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    Case Presentation TB

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    fitrizelia
    This document presents a case study of a 4.5 year old girl admitted to the hospital with a cough, fever, night sweats, and hemoptysis. She has a history of contact with her aunt who is being treated for suspected tuberculosis relapse. On examination, she has elevated white blood cell count and platelets but normal CRP. Sputum and other diagnostic tests have been done but results are pending. The differential diagnoses include tuberculosis, typhoid fever, pneumonia, and others. The plan is to treat with ambroxol while awaiting diagnostic test results to guide further management.

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    Case Presentation TB

    Uploaded by

    fitrizelia
    772 views12 pages
    This document presents a case study of a 4.5 year old girl admitted to the hospital with a cough, fever, night sweats, and hemoptysis. She has a history of contact with her aunt who is being treated for suspected tuberculosis relapse. On examination, she has elevated white blood cell count and platelets but normal CRP. Sputum and other diagnostic tests have been done but results are pending. The differential diagnoses include tuberculosis, typhoid fever, pneumonia, and others. The plan is to treat with ambroxol while awaiting diagnostic test results to guide further management.

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    This document presents a case study of a 4.5 year old girl admitted to the hospital with a cough, fever, night sweats, and hemoptysis. She has a history of contact with her aunt who is being treated for suspected tuberculosis relapse. On examination, she has elevated white blood cell count and platelets but normal CRP. Sputum and other diagnostic tests have been done but results are pending. The differential diagnoses include tuberculosis, typhoid fever, pneumonia, and others. The plan is to treat with ambroxol while awaiting diagnostic test results to guide further management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    772 views12 pages

    Case Presentation TB

    Uploaded by

    fitrizelia
    This document presents a case study of a 4.5 year old girl admitted to the hospital with a cough, fever, night sweats, and hemoptysis. She has a history of contact with her aunt who is being treated for suspected tuberculosis relapse. On examination, she has elevated white blood cell count and platelets but normal CRP. Sputum and other diagnostic tests have been done but results are pending. The differential diagnoses include tuberculosis, typhoid fever, pneumonia, and others. The plan is to treat with ambroxol while awaiting diagnostic test results to guide further management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 12

    Case

    presentation
    Tuberculosis
    Anouk Claessens
    Oryza Tjoa

    Contents
    !

    Identication

    Anamnesis

    Physical examination

    Laboratory ndings & other diagnostics

    Conclusions & dierential diagnosis

    Plans and treatment

    Discussions

    Identication
    !

    Girl, 4,5 years old

    G1P0A0, a term, normal prenancy & birth


    (no maternal infections, no complications)

    BW/A: -2-0 SD, L/A: -2-0 SD, BW/L: -2-0 SD

    Vaccination status: BCG, DTP (1-3), polio (1-3), hepB (1-3), campak

    No previous illness

    Anamnesis (1)
    History
    ! Since 18 days productive cough, subfebril fever, noctural sweating and a
    cold.
    ! Midwife drug (?)
    ! Doctor: general complaints allergic cough drug (?) no eect
    ! 12 hours before admission: hemoptoe 2 spoons, subfebril fever,
    dyspnoe (-) ER
    ! 17.08.2014: RSMH
    ! Contact TB: (+) -> aunt treated for TB 5 years ago. Now suspicious for
    relapse, same room with child.

    Anamnesis (2)
    !
    !
    !
    !
    !

    F (-), noctural sweating (+)


    Aunt: atmitted 19.08 in hospital,
    suspicion of TB
    Cough (+), hemoptoe (-)
    No artritis / joint pains
    Dypnoe (-), chestpain (-)

    Present (20.08)

    5 points (max.) on international score



    5 point (max.) on indonesian score
    (family history, prolonged fever, chronic cough)

    Score

    points

    Positive TB skin test

    Large painless lymph nodes

    Unexplained fever, night sweats, 2?


    no response to malaria
    treatment

    Malnutrition, not improving


    >4weeks

    Length of illness <2 weeks

    2-4 weeks

    >4 weeks

    Angle deformity of the spine

    Joint/bone swelling or sinuses

    Weight for age

    >80%

    60-80%

    <60%

    Familie TB (past

    none

    Reported by Proved
    family
    sputum +

    Unexplained abdominal mass of


    ascites
    CNS: change in temperatment,
    convulsions or coma

    Score

    or present)

    Physical examination
    On admission
    ! Sens.: alert
    ! BP: ?, P: 108/min, T: 36.9, RR: 28/min
    ! L:99cm, BW:14kg
    ! Head: eyes: not sunken, conjunctivae: not anemic, sclerae: non-icteric,
    mucosa: wet.
    ! Thorax: symmetrical, no retractions
    ! Cor: S1S2, S (-), G (-)
    ! Pulm: inspection, percussion normal, vesicular (L>R), R (-), W (-)
    ! Abd: normal inspection, normal tympany and ausculation, no defense
    ! Extr: warm acra, CRT <3s

    Physical examination
    Present (20.08)
    ! Sens.: alert
    ! BP: ?, P: 98/min, T: 37.0, RR: 26/min, SpO2 98% (without oxygen)
    ! Head: eyes: normal, conjunctivae: not anemic, sclerae: not icteric, mucosa: wet,
    no lymphadenopathy
    ! Thorax: symmetrical, no retractions
    ! Cor: S1S2, S (-), G (-)
    ! Pulm: inspection and percussion normal, vesicular (+) N, R (-), W (-)
    ! Abd: normal inspection, peristalsis N, normal tympany and ausculation, no
    defense
    ! Extr: warm acra, CRT <2s

    Laboratory ndings
    19.08.2014
    17.08.2014

    Hb

    15,2 g/dl

    Hb

    14,2 g/dl

    AST

    25 U/L

    Leucocytes

    23.900 /mm3

    ALT

    15 U/L

    Platelets

    499.000 /mm3

    Albumin

    4,5 g/dl

    Ht

    41 %

    Ureum

    24 mg/dl

    Di. count

    0/4/0/26/64/6

    Kreat

    0,32 mg/dl

    CRP

    < 5

    Ca 2+

    9,8 mg/dl

    Na +

    143 mEq/L

    K +

    4,7 mEq/L

    IgM S. Typhi

    Negative

    Elevated Hb / Normal HT / Normal Alb -> (-)


    Elevated WBC -> infection
    Elevated platelets -> infection / blood loss ?
    Neutropenie + lymfocytose -> infection ?
    Normal CRP!

    Other diagnostics
    ! Sputum smear / culture: 18.08 19.09 20.08
    (no results yet)
    ! Gastric lavage + culture: not needed
    ! Urine / blood culture: no results yet

    ! X-thorax: intepretation radiology follows

    Consultations:

    ENT: epistaxis? -> no.


    Conclusion & DD
    4,5 years old girl with subfebrile fever, noctural sweating, productive cough,
    haemoptoe and positive TB contact, admitted 4 days ago, now progressing
    clinically but TB status unknown.

    Dierential diagnosis haemoptoe + fever


    Tuberculosis
    Thyphoid fever
    Malaria
    (Broncho)pneumonia
    DHF
    Bronchustumor
    Lungembolia
    Vasculitis
    Epistaxis

    Plan & Treatment


    Ambroxol 3x 7,5 g
    viscid or excessive mucus
    Ampicilin 3x500mg
    suspect infection
    Gentamycin 2x35mg
    suspect infection
    Clinical progression -> stop?

    Tranexamat acid 3x140 mg (2 days) prevention excessive blood loss
    Waiting for results of sputum / urine / blood culture
    Waiting for results of X-Th interpretation

    THANKYOU!!
    BEDANKT !!
    TERIMA KASIH!!

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