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MaraHincu2

pediatric case

Health & Medicine

Caz Clinic Chirurgie
Pediatrica
STENOZA CONGENITALA HIPERTROFICA A PILORULUI

Date generale
 C.D., de sex masculin, in varsta de 1 luna (n. 24.09.2023)
 Domiciliu: jud. Botosani, loc. Catamaresti-Deal
 Data internarii: 30.10.2023.

Motivele internarii
 Varsaturi in jet, la distanta, dupa fiecare masa
 Scaun absent
 Simptomatologie debutata cu aproximativ 3 saptamani
anterior internarii

Antecedente heredo-colaterale
 Mama: 20 ani, aparent sanatoasa
 Tata: 40 ani, declarativ clinic sanatos
Neagă contactul cu alte persoane bolnave ce prezintă
simptomatologie de natură respiratorie, TBC.

Antecedente personale fiziologice
 Prenatale: primul copil, născut prin operatie cezariana, la 39
saptamani, sarcina dispensarizata.
 Natale: Gn=3700g, Apgar=9.
 Postnatale: alimentație naturala, vaccinat in maternitate,
efectueaza profilaxia rahitismului cu Vit D 2 pic/zi

Antecedente personale patologice
 Nesemnificative

Conditii de viata si de mediu
 Locuinta tip casa
 Mediu rural
 Fara animale de companie
 Nu este expus fumului de tigara

Istoricul bolii
 Sugar de sex masculin, in varsta de 1 luna, fara APP
semnificative, se interneaza prin transfer de la Spitalul
Botosani, unde s-a prezentat in regim de urgenta pentru
varsaturi in jet, simptomatologie ce a debutat in urma cu
aproximativ 3 saptamani anterior prezentarii.

Examen clinic (elemente patologice)
 tegumente palide, uscate, elasticitate uşor diminuată, pliu cutanat leneş.
 prezenţa undelor peristaltice gastrice amplificate postprandial, la percuţie
sau la palparea superficială a abdomenului în regiunea epigastrică şi
hipocondru drept; inconstant se palpează o formaţiune ovoidală, de
dimensiunea unei măsline, localizată supraombilical, la dreapta liniei
mediene, având o consistenţă fermă, mobilă la palpare.
 vărsături postprandiale zilnice
 tranzit intestinal încetinit, cu scaune rare, reduse cantitativ, dar explozive.

Ecografie abdominala-30.10.2023
 Examinare dificila, stomac mult destins cu continut lichidian
care nu se muleaza pe regiunea antro-pilorica. Regiunea
antrala/canal piloric cu aspect globulos, cu perete gros de
7,7mm a versantului anterior si de 6,3mm a versantului
posterior.

Ecocardiografie-31.10.2023
 FOP, fara semnificatie hemodinamica. Recomandari: Control
ecocardiografic peste 1 an.

Diagnostic pozitiv
 Stenoza hipertrofica de pilor
 Tulburari hidroelectrolitice

Alimentatie si tratament
 Se decide interventia chirurgicala. Protocol operator: In
data de 31.10.2023, sub anestezie generala s-a practicat
Piloromiotomie extramucoasa Fredet-Ramsted-Weber prin
fereastra ombilicala.

Evolutie
 Evolutia postoperatorie a fost favorabila, prezentand doar
un singur episod de varsatura postprocedural, ulterior cu
oprirea acestora.

Recomandari
 Igiena locala riguroasa
 Administrare de probiotic pentru disbioza intestinala
 Continua alimentatia la san, la cerere

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chirpedcazrezidentiat12345678912345.pptx

1. Caz Clinic Chirurgie Pediatrica STENOZA CONGENITALA HIPERTROFICA A PILORULUI

2. Date generale  C.D., de sex masculin, in varsta de 1 luna (n. 24.09.2023)  Domiciliu: jud. Botosani, loc. Catamaresti-Deal  Data internarii: 30.10.2023.

3. Motivele internarii  Varsaturi in jet, la distanta, dupa fiecare masa  Scaun absent  Simptomatologie debutata cu aproximativ 3 saptamani anterior internarii

4. Antecedente heredo-colaterale  Mama: 20 ani, aparent sanatoasa  Tata: 40 ani, declarativ clinic sanatos Neagă contactul cu alte persoane bolnave ce prezintă simptomatologie de natură respiratorie, TBC.

5. Antecedente personale fiziologice  Prenatale: primul copil, născut prin operatie cezariana, la 39 saptamani, sarcina dispensarizata.  Natale: Gn=3700g, Apgar=9.  Postnatale: alimentație naturala, vaccinat in maternitate, efectueaza profilaxia rahitismului cu Vit D 2 pic/zi

6. Antecedente personale patologice  Nesemnificative

7. Conditii de viata si de mediu  Locuinta tip casa  Mediu rural  Fara animale de companie  Nu este expus fumului de tigara

8. Istoricul bolii  Sugar de sex masculin, in varsta de 1 luna, fara APP semnificative, se interneaza prin transfer de la Spitalul Botosani, unde s-a prezentat in regim de urgenta pentru varsaturi in jet, simptomatologie ce a debutat in urma cu aproximativ 3 saptamani anterior prezentarii.

9. Examen clinic (elemente patologice)  tegumente palide, uscate, elasticitate uşor diminuată, pliu cutanat leneş.  prezenţa undelor peristaltice gastrice amplificate postprandial, la percuţie sau la palparea superficială a abdomenului în regiunea epigastrică şi hipocondru drept; inconstant se palpează o formaţiune ovoidală, de dimensiunea unei măsline, localizată supraombilical, la dreapta liniei mediene, având o consistenţă fermă, mobilă la palpare.  vărsături postprandiale zilnice  tranzit intestinal încetinit, cu scaune rare, reduse cantitativ, dar explozive.

10. Ecografie abdominala-30.10.2023  Examinare dificila, stomac mult destins cu continut lichidian care nu se muleaza pe regiunea antro-pilorica. Regiunea antrala/canal piloric cu aspect globulos, cu perete gros de 7,7mm a versantului anterior si de 6,3mm a versantului posterior.

11. Ecocardiografie-31.10.2023  FOP, fara semnificatie hemodinamica. Recomandari: Control ecocardiografic peste 1 an.

12. Diagnostic pozitiv  Stenoza hipertrofica de pilor  Tulburari hidroelectrolitice

13. Alimentatie si tratament  Se decide interventia chirurgicala. Protocol operator: In data de 31.10.2023, sub anestezie generala s-a practicat Piloromiotomie extramucoasa Fredet-Ramsted-Weber prin fereastra ombilicala.

14. Evolutie  Evolutia postoperatorie a fost favorabila, prezentand doar un singur episod de varsatura postprocedural, ulterior cu oprirea acestora.

15. Recomandari  Igiena locala riguroasa  Administrare de probiotic pentru disbioza intestinala  Continua alimentatia la san, la cerere

chirpedcazrezidentiat12345678912345.pptx

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chirpedcazrezidentiat12345678912345.pptx