Hemorrhagic disease of the newborn. History of Disease (propaedeutics of childhood diseases)

RUSSIAN STATE MEDICAL UNIVERSITY Faculty of Pediatrics Department of propaedeutics of childhood diseases with courses healthy child and general child care. Head of the department: prof. V.A.Filin Lecturer: assistant S.S.Galaeva. CASE HISTORY patient: Vedeneeva Yulia Olegovna. Age: 4 years old. Date of admission to the hospital: 03/06/2001 Supervision date 03/27/2001. Clinical diagnosis. The main disease: chronic gastroduodenitis in the acute stage. Complications of the underlying disease: no. Concomitant diseases: acute rhinitis, right-sided acute catarrhal otitis, SARS, cholestasis syndrome, caries. Curator: 3rd year student of group 332 Meshchenkova Natalya Vladimirovna Moscow, 2001. Passport part 1. Full name Vedeneeva Yulia Vladimirovna 2. Date of birth - 11/21/1996. 3. Age - 4 years. 4. Gender - female. 5. Permanent place of residence - Moscow, st. Zelenodolskaya, 12, apt. 274. 6. Children's institution – kindergarten No. 755. 7. Information about parents: Mother: Klochkova Tatyana Alexandrovna, 32 years old, housewife. Father: Vedeneev Oleg Alexandrovich, 30 years old, driver. 8. There are no data on blood type. 9. Allergic reactions - ampicillin, gentamicin, levomycetin, broncholithin, sweet mixtures, village eggs, tangerines, carrot juice. 10. Date of admission - 06.03.2001. 11. Date of curation - 27.03.2001. Clinical diagnosis. The main disease: chronic gastroduodenitis in the acute stage. Complication of the underlying disease: no. Concomitant diseases: acute rhinitis, right-sided acute catarrhal otitis, SARS, cholestasis syndrome, caries. Anamnesis. 1. History of the disease. 1) Complaints. The child was admitted to the department with complaints of acute cutting pain over the entire surface of the abdomen, stool disorders (diarrhea), nausea and vomiting (single), fever up to 380C. At the time of supervision, complaints of pain that occur 30-40 minutes after eating or at night, and after eating, the intensity of pain decreases, but after a while it intensifies again ("mynintan's rhythm of pain"), localized in the pyloroduodenal zone, belching, bouts of nausea after food, stool disorders. Complaints of nasal congestion, difficulty in nasal breathing. 2) Anamnesis morbi The disease manifested itself for the first time at 7 months - dyspeptic disorders were noted at the reception fatty foods. Constipation began at 1 year. At 2-3 years old, a reaction to the intake of fatty meat food (shish kebab) was noted: nausea, vomiting, diarrhea, fever, sharp pains in the epigastrium. At the age of 2 he was diagnosed with acute gastroduodenitis, at 3.5 - chronic gastroduodenitis. 05.03.2001 the girl's diet was violated (the patient ate fatty pilaf). There was a fever, nausea, vomiting, diarrhea, sharp pains in the abdomen. The mother called an ambulance. The girl was taken to the IDKB on March 5 to the surgical department with a preliminary diagnosis of acute appendicitis. The diagnosis was not confirmed and the girl was transferred to the 1st therapeutic department on March 6 for an examination for gastropathology. 2. Anamnesis vitae. 1) Family history. 2) Obstetric history. Child from the 4th pregnancy, the first three were interrupted. Abortions were with complications - endometritis. During pregnancy there was a threat of miscarriage at the 15th week, low placentation. The pregnancy was difficult, with toxicosis, the mother had hypertension. During pregnancy, the mother had a sore throat and took indomethacin. Delivery occurred at 41 weeks. The girl was born in asphyxia, there was a surgical intervention (the uterus was opened). The weight of the newborn was 2950 g, height - 47 cm. Weight-height index (Quetle I) - 62.77 g/cm. Apgar score - 7 points. 3) The neonatal period. During the birth, the child suffered a stroke, after which a 4x5 mm cyst was found in the brain. The girl had hydrocephalic hypertensive syndrome. The child was put to the breast on the 3rd day, from the 2nd week of life she was transferred to artificial feeding due to mother's agalactia. The mother and child were discharged from the maternity hospital on the 7th day. 4) The period of infancy. During infancy lagged behind in physical (up to 5.5 months did not gain weight and height). Nervously- mental development by age: 3-4 months. Started walking at 8 months. - get up, at 10 months. - walk, 1.5 years - talk. Preventive vaccinations by age. Allergic reactions to vaccinations were absent. 1 month - rhinitis, chronic tonsillitis. 4.5 months - an attack of false croup. 5 months - rickets. From 7 months dyspeptic disorders were noted in the form of diarrhea when eating fatty foods, constipation began at the age of 1 year. 5) History of life at an older age. Attends kindergarten. Past diseases: Frequent acute respiratory viral infections, acute respiratory infections (every 4-5 months). 6) Social history. He lives in a 4-room apartment with his parents and relatives (9 people in total, of which 2 are children). Has a separate bed. Sanitary and hygienic conditions are unsatisfactory (the apartment is old, damp, mold growth is noted in damp places). The daily routine is not respected. The duration of a night's sleep is 8 - 9 hours. The diet is not followed. 7) Allergological history. There are manifestations of household sensitization (nasal congestion, difficulty in nasal breathing, sneezing) to mold. Drug allergy to ampicillin, gentamicin, levomycetin, broncholithin, sweet mixtures. food allergy to rustic chicken eggs , tangerines, carrot juice. History conclusion. Based on complaints (pain localized in the pyloroduodenal zone, dyspeptic symptoms and nasal congestion, difficulty in nasal breathing), anamnesis morbi (repeated identical reactions to fatty meat food - dyspeptic symptoms, fever, pain syndrome), anamnesis vitae (the father suffers from chronic gastritis, erosive bulbitis, mother - gastroduodenitis, bulbitis, colitis, grandfather - stomach ulcer, grandmother died of intestinal cancer) it can be assumed that the digestive system of a chronic course, acquired genesis with a hereditary predisposition, and the respiratory system - an acute course, acquired genesis. status praesens. I. Evaluation and justification of the severity of the child's condition. The severity of the condition is assessed taking into account the severity of the toxicosis syndrome and taking into account the functional damage to the respiratory and digestive systems. . The syndrome of toxicosis is weakly expressed (the patient is mobile, active, there is no drowsiness and lethargy, there were no disturbances in consciousness and sleep). . Respiratory system - the syndromes of damage are expressed: acute rhinitis (nasal congestion, difficulty in nasal breathing, mucopurulent discharge in the nasal passages), no signs of respiratory failure were detected, respiratory failure and FRR / respiratory failure correspond to age. . Digestive system - expressed lesion syndromes: chronic gastroduodenitis in the acute stage (pain localized in the pyloroduodenal zone, dyspepsia). Based on this, the severity of the child's condition is moderate. II. Evaluation and conclusion on physical development. The child at the time of curation is 4 years, 4 months, 6 days old. Age group - 4 years. 1 age interval - 6 months. 1) Formulas. | Indicators | Actual | Calculation | Norm | Difference | Voz.int | Evaluation | | | | | | |. | | | Height, cm | 90.5 | 130 - (4x7) | 102 | -11.5 | -3.2 | Very low. | | Weight, kg | 12.7 | 19 - (1x2) | 17 | -4.7 | -4.8 | Very low. | | Okr. chest, cm | 50 | 63 - (6x1.5) | 54 | -4 | -5.4 | Very low. | | Around the head, cm | 48 | 50 - (1x1) | 49 | -1 | -2 | Below average | . Tour Index: approx. chest - approx. heads = 50 - 48 = 2; (1n - 2n = 4 - 8 cm, where n is age in years). . hhead / hbody = 17 / 90.5 ~ 1 / 5.5; (1 / 6 for 4 years.) Conclusion according to the formulas: physical development is very low, since the growth is very low, inharmonious, lack of mass for this height, disproportionate (mismatch hhead / hbody (1/5.5)). 2) Valuable assessment. | Indicators | Actual | Centile | Corridor | Interpretation | | Height, cm | 90.5 | 0-3 | 1 | "och. low values» | | Weight, kg | 12.7 | 0-3 | 1 | "och. low values» | | Okr. chest, cm | 50 | 3-10 | 2 | "low values" | | Okr.head, cm | 48 | 3-10 | 2 | "low values" | | Conclusion on centiles: physical development is very low, since the growth is very low, harmonious (height and weight are in the same corridors), proportional (chest circumference and head circumference are in the same corridors). 3) Somatotype. Corridor (height) + corridor (weight) + corridor (chest circumference) = 1 + 1 + 2 = 4, therefore, microsomatotype (3 - 10). Conclusion: physical development is very low, since the growth is very low, inharmonious, lack of mass for this height, disproportionate (mismatch hhead / hbody (1/5.5)). III. Assessment of biological age and its correspondence to the calendar. . According to physical development: -3.2 age intervals, therefore, corresponds to 2.5 years. . By secondary sexual characteristics: Ma0, P0, Ax0, Me0; points - 0.0. The process of puberty has not yet begun, secondary sexual characteristics are not expressed. . Dental formula: number 20, dairy; |2012 |2102 | |2012 |2102 | Corresponds to 4 years. . Pathologies from mental development are not revealed. Neuropsychic development corresponds to age. Conclusion: the biological age corresponds to the calendar one (dental formula and neuropsychic development correspond to age), with a sharp lag in physical development. IV. Assessment of neuropsychic development and compliance with the calendar age. Consciousness is clear. Physical, motor activity without changes. Sleep is calm, normal duration (9-10 hours), transitions from wakefulness to sleep no more than 30 minutes. Skin sensitivity, vision, hearing, taste, smell and functions of the vestibular apparatus without disturbance. IN children's team sociable, has many friends, is friends mainly with boys, playful (teachers complain of noisy behavior). She loves to draw, can count to 10 and back, she told a poem of two quatrains. Conclusion: neuropsychic development corresponds to the calendar age. V. Skin. Subcutaneous tissue. Nails. Hair. . Anamnesis. There are no complaints. There were no contacts with infectious patients. . Inspection. 1) Skin. The color is pale pink. The skin is clean. There are no scratch marks. There is a weakly expressed venous network on the abdomen. Skin folds (behind the ears, on the neck, in the armpits, inguinal region, on the hips, under and between the buttocks, in the interdigital spaces) are not hyperemic, there is no maceration. The symptom of hepatic palms is negative. Ecchymosis on the left and right knees (~0.5x0.5 cm), of different age, single, post-traumatic. The rash is absent. 2) Visible mucous membranes. The inner surfaces of the lips, cheeks, soft and hard palate, gums, conjunctiva: the color is pink, the humidity is moderate, there are no rashes. Zev: pale pink, no swelling, no plaque, tonsils do not protrude beyond the anterior arches of the soft palate. Sclera: the color is normal (white), the vascular network is moderately expressed, subictericity is not noted. 3) Skin appendages (hair, nails). Light brown hair, normal type. Nails: round shape, pink color, brittleness and symptom of "polished" nails are absent. 4) Subcutaneous fat. The subcutaneous fat layer is poorly expressed. Distributed evenly. Edema on the face, lower extremities, in the area of ​​the sacrum is absent. . Palpation. 1) Skin. The skin is elastic. Skin thickness: on the back of the hand - 1 mm; in the elbow bend - 1 mm; on the anterior surface of the chest above the ribs - 2 mm. Humidity in symmetrical parts of the body: chest, trunk, armpits, groin, palms, soles is moderate. The temperature in symmetrical parts of the body: chest, trunk, limbs is symmetrical, not increased. pain, temperature and tactile sensitivity skin is preserved, symmetrical. There is no vascular fragility. The pinch sign is negative. Dermographism is red, appears after 1 minute, disappears after 3 minutes, the character is localized. 2) Subcutaneous fat. The thickness of the skin folds: above the biceps - 5 mm; over the triceps - 5 mm; under the shoulder blade - 3 mm; above the ilium - 10 mm. The sum of the thickness of 4 skin folds is 23 mm (corresponds to the 2nd centile assessment corridor). The consistency is not thick, not edematous. Edema in the lower leg above the tibia, in the area of ​​the sacrum is absent. Turgor of soft tissues on the inner surface of the thigh and shoulder is elastic. . Evaluation of the state of nutrition and harmony of physical development. With a height of 90.5 cm, the median weight is 13.1 kg. The lack of mass is 0.4 kg (~3%), which indicates a normal diet. Physical development is inharmonious, as there is a lack of mass with a given growth. Conclusion: when examining the skin, skin appendages, subcutaneous fat layer, no pathology was found. VI. Musculoskeletal system. Bone system. . Anamnesis. There are no complaints at the time of curation. . General inspection. The position is free, active. The gait is correct and stable. The posture is broken - there is a slight stoop. Deformations and stigmas of deembryogenesis are absent. Height - 90.5 cm. Build disproportionate:. hhead / hbody = 17 / 90.5 ~ 1 / 5.5; (1/6 for 4 years.). . Study separate parts skeleton. Skull bones. Inspection. The shape of the head is rounded. Head circumference 48 cm (deficit by 2 age intervals). The skull is symmetrical. The medulla of the skull relates to the facial as 2: 1. On the facial skull, the palpebral fissures, nasolabial folds, and the level of the ears are located symmetrically at the same level. The bite is correct. The bridge is unchanged. Mouth: sky round shape , milk teeth, 20 pieces, white enamel, caries of several teeth is noted. Palpation. The condition of the sutures of the skull is normal, the integrity of the bones of the skull is preserved. Percussion. During percussion of the skull bones, no changes in percussion sound were detected; bone sound was heard over the entire surface. Rib cage. Inspection. The chest is conical, symmetrical. Chest circumference 50 cm (deficit by 5.4 age intervals). The ratio of the anteroposterior and lateral dimensions is 2: 3. Palpation. The chest is elastic, soreness is not noted. The epigastric angle is close to a straight line (normosthenic body type). The ribs, collarbones are intact, painless on palpation. Percussion. On percussion of the chest, pain is not noted, a clear lung sound is detected above the lung fields. Spine. Scoliosis was not identified. The left and right shoulders are at the same level. The angle of the left and right shoulder blades is at the same level. Waist triangles are symmetrical. Mobility in the cervical thoracic and lumbar regions was preserved. The pelvic bones are not deformed, there is no pain on percussion and palpation. Upper and lower limbs. Inspection. On examination, the length of the right and left, upper and lower limbs, respectively, are equal. Visually, the ratio of the length of the shoulder and forearm, as well as the thigh and lower leg, is approximately 1/1. The shape of the joints is correct, the joints are symmetrical, the skin above their surface is not hyperemic. Edema and thinning of the skin is not observed. Palpation. On palpation of the bones of the extremities, pain, deformity, and integrity were not detected. The temperature of the skin over the symmetrical joints is the same (does not differ from the temperature of the surrounding tissues). “Floating patella” syndrome is negative. Limitations of movements in the joints during active and passive movements were not revealed. The arch of the foot is high, flat feet are not revealed. Anthropometry of joints. Elbow joint: right - 16.5cm / 15cm / 14.5cm; left - 16cm / 15cm / 14.5cm. Knee joint: right - 26cm / 24cm / 22cm; left - 27cm / 24cm / 22.5cm. Muscular system. . Inspection. Muscle development corresponds to age and sex, distributed evenly, symmetrically. . Palpation. Muscle palpation is painless. The abdominal and back muscles are developed satisfactorily (in the standing position, the stomach is pulled in, the shoulder blades are pulled up to the chest). The respiratory muscles are actively involved in the act of breathing, lagging behind and sparing any muscle group was not revealed. Muscle strength is satisfactory (the child provides sufficient resistance with active and passive extension of the limbs). With passive flexion and extension of the limbs in the joints, a satisfactory muscle tone is determined. The range of motion in the joints, determined during active and passive movements, was preserved. Conclusion: the study of the musculoskeletal system revealed no pathology. VII. Respiratory system. . Anamnesis. Complaints at the time of curation for a runny nose, difficulty in nasal breathing. . Inspection. Nose: the shape of the nose is not changed, breathing through the nose is difficult, the nasopharyngeal mucosa is moderately hyperemic, there is moderate, mucopurulent mucus in the nasal passages. Zev: pale pink, no swelling, no plaque, tonsils do not protrude beyond the anterior arches of the soft palate. Chest: The chest is symmetrical. Breathing is deep, rhythmic. Both halves of the chest are symmetrically involved in breathing. Respiratory rate 26 per minute at rest (N = 25). The ratio of heart rate / respiratory rate = 100 / 26 = 4 / 1. Palpation. The chest is painless, elastic. Mixed breathing, there is no lagging of one of the halves of the chest during breathing. Respiratory movements due to contraction of the intercostal muscles, diaphragm and muscles of the abdominal wall. The circumference of the chest during quiet breathing is 50 cm, at the depth of maximum inhalation 53 cm, with maximum exhalation 48 cm, chest excursion = 5 cm. The thickness of the skin-subcutaneous folds on symmetrically located areas of the chest is the same. . Percussion. Comparative percussion: On the symmetrical parts of the chest, a clear pulmonary sound is determined: In front - along the left midclavicular line to the II m / r, along the right midclavicular line to the VII rib (relative dullness of the liver). Laterally - along the left mid-axillary line to the V-VI ribs (Traube space), along the right mid-axillary line to the VII rib (relative dullness of the liver) Behind - up to the X rib along the right and left scapular lines. Topographic percussion: The upper border of the lungs: the height of the tops in front is 2 cm above the level of the clavicle (right and left); behind - at the level of СVII, spinous process. The width of the Krenig fields (determined by the method of indirect percussion from the middle of the upper edge of the trapezius muscle alternately towards the neck and shoulder until dulling) - 4 cm. Lower border of the lungs | | Right | Left | | on the midclavicular line | VI rib | - | | midaxillary line | VII rib | IX rib | | along the scapular line | | X edge | | Paravertebral line | Spinous process ThXI | Conclusion: the boundaries of the lungs correspond to the age norm. Mobility of the lower edge of the lungs | | Right | Left | | | Inhale | Exhale | Total | Inhale | Exhale | Total | | On the scapular line | 3.0 | 2.0 | 5.0 | 3.0 | 2.0 | 5.0 | | On the rear axillary | 3.0 | 2.5 | 5.5 | 3.0 | 2.5 | 5.5 | | lines | | | | | | | Filatov's symptom (shortening of percussion sound in front in the area of ​​the sternum handle) is negative. Symptom of Philosophov's cup (shortening of percussion sound in the area of ​​the first and second intercostal spaces in front of the sternum) is negative. Percussion of the intrathoracic lymph nodes (along the spinous processes of the vertebrae from the level of the intersection of the line drawn along the spina scapulae with the spine in the patient's half-bent position) reveals a clear pulmonary sound. . Auscultation. Basic breath sounds. Vesicular breathing is heard in symmetrical areas of the chest. In places of obligatory listening - axillary regions, paravertebral spaces, between the spine and scapula (lung root region), subscapular regions and the region of the heart - vesicular breathing is auscultated. Adverse breath sounds. Wheezing, crepitations, pleural friction noise, pleuropericardial murmur are not heard. Bronchophony is the same in symmetrical areas of the chest. The ratio of inhalation and exhalation: exhalation is not audible. Conclusion: in the study of the respiratory system, the following lesion syndromes were identified: acute rhinitis (difficulty in nasal breathing, moderate, mucopurulent mucus in the nasal passages), no signs of respiratory failure were detected, respiratory failure and FRR / respiratory failure correspond to age. VIII. The cardiovascular system. . Anamnesis. There are no complaints. Weakness, fatigue physical activity , shortness of breath are absent. There is no pain in the region of the heart. . Inspection. The color of the skin and visible mucous membranes is pale pink. There is no disproportion in the development of the upper and lower halves of the body. Edema (on the feet and legs), ascites are not visually determined. Respiratory rate = 26 per minute, the rhythm is correct, there is no shortness of breath. The shape of the fingers and nails is not changed, the symptom of "drum sticks" and "watch glasses" is absent. Examination of the vessels of the neck: the veins of the neck are not dilated, not swollen; there is no positive venous pulse, there is no symptom of "carotid dance". Examination of the heart area: the chest in the heart area is not changed, there is no heart hump. There is no visible pulsation (apical, cardiac impulse, epigastric pulsation and pulsation in the jugular fossa). . Palpation. The apex beat is palpated in the 4th intercostal space along the left midclavicular line; medium strength, localized, S ~ 1 cm2. Cardiac impulse, epigastric pulsation, pulsation at the base of the heart, aorta in the jugular fossa and trembling in the region of the heart are not determined. There are no zones of palpation pain and hyperesthesia. Examination of peripheral arteries The pulse on the temporal, carotid, brachial, radial, popliteal arteries, as well as the arteries of the dorsal foot is symmetrical, synchronous. The elasticity of the arteries is not changed, the arteries are not tortuous, the arterial walls are smooth. Auscultation of the arteries revealed no pathological changes. The arterial pulse on the radial arteries is symmetrical, synchronous, rhythmic, well filled, firm. NRR = HR = 100 per minute. There is no pulse deficit (N = 105 per minute) Arterial pressure: 100/60 mm Hg. on the right brachial artery; 98/60 mmHg on the left brachial artery. Estimated art. pressure for 4 years: 93/64 mm Hg. Max art. pressure for 4 years: 108/78 mm Hg. Min art. pressure for 4 years: 78/48 mm Hg. Examination of the veins Pulsations and swelling of the external and internal jugular veins are absent. Expansions of the veins of the chest, no abdominal wall. There is no swelling or pain along the way. . Percussion. Relative dullness of the heart Limits of relative dullness of the heart: o right edge: 0.5 cm medially from the right parasternal line; o left outer edge: 1 cm outward from the left nipple line; o upper edge: at the level of II m / r along the left parasternal line. The diameter of the relative dullness of the heart: 9 cm (N = 8-12 cm) Conclusion: the boundaries of the relative dullness of the heart correspond to the norm. Absolute dullness of the heart Limits of absolute dullness of the heart: o right inner edge: left edge of the sternum; o left outer edge: 1.5 cm outward from the left parasternal line; o upper edge: at the level of III m / r along the left parasternal line. The diameter of the absolute dullness of the heart: 3.5 cm (N = 3 - 4 cm) The width of the vascular bundle is 3 cm at the level of the II intercostal space. Conclusion: the limits of absolute dullness of the heart correspond to the norm. . Auscultation. Heart rate 100 per minute. The rhythm is right. At the I point of auscultation (the apex of the heart - the mitral valve) - the I tone prevails over the II tone, coincides with the apex beat and pulsation of the carotid arteries, there are no noises. At the II point of auscultation (II intercostal space to the right of the sternum - the aortic valve) - the II tone prevails over the I tone, there are no noises. At the III point of auscultation (II intercostal space to the left of the sternum - the valve of the pulmonary artery) - the accent of the II tone, there are no noises. At the IV point of auscultation (at the base of the xiphoid process - the tricuspid valve) - the I tone prevails over the II tone, there are no noises. At the V point of auscultation (the Botkin-Erb point, located in the IV intercostal space on the left edge of the sternum - additional auscultation of the aortic valve) - the I tone prevails over the II tone, there are no noises. There are no additional tones, gallop rhythm, splitting of I and II tones. There is no pericardial rub. Conclusion: in the study of cardio-vascular system no pathology was found; there were no signs of heart and vascular insufficiency, no shortness of breath, no cyanosis; FRR/RR, FRR, BP corresponded to the age norm, changes in the boundaries of the heart and violations of the auscultatory picture of the heart were not detected. IX. Digestive system. Gastrointestinal tract. . Anamnesis. Complaints of pain that occurs 30-40 minutes after eating or at night, and after eating, the intensity of pain decreases, but after a while it intensifies again ("moynintan's rhythm of pain"), localized in the pyloroduodenal zone, belching, bouts of nausea after eating. Appetite preserved, no weight loss. Swallowing is free. Stool - constipation, followed by diarrhea. No gastrointestinal bleeding was noted. . Inspection. Examination of the oral cavity. The oral cavity is sanitized. The mucous membrane of the inner surface of the lips, cheeks, soft and hard palate is pink, clean. gums Pink colour, clean, moist, shiny. The tongue is moist, edematous, lined with a white coating at the root, painless, pink in color. The pharynx is pink, the tonsils do not protrude beyond the anterior arches of the soft palate. The mucous membrane of the pharynx is clean, moist, smooth. Examination of the abdomen. The skin is clean, pale pink. The abdomen is rounded, not enlarged, symmetrical, participates in the act of breathing, visible peristalsis of the stomach and intestines is not observed, venous collaterals are absent. Hernial formations are not observed. Puffiness of the anterior abdominal wall is not observed. . Palpation. Superficial approximate palpation: On palpation, the abdomen is soft, pain in the epigastrium is noted. Tumor formations and hernias, peritoneal symptoms (Shchotkin-Blumber syndrome) were not detected. Zones of hypertension are not marked. Abdominal circumference in the umbilical region = 49 cm. Deep methodical sliding palpation according to Obraztsov-Strazhesko: The sigmoid colon is palpated in the left iliac region in the form of a smooth elastic cylinder with a diameter of about 1.5 cm, painless, easily displaced, does not growl. The caecum is palpated in the right iliac region in the form of a moderately tense, slightly enlarged cylinder with a diameter of about 2 cm, rumbling when pressed on it, easily shifting, painless. The terminal ileum is palpated in the form of a cylinder 1 cm in diameter, painless, there is peristalsis under the palpating hand. The appendix is ​​not palpable. The ascending colon is palpated by bimanual palpation in the form of a cylinder with a diameter of about 2 cm, does not growl, is painless. The transverse colon is palpated by bilateral palpation (with a preliminary determination of the lower border of the stomach by auscultoaffliction at a level of 3.5 cm below the xiphoid process) in the form of a soft cylinder about 2 cm in diameter, does not growl, is painless. The descending colon is palpated by the method of bimanual palpation in the form of a cylinder, 2 cm in diameter, does not growl when pressed on it, is painless. The lower border of the stomach is determined by the method of auscultation at a level of 3.5 cm below the xiphoid process. The greater curvature of the stomach is palpable in the form of a soft elastic roller, slightly painful. The gatekeeper is not palpable. splash noise on the right middle line abdomen is not determined by percussion palpation. . Percussion. Over the entire surface is determined tympanic percussion sound. Free and encapsulated fluid in abdominal cavity not found. Mendel's sign is negative. . Auscultation. Live intestinal motility is heard over the entire surface of the abdomen. No peritoneal friction noise or vascular noises were detected. Liver and gallbladder. Anamnesis. After eating fatty foods, there is pain in the epigastrium, fever up to 380C, diarrhea. Yellowness of the skin and mucous membranes was not detected. Skin itching is absent. . Inspection. Protrusions in the area of ​​the right hypochondrium are not defined. Restriction of breath in this area is not observed, there is no pulsation. . Palpation. Liver. The liver is palpated at a level of 2 cm from the edge of the costal arch along the right midclavicular line. The edge of the liver is soft, even, with a smooth surface, slightly pointed, painless. Gallbladder. The gallbladder is not palpable. Ortner's symptom (pain when tapping the edge of the hand along the right costal arch when holding the breath on inspiration) is negative. Kehr's symptom (a significant increase in pain sensitivity on inspiration during palpation of the gallbladder with the thumb of the right hand) is negative. Murphy's symptom (a significant increase in pain on inspiration with deep immersion of the fingers of the right hand in the gallbladder area) is negative. Mussy's symptom (pain on pressure between the legs of the right sternocleidomastoid muscle at the upper edge of the clavicle) is negative. Boas' symptom (reflex pain on pressure to the right of the VIII vertebra on the back) is negative. . Percussion. The size of the liver according to M.G. Kurlov: . 1st size - on the right mid-clavicular line: 6 cm. 2nd size - along the anterior midline: 5 cm. 3rd size - on the left costal arch: 4 cm. Conclusion: the size of the liver is normal. Borders of the liver according to V.P. Obraztsov: Upper limit. along the right anterior axillary line: VII rib along the right midclavicular line: VI rib Lower border. along the right anterior axillary line: X rib along the right midclavicular line: edge of the costal arch along the right parasternal line: 2 cm below the edge of the costal arch along the anterior midline: 1/3 of the distance from the xiphoid process to the navel Conclusion: the borders of the liver correspond norm. . Auscultation. The noise of friction of the peritoneum in the right hypochondrium is absent. Pancreas. . Anamnesis. Complaints of periodic bouts of nausea, stool disorders (constipation, followed by diarrhea). . Palpation. The pancreas is not palpable according to the Groth method. Palpation of the Chauffard zone, Desjardin's point, Mayo-Robson's point is painless. Conclusion: in the study of the digestive system, the following lesion syndromes were identified: chronic gastroduodenitis in the acute stage (pain that occurs 30-40 minutes after eating or at night, and after eating the pain intensity decreases, but after a while it intensifies again (“moynintan rhythm of pain ”), localized in the pyloroduodenal zone, belching, bouts of nausea after eating, stool disorders). X. Hematopoietic system. . Anamnesis. There are no complaints. . Inspection. The color of the skin and visible mucous membranes is pale pink. There is no hemorrhagic rash. There is no visual enlargement of the lymph nodes. There is no enlargement or asymmetry of the abdomen. The shape of the joints and the range of motion in the joints are unchanged. . Palpation. Groups of lymph nodes. a) Cervical back - single, pisiform, painless, elastic, mobile. b) Tonsillar - 2 l / y, millet-like, painless, elastic, mobile. c) Submandibular - 2-3 l / y, lenticular, painless, elastic, inactive. d) Axillary - 3-4 l / y, millet-like, painless, elastic, mobile. e) Inguinal - 2-3 l / y, lenticular, painless, elastic, mobile. The remaining groups of l / y (occipital, parotid, mental, supraclavicular, subclavian, thoracic, cubital) are not palpable. Spleen. Not palpable. Liver. The liver is palpated at a level of 2 cm from the edge of the costal arch along the right midclavicular line. The edge of the liver is soft, even, with a smooth surface, slightly pointed, painless. Flat bones. Palpation of the flat bones (skull bones, sternum, shoulder blades, ribs, pelvic bones) did not reveal any deformities or integrity violations. . Percussion. Spleen. The size of the spleen: longitudinal - 6.5 cm along the X rib (N=X rib) transverse - 3.5 cm along the midaxillary line. Lower pole - XI rib Upper pole - along the upper edge of the IX rib. Liver. The boundaries and dimensions of the liver correspond to the norm (see the digestive system). Conclusion: the study of hematopoietic organs revealed no pathology. XI. Urogenital system. . Anamnesis. There are no complaints about pain in the lower abdomen and lumbar region. Headache, subfebrile temperature were not noted. There is no pain during urination. There is no change in the frequency of urination and the volume of urine excreted (urinates 6-7 times a day, approximately 120-150 ml). Changes in the color of urine and pronounced edema are not observed. Daily diuresis - 480 ml (day - 340 ml, night - 140 ml). There is no nocturnal enuresis or daytime urinary incontinence. BP = 100/60 mm Hg . Inspection. When examining the kidney area, there is no swelling of the lower back, no redness of the skin. The shape and size of the abdomen are not changed. The state of the external genital organs is unchanged, developed correctly, according to the female type. Sexual development formula: Ma0, P0, Ax0, Me0; points - 0.0. . Palpation. There are no edemas on the face, in the lumbar region, sacrum, lower extremities. Ascites is not determined by the fluctuation method. Wave sign is negative. The kidneys are not palpated by the method of bimanual palpation in the supine position and in the vertical position. Pain on palpation in the region of the upper (crossing of the vertical line passing along the outer edge of the rectus abdominis muscle and the horizontal line passing through the navel) and lower (one third of the distance from the anterior midline to spina iliaca anterior superior) ureteral points is absent. The bladder is not palpable. Boas-symptom (reflex pain when pressed to the right of the XII vertebra on the back) is negative. Edema in the lumbar region, sacrum and lower extremities is not determined. Percussion. The bladder does not protrude above the pubic symphysis. Tapping symptom is negative. Conclusion: physical examination of the genitourinary system revealed no pathology, no signs of toxicosis, no extrarenal symptoms, no signs of renal failure; sexual development corresponds to age. XII. Data of laboratory and instrumental methods of research and consultations of specialists. Protocol of endoscopic examination dated 14.03.2001. The mucous membrane of the esophagus, cardia - without features. Muddy parietal mucus in the stomach. The gatekeeper is closed. In the antrum - variegated edematous mucosa. In the bulb of the duodenum - patchy edematous mucosa. In the postbulbar regions - pink mucosa. Conclusion: antrulogastritis, bulbitis. The protocol of ultrasound of the abdominal cavity dated 13.03.2001. Liver: smooth contours, homogeneous parenchyma, increased echogenicity, right lobe 81 mm, left lobe 38 mm (N=84x42). Gallbladder: the shape is normal, the walls are not thickened, the contents are homogeneous, echogenicity is enhanced. Pancreas: contours are even, echogenicity is not enhanced, Wirsung's duct N. Spleen: contours are even, parenchyma is homogeneous, echogenicity is not changed, splenic vein N. Bladder: contours N. Conclusion: cholestasis syndrome. Results of clinical analyses. I. Complete blood count dated 07.03.2001. voz.norm. Erythrocytes 4.89x1012 /l 4.89x1012 /l Hemoglobin (Hb) 143 g/l 136 g/l Platelets 234x109 /l 160-320x109 /l Leukocytes 10.6x109 /l 10.2x109 /l stab 9% 1-6% segmented 76% 40-45% eosinophils 1% 0-1% basophils 0% 0-1% lymphocytes 10% 40-45% monocytes 4% 3-9% Erythrocyte sedimentation rate 8 mm/h to 8 mm/h Hematocrit (Ht ) 41.2% 30-45% Complete blood count from 12.03.2001. voz.norm. Erythrocytes 4.11x1012 /l 4.89x1012 /l Hemoglobin (Hb) 133 g/l 136 g/l Platelets 287x109 /l 160-320x109 /l Leukocytes 3.9x109 /l 10.2x109 /l stab 12% 1-6% segmented 15% 40-45% eosinophils 1% 0-1% basophils 0% 0-1% lymphocytes 69% 40-45% monocytes 3% 3-9% Erythrocyte sedimentation rate 6 mm/h to 8 mm/h Hematocrit (Ht ) 34% 30-45% II. Biochemical analysis blood from 03/12/2001 Shch.phosphatase 429 units / l. 70-612 U/L ALaT 19 U/L 6-40 U/L ASaT 40 U/L 6-45 U/L Total bilirubin 10.1 mmol/L 1.5-17.1 Direct bilirubin 2.1 µmol/L l 0-4.5 Volume protein 67 g/l 54-87 g/l Glucose 4.6 mmol/l 3.88-5.55 Creatinine 59 µmol/l 44-90 Cholesterol 4.3 mmol/l 3, 1-6.5 Urea 3.9 mmol/l 1.5-8.3 (-lipoproteins 39 units 35-55 K+ 4.82 mmol/l 3.6-6.3 Na+ 143 mmol/l 140-160 Ca2+ 1.03 mmol/l 1.0-1.3 Conclusion: neutrophilia is observed in the blood tests, then lymphocytosis The rest of the parameters are unchanged III. 1026) Reaction (pH) acidic Protein none Squamous epithelium single in ph Leukocytes 14-16 in ph Erythrocytes 12-14 in ph (changes) Mucus a lot General analysis of urine dated 30.03.2001 Color light yellow Relative density 1.018 (1008-1026) Reaction (pH) weakly alkaline Protein no Glucose no Squamous epithelium in moderate quantity Leukocytes 6-8 per ph Erythrocytes 2-3 per ph Mucus a little IV. urinalysis dated 16.03.2001 Oxalates 3.78 mg/day (14.5) Uric acid 1.01 mlm/day (0.5-2.0) Ca 0.00 mg/day (60-160) Р 0 0.00 g/day (0.8) Conclusion: no pathology was detected in urine tests. V. Analysis of feces from 28.03.2001 The form is decorated Color is light brown Reaction to occult blood is negative. Muscle fibers are a little. Fecal analysis for worm eggs dated 30.03.2001 No worm eggs were found. ECG from 12.03.2001 Sinus rhythm, heart rate=100 bpm, vertical position electrical axis of the heart. ENT consultation: From 19.03.2001 The mucous membrane of the nose, oropharynx is moderately hyperemic, moist. In the nasal passages scanty mucus. Ears: b/l light. Conclusion: acute rhinitis. From 26.03.2001 The mucous membrane of the nose, oropharynx is moderately hyperemic, moist. Nasal passages moderate, green mucus. The palatine tonsils are not enlarged, clean. Ears: AS - N, AD - b/l pink. Conclusion: right acute catarrhal otitis media in ARVI. From 30.03.2001 Ears: passages are clean, free, b / l light. Nasal passages moderate, green mucus. The palatine tonsils are not enlarged, without pathological contents. Conclusion: right acute catarrhal otitis media, acute rhinitis. Neurologist's consultation: Complaints about excitability, refusal of the "potty", does not hold urine when crying. In the neonatal period, she suffered a subarachnoid hemorrhage. She was treated for hemi-syndrome. Child vertically challenged , deviation of the tongue to the left, the left nasolabial fold is smoothed. Conclusion: residual-organic signs of CNS damage, asthesoneurotic syndrome. XIII. The general conclusion of the medical history (presumptive diagnosis of the lesion). 1) Evaluation and justification of the severity of the patient's condition at the time of curation. The child's condition at the time of curation is of moderate severity, tk. toxicosis syndrome is weakly expressed (the patient is mobile, active, drowsiness, lethargy, impaired consciousness and no sleep); symptoms of damage are expressed: . respiratory system: acute rhinitis (nasal congestion, difficulty in nasal breathing, mucopurulent discharge in the nasal passages), right-sided acute catarrhal otitis media, no signs of respiratory failure were detected (RR and NRR / RR correspond to age). . digestive system: chronic gastroduodenitis in the acute stage (pain in the epigastrium, dyspeptic symptoms) 2) Conclusion on the physical development of the child. . physical development is very low, since the growth is very low, disharmonious (lack of mass for a given height), disproportionate (mismatch h head / h body (1 / 5.5)). . Development of secondary sexual characteristics: Ma0, P0, Ax0, Me0; points - 0.0. The process of puberty has not yet begun, secondary sexual characteristics are not expressed. . The biological age corresponds to the calendar one (dental formula and neuropsychic development correspond to the age). 3) The nature of the underlying disease. Chronic course, acquired genesis, hereditary predisposition. 4) The main lesion system is the gastrointestinal tract. The diagnosis was made on the basis of: Complaints: pain that occurs 30-40 minutes after eating or at night, and after eating, the intensity of pain decreases, but after a while it intensifies again ("mynintan's rhythm of pain"), localized in the pyloroduodenal zone, belching, bouts of nausea after eating, disorders stool (constipation followed by diarrhea). . Anamnesis of the disease and life: hereditary predisposition, violation of the diet, aggravated obstetric history (pregnancy with complications, early transfer to artificial feeding). . Laboratory and instrumental data: EGDS dated 14.03.2001: antrulogastritis, bulbitis. 5) Other organ systems: . Liver and gallbladder - cholestasis syndrome based on abdominal ultrasound from 03/13/2001. Respiratory system - acute rhinitis (difficulty in nasal breathing, moderate, mucopurulent mucus in the nasal passages). . Hearing organ - right-sided acute catarrhal otitis media. The diagnosis was made on the basis of the ENT examination on 30.03.2001. . ARVI - based on a clinical blood test (neutrophilia, lymphocytosis, ESR at the upper limit of normal), marked inflammatory reactions (rhinitis, otitis media) are noted. . Skeletal system - caries, on the basis of examination and anamnesis of life (suffered rickets).

E.S. Sakharova, PhD, Leading Researcher, Pediatrician-Neonatologist, Yu.E. Veltishchev Federal State Budgetary Educational Institution of Higher Education "RNIMU them. N.I. Pirogov" Ministry of Health of the Russian Federation, Moscow
The achievements of modern neonatology, the improvement of resuscitation technologies, the introduction of measures aimed at creating favorable conditions for long-term extrauterine development of the fetus can save the lives of premature and extremely immature children born in the middle of pregnancy. At the same time, the high frequency of damage to immature internal organs and body systems of premature babies in the postnatal period contributes to the formation of chronic pathology and impaired neurocognitive development in the future (2, 4).

Keywords: premature baby, extremely low birth weight, retinopathy, cerebral palsy, hypertension syndrome
keywords: premature infant, extremely low birth weight, retinopathy, infantile cerebral paralysis and hypertensive syndrome

Having survived a difficult period of postnatal adaptation in the intensive care unit and pathology of newborns, a child born prematurely is affected by many factors that eventually affect the outcome of prematurity: changes in the bronchopulmonary system, hemodynamic instability, imperfections in the conduction system of the heart, humoral and nervous regulation, specific the level of metabolism against the background of "posthypoxic nephropathy", dysfunction of the gastrointestinal tract, weakness of the immune defense with or without damage to the central nervous system (1,2,4).

Thus, neither the diseases nor the general problems associated with prematurity end in the neonatal period, and the developmental prognosis remains unpredictable for a long time. Given the high risk of developing severe neurological deficits and chronic lung pathology, two main problems are obvious - the pathology of the respiratory and central nervous systems. Pediatricians of the outpatient network focus their attention on this, forming the usual stereotype of treating a premature baby as a small inferior creature. It is in the polyclinic network that premature babies receive the supervision of a variety of specialists who often interpret the condition of patients without taking into account the physiology of the latter.

Analysis of case histories showed that some doctors exaggerate the slowdown in the growth of skills and indicators psychomotor development, constantly drawing a parallel with full-term peers, and others underestimate the health status of premature babies due to lack of experience in managing children, especially those with low and extremely low birth weight (2).

To illustrate the above Let's trace the history of the development of the child Anton P., who was born prematurely, was observed in the outpatient network, when the boy was 9 months old, the parents asked for help at the Center for the Correction of the Development of Premature Children.

History of life and disease: mother is 35 years old, lives with her family in the Moscow region (nearest suburbs), has a secondary education, living conditions are satisfactory. The 3rd pregnancy with this child (1 pregnancy - term delivery, the child is healthy, the 2nd pregnancy ended in spontaneous abortion, the 3rd pregnancy arose against the background of secondary infertility 10 years after the last one), proceeded against the background of a threatened miscarriage from 8 weeks, combined preeclampsia. Childbirth 2nd premature spontaneous in cephalic presentation at the 28th week of gestation, occurred in the Moscow Region maternity hospital with subsequent transfer to the intensive care unit and the neonatal pathology department of a multidisciplinary hospital. The baby's body weight at birth is 970 g, length is 37 cm, head circumference is 24 cm, chest circumference is 23 cm. Apgar score is 4 points at the first and 5 points at the fifth minute of life. The condition at birth was interpreted as extremely severe against the background of respiratory disorders, depression of the central nervous system, the development of acute pneumonia, ulcerative necrotic enterocolitis, anemia, and general edematous syndrome. From the first minutes of life, the boy was on a ventilator for 7 days, then for 10 days he received assisted ventilation using the CPAP method; nutrition. According to the results of neurosonography, ultrasound signs of cerebral ischemia, periventricular edema of the brain parenchyma, intraventricular hemorrhage of the 2nd degree on both sides were revealed; ultrasound research abdominal organs showed signs of hypoxic nephropathy, hepatosplenomegaly. Chest X-ray shows signs of pneumonia, bronchopulmonary dysplasia. The boy was in the incubator for 25 days, fed through a tube for 29 days, by the 39th day of life the child's condition stabilized, and he was discharged home.

At the age of 1 month and two weeks, the boy was examined by specialists of the children's polyclinic. On the 46th day of life, he received a consultation from an ophthalmologist who diagnosed stage 1 retinopathy of prematurity, recommended instillations of emoxipine and dexamethasone, and monitored every 2 weeks for the next 2 months. At the age of 5 months, the boy was sent for a planned consultation to the ophthalmological department of the Children's Hospital in Moscow, where retinopathy of prematurity, lip stage, cicatricial phase was detected, and surgical treatment was performed - OD-schwartectomy. OS-lens-schwartectomy, OU-puncture orbitotomy with the installation of an irrigation system in the retrobulbar space, as a result of treatment, the ophthalmological diagnosis was as follows: retinopathy of prematurity of the lip, stage, cicatricial phase, operated. OD Avitria. OS Afakia. Avitria, Vis OU - object vision.

Given the hypoxic-ischemic brain damage in the intranatal period, the boy was observed by a neurologist in a children's clinic, who noted a low rate of increase in psychomotor skills against the background of muscular dystonia and hypertension syndrome, and therefore courses of dehydration, nootropic and physiotherapy were continuously conducted, magnetic resonance was recommended brain tomography, electroencephalogram. When Anton was 9 months old, his parents decided to apply to a specialized Premature Baby Observation Center.

Mother's complaints at first visit: developmental delay

Key words: cerebral palsy, spastic diplegia, hypertensive-hydrocephalic syndrome, psychomotor retardation, retinopathy of prematurity lip stage, cicatricial phase, operated, prematurity

Treatment in a children's clinic: emoxipine, dexamethasone, diacarb, asparkam, cerebrolysin, cortexin, gliatilin, pantogam, elkar, massage, exercise therapy, physiotherapy courses (collar zone electrophoresis with 2.4% eufillin solution, magnetotherapy, applications with ozokerite on the lower extremities) .

Data of examination and examination at the Center for the Correction of the Development of Premature Babies:

• Actual age 9 months, corrected age 6.5 months. Body weight 8700 g, length 69 cm, head circumference 44.5 cm, indicators of physical development are low and harmonious.
• Neurological status: psychomotor development (assessment is made on a scale kat / klams):
  • kat (problem solving) - it is difficult to assess development, the child does not see well (he takes a toy, looks at it, brings it close to his eyes, twirls it in his hands, follows the flashlight well at close range in all directions);
  • klams (language / speech) - focuses on the call from top to bottom and upwards.
• Motor skills - sits without support, can crawl.
• Unconditioned reflexes: r. Babinsky, cervical straightening reaction, straightening reflex of the body, Landau reflex upper and lower, tendon reflexes (knee, from the biceps muscle, from the triceps muscle, abdominal reflexes) are symmetrical, muscle tone is satisfactory, FMN - converging non-permanent strabismus.
• Orthopedic status: the head is located in the midline, rounded, the frontal and parietal tubercles are contoured, the occiput is oblique. Head turns in full, sternocleidomastoid muscles are soft. The axis of the spine is straight.
• Upper limbs: movements in the joints in full, brushes in the middle position. Lower extremities: movements in the joints in full, feet in the middle position, hip joints: the joint area is not changed, gluteal, popliteal folds are symmetrical, hip abduction is in full, slippage s-m is negative, Trendelenburg s-m is negative, s-m idiopathic click is negative.
• Somatic status: body temperature 36.8 degrees Celsius, respiratory rate 30 per minute, heart rate 120 bpm.
• Skin and mucous membranes are pink, clean, sweating. Peripheral lymph nodes: submandibular, cervical, inguinal, up to 5 mm in size, elastic consistency, mobile, axillary, cubital, not palpable.
• Large fontanel: 1*1cm. Chest: cylindrical, rosary on the ribs. Breathing through the nose is free, carried out in all parts of the chest, puerile. Heart sounds are clear, rhythmic. The abdomen is soft. The liver at the edge of the costal arch, the spleen and kidneys are not palpable. The external genitalia are formed correctly. The stool is yellow, independent, mushy. Urination is free.

The results of the examination and laboratory tests conducted at the Center for the Correction of the Development of Premature Babies:

• Orthopedic status is satisfactory.
• Somatic status - rickets of the 2nd degree, acute course.
• Neurosonography - ultrasound signs of expansion of the interhemispheric sulcus, compensatory expansion of the cerebrospinal fluid system, the changes are residual, cerebral blood flow during Doppler is not changed.
• Electroencephalography - no pathological activity was detected.
• Otoacoustic emission - test passed.
• ECHO - cardiography - ultrasound signs of an open oval window.
• ECG - sinus rhythm, heart rate 110 beats per minute.
• Ultrasound of the abdominal organs, kidneys, thymus, hip joints - no structural changes were detected.
• Cl. blood and urine tests were within normal limits.
• The conclusion of the ophthalmologist - OU-retinopathy of prematurity IVb stage, cicatricial phase, operated, OD Avitria. OS Afakia. Avitria.
• The conclusion of the neurologist - psychomotor development corresponds to the corrected age, the neurological status is satisfactory.

Analysis of the medical history of Anton P. Obstetric and gynecological history of the mother:

• age 35
• this pregnancy arose against the background of secondary infertility 10 years after the last one (spontaneous abortion)
• threat of interruption, combined preeclampsia
• delivery at 28 weeks gestation

Conclusion: obstetric and gynecological anamnesis burdened, pregnancy complicated, premature birth

The period of adaptation of the newborn:

• gestational age - 27 weeks,
• body weight at birth 970 g, length 37 cm,
• head circumference 24cm, chest 23cm,
• Apgar score - 4/5 points
• clinical diagnosis Keywords: cerebral ischemia of the 3rd degree, depression syndrome, immature SDR, DN of the 3rd degree, acute pneumonia, necrotizing ulcerative enterocolitis, early anemia of prematurity, general edematous syndrome, profound prematurity
• terms of adaptation: incubator - 25 days, probe - 39 days, home on the 49th day of life
• treatment: mechanical ventilation - 7 days, CPAP - 10 days, erythrocyte mass, a/b, immunoglobulin, infusion therapy
• feeding: parenteral nutrition, up to 6 months breast milk, from 6 months of the mixture Frisolak-2, Nan-2.
• examination: NSG-VZhK 2 st., ECHO-KG-LLC
• the optometrist did not look at the child!

Conclusion: the boy was born with extremely low weight, suffered cerebral ischemia, respiratory distress syndrome, severe anemia of prematurity, received intensive care. An error in management during this period is the absence of an examination by an ophthalmologist, however, the mother was strongly advised to urgently contact an ophthalmologist at the place of residence immediately after discharge from the department of the 2nd stage of neonatal care. The mother complied with the recommendation.

Assessment of vision function:

• the first examination by an ophthalmologist in a children's clinic on the 46th day of life (38 weeks of gestation) - diagnosis: retinopathy of prematurity stage 1-2; treatment: 1% emoxipine solution, 0.1% dexamethasone solution; observation: examination 1 time in 2 weeks for 2 months, the diagnosis did not change during the observation period.
• at 5 months of age, an examination by an ophthalmologist at the Moscow Children's Hospital at the initiative of the mother - diagnosis: OD retinopathy of prematurity, active phase IV b Art., OU-retinopathy of prematurity GUb stage, cicatricial phase; treatment: surgical 1) OD-schwartectomy; OS-lens schwartectomy; 2) OU-puncture orbitotomy with the installation of an irrigation system in the retrobulbar space
• at 9 months, the diagnosis of an ophthalmologist was OI-retinopathy of prematurity, lip stage, cicatricial phase, operated, OD Avitria. OS Afakia.
Avitria
vision function: wears a lens on the left eye, Vis OU - object vision.

Conclusion: despite the sufficient frequency of examinations by the ophthalmologist, the moment of retinal detachment in the child was missed, and therefore the moment of possible appropriate treatment.

Evaluation of the child in the children's clinic:

Diagnosis upon referral from a children's clinic Key words: cerebral palsy, spastic diplegia, hypertensive-hydrocephalic syndrome, psychomotor retardation, retinopathy of prematurity lip stage, cicatricial phase, operated, profound prematurity

Treatment by a neurologist at a children's clinic: diacarb, asparkam, cerebrolysin, pantogam, elkar, massage, exercise therapy

Conclusion:

1. the assessment of the premature baby was carried out without taking into account prematurity (corrected age is the difference between the actual age and the missing weeks of gestation up to 37), development was sufficient for the corrected age,
2. assessment of development in this case was carried out without taking into account the child's low vision, however, it is known that children with residual vision have a reduced rate of formation of motor skills;
3. a decrease in the rate of motor development was mistaken for motor disorders;
4. an MRI of the brain in this case is not required, since according to the NSG - there are no data either for hydrocephalus or for defects in the brain parenchyma;
5. the child has no seizures, no immunodeficiency conditions, no acute diseases, more than 6 months have passed since the introduction of blood products and immunoglobulins, so honey. withdrawal from vaccinations is set unreasonably;
6. indicators of psychomotor development correspond to the corrected age, no motor disorders were detected, there are no data for hypertensive-hydrocephalic syndrome, nootropic and dehydration therapy is not indicated for the child.

Thus, based on the survey, we can conclude the following conclusion:

• a very premature boy suffered cerebral ischemia in the neonatal period, intraventricular hemorrhage of the 2nd degree, followed by compensation of liquorodynamics and blood flow;
• is currently developing according to the corrected age against the background of a satisfactory neurological status;
• by 9 months of life, the main problem is the child's low vision;
• an MRI of the brain is not required;
• dehydration therapy, nootropic drugs, physiotherapy is not required;
• procedures associated with the stimulation of visual function are allowed, classes with a typhlopedagogue are shown.

Clinical diagnosis: extremely low birth weight, hypoxic-ischemic CNS damage (periventricular edema, IVH 2 tbsp.), recovery period, OI-retinopathy of prematurity lip stage, cicatricial phase, operated, OD Avitria. OS Afakia. Avitria, rickets of the 2nd degree, acute course, deep prematurity.

• adapted mixture Nutrilon-2, complementary foods
• vaccination is allowed - Mantoux reaction, BCG, then general scheme according to the national vaccination schedule
• observation by an ophthalmologist, corrective lens for the left eye, classes with a tiflopedagogue
• preparations of vitamins D in the age therapeutic dosage, vitamins A, E, calcium and phosphorus in the prophylactic age dosage
• follow-up at a specialized Prematurity Follow-up Center

Thus, various approaches to the management of a child born prematurely, taking into account the problems of extreme morpho-functional immaturity and without, have been demonstrated. The latter determines the need for targeted observation of individual development options, planned correction, as well as special knowledge in the conditions of the “follow-up observation” center as an obligatory stage of nursing with these perinatal problems in order to improve social and medical habilitation (1-4).

BIBLIOGRAPHY

1. A.I. Safina, I.Ya. Lutfulin, N.L. Rybkin. Follow-up care of preterm infants at the Emory University Developmental Clinic (USA). // Bulletin of Modern Clinical Medicine. - 2013. - No. 1(6). - S. 86-90.
2. E.S. Sakharova, E.S. Keshishyan. Tactics of management of very preterm infants in the outpatient network. // Lecture for doctors. - M. - 2007. - 109 p.
3. P.P. Violinist. Prediction and prevention of severe outcomes of retinopathy of prematurity. // Abstract. ...cand. honey. Sciences. -M., -2004. -25 s.
4. Als H. Newborn Zndividualized Developmental Care and Assessment Program (NLD-CAP): New frontier for neonatal and perinatal medicine. // Journal of Neonatal-Perinatal Medicine; 2009; 2:135-147.

Pregnancy doesn't always go perfectly. Sometimes it lasts less than expected, and there's nothing you can do about it. The child was born prematurely - but is it so terrible? And how should parents behave in a situation where everything around is simply “saturated” with stereotypes, they say, a premature baby is inferior? So, the case history: a premature baby is the topic of conversation for today.

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Photo gallery: Case history: premature baby

How to deal with such a child?

First, from the very birth (and preferably even before it), start communicating with the child. From the very first days of life, immature children need special peace, so doctors try to limit the number and duration of visits. However, you will be allowed to watch the child through the glass walls of the ward: even if the baby is placed in the incubator, his movements are clearly visible. Pay attention to how he reacts to the touches of nurses, whether he tries to move his fingers.

After some time, you will be allowed to take the child in your arms, feed and swaddle. Premature babies during the first weeks of life need close contact with their mother for a more complete "completion" prenatal development. According to research, the more diverse and saturated with emotions the communication of a newborn with his mother, the sooner the child will grow, gain weight and develop mentally.

Even the most immature baby can already see and hear much better than we think. That is why, regardless of whether there is a reaction to your actions, talk with your child as much as possible, tell him stories, sing songs, stroke his arms and legs. A baby can remain at first glance indifferent to such communication for up to 3-5 weeks (and a very premature one even longer), but he can perceive a lot and accumulate impressions. The child is simply physically still very weak in order to react more actively. As soon as you see the first response (animation, eye contact), help the baby feel that you are pleased with his actions.

You can hang a bright rattle in a crib or a pitcher, put multi-colored socks on your baby, let him listen to a recording of the voice of his family members or pleasant music. It has been proven that in this way babies are able to quickly learn to distinguish the colors of objects, the tonality and pitch of the sound, and the fullness and brightness of the impressions stimulate its psycho-emotional development. But remember: not all stimulation is useful. For example, you do not need to use perfume and toilet water before visiting the hospital. Some smells tend to irritate children, cause nervous excitement and allergies.

Start journaling and taking photos. You can start recording your baby's behavior almost the day after the birth. Such a diary of early development is very important - it helps all family members get to know the character of the child even before discharge and prepare in advance for his appearance in the house. The diary should not be abandoned in the future. Its purpose is not only to become a family heirloom later. If a child suddenly begins to have behavioral or learning difficulties, such a recorded history of his early development will provide material for specialists to help in a clearer vision of the situation. You can ask the doctor to take videos or photographs of the baby during your stay in the hospital (only you will have to take pictures without a flash). It will also be interesting and useful for all other family members to get to know the baby in advance.

Where is the norm, and where is the deviation?

Remember that the development of a child is always individual. The main thing for mom and dad is whether their children develop normally. Only at the same time, we often do not take into account that each of us puts his own meaning into the concept of the norm. Some parents care, first of all, about a high intellectual level, others - about the physical achievements of the child, others agree that their child "studied at least for C grades."

Psychologists working with premature babies use two normal criteria:
the existing set of necessary motor, speech and gaming skills and the adaptability of the child (the ability to make decisions and navigate in life situations). In the first case, what the child has learned to do is evaluated, and in the second, how (how correctly and quickly) he does it is considered.

Sometimes parents make the mistake of comparing their child's "accomplishments" with the standards for full-term babies. Such comparisons are acceptable in principle, however, during the first 5-7 months, you still need to make some allowance. If, for example, the baby was born at the age of eight months, and now he is three months old, then it would be more correct to focus on indicators for a two-month-old child.

Don't miss a number of warning signs! Do not panic if the baby suddenly becomes passive or more capricious than usual - this is how a premature baby can even react to changes in the weather. However, some symptoms can become really disturbing:
- long-term absence of a reciprocal look, subject to normal vision in a child older than two months;
- the presence of a painful reaction to touch (convulsive movements, crying, screaming), to the look or voice of adult family members after two months.

Parents sometimes ignore such phenomena, especially if the child has poor health. During illness, a premature baby may also behave inappropriately. However, most often this indicates a special state of the psyche that occurs in some premature babies - infantile autism (mental isolation from the outside world).

How to communicate with a doctor?

Feel free to ask questions. According to recent studies, for half of mothers the medical history of their child is a dark forest, and another 20% simply do not try to figure out the wording. medical terms and do not require the necessary explanations from a specialist. Remember: you have the right to receive full information about the health of the child, about what kind of help he needs, what is the forecast of his development. The doctor is obliged to explain all this to you in an accessible form, answering any questions.

You may be interested not only in the physical, but also mental health child. Sometimes, with the immaturity of the body, the work of the brain is disrupted. If your child already has a confirmed diagnosis, ask about the nature and causes of this condition. It is also important to know which part of the brain suffers from this disease.

GOUVPU ASMU RosZdrava

Department of Pediatrics No. 1, with a course of childhood infections

Head Department: Professor G.I. Vykhodtseva

Lecturer: ass. PhD O.V. Nevskaya

Prepared by: Art. 5 course 536 gr., A.V. Tuzhulkin

The history of the development of the newborn

Mother's name:_________

Child: boy, ___days

Clinical diagnosis:

period of early adaptation. Borderline conditions: physiological weight loss (5%), physiological jaundice, toxic erythema, transient intestinal catarrh. Full-term - 37 weeks, corresponds to the gestational age. Risk group for birth trauma

Barnaul 2008

Passport part

FULL NAME. mothers:________

Age: 37 years old.

Place of work, profession: housewife.

Bad habits: denies.

FULL NAME. father:_________

Age: 40 years old

Place of work, profession: employed

Bad habits: smokes.

Mother's health status

The presence of somatic diseases, endocrine pathology. Available congenital anomaly kidney development: "humpback left kidney". Allergological anamnesis is not burdened.

Obstetric and gynecological history

Denies gynecological diseases. Sixth pregnancy, fourth birth.

I pregnancy in 1990 ended in urgent delivery, the weight of the child is 3700 g. B / o.

II pregnancy in 1991 ended in urgent delivery, the weight of the child was 3800 g. ICP, died at 11 years old.

III pregnancy in 1992 - medical abortion.

IV pregnancy in 2000 - urgent delivery by abdominal route, (primary weakness of labor), the weight of the child is 3200 g.

V pregnancy in 2008 - medical abortion.

VI pregnancy in 2008 - real. She was registered from 12-13 weeks. It proceeded against the background of toxicosis in the first half of pregnancy, against the background of anemia, took iron preparations (Sorbifer). Revealed central presentation placenta, true placental ingrowth is not excluded.

She underwent inpatient treatment at 15-16 weeks, at 23-24 weeks, at 30 weeks, at 36 weeks.

Features of the course of labor: fourth labor, urgent at 37 weeks. Delivery in an operative way, in a planned manner. Complications - bleeding, hysterectomy was performed.

Apgar score at the 1st minute of life: heartbeat - 2b.; breathing - 2 points; muscle tone - 1b.; reflex excitability - 1b.; skin color - 2b.; the total number of points is 8.

Apgar score at the 5th minute of life: heart rate -2b.; breathing - 2 points; muscle tone - 1b.; reflex excitability - 1b.; skin color - 2b.; the total number of points is 8.

Birth weight 3310, height 52 cm, head circumference 35 cm, chest circumference 34 cm.

Card of primary resuscitation care for a newborn in the delivery room:

Spontaneous breathing regularly for 20 minutes

Heartbeat, heart rate 140 beats per minute, stable for 20 minutes.

Pulsation of the umbilical cord - 10 sec.

Voluntary muscle movements for 20 minutes, observations.

The color of the skin is pink during 20 minutes of observation.

Produced: warming with radiant heat, suction of mucus from the upper respiratory tract.

Diagnosis: adaptation period 20 minutes, 40 seconds

Outcome: 8 points on the Apgar scale, the condition is satisfactory.

status praesens

Date: 30.10.08. - 4th day. The general condition is satisfactory. Reaction to examination: when unfolding diapers - sipping, when viewed calmly. The posture of the child is semi-flexor. Motor activity is reduced. Icteric skin on the face and trunk - 2nd degree on the Cramer scale, moderate intensity. Dryness and peeling of the skin is not observed, there is no local cyanosis. There are rashes on the skin in the form of single erythematous, dense spots with a diameter of 0.5-1 cm, which have a vesicle with serous contents in the center, are located singly in the region of the right and left elbow joints, on the extensor surfaces, as well as on the lateral surface of the abdomen left. There are telangiectasias on the skin of the posterior cervical region, in the region of the sacrum. Dermographism white unstable. There are no edema, diaper rash. Subcutaneous fat is moderately developed, turgor and elasticity of soft tissues are preserved. Cervical, occipital, chin, axillary, inguinal lymph nodes are not palpated.

Musculoskeletal system. Muscle tone reduced, hypotension more on the upper extremities. The shape of the head is dolichocephalic. A large fontanel measuring 2 x 2 cm, not tense, does not sink, does not bulge. The small fontanelle is closed, the sutures are closed. The clavicles were intact on palpation. There are no stop violations. No limb deformities were found. When breeding the hip joints, there are no restrictions on mobility, "looseness", a symptom of a click are not detected.

Respiratory system.

The shape of the chest is barrel-shaped, symmetrical. Nasal breathing is not difficult. The scream is loud. Breathing is rhythmic, synchronous, respiratory rate - 50 per minute. Auxiliary muscles are not involved in the act of breathing. With percussion of the chest - a box sound. Auscultation revealed puerile breathing, no wheezing.

The cardiovascular system.

Digestive organs.

Examination of the oral cavity: tongue, frenulum of the tongue, hard and soft palate, pharynx - without pathological changes. The shape of the abdomen is rounded. On palpation, the abdomen is soft. The child is calm on palpation. Palpation of the liver by 1.5 cm, protrudes from the edge of the costal arch, the spleen is not palpated. The umbilical wound is dry, clean. Transitional stool (liquid, dark green in color, with undigested lumps)

Urogenital system.

The external genital organs are formed according to the male type. There is no discharge from the external genitalia. The testicles are descended into the scrotum.

Nervous system.

The child is calm. A triple study of physiological reflexes revealed: the sucking reflex is alive, the search, proboscis reflexes are alive, the Babkin reflex is reduced on the left, alive on the right. Grasping on the left is reduced, Moro's reflex: I phase is saved, II phase is not performed. Babinsky's reflex is alive, the support reflex is preserved, while examining the stepping reflex - a decussation in the lower third of the leg. Bauer's reflexes, defenses preserved. There were no focal symptoms of cranial nerve damage, meningeal symptoms were not detected.

Assessment of physical development on the Dementieva scale.

With a gestational age of 37 weeks, due body weight 2771 + -418, actual body weight 3310 g. 3310-2771=539 539/418=1.3 sigma.

D., body length 47.6 (+-2.3), fact., body length 52 cm. 52-47.6 = 4.4; 4.4/2.3=1.9 sigma.

D., head circumference: 33.7 (+ -1.5), actual, 35; 35-33.7=1.3/1.5=0.8(within 1 sigma).

D., chest circumference: 31.7 (+ -1.7), Fact., = 34cm .; 34-31=3/1.7=1.76

Weight-to-height ratio due: 57.9(+-6.6); fact.,=3310/52=63.65

63.65-57.9=5.75 (within one sigma)

Conclusion: physical development corresponds to gestational age.

Assessment of physical development by the centile method:

The actual height of the child is 52 cm, the indicator is in the zones of 25-75 centiles, - the growth is average.

The actual weight of the child is 3310, the indicator is in the zones of 25-75 centiles, - the weight is average.

Growth and weight indicators do not go beyond the boundaries of some centile zones - development can be considered harmonious.

The chest circumference is 34 cm, the indicator is in the zones of 25-75 centiles, the chest circumference is medium.

The head circumference is 35 cm, the indicator is in the zones of 25-75 centiles - the head circumference is average.

Conclusion: physical development is average, harmonious, proportional.

Estimation of the gestational age of the child according to the totality of morphological criteria (Bollard school)

Skin -4 b; lanugo-2; folds on the foot-3; mammary glands-4; ear-1; genitals-2. total points-16

Assessment of neuromuscular maturity according to Bollard:

Baby pose-3 b; square window - 2; hand response -2; popliteal angle-3; scarf symptom - 4; pulling the heel to the ear -4; total points - 18.

The sum of points = 34 indicates the morphological and neuromuscular maturity of the newborn.

feeding

Feeding in this child is artificial, adapted milk mixtures.

Power calculation:

1. According to Zaitseva's formula: daily volume of milk \u003d 66.2 x 3 \u003d 198 ml.
2. According to the Tour formula: 10 x 3 = 30 ml - one-time volume of milk.
3. According to the Finkelstein formula: 3 x 80 = 240 ml - daily volume

Preliminary diagnosis

period of early adaptation. Borderline conditions: physiological weight loss (5%), physiological jaundice, toxic erythema, transient intestinal catarrh. Full-term -37 weeks, corresponds to the gestational age. Risk group for birth trauma.

Survey plan

Laboratory research methods:

1. Clinical blood test.
2. Biochemical blood test (total protein, bilirubin (direct, indirect, fractions, glucose,)

1. ECHO KG
2. neurosonogram
3. abdominal ultrasound

Results of additional examination methods.

Laboratory examination methods:

1. KLA dated 10/28/08: hemoglobin 202 g/l erythrocytes 5.84 x 10 12/l; leukocytes 20.5x10 9 vl.

Conclusion: indicators are within the normal range.

1. Blood sugar from 10/28/08: 3.0 mmol/l

Conclusion: within the physiological norm.

Instrumental examination methods:

1. ECHO KG from 29.10.08. Conclusion: no structural pathology was revealed.

Clinical diagnosis and its rationale

Preliminary diagnosis: “Period of early adaptation. Borderline conditions: physiological weight loss (5%), physiological jaundice, toxic erythema, transient intestinal catarrh. Full-term 37 weeks, corresponds to the gestational age. Risk group for birth trauma, ”is confirmed by the data of additional research methods, and during dynamic monitoring of the child.

1. The period of early adaptation - because. the child lives in utero for the fourth day, the period of early adaptation lasts up to 7 days. Since no pathological conditions were detected during the observation period, according to the Apgar scale, the condition is satisfactory at the first and fifth minutes.

1. An objective examination revealed the following changes:

• Decrease in initial body weight: on the 4th day, body weight 3158, initial 3310, the decrease is 5% - which is acceptable norm - physiological state for the first time in the life of a newborn, it means a decrease in body weight physiological.
• Physiological jaundice - because it appeared on the 3rd day of life, 2nd degree of distribution on the Cramer scale, on the 5th day - 1st degree, degree of distribution (on the face).
• Changes on the part of the skin: rashes in the form of single erythematous, dense spots with a diameter of 0.5-1 cm, which have a vesicle with serous contents in the center, are located singly, in the region of the right and left elbow joints, on the extensor surfaces, as well as on the lateral surface of the abdomen on the left - which is typical for toxic erythema, given that the general condition is not disturbed and the body temperature is normal, on the 5th day the rash disappeared from the lateral surface of the abdomen - we can conclude that this is a transient change in the skin occurring in 5-10% newborns - toxic erythema.
• Transient catarrh of the intestine - because. from the 4th day, the child has a liquid, watery greenish stool, with undigested lumps - a transitional stool, which is the norm at this age.

The above changes refer to borderline states, these are reactions that reflect the process of adaptation to childbirth, new living conditions and are physiological.

1. Full-term - because. the child was born at a full 37 weeks of gestation.
2. Corresponds to the gestational age - based on the assessment of physical development on the Dementieva scale: physical development corresponds to the gestational age. According to the assessment of the degree of maturity on the Ballard scale: the sum of points = 34, indicates the morphological and neuromuscular maturity of the newborn.
3. The risk group for birth trauma - based on obstetric anamnesis history: surgical delivery - which is a predisposing factor to the development of birth trauma.

Clinical diagnosis: Early adaptation period. Borderline conditions: physiological weight loss (5%), physiological jaundice, toxic erythema, transient intestinal catarrh. Full-term 37 weeks, corresponds to the gestational age. Risk group for birth trauma.

Differential Diagnosis

Toxic erythema with pemphigus of newborns: with benign pemphigus of newborns, the blisters are larger in diameter, around them there is a corolla of hyperemia, filled with serous-purulent contents. Bubbles are at different stages of development, erosion is formed during the opening. They are usually located in the lower half of the abdomen, in the folds, on the limbs. There may be symptoms of intoxication, fever to subfebrile figures.

With toxic erythema, erythematous spots with vesicles in the center, the vesicles are small, with serous contents, the location of the rash on the extensor surfaces of the joints. The bubbles do not open, the elements dissolve without a trace after 2-3 days. Body temperature is normal, there are no symptoms of intoxication.

Treatment plan

1. Newborn's primary toilet:

In the delivery room, carry out the prevention of gonoblenorrhea: instillation of a 20% solution of sodium sulfate on the conjunctiva of the lower eyelid. Treatment of the umbilical cord with a 5% solution of potassium permanganate.

In the children's department:

• Wash your hair with baby soap under warm running water.
• Remove the cheese-like grease with sterile wipes moistened with sterile vaseline oil.
• Treat the body, especially the folds, with a 0.5% solution of chlorhexidine.
• Treat the cord residue with 5% potassium permanganate solution. On the 2nd day, surgically remove under aseptic conditions, put a napkin with 0.5% chlorhexidine, apply a tight bandage.
• In the folds powder "Dermatol"
• Buttocks and gluteal folds smear with tannin ointment

1. Current toilet:

• Every morning, face, mouth, nasal passages should be treated with napkins with sterile vaseline oil.
• Treatment of the eyes with cotton swabs moistened with distilled water, from the outer corner to the inner, with separate swabs for each eye.
• Treatment umbilical wound: 3% hydrogen peroxide, dry with a dry cloth, then treat with 5% potassium permanganate solution.

1. for the prevention of hemorrhagic syndrome - in the first hours of life intramuscularly vikasol 3 mg, once.
2. Because the child has a risk group for birth trauma - apply a Shants collar.
3. Nutrition: natural, breastfeeding at the request of the child. In the absence of milk in the mother with an adapted milk formula - 7 meals a day, according to the calculated volumes.
4. Compliance with the thermal regime in the ward. Body temperature is measured on the first day 4 times a day, then 2 times a day.

Diary

1. 5th day

Weight: 3160 g.

The general condition is satisfactory. Reaction to examination: when unfolding diapers - sipping, when viewed calmly. The pose of the child is flexor. Motor activity: the child is active. The skin is icteric on the face, icterus of moderate intensity. Dryness and peeling of the skin is not observed, there is no local cyanosis. Rashes on the skin in the form of single erythematous, dense spots with a diameter of 0.5-1 cm, which have a vesicle with serous contents in the center, are located singly in the region of the right and left elbow joints, on the extensor surfaces. There are no edema, diaper rash.

The shape of the chest is barrel-shaped, symmetrical. Nasal breathing is not difficult. The scream is loud. Breathing is rhythmic, synchronous, respiratory rate - 41 per minute. Auxiliary muscles are not involved in the act of breathing. With percussion of the chest - a box sound. Auscultation revealed puerile breathing, no wheezing.

Heart rate - 156 per minute. The limits of relative cardiac dullness correspond to age norms. On auscultation, the tones were muffled, rhythmic, and no murmurs were detected.

The shape of the abdomen is rounded. On palpation, the abdomen is soft. The child is calm on palpation. Palpation of the liver by 1.5 cm, protrudes from the edge of the costal arch, the spleen is not palpable. The umbilical wound is dry, clean. The stool is transitional (liquid, dark green in color, with undigested lumps).

A threefold study of physiological reflexes revealed: the sucking reflex is alive, the search, proboscis reflexes are alive, the Babkin reflex is alive, symmetrical. Grasping lively, symmetrical. Moro reflex: I phase, II phase are present. Babinsky's reflex is alive, the support reflex is preserved, while examining the stepping reflex - a decussation in the lower third of the leg. Bauer's reflexes, defenses preserved. There were no focal symptoms of cranial nerve damage, meningeal symptoms were not detected.

Stage epicrisis

Vaccination against hepatitis B was carried out on 27.10.08. - intramuscularly 0.5 ml., series 002-0208 2 11 Moscow

BCG vaccination:

Genetic screening for PKU, congenital hypothyroidism, adrenogenital syndrome, cystic fibrosis, galactosemia was performed on 31.10.07.

• Every morning, face, mouth, nasal passages should be treated with cotton pads moistened with a solution of furacillin (1 tablet per half a glass of boiled warm water), or vaseline oil.
• Treatment of the eyes with cotton swabs moistened with a solution of furacillin (1 tablet per half a glass of boiled warm water), from the outer corner of the eye to the bridge of the nose, with separate swabs for each eye.
• Treatment of the umbilical wound: 3% hydrogen peroxide, dry with a dry cloth, then treat with 5% potassium permanganate solution, - 1 time per day.
• Washing under running water from front to back before each swaddling, which is carried out before each feeding.
• Hygienic baths daily, water temperature 37-38 C, in a slightly pink solution of potassium permanganate (previously dilute in a small container and add the solution to the bath until a slightly pink color). Wash once a week with baby soap.
• The temperature in the room where the child is located should not be less than 24-25 C. The crib should be away from possible drafts.
• Walks in the fresh air from the 5th day after discharge, first 5 minutes, then daily increase the time spent in the fresh air.
• Breastfeeding, at the "requirement" of the child, but the breaks between feedings should not exceed 3 hours.

Mother's recommendations: adherence to sleep (desirable daytime sleep), avoid overwork, conflicts. Daily outdoor walks. Nutrition should be regular, exclude spicy, fatty, spices, legumes, chocolate, sweets, citrus fruits, red fish, caviar. You can eat non-fat meat, “white” fish, green apples from fruits, stewed vegetables, in moderation White bread, dairy products (cheese, boiled milk, low-fat yogurt, cottage cheese). Drink more fluids - dried fruit compote, green apple juice, weak tea with milk.

Bibliography

1. Neonatology: Tutorial: In 2 volumes. / N. P. Shabalov. M. MEDpressinform, 2006
2. Propaedeutics of childhood diseases / Ed., Geppe N. A., Podchernyaeva N. S.: a textbook for medical students, universities. - M .: GEOTAR - media 2008.
3. Guidelines for independent work of students of the pediatric faculty / edited by prof., G.I. Vykhodtseva. Barnaul 2005

I. PASSPORT DATA

FULL NAME. child: x

Age: 5 months.

Permanent residence address: Ivanovo region, Lezhnevsky district

Which institution sent: Lezhnevskaya CRH.

Diagnosis at referral: SARS, congenital heart disease (tetralogy of Fallot).

Clinical diagnosis:

Congenital heart disease (tetralogy of Fallot), circulatory failure IIA, phase of primary adaptation. Hypostatura II degree, period of progression, postnatal, mixed origin.

Residual effects of SARS.

II. ANAMNESIS

Disease history.

Upon receipt of a complaint of cough, elevated temperature, anxiety. Cough - with the separation of a small amount of mucous sputum.

I fell ill on 17/IV 98, when the temperature rose to 38.3 degrees. After taking aspirin, the temperature returned to normal, but on the morning of 18/IV it rose to 38 degrees. He was examined by a paramedic, ampioks was prescribed. On 18 and 19/IV the temperature did not rise, dry cough, anxiety, loss of appetite appeared. When contacting the CRH doctor, he was diagnosed with SARS, the child was sent to the clinic "Mother and Child" for examination and treatment.

The child suffers congenital defect heart (diagnosis was established in the 1st Children's Clinical Hospital in Ivanov, where the child was treated after the maternity ward). Was on examination at the clinic "MID" in February 1998.

Prior to curation, the child received the following treatment: digoxin, nitrosorbide, panangin for the underlying disease, and lincomycin.

Anamnesis of life.

1. Antenatal period.

Child from first pregnancy, first birth.

Pregnancy proceeded against the background of anemia of the I degree, varicose veins, diffuse increase thyroid gland, SARS in the second half of pregnancy.

There is no information about the threat of miscarriage, nutrition of a pregnant woman, occupational hazards, and measures to prevent rickets.

Extragenital pathology in the mother is not observed.

The course of labor is normal, delivery at 40-41 weeks. No obstetric interventions were performed. information by nature amniotic fluid and assessment of the newborn on the Apgar scale is not.

Conclusion on the development of the child in the antenatal period: a risk factor may be a diffuse enlargement of the thyroid gland, SARS in the second half of pregnancy.

2. Neonatal period.

He was born full-term, weight at birth 3040 g, length at birth 53 cm. He screamed immediately. Recovery measures were not applied. There was no birth injury. Shortly after birth, cyanosis appeared.

The remainder of the umbilical cord fell off on the 3rd day, the umbilical wound healed on the 5th day. Was applied to the chest after 1 day.

On the 6th day he was discharged in the 1st hospital. Weight at discharge 3000 g.

Conclusion on the development of the child in the neonatal period: mass-growth coefficient = 57.3 - malnutrition of the 1st degree; manifested pathology of intrauterine development - congenital heart disease.

3. Feeding the baby.

She is currently bottle-fed. Complementary foods were introduced at 3.5 months in the form of porridge at 70.0. Receives juices from 1 month, fruit puree- from 2 months. Was weaned at 1.5 months, received formula until 4 months, currently whole milk and formula.

Diet - 7 times a day after 3 hours with a night break of 6 hours.

Conclusion on breastfeeding: early transfer to artificial feeding; early introduction of porridge, lack of vegetable puree. 4. Information about the dynamics of physical and psychomotor development.

Holds his head from 5 months, badly. Don't sit, don't stand.

Speech development: cooing for about 2 months.

Height is currently 61 cm (with due for this age 67 cm),

weight - 4266 g (with due given growth 6208 g) - mass deficit

The sum of the corridors is 4, the difference is 1.

DDU does not attend.

Conclusion on the psychomotor and physical development of the child: delayed physical and psychomotor development; reduced height and low body weight, hypostatus II degree.

5. Information about preventive vaccinations.

Not carried out.

6. Past diseases.

Diagnosed with congenital heart disease.

noted allergic reaction on orange juice in the form of erythema of the cheeks, reaction to ampiox.

From 4.5 months - allergic constitutional dermatitis.

7. Living conditions.

Material and living conditions are satisfactory. Child care is adequate. The mode of the child is age appropriate. Walks daily. Meals are regular. Behavior at home - the child is restless.

8. Information about the child's family.

Mother - Baushina Elena Alexandrovna, 23 years old, does not work. Healthy.

Father - Baushin Sergey Evgenievich, 22 years old, Lezhagropromtrans - driver. Healthy.

occupational hazards and bad habits father and mother are not mentioned.

Heredity is not burdened.

Family tree