μg / l.

5. Interpret blood tryptase results.
Answers:
1. Anaphylactic shock.
2. Emergency care
1 . Put the child on his back , with raised legs - helps to treat hypotension . P overnuty
head facing sideways, push the lower jaw, tongue lock. Provide fresh air or oxygen
inhalation.
2. Adrenaline intravenously injected into the outer surface of the thigh 0.15 mg,
max. 0.3 g, a solution of 0.1 % - 1 mg / ml . You can repeat the administration every
≈5–15 min, in the absence of improvement or low blood pressure (in most patients the
general condition improves after the introduction of 1-2 doses).
3. Oxygen should be supplied through a face mask (usually 6-8 l / min) .
4 . Provide intravenous access with two large diameter peripheral catheters .
5 . Infuse infusions of solutions - in patients with a significant drop in blood pressure

who do not respond to the introduction of adrenaline in / m, pour 1-2 liters of 0.9% NaCl
as quickly as possible (10 ml / kg body weight during the first 5– 10 min).
6 . Monitor blood pressure as well as, depending on the patient's condition, ECG,
pulse oximetry or arterial blood gasometry.
7 . In a patient with a drop in blood pressure, without a reaction to repeated

intravenous administration of adrenaline and intravenous infusion of solutions →
consider the appointment of adrenaline 0.1-0.3 mg in 10 ml of 0.9%
NaCl intravenously for several minutes or with constant IV infusion of 1–10 μg / min
(solution of 1 mg in 10 ml of 0.9% NaCl [0.1 mg / ml, 1: 10000]).
8. Additional drugs
If blood pressure remains low - enter alpha-adrenomimetics daily every 10-15

minutes. to improve the condition:
- 0.2% solution of norepinephrine - 1-5 mg / kg
In the absence of effect - pre-titrated administration of dopamine at a dose of 8-10 μg /
kg per minute. under the control of blood pressure and heart rate.
5. Tryptase - trypsin-like enzyme contained in the granules of mast cells and

basophils. As a result of degranulation that occurs during an immediate type of allergy,
the level of tryptase in the blood increases.
It is believed that the normal level of tryptase in the serum 2 -14 μg / l, the patient
has 18 μg / l. This indicates an active allergic reaction.
Usually 12-14 hours after the end of symptoms, tryptase levels return to normal. This is
used to differentiate an allergic reaction from systemic mastocytosis.
Problem 57
The child is 6 months after 5 hours. after a rapid rise in body temperature to 40 ° C on the
skin of the entire body surface appeared dense to the touch petechiae and ecchymoses of
irregular shape, cherry color, which do not disappear when pressed. During the last 3 hours,
the number of rash elements increased significantly, necrosis appeared in the center of some,
the body temperature continued to rise, the child lost consciousness, vomiting "coffee
grounds" appeared. Heart rate 212 per minute, weak pulse, anuria, AT 40/10 mm Hg ZAK:
leukocytes 3,8х10 9 / l, eosinophils - 0, rod-nuclear - 24%, segment- nuclear - 52%, ESR -35
mm / h.
5. Interpret the clinical blood test.
Answers:
1. Meningococcemia ITS 3rd century.
2. TREATMENT:
Pre-hospital stage of treatment:

8. Glucocorticoids - prednisolone, hydrocortisone or dexazone 2-3 mg / kg on
prednisolone - without ITS, 5 mg / kg - at ITS of the I degree, 10 mg / kg - at ITS of the
II degree, 15-20 mg / kg - at ITS of the III degree .
9. Infusion therapy with saline or rheopolyglucin to stabilize BCC.
10. Inotropics (dopamine) - to support hemodynamics.
Hospital stage of treatment:
4. Depending on the severity of hospitalization in the intensive care unit and

intensive care unit, or the neuroinfection department of an infectious hospital.
5. Antibacterial therapy: in the presence of ITS drug of choice - chloramphenicol

succinate at a dose of 100 mg / kg / day, when removing a patient with ITS prescribe
penicillin 200 mg / kg / day, or third-generation cephalosporins - cefatoxime 100-200
mg / kg / day, ceftriaxone kg / day.
In severe form and the need to protect against nosocomial infection , 3rd generation
aminoglycosides are additionally used - amikacin up to 20 mg / kg / day, netilmicin 1.5-
2 mg / kg every 8 hours.
6. Detoxification therapy in moderate forms is performed with glucose-saline

solutions, taking into account the daily fluid requirements and pathological costs.
7. In-syndrome therapy is carried out in accordance with the existing syndromes,

their treatment is carried out according to the relevant treatment protocols
5. HOW: leukopenia with a shift to the left, increased ESR
Problem 58
A 4-month-old child fell ill 2 days ago, when the temperature rose to 38.9 ° C, appeared
liquid stools, watery, bright yellow with lumps of undigested food, without pathological
impurities up to 20 times a day, vomiting 2-3 times. On examination: the condition is serious,
the child is lethargic. The mucous membrane is dry. The skin is pale, dry, in a fold that
straightens slowly. Tissue turgor is reduced. The big temple sinks. The child has a
pronounced thirst. Heart sounds are weakened, tachycardia, the phenomena of peripheral
vasospasm are noted. Tachypnoe. The abdomen is enlarged, flatulence is pronounced. Liver,
spleen are not enlarged. Diuresis is reduced.
Blood test "Blood electrolytes": K - 3, 2 mmol / l, Na - 130 mmol / l, Cl - 95 mmol / l.
5. Interpret the blood test "Blood electrolytes".
Answers:
1. GKI, severe, enterocolitis, dehydration II.
2. TREATMENT
1. Rehydration therapy.
Oral rehydration is preferred. To do this, use glucose-saline solutions.

Oral rehydration is carried out in 2 stages:
Stage 1: the first 4-6 hours to eliminate water-salt deficiency. With grade 1 exsiccosis, the
required volume of fluid is 30-50 ml / kg of body weight, with grade 1 exsiccosis - 100 ml / kg
of body weight of the child.
Criteria for the effectiveness of the 1st stage of oral rehydration:
 reduction of fluid loss with stool and vomiting;
 disappearance of thirst;
 increase in tissue turgor;
 moistening of mucous membranes;
 increase in diuresis;
 disappearance of signs of disturbance of microcirculation.
With the effectiveness of the 1st stage of rehydration in 4-6 hours begin stage 2, which is the
maintenance of current fluid loss.
The approximate volume of solution at this stage is 50-100 ml / kg body weight or 10 ml / kg

after each defecation.
1. Antibacterial therapy.
Indications for antibacterial therapy:
A) In all forms for children under 1 year:
 children with immunodeficiency;
 HIV-infected children with AIDS;
 children undergoing immunosuppressive therapy;
 children with hemolytic anemia.
B) Cholera regardless of age; If necessary, antibacterial drugs are prescribed:

 trimethoprim / sulfametaxazole;
 nalidixic acid preparations;
 cephalosporins of the 3rd generation.
The course of antibacterial therapy for GKI - 5-7 days. The indication for drug replacement is
its ineffectiveness within 3 days.
In cholera, the drugs of choice are erythromycin, nalidixic acid, nitrofuran drugs,
trimethoprim / sulfametaxazole, for children older than 8 years - tetracyclines.
In cholera, antibacterial drugs are prescribed after the first stage of rehydration, 3-6 hours
after hospitalization.
3. Adjuvant therapy:
A) Enterosorption - preference is given to aluminosilicate sorbents, which are prescribed from
the first days of the disease. The course of enterosorption in GKI - 5-7 days. The criterion for
early withdrawal of the drug is the normalization of stool or its delay for 2 days. B)
Probiotic therapy : in the absence of antibacterial drugs in the appointments. The course of
probiotic therapy in the acute period of GKI lasts 5-10 days. Lactial GG 1 drop with food once
a day. Probiotic therapy is also indicated during the period of convalescence of GCI with
physiological probiotics (containing normal microflora) in order to restore the normal intestinal
microflora for 3-4 weeks. B) fermentoterapiya: Creon 10 000, 1 000 IU per kg of lipase at
every meal. Capsule carefully rozk Riva and adds tion minimikrosferychni granules to soft
foods with acidic environment (pH <5.5) that does not require chewing, or fluid from the acidic
environment (pH <5.5). It can be apple puree or yogurt . P is prescribed in the stage of
convalescence in the presence of signs of dysfermentatemia in children who have relapsed
into GKI. The course of enzyme therapy 2 3 weeks.
4. Diet therapy: In the acute period of GKI it is recommended to reduce the daily amount of
food by 1 \ 2 - 1 \ 3. It is possible to increase the frequency of feedings to 8-10 per day in
infants and the urge to vomit. Today, the most physiological is the early, gradual recovery of
nutrition. Restoration of qualitative and quantitative composition of food is carried out in the
shortest possible time. In children 1 year of age, breastfeeding should be maintained. It is
recommended to replace the usual adapted milk formulas with low-lactose formula-fed infants
in the acute period of GKI. The duration of low-lactose diet is individual.
5. Decrease in quantity of Sodium (135-150 norm), Potassium (4-5.5 norm)
Task 59
A 12-year-old boy during the epidemic outbreak in the city, the disease began very acutely:
the body temperature rose to 40.0 ° C, there were significant signs of intoxication, intense
headache, chills, eye pain when moving, aching pain in m ' tongues, joints, bones. The face is
hyperemic, injection of scleral and conjunctival vessels, granularity and moderate hyperemia
of the pharynx . There is no rash. On examination - the skin is red, to the touch -
hot. Percussion over the lungs clear lung sound, auscultation - hard breathing. Physiological
departures are normal.
The following results were obtained during the clinical blood test: Hemoglobin - 128 g /
l; Er. - 4,3x 10 9 / l; k.p. - 0.9. Leukocytes - 3.5x10 9 / l; e - 1%; n - 2%; c - 28; l - 66%; m -
3%; Platelets - 210x10 9 / l; ESR - 9 mm / year.
Answers:
1. Acute respiratory viral disease, influenza (clinically), moderate.
1. Fighting fever
For emergency care: 50% analgin 0.1 ml / year of life = 1.2 ml + diphenhydramine 1% 1
mg / kg ( 1.5-3.0 ml ).
For further oral or ibuprofen 5-10 mg / kg 3 times a day, ie every 8 hours.
or paracetamol 10-15 mg / kg every 6 hours.
In the intake of large amounts of fluids, including tea with lemon, raspberries, alkaline
mineral waters, juices, fruit drinks .
Etiological therapy:
Tamiflu 1 capsule 75 mg 2 times a day orally for 5 days
Groprinosin syrup is a direct-acting antiviral. 3 times a day × 10-15 ml , orally after
meals, at regular intervals.
Anaferon - antiviral and immunomodulatory action. For the first 2 hours, the drug is
taken 1 tablet every 30 minutes (5 doses), then during the first day - another 3 tablets
at regular intervals (only 8 tablets during the first day). Starting from the 2nd day to
continue drug taking 1 tablet 3 times daily until complete
recovery , 30 minutes before or 30 minutes n donkey food.
3. When conducting a clinical blood test, the following results were obtained :
Hemoglobin - 128 g / l - normal
Er. - 4,3x 10 9 / l; - norm
k.p. - 0.9. - norm
Leukocytes - 3.5 x 10 9 / l; - reduced (rate 4.5-10.0 x 10 9 / l ) e - 1%; - rate n - 2%; c - 28; -
liquefaction of neutrophils ( 44.0-64.0 %) l - 66%; - increased (rate 30.0-45.0 %) m -
3%; - norm
Relative lymphocytosis, due to a decrease in neutrophils and an increase in

lymphocytes, is a sign of a viral infection.
Platelets - 210x10 9 / l; -
ESR rate - 9 mm / year - rate.
Problem 60
A 4-year-old child is ill for 3 days. The disease has a slow onset: subfebrile temperature,
cough "barking", and then became silent, the voice is aphonic, breathing is noisy with the
involvement of the compliant areas of the chest. Cyanosis of the nasolabial triangle
appeared. Dry rales are heard in the lungs. Heart tones are rhythmic, muted, 122 beats. in 1
minute The child was vaccinated in violation of the vaccination schedule. When determining
the level of antibodies to diphtheria toxoid IgG - the result of 0.01 IU / ml.
Answers:
1. Diphtheria of the larynx, stage of stenosis 2 tbsp.
TREATMENT
1. I was hospitalized in the boxed department of an infectious hospital.
2. Diet - vitaminized, high-calorie, sparingly processed food.
3. Etiotropic therapy - the introduction of diphtheria serum (PDS) .

o In
moderate diphtheria, the first dose of PDS is 50,000 - 80,000 IU, after 24 h, if
necessary, a second dose is administered.
4. Antibacterial therapy: parenterally semisynthetic antibiotics of the penicillin and

cephalosporin series. The duration of the course of antibacterial therapy is 10-14
days. The drugs are prescribed in age doses.
5. Local sanitation of the oropharynx - rinsing and irrigation of the oropharynx with
disinfectant solutions.
6. Detoxification therapy with glucose-salt and colloidal solutions in moderate and

severe forms, taking into account the daily fluid requirements and pathological costs.
7. Glucocorticosteroids - at a dose of 2-3 mg / kg of prednisolone . In blood tests

rhen
5. Antibodies to diphtheria are doubtful (0.01 and less negat, 0.01-0.09 doubtful., 0.1 TV is
more positive)
Task 61
A 4-year-old child on the 5th day after taking paracetamol, which exceeded the maximum
allowable dose by 4 times, developed disturbances of consciousness, excitement, alternating
with drowsiness, loss of consciousness, nosebleeds, tremor and hyperkinesis of the upper
extremities. Objectively: t ° - 38.2 ° C, Ps- 110 / min., BH- 32 / min., From the mouth 'liver
odor' Sclera and skin are yellowish, stellate angiomas on the upper half of the torso. Liver -
not enlarged, spleen +1 cm In the clinical analysis of blood: K - 2.8 mmol / l, Na - 100 mmol /
l, ammonia - 98 μmol / l . What is the most likely diagnosis?
5. Interpret the blood test.
Answers:
1. Acute liver failure.

2. Emergency aid
Intensive care is based on the etiological principle (treatment of pathology that led to
liver failure), and prevention and treatment of the main syndromes of liver failure during the
period required for spontaneous regeneration of hepatocytes (10 - 14 days).
• In order to prevent encephalopathy, patients are excluded from the diet of animal proteins
and fats.
• Strict bed rest, boxed ward, medical staff maintaining complete asepsis and
antiseptics.
• Elimination of hepatotoxic factors (hypoxia, hypovolemia, hemorrhage,
intoxication) :
1) Start crystalloid infusion therapy for elimination of hyponatremia and hypokalemia: 0,9%
NaCl 5-10 ml / kg + deficit ka Leah ( D (K)).
D (K) = (3.5-2.8) x 16 kg (normal weight at 4 years) x 0.3 = 3.36 mmol / day
3.36 mmol K = 3.4 ml of 7.5% KSI
2) to eliminate hypoxia use oxygen therapy (supply of 3 - 4 l / min of oxygen through an
intranasal catheter )
3 ) restoration of BCC, improvement of rheological properties of blood, elimination of

intestinal paresis increase hepatic blood flow. For this purpose, use a solution of euphyllin
(2.4% to 20 - 30 ml / day).
4 ) Increase in oncotic blood pressure by using albumin (200 - 300 ml), 10% solution of
mannitol (1 kg / kg), reopopliglucin (up to 400 ml / day), reduces interstitial edema of the
liver, lungs, kidneys;
5) for the prevention of gastrointestinal krovot EV using 150

mg C ymet and railway and well, / in slow infusion or 5-10 times s day (maximum rate of
infusion - 150 mg / h ) or orally by 200-400 mg for every 4-6 hours, the maximum daily dose
of 1.6-2 g
6 ) detoxification of the body is carried out by :
- Enteral first detoksykatsi th : E nteroshel orally 3 times a day for 1.5-2 hours before or 2
hours after eating or taking drugs, drinking plenty of water. P azo dose 5 g (teaspoon ), daily -
15 g . The course of treatment is from 7 to 14 days.
- och yschennya intestine (frequent cleansing enemas, f ryhnichennya intestinal

flora - antibiotics : kanamycin to 6 g / day, ampicillin - 1 g every 4 hours , 5 days )
- correcting violations dysbiotic - "L aktovit forte " 1 capsules and 2 times a day 40 minutes
before her Zhi or immediately before meals , treatment carried out for 3-4 weeks.
To consolidate the obtained clinical effect in 10―14 days after the end of treatment in the
absence of complete normalization of the microflora appoint maintenance doses of the drug
(half the daily dose) for 1―1.5 months.
7 ) Improvement of energy processes in hepatocytes is achieved by the introduction of 10 -

20% glucose solutions (up to 5 g / kg per day), which prevents the breakdown of the body's
own proteins and the growth of ammonia intoxication.
8 ) To stabilize cell membranes of hepatocytes in the prescribed glucocorticoids ( d at 10 -
15 mg / kg of hydrocortisone on days 1-2 days with gradual dose reduction ).
9 ) To stimulate lipotransport mechanisms and stabilize energy metabolism, use choline

chloride (10 ml of 10% solution in 200 ml of glucose, after anterior atropinization,
twice a day).
10 ) For the binding of ammonia in the blood is injected glutamic acid (40 - 50 ml solution of
1% pa Together with glucose solution, three times) or A lfa - arginine 300-500 mg / kg / day in
/ drip, every 8 hours .
11 ) Drugs that reduce cytolysis - hepatoprotectors : G lutargin 21 days for 0.125 three times
a day; after 1 month repeat the course and G epabene after the first course of G lutargin, 1
capsule twice a day, 20 minutes before meals 1 month.
12 ) As part of immunosuppressive therapy is also used antioxidants Ae vitamin inside after

her Zhi daily 1 capsule per day for 30-40 days .
In case of deterioration, plasmapheresis is used .
5. In the clinical blood test:
K - 2.8 mmol / l - hypokalemia, the lower limit of normal 3.5 mmol / l
Na - 100 mmol / l - hyponatremia, the lower limit of 127 mmol / l
ammonia - 98 μmol / l - g hyperammonemia, the upper limit of normal 60 μmol / l

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Task 1

1. Establish a preliminary diagnosis.

1. Moderate iron deficiency anemia.

The last thing is for the child to be outdoors

P ryznachennya vitamins C, B1 , B6 , folic acid

3. In the analysis of blood decrease in the number of erythrocytes hemoglobin,

1. Establish a preliminary diagnosis.

1. Foliyevodefitsytna B12-deficiency anemia, Mr. iperreheneratorna ( reticulo.

2. D iyeta: rich meat products, liver, eggs, cheese, milk.

F oliyeva acid 0,001 enterally 1 per day rate 4-6 weeks

3. In the analysis of blood decrease in the number of erythrocytes, hemoglobin,

A 16-year-old girl suffers from menorrhagia. Complains of flickering flies in front of

1. Establish a preliminary diagnosis.

3. In the analysis of blood decrease in number of erythrocytes, hemoglobin, indicating

1. Establish a preliminary diagnosis.

2. Additionally: determination of antiplatelet antibodies . P lazmaferez (replacement

3. Data of laboratory methods of research:

1. Establish a preliminary diagnosis.

2 . Additional research: antiplatelet blood pressure, it is necessary to

+ GCS: prednisolone 2 mg / kg / day for 2-3 weeks with subsequent dose

+ Immunoglobulins: administration of human Ig at a dose of 0.4 or 1 g / kg for 5 or

Splenectomy or pulmonary embolism is performed in the absence or instability of

1. Establish a preliminary diagnosis.

D aggregates (heparin, curantil, trental):

Heparin 200-500 IU / kg / day; the initial dose is 50 IU / kg (intravenous injection ), the

Duration of heparin administration (within 2-4 weeks)

And antihistamines (tavegil, suprastin, pipolfen);

In severe cases, glucocorticoids and plasmapheresis: Prednisolone at a dose of 1-2

3. According to laboratory tests (leukocytosis, neutrophilia, eosinophilia, elevated ESR).

1. Establish a preliminary diagnosis.

An important component of treatment is a complete diet enriched with proteins and

Prescribe drugs of recombinant genetically engineered somatropin in a daily dose of

Treatment is carried out for life.

Girl R., 14 years old, complains of constant irritability, sleep disturbances,

1. Establish a preliminary diagnosis.

3. General blood test: minor erythrocytopenia; c- reduced number; l- increased

1. Establish a preliminary diagnosis.

Vitamin D (Aquadetrim) 4,000 ME, 1 drop contains approximately 500 IU of vitamin D3 ,

1. Establish a preliminary diagnosis.

1. Rickets of the III century. severe, calcium penic variant.

Correction of hypocalcemia: 5 - 10% solution of calcium chloride - 1 teaspoon 3 times a

Vitamin D (Akvadetrym) 5000 IU, Mr rotyahom 30 - 45 days. In the future, to prevent

In 2 weeks from the beginning of medical treatment - to appoint baths:

3. General blood test: erythrocytopenia, Hb - reduced, blood Ca -

1. Establish a preliminary diagnosis.

3. Interpret the results of the laboratory test.

1. Dyskinesia of the biliary tract by hypotonic type.

1. Establish a preliminary diagnosis.

2. With HP-associated gastric and duodenal ulcers:

1. Table №5n for 5-7 days, then table №5 according to Pevzner.

Antisecretory therapy is prescribed (selective blockers of H2 -receptors of histamine

Bleeding peptic ulcer: prolonged treatment of PPIs (possibly with an H 2 -

Regulatory peptides have a depressant effect on the function of the pancreas:

After elimination of a pain syndrome (in 4 - 6 days) pancreatic enzymes -

3 .: er. - norm, H - slightly reduced, KP - reduced, reticulocytes - norm, anisocytosis

1. Establish a preliminary diagnosis.

Antimicrobial therapy - 5 days (first choice drugs - furamag, sulfametaxol /

semi-synthetic penicillins in combination with β -lactomase inhibitors - amoxicillin and

2nd generation cephalosporins: cefuroxime (zinacef, ketocep, cefurabol),

3rd generation cephalosporins: cefotaxime (claforan, clafobrin), ceftazidime (fortum,