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Department of pneumophthisiology - TB
Represented by :
GROUP :
Date :
Department of pneumophthisiology - TB
Represented by :
GROUP :
Date :
General Data :
i) Name : Arapu Vlad
ii) Sex :male .
iii) Age : 6 months .
iv)
V1)
Present Complains :
The patient complains from dry cough without hemoptysis from
11/01/2016, expectoration, fatigue, bad general state, and intermittent fever
38 degree . A little pain in the chest , loud breathing sounds , agitation , loss
of apetite
Objective examination:
i) General state : Good.
ii) Consciousness : Clear.
iii) Posture of patient : Active.
iv) Constitution : Asthenic.
v) Normal facial expressions.
vi) No local enlargements in the neck.
vii)
Respiratory System
Complains :
Dry cough without hemoptysis, a little pain in the chest.
Inspections :
i) thorax is cylindrical in shape without deformation
ii) Symmetrical right and left sides..
iii) Clavicles and the shoulder blades are at the same level.
Palpation :
i) Normal thorax elasticity .
ii) Normal chest size and shape.
iii) Warm, dry skin.
iv) No tender spots.
v) Symmetrical chest expansion.
vi) diminished vocal vibration
Percussion : NO CHANGES
Respiratory rate : 36/min
1. limit of pulmonary
right
left
a) anterior
b) posterior
Spinousus process C 7
Spinousus process C 7
2. Kronig area
5 cm
4 cm
Limit of inferior
pulmonary
right
left
a) parasternal
6 intercostal
b) medioclavicular
6 intercostal
apex
c) anterior axillary
7 intercostal
7 intercostal
d) medial axillary
8 intercostal
8 intercostal
e) posterior axillary
9 intercostal
9 intercostal
f) scapular
10 intercostal
10 intercostal
g) paravertebral
11 thoracic vertebra
11 thoracic vertebra
Mobility of pulmonary
base to the medial
axillary line
7 cm
6 cm
Auscultation :
Auscultation reveal : Dry rales.
Cardiovascular System
Complains :
Increased heart rate : 120 beats/min
Palpation :
i) Apex beat present in the fifth intercostals space , with the area of 1.5-2
cm and moderate height and power.
ii) No enlargement of the right ventricle.
Percussion :
i) Normal size , position , and shape of the heart .
ii) Normal length of the vascular bandle.
iii) Normal heart borders.
iv)
Heart configuration
Intercostals
Space
I
II
III
IV
V
Right
Left
Auscultation :
Regular rate and rhythm , Regular S1,S2 , No murmurs was heard , At the
following auscultation points:
i) The Mitral valve At the area of the apex beat.
ii) The Aortal In the second intercostals space , to the right of the sternum.
iii) The Pulmonary trunk In the second intercostals space , to the left of the
sternum.
iv) The Tricuspid valve At the lower part of the sternum , near its junction
with the xiphoid process.
v) Point of Erb At the left of the sternum between the 3rd and
4thintercostals space.
Digestive System
Complains :
No complains related to digestive System.
Inspection :
i) Normal symmetric form and volume of the abdomen.
ii) Normal colour of the abdomen.
iii) No signs of caput medusa was observed.
iv) No presence of surgical scars or other skin abnormalities.
Auscultation :
Frequently bowel sounds are heard in each of the nine regions of abdomen.
Palpation :
The spleen wasnt felt during palpation ( No enlargement of the spleen ).
Complains :
pulsation in the right costal margin and right upper quadrant not determined
Inspection :
Palpation :
Urinary System
Complains :
No complains related to Urinary System.
Endocrine System
The patient didnt complains about pain the level of the thyroid glands , and
no enlargement of the glands was observed
.
Nervous System
Complains
Consciousness :
the patient dosent shows any changes on the consciousness level , respond
to stimuli and speech ( absence of lethargy or coma ) .
Cranial Nerves examination :
absence of cranial nerves palsies sign .
Autism :
absence of autism , normal neural development for this age .
Cognitive development :
the normal cognitive development for this age , as the mother mentioned
is in the normal range .
Meningeal Sign :
Absence of Nuchal rigidity , Kernigs sign cannot be elected , Brudzinski
sign cannot be elected , so absence of meningitis
On x-ray examination was shown lung tissue of both lung in hilar region
Strengthened, enlargement of the hilum, more evident on the right side.
Microscopic examination performed on 05.08.2014 is negative (-). On
April another microscopic examination was performed and was also negative (-).
Gastric lavage test is also negative (-).
AFB, culture also negative (-)
Prelminary diagnosis :
Tb intrathoracic lymph node , progressive phase ( infiltration, dissemination )
New case : the pation didnt git any anti tb tretmanet at lest one month
Chest X-Ray :
Conclusion : intrathoracic Tb in the right
Differential Diagnosis
Asthma :
In asthma characterized wheezing , cough and
slight cyanosis , but in asthma there is no fever ,
and the exacerbation of asthma is related to
allergic exposure ( specially on spring season when
pollen is distributed ) , to make a decisive
diagnosis for asthma we use an spirometery , and
spirometery after -agonist inhalation .
Aspiration Of Foreign Body : for foreign body
aspiration it characteristics stridor on inspiration ,
and if its impact the right bronchus can lead to
wheezing , but its different from
bronchopneumonia that its exacerbates more
rapidly with moderate to severe cyanosis , and
episode of choking and heavy coughing , and in
some situation the parents evidence the aspiration
of the foreign body on the mouth of the child .
Croup (laryngotracheobronchitis) : in croup
with a mirror laryngoscopy we can observe that
there is edema , redness , and inflammation
and larynx and sub-glottic region , and in
addition to this with X-ray from lateral view we
can observe a steeple sign of narrowing of the
subglottic region , and patient will present with
stridor and barky cough that is different from
bronchopneumonia .
Clinical diagnosis :
Tb of intrathoracic lymph node , progressive phase ( infiltration, dissemination )
AFB negative. Nr.1615, from 02/06/14 new case
1) The patient should be provided with clean fresh air and a good healthy
environment.
2) Diet plan that provides the optimum conditions for the patient reaction to the
disease, rich in proteins, vitamins, fibres and minerals.
3) Administration of anti-TB drugs: (This baby is at 6 months 4200g we
prescribe formula 2HRZE S + 4 HR .)
1-Isoniazed: 150 mg in the morning
2-rifampcin: 150 mg in the morning