Pediatrics E-Book

Michaela Kreckmann

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 687

Veröffentlichungsjahr: 2019

Beschreibung

Sharpen your diagnostic and problem-solving skills with these 85 selected pediatric teaching cases, fully detailed and illustrated

Going well beyond the purely theoretical, this collection of cases will help you simulate the thought process you would engage when working with real patients. Supplemented by excellent color photographs and radiologic images, diagnostic imaging studies, lab results, tables and schematics, and more, the book is packed with valuable information that will help clear your way to greater confidence in managing your pediatric patients.

Key Features:

• Great clinical relevance with emphasis on a case- and problem-oriented approach
• Suggestions for questions to ask in taking the history
• Answer section with detailed commentary on the individual cases
• Cases highlighting social pediatrics, adolescent psychiatry, and pediatric surgery
• Training in the use of diagnostic imaging
• Helpful as a supplement when preparing for board examinations

Kreckmann's Pediatrics: A Case Book will be a valuable companion for students and interns preparing for clinical rotations and for pediatric board examinations as well.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Pediatrics

A Case-Based Review

Michaela Kreckmann, MD

Private PracticeSaarbrücken, Germany

141 illustrations

ThiemeStuttgart • New York •Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 2nd German edition published and copyrighted 2008 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Fallbuch Paediatrie

Translator: Gertrude Champe, Surry, ME, USA

Names: Kreckmann, Michaela, author.

Title: Pediatrics : a case-based review / Michaela Kreckmann ; translator, Gertrude Champe.

Other titles: Fallbuch Phadiatrie. English

Description: Stuttgart; New York : Thieme, [2019] | “This book is an authorized translation of the 2nd German edition published and copyrighted 2008 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Fallbuch Paediatrie““Galley. | Includes index. |

Identifiers: LCCN 2019020002 (print) | LCCN 2019021658 (ebook) | ISBN 9783132053717 () | ISBN 9783132053618 (alk. paper) | ISBN 9783132053717 (e-ISBN)

Subjects: | MESH: Pediatrics | Diagnosis, Differential | Diagnostic Techniques and Procedures | Case Reports

Classification: LCC RJ50 (ebook) | LCC RJ50 (print) | NLM WS 100 | DDC 618.92/0075““dc23

LC record available at https://lccn.loc.gov/2019020002

© 2019 Georg Thieme Verlag KG

Thieme Publishers StuttgartRüdigerstrasse 14, 70469 Stuttgart, Germany+49 [0]711 8931 421, [email protected]

Thieme Publishers New York333 Seventh Avenue, New York, NY 10001, USA+1-800-782-3488, [email protected]

Thieme Publishers DelhiA-12, Second Floor, Sector-2, Noida-201301Uttar Pradesh, India+91 120 45 566 00, [email protected]

Thieme Publishers Rio, Thieme Publicações Ltda.Edifício Rodolpho de Paoli, 25⍛ andarAv. Nilo Peçanha, 50 – Sala 2508Rio de Janeiro 20020-906 Brasil+55 21 3172 2297 / [phone]

Cover design: Thieme Publishing GroupTypesetting by Thomson Digital, India

Printed in Germany by CPI Books                       5 4 3 2 1ISBN 978-3-13-205361-8

Also available as an e-book:eISBN 978-3-13-205371-7

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface

This casebook presents 85 disease patterns observed in daily pediatric practice. The intention is to make the preparation for examinations easier for the students. The descriptions of the medical histories and situations are as close as possible to clinical events as they have been encountered in the emergency department or reported by patients, parents, and nurses. Laboratory results, X-rays, and other diagnostic results are presented for analysis. This book explains the importance of why medical histories should be taken, diagnoses established, and treatment planned. In addition to everyday, easily diagnosed general pediatric and neonatal diseases, this book also presents misleading and easily misinterpreted symptoms that are intended to illustrate the special problems of pediatric diagnosis. Naturally, this book includes cases exemplifying classic emergency situations, which can be expected in everyday pediatric practice. Special problematic cases in social pediatrics and related fields are examined and discussed, such as pediatric surgery and child and adolescent psychiatry. The diagnosis and treatment described for such cases are based on the current guidelines of pediatrics associations and recommendations in the current specialized literature.

However, this book cannot and does not intend to replace a textbook. Rather, it is intended to encourage a critical approach to the, often dry, subject matter and to clarify and simplify problems by presenting them in a clinical context. It is also meant to help young colleagues in their first steps in clinical practice. For this purpose, it suggests simple and structured workflows for diagnosis and treatment and practical tips for interacting with little children, who are often frightened and uncooperative, and their parents. The student is trained to think and act like a doctor through case- and problem-oriented practice.

Last but not the least, this book would also like to show students the joy that work in pediatrics can bring, especially in light of the current public discussion of health policy. I myself have experienced most of these cases, or similar ones, as a resident in a hospital for children and adolescents in the Saarland, Germany. Every interested student and future colleague is warmly invited to take a look inside this book and enliven all the study of theory with a taste of clinical daily life.

This book would not have been possible without the help of many people. I owe a heartfelt thanks, first of all, to the children and parents who were willing to be photo models, and to Dr. Thomas Liebner, the head physician of the Clinic for Children and Adolescents in the Reinhard-Nieter Hospital, Wilhelmshaven, Germany, for his support and valuable advice. My thanks also to my colleagues for their encouragement and to the staff at Thieme Publishers, in particular Angelika-Marie Findgott, Joanne Stead, and Apoorva Gaurav Prabhuzantye, without whose active participation, constructive criticism, and persistent inquiries, this book would not have become what it is today. A lot of thanks to Gertrude Champe for her great translation. I also thank my family and all my friends for their patience, and especially my husband and children, who supported my work with thoughtful critiques and lovingly tolerated everything that they had to go through.

Michaela Kreckmann, MD

Table of Contents

By cases

Case

Description

1  

Six-year-old boy with high fever, vomiting, and headache

2  

Child with barking cough and dyspnea

3  

Child with high fever and seizure

4  

Apathetic infant with persistent skin folds

5  

Two-year-old girl with colic-like stomach pains and vomiting

6  

Twelve-month-old boy comes for a health screening

7  

Ten-year-old boy with painfully swollen knee

8  

Girl with petechial dermatorrhagie

9  

Infant with projectile vomiting

10

Young girl with recurrent shortness of breath

11

Fourteen-month-old toddler with “runny ear”

12

Three-year-old boy who has had contact with chicken pox

13

Five-year-old girl with a swollen jaw angle

14

Severely ill infant with cough and shortness of breath

15

Young girl with difficulty swallowing and fatigue

16

Two-year-old boy with coughing fit and cyanosis

17

Twelve-month-old boy with screaming fit and swollen testicles

18

Eight-year-old boy with macrohematuria

19

Boy almost 1-year-old with failure to thrive

20

Macrosomal newborn after obstructed labor with shoulder dystocia

21

Ten-year-old girl with fever and headache

22

Eight-year-old boy with high fever and rash

23

Five-year-old girl after fall from jungle gym

24

Infant with high fever, sucking weakness, and vomiting

25

Toddler burned by boiling water

26

Five-year-old girl with abdominal pain and anal itching

27

Fourteen-year-old girl with weight loss and social withdrawal

28

Newborn whose mother has poorly controlled diabetes mellitus

29

Five-year-old girl with hematuria

30

Three-year-old boy with numerous pigment spots

31

Feverish 2-year-old girl with pustulent crusty rash

32

Hypotrophic newborn with abnormal phenotype

33

Five-year-old boy with knee pain and protective limping

34

Ten-year-old boy with scleral icterus

35

Fifteen-month-old child with an abrasion and no tetanus vaccination

36

Fifteen-year-old girl found unconscious with hypothermia

37

Two-year-old child who has ingested an unknown fluid

38

Five-day-old newborn with icterus and sucking weakness

39

Three-year-old girl refusing to eat

40

Newborn with morphological abnormalities

41

Two siblings with itching and eczematous changes on the skin of the neck and head

42

Consultation regarding “sudden infant death syndrome” (SIDS)

43

Five-year-old boy with high fever and abdominal pain

44

Four-year-old boy with recurrent urinary tract infections

45

Seven-year-old boy with pneumonia and bone pain

46

Four-year-old boy with fever and exanthema

47

Four-year-old girl with facial swelling

48

Five-year-old girl with pale skin and splenomegaly

49

Seven-year-old girl with headaches and abnormal behavior

50

Four-year-old boy with pain in right lower abdomen

51

Three-year-old girl with protective posture of right arm

52

Ten-year-old boy with tingling paresthesia, speech disorder, and headache

53

Sixteen-month-old boy with undescended testis

54

Eight-year-old boy with abdominal pain and weight loss

55

Premature birth in the 28th week of pregnancy with shortness of breath and abdominal pain on pressure

56

Five-year-old boy with intense abdominal pain

57

Two-year-old boy with a high fever, rash, and swollen joints

58

Four-month-old screaming infant with inguinal swelling

59

Nineteen-month-old girl with bloody diarrhea, hematomas, and anuria

60

Newborn with persistent cyanosis

61

Four-year-old boy with rattling breath and hypersalivation

62

Six-year-old boy with failure to thrive and recurrent pulmonary infections

63

Fourteen-year-old girl who collapsed on a school trip

64

Three-year-old boy with deteriorating general condition and gastroenteritis

65

Healthy newborn delivered by cesarean section

66

Eleven-year-old boy with high fever and joint pain

67

Newborn boy with conspicuous genitals

68

Six-year-old girl with abnormal appearance

69

Premature baby with acute deterioration of general condition

70

Four-year-old girl with fatigue and difficulty concentrating

71

Exasperated parents with an 8-week-old screaming baby in the emergency department

72

Five-month-old infant with severe cough for the past few weeks

73

Fourteen-year-old girl with recurrent abdominal pain

74

Fifteen-year-old boy with no signs of progressing puberty

75

Two separate cases of infants following a fall from the changing table

76

Attention in the delivery room for newborns with congenital deformities

77

Newborn born in the 41st week of pregnancy after pathological CTG

78

Young boy with palpitations, reduced performance, and shortness of breath

79

Almost 2-year-old boy, with neurodermatitis

80

A young colleague during the pediatric admission examination

81

Five-month-old boy with therapy-resistant diarrhea

82

Thirteen-year-old school girl with petechiae in poor general condition

83

Fourteen-month-old boy with persistent nosebleed and hematomas

84

Uncontrollable 6-year-old boy with aggressive behavior

85

Twelve-year-old boy with painful swelling of the right foot

Appendix

Source of Images

Forms of juvenile idiopathic arthritis (JIA)

Childhood diseases

Body mass index

Important reference values

Index

Table of Contents

By topics

Development, Prevention, and Examination

Case 6

Case 35

Case 42

Case 68

Case 80

Nutrition and Eating Disorders

Case 71

Case 74

Genetics

Case 32

Case 40

Neonatology

Case 20

Case 28

Case 38

Case 55

Case 65

Case 69

Case 77

Metabolic Diseases and Water and Electrolyte Balance Disorders

Case 4

Case 54

Case 62

Infectious Diseases

Case 7

Case 12

Case 15

Case 22

Case 26

Case 31

Case 34

Case 39

Case 64

Case 66

Case 72

Case 82

Case 85

ENT and Respiratory Organ Diseases

Case 2

Case 10

Case 11

Case 13

Case 14

Case 21

Case 43

Case 61

Case 70

Cardiac and Circulatory Diseases

Case 60

Gastroenterology

Case 5

Case 9

Case 19

Case 50

Case 56

Case 58

Case 73

Case 76

Urogenital Diseases

Case 17

Case 18

Case 24

Case 44

Case 47

Case 53

Case 59

Case 67

Hematological and Oncological Diseases

Case 8

Case 29

Case 45

Case 48

Case 49

Case 81

Case 83

Rheumatological and Immunological Diseases

Case 46

Case 57

Diseases and Injuries of the Postural and Motor Apparatus

Case 33

Case 51

Skin Diseases

Case 41

Case 79

Neuropediatrics

Case 1

Case 3

Case 30

Case 52

Case 63

Accidents and Poisoning in Childhood

Case 16

Case 23

Case 25

Case 37

Case 75

Psychiatry for Children and Youths

Case 27

Case 36

Case 78

Case 84

Table of Contents

Answers and Comments

1  

Meningitis

2  

Krupp syndrome

3  

Febrile seizure

4  

Severe exsiccosis/toxicosis in acute gastroenteritis

5  

Invagination

6  

Health screenings and the health log

7  

Lyme borreliosis

8  

Schoenlein–Henoch purpura

9  

Hypertrophic pyloric stenosis

10

Bronchial asthma

11

Acute otitis media

12

Varicella (chicken pox)

13

Lymphadenitis colli

14

Bronchiolitis

15

Infectious mononucleosis

16

Foreign body aspiration

17

Testicular torsion

18

Post-streptococcal glomerulonephritis

19

Celiac disease

20

Injuries of birth trauma

21

Acute sinusitis

22

Childhood diseases: Scarlet fever, measles, mumps, pertussis

23

Cerebral concussion

24

Urosepsis/Urinary tract infection

25

Burns

26

Oxyuriasis

27

Anorexia nervosa

28

Diabetic (embryo-) fetopathy

29

Nephroblastoma (Wilms tumor)

30

Neurofibromatosis (von Recklinghausen disease)

31

Contagious impetigo in atopic dermatitis

32

Ullrich–Turner syndrome

33

Hip diseases in childhood

34

Hepatitis A

35

Immunizations

36

Alcohol intoxication and alcohol abuse

37

Intoxications

38

Neonatal icterus (Hyperbilirubinemia)

39

Gingivostomatitis herpetica (ulcerative)

40

Down syndrome (Trisomy 21)

41

Pediculosis capitis (Head lice)

42

Sudden infant death

43

Lobar pneumonia

44

Urinary tract infection and vesicoureterorenal reflux

45

Acute lymphatic leukemia

46

Kawasaki syndrome

47

Nephrotic syndrome

48

Spherocytosis (Hereditary spherical cell anemia)

49

Medulloblastoma

50

Acute appendicitis

51

Chassaignac’s paralysis

52

Migraine

53

Undescended testis

54

Diabetes mellitus Type I

55

Respiratory distress syndrome, retinopathy of prematurity, NEC

56

Constipation

57

Systemic juvenile chronic arthritis (Still syndrome)

58

Inguinal hernia

59

Hemolytic–uremic syndrome (HUS)

60

Congenital heart defect

61

Tonsillitis, peritonsillar abscess, rheumatic fever

62

Cystic fibrosis

63

Epileptic seizure

64

Salmonella enteritis

65

First care and first examination of a neonate

66

Influenza (the flu)

67

Hypospadia

68

Normal and pathological development of puberty

69

Bacterial infections of the neonate

70

Adenoid hyperplasia

71

Counseling of parents of screaming child, breastfeeding, and nutrition

72

Tuberculosis

73

Cardinal symptom abdominal pain

74

Overweight and obesity

75

Falling from the changing table (craniocerebral trauma, child abuse)

76

Omphalocele and laparoschisis

77

Neonatal diseases caused by pre-birth injuries

78

Somatization syndrome

79

Neurodermitis

80

Anomalies in pediatric examination; neonatal reflexes

81

Neuroblastoma

82

Meningococcal sepsis/Waterhouse–Friderichsen syndrome

83

Idiopathic thrombocytopenic purpura (ITP)

84

Attention deficit hyperactivity disorder (ADHD)

85

Acute hematogenous osteomyelitis

Cases

Case 1

1 Six-year-old boy with high fever, vomiting, and headache

A 6-year-old boy is presented to the emergency department as he has suddenly spiked a fever, between 39°C and 40°C since the day before, that could not be reduced with leg compresses and paracetamol. The boy is complaining of severe head and neck pain and has already vomited several times.

1.1 What do you look for in the clinical examination to explain the high fever, the head and neck pain, and the vomiting in particular?

Among other things, in the clinical examination you make the following observation (see Fig.).

1.2 Interpret the findings. What diagnosis do you suspect and what differential diagnoses can be considered?

1.3 What examinations do you perform to confirm the diagnosis?

1.4 Name the various forms of the disease and their causes.

1.5 Name typical cerebrospinal fluid findings by which the different forms can be distinguished.

Case 2

2 Child with barking cough and dyspnea

A 3-year-old girl awakes from sleep with a barking cough, inspiratory stridor, and dyspnea. The parents think that their child is suffocating and immediately bring the child to the emergency department. As you examine the pale and anxious girl. you notice a strong inspiratory (resting) stridor and marked inter- and subcostal retractions. The rectal temperature is 36.8°C.

2.1 What is your diagnosis? What important differential diagnosis are you considering?

2.2 Explain the etiology of the disease and define it for differential diagnosis.

2.3 Describe the different degrees of severity of the disease. What therapy is indicated for each?

Stage

Symptoms

Treatment

I

II

III

IV

Case 3

3 Child with high fever and seizure

Late evening a 3-year-old girl is brought into the emergency department, who has just been brought in by ambulance. The child appears tired but otherwise has adequate reactions. The rectal temperature is 39.8°C. The parents are very upset. After you have reassured them, they tell you that the child has been fretful all evening. While they were telling her a bedtime story the child suddenly rolled her eyes and her arms and legs twitched for 3 minutes. She also turned blue. Thinking that the child was about to die, they immediately called the ambulance. By the time the EMTs arrived, it had all passed. They informed that no medical measures were required.

3.1 What is your suspected diagnosis? What do you explain to the parents in order to reassure them?

3.2 What immediate measures should you undertake?

3.3 What diagnostic measures should be initiated?

3.4 There are two forms of this clinical picture. Explain them.

Case 4

4 Apathetic infant with persistent skin folds

Parents bring you their 6-month-old infant during the night shift. They report that since the day before, he has been suffering recurrent watery diarrhea and vomiting. In addition, he has a fever of up to 39°C. He is now apathetic, sleeps a lot, and neither eats nor drinks. The parents also noticed that since that night, his diaper has always been dry.

During the examination, you observe pale gray, mottled skin color and dry mucosa, dark circles under the eyes with infrequent blinking, and persistent skin folds (see Fig.). The fontanelle is depressed, pulse is 160 beats/min, blood pressure 80/50 mmHg, and weight 7,200 g. The parents say that in the previous week, the boy still weighed 8,200 g.

In a blood study, among other things, you find the following values: sodium 158 mmol/L, potassium 5.2 mmol/L, and hematocrit 46%.

4.1 What is your diagnosis?

4.2 Explain the different forms and degrees of severity of this clinical picture. What form, with what degree of severity, does the infant have?

4.3 What treatment do you initiate?

4.4 What must you pay attention to during the treatment?

Case 5

5 Two-year-old girl with colic-like stomach pains and vomiting

Three days ago, a 2-year-old girl became ill with symptoms of gastroenteritis, including diarrhea and vomiting. The symptoms improved on a low-fat diet. On the morning of admission, the girl again suffered an attack of vomiting. She screamed and hunched over with pain. Between the attacks, which were obviously painful, the child was rather quiet and seemed almost apathetic. In the admission examination, she appears pale. In the right, middle abdomen you palpate a cylindrical structure, painful on pressure. You then perform abdominal sonography and see the following findings in the right, middle abdomen (see Fig.).

Abdominal sonography, right, middle abdomen

5.1 What is your suspected diagnosis?

5.2 What further measures will you undertake?

5.3 What complications must you watch for?

Case 6

6 Twelve-month-old boy comes for a health screening

A 12-month-old boy born prematurely in the 29th week of pregnancy with a birth weight of 800 g, is brought for a health screening. It was determined in the previous screening that in spite of his premature birth, he developed quite well. However, there were a few deficits, especially in the motor area. For this reason, he was prescribed Vojta physiotherapy. The mother informed that she does not do the exercises at home because they make the boy cry, so, she agreed with the physiotherapist to continue the treatment by the Bobath method. During the conversation you notice that the boy is sitting on the floor and cheerfully playing with his older brother with the ball brought in from the waiting room.

6.1 What is the purpose of health screening? What is the health log?

6.2 Explain the usual course of a health screening.

The parents are principally interested to know whether the child has already made up for the delayed development caused by premature birth. When you ask, you are told that the boy has been able to sit for 4 weeks. His parents report that he can turn from his back to his stomach and vice versa and is making his first attempts at crawling. But when he does this he can only brace himself on his arms very briefly, as his arms are still quite weak. He forms chains of syllables like “wawawa” and understands speech well, i.e., he understands simple commands like “Give me the ball.” He knows his family perfectly well and shows fondness for them where until 4 weeks ago he showed stranger anxiety. His parents say that he examines his toys intently with his fingers and his eyes, puts them in his mouth, shakes objects and uses them to pound with, and throws the ball when he plays with his older brother.

6.3 How would you assess the boy’s developmental status?

6.4 What do you think about the fact that the mother does not perform the physiotherapeutic treatment as you prescribed?

Case 7

7 Ten-year-old boy with painfully swollen knee

A 10-year-old boy is brought to the emergency department because of pain and swelling of the right knee. There is no fever. The parents report that in preceding weeks, the boy complained repeatedly of joint and muscle pain in various locations; this was interpreted as “growing pains.” In addition, the mother describes a skin rash that spread in rings but then disappeared spontaneously. In the physical examination you also observe a little redness and swelling on the right earlobe (see Fig.).

7.1 What is the most likely clinical picture here? What is the name of the skin finding shown in the figure?

7.2 What further symptoms must be expected with this disease?

7.3 What treatment do you suggest for the patient?

Case 8

8 Girl with petechial dermatorrhagie

A 4-year-old girl fell ill 2 weeks ago with a febrile respiratory infection. Now she has been brought to the emergency department because of a new maculopapular rash with individual petechial dermatorrhagie (see Fig.). The petechiae are located primarily on the extensor side of the lower leg and on the buttocks. The little girl also complains of abdominal pain.

8.1 What is the most likely diagnosis?

8.2 Which differential diagnoses are you considering? Briefly characterize these diseases.

8.3 What treatment do you initiate?

Case 9

9 Infant with projectile vomiting

A 5-week-old boy has been projectile vomiting after every meal for the past few days. He is increasingly restless and can barely be soothed. The parents bring him to the pediatrician who refers him to you for admission with suspected hypertrophic pyloric stenosis. An ultrasound image in confirmation of his suspicion is also sent along (see Fig.).

9.1 Describe what you see on the ultrasound image in the figure.

9.2 Explain the pathogenesis.

9.3 List the typical symptoms.

9.4 What treatment do you suggest?

Case 10

10 Young girl with recurrent shortness of breath

A 14-year-old girl has been suffering for 2 years from shortness of breath in March and April. These symptoms occur primarily outdoors. Her primary physician has ordered an allergy test which showed significant reactions to the allergens of birches and hazel pollen as well as cat dander. Demand medication with a β2-sympathomimetic (metered dose aerosol) was initiated. The girl’s parents bring her to the emergency department of a hospital for children and adolescents because of shortness of breath and dry cough that has been increasing for the past 2 hours and is not improved by the medication. The admission examination reveals wheezing, from a distance, and on inspection massive thoracic retraction is found. Breath sounds are not audible over the lungs. The X-ray image shows the following finding (see Fig.).

Thoracic X-ray

10.1 Describe the thoracic X-ray result. What do you notice? What is your diagnosis?

10.2 Explain the pathogenesis of this disease.

10.3 What acute treatment do you initiate?

10.4 What long-term treatment would you consider useful?

Case 11

11 Fourteen-month-old toddler with “runny ear”

A 14-month-old boy, who has had a cold for a few days, is brought to the emergency department at night. The parents noticed a yellowish secretion running from the boy’s right ear. During the day the child was very restless and repeatedly clutched his right ear. Physical examination yields the following pathological findings: serous rhinitis, tragus pain right, swollen lymph node in jaw angle right, reddened tonsillar ring, temperature 39.5°C. The following abnormalities are seen with the otoscope (see Fig.).

11.1 Describe the otoscopic finding. What is your diagnosis?

11.2 List the most frequent causes of this disease.

11.3 What possible serious complications do you know of?

11.4 What therapeutic procedure would you consider useful here?

Case 12

12 Three-year-old boy who has had contact with chicken pox

A 3-year-old boy attends a kindergarten in which several cases of chicken pox have occurred in the past week. Fearing that their child could have become infected, the parents want to know what they should be looking out for.

12.1 Explain the typical symptoms of the disease to the parents.

12.2 In your opinion, how could the boy have become infected? When would you expect to see the first symptoms?

The parents are particularly concerned because the boy’s mother is pregnant (32nd week of pregnancy).

12.3 Are there any dangers to mother and child at this stage of pregnancy? Would you have to expect complications if the mother were in another stage of pregnancy?

12.4 Is there any possibility of inoculation?

Case 13

13 Five-year-old girl with a swollen jaw angle

A 5-year-old girl is brought to a pediatric hospital by her parents. She has severe swelling and redness in the right jaw angle that has increased massively since the day before (see Fig.). On examination, a unilateral lymphadenitis colli with incipient abscess and suppurative tonsillitis and a temperature of 38.9°C are diagnosed.

13.1 Name the possible causes of swollen neck lymph nodes.

13.2 What other studies do you order for this girl?

13.3 What treatment do you initiate?

In spite of 10 days of intravenous antibiosis, the local finding does not improve. On the contrary, the swelling has increased, and palpation reveals fluctuation.. The patient’s general condition is not impaired. Repeated ultrasound examinations of the neck show an increasing number of necrotic foci. With the parents’ agreement, the lymph node is excised in an ENT clinic. Microbiological examination of the abscess contents shows the following picture after staining (see Fig.).

Ziehl–Neelsen stain

13.4 What pathological finding can you determine? What treatments does this require?

Case 14

14 Severely ill infant with cough and shortness of breath

A 6-week-old infant has been suffering for 3 days from a cold, fever up to 38°C, and increasing dry cough. In the past few hours, the child became progressively worse. The child no longer drank, cried, clearly had severe shortness of breath, became increasingly pale, and seemed apathetic. At this point the parents called the emergency doctor. He immediately has the child transported to a pediatric clinic, with oxygen administration. The child is pale with nasal flaring, tachydyspnea, and massive thoracic retractions. On auscultation, bilaterally weakened breath sounds over the lungs and individual fine crackles and expiratory wheezing are heard.

14.1 What do you think causes these symptoms? What are your next steps?

You order a thoracic X-ray (see Fig.).

14.2 What is your diagnosis on the basis of the thoracic X-ray and the medical history? Describe the radiological changes typical for this clinical picture.

14.3 List the most frequent pathogens of this disease.

14.4 What therapeutic possibilities are available?

Case 15

15 Young girl with difficulty swallowing and fatigue

A 15-year-old girl has had increasing throat pain for the past few days, difficulty swallowing, fatigue, exhaustion, and fever between 39°C and 40°C. She shows up with her mother during the day.

The girl reports a feeling of pressure, primarily in the right upper abdomen. The mother also reports a fine to moderately spotty skin rash on the day before that has now faded.

15.1 What is your suspected diagnosis?

15.2 With your suspected diagnosis, what examination findings do you expect?

15.3 List the most frequent causes of this disease.

15.4 What advice do you give the patient? When will the symptoms improve?

Case 16

16 Two-year-old boy with coughing fit and cyanosis

A 2-year-old boy playing alone in his playroom suddenly experiences a severe cough. When the mother comes in, the child is gasping for air and his face is reddish-blue. The mother suspects that the child has choked on something and tries to extract the foreign body by positioning the boy with his head down and pounding on his back. The cough improves but no foreign body appears.

The mother then takes the child to the emergency department of a nearby hospital.

16.1 What typical clinical symptoms and examination results do you expect if this is really a foreign body aspiration?

16.2 You order a thoracic X-ray (see Fig.). Describe the abnormalities.

Thoracic X-ray in expiration

16.3 What treatment do you initiate if this is really an aspiration?

Case 17

17 Twelve-month-old boy with screaming fit and swollen testicles

A 12-month-old boy is brought into the emergency department by his parents because for the past 2 hours, he has been crying without interruption and cannot be soothed. As he was changing the diaper, the father noticed redness and swelling of the scrotum. There is no fever. Examination reveals that the scrotum is reddish-livid in color. The right testicle is painful and coarsely swollen (see Fig.).

17.1 What is your suspected diagnosis? What differential diagnoses can be considered?

17.2 How do you confirm the diagnosis?

17.3 What are your next steps?

Case 18

18 Eight-year-old boy with macrohematuria

An 8-year-old boy’s primary physician admits him to a pediatric hospital because of macrohematuria that has been present for 2 days. Physical examination reveals no abnormalities except a very high blood pressure (140/90 mmHg). The spontaneous urine is, in fact, stained red. The parents report a purulent tonsil infection 3 weeks ago which was treated for 10 days with penicillin.

18.1 What causes of macrohematuria do you know? What other causes are there for “red urine”?

18.2 What is your suspected diagnosis?

18.3 What is your diagnostic procedure?

18.4 How do you treat the boy?

Case 19

19 Boy almost 1-year-old with failure to thrive

An 11-month-old boy (see Fig.) is brought for health screening. The mother reports that the boy has been in an increasingly bad mood and cries a lot. She complains that there’s not a thing she can do with him. Other mothers in the play group have noticed this.

What is more, he does not want to eat enough but nevertheless he produces voluminous, sour-smelling loose stools several times a day. Among other things, his body length and weight are measured, and the values are recorded in percentile curves (see Fig. percentile curves).

Eleven-month-old boy

Percentile curves

19.1 What is the purpose of percentile curves? What are somatograms? What important information do they provide?

19.2 What information do you derive from the percentile curves of the 11-month-old boy?

19.3 What is your suspected diagnosis on the basis of the medical history, the growth and weight development, and the external appearance of the boy? What differential diagnosis must you consider?

19.4 With your suspected diagnosis on physical examination, what further findings do you expect?

19.5 How do you confirm your suspected diagnosis?

Case 20

20 Macrosomal newborn after obstructed labor with shoulder dystocia

A few-minutes-old macrosomal newborn (birth weight 4,050 g) is presented for newborn examination. The child was delivered by vacuum extraction because of obstructed labor with shoulder dystocia. Physical examination reveals a soft high-parietal swelling on the right side of the head and a ring-shaped scrape on the skin of the head. The newborn does not move its right arm (see Fig.)

20.1 What could the soft swelling on the head be? Name a typical differential diagnosis and distinguish the two clinical pictures from each other.

20.2 What is the most probable cause of the position of this newborn’s arm?

20.3 List additional birth injuries.

Case 21

21 Ten-year-old girl with fever and headache

A 10-year-old girl has had a cold and cough for a week. She was already recovering when she suddenly developed a high fever. Now she is also complaining of severe frontal headaches that are always particularly intense when she bends her head forward.

21.1 What is your suspected diagnosis?

21.2 What additional symptoms found on physical examination would confirm your suspected diagnosis?

21.3 List the most frequent causes of this disease.

21.4 What do you do next?

Case 22

22 Eight-year-old boy with high fever and rash

An 8-year-old boy visits his aunt on the weekend. After going on a bicycle ride with her, he suddenly no longer feels well and complains of a scratchy throat. Thereupon, the aunt takes his temperature. The boy’s temperature is 39.8°C, so she treats her nephew’s symptoms with paracetamol. The next day, the temperature is 38.9°C. The aunt now notices a skin rash all over the boy’s body. She is concerned and immediately takes her nephew to the emergency department, suspecting that this is definitely “measles or mumps.” Examination yields an exanthema with fine, slightly raised spots (see Fig.), red oral mucosa, and red tonsils.

22.1 What is your suspected diagnosis? What are the grounds for this? Describe typical symptoms, incubation period, and treatment of the disease.

22.2 The aunt suspects “measles.” What are the characteristic symptoms of measles?

22.3 Why can the disease not be mumps? Name the most important symptoms, incubation period, and treatment of mumps.

22.4 An additional children’s disease is whooping cough. What are the clinical symptoms of whooping cough? How long is the incubation time? How would you proceed with treatment?

Case 23

23 Five-year-old girl after fall from jungle gym

While playing at a playground, a 5-year-old girl fell on her back from a jungle gym, from a height of 1.80 m onto sandy ground. The mother found the child unconscious, lying on her back. A little laceration on the back of her head was bleeding. A short while later, the little girl regained consciousness but couldn’t remember anything.

On the way to the hospital, she vomited several times. During her examination, the girl gives the impression of being tired but otherwise reacts appropriately. The retrograde amnesia persists. There are no abnormal findings except for the occipital laceration and a scrape on the left shoulder. There are also no abnormalities in the neurological examination.

23.1 What is your diagnosis? What are the grounds for your decision?

23.2 What further measures do you undertake?

23.3 List possible complications.

Case 24

24 Infant with high fever, sucking weakness, and vomiting

A 5-month-old male infant is brought to the hospital outpatient department. He is acutely ill with a high fever, vomits occasionally, and has increasing difficulty nursing. The parents also report that his diapers have been dry for the past 12 hours. He appears to be very sick.

The skin is pale and blotchy, the extremities are cold and the trunk is feverishly hot. The rectally measured body temperature is 39.6°C. When he is touched, he cries pitifully, but otherwise is limp and apathetic. On examination you cannot find a reason for the fever. You order blood and urine studies. The following pathological blood values are found: leukocytes16,400/μL with marked left shift, CRP 95 mg/L, sed rate 90/145, creatinine 78 μmol/L, urea 8.6 mmol/L. Urinstix (bag urine) read: leukocytes +++, erythrocytes ++, nitrite +, protein +. Microscopic examination of the urine sediment shows the following picture (see Fig.). You admit the child.

Microscopic examination of urine

24.1 Give the grounds for your decision to admit the child. What do you suspect?

24.2 How do you confirm the diagnosis?

24.3 List the most frequent causes of this disease.

24.4 What treatment do you initiate? Are any additional measures required?

Case 25

25 Toddler burned by boiling water

A 2-year-old girl has had a cold for a few days. The mother inhales with the child over a bowl of steaming water. In an unguarded moment, the girl pulls the bowl off the table and the hot water poured over the child’s left arm, abdomen, and left thigh (see Fig.). The helpless mother immediately brings the loudly crying child to the clinic.

25.1 What should the mother have done immediately? What are the first-aid measures?

25.2 Determine the extent of the burns this child has suffered. Why is it important to determine the extent?

25.3 What do you do next?

25.4 What degrees of burn severity do you know?

Case 26

26 Five-year-old girl with abdominal pain and anal itching

A 5-year-old girl is brought to you at night in the emergency department with abdominal pain. Palpation and auscultation of the abdomen reveal no abnormal findings. When the anal region is inspected, traces of scratches are found but there is no indication of eczema-like or inflammatory changes. The child tells that her “bottom itches so badly.”

The status of other organs shows no other abnormalities.

26.1 What is your suspected diagnosis?

26.2 How do you confirm the diagnosis?

26.3 Explain the path of infection to the parents.

26.4 What treatment do you initiate?

Case 27

27 Fourteen-year-old girl with weight loss and social withdrawal

A 14-year-old girl (see Fig.) has had an intended weight loss of 16 kg in the past year. Her body weight now is only 40 kg with a height of 160 cm. She says that she started her “diet” because at school they called her “fatty.” All her girlfriends have “model figures.” Even now, she feels too fat. Her parents observed increasing social withdrawal and the girl doesn’t take part in family meals anymore. She would rather prepare “healthy” low-calorie food for herself (for instance, half apple or one carrot for breakfast, one low-fat yogurt for lunch, salad for supper).

The mother suspects that her daughter also secretly forces herself to vomit. Moreover, the girl works out several times a day on the family’s home exercise machine. The rather hefty mother reports that she “simply can’t get through to her daughter anymore.” There is no conversation; the daughter thinks that everything is an attack on her “healthy” lifestyle.

27.1 What is your suspected diagnosis?

27.2 List the most important diagnostic criteria.

27.3 List causes of this disease.

27.4 What do you do next?

Case 28

28 Newborn whose mother has poorly controlled diabetes mellitus

A colleague in gynecology brings you a 3-hours-old newborn male, born by natural delivery, of a 32-year-old, poorly balanced Type 1 diabetic (HbA1C 7.5%) mother, for consultation.

The child’s birth weight was 4,680 g, body length 58 cm, head circumference 38 cm, APGAR 8/9/9, navel artery pH 7.20. The postpartum blood sugar checks in the delivery room were 48 mg/dL (2.6 mmol/L) after 30 minutes and 45 mg/dL (2.5 mmol/L) after 1 hour.

In the nursery, the boy exhibited expiratory grunting, tachypnea, and acrocyanosis. The blood tests showed these values among others: blood sugar 32 mg/dL (1.8 mmol/L); serum calcium 1.7 mmol/L; capillary blood gas: pH 7.23, pCO2 58 mmHg, pO2 46 mmHg, HCO3− 22 mmol/L; peripheral oxygen saturation 90%.

28.1 What clinical picture are you considering? Explain the pathogenesis of the child’s clinical picture.

28.2 What symptoms can generally be expected in newborns with this clinical picture?

28.3 What measures do you undertake? As consultant, what do you recommend to your colleague in gynecology?

28.4 What prophylactic measures are recommended to women with Type 1 diabetes during pregnancy? What are the grounds for this?

Case 29

29 Five-year-old girl with hematuria

A 5-year-old girl is brought to the emergency department by her parents because of intense abdominal pain, burning sensation during urination, and blood in the urine. The child was examined by a physician, who diagnosed urethritis and initiated symptomatic treatment as well as antibiosis with Cefaclor. The complaints disappeared with this treatment, but there is still blood in the urine.

The parents inform that the girl has often been tired and listless in recent days. In the physical examination, you observe that the girl’s skin is pale. In palpating the abdomen, you feel a structure the size of a chicken egg in the right upper abdomen. Spleen and liver are not enlarged; the lymph nodes are not palpable. In the laboratory results, among other things, the following values are found: leukocytes 9,500/μL, Hb 8.3 g/dL, hematocrit 25%, thrombocytes 320,000/μL, CRP negative, sed rate 98/144; urine: leukocytes/erythrocytes/protein positive, and nitrite negative.

Abdominal sonography shows the following findings in the right upper abdomen (see Fig.).

Longitudinal section in right flank

29.1 Describe the sonography result. What is your suspected diagnosis? What differential diagnosis must you consider?

29.2 How do you proceed?

29.3 What do you know about the prognosis for the disease you suspect?

Case 30

30 Three-year-old boy with numerous pigment spots

A 3-year-old boy is brought to the clinic because while he was playing, a swing crashed into his head. The mother was concerned because of a large lump on the boy’s forehead. The boy did not lose consciousness, did not vomit, or behave abnormally. The neurological examination is normal. Physical inspection showed about 12 large, brownish pigment spots of varying sizes (see Fig.) distributed over the whole body.

30.1 What is your suspected diagnosis regarding the skin changes?

30.2 What further clinical abnormalities/changes can be associated with this disease?

30.3 Which classification of this disease do you know of?

30.4 List other diseases in the same spectrum and give their characteristic symptoms.

30.5 The boy was brought in because of a blow to the head. What diagnostic and therapeutic procedures do you initiate?

Case 31

31 Feverish 2-year-old girl with pustulent crusty rash

A 2-year-old girl has had atopic dermatitis since she was 6 months old. For the past few days, she has had pustulent, crusty, itching skin changes with a honey-colored crust, especially in her face (see Fig.) and the crooks of her arms. They now appear to be distributed over her whole body. Since the day before, the girl has had a fever up to 39°C. Her general condition is reduced.

Her brother, who is 2 years older, has similar perioral crusty skin changes.

31.1 What is your suspected diagnosis?

31.2 What triggers the disease?

31.3 List one complication of the disease.

31.4 What treatment do you initiate?

Case 32

32 Hypotrophic newborn with abnormal phenotype

A 3-day-old little girl is examined in the nursery. This is the first child of a 30-year-old woman, born at term. The child’s birth weight was 2,550 g, body length 44 cm, head circumference 32 cm, APGAR 9/10/10, umbilical cord pH 7.28. The physical examination revealed the following anomalies: gothic palate, wide spacing between nipples, webbed neck, low hairline at the nape of the neck, and changes in the hands (see Fig.).

32.1 Which clinical picture do these symptoms suggest?

32.2 What other abnormalities do you expect?

32.3 How do you confirm the diagnosis?

32.4 What do you tell the parents about the course and prognosis of the disease? What therapy does the diagnosis call for?

Case 33

33 Five-year-old boy with knee pain and protective limping

A 5-year-old boy has been complaining of pain in his right knee since the day before. The pain has gotten so intense that he can hardly walk. There is no fever. Anamnestically, he had a respiratory infection a week earlier and also has a distinct protective limping on the right side. Examination shows painful limitation of movement in the right hip joint. The joint is neither warm and swollen, nor red. All other joints, including the right knee joint, are freely movable. Ultrasound examination of the hip joint shows that compared to the other side, the intra-articular space is widened (see Fig.).

Sonographic longitudinal section of the proximal femur in the area of the femur neck

33.1 What is your diagnosis? Justify your decision.

33.2 Explain the clinical picture of Perthes disease.

33.3 What do you know about slipped capital femoral epiphysis?

Case 34

34 Ten-year-old boy with scleral icterus

During vacation, a 10-year-old boy went camping with his family at a popular camp site that is no longer maintained daily by park rangers. The family has been home for 3 weeks. For the past few days, he has been complaining of upper abdominal pain, nausea, and lack of appetite. He feels listless and tired and has a slight fever (38.4°C). Since the day before, the mother has noticed yellowing of the sclera and so the boy is brought to the emergency department.

34.1 What diseases can be considered? What is the most likely diagnosis?

34.2 What diagnostic procedures do you order to confirm your suspected diagnosis? What findings would you expect?

34.3 Name additional clinical signs you would find if your suspected diagnosis is confirmed.

34.4 What do you know about the infectious pathway and incubation time of the disease? When may the boy return to school?

34.5 Do cases of this disease have to be reported?

Case 35

35 Fifteen-month-old child with an abrasion and no tetanus vaccination

A 15-month-old child gets a scrape wound while playing on the playground. The wound is very soiled with earth. The child is brought to the emergency department. The parents, who up to now have refused all vaccinations for the child, are worried now and request an anti-tetanus vaccination.

35.1 What are your first steps?

The medical history reveals that the child has a cold at the moment. “… and actually, when someone has a cough and a cold, it’s not right to give a vaccination,” the parents inform.

35.2 Are the parents right? Name the general contraindications for vaccination.

The parents continue to be concerned that their child could suffer adverse effects from the vaccination. They have heard that there can be brain damage.

35.3 What is meant by the adverse effects of vaccination? What is your reaction to the parents’ assertion? What reactions to vaccination can the parents expect?

You have answered the parents’ questions and informed them. The parents give their permission.

35.4 Must the parents’ permission be recorded in writing? How do you proceed in vaccinating the child?

35.5 According to the recommendations of the United States Centers for Disease Control and Prevention (CDC), a 15-month-old child has normally already received various immunizations. What are they? List the ages at which these immunizations are normally given.

Case 36

36 Fifteen-year-old girl found unconscious with hypothermia

EMTs bring in a 15-year-old girl in the early morning hours to the emergency department of a pediatric clinic. She was found unconscious in the city park by passers-by. She was lying in vomit and her clothes were completely wet. Using the personal data on a student ID that the girl was carrying, it was possible to inform the parents. The girl was invited on the evening before to a going away party for a classmate.

Examination reveals the following: unconscious patient, defense response to painful stimulus, no external signs of injury, distinct smell of alcohol, symmetrical proprioceptive reflexes, no pathological reflexes, pupils moderately large, prompt light reaction, auscultation of heart and lungs as well as abdominal palpation normal, blood pressure 100/70 mmHg, heart rate 60/min, body temperature (rectal) 35.1°C, and blood sugar 63 mg/dL (3.5 mmol/L).

36.1 What is your suspected diagnosis?

36.2 What acute measures do you initiate?

36.3 What do you do next?

Case 37

37 Two-year-old child who has ingested an unknown fluid

In your pediatric emergency department, you receive a phone call from an agitated father. His 2-year-old daughter was unattended for only a short time and during that time she swallowed almost all of a bottle of “some kind of medicine, he wasn’t quite sure what it was.”

37.1 The father asks you what he should do now. What additional information do you ask for on the telephone and what advice do you give the father?

About 45 minutes after the call, the father comes to the clinic’s emergency department with his daughter. He has brought the almost-empty bottle along (see Fig.). The father informs that the bottle hadn’t been quite full (5 mL syrup containing 200 mg paracetamol and 2.275 g sorbitol). The child weighs 11 kg. The little girl does not seem impaired; she is playing cheerfully with the teddy bear she brought along. The child’s face and hands are still completely sticky with the syrup and there are also traces of the medicine on her T-shirt. Physical examination shows no abnormalities.

37.2 Approximately how much of the active agent has the little girl consumed? How do you estimate the toxicity of the active agent consumed?

37.3 What symptoms must you expect with paracetamol poisoning?

37.4 What measures do you initiate?

37.5 Give your reasons for the preferred use of activated charcoal for primary elimination of the poison. However, for what kinds of poisoning is activated charcoal without effect or contraindicated?

Case 38

38 Five-day-old newborn with icterus and sucking weakness

A 5-day-old newborn whose parents observed her yellow skin color and sucking weakness is brought to the pediatric clinic. The little girl is the second child of a healthy mother and is exclusively breastfed. The pregnancy was unremarkable and the outpatient birth was without complications. The birth weight was 2,980 g, body length 49 cm, head circumference 35 cm, APGAR 9/10/10, and navel artery pH 7.26. The mother’s blood group is O Rh positive.

Examination shows the child’s icteric skin color and scleral icterus. Moreover, the child appears listless and tired. The rest of the examination results are normal. In particular, you do not palpate hepatomegaly. Weight 2,780 g, temperature 36.8°C. The laboratory analysis of the child’s blood shows the following values (see Fig.):

Laboratory

38.1 What is your suspected diagnosis?

38.2 Explain the causes of the clinical picture to the worried parents.

38.3 What do you do next? What are the possible complications if the clinical course is unfavorable?

Case 39

39 Three-year-old girl refusing to eat

A 3-year-old girl is brought to you because of a very high fever. Moreover, she has been refusing to eat for 2 days, hardly drinks anything, and salivates profusely. Examination shows that the child is in impaired general condition, with decreased skin turgor and rings around her eyes. She has foul breath. On the mucosa of mouth and tongue, there are multiple white-coated bubbles and ulcerations; the gums seem swollen and they are bleeding in spots (see Fig.). You palpate painfully swollen cervical lymph nodes.

39.1 What is your suspected diagnosis?

39.2 Explain the etiology of the disease.

39.3 What further measures do you initiate?

39.4 The little girl’s brother is 3 weeks old. The worried mother would like to know whether there is any danger for the little boy.

Case 40

40 Newborn with morphological abnormalities

While on night duty, you are called into the delivery room, where a little girl has just been born. The obstetrician has observed morphological abnormalities in the child.

On inspecting the newborn, you observe the following abnormalities: The eyelid axis slants upward toward the temple, there is a sickle-shaped skin fold at the inner, upper edge of the eyelid that extends to the lower lid and covers the nasal lid commissure. Excess skin at the nape, short, plump hands and feet, single transverse palmar crease on both sides, sandal gap (see Fig.).

40.1 What is your suspected diagnosis? What other typical symptoms or findings do you look for?

40.2 What is at the basis of the clinical picture?

40.3 What do you know about the prognosis for this disease?

Case 41

41 Two siblings with itching and eczematous changes on the skin of the neck and head

The mother of a 5-year-old boy notices that her son has been constantly scratching his neck and head for the past few days. She inspects the skin of his head and finds scratch marks and also eczematous skin changes, particularly behind the ears and on the neck. The mother also finds similar but milder changes in the skin of the older sister’s head. The girl also complains of itching. The mother brings the children to the emergency department. Examination of the boy reveals the following changes on his head (see Fig.).

41.1 What is your suspected diagnosis?

41.2 How can you confirm the diagnosis?

41.3 What treatment do you initiate?

41.4 What additional recommendations do you give the family?

Case 42

42 Consultation regarding “sudden infant death syndrome” (SIDS)

In the newborn nursery, you are caring for a little girl whose brother died because of sudden infant death syndrome at the age of 8 months. The parents of the newborn are very scared that they will suffer the same fate again.

42.1 What is meant by “sudden infant death?” What does the acronym “SIDS” stand for?

42.2 How is the risk for this newborn of sudden infant death assessed? What do you explain to the parents?

42.3 What diagnostic or treatment consequences result for the newborn?

42.4 What do you recommend to the parents in order to decrease the risk of sudden infant death?

Case 43

43 Five-year-old boy with high fever and abdominal pain

A 5-year-old boy is presented to the emergency department with a high fever and intense stomach pain. The complaint began 2 days earlier and the boy got progressively worse. He coughed and vomited repeatedly and hardly ate or drank. Examination of the boy reveals the following findings (see Fig. for admission findings). The laboratory findings are as follows: leukocytes 27,800/μL, Hb 10.6 g/dL, hematocrit 32%, thrombocytes 370,000/μL, sodium 132 mmol/l, potassium 4.6 mmol/L, creatinine 1.0 mg/dL, GOT 12 U/L, GPT 8 U/L, γ-GT 20 U/L, CRP 38 mg/dL, and sed rate 180 mm in the first hour.

43.1 What possible diseases are you considering? What studies do you order to arrive at a diagnosis?

Among other things, you ordered a thoracic X-ray (see Fig.).

Thoracic X-ray

43.2 Describe what you see on the survey radiograph of the thorax. What is your diagnosis on the basis of the medical history, clinical picture, and diagnostic findings?

43.3 What pathogens do you suspect in the child? Which pathogens are quite commonly typical for the disease at this age? Which pathogens do you expect in newborns or school children?

43.4 Name additional forms of this disease. Which pathogens do you expect in these forms?

43.5 What treatment do you initiate?

Case 44

44 Four-year-old boy with recurrent urinary tract infections

A doctor in private practice refers a 4-year-old boy for admission because of an acute urinary tract infection. The boy has been sick with a high fever and abdominal pain since the day before. The examination in the doctor’s office revealed leukocytes and erythrocytes in the urine. Nitrite was positive. In the past 2 years, the boy had been treated with antibiotics three times for urinary tract infections.