1 / 12

PREZENTARE DE CAZ

PREZENTARE DE CAZ. BOALA DOWN. P.M. sex feminin,4 luni si 2 sapt. localitatea Berzunti, jud. Bacau M.I. – febra (39 º C) – dispnee cu polipnee – tuse productiva. A.H.C. – mama 14 ani – tata 21 ani, aparent sanatosi

kenyon
Download Presentation

PREZENTARE DE CAZ

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PREZENTARE DE CAZ • BOALA DOWN

  2. P.M. sex feminin,4 luni si 2 sapt. localitatea Berzunti, jud. Bacau • M.I. – febra (39 ºC) – dispnee cu polipnee – tuse productiva

  3. A.H.C. – mama 14 ani – tata 21 ani, aparent sanatosi • A.P.F. – I P, I G, sarcina fiziologica, nastere naturala, prezentatie craniana, Gn=2700g , T=?, Apgar (?) – icter fiziologic 5 zile, scadere fiziologica in greutate 200g (7,4%) – vaccinat conform schemei IOMC, ultima vaccinare pe 25.X.2006 (AP) – profilaxia rahitismului cu Vigantol 2 pic/zi – alimentat natural – 3 luni, de la 3 luni primeste banana cu biscuit. • A.P.P. – 3 luni 3 sap: Infectie respiratorie si obs. Boala Down • Istoricul bolii – Sugar de sex feminin, in varsta de 4 luni si 2 sap,distrofic, cu un episod de infectie respiratorie in antecedente, prezinta de aproximativ 5 zile febra, dispnee cu polipnee, tuse productiva, fiind spitalizat la Onesti. Simptomatologia accentuandu-se se transfera in clinica noastra pentru continuarea investigatiilor, diagnostic si tratament.

  4. Examenul clinic • Stare generala:influentata, febril (39ºC) • Talie: 58 cm Greutate: 4100g (normal=5950g) • Stare de nutritie:precara IP=0,71 • Stare de constienta: pastrata • Facies:aspect downian, fante mongoloide, hipertelorism • Tegumente:palide, elastice, cruste mielicerice la nivelul scalpului • Mucoase:congestie faringiana, depozite albicioase pe mucoasa bucala, secretie conjunctivala seroasa • Fanere: normal implantate • Tesut conjunctiv-adipos:slab reprezentat, Pca=1cm, Pct=0,5cm, pliuri adductori simetrice

  5. Examenul clinic • Sistem muscular:hipoton, normotrof, normokinetic • Sistem osteo-articular: aparent integru, mobilitate activa si pasiva normala, FA=2/1 cm, normotensiva, plagiocefalie • Aparat respirator: torace normal conformat, excursii costale simetrice, murmur vezicular aspru, raluri bronsice bilateral, dispnee cu polipnee, FR=62/min, tiraj subcostal si intercostal, stridor laringian • Aparat cardio-vascular: soc apexian sp IV ic stg, linia axilara anterioara, zg cardiace ritmice, suflu sistolic gr II/VI parasternal stg, AV=120/min • Aparat digestiv: cavitate bucala normal conformata, apetit prezent, abdomen destins, depresibil, tranzit intestinal fiziologic • Ficat: 1 cm sub rebord, splina nepalpabila

  6. Examenul clinic • Aparat uro-genital: mictiuni fiziologice, urini normocrome OGE normal conformate • SNC: fara semne de iritatie meningeana, retard psiho-motor, nu tine capul • Organe de simt: normal clinic

  7. Diagnostic prezumtiv clinic si anamnestic • Pneumonie interstitiala • Obs boala Down • Obs MCC • Distrofie gr. II • Stomatita albicans

  8. GA 10900/mm3 PN 50%, L 48%, E 2% Hb 10,9g/dl,Ht 31,9%, VEM =81,93, CHEM =34,3% HEM=pg Tr 449000/mm3 VSH 7mm/h CRP absent Fe seric in lucru TGP 22UI Uree 0,32 g‰ P 4,68mg% FA 588 U/l PT 59 g‰ Na 121,7 mmoli/l K 2,88 mmoli/l Sumar urina normal MFOP/CL absent Investigatii paraclinice

  9. Investigatii paraclinice • Ex genetic: • EKG: • Echocardiografie:FO permeabil (posibil DSA ostium sec.)  necesita ECHO Doppler. • Rg cardio-toracica:infiltratie interstitiala trabeculara arborizata in ambele hemitorace, pe fond de intens emfizem generalizat. Cord normal radiologic • Ex ORL:Rinofaringita acuta. Laringomalacie • Ex oftalmologic:hipetelorism, epicantus, conjunctivita catarala • Echografie abdominala: normala

  10. Diagnostic pozitiv • Pneumonie interstitiala • Obs boala Down • FO permeabil (obs. DSA) • Laringomalacie • Rinofaringita acuta • Stomatita albicans • Conjunctivita catarala • Anemie carentiala • Distrofie gr.II

  11. Tratament • Alimentatie mixta (san si lapte praf) • Penicilina G 400.000 UI/zi • Brofimen 5 pic X 3 ori/zi • Paracetamol sirop 2,5 ml X 3 ori/zi • DNF cu ser fiziologic • Fenobarbital 30 mg/zi • Badijonaj bucal cu Glicerina boraxata

  12. Evolutie • infectia respiratorie are evolutie favorabila sub tratament • prognosticul bolii Down este in functie de cariotip • Particularitatea cazului • Aparitia bolii Down la o mama foarte tanara • (14 ani) • Asocierea bolii Down cu malformatie cardiaca • Diagnosticarea bolii Down cu ocazia unei infectii respiratorii

More Related