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

MOSCOW 2009

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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: In normal- Of patient-
Body height 80 cm. 83 cm.
Body weight 12.7 kg. 12 kg.
Circumference of 48 cm. 47 cm.
head

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Circumference of 52 cm. 56 cm.
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.
Respiratory system:
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 :
Lines Right Left
th
Midclavicular line 6 rib Lower border of left
lung along the
midclavicular line
remarkable away
from sternum at
height of 4th rib and
sharply goes down.
Mid-axillary line 8th rib 9th rib
Scapular line 9th -10th rib 10th rib
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Paravertebral line 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.

Circulatory organs:
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 normal- In patient-
Upper 3rd rib 3rd rib
Left Between left Between left
midclavicular line and midclavicular line and
parasternal line, parasternal line,
nearer to nearer to
midclavicular. midclavicular.
Right Left border of Left border of
sternum sternum

Borders of relative dullness of heart:

Borders: In normal- In patient-
Upper 2nd rib 2nd rib
Left 0.5-1 cm outside 1 cm outside from
from left left midclavicular
midclavicular line. line.
Right Right parasternal line Right parasternal line
Apex beat 1-2 cm outside from 1 cm outside from
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 left midclavicular line left midclavicular line
at 5th intercostal at 5th intercostal
space. 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.

Digestive organs:
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.

Urogenital system:
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.
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Meningeal symptoms: negative
Vaccinated according to age.

II. PLAN OF INVESTIGATION

1. Blood analysis:
Indicators: Normal 03-04-2009
RBC 3.8-5.8 x 4.65 x
1012/l 12
10 /l
WBC 3.5-10.0 x 6.50 x
109/l 9
10 /l
Hb 11-16 g/dl 13.1 g/dl
HCT 35-50 % 34.6 %
MCH 26.5-33.5 pg 28.1 pg
MCHC 31.5-35 g/dl 37.9 g/dl
Lymphocytes 17-48 % 65 %
Monocytes 4-10 % 6.3 %
Granulocytes 43-76 % 27.8 %
Platelet count 150-390 x 345 x 109/l
109/l
ESR 2-8 mm/h 4 mm/h
Assessment : lymphocytes are increased.

2. Urine analysis:
Indicators: 06-04-2009
Colour Light yellow
Transparency complete
Density 1016
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 Albumin absent
Epithelium 3-4
WBC 2-3
RBC absent
pH 8.0
Assessment: normal.

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) General blood analysis
(2) General urine analysis
(3) Echo Cardiography
(4) Echo Doppler cardiography
(5) Consultation with ENT doctor.

» Plan of treatment:
(1) Bed rest regime.
(2) Diet – hypoallergenic table N. 15
(3) Diclofenac sodium (Voltaren Oral) 12.5 mg, 3 times/day
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 (4) Ampicillin (anti-bacterial preparation) 300 mg/day
(5) Naftifine (anti-fungal preparation) 0.05 %, 2 drops, 3
times/day
(6) Anti-inflammatory preparation, Protargol (Argentum
proteinate) 2 % 3-4 drops upto 1 month.
(7) Suprastin (anti-histamine ) 1/3 tab., 2 times/day.

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
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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 T-
wave 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
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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).

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VI. THE DAILY NOTES
07/04/2009
• No complains, slept well at last night, respiration rate- 24/min.,
blood pressure- 90/60 mmhg. On auscultation of lungs-
vesicular 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.

08/04/2009

• No complains, slept well at last night, respiration rate- 25/min.,

blood pressure- 100/70 mmhg. On auscultation of lungs-
vesicular 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) –

favourable.

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