SITUATIONAL PROBLEM K003173

1. Dysfunction of the gallbladder according to hypomotor. An inflection in the area of the body of the ZhP.

2. The statement of this diagnosis is based on the history data: the duration of abdominal pain in the right hypochondrium for 6 months in combination
with dyspeptic manifestations. Burdened by heredity on the mother’s side.
Clinical manifestations of abdominal pain syndrome, dyspepsia,
positive blistering symptoms. Data from dynamic ultrasound of the biliary
systems. Absence of changes from laboratory researches.
3. The plan for additional research should include: analysis of feces for
helminth eggs, biochemical blood test (cholesterol, alkaline phosphatase;
bilirubin (total and direct), ALT, AST).

4. Table number 5.

Choleretic agents (cholekinetics).

Prokinetic.

Ursodeoxycholic acid preparations.

5. Compliance with dietary recommendations, diet, sleep and rest, courses, timely sanitation of foci of chronic infection.

CASE STUDY 173 [K003174]
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Main part
Ilya K., 16 years old, went to the district pediatrician with complaints of pain in
epigastric region, occurring mainly after ingestion of fatty foods,
belching with air up to 15 times a day, periodically a taste of bitterness in the mouth, rarely heartburn
(1 time per week). About 6 months ago, abdominal pain and heartburn appeared. First time
these symptoms occurred intermittently, mainly after overeating, but in the last
month, the symptoms became obsessive, causing significant discomfort. The boy became
get tired quickly, school performance deteriorated. Meals with long breaks
abuses dry food. Smokes 1-2 cigarettes a day. Alcohol – beer 1-2 times
per month.
Objectively: a state of moderate severity due to pain and dyspeptic syndromes,
height 180 cm, weight 65 kg. The skin is pale, dry. In the armpits, inguinal region –
local hyperhidrosis. The tongue is moist, densely coated with a white-yellow coating,
bad breath. Teeth are sanitized. The abdomen is painful on palpation in the center
epigastrium, pyloroduodenal zone. The liver is not enlarged. Chair 1 time per day,
decorated, without pathological impurities. urination free,
painless.
General blood analysis:
hemoglobin – 128 g/l, color index – 0.91, erythrocytes – 4.2×1012/l; leukocytes –
7.4×109/l; stab neutrophils – 1%, segmented neutrophils – 53%,
eosinophils – 3%, lymphocytes – 36%, monocytes – 7%, ESR – 6 mm/hour.
Blood chemistry:
total protein – 74 g / l, ALT – 17 U / l, AsAT – 22 U / l, alkaline phosphatase – 138 U / l, amylase – 100 U / l,
thymol test – 4 units, bilirubin – 15 µmol/l.
EFGDS – the mucous membrane of the esophagus in the lower third is hyperemic, edematous, hyperemia by type
“tongues of flame”, erosion up to 0.3 cm on the back wall, the cardia does not close enough,
located below the esophageal opening of the diaphragm. In the stomach, bile, mucous
antrum hyperemic, moderately edematous. Mucous bulb
duodenum and postbulbar departments hyperemic. Cytological
research on Hp (-)
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Name the etiopathogenetic causes and predisposing factors for
occurrence of this pathology in older children.
4. List the complications of this pathology in children.
5. List the principles of treatment for this child.

SITUATIONAL PROBLEM K003174
1. GERD (reflux esophagitis). Chronic gastroduodenitis superficial Hp (-), exacerbation. Duodenogastric reflux.

2. The diagnosis was made on the basis of:

– complaints (pain in the epigastric region, which occurs mainly after eating fatty foods, belching with air up to 15 times a day, periodically a taste of bitterness
in the mouth, rarely heartburn (once a week), increased fatigue, decreased academic performance
at school);
– anamnesis (nutrition with long breaks, abusing dry food,
smokes, abdominal pain and heartburn appeared about 6 months ago);
– an objective examination (the tongue is densely coated with a white-yellow coating, unpleasant
odor from the mouth, the abdomen is painful on palpation in the center of the epigastrium,
pyloroduodenal zone).
– EFGDS data.
3. Gastroesophageal reflux.
Predispose to the development of GERD aggravated heredity, diseases
Gastrointestinal tract, autonomic dysregulation, obesity, senior school age, male sex,
helminthic parasitic infestations.
4. Barrett’s esophagus.
Esophageal stricture.
Esophageal ulcer.
5. Diet therapy and regimen – frequent and fractional meals (5-6 times a day); reception
mechanically and chemically sparing food; the last meal should be
later than 3 hours before bedtime; avoid eating foods that increase GER; not
lie down after eating; sleep on a bed with an elevated head end by 15 cm;
avoid stress on the abdominal muscles, tilt work, wearing tight belts,
belts.
Medical treatment:
Proton pump blockers, prokinetics, antacids.

CASE STUDY 174 [K003175]
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Main part
A 9-year-old girl complains of episodic stabbing pains in the right hypochondrium and
umbilical region, occurring 30-40 minutes after eating fatty
food, after exercise, lasting no more than 15 minutes, pass
alone or after using No-shpy. Periodic nausea and vomiting. Chair
unstable. Moderately pronounced asthenic syndrome (periodic sleep disturbance,
increased fatigue, decreased mental and physical performance),
appetite is reduced.
Complaints are noted within 1 year. Six months ago, the family moved to live in a private house,
There are pets (cats, dogs). The child’s parents did not examine
treated. Heredity for the pathology of the gastrointestinal tract is burdened: mother
(32 years old) – chronic cholecystitis, maternal grandmother – cholelithiasis
disease (operated at the age of 54 years). Allergological anamnesis is not burdened.
Objectively: the skin and visible mucous membranes are clean. Tongue lined
white bloom. Peripheral lymph nodes are not enlarged. Heart sounds are clear
rhythmic. Heart rate – 78 beats per minute; BP – 100/65 mm Hg. Art. respiration is vesicular,
there are no wheezing. The abdomen is soft, palpable in all departments. On palpation
pain in the right hypochondrium and umbilical region is determined. Bubble
symptoms are mildly positive. The liver and spleen are not enlarged.
General blood analysis:
hemoglobin – 128 g/l, color index – 0.91, erythrocytes – 4.2×1012/l; leukocytes
7.2×109; stab neutrophils – 1%, segmented neutrophils – 51%,
eosinophils – 6%, lymphocytes – 36%, monocytes – 8%, ESR – 6 mm/hour.
General urine analysis
color light yellow, transparent; pH – 6.0; density – 1017; protein – no; sugar – no;
epithelial cells – 1-2 in the field of view; leukocytes -1-2 in the field of view.
Blood chemistry:
cholesterol 4.4 mmol / l, alkaline phosphatase – 390 units / l (norm up to 360 units / l), bilirubin
(total) – 20 µmol / l, ALT – 19.8 units, AST – 14.6 units. (norm up to 40 units).
Coprogram – muscle fibers without striation (++), fatty acids (++),
Giardia cysts were found.
Scraping for enterobiosis was negative.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Make a plan for an additional instrumental examination of the patient for
confirmation of the diagnosis.
4. What diseases should be included in the circle of differential diagnosis?
5. List the principles of treatment for this child.

SITUATIONAL PROBLEM K003175
1. Dysfunction of the biliary tract by hypermotor type. Related
diagnosis: giardiasis.
2. Diagnosis “dysfunction of the biliary tract by hypermotor type”
issued on the basis of:
1. Complaints – episodic stabbing pains in the right hypochondrium and umbilical
areas that occur 30-40 minutes after eating fatty foods, after
physical activity, lasting no more than 15 minutes, pass on their own
or after using No-shpa, nausea, vomiting, unstable
stool, sleep disturbance, increased fatigue, decreased mental and physical
performance.
2. Burdened anamnesis (mother (32 years old) – chronic cholecystitis, grandmother
mother’s line – cholelithiasis (operated at the age of 54),
objective status (tongue covered with white coating, palpation of the abdomen
soreness is determined in the right hypochondrium and paraumbilical region, cystic
symptoms are mildly positive).
The concomitant diagnosis of giardiasis was made on the basis of:
1. Complaints of unstable stools, recurrent abdominal pain, nausea,
the presence of a moderately pronounced asthenic syndrome (periodically impaired
sleep, increased fatigue, decreased mental and physical
performance).
2. Anamnesis (the family lives in a private house, there are household
animals (cats, dogs).
3. Detection of Giardia cysts during scatological examination.

Ultrasound of the abdominal organs;

Ultrasound of the gallbladder with an assessment of motor function.

4. The list of differential diagnosis should include: hr. gastroduodenitis,
sphincter of Oddi dysfunction, gallstone disease, cholecystitis, congenital malformations of the gallbladder
bubble.
5. Table number 5, fractional meals in small portions 5-6 times a day
certain hours, which achieves chemical, mechanical, thermal sparing
mucous membrane of the gastrointestinal tract.
Drug therapy: choleretics, antacids, antigiardia therapy
(nifuratel).

CASE STUDY 175 [K003314]
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Main part
Girl M., 16 years old, came to the district pediatrician with complaints of pain in
stomach, burning sensation behind the sternum, belching of sour, air, heartburn.
From the anamnesis: a child from the first pregnancy, which proceeded against the background of a severe
intrauterine hypoxia of the fetus, urgent independent childbirth. At 1 year of age
was under the supervision of a neurologist with a diagnosis of perinatal encephalopathy
ischemic-hypoxic genesis.
Pains in a stomach disturb within 3 years. Not examined on an outpatient basis, no treatment
received. During the last year, the girl developed heartburn, belching, periodically
observed episodes of coughing at night. Heredity is burdened: in the mother –
chronic gastritis, the father has erosive duodenitis.
Objectively: weight 48 kg, height 158 cm. State of moderate severity. The position is active.
Responds well to inspection. The skin is clean, marked marble
picture. The food is satisfactory. The tone and strength of the muscles are not disturbed. Skeleton developed
proportionately, without distortion. Above the lungs percussion – a clear pulmonary sound.
Auscultatory – vesicular breathing, no wheezing, respiratory rate – 18 in 1 minute. Heart sounds
medium sonority, the rhythm is correct. Ps – 78 in 1 minute. Tongue coated at the root
loose coating of white. The abdomen is soft on palpation, moderately painful in
epigastric region. Liver at the edge of the costal arch. Stool and diuresis are not disturbed.
The examination revealed:
Laboratory data.
Complete blood count: erythrocytes – 4.5 × 1012 / l, hemoglobin – 124 g / l, color indicator –
0.9, leukocytes – 6.5×109/l; eosinophils – 1%; stab neutrophils – 3%;
segmented neutrophils – 57%; lymphophytes – 31%; monocytes – 8%, ESR – 8 mm/h.
Urinalysis: quantity – 50.0 ml, specific gravity – 1019, complete transparency,
sugar – no, protein – no, leukocytes – 1-2-0-1 in the field of view; epithelial cells –
units in the field of view.
Biochemical blood test: total bilirubin – 14.1 µmol/l, direct – 2.5 µmol/l,
ALT – 48.1 nm/sl.
FEGDS: there is edema, confluent erosion of the esophageal mucosa. Antral mucosa
of the stomach is sharply hyperemic, edematous. The mucosa of the duodenal bulb
the intestines are hyperemic.
HELPIL-test – sharply positive.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Draw up and justify a plan for an additional examination of the patient.
4. What drugs should be prescribed to the patient?
5. After what period of time and what drugs can be repeated
eradication of Helicobacter pylori?

SITUATIONAL PROBLEM K003314
1. Gastroesophageal reflux disease. Chronic superficial
Hp-associated gastroduodenitis, exacerbation stage.
2. The diagnosis is confirmed by complaints (abdominal pain, burning sensation for
sternum, belching with sour, air, heartburn), anamnesis data (abdominal pain
disturbed for 3 years), objective data (palpation of the abdomen is painful in the area
epigastrium), instrumental methods (FEGDS – confluent erosion of the mucosa
esophagus, hyperemia of the antrum of the stomach, duodenal bulb
intestines).
3. The patient is recommended: scatology, ultrasound of the abdominal organs.
4. Proton pump inhibitors.
Antibacterial drugs for the eradication of HP.
Prokinetics.
Antacids
5. Repeated Hp eradication can be carried out no earlier than after 3 months.
Use drugs of other groups.

CASE STUDY 176 [K003328]
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Main part
Call to the girl M. 3.5 years old with complaints of severe weakness, pallor and jaundice
skin, fever, dark urine.
Anamnesis of life without features.
From the anamnesis of the disease, it is known that the child has been ill for about 2 weeks, when
cough, mucous discharge from the nose, temperature 38.5 °C. Received Analgin,
Biseptol. 4-5 days ago, the parents noted an increase in weakness, the child became drowsy,
dark urine appeared. The district pediatrician suspected an infectious
hepatitis. She was hospitalized, but from further stay in the hospital
refused. According to the discharge from the hospital:
Complete blood count: hemoglobin – 55 g / l, erythrocytes – 2.2 × 1012 / l, color indicator –
0.98, reticulocytes -11%, platelets – 230×109/l, leukocytes – 12.3×109/l, myelocytes –
1%, stab neutrophils – 7%, segmented neutroils – 55%, eosinophils –
1%, lymphocytes – 30%, monocytes – 5%, ESR – 45 mm/h, pronounced anisocytosis, in
microcytes are found in some fields of view.
Biochemical blood test: total protein – 70 g / l, urea – 3.7 mmol / l, creatinine –
60 mmol/l, bilirubin: direct – 7 µmol/l, indirect – 67.2 µmol/l, free
hemoglobin – 0.1 µmol/l, potassium – 4.0 mmol/l, ACT – 28 units, ALT – 30 units.
Urinalysis: positive urobilin, no free hemoglobin, protein
– 0.33%, leukocytes – 1-2 in the field of view.
Coombs test with erythrocytes is positive.
On examination, the condition is very serious. Consciousness is confused. Sharp pallor of the skin
covers, icterus of the sclera. A systolic murmur is heard from the side of the heart.
The liver protrudes from under the costal arch by 4 cm, the spleen – by 3 cm, their palpation is slightly
painful. He urinates well, urine of “dark beer” color. The chair was yesterday, painted.
Questions:
1. Suggest the most likely diagnosis.
2. Assess the complete blood count.
3. With what diseases is it necessary to make a differential diagnosis?
4. What therapy should be prescribed?
5. What type of hemolysis is in this disease?

SITUATIONAL PROBLEM K003328
1. Autoimmune hemolytic anemia.
2. In the general blood test: anemia, reticulocytosis, leukocytosis, accelerated
ESR, anisocytosis, microcytosis, hyperbilirubinemia.
3. Differential diagnosis must be carried out with the following
diseases:
hemolytic anemia of a hereditary nature, infections, hepatitis,
acute leukemia.
4. -Hormonotherapy – glucocorticoids at the rate of 2 mg/kg per day;
-hemotransfusion – transfusion of washed Eg – mass;
-symptomatic therapy – correction of protein metabolism;
– vitamin therapy.
5. In autoimmune hemolytic anemia, intracellular
hemolysis, signs of which are hyperbilirubinemia, mainly due to
indirect fraction and positive Coombs reaction.

CASE STUDY 177 [K003330]
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Main part
A mother with a 5-year-old child turned to a district pediatrician due to an injury
knee joint. Complaints of pain and limitation of movement in the right knee joint,
which appeared 2 hours after falling off the bike.
From the anamnesis it is known that from the age of 1 year, after bruises, the boy develops
extensive subcutaneous hematomas, bleeding from the nose several times a year. AT
at the age of 3 and 4 years after bruises, a tumor appeared around the ankle and elbow
joints, soreness, restriction of movement in them. All of the above injuries
required hospitalization and specific therapy.
The younger brother of 6 months also has prolonged nosebleeds.
On examination, the child’s condition was severe. Complains of pain in the knee joint, on the leg
cannot come. The skin is pale, on the lower extremities, large on the forehead
extravasates. The right knee joint is enlarged, hot to the touch,
painful, movements in it are limited. In the area of the left elbow joint there is
restriction of mobility, a slight increase in its volume as a result of injury,
transferred at 4 years of age.
Complete blood count: hemoglobin – 100 g / l, erythrocytes – 3.0 × 1012 / l, reticulocytes – 3%,
platelets – 300×109/l, leukocytes – 8.3×109/l, stab neutrophils – 3%,
segmented neutrophils – 63%, eosinophils – 3%, lymphocytes – 22%, monocytes – 9%,
ESR – 12 mm/hour. The duration of bleeding according to Duke is 2 minutes 30 seconds. Time
blood clotting according to Lee-White for more than 15 minutes.
Questions:
1. Suggest the most likely diagnosis.
2. What additional research methods need to be carried out to confirm
diagnosis?
3. With what diseases is it necessary to make a differential diagnosis?
4. What therapy should be prescribed?
5. Why did the pain in the joint appear only 2 hours after the injury?

SITUATIONAL PROBLEM K003330
1. Hemophilia. Hemarthrosis of the right knee joint.
2. – Analysis of the child’s pedigree;
-determination of VIII and IX factors;
– plasma recalcification time.
3. Differential diagnosis must be carried out with the following
diseases: immune thrombocytopenic purpura, hemorrhagic vasculitis,
reactive arthritis.
4. Replacement transfusion of factor VIII 10-20 U/kg, in its absence:
cryoprecipitate 10-15 U/kg intravenously by bolus.
5. As the hematoma develops, the pressure increases in it, it compresses
periosteum, which causes severe pain.

CASE STUDY 178 [K003331]
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Main part
A call to the patient K. 4 years old with complaints of severe weakness, vomiting, pallor of the skin
integument, decreased urination.
From the anamnesis it is known that a week before the visit, the boy’s temperature rose to
38 ° C, cough appeared. Received Ampicillin inside. 2 days ago my mother noticed that
the child became lethargic, turned pale, repeated vomiting was noted, and became less likely to urinate.
The mother was tested in a private clinic.
On examination, the condition is very serious. Sluggish, conscious, but hardly visible on examination.
reacts. The skin is sharply pale, with a waxy tint, slightly icteric,
a small number of small fresh bruises on the limbs and trunk. sclera
icteric. Peripheral lymph nodes are small. Rhythmic heart sounds
a systolic murmur is heard at the apex. The liver protrudes from under the edge of the costal
arc by 3 cm, the edge of the spleen is palpated. Rarely urinates, on examination he excreted 30 ml
reddish urine. Dark colored chair, decorated. BP – 120/80 mm Hg. Art.
Complete blood count: hemoglobin – 30 g / l, erythrocytes – 1.2 × 1012 / l, color indicator –
0.9, reticulocytes -15%, platelets – 60×109/l, leukocytes – 10.5×109/l, metamyelocytes –
2%, myelocytes – 1%, young – 3%, stab neutrophils – 7%, segmented
neutrophils – 63%, eosinophils – 1%, lymphocytes – 18%, monocytes – 5%, ESR – 45 mm/hour,
anisocytosis, schizocytes in each field of view.
Biochemical blood test: total protein – 61 g / l, bilirubin: indirect – 30 μmol / l,
direct – 15 µmol/l, urea – 56 mmol/l, creatinine – 526 mmol/l, cholesterol – 3.6
mmol/l, potassium – 4.5 mmol/l, sodium – 145 mmol/l, free hemoglobin – 0.3 mmol/l,
ACT – 25 units, ALT – 35 units.
Urinalysis: color – pinkish, specific gravity – little urine, protein -1.165%, glucose
– no, urobilin – positive, Gregersen’s reaction – positive, squamous epithelium –
few, leukocytes – 10-15 per field of view, erythrocytes – entirely, cylinders: waxy
– 1-2 in the field of view, hyaline – 3-4 in the field of view.
Questions:
1. Suggest the most likely diagnosis.
2. Explain the pathogenesis of hemolysis.
3. Name the biochemical signs of intravascular and intracellular hemolysis.
4. With what diseases it is necessary to carry out differential diagnostics?
5. What emergency measures are required for this patient, and for what
pathological processes they are directed?

SITUATIONAL PROBLEM K003331
1. Hemolytic – uremic syndrome. Renal failure.
hemolytic anemia. Idiopathic thrombocytopenic purpura.

2. The following factors play the main role in the pathogenesis of hemolysis:

1. Violation in the electrolytic exchange – a significant overload of Eg with Na and C1 ions; their edema occurs;
2. Er acquire distorted forms in the form of sticks, disks, eggshells with
scalloped edges. As a result, the premature destruction of Eg occurs.
3. A common sign of hemolysis is a decrease in the level of the haptoglobin protein.
A sign of intravascular hemolysis is the presence of free Hb plasma in
combination with Hb – uria. A sign of intracellular hemolysis is an increase
total serum bilirubin due to the indirect fraction up to 155.0 µmol/l and more.
4. Differential diagnosis should be carried out with renal
insufficiency:
renal failure develops against the background of renal pathology without hemolysis and
Tg – singing.

5. It is necessary to carry out the following emergency measures:

– hormone therapy – glucocorticoids at the rate of 2 mg/kg per day;

– hemotransfusion – transfusion of washed Eg – mass;

– symptomatic therapy;

– correction of water-electrolyte, protein metabolism;

– cardiac glycosides;

– vitamin therapy.

In more severe cases – exchange transfusion, peritoneal dialysis, hemodialysis.

CASE STUDY 179 [K001040]
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Main part
At the appointment with a district pediatrician, a mother with a 10-year-old boy complained of
purulent discharge from both halves of the nose and into the nasopharynx; high body temperature
38.0°C; loose cough during the day, worse at night; obstructed nasal
breath; pain in the cheek area on the right.
From the anamnesis it is known that the child has been ill for 10 days, when a runny nose appeared. Mum
treated the child on her own, instilled vasoconstrictor drops into the nose for 7
days. The deterioration in the child’s well-being occurred the day before: there were real
complaints. Previously had an allergic reaction in the form of a rash on the skin to taking medications
penicillin series.
Objectively: the condition is satisfactory, the child’s body temperature at the moment
inspection 37.5 ° C, blows out purulent contents from both halves of the nose. Nasal
breathing is severely difficult. Palpation and percussion at the projection site of the maxillary
sinuses are moderately painful. With pharyngoscopy, purulent fluid flows down the back of the pharynx.
detachable.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Draw up and justify a plan for an additional examination of the patient.
4. What drug groups would you recommend to the patient as part of a combination
therapy? Justify your choice.
5. List the diseases with which it is necessary to differentiate this pathology in
children.

SITUATIONAL PROBLEM K001040
1. Acute bilateral purulent sinusitis.
2. The diagnosis of “acute bilateral purulent sinusitis” is established on
the basis of the patient’s complaints about purulent discharge from both halves of the nose and into the nasopharynx;
high body temperature of 38.0 °C; loose cough during the day, worse at night;
difficult nasal breathing; pain in the cheek area on the right; anamnestic data
(the child has been sick for 10 days), objective data (presence of purulent contents from both
halves of the nose when blowing your nose, a sharp difficulty in nasal breathing, the presence of
pharyngoscopy along the posterior wall of the pharynx of a purulent discharge, pain during
palpation and percussion in the projection area of the maxillary sinuses).
3. The patient is recommended: consultation of an otorhinolaryngologist for
clarification of the diagnosis and coordination of therapy; general blood test to clarify the nature
inflammation; Ultrasound of the paranasal sinuses to visualize the condition of the paranasal sinuses;
according to indications, X-ray of the paranasal sinuses or computed tomography
paranasal sinuses to visualize the condition of the paranasal sinuses, their walls and
structures of the nasal cavity.
4. Antibiotics: macrolides. The choice of drug from this group is based on
information on the sensitivity of the main pathogens of acute purulent sinusitis and
the absence of cross-allergy of drugs of the macrolide group and the group
penicillins to which the child is allergic. Saline solutions
(standardized) into the nasal cavity as elimination therapy.
Mucoregulators to improve drainage function. Topical decongestants in
as a relief therapy.
5. Acute rhinitis, allergic rhinitis, foreign body in the nasal cavity,
adenoiditis.

CASE STUDY 180 [K001043]
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Main part
At the appointment with a district pediatrician, a mother with a 4-year-old boy complained of
pain in right ear.
From the anamnesis it is known that the child is ill on the 2nd day, when after hypothermia
there was a sharp pain in the right ear, body temperature increased to 38.0°C. Mum
instilled drops of Otipax in the child’s ear, gave Nise. A year ago there was an episode of acute
otitis media (without suppuration). Observed by an otolaryngologist for hypertrophy
adenoids III degree from the age of three.
On examination: body temperature 37.4°C, nasal breathing is difficult, the child
breathes through the mouth, nasal tone of voice, palpation of the right tragus is painful,
palpation and percussion of the behind-the-ear region is painless. From the right ear canal –
purulent discharge.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Make a plan for additional examination of the patient.
4. Which group of drugs would you recommend to the patient as part of a combination
therapy? Justify your choice.
5. What is your further tactics of managing the patient after recovery? Justify
Your choice.

SITUATIONAL PROBLEM K001043
1. Acute purulent otitis media on the right. Hypertrophy of the adenoids 3 tbsp.
2. The diagnosis of “acute purulent otitis media on the right” was established on the basis of
patient complaints of pain in the right ear, purulent discharge from the right ear,
history data (the child is sick for 2 days. After hypothermia, a sharp pain appeared in
right ear, body temperature increased to 38.0 ° C, suppuration appeared in the morning from
right ear. A year ago there was an episode of acute otitis media (without suppuration));
objective data (body temperature 37.4 °C, palpation of the right tragus is painful,
palpation and percussion behind the ear painless, suppuration from the right ear).
The diagnosis of “hypertrophy of the adenoids 3 tbsp.” established on the basis of objective data
(nasal breathing is difficult, the child breathes through the mouth, nasal voice is determined,
anamnestic data (diagnosis of “adenoid hypertrophy grade 3” was established by an otorhinolaryngologist at the age of 3 years).
3. 1. Consultation with an otorhinolaryngologist to clarify the diagnosis and
therapy approvals;
2. Complete blood count;
3. Buck. sowing discharge from the ear for microflora and sensitivity to
antibiotics to identify the pathogen and determine sensitivity to
antibiotics, which is necessary to select a rational antibacterial
therapy;
4. 1. Antibacterial therapy: aminopenicillins, penicillins with
beta-lactamase inhibitor, cephalosporins, macrolides. The choice of drugs is based on
empirical knowledge of the main causative agents of acute suppurative otitis media and their
sensitivity to antibiotics.
2. Topically: antibiotic ear drops. Choice of drug
based on empirical knowledge of the main causative agents of acute purulent
otitis media and their sensitivity to antibiotics and the possibility of prescribing this drug for perforation of the tympanic membrane in children without
age restrictions.
3. Non-steroidal anti-inflammatory drugs are used for
pain relief and hyperthermia.
5. The pediatrician should observe the patient together with the otorhinolaryngologist, it is necessary to carry out otomicroscopy in dynamics (control
scarring perforation of the tympanic membrane), in a month refer the child to
planned adenotomy to restore nasal breathing.

CASE STUDY 181 [K001044]
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Main part
At the appointment with the district pediatrician, a mother with a 10-year-old girl complained of
increase in body temperature 38.0–39.0 ° C, sore throat on the left, aggravated by
swallowing, pain radiates to the left ear, increased salivation.
Sick for 7 days, mother treated the child by gargling with chamomile, with an increase
body temperature was given Paracetamol. The night before, the girl’s condition worsened.
Body temperature rose to 38.5°C, increased pain in the throat on the left. Within three years
the child had frequent sore throats, 3-4 times a year.
Objectively: the child’s body temperature is 38.0°C, the skin is pale, palpable
enlarged painful submandibular lymph nodes on the left, the girl has trismus
masticatory muscles, with pharyngoscopy, hyperemia of the pharynx is determined,
asymmetry of the pharynx due to bulging of the anterior palatine arch and soft palate on the left,
hyperemia and enlargement of the left palatine tonsil.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Draw up and justify a plan for an additional examination of the patient.
4. Determine the tactics of treating the patient. Which drug group would you recommend?
patient in combination therapy? Justify your choice.
5. List the diseases with which it is necessary to conduct a differential
diagnosis in this situation.

SITUATIONAL PROBLEM K001044
1. Peritonsillar abscess on the left (antero-upper). Submandibular
lymphadenitis on the left. Chronic tonsillitis.
2. The diagnosis of “peritonsillar abscess on the left (antero-superior)” was established
based on the patient’s complaints:
– increased body temperature 38.0-39.0 ° C, sore throat on the left,
aggravated by swallowing, pain radiates to the left ear, increased
saliva formation;
– anamnesis: sick on day 7;
– objective data: trismus of masticatory muscles, with pharyngoscopy
hyperemia of the pharynx is determined, asymmetry of the pharynx due to bulging
anterior palatine arch and soft palate on the left, hyperemia and enlargement
left palatine tonsil.
The diagnosis of “submandibular lymphadenitis” on the left was established on the basis of objective
data (palpable enlarged painful submandibular lymph nodes
left).
The diagnosis of “chronic tonsillitis” was established on the basis of anamnestic
data: for three years the child had frequent tonsillitis, 3-4 times a year.
3. Consultation with an otorhinolaryngologist to confirm the diagnosis and
determining the treatment strategy for the patient. A smear from the pharynx for microflora and
susceptibility to antibiotics is necessary for differential
diagnosis and selection of a course of adequate antibiotic therapy. General blood analysis
to determine the nature of inflammation. General urinalysis to rule out complications
from the urinary system.
4. Urgent hospitalization is needed in the otorhinolaryngological pediatric
department for surgical assistance (opening of the paratonsillar
abscess); Prescribing antibiotics – drugs of choice: aminopenicillins,
beta-lactamase inhibitor penicillins, cephalosporins, macrolides. Choice
preparations is based on empirical knowledge of the main causative agents of inflammatory
diseases of the pharynx and their sensitivity to antibiotics.
Topical antibiotics: antiseptic solutions for
rinses (Benzydamine, Furazidin potassium, Ketoprofen lysine, Nitrofural). Choice
drug is based on empirical knowledge of the main causative agents of inflammatory
diseases of the pharynx and their sensitivity to antibacterial drugs.
Non-steroidal anti-inflammatory drugs (NSAIDs) are used to relieve
pain syndrome and hyperthermia. 1 month after the acute
inflammation in the pharynx, a planned tonsillectomy is indicated.
5. Paratonsillitis, retropharyngeal abscess, tonsillitis, diphtheria of the pharynx.

CASE STUDY 182 [K001045]
Instruction: READ THE SITUATION AND GIVE DETAILED
ANSWERS ON QUESTIONS
Main part
At the appointment with a district pediatrician, a mother with a 3-year-old child complaining of pain in
throat, salivation, difficulty swallowing and difficulty breathing.
From the anamnesis it is known that the child fell ill suddenly, against the background of complete health,
developed fever and sore throat. Body temperature is febrile (up to 40°C). In 2 hours
there was difficulty in breathing.
Objectively: the child’s condition is moderate, body temperature is 38.8°C. child
capricious and agitated. The skin is pale, marked acrocyanosis. noted
salivation, the child refuses to eat and drink. Muffled voice (as if
the patient talks “with a hot potato put in his mouth”). Lung
coughing. Painful palpation of the larynx. Breathing is difficult
inspiratory dyspnea, respiratory rate – 40 per minute, determined by retraction of the supra- and
subclavian fossae, intercostal spaces, heart rate – 140
beats per minute, BP – 100/60 mm Hg. Art. On pharyngoscopy: moderate hyperemia of the posterior
the walls of the pharynx, a brightly hyperemic enlarged in size is visible,
infiltrated epiglottis.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Indicate the most likely etiology of this disease.
4. Determine the tactics of treating the patient. Which drug group would you recommend?
patient in combination therapy? Justify your choice.
5. In a child, bacteriological analysis of a swab from the pharynx revealed hemophilic
stick type – B (Haemophilus influenzae type b (Hib)). The child is not vaccinated against hemophilic
infections. What is your next strategy? Justify your choice.

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