Boy of 9 years old has signs of acute respiratory disease – head ache, weakness, dry intensive cough, nasal congestion.
Posted: Fri May 06, 2022 9:27 am
Boy of 9 years old has signs of acute respiratory disease – head ache, weakness, dry intensive cough, nasal congestion. First two days of the disease was fever, but temperature decreased after the paracetamol input.
From the anamnesis vitae is known that boy was born from the 1 pregnancy, birth without pathology. Vaccination was made according to the table.
During the examination of the child the boy is the right stature, satisfied fat. Skin is clear, pale-rose. On the mucous membrane of pharynx intensive catarrhal changes, rhinorhaea. Frequent cough with excretion of small unfilmy phlegm of light color is saved. Lymphatic nodes are palpated under the jaws and at the facial neck surface - like small, painless, and elastic. During the auscultation breathing is harsh, diffused bilateral, single, bubbled, moist wheezes that disappear after the cough, diffused dry wheeze are heard. Breathing frequency is 32/min. During the percussion – pulmonary sound with box tone. Cordial tones are rhythmical, loud, moderate tachycardia. Abdomen is mild, painless. Liver and spleen are not enlarged. Physiological excrements are normal. Blood test: Hb – 120 g/l, Er – 3,2x1012/l, Leuc- 8,4x109/l, s – 2%, segm – 21%, e – 7%, Lymp – 63%, m – 6%, ESR – 14 mm/h.
Tasks.
Please, form the preliminary diagnosis.
Create plan of examination of the patient and interpret CBC
List main principles of therapy.
From the anamnesis vitae is known that boy was born from the 1 pregnancy, birth without pathology. Vaccination was made according to the table.
During the examination of the child the boy is the right stature, satisfied fat. Skin is clear, pale-rose. On the mucous membrane of pharynx intensive catarrhal changes, rhinorhaea. Frequent cough with excretion of small unfilmy phlegm of light color is saved. Lymphatic nodes are palpated under the jaws and at the facial neck surface - like small, painless, and elastic. During the auscultation breathing is harsh, diffused bilateral, single, bubbled, moist wheezes that disappear after the cough, diffused dry wheeze are heard. Breathing frequency is 32/min. During the percussion – pulmonary sound with box tone. Cordial tones are rhythmical, loud, moderate tachycardia. Abdomen is mild, painless. Liver and spleen are not enlarged. Physiological excrements are normal. Blood test: Hb – 120 g/l, Er – 3,2x1012/l, Leuc- 8,4x109/l, s – 2%, segm – 21%, e – 7%, Lymp – 63%, m – 6%, ESR – 14 mm/h.
Tasks.
Please, form the preliminary diagnosis.
Create plan of examination of the patient and interpret CBC
List main principles of therapy.