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The history of the disease in pediatrics. Diagnosis: chronic non-specific enterocolitis

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History of the disease by Pediatrics.

Diagnosis: chronic non-specific enterocolitis

Complaints

At the admission, in the words of the mother, the child was concerned about painful character in the mesogastric region, often on the left, arising after food, after 1-1.5 hours. The mother also noted some irritability, a slight decrease in appetite, a periodic alternation of constipation and diarrhea.

At the time of the curia: the child does not complain.

Anamnesis of the disease

Over the past year, in the words of the mother, the child was often bothered with pain, nourishing in the mesogastric region, often on the left, arising after 1-1.5 hours after eating. The mother also notes in the child the alternation of diarrhea (liquid castious-stool) with constipation (when the chair was only several times a month), irritability. For medical help he did not address, he treated the child independently with broths of chamomile and chinchillas. The disease has occurred with periods of exacerbations and remissions. On the advice of the pediatrician, the child was sent to a children’s health facility with a gastroenterological pathology. During the visit to this institution, the child’s condition improved.

Anamnesis of life

The child was born from normal 3 pregnancies, 3 urgent births, 3 children in the family. Pregnancy has proceeded well, delivery without pathology. Born in time with an assessment on the Apgar score of 9 points, cried immediately. Weight at birth was 3650 grams, height – 54 cm. At the end of the first year of life, the weight of the child was 10.5 kg, height 77 cm. Appended to the breast 6 hours after birth, immediately tried to suck. The newborn’s period proceeded calmly. During the first year of life, the baby was naturally fed. The first supplement was introduced in 5 months, in 12 months it was separated from the breast. After a year, the baby’s nutrition was calorie, diverse. I began to recognize my mother in 2.5 months. Sit started in 6 months, stand in 9 months, walk independently in 1 year. In 5 months the first tooth appeared, the year of teeth was 8. In 3 months, began to pronounce separate vowels, and in 8 months the first word “mother” was said. Mentally and physically, after the first year of life, it grew and developed normally, not lagging behind its peers. Signs of rickets and exudative diathesis were not observed.

Acute diseases transmitted:

Other transmitted diseases: dysbiosis, rarely ARVI, bilateral otitis media

Vaccinations:

DTP: V1 0,5 p.399-7 4.1.94

V 2 0,5 s.399-7 18.2.94

V3 0,5 s.408-3 7.4.94

RV 0.5 s.465-2 4.5.95

  1. Polio
V1 4K p. 228 4.1.94
V2 с.228 18.2.94
V3 с.247 7.4.94
RV1 4К | || 187 с.274 5.1.95
RV1 с.291 20.2.95
RV2 с.296 31.7.95
RV2 с.316 19.10.95

1 round 18.03.96 4K 326

2nd round 22.04.96 4K 326

  1. B G 4.2.94 s.117 rub.4 mm
  2. Bull: 3.11.94 c.959 0.5
  3. Parity: 29.01.96 c.0609 0,5
  4. RM: 31.10.94 р.4

Conclusion: the child is vaccinated by general plan. Family history: the baby was born from healthy parents:

Family history: the child was born from healthy parents:

– mother: Soloveva Lydia Georgievna, 26 years old, works in Vyborg Sobies, a social worker;

– Father: Alexander Solovyov, 29 years old, works as an inspector of an accident in the traffic police

The family is financially secured. Tuberculosis, venereal diseases are denied by parents. Parents take care of the child’s health, follow all the recommendations of the pediatrician. There are two more girls in the family, both are healthy. Heredity is not burdened. Parents do not abuse alcohol, the father smokes in the family.

Conclusion: in general, family history is a favorable, unfavorable factor is the father’s smoking. Living conditions: the child lives with his parents and sisters in a separate apartment. In the room lives with one of the sisters. Everything is necessary, outdoor walks make 4-6 hours a day. The main educator in the family is the mother. Visit the children’s health facility with gastroenteropathology.

Conclusion: the living conditions are favorable.

Objective examination

At the time of the visit, the general condition the child is satisfactory, the consciousness is clear, the position is active. The face color is pale. Behavior of the child during inspection is calm. The complaint does not show.

The body is right. Skin covers are pale, clean, no edema is observed. Mucous membranes of lips, mouth, jaw, conjunctiva eyes of pink color, smooth, shiny. The presence of rash, hemorrhage, thrombosis is not observed. The subcutaneous fat layer is expressed moderately. Turgor skin is not changed. Lymph nodes are parotid, submaxillary, supraclavicular, subclavian, axillary, inguinal painless, not enlarged, medium density, not conjugated with surrounding tissues. The occipital and submaxillary glands are not enlarged, with palpation painless. Thyroid gland is not enlarged, soft, painless, nodes are not defined.

The muscular system is moderately developed, the tone and muscle strength are unchanged.

Bone system: the shape of the skull is mesocephalic, the condition of the crucifers and sutures is according to age. Chest type of asthenic type. Visible curvature of the spine is not observed. Limbs of the correct length and shape. Active and passive motions in the joints in full, with palpation, their pain is not noted.

Cardiovascular system: at palpation pulse is determined on the artery, satisfactory filling and stress, symmetrical, rhythmic, with a frequency of 105 strokes per minute, arterial pressure 90/60 mm Hg Art. At palpation, the apical impulse is determined in the fifth intercostal space 1 cm outside of the left midlectric line, moderate height and force, 1.5 cm long. During percussion, the following limits of relative cardiac dullness were detected:

– left: at 1 cm outside of the left midlectric line in the fifth intercostal space;

– right: 0.5 cm in the intrar from the right peritoneum line;

– upper: in the 2 intercostal space.

Respiratory system MA: hrudnaya cells astenycheskoy forms, ravnomerno uchastvuet akte in breathing. Breath of rhythmic, average depth, 25 movements per minute, predominantly abdominal. Voice shaking is the same on both sides. P / D = 4/1. With a comparative percussion on the entire surface of the lungs, a clear pulmonary sound is determined. At topographic percussion, the lower boundaries of the lung are found at the level:

The height of standing of the apices of the lungs in front 2 cm above the collarbone, At the back – at the level of the spinous process VII of the cervical vertebrae. The mobility of the lower lag edges is 6 cm, the right and left are the same. When auscultation over the entire surface of the lungs, vesicular breathing is heard, no wheezing. Bronchophonia is not changed.

Digestive system: mucous membranes of the mouth, pharynx and lips of pink, shiny, without pathological changes. The tongue is wet, is covered with a whitish scar, nipples are expressed. The tonsils are pink, not enlarged, without signs of inflammation. Dental formula:

The belly of the correct form, of normal size, symmetrical, uniformly participates in the act of breathing. With superficial palpation, the abdomen is mild, painful in the near-bowel region, without gross anatomical changes, the anterior abdominal wall is not edema. In deep palpation, in the left iliac region, the sigmoid colon is defined: dense, slightly painful, cylindrical, dense, not urticating; In the right ilium region, the intestine is defined: painless, soft, movable, cylindrical, and urticates with palpation. The transverse colon and the stomach are not palpable. When palpation, the lower edge of the liver is Kurlov: 8-7-6 cm. The spleen is not palpable. Its lower bound at the level of the IX rib is determined percurently. At the moment of excitation, the chair is frequent (up to 5 times a day) castious, without pathological impurities.

The genitourinary system: when examining the lumbar region, protrusion, redness, swelling is not noted. Choking on the lumbar region is painless. The kidneys are not palpated. Diuresis is about 800 ml per day. Urinalysis is painless, 8-10 times a day. Sex organs are developed according to sex and age.

Nervous system: consciousness is clear, the child is contact, in a good mood, calm. Active motor disorders are not observed. Student’s state: D = S, correct form, reaction to light, accommodation, convergence preserved. Eyeball movement in full. Mimic muscles are well developed. The smoothness of the nasolabial fold and the deviation of the tongue are not noted. Reflexes: peristaltic, tendon, knee, with Achilles tendons preserved. Pathological reflexes of Babynsky, stop clones are not called. Coordination of movements is not disturbed. Abdominal reflexes (upper, middle, lower) are unchanged. Meningeal symptoms (rigidity of the crotch muscles, a symptom of Brudzinsky) are absent. Vegetative disorders are not observed. Dermographism is red.

The organs of feelings:

– the ears: the right and left ear perceive the sound stimuli equally.

– eyes: visual acuity: OD + 2 , 0, OS = 1.0. sight binocular, normal trichromiasis

– olfactory and taste are not changed.

General conclusion on anamnesis and objective research: it is evident from the history of life that dysbiosis may be a predisposing factor for the development of this pathology , for 1 month of life, staphylococcal etiology. At the time of coaching, the results of objective research are within the normal range.

Rationale for the preliminary diagnosis.

Based on the complaints of the child (according to the mother) on a painful character in the mesogastric region (often on the left) arising after eating through 1-1.5 hours; on the basis of anamnesis data, showing periodic alternation of diarrhea and constipation; On the basis of objective research data that revealed pain in palpation in the umbilical region and in the region of the sigmoid colon, the presence of a frequent (up to 5 times a day) casings-like stool suggests that the child has a chronic non-specific enterocolitis.

  1. Clinical blood test (to determine the general condition of the child).
  2. Biochemical blood test (for the determination of enzyme activity).
  3. General urine test (to determine the general condition of the child and the exclusion of complications
  4. Kal on eggs worm (to exclude helminthis).
  5. Core program (for the study of functional activity of the digestive tract, liver and pancreas).
  6. Excision of enterobiasis (to exclude helminth infestation).
  7. Analysis of feces for dysbiosis (to determine the intestinal microflora of a child). || 384
  8. ECG (for determining the functional activity of the heart).
  • Colonophibroscopy.
  • Rectoromanoscopy .
  • Consultations of specialists:
  • Gastroenterologist
  • Ophthalmologist
  • Otorhinolaryngologist
  • Anthropometry:
  • weight – 14.5 kg
  • head circumference – 50 cm
  • breast circumference – 52 cm

Justification of the final diagnosis:

Based on the complaints of the child (in the words of the mother) on a painful character in the mesogastric region (often on the left) arising after eating 1-1.5 hours; on the basis of anamnesis data, showing periodic alternation of diarrhea and constipation; on the basis of objective research data that revealed pain in palpation in the umbilical region and in the region of the sigmoid colon, the presence of a frequent (up to 5 times a day) castious stool (in the period of curia); On the basis of data from a laboratory study (kooprogramma) that revealed changes that are characteristic of the chronic inflammatory process in the distal regions of the intestine (the presence of unchanged muscle fibers, neutral fat, fatty acids, leukocytes), it can be assumed that the child has a chronic non-specific enterocolitis.

Plan of treatment.

Diet № 4. The food should be freshly prepared, mechanically , chemically sparing, with increased the number of proteins, the restriction of carbohydrates, and the exclusion of foods rich in fiber, spices, spicy, salted, smoked, roasted dishes, whole milk. After 3-5 days, the diet is gradually expanded (table 4B, then 4V) and appoint it for 4-6 weeks. In the future, going to the general table, but exclude individually intolerable products.

Etiological treatment: antibiotic therapy (salazopyridazine, biseptol, etc.) are carried out in short courses.

Pathogenetic treatment – for the purpose of combating dysbiosis, biological preparations are prescribed: bifidum bacterium, lactobacterin, bificol, and others

Vitamin therapy – vitamins of group B (B1, B6, B12), folic acid, ascorbic acid, vitamins A, E, D.

Fermentotherapy: pancreatin is prescribed for the improvement of digestive processes , festal, mesim-forte, panzinorm.

To stimulate metabolic processes, appoint m tatsyl, pentoksil, apylak, pain and spasms – no-silos, papaverine. With constipation – typhine, sorbitol, Karlovy Vary salt; at ponylet – tanalbin.

During the remission period, it is recommended to take decoctions of medicinal herbs (St. John’s wort, chamomile, sage, plantain, etc.). At an inclination to constipation – to accept a crust of cortex. It is also recommended to take mineral water in the warmed state: with diarrhea – Essentuki number 4, with constipation – Batalinskaya, Slavyanskaya, Essentuki number 7.

Physiotherapy procedures are recommended – applications of paraffin on the stomach, ozocerite, electrophoresis of medicinal substances. || 670

Etiology and pathogenesis The formation of a chronic inflammatory process in the intestine in this case was facilitated by dysbiosis transmitted in Early childhood, this may also be attributed to the non-racial ing POWER, nerehulyarnыy pryem of food, hypovytamynozы. These factors lead to impairment of digestive processes, increase sensitization, increase the titre of antibodies to intestinal microbes, and some food products and intestinal tissues. Morphological changes occur in the villi, suction and membrane digestion are violated. Infiltration of the own mucosal plate with lymphoid and plasma cells occurs.

The course of the disease and the prognosis.

The course of the disease is chronic, recurrent.

Forecast: Forecast for unfavorable recovery. By following all the appointments, it is possible to achieve a lasting long-term clinical remission.

Prevention.

At the achievement of stable remission recommended use of mineral waters, spa treatment. When exacerbation is necessary rational appointment of antibiotics, with the simultaneous appointment of biopreparatov (bifidum – bacterin, bificol, etc.).

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