Cases 2009

Case 1
A 12-month-old infant is admitted to the hospital because of dehydration and
diarrhea of 3 days' duration. The infant weighed 10 kg at a well visit 1 week ago.
She has had 10 to 12 stools per day for the past few days and a temperature of
39°C. She has not urinated for the past 18 hours. Physical examination reveals
sunken eyes and dry, tenting skin. Which of the following would you do first?
A. Order a complete blood count and blood cultures.
B. Obtain a urine specimen for culture, electrolytes, and specific gravity.
C. Begin lactated Ringer solution, 20 mL/kg intravenously, after obtaining
blood for electrolytes and blood urea nitrogen.
D. Obtain stool for fats, reducing subtances, and culture.
Questions:

Assuming 10% dehydration, the best way to monitor initial improvement in the
child in a previous question is by measuring
A. weight gain
B. urinary output
C. central venous pressure
D. blood pressure
Questions:
1. Main principle of IV rehydration therapy.

Case 2
A 900-g infant of 27 weeks' gestational age developed respiratory distress
syndrome and required endotracheal intubation on the first day of life. At 36 hours
of age, the infant developed hypotension, bradycardia, cyanosis, and a tense
anterior fontanel. The most appropriate diagnostic test is
A. electroencephalography
B. echocardiography
C. serum coagulation profile
D. ultrasonography of the head
E. complete blood count with platelet determination
Questions:
1. What does mean the RDS 1 type? 2. Assessment of severity of hypoxia? 3. Make the initial diagnosis. Case 3
A 42-week-gestational-age, 3600-g, breast-fed, white female is noted to have
persistent hyperbilirubinemia at 2 weeks of age. On physical examination, the
infant has not gained weight since birth and has decreased tone, an umbilical
hernia, and an anterior fontanel measuring 4X6 cm. The most likely diagnosis is
A. Crigler-Najjar syndrome
B. Gilbert disease
C. biliary atresia
D. hypothyroidism
E. galactosemia
Questions:
1. Approach to the newborns with neonatal hyperbilirubinemia.

Case 4
A 4-week-old, A-positive, African-American, former 40-week-gestational-age
infant was born to an O-positive mother and developed hyperbilirubinemia
requiring 2 days of phototherapy in the newborn nursery after birth. The infant
appears apathetic and demonstrates pallor, a grade 2/6 systolic ejection murmur,
and a heart rate of 175. The most likely diagnosis is
A. anemia of chronic disease
B. cholestasis secondary to neonatal hepatitis
C. hereditary spherocytosis
D. sickle cell anemia hemolytic crisis
E. ABO incompatibility with continued hemolysis

Questions:
1. Approach to the newborns with neonatal hyperbilirubinemia


Case 5
A full-term male, product of a normal spontaneous vaginal delivery, appeared well
until 3 weeks of age, when he developed fever, irritability, and poor feeding.
Twelve hours later, the examination revealed a pale, lethargic infant with poor
suck and fair muscle tone. His temperature was 40°C, pulse was 180, and
respiratory rate was 60. His fontanel was firm, his chest was clear, his abdomen
was not distended, and no organs or masses were palpable. His skin showed
normal turgor with capillary refill less than 3 seconds. White blood cell (WBC)
count was 2.8 * 109/l, with 13% segmented cells and 12% bands. The most
appropriate next step in diagnosis is
A. blood culture
B. urine culture
C. chest radiography
D. head ultrasonography
E. spinal fluid analysis

Questions:
1. Make the initial diagnosis. 2. Main etiological and pathogenetic mechanisms of this disease? 3. Main principle the treatment of this disease? Case 6
A 15-year-old girl has experienced loss of 30 pounds during the past 6 months and
has developed amenorrhea. She denies vomiting, diarrhea, and abdominal pain and
claims to feel well. Physical examination reveals cachexia and a pulse of 40 per
minute. Electrolyte determination reveals a serum potassium level of 3.0 and
bicarbonate of 30. Hematocrit is 30, and eryfhrocyte sedimentation rate is 3
mm/hour. The most likely cause of this patient's condition is
A. inflammatory bowel disease
B. anorexia nervosa
C. bulimia nervosa
D. Addison disease
E. pituitary adenoma
Questions:
1. Make the initial diagnosis.
2. Main principle of diet for the child with malnutrition? Case 7
A 12-year-old with repeated episodes of streptococcal pharyngitis develops another
episode of sore throat. The rapid strep test is positive, and oral ampicillin is started,
with the first dose given in the office. One hour
later, she develops a funny feeling and a tingling sensation around her mouth. Next
she becomes apprehensive, has difficulty swallowing, and develops a hoarse voice.
On arrival at the emergency room, she has giant urticaria and the following vital
signs: pulse 130, respiratory rate 32, blood pressure 70/30, and temperature 37.20C.
The most appropriate therapy is
A. epinephrine
B. prednisone
C. Benadryl
D. cimetidine
E. lactated Ringer solution
The most likely diagnosis for the condition described in a previous question is
A. streptococcal toxic shock
B. scarlet fever
C. infectious mononucleosis
D. anaphylaxis
E. serum sickness
Questions:
1. emergency care of this situation?


Case 8
A l4-year-old white female with the diagnosis of severe recurrent reactive airway
disease since age 1 year comes to the emergency room with fever and cough for 2
weeks. The child has purulent sputum, bilateral wheezing, and rales but is not
"tight." Her weight is below the fifth percentile, she has no secondary sex
characteristics, and mild digital clubbing is noted. The most likely diagnosis is
A. steroid'dependent asthma
B. cystic fibrosis
C. allergic bronchopulmonary aspergillosis
D. tuberculosis
E. celiac disease
F. foreign body aspiration
Questions:
1. Make the initial diagnosis. 2. Main etiological and pathogenetic mechanisms of this disease? 3. Main principle the treatment of this disease?
Case 9
A 12-year-old presents with sneezing, clear rhinorrhea, and nasal itching. Physical
examination reveals boggy, pale nasal edema with a clear discharge. The most
likely diagnosis is
A. foreign body
B. vasomotor rhinitis
C. neutrophilic rhinitis
D. nasal mastocytosis
E. allergic rhinitis

Two weeks later, the patient described in a previous question complains of
headache, poor nasal airflow (mouth breathing), fever, and a change in the nature
of the nasal discharge; it is now mucopurulent. The most likely diagnosis is
A. sinusitis
B. foreign body
C. rhinitis medicamentosa
D. choanal stenosis
E. ciliary dyskinesia
Questions:
1. Main principle the treatment of this disease?
Case 10
A child has abdominal pain, arthritis, microscopic hematuria, and a purpuric rash
only on the lower extremities. Which of the following is the most likely diagnosis?
A. Meningococcemia
B. Varicella
C. Henoch-Schonlein vasculitis
D. Poststreptococcal glomerulonephritis
E. Infectious mononucleosis
Questions:
1. Make the initial diagnosis. 2. Main etiological and pathogenetic mechanisms of this disease? 3. Main principle the treatment of this disease? Case 11
A 5-year-old boy develops severe abdominal pain of 3 days' duration. He is unable
to eat and has occasional emesis. Physical examination reveals an anxious, acutely
ill child with generalized abdominal tenderness, voluntary guarding of the anterior
abdominal muscles, and normal findings on rectal examination. A surgical
consultant believes the child has an acute abdomen, possibly appendicitis. Before
the child is sent to the operating room, the urinalysis reveals 3 + hematuria and 1 +
proteinuria. You should
A. perform coagulation studies
B. obtain a complete blood count
C. perform renal ultrasonography
D. proceed with the operation
E. cancel the operation

On repeat physical examination, the patient described in a previous question now
has petechiae over the dorsal surfaces of the feet and hands and over the buttocks.
His platelet count is 350,000. The most likely diagnosis is
A. Kawasaki syndrome
B. Henoch-Schonlein purpura
C. Rocky Mountain spotted fever
D. meningococcemia
E. appendicitis with gram-negative sepsis
Questions:
1. Make the initial diagnosis. 2. Main principle the treatment of this disease? Case 12
A 7-year-old white male presents with malaise, chest pain, high spiking fevers, and
chills for 3 weeks. He has had no ill contacts, and he has missed school during the
last week of the illness. Physical examination reveals an acutely ill child with a
heart rate of 125, a temperature of 40.5°C, a fine but faint macular red-pink rash on
the trunk and proximal extremities, lymphadenopathy, a liver 4 cm below the right
costal margin, and a palpable spleen tip. Laboratory studies reveal a hemoglobin of
9.7 g/dL, a total white blood cell count of 26,000, and a platelet count of 650,000.
The most important step in evaluating this patient would be to order
A. an erythrocyte sedimentation rate (ESR)
B. Lyme titers
C. a chest radiograph
D. an echocardiogram
E. bone marrow aspiration
6. On further evaluation, the patient described in a previous question has no
evidence of pericardial tamponade or reduced cardiac function. His pulse
normalizes when he defervesces. The approach to the management of this patient's
pericardial effusion is to
A. perform pericardiocentesis
B. begin digitalization
C. improve preload with fluids
D. begin an oral nonsteroidal anti-inflammatory agent
E. begin methotrexate
7. The most likely diagnosis for the patient' described in a previous question is
A. systemic-onset juvenile rheumatoid arthritis
B. uremia
C. systemic lupus erythematosus
D. scleroderma
E. rheumatic fever


Case 13
All of the following are diagnostic features of Kawasaki disease EXCEPT
A. generalized lymphadenopathy
B. fever for at least 5 days
C. nonpuralent conjunctivitis
D. desquamation of the fingers
E. polymorphous rash
During the acute phase (1 to 10 days) of Kawasaki disease, mortality is related to
A. febrile seizures
B. aspirin intoxication
C. myocardial ischemia
D. coronary artery aneurysm
E. myocarditis

Questions:
1. Main clinical signs and symptoms of this disease?
2. Main principle the treatment of this disease?

Case 14
A 2-year-old male comes to your office with profuse watery diarrhea. His father
just returned from a trip to St. Petersburg, Russia, and has been suffering from
diarrhea for more than a week. His physician diagnosed Cryptosporidium infection
on stool examination. Which of the following steps would be appropriate?
A. Begin the patient on sulfamethoxazole.
B. Discuss aggressive oral rehydration with the child's mother to prevent
dehydration.
C. Send off three stool specimens for culture.
D. Arrange for endoscopy and biopsy.
E. Request an infectious disease consultation.
Questins:
1. Main principle of oral rehydration therapy for the child of the 1st year of 2. Main principle the treatment of this diseases?
Case 15
A 6-month-old breast-fed infant presents with a 24-hour history of diarrhea but no
emesis. On examination, the child is afebrile, has normal vital signs, but has
slightly sunken eyes and fontanel. She continues to nurse fairly well. The most
appropriate therapy is
A. slow intravenous rehydration and nothing by mouth
B. clear liquid diet for 24 hours, followed by dilute formula or breast milk for
several days until stools reduce in frequency
C. rapid infusion of intravenous saline
D. oral electrolyte solution given by mouth to make up a 5% to 10% volume
deficit over 6 hours and continuation of breastfeeding
E. begin tincture of opium or Imodium
Question:
1. Main principle of oral rehydration therapy for the child of the 1st year of life?

Case 16
A previously healthy, well-developed 6-month-oid infant develops diarrhea that
proves to be due to rotavirus infection that lasts 3 weeks and requires treatment
with intravenous and oral rehydration fluids. Thereafter, the infant is again fed
with the regular infant formula that was used before this illness. Each time the
infant receives this formula, the infant develops watery diarrhea, which is now
rotavirus negative. The most likely diagnosis is
A. stagnant bowel syndrome
B. primary disaccharidase deficiency
C. pancreatic insufficiency
D. dumping syndrome
E. secondary lactase deficiency
F. milk protein allergy
Questions:
1. Laboratory test for confirming of diagnosis?
2. Main principle of therapy?


Case 17
A telephone call comes from the mother of a 19-month-old infant who was fine
(except for an upper respiratory tract infection last week) until 6 hours ago, when
he suddenly began screaming every 10 minutes. He is afebrile; he vomited twice
but has no diarrhea, although he clearly has cramping abdominal pain. Which one
of the following would you do?
A. See the child immediately.
B. Recommend clear fluids and see the child in the morning.
C. Prescribe an antispasmodic, anticholinergic drug and see the child if he does
not improve.
D. Suggest a tap water enema.
E. Refer the mother to a surgeon.

On physical examination of the child described in a previous question, you feel a
mass in the right upper quadrant. You find bloody stool in the rectum. The most
likely diagnosis
A. appendicitis
B. gastroenteritis (Shigella)
C. gastroenteritis (viral)
D. intussusception
E. Meckel diverticulum
Questions:
1. Approach to the patients with acute abdominal pain?
Case 18
A 2-year-old previously well male is brought to you with cough and fever. His
history unremarkable. Physical examination revels toxic, ill child with fever,
dyspnea, and decreased breath sounds in the right middle lung fields.
Posteroanterior and lateral CHEST radiographs reveal an infiltrate in the right
middle lobe. His right lung is clear. Leukocyte count is 19,000/mm3 with 54%
polymorphonuclear neutrophils, 18% bane forms, and 28% lymphocytes. The child
is admitted to the hospital. Which of the following would you do first?
A. Repeat the leukocyte count.
B. Obtain a blood culture.
C. Obtain a throat culture.
D. Obtain a radiograph of his sinuses.
E. Schedule bronchoscopy.
Questions:
1. Make the initial diagnosis. 2. Main principle of therapy? 2. Which antibiotic would you choose for the patient?
A. Methilcillin
B. Ceftriaxone
C. Gentaniicin
D. Penicillin
E. Tetracycline
3. The patient is discharged after 3 days of using oral antibiotics. He fares well
until 2 weeks later, when 4 days after stopping antibiotics his cough becomes
worse. You should now
C. perform bronchoscopy
D. order a lung biopsy
E. order a leukocyte count and blood culture 4. Which of the following is the most likely diagnosis for this patient?
A. α1-Antitrypsin deficiency
B. Tuberculosis
C. Foreign body in the right mainstem bronchus
D. Pneumcystis carinii pneumonia

Case 19
A 12-year-old lost 2.5 kg during a 1-year period and developed a night cough and
dysphagia. An esophageal fluid level was noted on a chest radiograph, and barium
swallow showed a dilated esophagus that narrowed sharply at the gastroesophageal
junction. Barium slowly entered the stomach. The most appropriate treatment is
A. metoclopramide
B. colonic interposition
C. resection of the distal esophagus
D. an H2 blocker (cimetidine)
E. myotomy of the gastroesophageal junction

Questions:
1. Make the initial diagnosis. 2. Main principle of therapy? Case 20
A 3-year-old has had a loose cough without sputum for 2 months. The cough is
getting worse, especially at night. It keeps his parents awake although the child
sleeps through the cough. Family history revealed that the mother has eczema and
the father has had "hay fever." Additional historical facts that should be elicited to
determine whether this represents, serious illness include all of the following
EXCEPT
A. reduced exercise tolerance
B. failure to gain weight
C. chronic diarrhea
D. persistent fevers
E. serous otitis media
2. None of the additional symptoms listed in question is present. On physical examination, you hear an occasional wheeze in both lung fields. Other physical findings that would be indicative of chronic lung disease include which of the following? (Choose one or more.) B. Hyperexpansion of the chest with an increased anteroposterior diameter
C. Clubbing
3. The patient described in questions has none of the findings indicative of chronic lung disease. What would be the most likely diagnosis at this time? D. Asthma
E. Interstitial pneumonia

Case 21
An 18-month-old is noted to assume a squatting position frequently during play
time at the daycare center. The mother also notices occasional episodes of perioral
cyanosis during some of these squatting periods. The day of admission, the child
becomes restless, hyperpneic, and deeply cyanotic. Within 10 minutes, the child
becomes unresponsive. The most likely underlying lesion is
A. cardiomyopathy
B. anomalous coronary artery
C. tetralogy of Fallot
D. cystic flbrosis
E. aspiration pneumonia
Questions:
1. What factors which may lead to this situation? 2. Emergency care of this situation?
Case 22
A 4-month-old infant is noted to have a grade 4 holosystolic murmur that is harsh
over the left parasternal border. Results of both the chest radiograph and ECG are
normal, and the child is otherwise asymptomatic. The most likely cause of this
murmur is
A. large VSD with 3:1 shunt
B. an ASD secundum defect
C. a small VSD
D. pulmonic stenosis
E. pink tetralogy of Fallot
Questions:
1. Classification of CHD? 2. Hemodynamic features in this defect?
Case 23
A previously well 3 1/2-month-old presents with poor feeding, diaphoresis during
feeding, and poor growth. Vital signs reveal respirations of 70, pulse of 175, and
blood pressure of 90/65 mm Hg in the upper and lower extremities. The cardiac
examination reveals a palpable parasternal lift and a systolic thrill. A grade 4
holosystolic murmur and a middiastolic ramble are noted. The chest radiograph
reveals cardiomegaly. The most likely diagnosis is
A. cardiomyopathy
B. myocarditis
C. VSD
D. coarctation of the aorta
E. transposition of the great arteries
Questions:
1. Classification of CHD? 2. Hemodynamic features and clinical symptoms in this defect? Case 24
A 12-year-old female is noted to have a blood pressure of 170/110 mm Hg during a
routine grade physical examination for school sports participation. She is
asymptomatic but has been noted to have a grade 1-2/6 short systolic murmur at
the left sternal border. The next important step in her evaluation should include
A. chest radiograph
B. ECG
C. funduscopic examination
D. lower extremity blood pressure
E. a tilt test
Questions:
1. Make the initial diagnosis. 2. Additional investigation for confirming of this disorders?
Case 25
A 5-year-old white female has multiple bruises on her lower extremities and oral-
mucosal bleeding of 3 days' duration. Two weeks before these signs, she had a
mild respiratory tract infection. Physical examination reveals multiple ecchymoses
and petechiae; no lymphadenopathy or hepatosplenomegaly is noted. The next
diagnostic step is
A. a complete blood count
B. a piotbrotnbin time
C. a bleeding time
D. a partial thromboplastin time
E. an antinuclear antibody titer
Questions:
1. Make the initial diagnosis. 2. Clinical signs and symptoms of this disease 3. Main principle of therapy
Case 26
A 10-month-old white male presents with a 1-day history of persistent bleeding
after cutting his lip slightly. The family history is unremarkable, and the patient is
receiving no medications. Laboratory data reveal a hemoglobin value of 11 g/dL,
platelets of 350,000, a prothrombin time of 11.8 seconds, and a partial
thromboplastin time (PTT) of 100 seconds, which is corrected by mixing of normal
plasma. The most likely diagnosis is
A. von Willebrand disease
B. hemophilia A
C. Hageman factor deficiency
D. scurvy
E. anticardiolipin antibody syndrome

Questions:
1. Make the initial diagnosis. 2. Clinical and laboratory signs of this disease?
Case 27
A 1-year-old presents with pallor of 3 months' duration. Past medical history
reveals neonatal hyperbilirubinemia that was treated with phototherapy for 1 week
and a father who had a splenectomy at the age of 2 years for unknown reasons. On
physical examination, the child is pale and has splenomegaly (4 cm below the left
costal margin). The most likely diagnosis is
A. sickle cell anemia
B. thaiassemia
C. paroxysmal nocturnal hemoglobinuria
D. spherocytosis
E. Diamond-Blackfan syndrome
Questions:
1. Etiology of this disease 2. Clinical manifestation of this disease 3. Main principle of therapy.
Case 28
An 18-month-old Caucasian male is brought to your office for a routine health
maintenance visit. The mother reveals that the child always appears hungry; in
fact, he drinks a quart of whole milk a day and also eats dirt. Intake of solid foods
is sporadic, but the mother states that she thought all 18-month-olds were "picky
eaters." Physical examination reveals mild pallor of the conjunctivae. He has no
hepatosplenomegaly, and the rest of the examination findings are normal. Based on
the information, which of the following would be the most likely to determine the
diagnosis?
A. Complete blood count, including blood smear
B. Reticulocyte count
C. Lead screen
D. Ophthalmologic consultation
E. Testing stools for occult blood

24. A blood smear taken from the patient described in a previous question shows a
microcytic hypochromic anemia. Iron supplementation therapy is started. When
will the reticulocyte response be maximum?
A. 1 to 2 days
B. 5 to 7 days
C. 14 to 21 days
D. 3 to 4 weeks
E. About 6 weeks
25. In the patient described in a previous questions, when the hemoglobin and
hematocrit return to normal, which should be done?
A. Stop iron supplementation
B. Continue iron for 1 to 2 weeks
C. Continue iron for 4 to 8 weeks
D. Continue iron for 4 to 6 weeks
Case 29
A 4-year-old child of Thai parents exhibits pallor and hepatosplenomegaly. His
blood count shows a hemoglobin value of 5.0 g/dL and MCV of 55 fL. His blood
smear shows severe anisopoikilocytosis, and his serum ferritin level is within the
range of normal for his age. Which of the following are likely possible causes of
this child's anemia?
A. a-Thalassemia
B. Hemoglobin E
C. β -Thalassemia
D. Sickle cell anemia
E. Choices A, B, and C above

Questions:
1.
Main laboratory criteria for this blood disorders. Case 30
A 4-year-old male developed an upper respiratory tract infection that was followed
in 2 weeks by general edema. His blood pressure is normal. Urinalysis reveals 2 to
5 red blood cells per high-power field and 4 + protein. His BUN is 19 mg/dL,
creatinine 0.6 mg/dL, cholesterol 402 mg/dL, serum albumin 0.9 g/ dL,
antistreptolysin O titer 1:16, and C3 92 mg/dL. The most likely diagnosis would be
A. poststreptococcal glomerulonephritis
B. membranous glomerulonephritis
C. minimal change nephrotic syndrome
D. membranoproliferative glomerulonephritis
E. focal sclerosis
Questions:
1. Main pathogenetic mechanism of this disease development 2. Main principle of therapy.
Case 31
A 3-year-old female presents with vomiting, diarrhea, and fever. A urinalysis
shows pyuria and hematuria, and a culture grows greater than 105 colonies of E.
coli. She responds well to hydration and intravenous antibiotics. What imaging
studies, if any, are appropriate during the acute phase of the infection?
A. Renal and bladder ultrasonography
B. intravenous urogram
C. VCUG
D. CT scan of the abdomen
E. None
Questions:
1. Make the initial diagnosis. 2. Additional laboratory test for confirming of this disease. 3. Main therapeutic principles.
Case 32
An infant is brought to the emergency room with vomiting, lethargy, dehydration,
and failure to thrive. Intravenous administration of fluids is begun. Serum
electrolyte values are sodium 124 mEq/L, chloride 88 mEq/L, and potassium 6.8
mEq/L. Serum glucose level is 35 mg/dL. The child is hypotensive and has areas
of hyperpigmentation. The most likely diagnosis is
A. Addison disease
B. Waterhouse-Friderichsen syndrome
C. 17-hydroxylase deficiency
D. Gushing syndrome
E. adrenoleukodystrophy
Treatment for the infant described in a previous question should include which of
the following? (Choose as many as are appropriate.)
A. Desoxycorticosterone acetate (DOCA)
B. Hydrocortisone hemisuccinate
C. Adrenalectomy
D. Insulin
E. Glucagon

The boy of 12 years old, was admitted to the clinic with the complaints of pains in lumbar area, frequent urination, with small portions. The child was born from the second pregnancy, which was complicated by nephropathy. The child was born in time. The weight at birth was 3500 g, length was 53 cm. The boy was sick from birth, the analyses of urine was marked by leukocyturia. There were periods of temperature rising up to 38,6 С°. The boy was examined in a hospital at the age of 2 years. The vesicoureteral reflux of I-II degrees was defined. The child was observed by the doctor regulary. Leukocyturia and bacteriuria were determined repeatedly. Medical examination
The skin was pale, there was no edema. The mucous of the oral cavity was clean. Vesicular respiration was defined in the lungs. There were no rales. Cardiac sounds were rhythmical, without murmur. Abdomen was soft, painless. Pasternatsky sign was positive from the both sides. Investigation
CBC: Le - 11,0·10^9/L: Ne - 81%, Ly - 19%, ESR - 25 mm/h.
Urinalysis: protein - 0,33 g/L, Le - 100 per high-power field, Er - 1-2 per high-
power field, bacteriuria.
Renal ultrasonography: outlines of kidneys were rough. The right kidney was
condensed, the frame of the kidney was broken.

Assignment
1. Make the initial diagnosis: urinary tract infection, chronic pyelonephritis, exacerbation stage, vesicoureteral reflux 2. What functional methods of research are necessary for confirming The girl of 12 years old, was sick for 1 year, complained of fasting pains in epigastric area, which occured in the morning and in 1,5-2 hours after meal, at night, it disappeared after meals. The acidic regurgitation was disturbed. The mother of the child had peptic ulcer in the anamnesis, the father had gastritis. Medical examination
Physical development was normal. The skin and mucosas of the oral cavity were clean. On palpation abdomen was intense, morbid in the epigastric area and in the pyloroduodenal zone. The liver was not enlarged, painless. There were no pathologies in other organs. Investigation
CBC: Hb - 128 g/L, Er - 4,2·10^12 /L, color index - 0,91, Le - 7,2·10^9/L.
Urinalysis is normal.
Ultrasonic investigation: The liver was not enlarged. The gallbladder had
strangulation. The pancreas had homogeneous structure.
Assignment
1. Make the initial diagnosis: peptic ulcer 2. What researches are necessary for confirming the diagnosis? 3. What does irradication of Helicobacter pylori mean? The boy of 1 year and 2 months old, was admitted to the hospital with the complaints of poor appetite, the child had fatigue, and perversion of taste (pica). The child was from the first pregnancy. The mum had anemia, during pregnancy. The child was born with weight of 3150 g, length of 51 cm. The child had breastfeeding for 2 months. Then he received cow’s milk, porridges, cottage cheese, and vegetable mashed potatoes. The boy began to receive meat only since 11 months. Medical examination
At admission to the hospital his general condition was of moderate severity. The skin was clean, pale. Mucous of oral cavities was clean, pale. The conjunctivas of eyes were pale. Cardiac sounds were rhythmical. The systolic murmur was auscultated, on the apex of the heart. Abdomen was soft, painless, liver projected from the superior border of the rib arch for 3 centimeters. The spleen was unpalpable. Investigation
CBC: Hb - 85 g/L, Er - 2,8·10^12/L, Ret - 1,9%, colour index 0,71, Le -
7,2·10^9/L, ESR - 6 mm/h.
Blood chemistry: total protein - 68 g/L, iron of serum - 7 mcmol/L (N - 10,4 -
14,2 mcmol/L), total iron binding capacity – 75,8 mcmol/L (N – 54-72 mcmol/L).

Assignment
1. Make the initial diagnosis: iron deficiency anemia 2. What reasons are promoted for the development of the disease? 3. What treatment is necessary for the child? The boy of 3 month old had the expressed xeroderma, itching on cheeks, From anamnesis: the first symptoms appeared after the first introduction of
milk formula as cheeks redness and itching.
Medical examination
Physical development was normal. The skin was dry. There were hyperemia, dryness and infiltration of cheeks. Respiratory sounds were normal. Cardiac sounds were rhythmical. Abdomen was soft, painless. Stool was normal. Investigation
CBC: Hb - 122g/L, Er - 3,2·10*12/L, Le - 7,0·10*9/L, ESR - 6 mm/h.
Immunology: IgE – 910 IU/l (normal level up to 100 IU/l)

Assignment
1. Make the initial diagnosis: atopic dermatitis 2. What are the most important causes of the disease? 3. What treatment would you recommend for this child? The child of 3 years old fell ill acutely. There was runnig temperature up to 39ºC, dry, painful cough, and headache. The child was from the first pregnancy, the pregnancy was with toxicosis. The child had respiratory distress syndrom in the newborn period. The child was frequently ill with acute respiratory infections. He had tonsillitis, chickenpox, and rubella. Medical examination
General condition was serious. The skin was pale, nasolabial cyanosis of
triangle was determined. Mucous of oral cavities was clean, dry. Respiration was "grunting respiration", the number of respiratory movements was 62 for once minute. The chest was enlarged in the front - back size, the right part of the chest slowed down in respiration. On percussion the area of dull percussion was defined in the right side. On auscultation bronchial breath sounds, diminished breath sounds in the right side and fine moist rales were determined. The cardiac sounds were clear, clean. The stomach was soft, painless. The liver was determined near the edges of the rib. Investigation
CBC: Hb -105 g/L, Er - 3,5·10^12/L, Le - 18,6·10 ^9/L, ESR - 28 mm/h.
Chest X-ray: the intensive darkness was marked in the area of VIII -IX segments
of the right lung.
Assignment
1. Make the initial diagnosis: acute pneumonia 2. Name the main principles of antibacterial therapy of this disease. 3. What complications of the disease do you know? The boy of 4 days old was admitted to the clinic with the expressed jaundice. The mother was 23 years old, she had 0 ( I ) , Rh-negative blood
group. The father of the child had A (II) Rh-negative blood group. The first
pregnancy was completed by the medical abortion at the period of 10 weeks. It
was the second pregnancy; there was toxicosis in the second period of
pregnancy. It was full term pregnancy. The birth weight of the child was 3200 g,
the length of the body was 52 cm. The child cried at labor at once, the cry was
loud. The yellowness of the skin and scleras was marked to the end of the first
day. The jaundice increased amplified to the second day.
Medical examination
At admission to the hospital the state of the child was serious; it was defined by expressed jaundice of the skin and scleras. The child was flaccid, there was marked hypotonia of muscles, hyporeflexia. The liver was enlarged from the margin of the rib arch for 3 cm, the spleen was near the margin of the rib arch for 1 cm. The boy has A (II) Rh -negative blood group. Investigation
CBC: Hb - 141 g/L, Er - 3,9·10^12/L, Le - 4,9·10^9/L, ESR - 2 mm/h.
Blood chemistry (on the second day of life): total protein - 54 g/L, indirect
bilirubin - 180 mcmol/L, direct bilirubin - was not present.
Assignment
1. Make the initial diagnosis: hemolytic disease on newborns due to ABO 3. What blood group does this child have? The girl of 13 years old, was admitted to the hospital with the complaints of polyarthralgia during last 4 months, the child had a prolonged subfebrile condition, fatigability. Before the onset of the disease the patient had preceding acute respiratory viral infection, which was accompanied by high fever. The subfebrile fever was preserved after the survived infection. Medical examination
The condition of the child was moderate. On the face there were erythematic lesions, mainly on the cheeks and on the nose. The radiocarpal, ulnar, and talocrural joints were changed, tumescence and morbidity were defined. The respiration was vesicular. The cardiac sounds were rhythmical. There were no pathological murmurs. The palpation of the abdomen was soft and painless, the liver and spleen were not enlarged.
Investigation
CBC: Hb - 100 g/L, Er - 4,2·10^12/L, Le - 15·10^9/L, E SR - 50 mm/h.
Urinalysis: specific gravity - 1012, protein - 0,33 g/L, Le - 3-6 per high-power
field, Er - 20-25 per high-power field.
Blood chemistry: common protein-83g/L, albumin - 46 %, γ-globulin - 32%.
Assignment
1. Make the initial diagnosis: systemic lupus erythematosus 2. What additional inspections are necessary to confirm the The boy of 11 months old, was admitted to the hospital with the complaints of physical development retardation (weight of the body was 7 kg), dyspnea, cyanosis around the mouth at physical exertion. The child had poor weigt gain since the age of 2 months. The child was not Medical examination
The skin was pale with cyanotic shade, peripheral cyanosis, signs of "drumstick", and "watch"s glasses ". The area of the heart was not changed visually. The borders of the heart were defined - the left border – the midclavicular line, the right- the right parasternal line, the upper - second intercostals space. Cardiac sounds were normal, the heart rate - 140 per minute, respiratory rate - 40 per minute. The systolic murmur was auscultated along the left margin of sternum, the second heart sound was weakened in the second intercostal at the left side. Respiration was vesicular, there were no rales. The abdomen was defined at palpation as soft, and painless. The liver and spleen were not enlarged. Investigation
CBC: Hb - 170 g/L, Er - 5,4·10^12/L, hematocrit - 45 % (normal - 47%), Le -
6,1·10^9/L, ESR- 2 mm/h.
Urinalysis is normal.
Blood chemistry: total protein - 69 g/L, urea nitrogen - 5,1 mmol/L, cholesterol -
3,1 mmol/L.
Assignment
1. Make the initial diagnosis: tetralogy of Fallot
2. What is the anatomy of the heart defect?
3. What additional researches are necessary for determining the diagnosis?
The boy of 3 years old was admitted to the hospital in 2 days from the beginning of the disease. The state of the child at admission was serious, the temperature was 38ºC, there were positive meningeal signs, strabismus. The onset of the disease was acute, the temperature of the body was high, twice there was vomiting. Medical examination
The state of the child was serious, there were fatigue, weakness. The skin was pale, the head was thrown back, there were positive meningeal signs, strabismus. Mucous of oral cavities was clean; there was hyperemia of the pharynx. Vesicular breath sounds were heard over lung fields. The cardiac sounds were rhythmical, there was systolic apex murmur. The abdomen was soft, painless at palpation. The liver went out from the margin of the rib arch for 2,5 centimeters. The Kernig sign and Brudzinsky sign were positive. Stool was normal. Investigation
CBC: Hb - 96 g/L, Le - 37,2· 10^9/L, ESR - 57mm/h.
Cerebrospinal fluid: Le - 6000cells, blasts - 1%, Ne - 60%, Ly - 39%, protein -
16,5 mg/dl, glucose - 1,2 mmol/L.
Assignment
1. Make the initial diagnosis: bacterial meningitis 2. Define the etiology of the disease. 3. What etiological treatment is necessary for this patient? The child of 6 years old was ill for one year. The child had complaints of weakness, fatigue, bad appetite, pain in the right hypochondrium. Medical examination
The skin was pale, sclera was icteric. The enlargement of the liver was marked. Urine and feces were of normal colour. Investigation
CBC: Hb - 112 g/L, Er - 3,4·10^12/L, Le - 8,2·10^9/L, ESR - 7 mm/h.
Blood chemistyr: level hepatocellular enzyme (AlAt, AsAt) was enlarged in 5
times.
Serological tests:
HBs Ag + (positive),
HBe Ag + (positive),
HBcorAg- (negative),
a\HBe - (negative).
Assignment
1. Make the complete clinical diagnosis: hepatitis B 2. What treatment is necessary to prescribe to the patient? The boy is of 4 months old. The child was born in time, the weight was 2600 g. Asphyxia was defined at birth. The child required resuscitation. From maternity house the child was admitted to the hospital with the diagnosis of pneumonia. The diagnosis of sepsis was made in the hospital. The child was treated in the hospital, then in the polyclinic. The inoculations were not made in the maternity home. Now this patient is healthy. He is in good condition. Assignment
1. It is necessary to make up the schedule of immunization for the The boy of 4 month old had insignificant xeroderma, hyperemia on the cheeks. The first changes on the skin appeared in 3 months of age, after
introduction of infant formulae. The changes on the skin were expressed. The
child had the expressed xeroderma, itching, and vesicular eruption in wrinkles of
the skin. The patient received prolonged treatment which included a diet,
antihistamine medicines, oils, creams. Now the boy has the period of remission
of the pathological process. The child has the following inoculations: BCG, and
two inoculations for hepatitis B.
Assignment
1. Give your suppositions about the diagnosis.
2. You need to make up the schedule of inoculations for the
The girl of 12 years old complained of fatigability, bad appetite, pain in ulnar, knee joints, running temperature. The girl had tonsillitis a month ago. Medical examination
General state was moderate. The skin was pale. On face the hyperemia was not defined. Vesicular breath sounds were auscultated over lung fields. The heart borders: the right - the right border of the sternum, the upper border - between the second and the third ribs, the left - 3 cm to the left from the midclavicular line. On auscultation the systolic murmur were heard in the heart apex and in the Erba's point. Pulse was 108 beats per minute. The joints of ulnar and knee were hot and painful. The liver and spleen were not enlarged. Investigation
CBC: Hb - 108 g/L, Er - 3,0·10^12/L, Le - 12,0·10^9/L , ESR - 28 mm/h.
Blood chemistry: total protein - 80 g/L, albumin - 46 %, γ-globulins - 25 %,
C-reactive protein - positive.
Assignment
1. It is necessary to make the initial diagnosis: acute rheumatic fever 2. What analyses are necessary for determining the diagnosis? The boy of 11 years old was admitted to the clinic with the complaints of edema, delicacy, poor appetite. The child had previous acute respiratory infection two months ago. The edema on the face, poor appetite appeared one week later. Then the edema appeared on the legs, on the abdomen. Medical examination
The condition of the child was serious. The skin was pale, generalized edema was noticed on the face, legs scrotum and abdomen. Vesicular breath
sounds were heard over lung fields. The cardiac sounds were moderately
muffled. The blood pressure was 125/60. The abdomen was enlarged in size,
there was edema. The liver was not enlarged. Urination was normal.
Investigation
CBC: Hb - 115 g/L, Er - 3,0·10¹²/L, Le - 10,0·109/L, ESR - 42 mm/h.
Urinalysis: specific gravity - 1035, protein - 3,2 g/L, Le - 5-8 per high-power
field, Er - 1-2 per high-power field.
Assignment
1. Give the initial diagnosis of the disease: nephrotic syndrom
2. What analyses are necessary for determining the diagnosis?
3. What is the treatment of choice?
The boy of 8 month old was admitted to the hospital. At admission the mother said about the child's poor gain in weight, frequent cough, relapsing bronchitis. The mother marked the child's large volume liquid fatty stool. The pregnancy proceeded without complications, the child was born in time. At birth the weight of the child was of 3500 g, length 53 cm. The child had breastfeeding, complementery foods was started since 5 months. Now the weight of the child's body is 6300 g, length - 68 cm. Medical examination
Current general condition of the child was serious. The skin was pale and clear. The subcutaneus fat was weak, on the chest it was absent. The turgor of tissues was reduced. The muscle tone was reduced. The hard respiration was defined in the lungs. Sounds were tympanic by percution of lungs. The cardiac sounds were rhythmical and clear. The stomach was enlarged in size. The liver was palpable 3 cm out from the margin of the rib arc. Stool was 6 times per day, with large size, liquid. Investigation
CBC: Hb - 105 g/L, Er - 3,0·1012/L, Le - 7,2·1012/L.
Chloridums of sweat - 95 mmol/L.
Chest X-ray - there was intensifying pulmonary drawing on all lungs fields.
The sings of bronchitis are available.
Assignment
1. It is necessary to make the diagnosis: cystic fibrosis 2. It is necessary to determine physical development of the child, to define 3. Define the main principles of therapy of the disease. A 2 months old male child born of II degree consanguineous marriage presented with cough since 7 days, fever since 5 days and 5-6 episodes of generalized tonic clonic convulsions since 2 days. He was full term normal vertex vaginal hospital delivery without antenatal or postnatal complications and birth weight of 2,4 kg. There was no history of rash or focal neurological deficits. Medical examination
The boy was febrile with a heart rate of 130 per min. He had shallow breathing and anterior fontanelle was bulging. He had generalized lymphadenopathy (cervical, axillary and inguinal). His pupils were pinpoint and not reactive to light. On systemic examination, he had hypertonia with brisk reflexes and extensor planters. There were no meningeal signs. He had a moderate hepatosplenomegaly and on respiratory system examination had bilateral fine crepitations. In view of hepatosplenomegaly with generalized lymphadenopathy with raised intracranial tension and seizures, congenital infection was considered. Investigations
CBC - Hb - 80g/L, WBC - 28,2·10^9/L (51% polymorphs and 49%
Cerebrospinal fluid analysis was done which showed high proteins (147 mg/dL) with 4 polymorphs and 2 lymphocytes/mm3 and sugar of 45 mg/dL with corresponding blood sugar of 48 mg/dL. a/Toxoplasma IgG was positive - 170 IU/dL (normal<10IU/dL), and CSF Toxoplasma IgG was 240 IU/dL suggestive of CNS Toxoplasmosis. a/CMV, Rubella, Herpes simplex IgM and IgG were negative. CT scan of the brain was done which showed extensive periependymal, subcortical white matter calcifications with basal and cisternal exudates. Assignment:
Make the initial diagnosis: toxoplasmosis What etiology treatment is necessary for this patient? NB! The answers on the cases are marked by a red color.

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