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FAR EASTERN FEDERAL UNIVERSITY LOCATED IN VLADIVOSTOK, PRIMORSKY KRAI, RUSSIA

Name: ROBERT Age: 9 months

Clinical diagnosis: Community-acquired bilateral focal pneumonia, DN, acute course Main complains: Cough, runny nose, difficulty in nasal breathing, depression of the child.

Complication: nil

Name: Z.MOHAMED RILVAN,

GROUP: С7116B

Passport data

Name: ROBERT

Gender: Male

Age: 9 months

Home address: NO 2, SUHANOVA STREET, VLADIVOSTOK,RUSSIA.

Attends: Toddler

Date of admission to the hospital: 25.11.2020

Complaints On admission: according to the mother, complaints of Cough, runny nose, difficulty in nasal breathing, depression of the child

Complaints upon admission

Cough, runny nose, difficulty in nasal breathing, depression of the child.

Anamnesis morbi

patient got sick again. Prior to admission to the hospital, underwent treatment from 10.11.2020 to 24.11.2020 in a rural hospital. They were treated with cefazolin (according to the mother). Due to the improvement, he was discharged. The next day the temperature rose - 39.6, cough, runny nose. In this regard, an ambulance was called, which he was hospitalized in the State Children's Clinical Hospital, where he was diagnosed with community-acquired bilateral focal pneumonia, acute course.

Anamnesis of vitae

The child from the first pregnancy, urgent delivery, was born at the time of 40 weeks. The delivery went without complications. Apgar score - 7/8 points. Birth weight - 3260 g. Height - 53 cm. Applied to the breast for 1 day, actively sucking. She is breastfed.

Mom - 20 years old, healthy. During pregnancy, she prevented rickets by using an aqueous solution of Vit. D. Did not work during pregnancy, denies physical and mental injuries. Nutrition during pregnancy was complete and balanced. Father -, 30 years old. Healthy. Works at VEGU as a teacher.

Postponed diseases: Was inpatient treatment in a rural hospital from 10.11.2020 to 24.11.2020 for pneumonia. Discharged with improvement.

Vaccinations were made: BCG - at 3 months.

Hereditary diseases

He denies hereditary diseases, endocrine diseases, tuberculosis, mental and venereal diseases in relatives. No hemotransfusion was performed.

Allergic history: allergic to sugar.

Living condition

Living conditions are good. They live in their own house with all the amenities with their parents (grandparents). There are 5 people in the family. Sanitary and hygienic conditions (sleep schedule, provision of clothes, furniture, toys) are satisfactory. Epidemiological history: there are no infectious diseases in the family or apartment. Blood transfusions, as well as plasma transfusions and administration of immunoglobulin were not performed.

Family tree

Status presense

General condition of moderate severity, consciousness. Temperature 37.0 ° С, BH - 40 per min. Heart rate - 128 per min. Reaction to examination: restless. The physique is correct. The food is satisfactory. The skin is pale, without pigmentation, cyanosis of the nasolabial triangle. The mucous membranes, conjunctiva are clean, without features. There is no injection of vascular sclera. The tongue is coated, moderately whitish. The pharynx is hyperemic, tissue turgor is preserved, elasticity is preserved, tonsils are not hypertrophied, there is no edema. Peripheral lymph nodes are not enlarged. Nasal breathing is difficult, the discharge is serous. Cough - dry, unproductive, frequent. There is no shortness of breath. There is a dullness of the pulmonary sound on the left. Auscultatory breathing is hard, carried out in all departments. Wheezing is moist, finely bubbly, localized in the subscapularis region on both sides. The abdomen is soft and painless.

Inspection data at the time of Admission

The general state of moderate severity, clear consciousness, reaction to examination, dissatisfied, low mood. The physique is correct. The appearance is age appropriate.

Lowered appetite. Physical development is average, harmonious. Body weight - 8800 g, body length - 69 cm. The child develops in accordance with the age norm. The stigmas of dysembryogenesis were not identified.

Skin examination

Inspection: the skin is clean, pale pink, cyanosis of the nasolabial triangle. Visible mucous membranes are pink. Vein dilatation is not observed (Filatov and Frank's symptom is negative) The medusa head symptom is also negative. Hair growth is uniform, nails are normal.

Palpation:skin of moderate moisture, temperature, elastic. The "pinch" symptom is negative.

Red dermographism is noted. The latent period lasts 12 seconds, the explicit one - 2 minutes.

Study of subcutaneous fat

Inspection: evenly distributed, the degree of fat deposition is average.

On palpation, the thickness of the subcutaneous fat layer on the abdomen is 1.5-2.0 cm, on the chest 1 cm, on the back - 1 cm, on the inner surface of the shoulder - 1 cm, thighs 1.5 cm, on the face 1.5 cm. The subcutaneous fat layer is soft in consistency, tissue turgor is normal. There are no swelling.

Study of peripheral lymph nodes

Palpation:the occipital and behind the ear are not palpable, the submandibular - lentil solution, but single, mobile, not soldered to the skin, motionless. The chin, supraclavicular and subclavian are not palpable, axillary the size of a small pea, single, not adhered to the skin, painless. Thoracic, ulnar and inguinal are not palpable.

When examining the Pirogov-Valdeyer lymphatic ring, the palatine and lingual tonsils are not enlarged, there is no plaque.

Examination of the skeletal system:

Front view:

The shape of the head is round, the position is correct. The rib cage is cylindrical, without deformations. Legs are straight. The epigastric angle is greater than 90є.

Rear view: The shoulders and shoulder blades are symmetrical.

Side view:

The head is round and straight. The position is correct, the stomach protrudes somewhat forward

Examination of the foot:

Normal (according to Aralov-Aralants) - the inner edge of the foot crosses both lines (through the big toe and the base of the second toe).

Palpation of the head: bones to the touch are dense, without pathological tuberosities and protrusions.

Palpation of the chest: painless, no rickety rosary, epigastric angle greater than 90є

Study of the muscular system:

Inspection:Muscles are moderately developed. The muscle relief is poorly visible. Muscle groups of the same name are symmetrical.

Palpation- muscle tone and strength in symmetrical areas are the same. Muscle tone is normal. Muscles are elastic, firm to the touch. The strength of the muscles is preserved, the child provides sufficient resistance to the voluntary movements of the investigator. Soreness when feeling, active and passive movements is absent.

Physical development assessment

The empirical way

Child indicators	standard	% deviation
Height 69 cm	70.5 cm	2.1%
Weight 8.8 kg	9.2 kg	4.3%
Chest circumference 46 cm	46.5 cm	one%
Head circumference 45.5 cm	44.5 cm	2.3%

Conclusion physical development is age appropriate

Assessment of neuropsychic development

Sits on his own, sits. He gets up, walks with support. Acts freely with toys, depending on their properties. She speaks separate words - dad, mom, baba, yum-yum. Knows his name, responds. Performs previously learned actions at the command of an adult. Tries to imitate adults. Knows how to handle a spoon, drink from a cup.

Conclusion: neuropsychic development is age appropriate.

Respiratory examination

Inspection: The shape of the chest is cylindrical, symmetrical. There are no deformations (no “chicken breast”), and there is also no Filatov-Garrison peripneumatic sulcus.

Breathing is hard, nasal breathing is difficult, mucous discharge from the nasal cavity. The breathing type is mixed. NPV is 40 in 1 minute, breathing is rhythmic... The pharynx is hyperemic, the tonsils are not hypertrophied. The auxiliary muscles are not involved in the act of breathing. The rhythm is correct, uniform, equal in depth. No shortness of breath. Symptom Filatov and Frank are negative.

Palpation: The chest is painless and elastic on palpation. The width of the intercostal spaces is moderate. The costal "rosary" is absent. The chest is symmetrically involved in the act of breathing. Pleural friction is not detected by touch.

With comparative percussion lungs (mediated percussion) there is a dullness of the pulmonary sound on the left.

Lower bound	Right lung	Left lung
periosternal line	5 intercostal space	not defined
midclavicular line	6 rib	not defined
anterior axillary	7 intercostal space	7 intercostal space
middle axillary	7 rib	7 rib
posterior axillary	8 rib	8 rib
scapular line	9 rib	9 rib
paravertebral line	spinous process of 10 thoracic vertebra

Auscultation: breathing hard. Wet fine bubbling rales are heard, localized in the subscapularis region on both sides. No crepitation. There is no "pleural friction noise".

The state of the tracheobronchial lymph nodes - with percussion - a symptom of Corany de la Camp - dullness of the percussion sound on the 4th thoracic vertebra. The symptom is negative. Filatov's symptom is negative. On auscultation, Smith's symptom is negative (there is no blowing noise over the handle of the sternum) D Espin's symptom is an increase in sound conduction in the region of 1-2 thoracic vertebrae (negative symptom).

Study of the circulatory system

Inspection: No visible protrusions and pulsations were found in the cardiac area. Pulsation of the carotid arteries, swelling and pulsation of the cervical veins are not observed. The apical and cardiac impulse is not visually determined.

Palpation:The apical impulse is localized, in the 5th intercostal space with an area of I cm2, of moderate strength and amplitude. The symptom of "feline purr" is negative. Systolic and diastolic tremors in the region of the heart are absent.

Percussion

Relative dullness of the heart

The right border is slightly inward from the right parasternal line.

Left border - 1 cm outward from the left mid-clavicular line

The upper border is the second intercostal space

Absolute dullness of the heart

Right border - left edge of the sternum

Left border - 1 cm medially from the left mid-clavicular line

The upper border is the third intercostal space.

Auscultation: tones are slightly muted... There are no side noises in the form of pericardial friction noise. The arterial pulse on the radial arteries is symmetrical, rhythmic, of moderate filling and tension, there is no pulse deficit.

Vascular auscultation:on the carotid and subclavian arteries I and II tones are heard. On the femoral artery, tones are not heard.

On palpation: arteries are elastic, elastic, painless.

Digestive system examination:

Inspection: lips are pink, moderately moist, without manifestations, cracks. Mouth - the mucous membrane is hyperemic. The tongue is pale, moist, with a white coating, the papillae are well developed. The teeth are set vertically. The dental formula is age appropriate. Gums pink, do not bleed, no ulcers. The tonsils are not hypertrophied. The skin in the area of ??the salivary glands is not changed. The abdomen is of the correct rounded shape, symmetrical, not swollen, no protrusions or depressions. The front wall evenly participates in the act of breathing. There is no visible peristalsis of the stomach and intestines. Venous collaterals are not expressed.

On superficial palpation:- the abdomen is soft, painless, not tense. Hernial protrusions and discrepancies of the rectus abdominis muscles are absent. Symptom Shchetkin-Blumberg negative.

With deep palpation:according to the Obraztsov-Strazhesko method, the greater curvature of the stomach is palpated in the epigastric region in the form of a roller but both sides of the midline of the body are 3 cm above the navel. In the left ileal region, the sigmoid colon is found in the form of a smooth dense cord, sluggish and rarely peristaltic. In the right ileal region, the cecum is palpable in the form of a moderately tense cylinder, d about 1 cm. The transverse colon is not palpable. Palpation of the pancreas according to Groth's method is not palpable. Mayo-Robson's point (painful point of the body and tail of the pancreas is painless. Desjardins point (painful point of the head of the pancreas is painless.

Quiet Percussion:a low tympanic sound is noted in the stomach, the zone of gastric tympanitis is not enlarged. Mendel's symptom is negative. No splash noise is detected.

Auscultation: “rustling” sounds are heard in the area of ??the stomach projection. There is no peritoneal rubbing noise.

Liver and gallbladder

When viewed, visible protrusions in the right hypochondrium are not noted.

Palpation: The edge of the liver is rounded, even, protrudes 1 cm beyond the edge of the costal arch, painless, the gallbladder is not palpable.

Ш Kerr's point (vesicle point) is painless

Ш Boas point is painless.

Ш Grekov-Ortner symptom is negative

Ш Georgievsky-Mussey symptom is negative

Ш Murphy's symptom is negative

Liver percussion:

Borders of the liver according to Kurlov

I size - 7 cm

II size - 5 cm

III size - 4 cm

Spleen

When viewed in the area of ??the spleen, there is no bulging in the left half of the abdomen and the left half is symmetrical in the act of breathing. When percussion, a clear sound is heard, which turns into a blunt one, the anterior border does not go beyond the anterior axillary line, but the posterior border does not go beyond the posterior axillary line. On auscultation, there is no peritoneal friction in the spleen area.

urinary system

There are no protrusions above the pubis, the kidneys are not palpable, the costal-vertebral and costal-lumbar points are painless. The anterior hypochondrium is painless. Painful ureteral points are painless.

Percussion of the bladder did not give results, because the bladder was empty. Pasternatsky's symptom is negative.Urination 4-5 times a day, free, painless. There are no dysuric phenomena.

Endocrine system

On examination of the neck, there are no visible changes; on palpation, the thyroid gland is not enlarged.

Preliminary diagnosis and its rationale

Considering:

Ё anamnesis data: Re-ill. Prior to admission to the hospital, GDKB No. underwent treatment from 10.11.05 to 24.11.05 in a rural hospital. They were treated with cefazolin (according to the mother). Due to the improvement, he was discharged. The next day the temperature rose - 39.6, cough, runny nose. In this regard, an ambulance was called, which he was hospitalized in the State Children's Clinical Hospital, where he was diagnosed with community-acquired bilateral focal pneumonia, acute course, DN About art.

Ё complaints on admission: Cough, runny nose, difficulty in nasal breathing, depressed child's condition

Ё based on the examination of the patient upon admission: Temperature 37.0 ° C, respiratory rate - 40 per min. Heart rate - 128 per min. Reaction to examination: restless. The physique is correct. The skin is pale, cyanosis of the nasolabial triangle. The mucous membranes, conjunctiva are clean, without features. The tongue is coated, moderately whitish. The pharynx is hyperemic, tissue turgor is preserved, elasticity is preserved, tonsils are not hypertrophied, there is no edema. Nasal breathing is difficult, the discharge is serous. Cough - dry, unproductive, frequent. There is no shortness of breath. There is a dullness of the pulmonary sound on the left. Auscultatory breathing is hard, carried out in all departments. Wheezing, moist, finely bubbling, localized in the subscapularis region on both sides. The abdomen is soft and painless.

Preliminary diagnosis: Community-acquired bilateral focal pneumonia, DN, acute course

Patient examination plan

Ё UAC - 11/25/2020

Ё OAM - 11/25/2020

Ё ECG -25.11.2020

Ё Radiography of the OGK - 11/25/2020

Ё B / X blood test: commonly. Protein, bilirubin, ALT, AST - 11/25/2020

Ё Blood on KLA (mom)

Ё Tank. feces study (for mom)

Ё Fluorography (for mom)

Ё Blood on RW (mom)

Ё Physiotherapist consultation 11/25/2020

Ё UAC - 02.12.2020

Ё OAM - 02.12.2020

Ё Radiography of the OGK - 02.12.2020

anamnesis peripheral lymph research

Results of laboratory, instrumental and other research

1. UAC dated November 26, 2020

Erythrocytes - 3.9 * 1012 / l

Hb- 111 g / l

Color indicator - 0.85

Leukocytes - 5.8 * 106 / l

Eosinophils - 1%

Neutrophils:

- stab - 2%

- segmented - 31%

Lymphocytes - 64%

Monocytes - 2%

ESR - 23 mm / h

Conclusion: monocytopenia, increased ESR

2. OAM dated November 26, 2020

Quantity - 18

Color - light / yellow

Reaction - acidic

Ud. Weight - 1012

Transparency - cloudy

Protein - neg.

Salts: urates all over

Conclusion: urophrotic syndrome

3. ECG of November 28, 2020

Heart rate - 150 beats / min

EOS is normal

4. X-ray from 11/25/2020

On the OGK, focal shadows in the medial zones of the pulmonary fields against the background of a diffuse enhancement of the pulmonary pattern and increased transparency of the mantle zones of the pulmonary fields. The contours of the lungs are indistinct, non-structural.

Conclusion: bilateral bronchopneumonia

5. Blood on MCA - neg.

6. B / X blood test from 11/29/2020

AsAT - 35.1 units / l (N - 0 -82)

ALAT - 26.4 units / l (N -0 -56)

Total protein - 64.0 g / l (N - 50-89)

Bilirubin - 7.00 мmol / l (N - 3.4 - 17.1)

Direct bilirubin 0.00 мmol / l (N - 0.34)

Conclusion: no pathology

7. ОАМ from 02.12.2020

Quantity - 30

Yellow color

Reaction - acidic

Ud. Weight - 1012

Transparency - N

Protein - neg.

Leukocytes - 2-1-1 in the field of view

Salts: oxalates ++

Conclusion: urophrotic syndrome

8. UAC dated 02.12.2020

Erythrocytes - 4.05 * 1012 / l

Hb - 109 g / l

Color indicator - 0.8

Leukocytes - 10.3 * 106 / l

Eosinophils - 2%

Neutrophils:

- stab - 6%

-segmented - 39%

Lymphocytes - 52%

Monocytes - 1%

ESR - 23 mm / h

Conclusion: grade I anemia (Hb)., Slight leukocytosis with a shift to the left, monocytopenia, increased ESR.

9. X-ray from 05.12.2020

Diffuse enhancement of the pulmonary pattern. The right dome of the diaphragm is raised. Relaxation of the right diaphragm dome.

Conclusion: Positive dynamics

Clinical diagnosis and justification

Considering:

Ё anamnesis data: Re-ill. Prior to admission to the hospital, underwent treatment from 10.11.2020 to 24.11.2020 in a rural hospital. They were treated with cefazolin (according to the mother). Due to the improvement, he was discharged. The next day the temperature rose - 39.6, cough, runny nose. In this regard, an ambulance was called, which he was hospitalized in the State Children's Clinical Hospital, where he was diagnosed with community-acquired bilateral focal pneumonia, acute course, DN About art.

Ё complaints: Cough, runny nose, difficulty in nasal breathing, depression of the child

Ё on the basis of objective research data: Temperature 37.0 ° С, respiratory rate - 40 per min. Heart rate - 128 per min. Reaction to examination: restless. The physique is correct. The skin is pale, cyanosis of the nasolabial triangle. The mucous membranes, conjunctiva are clean, without features. The tongue is coated, moderately whitish. The pharynx is hyperemic, tissue turgor is preserved, elasticity is preserved, tonsils are not hypertrophied, there is no edema. Nasal breathing is difficult, the discharge is serous. Cough - dry, unproductive, frequent. There is no shortness of breath. There is a dullness of the pulmonary sound on the left. Auscultatory breathing is hard, carried out in all departments. Wheezing is moist, finely bubbly, localized in the subscapularis region on both sides. The abdomen is soft and painless.

Ё Based on the results of laboratory, instrumental and other studies: OAM - uronephrotic syndrome KLA - grade I anemia (Hb - 109 g / l)., Slight leukocytosis with a shift to the left, monocytopenia, increased ESR., Radiography - On OGK, focal shadows in the medial zones pulmonary fields against the background of diffuse enhancement of the pulmonary pattern and increased transparency of the mantle zones of the pulmonary fields. The contours of the lungs are indistinct, non-structural.

B / X blood test - no pathology.

Clinical diagnosis:

· Main: Community-acquired bilateral focal pneumonia, DN, acute course

· Accompanying: Anemia of the 1st degree.

Etiology

Community-acquired pneumonia develops from 2-4 weeks of age. During this period and in the second month of life, respiratory viruses (MS virus, adenovirus, parainfluenza viruses) and bacteria (S. aureus, pyogenic streptococcus and gram-negative enterobacteria) become the causes of CAP. Pathogens such as pneumococcus and Haemophilus influenzae are rare in this age period.

From 2 months to 3 years, the role of respiratory viruses in the etiology of CAP increases. They can be both an independent cause of the disease and create viral-bacterial associations. Most important are the MS virus, which occurs in about half of cases; in a quarter of cases, the cause of the disease is parainfluenza viruses of types 3 and 1; influenza A and B viruses and adenoviruses play a minor role. Rhinoviruses, enteroviruses, coronaviruses are rarely detected. Also described are pneumonia caused by viruses of measles, rubella, chickenpox. In addition to the independent etiological significance, respiratory viral infection in young children is an almost obligatory background for the development of bacterial inflammation.

The bacterial pathogens most common in children with CAP are the same as in adults: S. pneumoniae, H. influenzae, M. pneumoniae, C. pneumoniae, S. aureus, and S. pyogenes. However, in early childhood, the etiological role of pneumococcus increases markedly only by 6 months of age and accounts for 35-45% of all cases of pneumonia.

H. influenzae, type b, and nontypeable haemophilus influenzae as a cause of CAP occur in children from 3-5 months of age and occurs in approximately 10% of all CAP cases in children under 7 years of age.

S. aureusand S. pyogenis, E. coli and K. pneumoniae as the cause of pneumonia occur mainly in children of the first 2-3 years. The etiological significance of each of them is small and does not exceed 2-5% of all cases of CAP, but they cause the most severe diseases in children, complicated by the development of shock and destruction. Diseases caused by S. aureus and S. pyogenis usually complicate severe viral infections such as influenza, chickenpox, measles, herpes infection.

Pneumonia caused by atypical pathogens in children is mainly caused by M. pneumoniae and C. trachomatis et pneumoniae. Legionellosis and psitacosis were until recently considered very rare pathologies. However, in recent years, there have been indications of a possibly large role for L. pneumoniae in the genesis of pneumonia in childhood. The role of M. pneumoniae as a cause of CAP in children has clearly increased in recent years. Basically, mycoplasma infection begins to be diagnosed in the second year of life. C. pneumoniae as a cause of pneumonia is detected at almost any age.

Data on the etiology of CAP in young children are given in table.

Table

Etiology of community-acquired pneumonia in young children

Age	Viruses	Bacteria
2 weeks - 2 months	MS virus, adenovirus, parainfluenza viruses	S. aureus, S. pyogenes, gram-negative enterobacteria (E. coli, K. pneumoniae), C. trachomatis

Pathogenesis

The pathogenesis of the development of pneumonia in children does not differ significantly compared to adults. A lower level of anti-infectious protection, especially characteristic of young children, a relative lack of mucociliary clearance, especially with a respiratory viral infection, and a tendency to swelling of the respiratory mucosa and the formation of viscous sputum with the development of inflammation of the respiratory tract, which also disrupts mucociliary clearance, can be noted.

Of the four main pathogenetic mechanisms of pneumonia development (aspiration of oropharyngeal secretion; inhalation of aerosol containing microorganisms; hematogenous spread of microorganisms from the extrapulmonary focus of infection and direct spread of infection from neighboring affected organs) in children, microaspiration of oropharyngeal secretion is of greatest importance in the development of CAP. The second most important place is occupied by the hematogenous spread of infection. Aspiration of large amounts of the contents of the upper respiratory tract and / or stomach is typical for newborns and children in the first months of life. Mechanical obstruction of the airway is most important, especially in cases of meconium aspiration or aspiration during feeding and / or vomiting and regurgitation.

Factors predisposing to aspiration (including microaspiration):

· encephalopathy of various origins (posthypoxic, with malformations of the brain and hereditary diseases, convulsive syndrome);

· dysphagia (vomiting and regurgitation syndrome, esophageal-tracheal fistulas, chalasia, gastroesophageal reflux);

· mechanical violations of protective barriers (nasogastric tube, endotracheal intubation, tracheostomy, gastroduodenoscopy);

· repeated vomiting with intestinal paresis, severe infectious and somatic diseases.

Differential diagnosis

The differential diagnosis of pneumonia in children is closely related to the age of the child, as it is determined by the characteristics and nature of pulmonary pathology at different age periods. In infancy, the need for a differential diagnosis arises in diseases that are difficult to respond to standard treatment. In these cases, it should be remembered that, firstly, pneumonia can complicate another pathology. Secondly, the clinic of respiratory failure can be caused by conditions such as:

· aspiration,

· foreign body in the bronchi,

· nondiagnosis - previously tracheoesophageal fistula, gastroesophageal reflux,

· malformations of the lung (lobar emphysema, coloboma), heart and large vessels,

· cystic fibrosis and б-antitrypsin deficiency.

In children of the second or third years of life and at an older age, with difficult to treat pneumonia, the following should be excluded:

· Cartegener's syndrome;

· hemosiderosis of the lungs;

· nonspecific alveolitis;

· selective immunodeficiency IgA.

Differential diagnosis at this age is based on the use of endoscopic examination of the trachea and bronchi, conducting a scintigram of the lungs, angiography, conducting sweat and other tests for cystic fibrosis, determining the concentration of б1-antitrypsin, etc.

Finally, pulmonary tuberculosis must be ruled out at all ages.

In patients with severe immunity defects, with the appearance of shortness of breath and focal infiltrative changes in the lungs, it is necessary to exclude:

· progression of the underlying disease;

· involvement of the lungs in the main pathological process (for example, with systemic diseases of the connective tissue);

· the consequences of the therapy (drug damage to the lungs, radiation pneumonitis)

Treatment plan

Ё Antibiotic therapy

Ё Mucolytics

Ё Antihistamines

Ё Syndromic

Ё Physiotherapy

Food

6.00 - breast milk 200 ml.

10.00- breast milk 150 ml. Fruit puree - 50 g.

14.00 - Broth 50.0 ml, minced meat - 50.0 g.

Mashed potatoes 100 g. Compote - 100 ml

18.00- breast milk 100 ml. Porridge 10% - 100 g.

22.00 - breast milk 200 ml.

Treatment

The main method of treating pneumonia is antibiotic therapy, which is prescribed until the results of bacteriological research are obtained. (the results of the latter become known 2-3 days after the sampling and in most cases of a mild course of the disease do not have a significant effect on the tactics of treatment).

When choosing a starting antibiotic therapy in children aged 2 months to 6 years, 3 groups of patients can be distinguished:

· patients with non-severe pneumonia who do not have modifying factors or have modifying factors of the social plan;

· patients with modifying factors that aggravate the prognosis of the disease;

· patients with severe pneumonia with a high risk of poor outcome.

Patients of the first group - with mild pneumonia and no modifying factors - are most advisable to prescribe antibacterial drugs inside. But in some cases (lack of confidence in the fulfillment of appointments, a rather serious condition of the child when the parents refuse to be hospitalized, and other similar situations), a stepwise method of therapy is justified, when in the first 2-3 days the treatment is carried out parenterally, and then when the condition improves or stabilizes the patient is prescribed the same antibiotic by mouth. For this purpose, amoxicillin, amoxicillin clavulanate, cefuroxime can be used, which are presented in two forms - for parenteral and oral administration. In addition to Я-lactams, macrolides can also be used. But, given the etiological significance of Haemophilus influenzae (up to 7%) in children of this age group, Of the wide range of macrolide antibiotics, azithromycin is the drug of choice for starting empiric therapy. Other macrolide drugs are alternative drugs for intolerance to Я-lactam antibiotics or when they are ineffective in case of pneumonia caused by atypical pathogens - M. pneumoniae, C. pneumoniae.

Patients of the second group - CAP with the presence of modifying factors (with the exception of social) - are shown parenteral administration of antibiotics or the use of a stepwise method of administration. The drugs of choice, depending on the severity and prevalence of the process, the nature of the modifying factor are amoxicillin clavulanate, cefuroxime or ceftriaxone, cefotaxime. Alternative drugs for the ineffectiveness of the initial therapy are 3-generation cephalosporins (with the initial administration of amoxicillin clavulanate, cefuroxime), glycopeptides, carbapenems, cefepime. If aspiration is suspected in children with encephalopathy, severe malnutrition, vomiting syndrome, add lincosamines. Macrolides in this group are rarely used, since the overwhelming number of pneumonia caused by atypical pathogens is not difficult.

Patients with a high risk of an unfavorable outcome, severe purulent-destructive complications are shown to prescribe antibacterial therapy according to the de-escalation principle, involving the use of carbapenems as a starting drug or a combination of glycopeptides with aminoglycosides.

Symptomatic therapy

Antitussive therapyoccupies an important place in the treatment of pneumonia, being one of the main areas of symptomatic therapy. Of the antitussive drugs, the drugs of choice are mucolytics, which dilute bronchial secretions well by changing the structure of mucus. Mucolytics are used internally and by inhalation:

The second direction of symptomatic therapy isantipyretic therapy. Currently, the list of antipyretic drugs in childhood is limited to paracetamol and ibuprofen. The indication for their appointment is febrile fever (over 38.50C). At temperatures above 40 ° C, a lytic mixture is used.

Physiotherapy

With pneumonia, Dance therapy (dynamic electroneurostimulating therapy) is used according to the immunomodulatory technique (chest in the zones of the 7th cervical vertebra - 7 minutes, jugular fossa - 2-3 minutes, "herringbone", "slobber" up to 15 minutes) No. 10- 12 procedures.

For the correction of asthenovegetative manifestations in pneumonia, non-contact electromagnetic field relaxation therapy (BEPRT) is carried out with the "DETA" apparatus according to programs for correcting the vegetative status and the state of the central nervous system. Medicinal electrophoresis, which has a bronchodilator, antiallergic, vegetative-regulatory effect (2% aminophylline, 1-3% potassium chloride, 2-3% calcium chloride, 1-2% magnesium sulfate, heparin 15-20,000 units, 3% sodium thiosulfate solution, 0.5-1.5 copper sulfate, 1% ascorbic acid with concomitant anemia, 0.2% platyphyllin solution, with lung atelectasis), can alternate with electrophoresis of Aloe extract 1: 3 with resorptive and restorative effect.

In the period of convalescence, to increase immunobiological reactivity, UV-general, general aeroionization (using a Chizhevsky chandelier), coniferous and carbon dioxide baths, sun-air baths, bioptronic color therapy according to the program "Strengthening the protective forces" by the method of illuminating the oral cavity and throat with orange are used (1 min), neck-clavicle red (1 min) on the left and right, sternum green (1 min), spleen yellow (2 min), hands "snuffbox" with yellow (1 min) light No. 8 daily.

TEMP.	25.11.2020	26.11.20	27.11.20	28.11.20	29.11.20	30.11.20	01.12.20	02.12.20	03.12.20
	M	E	M	E	M	E	M	E	M	E	M	E	M	E	M	E	M	E
41 C
40 C
	39.6	39.6
			39.2	39.2
39 C
					38.4	38.4
38 C
											37.8	37.8
							37.4	37.4
37 C
									36.4	36.4			36.4	36.4	36.4	36.4	36.4	36.4
36 C
35 C
HEART RATE	135	135	135	135	133	133	130	130	130	130	130	130	126	126	124	124	120	120

Diary

11/29/2020

t - 36.3 ° C BH -38 per min. Heart rate -130 / min. Complaints about cough. A state of moderate severity. Consciousness is clear, the reaction to examination is adequate, the skin and visible mucous membranes are clean, moist. Breathing in the lungs is hard, wheezing of small caliber on both sides. Heart sounds are rhythmic, the abdomen is soft, painless. Stool and urination are not disturbed.

30.11.2020.

t - 37.8 ° C BH -38 per minute HR-130 per minute. A state of moderate severity.

Complaints about cough, loss of appetite. Consciousness is clear, the reaction to examination is adequate, the skin and visible mucous membranes are clean, pale. Breathing in the lungs is hard, carried out in all departments, moist rales on both sides. Rhythmic heart sounds. The abdomen is soft and painless. Stool and urination are not disturbed.

01.12.2020

t - 36.4 ° C BH -40 per minute HR-126 per minute. The condition is stabilizing,

Complaints of cough, loss of appetite, weakness, a state of moderate severity. Consciousness is clear, the reaction to examination is adequate, the skin and visible mucous membranes are clean, pale. The pharynx is hyperemic, the cough is rare. Breathing is hard in the lungs. Heart sounds are muffled, rhythmic. The abdomen is not swollen, soft, painless. The liver is not enlarged. Stool and urination are not disturbed.

03.12.2020

t - 36.4 ° C BH - 30 per minute, heart rate - 120 per minute. A state of moderate severity. Complaints about cough. The skin is clean, the mucous membranes are moist, breathing in the lungs is hard. Rhythmic heart sounds. The abdomen is soft and painless. Stool and urination are not disturbed.

Prescribed treatment

1. Antibiotic CP III generation. (from 25th to 3rd day)

Stericef 500

S. in \ m, 1 r / d

2. Sol. Papaverini 0.5

Sol... Supraflini 0,3 (from 25th to 5th)

S. in \ m 2 p \ d

3. Bromgexini 8 (25th to 5th)

S. 1 \ 3 tab. 3 r \ d

4. Vnutriorg. Electrophoresis (from 28th to 2nd day)

5. Sol. Proforgoli 2% (25-27 numbers)

S. 2 cap. 3 r \ d

6. Inhalation with physical solution number 7 (from 25 to 5)

7. Bifidumbacterini 5 doses * 2 r / d (from 29th to 5th day)

8. Sol. Zinomicini 30% - 0.5 ml (from 3rd to 5th day)

S. in \ m 2 p \ d

Epicrisis

Sick N. On February 20, 2020, he was admitted on an emergency basis on November 25, 2020 in a state of moderate severity with complaints of Cough, runny nose, difficulty in nasal breathing, depressed state of the child

As a result of the examination (examination, laboratory tests) carried out in the clinic:

The skin is pale, without pigmentation, cyanosis of the nasolabial triangle. The mucous membranes, conjunctiva are clean, without features. There is no injection of vascular sclera. The tongue is coated, moderately whitish. The pharynx is hyperemic, tissue turgor is preserved, elasticity is preserved, tonsils are not hypertrophied, there is no edema. Peripheral lymph nodes are not enlarged. Nasal breathing is difficult, the discharge is serous. Cough - dry, unproductive, frequent. There is no shortness of breath. There is a dullness of the pulmonary sound on the left. Auscultatory breathing is hard, carried out in all departments. Wheezing, moist, finely bubbling, localized in the subscapularis region on both sides.

OAM -unephrotic syndrome KLA - anemia I stage (Hb - 109 g / l)., slight leukocytosis with a shift to the left, monocytopenia, increased ESR. zones of pulmonary fields. The contours of the lungs are indistinct, non-structural. B / X blood test - no pathology.

Diagnosis:

· Main: Community-acquired bilateral focal pneumonia, DN, acute course

· Accompanying: Anemia of the 1st degree.

Ї The patient continues treatment.

Ї The prognosis for life is favorable.

List of used literature

1. N.P.Shabalov. "Childhood Diseases", ed. Peter, St. Petersburg, 2000.

2. G.A. Samsygina "PNEUMONIA IN CHILDREN", Department of Children's Diseases No. 1 of the Pediatric Faculty with the course of cardiology and rheumatology, FUV, Russian State Medical University, 2005.

3. HELL. Tsaregorodtsev, V.A. Tobolin "Pharmacotherapy in pediatric pulmonology", Medpraktika. M 2002.

4. John W. Graef, Pediatrics, M. 1997.

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