UNEVERSITATEA DE STAT DE MEDICINA SI

FARMACIE NICOLAE TESTEMITANU

DIN REPUBLICA MOLDOVA

Department of pneumophthisiology - TB

Represented by :
GROUP :
Date :

UNEVERSITATEA DE STAT DE MEDICINA SI

FARMACIE NICOLAE TESTEMITANU
DIN REPUBLICA MOLDOVA

Department of pneumophthisiology - TB

Represented by :
GROUP :
Date :

 General Data :
i) Name : Arapu Vlad
ii) Sex :male .
iii) Age : 6 months .
iv)

Date of birth : 26/09/2015

v) Occupation :Home stay .

vi) Address : Stefan Voda
vii)

V1)

Date of hospitalization : 15/01/2016

Defenetive diagnosis: intathoracic lymph node TB progressive phase

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

 History of present disease:

The patient started complaining from cough without hemoptysis, persistent

fever, fatigue, and pain in the chest (pleural involvement). And its detected
by an active way as contact with mother with MDR TB, performed mantoux
station revealing of induration of 10 ml , onset of disease was acute in
11.01.16 , in 24/12/2015 was performed chest X-ray and was revealed right
lung infiltration , was treated with augmantim from 24/12/2015 till
31/12/2015 , after that started with cefiruxime from 31/12/2015 and the
mother didnt buy the medications and in 11/01/2016 the condition of the
baby worsened , as I mentioned above he was in contact with his sick
mother and was hospitalized in his village (Stefan Voda) , detected there
some abnormalities in X-RAY , and was directed to TB hospital in
Chisinau . The baby was vaccinated 28/09/2015 scare of 2mm (not
qualitative) , and was born 8 months , 2800g weight , with big fontanels
about 1X1 CM

Epidemiological risk factor : contact with sick mother

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)

Normal skin colour .

viii) Normal elasticity , and humidity.

ix) Normal hair growth.
x) Normal subcutaneous fatty tissue .
xi) No signs of peripheral edema.
xii) Palpation of the lymph nodes : normal dimensions , and no pain
during the palpation.
xiii) Normal muscles and bones structure, absence of inflammation signs
in the joints

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.

iv) Supraclavicular fossa equal on both sides .

v) Asthenic chest

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

4 cm superior from the

clavicule

3 cm superior from the

clavicule

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

Inspection of the heart region :

i) Presence of the normal pulsation in the fifth intercostals space medially
of the left midclavicular line.

 Inspection of the peripheral vessels :

i) Normal carotid pulse , synchronous to the heart beat.
ii) Jugular pulsation , are hardly noticeable.
iii) No pathological phenomenon ( swollen arteries ,
pronounced pulsation , turgescent jugular veins , .. ).

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

Cardiac dullness is not detected

The vascular pedicle not exceed
the lateral border of the sternum
At a distance of 1 cm from the
right border of the sternum
At a distance of 0.5 cm from the
right edge of the sternum
At the right lateral border of the
sternum

Cardiac dullness is not detected

The vascular pedicle not exceed
the lateral border of the sternum
At a distance of 1.5 cm from the
left border of the sternum
2 cm from the lateral border of
the sternum
On the midclavicular line at the
point of the apex beat

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.

No signs of cardiovascular abnormalities or diseases.

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 ).

Liver and gallbader

Complains :

pulsation in the right costal margin and right upper quadrant not determined

Inspection :

Liver size after Curlov: between point 1 and 2 to 13 cm between point

3 and 4-9 cm between point 3 and 5 to 8 cm. Liver protrudes below
the costal margin with about 2 cm.

Palpation :

Liver + 2 cm, with a smooth surface, hard consistency,no pain.

Urinary System
Complains :
No complains related to Urinary System.

Inspection : ( Lumbar region )

i) No swelling regions was observed.
ii) Normal skin colour.

iii) No signs of Edema was observed.

Palpation : ( Kidney palpation)

The inferior pole of the right and left kidneys was palpated .

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

No complains related to nervous System.

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

Laboratory plan and instrumental exploration

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 (-)

.General Blood Analysis ( CBC )

*)Blood test analysis in general was in the normal range without
showing any pathologies.

.General Urine Analysis

*)Urine test analysis in general was in the normal range without showing
any pathologies.

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

.Treatment of the patient :

Anti-Biotics for treatment of tuberculosis
Streptomycin 1,2g/day in 3 divided doses I.M , For 14 Days .
Isoniazid 0,075g/day in 3 times for 14 days.
Pyrazinamide 0,7g/day in 3 times for 21 days.
Rifampicin 0,15g/day in 3 times for 14 days .

Plan of the treatment :

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

3-primazimed: 375 mg in the morning

4-streptomycin: 225 mg in the morning

2 months remain in intensive care in the hospital followed by ambulatory period

with taking isoniazed and rifampicin for 4 months and to be monitored with
bacterioscopy for 3 ,5, 6 months