Yabani A. Mkunji. Cases

TUMA/KCMUCo/MD.
2016/2017/TZ/1897
Name: Batul Nyindo
Age:74yrs
Sex: Female
Address: Mjohoroni
Tribe: |Pare
Religion: Muslim
Occupation: farmer
Date of admission: 3rd January 2021
Chief complain:
Abdominal pain 1/7
History of presenting illness:
The patient was apparently well until 1 day ago when he started complaing of sudden
onset of abdominal pain
Review of other system.
Central nervous system
Dinied history of headache, dizziness, convulsion, blurred vision or loss of consciousness.
Musculoskeletal system
He has no history muscle pain,no history of joint pain no history of bone pain no history of
swellingor stiffness .
Genitourinary system
Dinied history of painful urination, increased urinary frequency or blood in urine
Past medical and surgical history
This is 4th admission
The 1st was Ifakara Hospial due to difficult urination and diagnosed to have urethral
stricture in 2003
2nd at KCMC hospital due to Hypertension 2015
3rd at KCMC hospital and diagnosed to have DM 2019 and PUD
1
No history of surgery.
No history of blood transfusion.
No history of food or drugs allergy reported by the patient.
Family and social history
Married with 1 wife, living together and has 3children all are alive and well
Has history of cigarettes smoking for 30years with an average of 1packet/day that's is
average of 15packs/ years,
He had history of alcohol use since he had 25year,he normaly used beer,mbege,wine
sometimes and he stopped 2018.
No family history of chronic illness in the family.
Physical examination
General examination
Patient was oriented to time, place and person, afebrile,pale+ not jaundiced, not cyanotic,
no finger clubbing, no lower limb edema and no lymph node enlargement.
Vitals signs
Blood pressure: 133/80mmHg, Radial pulse rate: 76beats/minute, Respiratory rate:
22breath/minute, Axillary temperature: 36.5°C, SPO2: 95% on room air.
RBG on admission: 6mmol/l.
Systemic examination
Respiratory system
Inspection: Normal breathing pattern, symmetrical chest moves with respiration, no

chest deformity, no any surgical or traditional scar.
Palpation: Trachea centrally located, no tenderness,symmetrical chest expansion with

chest expansion of 5cm,normal tactile vocal fremitus
Percussion: Bilateral resonant note heard on both side of the chest
Auscultation:normal breathing sound were heard bilateral
Cardiovascular system
Inspection: No any chest deformity, no surgical marks, no pre-cordial hyperactivity
Palpation: Apex beat felt at 5th intercostal space, midclavicular line, no hives or thrills.
2
Auscultation: First and second (S1 and S2) heart sounds were heard with no murmur
Per abdomen:
Inspection: Obese abdomen that moves with respiration, inverted umbilicus, with
traditional marks on epigastric region and lumbar region, no visible swelling,no visible
peristalysis or distended veins.
Palpation: No tenderness, no palpable mass or organomegaly on both superficial and
deep palpation.
Percussion: Tympanic note was heard.
Auscultation: 4 bowel sounds/minute were heard,no aorticand renal bruit sound heared

The patient is fully conscious, oriented to time, place and person with GCS of 15/15,
normal gait, normal short term, long term memories and normal speech.
All cranial nerves (CN I-CN XII) were intact.
Inspection of both upper and lower limbs: No muscle atrophy, no any deformity
Limbs Right upper Left upper limb Right lower Left lower limb
limb limb
Tone Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Sensation Intact Intact Intact Intact
Summary
This is 47yrs old male from Rau admitted with chief complaining of vomiting 2
weeks projectile in nature associated with generalized body weakness,early
satiety,heartbeat awareness,coughing and confusion.He is known case of controlled
HTN,DM,PUD,Stricture and CKD-4, he is smoker with average of 15pack per year with
alcohol uses 4bottle per day for 20years.On examination he is pale +,hyponatremia of
101.70.
Provisional diagnosis
Chronic Kidney Diseases stage 3
3
Essential primary Hypertension
Diabete mellitus
Hypo osmolality and hyponatremia
Differential diagnosis
Heart failure
Investigations
Laboratory investigations done
Helicobactor Pylori Antigen -negative
Serum cortisol
Serum ACTH
Thyroid Function Test(TSH)-2.90uIU/ml
T4-81.1ng/mL
T3-<1.00ng/mL
Potassium 3.40(3.76)mmol/L
Urea 6.27(8.19)mmol/L
Serum creatinine 256(251)umol/L
Serum sodium-135.70(101.40)mmol/L
Erythrocyte Sedimentation Rate(ESR)
HB=11.2(11.3)g/dl L
Leucocyte count 4.31
Plt=415
H Pylory-Antigen stool =-ve
Radiological investigations
.CXR =Normal
Plan
Admit the patient medical ward
4
Management
Carvedilol Solid oral dosage form:6.25mg,(Dosage 12.5mg PO OD 2/52)
Nifedipine Retard 20mg,(dosage :20mg PO OD 2/52)
Asprin /Ascard 75mg PO OD 2/52
. Gliclazide 80mg PO OD 2/52
Sodium chloride 3%IV 250mls
Encourage oral feeding
OGD to evaluate the cause
1st day post admission (08 Augusty 2020)
Today no new complains.
On examination, the patient well looking, not pale, not jaundiced, no lymphadenopathy and no
peripheral edema.
Vitals signs:
BP:162/117 mmHg, Radial pulse rate: 77 beats/minute, Respiratory rate: 21
breath/minute, Axillary temperature: 36.4 ºC.SPO2=96 RA,FBG=5.6
Plan 01
Continue with medications.
Repeat serum sodium today
Re review medication at home.TSH(Normal),cortisol ,urine sediment and dipstick
,ECG,Urine sodium,OGD ,ESR
2 day post admission
Today no new complain ,
Vitals sign
BP=155/113mmHg, PR=81bpm, RR=22bpc,SPO2=98%, FBG=4.4,ESR=110
Na-135.70, OGD results suggests GERD nad Duodenal ulcer
Plan 02
Continue with medication
Stop aspirin
5
Do H pylorus antigen
Keep on PPI
Discharge summary
Patient presented with vomiting for 2 week where the patient diagnosed to have
GERD,Duodenal Ulcer comfirmed by OGD,he has been in the ward for 3 days,he is
discharged in improved condition and given Carvedilol,omeprazole,nifedipine and CTA on
24th Augusty.
TUMA/KCMUCo/MD/2015/2016/2846
CASE 4, FILE NO: 80944
Name: Emeritha Daniel Maffa
Age:46 years
Sex: Female
Address:Karatu
Tribe:Mburu
Religion: Christian
Occupation:Student
Date of admission: 10thAugust 2020
Informant: herself
Chief complain:
Vomiting blood for 1day
The patient was apparent well untill one day a go when she started to experience
vomiting fresh blood one episode which was sudden onset projectile in nature,associated
with generalized body weakness,dizziness and moderate headache since yesterday
morning,easy fatigability ,awareness of heartbeat with no history of chest pain or
shortness of breathing no history of fever,no abdominal distension,no abdominal pain no
6
no loss of appetie no history of palpitation no history of gum bleeding or history of
schistosomiasis,
Also the patient reported to pass 14 episodes of black tarry stool, 8 at home, 2 at Seriani
Hospital and 4 at Fame Hospital,where at fame health centre, investigation was done
hb=7.9 and she received 1unit BT then referred to us for further investigation and
management
Review of other system
No history of headache, dizziness, convulsion, blurred vision or loss of consciousness.
Muscle skeletal system
No history of joint pain, stiffness or muscle pain.
No dysuria, increased urinary frequency or hematuria.
• This is the first admission in her life.
No history of surgery reported
• She has one history of blood transfusion in prior to be referred at KCMC
• No history of food or drugs allergy reported by the patient.
Form four student ,last born in her family of 9 children
There is history of this condition in her family where her sister and brother were
diagnosed to have peptic ulcer diseases 5 and 4 years a go respectively
No history of chronic diseases like HTN DM in her family
No history of cigarrate, smoking and alcohol use.
General examination
Patient was ill looking, afebrile with temp of 36.5°C, severe pale, not jaundiced, not
cyanotic,not dyspneic no finger clubbing, no lower limb edema and no lymph node
enlargement.
Vital signs
7
Blood pressure: 109/48 mmHg, Radial pulse rate: 109beats/minute, Respiratory rate: 21
breath/minute, Axillary temperature: 36.5ºC, SPO2: 98% on room air,RBG=6.6mmol/L
Per abdomen:
Inspection: flat abdomen with no surgical scar, moves with respiration, umbilical
inverted, no any visible swelling, bowel movement or distended vein.
Palpation: Soft abdomen non tender with noany palpable mass or organomegaly on both
superficial and deep palpation.
Auscultation: 4 bowel sounds/minute were heard with no any arterial bruits auscultated
Respiratory system
Inspection: Normal chest wall with normal chest expansion no deformity,, no any
surgical or traditional scar
Palpation: Trachea centrally located, symmetrical chest expansion(4cm), no tenderness,

no swelling.
Percussion: Bilateral resonant note heard on both side of the chest.
Auscultation: Bilateral breath sounds were heard( vesicular sounds).
Palpation: Apex beat felt at 6th intercostal space, lateral to the midclavicular line, no
hives or thrills.
Auscultation: First and second (S1 and S2) heart sounds were heard with no murmur.
The patient is fully conscious, oriented to time, place and person with GCS of 15/15,
normal gait, normal short term, long term memories and normal speech.
Cranial nerve I (olfactory nerve) was intact because the patient was able to identify the
smell of the soap.
8
Cranial nerve II (optic nerve) was intact because the patient was able to read the words
written on the piece of paper and she was able to count fingers at a distance of 2 meter
and both pupils were equally reacting to light and accommodated.
Cranial nerves III, IV and VI (oculomotor, trochlear and abducens nerves) were tested in
all directions by using “H-sign” and all cranial nerves were intact.
Cranial nerve V (trigeminal nerve) was intact because the patient was able to identify the
sensation on the face elicited by using the cotton wool in all branches of trigeminal nerve
and she was able to oppose the resistance of my fingers during the opening and closure of
the mouth.
Cranial nerve VII (facial nerve) was tested by telling the patient to close the eyes tightly,
smiling and wrinkling the forepart of the head and the facial nerve was intact.
Cranial nerve VIII (vestibulocochlear nerve) was intact because the patient was able to
hear my voice, rinne and webber tests were normal.
Cranial nerve IX and X (glossopharyngeal and vagus nerves) were intact because the
uvula was symmetrically moving after telling the patient to say “Ah”.
Cranial nerve XI (accessory nerve) was intact because the patient was able to shrug her
shoulders and moving her neck to the side against resistance.
Cranial nerve XII (hypoglossal nerve) was intact because the patient was able to move
the tongue in and out and she was able to oppose the resistance by using her tongue.
Inspection of both upper and lower limbs: No muscle atrophy, no any deformity or scars.
Limbs Right upper Left upper Right lower Left lower

limb limb limb limb
Power 5/5 5/5 5/5 5/5
Summary
This is Ementha Daniel Maffe,17years old female admitted with chief complain of
vomitting blood for 1day associated with passing black tarry stool,easy
9
fatigability,awareness of heartbeat,with no chest pain,no SOB.On examination she is
severely pale,wih HB of 5.8
Diagnosis
Upper gastrointestine bleeding secondary to unknown cause
Osophageal varices
Peptic ulcer diseases
Gastritis
Mallory well tear
Oesophagitis
Investigations
Laboratory investigations
FBP: -Hb 5.8
HCT=17.7
Platelet count=137
Blood grouping and cross match
Serum creatinine
Serum sodium
Serum potassium
ASALT
ALAT
Total protein
Albumin
Peripheral blood smear =normacytic normochromic anaemia
Pylori antigen est=+ve
Radiological investigation
Abdominal U/S +RUV was normal
Plan
10
Admit the patient M/ICU
Management
Pantoprazole 40mg IV stat
Blood transfusion 3units of blood
IV fluids NS alt DNS 3L
Octreotide 100mcg iv start,then 50mcg iv tds 24hrs
Pantoprazole 40mg iv od for 3/7
Need OGD
Complete for AST/ALT,electrolyte,Total protein/albumin,PBS
1st day post admission (11 August 2020)

No more vomiting blood,reported one episode of melena
On examination, alert, oriented to personal place and time, not jaundiced, not pale and no
lymphadenopathy.
Vitals signs:
BP:108/68 mmHg, Radial pulse rate: 107beats/minute, Respiratory rate:
24breath/minute, Axillary temperature: 36.4ºC,SO2=100%in RA
Plan02
1. Control HB and Stool analysis
2. Continous with medication
3. Continous oral sips
4. Plaziquantel 1.2g po start
5. Transfer to general ward
2nd post admission
Per today ,no new complain
On examination ,alert,afrebrile,not pale,not jaundice
Vital sign
BP115/76mmHg ,PR=73bpm,RR=19bpc, Temp=36.2C,SO2 99%RA
Plan 03
Need stool for h.pylory antigen and then possible eradication.
11
Control HB and Ferritin
Discharge home tomorrow
Discharged summary
17yrs old female with working diagnosis of Peptic Ulcer Diseases confirmed by OGD,
reported doing fine since 2 days of treatment,she is discharged with controlled HB of
9.1 afer receiving 2unit of blood,clarithromycine,amoxicillin,rabeprazole,ferrous
sulphate and folic acid and CTA on Friday 28 August 2020 on Gastroenterology.
MEDICAL DEPARTIMENT CASE CLERKSHIP
(TUMA/MD/2015/2016 /2846)
CASE 5
DEMOGRAPHIC DATA
Hospital Registration Number:77449
Name: Mwanaidi Ismail Kimaro
Age: 84 years
Sex: Female
Religion: Muslim
Tribe: chagga
DOA: 08/08/2020
A referral from Hai distric Hospital
CHIEF COMPLAINT
Difficult in breathing for 4/7days
HISTORY OF PRESENTING ILLNESS
The patient was apparent well until 4 days a go when experienced difficult in breathing
whichstarted suddenly while she was eating,she chocked on food this condition progressive
worsening with time necessiating oxygen therapy,it is associated with inability
speak,generalized body weakness and one epsode of loss of consciousness with no history of
cough,no history of chest pain no fever
12
Also the patient reported to have history of confusion characterized by talking inappropriate
word for the past 1 week with no history of headache,no history of dizziness no history of
convulsion no history of any neurological deficit .
Also has history of lower limb swelling that have improved with the use of lasix,has no history
of awareness of heartbeats no history of PND no history of exertion dypsnoea .During this
course of illness the patient was admitted at peripheral hospital-put on lasix,metrol and
ceftriaxone but mental status kept on deteriorating with time then referral to KCMC for
further care.
REVIEW OF OTHER SYSTEMS

Gastrointestinal syste
No nausea, no vomiting, no difficult in swallowing, no abdominal pain, no diarrhea,
muscleskeletal system
No joint pain, no muscle paina,

Ear, nose and throat
No ear pain, no ear discharge, no nasal discharge, no sore throat
PAST MEDICAL AND SURGICAL HISTORY
-This is the third admission
-The first admission was 2007 due to Hyperension and keep on

lasartan,bendrofluazide,solubleaspirin
-Second admission at KCMC due to CKD
No history of surgery
-No history of blood transfusion.
-No known history of food nor drug allergy.
FAMILY AND SOCIAL HISTORY
-She is married to one husband and they live together
-There is hx of Hypertension in family (her mother) but no hx of DM in the family
-No hx of cigarettes smoking or alcohol usage
13
ON EXAMINATION
General examination: Unconciouss,mild pale note jaundiced ,mild pitting lower limb
edema,NGT insitu ,urethral catheter in situ with cloudy urine, no finger clubbing, no
lymphadenopathy,
Vital signs: BP= 124/49mmHg, on right arm in supine position
PR= 86 bpm regular-regular with strong volume on right radial artery
RR= 10 breaths per minute
T= 36.4oC axillary temperature
RBG=10.5
PSO2= 92% on oxygen
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
INSPECTION
Normal chest contour, no traditional mark or surgical mark

PALPATION
-Chest expansion 4cm, Trachea shifted to the right, no tenderness , no any palpable mass
PERCUSSION
Normal resonant percussion note

ASCULTATION
Gasping bilateral air entry with transmitted sound all over the
chest,bilateral course crepitation .
CARDIOVASCULAR SYSTEM
INSPECTION
No precordial hyperactivity no any scar
PALPATION
Cold extremities, irregular irregular pulse ,weak non collapsing
synchronous to other pulses,raised JVP ,Apex beat in 5 th ICS, No thrill,
no heave.
14
ASCULTATION
S1 and S2 heart sounds were heard, no murmurs
P/ ABDOMEN
INSPECTION
-Obese abdomen moves with respiration with Inverted umbilicus, no any obvious mass
PALPATION
The abdomen is mild hard on touch, no tenderness no organomegaly

PERCUSSION
Normal tympanic percussion note heard
ASCULTATION
Normal 3-4 bowel sounds per minute heard, no renal/ aortic bruises heard
CENTRAL NERVOUS SYSTEM EXAMINATION
Unconscious with GCS= 6/15

Pupil dilated;on the left sluggish react to light,no sign of meningeal
irritation .
.
MOTOR EXAMINATION
INSPECTION
No muscle wasting
No fasciculation
TONE
Muscles are of normal tone
POWER
power is 0/5 in both upper and lower limbs
COORDINATION
Normal coordination on finger to nose test .
SENSORY EXAMINATION
Normal sensation
REFLEXES
Bisceps, Triceps, brachio-radialis, patella and Achilles tendon reflexes are
normal.
SUMMARY
15
A 85 years old female, with DIB associated with LOC, GBM,inability to
speak,confusion,forgetfulness,insomnia and lower limb edema.On
examination she is gasping,bilateral air entry with transmitted sound
all over the chest,unconsious with GCS 6/15,pupil dilated with power of
0/5
Diagnosis: Hypertension heart disease

Stroke,not specified as haemorrhage or infarction
Chronic kidney disease,stage 5
Pneumonia ,unspecified
Cardiogenic shock
Atrial fibrillation and flutter
Differential Diagnosis
-COVID -19
Investigations
FBP
Serum blood creatinine
Serum sodium
Serum potassium
Total Protein
Albumin
PT-INR
LDL cholesterol
Serum HDL Chole
Radiological investigations
Chest Xray (AP): showed bilateral opacification Showed dilated hear
CT scan showed bilateral asymmetric subpleural group glass opacities with reticular opacities in
boy lungs bronchial dilation seen. Featuo suggestive of resolving COVID 19
ECG
Plan
Admit the patient at MII
Management
16
Cefriaxone 1gm
Metronidazole start,1L RL,DOPAMINE INFUSION
Also
Urgent ECG-effort made 1hrs now without success
Dopamine infusion 2L of RL
Ceftriaxone 2gm BD,Metronidazole 500mg TDS,Digoxin start
Continue with oxygen therapy
Monitor vital signs
Counsell relatives on prognosis
CT scan of the head reveal cerebral atrophy ?ischemic stroke too early
Add mentainance digoxin 0.25 od and conrol ECG
Sol aspirations
1st day post admission (25thJune 2020)
Today the patient is gasping
On examination, the patient is very sick,afebrile,pale with LLE

Vitals signs:
BP:100/40mmHg, Radial pulse rate: 96beats/minute, Respiratory rate:
20breath/minute, Axillary temperature: 36.2 ºC.SO2=99% on 02face mask
Plan 02
Keep digoxin
Urine output hourly and bicarbonate level
Relatives need counseling as prognosis is guarded ,treat as MI as well
Aspirin/clopidogrel,heparin ,cardiac enzymes
CXR pneumonia and suggestives feaure of COVID-19 so transfer for isolation to
be tested.
DISCHARGE TO MORGUE SUMMARY
84years old female,known patient with HTN and CKD?ESRD her condition was
same in gasping state,urine output 100mls 24hrs,with anasacra BP 115-105
Systolic,and diastolic 43-38mmHg.PSO2 86-67she has a lot of secretion and
17
suction was done.At around 10:49am, SPO2 44%high flow,PR 66-67.No
spontaneous breathing,she has given Adrenaline iv with minimal resustation-
baging at 11:15am there was no sign of life,pupils dilated not reacting to
light.Death certified at 11:17am
Name: ABDI RAJAB MCHOVU
18
Age:41 years
Sex:Male
Address: Mabogini
Tribe: Chagga
Religion:Muslim
Occupation:famer
Date of admission:28thJuly 2020
Chief complain:
Vomiting blood for the past 18hrs

The patient was apparent well untill 18 hours when started to vomit blood which was
sudden onset two episodes,the vomitus was projectile in nature contained fresh blood
mixed with clots approximately half of small cup,it is associated with shortness of
breath ,light headiness,dizziness ,heartbeat awareness,syncope and fatigues,he dined
coughing ,chest pain no history of confusion no history of convulsion no history of
fever,no abdominal distension no loss of appetite no abdominal pain no early satiety or
constipation.
Also the patient report to pass black stool mixed with clott of blood two episodes,two
days before admission with no bad smell,not mixed with mucous.it is referral from TPC
hospital where initial treatment was done and referred to us for further management.
Review of other systems
Respiratory system
Denied history of joint pain, stiffness or muscle pain.
Denied history of painful during urination,increased urinary frequency or blood in urine.
This in 2rd admission
1st admission was 2019 at Hedaru hospital due ascitic Malaria and UTI
No history of surgery
No history of blood transfusion.
19
Married with 3 children, all are alive and well.
Working in rice plantation for more than 10 years
No family history of chronic illness in the family
No history of hematological diseases in his family.
Hehas no history of alcoholor cigarrate smoking.
General examination
Patient was ill looking ,alert,conciouss,oriened to people,place and time,severe pale not
jaundiced,not cyanosed , clubbing, no lymph node enlargementa no lower limb edema
Vital signs
Blood pressure: 92/47mmHg, Radial pulse rate: 105 beats/minute, Respiratory rate: 21
breath/minute, Axillary temperature: 36.ºC, SPO2: 94% on room air.
Per abdomen:
Inspection: Flat abdomen, inverted umbilicus, no any surgical or traditional scars, or
distended veins.
Palpation: Non tender,soft on palpaion, splenomegaly of 6cm below coastal margin
balotable notch palpated.
Percussion: normal tympanic note was heard.
Auscultation: bowel sound was positive
Respiratory system
Inspection: Normal symmetrical chest, moving with respiration, no any surgical or

traditional scar, no any chest deformity.
Palpation: Trachea centrally located, symmetrical chest expansion, no tenderness, no

swelling.
20
Auscultation: Bilateral breath sounds were heard with no abnormal breath sounds.
Palpation:Warm extremities ,weak pulse no JVP raised , Apex beat felt at 5th intercostal
space, lateral to the midclavicular line, no hives or thrills.
Auscultation: First and second (S1 and S2) heart sounds were heard with gallop rhythm
The patient is conscious, oriented to time, place and person with GCS of 15/15, normal
gait, normal short term, long term memories and normal speech.
smell of the soap.
the mouth.
Limbs Right upper Left upper Right lower Left lower
21
limb limb limb limb
Power 5/5 5/5 5/5 5/5
Summary
A 41yrs old male referral from TPC hospital admitted with complain of vomiting blood
past 18hrs associated with awareness of heartbeat,dizziness,and SOB and passing black
stool with no fouls smell.Past medical and family are not significant.On examination he
is severely pale with splenomegally measured 6cm palpable below costal margin.
Provisional diagnosis
Upper gastroentestine bleeding secondary to portal hypertension
Osophageal varices
Peptic ulcer diseases
Mallory-Weiss tear
Gastritis
Oesophagitis
Investigations
FBP: Hb 3.7g/dl, MCV 62.5, MCH 15, RDW 21.1(H), other parameters were within normal
range
Blood grouping and x-match - A +ve
Electrolytes: Serum sodium 129.1 mmol/l,(L)
RFT: serum creatinine 83umol/l.
22
Liver function: albumin 23(L)
Imagine
Echo,; doesn't done b"ce didn't pay.
Plan 01
Admit the patient MICU
Management
NPO,IV Fluid NS/DNS 1.5L/24hrs ,NGT
Pantoprazole 40mg IV OD for 5/7
Octreotide 100mcg
Stop propanolol
And ceftriaxone 1gm IV
Praziquantel 1.2g PO start
Plan 02
For BT 1unit and platelets 1unit
Waiting for OGD
1st day post admission (29thJuly 2020)

Today Patient complains of vomiting blood and one episode of melena
On examination, the patient is ill looking,NGT in situ,not draining anything , pale, not
jaundiced, no lymphadenopathy and no peripheral edema.
Vitals signs:
BP:108/60 mmHg, Radial pulse rate: 92beats/minute, Respiratory rate:
22breath/minute, Axillary temperature: 35.8ºC.
Plan 03
Continue with medication
BT 1 Unit today
IVF 2L/RL/DNS
OGD possible today
Day 2 post admission (29thJuly 2020)
23
Patient is improving with no new complain.
On examination, he is not pale, not jaundiced, no peripheral edema and no lymph node
enlargement.
Vitals signs:
BP: 99/36mmHg, PR: 73beats/minute, T: 36.7C, RR: 22beats/minute,SPO2=97
OGD result reveals Esophageal varices F3 with red signs
Plan02
to start on propanolol 20mg bid x4week and pantaprazole40mg bid x2weeks
To start oral sips,o councel about the results of OGD,and management(band
ligation)
Continues with soft meals,to trace blood,give fluids at least 3L of RL=NS in the
next 24hrs
Give pcm 1gm IV tds 3/7
Coninuous with other management
Plan 04
For discharge today
Discharge summary
Patient was discharged with Spironolactone 50mg od 1/12, lasix 40mg od 1/12,lactolose
30ml od 7/7 and erythromycin 500mg TDS 5/7 with HB control 9.1
24
Name: Salvatory Paulo Mushi
Age:51 years
Sex:male
Address:moshi
Tribe:Chagga
Religion:Christian
Occupation:Businesswoman
Date of admission:28thJuly 2020
Chief complain:
Abdominal pain for past 2/52

The patient was on usual status until 2 weeks a go when he started to experiences severe
abdominal pain more on the epigastric region non radiating localized more on the
epigastric aggravated by food intake and stop aching as it tightens,he denied history of
vomiting no diarrhea but reported to to pass black tarry stool with constipation no fever
reported,however reported to had lower urinary tract symptom for a year now,reported to
use urehral catheter each 28days.
Review of other system
Denied history of confusion,convulsion no history loss of consciousness and blurred vision
Respiratory system
Denied history of difficulty in breathing, chest pain, or cough.
25
No history of heartbeat awareness,no history of shortness of breath,no history of easy
fatigability
Denied history of joint pain, stiffness or muscle pain..
This is 4rd admission ,the first one was 2009 due to HTN on regular medication
Second was at KCMC due to CKD 2017
3rd one at KCMC due to BOO 2nd to prostate enlargement where he was scheduled for TURP but
postponed due to hyperkalemia
Had history of blood transfusion once at TPC

No history of surgery.
Divorced ,lives with his children,worked as peasant
He has history of alcohol use and cigarrate use less than one pack year
There is history of hypertension in one side of his parents.
General examination
Alert, afebrile, not pale , not jaundiced, no lower limb edema, no finger clubbing, and no
lymph node enlargement.
Vital signs
Blood pressure: 194/116 mmHg, Radial pulse rate: 83 beats/minute, Respiratory rate: 21
breath/minute, Axillary temperature: 36.1 ºC, SPO2: 94% on room air.

The patient is fully conscious, oriented to time, place and person with GCS of 15/15, ,
26
smell of the soap.
the mouth.
Limbs Right upper Left upper limb Right lower Left lower
limb limb limb
Power 4/5 4/5 4/5 4/5
Reflexes Normal Hypereflexia Normal Normal
27
Palpation: Apex beat felt at 5th intercostal space, lateral to the midclavicular line, no
hives or thrills.
Auscultation: First and second (S1 and S2) heart sounds were heard with no murmur
Respiratory system
Inspection: Normal symmetrical chest, moving with respiration, no any surgical or

traditional scar, no any chest deformity.
Palpation: Trachea centrally located, symmetrical chest expansion, no tenderness, no

swelling.
Auscultation: Bilateral breath sounds were heard with no abnormal breath sounds.
Per abdomen:
Inspection: normal shape abdomen that moves with respiration, inverted umbilicus, no
any surgical or traditional scars, no visible swelling or distended veins.
Palpation: tenderness on superficial palpation more on the epigastric region, no rebound
tendernessno organomegaly on both superficial and deep palpation.
Auscultation: 4 bowel sounds/minute were heard
GENITAL URINARY SYSTEM
DRE=Enlarged prostate
Summary
This is 51yrs old male presented to us with abdominal pain 2 week associated passed
black stool and constipation some time and lower urinary tract symptoms,he had HTN for
5 year and prostate enlargement and has history of cigarrate smoking less than one pack
per year.On examination he had tenderness on superficial palpation.
Provisional diagn
Primary Hypertension
Bladder Outlet Obstruction secondary to Prostate Enlargement

CKD with uremic or ulcer?
28
Investigations
FBP:- HB -8.0,
LEUCO=N
PLT=173
Serum creatinine =762(624)umol/L H
Urea =13.59(15.58)mmol/L H
Serum potassium=5.75(6.63)mmol/L H
Serum sodium=134.53(136.80)mmol/L L
ASAT=14.77U/I
ALAT=6.82U/I
Plan01
Admit the patient MEDICAL 1
Start management.
Management
Nifedipine 20mg Po BD 2/52
Hydralizine 20mg in 250mls of NS
Carvedilol 12.5mg po bd 2/52
Plan 02
Need EPO 400IU SC 3/7,Urgent electrolyte,(Na and K)
Possible OGD
29
Dialysis due to poor quality of life.shift potassium
1st day post admission (29thjuly 2020)
Patient still complain of abdominal pain and constipation and has tenderness on the
epigastric region on palpation region
On examination, alert and conscious patient is ill looking,pale+, not jaundiced, no
lymphadenopathy and no peripheral edema.
Vitals signs:
BP:120/76 mmHg, Radial pulse rate: 76 beats/minute, Respiratory rate: 20
breath/minute, Axillary temperature: 37.4 ºC.
Plan
Continue with medications.
Add lactulose 15mls tds 3/7
Pantoprazole 40mg iv OD,
Counseled on OGD
Consult renal team for possible dialysis(hep panels,hiv)
Noon ,Renal term: dialysis wasn't done due to financial.
Erythropoietin inj 4000IU SC three time per week for 1/12
2second day post admision(30 july 2020)
To day Patient reported to improve,pain reduction on epigastric region and
tenderness on deep palpation.
Vital sign :
BP =108/51mmHg,PR 84b/min, RR=18breath/min,PO2=99% on room air
Plan02
Continue with management,for OGD today,counsel on renal diet and salt
reduction
ESKD nearing,needs dialysis in viewing gastric like uremic.may be discharged
after pain control
Add carvedilol solid oral 6.25mg Po bd for 1/52
3rd post admission (1august 2020)
Per today no new complain,vial sign are stable,
30
Plan 03
Contious with management ,monitor vitals sign
Lactulose 10mls po tds 3/7 ,consider discharge tommorrow
Discharge summary
51years old man diagnosed to have HTN,CKD complication,he is in good
condition where pain was controlled and discharged home through Renal clinic on 24th August
and on 14th at Urology clinic.
31

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TUMA/KCMUCo/MD.

Inspection: Normal breathing pattern, symmetrical chest moves with respiration, no

Palpation: Trachea centrally located, no tenderness,symmetrical chest expansion with

Percussion: Bilateral resonant note heard on both side of the chest

Auscultation:normal breathing sound were heard bilateral

Central nervous system

Palpation: Trachea centrally located, symmetrical chest expansion(4cm), no tenderness,

Percussion: Bilateral resonant note heard on both side of the chest.

Auscultation: Bilateral breath sounds were heard( vesicular sounds).

Limbs Right upper Left upper Right lower Left lower

Tone Normal Normal Normal Normal

Power 5/5 5/5 5/5 5/5

Coordination Normal Normal Normal Normal

Reflexes Normal Normal Normal Normal

Sensation Intact Intact Intact Intact

Upper gastrointestine bleeding secondary to unknown cause

Peptic ulcer diseases

Mallory well tear

Peripheral blood smear =normacytic normochromic anaemia

Pylori antigen est=+ve

Abdominal U/S +RUV was normal

Blood transfusion 3units of blood

IV fluids NS alt DNS 3L

Octreotide 100mcg iv start,then 50mcg iv tds 24hrs

Pantoprazole 40mg iv od for 3/7

Complete for AST/ALT,electrolyte,Total protein/albumin,PBS

1st day post admission (11 August 2020)

2. Continous with medication

3. Continous oral sips

4. Plaziquantel 1.2g po start

5. Transfer to general ward

2nd post admission

Per today ,no new complain

On examination ,alert,afrebrile,not pale,not jaundice

BP115/76mmHg ,PR=73bpm,RR=19bpc, Temp=36.2C,SO2 99%RA

Discharge home tomorrow

MEDICAL DEPARTIMENT CASE CLERKSHIP

REVIEW OF OTHER SYSTEMS

No nausea, no vomiting, no difficult in swallowing, no abdominal pain, no diarrhea,

No joint pain, no muscle paina,

No ear pain, no ear discharge, no nasal discharge, no sore throat

PAST MEDICAL AND SURGICAL HISTORY

-This is the third admission

-The first admission was 2007 due to Hyperension and keep on

-Second admission at KCMC due to CKD

-No history of blood transfusion.

-No known history of food nor drug allergy.

FAMILY AND SOCIAL HISTORY

-She is married to one husband and they live together

-There is hx of Hypertension in family (her mother) but no hx of DM in the family

-No hx of cigarettes smoking or alcohol usage

Vital signs: BP= 124/49mmHg, on right arm in supine position

PR= 86 bpm regular-regular with strong volume on right radial artery

RR= 10 breaths per minute

T= 36.4oC axillary temperature

PSO2= 92% on oxygen

Normal chest contour, no traditional mark or surgical mark

Normal resonant percussion note

The abdomen is mild hard on touch, no tenderness no organomegaly