PEOPLE’S FRIENDSHIP UNIVERSITY OF RUSSIA
FACULTY OF MEDICINE DEPARTMENT OF PEDIATRICS HEAD OF DEPARTMENT- Проф. КУЗМЕНКО Л.Г.
PATIENT CASE HISTORY
NAME OF PATIENT: КАТАЛЬНИКОВ ИГОРЬ АНАТОЛОВИЧ
Преподаватель:Асс.Доц. Контемирова М. Г. Сura tor- Deepankar Srigyan Group- ML 511
Full name of Patient: Katalnikov Igor Anatolovich
Age (date of birth): 1 yr. 5 months (05-10-2007). Nationality: Russian Date of admission: 03-04-2009 at 20²⁰. Date of starting of curation: 07-04-2009 at 12 AM.
Diagnosis at admission: Exudative pericarditis. Clinical Diagnosis: Subacute non-specific exudative pericarditis.
ANAMNESIS OF THE DISEASE Child was admitted from 14-02-09 to 03-03-09 in the 5th department of this hospital with diagnosis of exudative pericarditis and after consultation of surgeon this child admitted in this department on 03-04-09 and here the clinical diagnosis is Subacute non-specific exudative pericarditis. Complains: there is no any complain according to child’s mother.
I. STATUS PRESENCE
General state: moderately severe at the time of admission. Position of the patient: active Body Constitution: Parameters:
Body height Body weight Circumference of head
In normal80 cm. 12.7 kg. 48 cm.
Of patient83 cm. 12 kg. 47 cm.
Circumference of chest
Physique(body build): normosthenic. Skin: dry, pale-pink, mucous clean. Subtaneous fatty layer: moderate & equal development.
Turgor of the tissues: normal satisfactory; no oedema; normal elasticity of skin.
Lymphatic nodes: lymph nodes are not palpable. Muscular system: moderate development, tonus & force normal. Skeletal system:
skull well developed,fundicular constitution: Size- 47 cm., skull sutures stabilized. Thorax: closer to cylindrical form. Vertebral column: is normal. Extremities: unchanged. Joints: unchanged, free movements of joints.
Type of respiration: thoracic; nasal respiration free, no discharge from nose. Respiratory rate- 24 per min. Voice: clear, Cough and dyspnoea are absent. Vocal tactile fremitus not changed; Bronchophonia(vocal resonance) not changed. Lungs:On comparative percussion- pulmonary/clear percussion note over the entire surface. Lower borders of lungs :
Lower border of left lung along the midclavicular line remarkable away from sternum at height of 4th rib and sharply goes down. 9th rib 10th rib
Mid-axillary line Scapular line
8th rib 9th -10th rib
At the level of At the level of spinous process of spinous process of th 11 thoracic 11th thoracic vertebrae. vertebrae. Mobility of lung’s borders: 0.5-1.0 cm. Character of breathing: weak bronchial breathing, no rales and no crepitations.
No visible chest deformity; Vessels of neck are not visible but jugular veins are palpable. Apex beat heard at 5th intercostal space 0.5 cm. inside from midclavicular line.
Borders of absolute dullness of heart: Borders:
In normal3rd rib
In patient3rd rib
Between left Between left midclavicular line and midclavicular line and parasternal line, parasternal line, nearer to nearer to midclavicular. midclavicular. Left border of sternum Left border of sternum
Borders of relative dullness of heart: Borders:
In normal2nd rib 0.5-1 cm outside from left midclavicular line. Right parasternal line 1-2 cm outside from
In patient2nd rib 1 cm outside from left midclavicular line. Right parasternal line 1 cm outside from
Right Apex beat
left midclavicular line at 5th intercostal space.
left midclavicular line at 5th intercostal space.
Tones: loud and rhythmic. • Sound: systolic murmurs maximum at apex on midclavicular
line at 5th intercostal space. Pericardial friction rub (abnormal heart sound) on auscultation. Pulse: rhythmic, frequent, uniform. Pulse rate- 100 /min. Arterial blood pressure: 90/60 mmhg.
Lips: pink, moist; Tongue: clean, moist. Buccal mucosa and gums are healthy; Oro-nasopharynx is clear, tonsils are normal; Number of teeth- 13 milk teeth, clean & healthy. Abdomen symmetrical, oval shaped, soft, without pain, scars absent. State around the umbilical region: hernias absent. Appetite normal, feeding 5-6 times in a day. Liver is palpable 1 cm below the costal margin, dense, smooth, absence gravity of pain. Spleen is not palpable. Stool: normal, frequency- 1-2 times in a day, formed, soft consistency, brown colour, without tenderness of defaecation, condition of rectum is good.
Type of urinary passage- free, 5-6 times in a day.Pasternsky's symptom absent. Urine: light yellow color, full transparent; Specific gravity of urine- 1016.
Neurological and endocrine system:
Sense organs: eyes- good visual acuity, good condition of conjunctiva and pupil. Ears- good audition, the condition of pinna & external meatus is good. Conciousness clear, good intellect, good mood. Sensitivity of tactile, painful and temperature is normal. Pathological reflexes (hyperkinesias, tremors) are absent. Condition of endocrinal glands is good.
Meningeal symptoms: negative Vaccinated according to age.
II. PLAN OF INVESTIGATION
1. Blood analysis:
Indicators: RBC WBC Hb HCT MCH MCHC Lymphocytes Monocytes Granulocytes Platelet count ESR Assessment : Normal 3.8-5.8 x 1012/l 3.5-10.0 x 109/l 11-16 g/dl 35-50 % 26.5-33.5 pg 31.5-35 g/dl 17-48 % 4-10 % 43-76 % 150-390 x 109/l 2-8 mm/h lymphocytes are increased. 03-04-2009 4.65 x 12 10 /l 6.50 x 9 10 /l 13.1 g/dl 34.6 % 28.1 pg 37.9 g/dl 65 % 6.3 % 27.8 % 345 x 109/l 4 mm/h
2. Urine analysis:
Indicators: Colour Transparency Density 06-04-2009 Light yellow complete 1016
Albumin Epithelium WBC RBC pH Assessment: normal.
absent 3-4 2-3 absent 8.0
3. Echocardiography: 03-04-2009
Conclusion: data of congenital heart disease absent. Liquid in pericardium (Exudative pericarditis). Systolic and diastolic functions are not disturbed.
4. Echo Doppler cardiography: 05-04-2009
Conclusion: without presence of dynamic changes in pericardial layer. At the posterior wall of right ventricle – 10 mm At the lateral wall of right atrium – 14 mm At the posterior wall of left ventricle – 4 mm At the lateral wall of left ventricle – 7 mm Control ECG and EchoCG after 10-14 days.
» Plan of investigation:
(1) (2) (3) (4) (5) General blood analysis General urine analysis Echo Cardiography Echo Doppler cardiography Consultation with ENT doctor.
» Plan of treatment:
(1) (2) (3)
Bed rest regime. Diet – hypoallergenic table N. 15 Diclofenac sodium (Voltaren Oral) 12.5 mg, 3 times/day
Ampicillin (anti-bacterial preparation) 300 mg/day Naftifine (anti-fungal preparation) 0.05 %, 2 drops, 3 times/day Anti-inflammatory preparation, Protargol proteinate) 2 % 3-4 drops upto 1 month. Suprastin (anti-histamine ) 1/3 tab., 2 times/day. (Argentum
III. Clinical Diagnosis
Principal disease: Subacute non-specific exudative pericarditis Complications: No Other conditions: No IV. THE SUBSTANTIATION OF THE DIAGNOSIS
According to anamnesis of disease child is admitted in this hospital with the diagnosis of exudative pericarditis but according to mother child has no any complains. So, Anamnesis of disease is one of the basis the clinical diagnosis. On auscultation Pericardial friction rub (abnormal heart sound) heard. According to blood analysis lymphocytes are more than normal. According to EchoCardiography liquid is present in pericardium. According to Echo-doppler cardiography there are signs of exudative pericarditis that’s why prescribed to control of ECG and EchoCG after 10-14 days.
V. Differential Diagnosis :
Since there is no specific test for acute idiopathic pericarditis, the diagnosis is one of exclusion. Consequently, all other disorders that may be associated with acute fibrinous pericarditis must be considered. A common diagnostic error is mistaking acute viral or idiopathic pericarditis for acute myocardial infarction and vice versa. When it is associated with acute myocardial infarction, acute fibrinous pericarditis may be confused with acute viral or idiopathic
pericarditis; this complication of infarction, is characterized by fever, pain, and a friction rub in the first 4 days following the development of the infarct (to be distinguished from the pericarditis in Dressler's syndrome, which is a form of post-cardiac injury pericarditis and which occurs a week or two following myocardial infarction). ECG abnormalities (such as the appearance of Q waves, brief ST-segment elevations with reciprocal changes, and earlier Twave changes in myocardial infarction) and the extent of the elevations of myocardial enzymes are helpful in differentiating pericarditis from acute myocardial infarction. Pericarditis secondary to post-cardiac injury is differentiated from acute idiopathic pericarditis chiefly by timing. If it occurs within a few weeks of a myocardial infarction or a chest blow, it may be justified to conclude that the two are probably related. If the infarct has been silent or the chest blow forgotten, the relationship to the pericarditis may not be recognized. It is important to distinguish pericarditis due to collagen vascular disease from acute idiopathic pericarditis. Most important in the differential diagnosis is the pericarditis due to systemic lupus erythematosus (SLE) or drug-induced (procainamide or hydralazine) lupus. In these conditions, pain is often present; sometimes in SLE the pericarditis appears as an asymptomatic effusion, and rarely, tamponade develops. When pericarditis occurs in the absence of any obvious underlying disorder, the diagnosis may be made on discovery of lupus erythematosus cells or a rise in the titer of antinuclear antibodies. Acute pericarditis may complicate the viral, pyogenic, mycobacterial, and fungal infections that occur in AIDS. Acute pericarditis is an occasional complication of rheumatoid arthritis, scleroderma, and polyarteritis nodosa, and other evidence of these diseases is usually obvious. Asymptomatic pericardial effusion is also frequent in these disorders. It is important to question every patient with acute pericarditis about the ingestion of procainamide, hydralazine, isoniazid, cromolyn, and minoxidil, since these drugs can cause this syndrome. The pericarditis of acute rheumatic fever is generally associated with evidence of severe pancarditis and with cardiac murmurs. Pyogenic (purulent) pericarditis is usually secondary to cardiothoracic operations, immunosuppressive therapy, rupture of
the esophagus into the pericardial sac, or rupture of a ring abscess in a patient with infective endocarditis and with septicemia complicating aseptic pericarditis. It is accompanied by fever, chills, septicemia, and evidence of infection elsewhere. Tuberculous pericarditis may present as an acute pericarditis associated with fever, weight loss, and other clinical manifestations of active systemic tuberculosis; the diagnosis may be aided by a positive tuberculin test and evidence of pulmonary or mediastinal tuberculosis. Tubercle bacilli can be cultured from the pericardial space only infrequently, and a biopsy of the pericardium with bacteriologic and histologic examination may be required. Alternatively, tuberculous pericarditis may present as a chronic asymptomatic effusion, as subacute effusive-constrictive pericarditis, or as frank chronic constrictive pericarditis (see below). Uremic pericarditis occurs in up to one-third of patients with chronic uremia and is seen most frequently in patients undergoing chronic hemodialysis. It may be fibrinous and is generally associated with an effusion that may be sanguineous. A friction rub is common, but pain is usually absent. Treatment with an anti-inflammatory agent and intensification of hemodialysis is usually adequate. Occasionally, tamponade occurs and pericardiocentesis is required. When uremic pericarditis is recurrent, persistent, or very troubling, pericardiectomy may be necessary. Pericarditis due to neoplastic diseases results from extension or invasion of metastatic tumors (most commonly carcinoma of the lung and breast, malignant melanoma, lymphoma, and leukemia) to the pericardium; pain, atrial arrhythmias, and tamponade are complications that occur occasionally. Mediastinal irradiation for neoplasm may cause acute pericarditis and/or chronic constrictive pericarditis after eradication of the tumor. Unusual causes of acute pericarditis include syphilis, fungal infection (histoplasmosis, blastomycosis, aspergillosis, and candidiasis), and parasitic infestation (amebiasis, toxoplasmosis, echinococcosis, trichinosis).
VI. THE DAILY NOTES
No complains, slept well at last night, respiration rate- 24/min., blood pressure- 90/60 mmhg. On auscultation of lungsvesicular breathing, Pericardial friction rub (abnormal heart sound) on auscultation, loud rhythmic, Pulce- 92/min. On pulpation of abdomen- soft, painless; urination without difficulty. Body temperature- 36.7°С.
No complains, slept well at last night, respiration rate- 25/min., blood pressure- 100/70 mmhg. On auscultation of lungsvesicular breathing, Pericardial friction rub (abnormal heart sound) on auscultation, loud rhythmic, Pulce- 92/min. On pulpation of abdomen- soft, painless; urination without difficulty. Body temperature- 36.6°С.
VII. Prognosis • For life (prognosis quoad vitam) – favourable; • For health (prognosis quoad valitudinem completat) –