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PERSONAL HISTORY Name: Ceban Doina 2. Age: 9 years 3. Date of birth: 9.10.1999 4. Sex: Female 5. Occupation: pupil 6. Habits: a. Smoking: no b. Drugs: no c. Alcohol: no 7. Date of hospitalization: 29.01.09 8. Allergic anamnesis: no 9. Marital status and residence: single. She lives with her parents and a sister in Chisinau. In an apartment with 2 rooms. Her father doesnt work, and her mother works in comfort. 10. Complains: no complains besides cough. There is no pain.
1.

PRESENT HISTORY The only symptom present is cough. At the beginning it was a dry cough, but after some time it was moist with sputum. The cough firstly began 1 month 23 weeks ago. The duration of cough is about 2-3 weeks. When she started coughing she went to doctor, which prescribed antitussive drugs for her. Unfortunately, the medications didnt help and she made a chest X-ray. The X-ray showed that the patient may be infected with TB. Since then, she was hospitalized and given drugs 2 times/day. PAST HISTORY In the past when the patient was 3 and half years old she had pneumonia. FAMILY HISTORY None of the family members caries a disease.

EXAMINATION 1. General examination: a. Body built and weight:

b. c.

Complexion (color of skin of face): normal skin color. Consciousness: clear

2. Face: Color of the sclera: blue sclera. b. Examination of lips and teeth:
a. 3.

Palpation of lymph nodes: Enlargement of lymph nodes (retro auricular, sub occipital)

4. Abdominal examination:
a. b. c. d. e.

Liver: normal Spleen: normal Temperature: no fever. Pulse: 76 beats/minute Blood pressure:

CHEST EXAMINATION INSPECTION

A) B)

Shape and form of the chest: normosthenic. Symmetrical and moves freely with respiration. Subtotal angle is about 90. Respiratory movements: 1. Depth: normal 2. Chest movements: symmetric participation during breathing. PALPATION

PERCUSSION 1. Comparative percussion:

2.

Topographic percussion:

AUSCULTATION 1. Breath sounds:

2. Vocal resonance:

INVESTIGATIONS
1.

Chest X-ray- small nodules in the right side/lung (limited:1-2 segments).

2.

ECG- sinusal rhythm. Electrical axis is vertical. Longitudinal rotation. P- Wave in leads 1 and 2 must be upright (positive) if the rhythm is going from the sinus node. Normal conduction (normal SA, AV and IV conduction). Normal R-wave and QRS complex. General blood analysis: 3 WBC- 5.3x10 /ul 3 LY- 2.7x10 /ul LY%- +50.9% MO%- 5.7% GR- 43,4% RBC- 4.66x106/ul Hgb- 12.2g/dl Color index- 0.8 Speed of sedimentation19mm/h

3.

4.

Urine analysis: Color- yellow color Consistency- 100.0 Leucocytes- 1-2 Epithelium- 1-3 Microscopy: Affection classification- extrapulmonary Patients type- backsliding (recidiva) Reason of examination- detection of the treatment Visual appearance of sputum- saliva 30.01.09 2.02.09 3.02.09 Negative Negative Negative

5.

6. Biochemical analysis: Bilirubin gen.- 10.0 Direct bilirubin- ------ Indirect bilirubin- 10.0 AST- 0.27 ALT- 0.45 Thymol test- 2.12 7. Tuberculin skin test (Mantoux)DIFFERENTIAL DIAGNOSIS Primary TB complex can be mistaken diagnosed by pneumonia, patients with pneumonia initially have symptoms of a cold which are then followed by high fever, shaking chills, and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Children who develop pneumonia often dont have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Doctor during

auscultation hears coarse breathing or crackling sounds. Sputum samples: can detect the causal agent. A blood test: measuring WBC can refer to the severity of the pneumonia, increase of neutrophils number can be seen in bacterial infections, increase in lymphocytes is seen in viral infection. Chest-x-ray usually ordered to confirm the diagnosis of pneumonia. COMPLICATIONS There were no complications developed. DIAGNOSIS Primary tuberculous complex in the right lobe (right lung). There are 4 phases: a. Progression (infiltration, destruction, dissemination) b. Regression (desorption, consolidation) c. Stationary (without roentgenological dynamics) d. Stabilization (recovery) Our case is in Regression phase. I category, AFB is negative. Grupa unua.