KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY COLLEGE

INTERNAL MEDICINE DEPARTMENT

REG No: TUMA/KCMUCo/MD.2016/2017/TZ/1965
CASE 01
NAME: ZUHURA O. MDEE (EHMS No. 95952)
AGE: 51 years old
SEX: Female
RESIDENCE: Bagamoyo
OCCUPATION: Small scale farmer
TRIBE: Chagga
RELIGION: Christian
DATE OF ADMISSION: 2020-12-19
CHIEF COMPLAINT: Abdominal swelling for 3/52
Difficult in breathing for 3/7
HISTORY OF PRESENTING ILLNESS:
The patient was well until last 3 weeks ago where she started to experience a
gradual onset of abdominal swelling that kept on worsen as days goes it was
associated with intermittent non radiating abdominal pain, both legs swelling,
decreased urine frequency. She denies any changes in bowel habits, yellowish
discoloration of the eyes, nose bleeding, gums bleeding, vomiting, nausea, itching
and dark urine. The symptom was aggravated when working, on long distance
walking and relieved when resting or sleeping.
Also 3 days ago patient started to experience difficult in breathing which was of
gradual onset progressively worsen as days goes on, associated with fever during
night periods, episodes of air hunger at night when sleeping, dry cough, easy
fatigability and awareness of heart beats. He denies to experience difficult in
breathing while lying flat. Symptoms aggravated on when walking and relieved at
rest. The symptoms were so severe that she can’t perform her daily activities like
farming and cooking.
REVIEW OF OTHER SYSTEMS:
Central nervous system: No headache, no diplopia, no paresthesia, no
numbness, no limbs weakness, no loss of conscious, no convulsions no speech
changes
Musculoskeletal system: No joint pain, No muscle pain, No joint swelling
Genitourinary system: No nocturia, no polyuria, no dysuria, no urethral discharge

PAST MEDICAL HISTORY

This is her first admission at hospital, no any history of chronic diseases like
hypertension, diabetes mellitus or tuberculosis. She is a known HIV positive
patient currently she is not on Antiretroviral therapy or other drugs

There is no history of blood transfusion, no history of previous surgery, no any

drugs allergies known.

FAMILY AND SOCIAL HISTORY

She is married living with her husband she has 5 children all are well the last one
who is 18 years old still lives with her, most of the times husband stays at Moshi
due to business issues and visit the family at Bagamoyo occasionally. There is no
any history of familial chronic disease like liver diseases, cancers and heart failure
in first-degree family members.

She is a farmer owns maize farm, her level of education is primary school, she
earns about ten thousand per day depending on whether it is harvesting period or
not. She denies any history of engaging in rice plantation activities, multiple sexual
partners and recent travelling history.

She has positive history of drinking alcohol about 4 units per day but denies
history of cigarettes smoking.
ON EXAMINATION

GENERAL EXAMINATION

 The patient is alert and well oriented, afebrile

 Well nourished
 Not pale
 No jaundice
 No cyanosis
 No finger clubbing
 Palpable lymph nodes on the left pre auricular region measuring more than 1
cm mobile and not matted
 Pitting lower limb edema grade III below and above the knee up to sacral
region, more on the right lower limb than the left foot also there was peeling
of the skin on the right thigh and was much warmer compared to the left.
 There was white oral thrush bilaterally on buccal mucosa.

Vitals signs: on admission

Blood pressure: 119/85mmhg
Temperature: 36.7c
Respiratory rate: 20br/min
Pulse rate: 75bpm
SPO2:  99% in Ra
ABDOMINAL EXAMINATION
Inspection
 Distended abdomen
 The abdomen slightly moves symmetrical with respiration
 The umbilical is inverted
 No any visible peristalsis
 No visible pulsation
 No visible prominent veins
 No scars or traditional marks.
Palpation
 Non tender abdomen with no any palpable mass on superficial palpation
 Slightly tenderness on right hypochondria region on deep palpation
 Spleen and kidneys were not palpable
 The liver was not palpable due to distension of the abdomen
Percussion
 The fluid thrills were present
 Normal tympanic note was heard from mid-umbilical line toward right side
up-to lumbar region 2 cm from right mid-clavicular line where it changed to
dullness then patient laid on her left lateral tympanic note was heard and
dullness shifted towards umbilical. Hence positive Shifting dullness.
 Liver span was 5cm measured on mid clavicular line.
Auscultation
 3 bowel sounds were heard in a minute 2cm right from umbilical
 There were any bruits on renal or abdominal aorta
GENITALIA
Inspection
 Well-defined triangular shaped hair pattern.
 Normal labia majora and minora
 No any discharge per vaginal/ urethral
 No any ulceration or rashes
Palpation
 Suprapubic region was non tender on palpation
 The bladder was not distended hence not palpable.
 Bimanual palpation of the uterus was not performed.
DIGITAL RECTAL EXAMINATION (DRE);
 Normal anal ridge and tone.
 Mobile anal mucosa.
 Fecal matter on gloves after withdrawal.

CARDIOVASCULAR SYSTEM
Peripheries
 The pulse rate was 90 beats/min, regular rhythm, normal character, normal
volume, radial to radial synchronized and radial femoral synchronized.
 Blood pressure was mmHg on laying position and mmHg on sitting position
 Raised jugular venous pressure 6cm from the sternal angle
 The carotid pulse was palpable with no bruits

Inspection
 No visible pericardial activity
  No chest deformity
 No any surgical scar
 No any traditional marks
Palpation
 No any chest tenderness on the chest
 Apex beat palpable left side midclavicular 5th intercostal space
 No any thrills
 No heaves were felt.
Auscultation
 Normal s1 and s2 sounds heard, no abnormal sounds were heard
 No murmurs were heard

RESPIRATORY SYSTEM
Inspection
 No chest deformity
 No scars or traditional marks both anteriorly posteriorly and lateral to the
chest
 Symmetrical chest movement on respiration
 Respiratory rate:20 breaths/min
Palpation
 No chest wall tenderness.
 Palpable trachea centrally located.
 Tactile vocal fremitus vibrations lateralized both sides normal
 Symmetrical normal chest expansion about 4cm on measurements.
 No palpable supraclavicular lymph nodes.
Percussion
  Normal resonance was heard on percussion both anteriorly, laterals and
posteriorly
Auscultation
 Vesicular breath sounds were heard supra-mammary on both sides of the
lungs
 Reduced breath sounds intra and infra-mammary on the both lungs
 Coarse crackles/crepitations were heard infra-scapular bilaterally from
posterior auscultation.
 Normal vocal fremitus was heard on both sides of the lungs

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher centers
Conscious with the GCS of 15/15, oriented to person, place and time, pupils were
both normal and reactive to light, both short- and long-term memory were intact,
normal speech.
Cranial nerves
Cranial nerve I: Can smell different scents
Cranial nerve II: There was normal visual acuity and visual field
Cranial nerve III, IV, VI: all extraocular muscles are intact, there was movement of
eye muscles in response to the ‘H’ sign
Cranial nerve V : No loss of sensation on the face, the patient could open and close
his mouth without difficulties. Could resist force against his mouth closing and
opening movements
Cranial nerve VII: normal bilateral facial expression and no loss of taste
Cranial nerve VIII: there was no hearing loss on both Rinne’s and Weber test
Cranial nerve XI and X: symmetrical and normal movement of uvula at the midline
Cranial nerve XI: Can shrug shoulders against resistance, can move neck freely.
Cranial nerve XII: Can protrude tongue and move in all directions
Motor functions
RIGHT
LEFT
Upper Lower Upper Lower
Tone Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Sensation Normal Normal Normal Normal
Babinski Down going Down going
Clonus Negative Negative

MUSCULOSKELETAL SYSTEM
Gait - Patient couldn’t walk
Arms - Normal Bulk, Normal skin color, Free movement
Legs- Could flex
Spine - Normal Spinal curve
SUMMARY
This is Zuhura Mdee, a 51 years old female who presented with abdominal
swelling for 3/52 and difficult in breathing for 3/7 associated with fever, air
hunger, dry cough and night sweats she denied history of weight loss. On
examination, there was reduced vesicular breath sounds and dullness on infra-
scapular and infra-mammary regions and painless bilateral pitting edema up to the
distal third of tibia.

PROVISIONAL DIAGNOSIS
1. Liver cirrhosis secondary to alcohol use
With differential of:
  Hepatorenal syndrome
 Viral hepatitis

2. Chronic kidney disease secondary to Hypertension

With differential of:
 Nephrotic syndrome

3. Human immunodeficiency virus disease

With differentials of:
 Hematological malignancy

INVESTIGATIONS
Labs investigations
1. Full blood picture
 Leucocyte count………….20.27 x 10^9 cells/L (High)
 Erythrocyte count………...1.98 x 10^9 cells/L (Low)
 Haemoglobin ……………. 6.7 g/dL (Low)
 HCT………………………16.3% (Low)
 MCH…………………...….33.8 pg (High)
 MCHC……………………41.1 g/dL (High)
 With normal MCV and RDW

Platelets count…………………… 139 x 10^9 cells/L (Low)

Differential
 Neutrophils .......... 77.0% 15.61 X 10^9/L (High)
 Lymphocytes ....... 18.0% 3.65 X 10^9/L (High)
With normal Monocytes, Eosinophils and Basophils

2. Urinalysis

3. Bio-chemistry (dipstick)
4. Renal function test
 Estimated GFR (eGFR) ......... 22 ml/min
 S-Creatinine ........................... 218 μmol/L (H)
 Serum Na+.............................. 113.83 mmol/L (L)
 BUN.........................................10.73 mmol/L (H)
With normal serum K+ of 4.04 mmol/L
5. Liver enzymes
 AST …………………60.48 U/L (H)
With normal ALT of 20 U/L
6. Liver functions test
 Serum albumin………...14.20 g/L (L)
 APTT............................ 76.5 seconds (H)
With normal INR=1.44, PT=17.8 sec

7. Serology
 HBsAg………………...…...Negative
 Hep. C Antibody test………Negative
 HIV 1/2 Rapid…………….. Positive
 CD4+……………………….446 cells\μL

Imaging studies
1. Chest X-ray
 Showed normal studies
2. Abdominal and Pelvis ultrasound
  Liver shrunken hyper echoic heterogeneous course texture with rough
irregular margins, measures 7.6cm.there is clear free fluid collection
in peritoneal cavity
 Impression features suggestive of massive ascites and Liver cirrhosis

3. Doppler USS
 Doppler USS of the right and left lower limb showed no DVT but
features suggestive of Bilateral cellulitis

4. OGD (Oesophago-gastro-duodenoscopy)

MANAGEMENT
NON-PHARMACOLOGICAL THERAPY
1. Low protein diet (0.6-0.75g/kg/day)
2. Fluid intake restriction
3. Weight maintenance and if obesity effort to lose weight is important.
MEDICAL THERAPY
 Fluconazole IV Infusion 200mg IV stat, then 100mg iv 7/7
 Spironolactone 50mg BD PO 5/7
 Ceftriaxone 1gm  IV od 5/7
 Furosemide (Lasix) Injection 80mg IV start then 60mg IV BD 3/7
 Co-trimoxazole 960mg OD 1/12
 Amoxycillin/Clavulanic Acid 625mg PO BD 5/7
 Multivitamin Tablet 1 tab OD 1/12
 Phytomenadione (Vitamin K1) Injection 1mls IM
 Tenofovir/Lamivudine/Dolutegravir (TLD) 300/300/30mg then changed to
Abacavir, lamivudine and efavirenz

FOLLOW UP
20th December 2020
Patient is well with no any new complain
Vitals: BP - 118/71 mmHg, T-36.7, RR- 24 bpm, PR- 78bpm, spO2- 96% on
oxygen.
Continue with management- Fluconazole 150mg PO OD 7/7, Spironolactone 50mg
BD PO 5/7, Ceftriaxone 1gm  IV od 5/7, Furosemide (Lasix) 40mg PO BD 1/12 ,
Co-trimoxazole 960mg OD 1/12, Amoxycillin/Clavulanic Acid 625mg PO BD
5/7, Ceftriaxone 1gm OD 5/7, Tenofovir/Lamivudine/Dolutegravir (TLD)
300/300/30mg 1tab
Renal team review

22th December 2020

The patient is well with no any new complain.
Vitals: BP - 106/61 mmHg, T-35.9, RR- 18bpm, PR- 81bpm, spO2- 94% on room
air.
Continue with management, do ascitic tapping,1.5 L slowly with iv fluids running
slowly green cannula, haematemics, to do OGD

24th December 2020 –

The patient is well with no any new complain.
Vitals: BP - 107/68 mmHg, T-37.1, RR- 19 bpm, PR- 65bpm, spO2- 95% on room
air.
Continue with management. Consider discharge, discharge with Lasix 40bd,
multivitamin, change ARVs  to Abacavir, lamivudine and efavirenz.

DISCHARGE NOTE
51 years old female SP , with working diagnosis of liver cirrhosis, renal failure
came with c/C of abdominal swelling for more than 3/52, she reports that recently
it has started to interfering with her breathing , causing difficult in breathing, she
also reports to have cough which is non productive cough, she also reports to have
lower limb swelling more on the right currently she cannot walk due to pain, she
also reports to have reduced urine output in the past 2/52 no history of diarrhoea,
no hx of vomiting,
ON EXAMINATION: a middle-aged woman, conscious , afebrile, not pale, not
jaundiced ,no lower limb edema no lymphadenopathy.
Vital signs: T=36.8C, BP=107/68mmHg, PR=67 bpm, RR=22br/min, SPO2=92%
ON P/A : abdomen is slightly distended, soft, no tender
Investigation done: Liver function Test shows APPT=76.5, PT =17.8, INR=1.44,
Albumin=14.2, HB =6.7,Neutrophil=15.61, Leukocyte=20.27, Ascitic protein
=9.6,CD4=446, UPCR=93.44, OGD= shows gastritis
So the patient currently is well improved, taped about 300 mls ascitic fluids, no
more difficult in breathing and lower limbs swelling is well reduced, so we
discharge the patient with Lasix 40mg bd , Multivitamin, Tramadol 50mg bd
Amoxiclav 625mg bd, Ant retroviral (ABC+3TC+EFV) and to come for renal and
gastroenterology clinic after 2weeks on 8/01/2021
PREVENTION
PRIMARY PREVENTION
1. For alcohol users should drink alcohol in moderation if fail to moderate its
better to stop completely.
2. Eat well balanced food, low fat diet.
3. Avoid large amount of salt in take in diet.
4. Quit smoking
5. Make physical activities part of your routine at least 15-30 minutes per day
5. Manage/control diabetes and hypertension if known or diagnosed
5. Abstain from unsafe sexual practice
6. Be faithful with one partner
7. Use condom to protect from unsafe sexual practices
SECONDARY PREVENTION
1. The patient should be given medications to treat her liver cirrhosis, chronic
kidney disease and HIV/AIDS problems and told to strongly adhere to
medications.
2. The patient should eat more vegetables and fruits, reduce raw salt intake and
high contents of fat diet
TERTIARY PREVENTION
1. Psychological counselling on how to cope and live with his condition
2. The patient should be informed about possible complication from her problem
and for the case of Chronic kidney disease may need dialysis in future.

PROGNOSIS
The prognosis for her case in moderate and will much depend on how patient will
adhere to medication and change in life style and dietary changes that we
instructed her to follow.

KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY COLLEGE

INTERNAL MEDICINE DEPARTMENT
 REG No: TUMA/KCMUCo/MD/1965
CASE 02
NAME: SAMSON KILEO (Ehms no. 339)
AGE: 75 years old
SEX: Male
RESIDENCE: HAI
OCCUPATION: Businessman
TRIBE: Chagga
RELIGION: Christian
DATE OF ADMISSION: 6th December 2020
INFORMANT: His son
CHIEF COMPLAINT: difficult in breathing for 1/7 day

HISTORY OF PRESENTING ILLNESS:

The patient was well until last 1 day where he started to experience suddenly onset
of difficult in breathing which progressively worsening with time, accompanied
with intermittent dry cough and difficult breathing while lying flat. He reported to
have a normal urine frequency and loss of appetite through the course of his
illness. The condition was aggregated by walking and slightly relieved by resting.
He denies any history of fever, headache, chest pain, night sweat, lower limb
edema, air hunger at night, awareness of heartbeats, TB contact and asthma. He has
not got any medication or treatment prior to admission.

REVIEW OF OTHER SYSTEMS:

Gastrointestinal system: no vomiting, no diarrhea, no constipation, no abdominal
pain
Musculoskeletal system: no joint pain, no muscle pain.
Genitourinary system: no hematuria, no dysuria, no polyuria/oliguria.

PAST MEDICAL HISTORY

He has been admitted twice, the first was at Jakaya Kikwete Cardiac institute 1
year ago for heart surgery with valve replacement and 2nd here at KCMC. He is a
known patient with Chronic kidney stage 5 for 3 years not on dialysis, Type 2
Diabetes Mellitus for 10 years on gliclazide and Hypertension for 3 years on
unknown medication (he doesn’t remember the names of medication)

There is no history of blood transfusion

There is history of heart surgery with valve replacement 1 year ago.

No any drugs allergies known.

FAMILY AND SOCIAL HISTORY

He lives with his 2 grandchildren; he is a businessman. There is no any chronic
disease like asthma/ hypertension or diabetes in first degree members.
He was a cigarette smoker, at least 4 cigarettes per day but stopped many years
back, also he was occasional alcohol drinker of both beer and local breweries
usually after work but stopped 4 years ago after being advised by health
professional.

ON EXAMINATION

GENERAL EXAMINATION
  The patient is ill looking elderly man dyspneic, alert, afebrile, oriented to
time, place and people.
 Well nourished
 Not pale
 No jaundice
 No cyanosis
 No finger clubbing
 No lymphadenopathy
 Pitting lower limb edema grade III below the knee equal bilaterally

Vitals signs: on admission

Blood pressure: 151/79 mmHg
Temperature: 37.7C
Respiratory rate: 27br/min
Pulse rate: 67 bpm
SPO2:  88-95% on oxygen.

RESPIRATORY SYSTEM
Inspection
 No chest deformity
 No scars or traditional marks both anteriorly posteriorly and lateral to the
chest
 Symmetrical chest movement on respiration
 Respiratory rate:27 breaths/min
Palpation
  No chest wall tenderness.
 Palpable trachea centrally located.
 Tactile vocal fremitus vibrations lateralized both sides normal
 Symmetrical normal chest expansion about 5cm on measurements.
 No palpable supraclavicular lymph nodes.
Percussion
 Normal resonance was heard on percussion both anteriorly, laterals and
posteriorly

Auscultation
 Vesicular breath sounds were heard supra-mammary on both sides of the
lungs
 Reduced vesicular breath sounds infra-mammary on the both lungs
 Coarse crackles/crepitations were heard infra-scapular bilaterally from
posterior auscultation.
 Normal vocal fremitus was heard on both sides of the lungs

ABDOMINAL EXAMINATION
Inspection
 Obese abdomen
 The abdomen moves symmetrical with respiration
 The umbilical is inverted
 No any visible peristalsis
 No visible pulsation
 No visible prominent veins
  No scars or traditional marks.
Palpation
 Soft non tender abdomen with no any palpable mass on superficial palpation
 No tenderness on deep palpation
 Spleen and kidneys were not palpable
 The liver edge could felt on inspiration.
Percussion
 Normal tympanic note was heard in all 9 quadrants.
 Liver span was 6cm measured on mid clavicular line.
Auscultation
 3 bowel sounds were heard in a minute 2cm right from umbilical
 There were any bruits on renal or abdominal aorta

GENITALIA
Inspection
 Well defined diamond shaped hair pattern, shaved and circumcised.
 Normal position of urethral meatus and glans penis.
 No swelling on scrotal region and hypopigmentation.
Palpation
 No palpable induration
 Both testes are palpable in respective to hemi scrotal region.
 Spermatic cord firm and non-tender.
DIGITAL RECTAL EXAMINATION (DRE);
 Normal anal ridge and tone.
 Mobile anal mucosa.
  Grade 1 and firm.
 Fecal matter on gloves after withdraws.
CARDIOVASCULAR SYSTEM
Peripheries
 The pulse rate was 67 beats/min, regular rhythm, normal character, normal
volume, radial to radial synchronized and radial femoral synchronized.
 Blood pressure was 151/79 mmHg on laying position and 148/80 mmHg on
sitting position
 Jugular venous pressure 4cm from the sternal angle
 The carotid pulse was palpable with no bruits

Inspection
 No visible pericardial activity
 No chest deformity
 Surgical scar
 No any traditional marks
Palpation
 No any chest tenderness on the chest
 Apex beat palpable left side midclavicular 5th intercostal space
 No any thrills
 No heaves were felt.
Auscultation
 Normal s1 and s2 sounds heard, no abnormal sounds were heard
 No murmurs were heard
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher centers

Conscious with the GCS of 15/15, oriented to person, place and time, pupils were
both normal and reactive to light, both short- and long-term memory were intact,
normal speech.

Cranial nerves
Cranial nerve I: Can smell different scents

Cranial nerve II: There was normal visual acuity and visual field

Cranial nerve III, IV, VI: all extraocular muscles are intact, there was movement of
eye muscles in response to the ‘H’ sign

Cranial nerve V : No loss of sensation on the face, the patient could open and close
his mouth without difficulties. Could resist force against his mouth closing and
opening movements

Cranial nerve VII: normal bilateral facial expression and no loss of taste

Cranial nerve VIII: there was no hearing loss on both Rinne’s and Weber test

Cranial nerve XI and X: symmetrical and normal movement of uvula at the midline

Cranial nerve XI: Can shrug shoulders against resistance, can move neck freely.

Cranial nerve XII: Can protrude tongue and move in all directions

Motor functions

RIGHT
LEFT
Upper Lower Upper Lower
Tone Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Sensation Normal Normal Normal Normal
Babinski Down going Down going
Clonus Negative Negative

MUSCULOSKELETAL SYSTEM

Gait - Patient could walk

Arms - Normal Bulk, Normal skin color, Free movement

Legs- Could flex

Spine - Normal Spinal curve

SUMMARY
45-year-old patient with a presentation of Difficult in breathing for the past one
day associated with fatigue and lethargy. He is a known CKD with optimal urine
output for the past week. known CKD for 3 years, not on dialysis, type 2 DM for
10 years on gliclazide, and HTN for 3 years on unknown medication. He uses
gliclazide, atorvastatin, soluble aspirin, He has a history of valve replacement
surgery at JKCI in 2019. Lives with four grandchildren and drinks occasionally
with a tobacco history.
O.E dyspneic on oxygen, worse on lying flat. fingers not clubbed, Chest- fine
crepitations generally CVE - gallop rhythm, no added sounds. lower limb edema
grade 1. PA- obese abdomen, temp-37.2, BP-141/93mmgh, PR-67bpm, RR-
24br/min, RBG-11.2mmol/dl, SPO2-96 on oxygen 6L/min.
PROVISIONAL DIAGNOSIS
1. Congestive heart failure New York Heart Association Class 3 secondary to
hypertension

Differential: -Acute respiratory distress syndrome secondary to COVID-19

-Pulmonary edema
-cardiomyopathy

2. Diabetes mellitus type 2

Differential: Late Onset Diabetes in Adults

INVESTIGATIONS
Labs investigations
8. Full blood picture
 Leucocyte count…………… 21.64 x 10^9/L H
 Erythrocyte count………....3.72 x 10^12/L L
 Haemoglobin ……………. 9.8 g/dl L
 HCT……………………… 27.9 % L
 MCV .....................................75.0 (84.3) fL L
 MCH .....................................26.4 (26.7) pg L
 With normal MCHC and RD

Normal Platelets count

Differential
 Neutrophils ................................................... 20.08 X 10^9/l H
 Lymphocytes ................................................. 0.45 X 10^9/ L
  Monocytes ..................................................... 1.02 X 10^9/l H
 With normal Eosinophils and Basophils.

9. Renal function test

 Estimated GFR (eGFR) ......... 12 (13) ml/min
 S-Creatinine ........................... 459 (422) μmol/L H
 Serum Na+.............................. 119.86 (127.36) mmol/L L
 BUN......................................... 24.53 (23.91) mmol/L H
 Normal Serum K+,
10.Liver enzymes
 ALT…………………………..43.00 (12.53) U/l H
 Normal AST
11.Serum phosphate……………………. 2.07 (1.58) mmol/l H
12.Serology
 HBsAg………………...…...Negative
 Hep. C Antibody test………Negative
 HIV Elisa…………………..Negative

Imaging studies
5. Chest X-ray
 X-Ray Chest – PA
Comments:
 shows bilateral mixed alveolar and interstitial infiltrates with
cardiomegaly.

6. ECG


MANAGEMENT
SUPPORTIVE THERAPY
 Patient on oxygen therapy with face mask 6L/min
  Patient lay on cardiac bed 45 degree
 Physiotherapy twice daily
MEDICAL THERAPY
 Furosemide (Lasix) Injection 120mg IV STAT
 Insulin Injection: soluble 5 IU SQ
 Calcium Gluconate Injection 1g IV STAT
 Salbutamol Nebulizer 5mls nebulize
 Gliclazide 80mg bd for 7/7
 Soluble Asprin 75mg od for 7/7
 Atorvastatin/20mg od for 7/7
 Vitamin B1,B6,B12,Folic acid Solid Oral dosage form (Nat B) 1tab
od for 7/7
 Heparin 1,000 IU/mL in 5mL 10,000 IU IV TDS for 5/7
 Ceftriaxone 1gm 2g STAT then 1g BD for 5/7
 Azithromycin Solid oral dosage (Tablet) form 500mg BD for 5/7 PO
 Tranexamic acid Inj. 500mg IV STAT
 Adrenaline Inj. 6mg in 6mls

FOLLOW UP
06th December 2020
Patient with likely an infectious cause of the Acute respiratory distress syndrome
likely forms bacterial or viral pneumonia with DM and CKD in the background.
O.E dyspneic on oxygen, worse on lying flat. fingers not clubbed, Chest - fine
crepitations generally CVE - gallop rhythm, no added sounds. lower limb edema
grade 1. PA- obese abdomen, temp-37.2, BP-141/93mmgh, PR-67bpm, RR-
24br/min, RBG-11.2mmol/dl, SPO2-96 on oxygen 6L
CXR - shows bilateral mixed alveolar and interstitial infiltrates with cardiomegaly.
Potassium low at 3.5.
Treat with high dose antibiotics (ceftriaxone and azithromycin). Give treatment
dose of heparin with 10k IU TDS s/c and Lasix 60mg TDS IV. Continue with oral
antiglycemics. Nurse in isolation in a prone position

07th December 2020

The patient has no new complain
O.E sick looking, not pale, afebrile, bilateral lower limb edema, dyspneic on a non-
rebreather mask, resp- bilateral crepitation, CVE- muffled heart sounds. vitals -
temp-37.3, BP-163/87, Pulse-72 regular, rr-30 , spo2-95% on oxygen ECG shows
bundle branch block, poor r wave progression
Trace renal function test, increase lasix 80mg TDS and stop heparin, nurse in Sub
ICU.

DEATH SUMMARY
called to review the patient, desaturating at 53% on maximum oxygen on a non
rebreather mask, the patient received 1mg of dopamine bolus and 1mg in 250N\S,
but he kept on desaturating, anesthesia was called for intubation, the patient was
still desaturating and at 5:53pm saturation was at 4%,resuscitation with CPR and
ambu-bag was start, with 1mg of dopamine stat, suction was done,6:07 the patient
was intubated and 1mg of dopamine added, resuscitation continued for 27 minutes
with five circles of adrenaline, pupils were fully dilated, central pulse were absent
and vitals were unrecordable. Death was certified at 6:27pm.
PREVENTION
PRIMARY PREVENTION
1. Drink alcohol in moderation if fail to moderate its better to stop completely.
2. Eat well balance diet.
3. Avoid large amount of salt in take in diet.
4. Quit smoking.
5. Physical exercise at least 3 times per week
6. Manage/control diabetes and hypertension if known or diagnosed
7. Avoid engagement in congested mass of people.
SECONDARY PREVENTION
1. The patient should be given medications to treat her DM type 2, control
hypertension and congestive heart failure and told to strongly adhere to
medications together with attending renal dialysis us instructed with Renal team.
2. The patient should eat more vegetables and fruits, reduce raw salt intake and
high contents of fat diet. ALL DIET SHOULD BE STRICT US GUIDED BY
RENAL TEAM
TERTIARY PREVENTION
1. Psychological counselling on how to cope and live with his condition how to
do self care to avoid injury especially to the lower limbs.
2. Visiting Diabetes, Hypertension and Cardiac clinics as scheduled for close
monitoring of the disease and efficiency of drugs.

KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY COLLEGE

INTERNAL MEDICINE DEPARTMENT
REG No: TUMA/KCMUCo/MD/1965
 CASE 03
NAME: ELIARUYA ELIMASIA (Ehms no. 52347)
AGE: 82 years old
RESIDENCE: Masama
OCCUPATION: Retired person of school board.
TRIBE: Chagga
RELIGION: Christian
DATE OF ADMISSION:
CHIEF COMPLAINT: Non projectile vomiting for 1/7
HISTORY OF PRESENTING ILLNESS:
The patient was well until last 1 day ago where he started to experience non
projectile vomiting of gradual onset worsen with time which occur most of the
time during or after eating characterized with recent eating food material, about 1L
in volume which can raise depending on amount of the food he ate with more than
4 episodes per day. It was associated with nausea, abdominal pain, abdominal
distention, difficult in passing stool, decrease urine output <2 frequency during a
day, headache, dizziness, blurred vision. He denies presence of blood in vomitus,
blood in stool, coughing blood, chest pain, fever. It was aggravated during meals
intake and brushing his teeth in the morning and relieved when stop eating. There
is no any history of travelling recently.
REVIEW OF OTHER SYSTEMS:

Respiratory system: No difficulty in breathing, no cough, no hemoptysis

Cardiovascular system: No easy fatigue, no awareness of heart beat, no orthopnea,

no paraxomal nocturnal dyspnea

Central nervous system: no convulsion, no syncope, no tinnitus, no loss of

consciousness
Musculoskeletal system: no joint pain, no muscle pain
PAST MEDICAL HISTORY

This is the admission He is a known patient with chronic kidney stage 5 and
currently on dialysis for 3 years at Reyna dialysis center. He was diagnosed with
Hypertension 3 years ago and was on hypertensive drugs(he doesn’t remember the
names of medication) until renal problems started where they stopped the
medications.

There is no history of blood transfusion

There history of minor surgery to construct fistula for dialysis

No any drugs allergies known.

FAMILY AND SOCIAL HISTORY

He lives with his wife and has 3 children he is a retired chairperson of school board
in Masama. Currently he is under the care of his wife including hospital bills.
There is no history of chronic diseases such as diabetes mellitus, hypertension,
epilepsy or asthma in first degree family members. He has no any history of
drinking alcohol or smoking cigarettes.

ON EXAMINATION

GENERAL EXAMINATION
  Elderly patient, ill looking, alert, afebrile, conscious, oriented to time, place
and people.

 Slightly wasted
 Not pale
 No jaundice
 No cyanosis
 No finger clubbing
 No lymphadenopathy
 Pitting lower limb edema grade III below the knee more on the right limb.

Vitals signs: on admission

Blood pressure: 90/60 mmHg
Temperature: 35.6C
Respiratory rate: 22br/min
Pulse rate: 60 bpm
SPO2:  92% on oxygen.

ABDOMINAL EXAMINATION
Inspection
  Scaphoid abdomen
 The abdomen moves symmetrical with respiration
 The umbilical is inverted
 No any visible peristalsis
 No visible pulsation
 No visible prominent veins
 No scars
 Traditional marks present
Palpation
 Soft non tender abdomen with no any palpable mass on superficial palpation
 No tenderness on deep palpation
 Spleen and kidneys were not palpable
 The liver edge could feel on inspiration.
Percussion
 Normal tympanic note was heard in all 9 quadrants.
 Normal tympanic note was heard from mid-umbilical line toward right side
up-to lumbar region 2 cm from right mid-clavicular line where it changed to
dullness then patient laid on her left lateral tympanic note was heard and
dullness shifted towards umbilical. Hence positive Shifting dullness.
 Liver span was 6cm measured on mid clavicular line.
Auscultation
 3 bowel sounds were heard in a minute 2cm right from umbilical
 There were any bruits on renal or abdominal aorta

GENITALIA
Inspection
 Well defined diamond shaped hair pattern and circumcised.
 Normal position of urethral meatus and glans penis.
 No swelling on scrotal region and hypopigmentation.
Palpation
 No palpable induration
 Both testes are palpable in respective to hemi scrotal region.
 Spermatic cord firm and non-tender.
DIGITAL RECTAL EXAMINATION (DRE);
 Normal anal ridge and tone.
 Mobile anal mucosa.
 Firm prostate
 Fecal matter on gloves after withdraws.

RESPIRATORY SYSTEM
Inspection
 No chest deformity
 No scars or traditional marks both anteriorly posteriorly and lateral to the
chest
 Symmetrical chest movement on respiration
 Respiratory rate:27 breaths/min
Palpation
 No chest wall tenderness.
 Palpable trachea centrally located.
 Tactile vocal fremitus vibrations lateralized both sides normal
  Symmetrical normal chest expansion about 5cm on measurements.
 No palpable supraclavicular lymph nodes.
Percussion
 Normal resonance was heard on percussion both anteriorly, laterals and
posteriorly

Auscultation
 Vesicular breath sounds were heard supra-mammary on both sides of the
lungs
 No any added sound
 Normal vocal fremitus was heard on both sides of the lungs

CARDIOVASCULAR SYSTEM
Peripheries
 The pulse rate was 67 beats/min, regular rhythm, normal character, normal
volume, radial to radial synchronized and radial femoral synchronized.
 Blood pressure was 90/60 mmHg on laying position.
 Jugular venous pressure 4cm from the sternal angle
 The carotid pulse was palpable with no bruits

Inspection
 No visible pericardial activity
 No chest deformity
 Surgical scar
 No any traditional marks
Palpation
 No any chest tenderness on the chest
 Apex beat palpable left side midclavicular 5th intercostal space
 No any thrills
 No heaves were felt.
Auscultation
 Normal s1 and s2 sounds heard, no abnormal sounds were heard
 No murmurs were heard

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher centers

Conscious with the GCS of 15/15, oriented to person, place and time, pupils were
both normal and reactive to light, both short- and long-term memory were intact,
normal speech.

Cranial nerves
Cranial nerve I: Can smell different scents

Cranial nerve II: There was normal visual acuity and visual field

Cranial nerve III, IV, VI: all extraocular muscles are intact, there was movement of
eye muscles in response to the ‘H’ sign

Cranial nerve V : No loss of sensation on the face, the patient could open and close
his mouth without difficulties. Could resist force against his mouth closing and
opening movements

Cranial nerve VII: normal bilateral facial expression and no loss of taste
Cranial nerve VIII: there was no hearing loss on both Rinne’s and Weber test

Cranial nerve XI and X: symmetrical and normal movement of uvula at the midline

Cranial nerve XI: Can shrug shoulders against resistance, can move neck freely.

Cranial nerve XII: Can protrude tongue and move in all directions

Motor functions

RIGHT
LEFT
Upper Lower Upper Lower
Tone Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Sensation Normal Normal Normal Normal
Babinski Down going Down going
Clonus Negative Negative

MUSCULOSKELETAL SYSTEM

Gait - Patient could walk

Arms - Normal Bulk, Normal skin color, Free movement

Legs- Could flex

Spine - Normal Spinal curve

SUMMARY
81 years male known patient with chronic kidney disease on dialysis for three
years, today complains of non- projectile vomiting of recent eating material, there
was no blood in the vomitous. vomiting preceded with nausea, abdominal pain and
heart burn, which is associated with gradual abdominal distention, does not report
to have change in bowel habits, no history of loose stool. Has bilateral lower limb
swelling , no facial puffiness, no difficult in breathing. on examination- elderly
patient, alert, conscious with a GCS OF 15/15,not pale, not jaundiced, has bilateral
pitting edema which is more on the right, no Palmer erythema VITALS: T-35.9
BP-100/57mmHg, PR-78bpm, RR-22br/min, SPO2- 94 PA- distended abdomen,
moves with respiration, no visible veins, positive shifting dullness. other systems
are essentially normal.
PROVISION DIAGNOSIS
1. Chronic kidney disease secondary to hypertension
Differential: Acute kidney injury

2. Gastritis secondary to uraemia

Differential: Peptic ulcer disease

INVESTIGATION
Labs investigations
13.Full blood picture
 Leucocyte Count ....................... 3.24 x 10^9/L L
 Erythrocyte Count ..................... 4.05 x 10^12/L L
 Haemoglobin ............................. 11.9 g/dl L
 HCT ........................................... 33.9 % L
 MCH .......................................... 24.6 pg L
 MCHC ....................................... 29.4 g/dL L
 RDW .......................................... 17.5 % H
 With normal MCV
 Normal Platelets count

Differential
 Neutrophils ............................................1.38 X 10^9/l L
 Other differentials were within normal range
 14.Renal function test
 Estimated GFR (eGFR) ......... 10 ml/min
 S-Creatinine ........................... 511 μmol/L (H)
 Normal Serum K+, Serum Na+

15.Liver enzymes
 AST and ALT were both within normal range

Imaging studies
7. Doppler USS

 Doppler USS of the right foot was done and showed: No evidence of
deep venous thrombosis, impression was cellulitis but clinically there
was no evidence of cellulitis.

8. OGD
 OGD showed features suggestive of Pan Gastritis.

9. Abdominal USS
 USS abdomen shows a shrunken liver and ascites

MANAGEMENT
NON-PHARMACOLOGICAL THERAPY
4. Low protein diet (0.6-0.75g/kg/day)
5. Fluid intake restriction
6. Weight maintenance and if obesity effort to lose weight is important.
7. Regular Dialysis 3 times per week.

MEDICAL THERAPY
 Rabeprazole Injection 20mg iv od 3/7
 Omeprazole 20mg- 40mg po BD 7/7
  Adrenaline Injection 200mg IV stat

FOLLOW UP
29th November 2020
Seen an 81 years male known patient with chronic kidney disease on dialysis for
three years, with c\c of non- projectile vomiting of recent eating material who was
temporarily discharged to go dialysis. Today the patient reports vomiting of
recently eaten food materials
O\E Elderly man, alert, conscious with a GCS OF 15/15,not pale, not jaundiced,
has bilateral pitting edema which is more on the right, no Palmer erythema
Vital signs:T-36.5,BP-130/90,PR-80,RR-23,SPO2-96 on RA. PA- distended
abdomen, moves with respiration, no visible veins, positive shifting dullness. other
systems are essentially normal
Give Raberprazole Injection: 20mg[ Dosage: 20mg iv od 3/7. His serum creatinine
levels were S.Creatinine-511 µmol/L(H),has gone for dialysis twice since then

30th November 2020

Seen an 81 years old patient during ward round with a working diagnosis of
Chronic kidney disease, no new complain today
On examination, an elderly man conscious, GCS 15/15, not pale, not jaundiced
with LL oedema. Vitals T- 35.9 B.P -112/61 P.R- 108 R.R- 23 SOP - 93ON RA
P/A distended abdomen, positive fluid thrills
Continue with his current medication and dialysis

1st December 2020

Seen a patient with a working diagnosis of CKD and gastritis
On examination clinically stable , not pale, P/A ascites
Check albumin, conventionally renal gram, discharge with warfarin , PPI and
Lasix

DEATH SUMMARY
81 years male known patient with chronic kidney disease on dialysis for three
years, today complains of non- projectile vomiting of recent eating material, there
was no blood in the vomitous. vomiting preceded with nausea, abdominal pain and
heart burn, which is associated with gradual abdominal distention, does not report
to have change in bowel habits, no history of loose stool. Has bilateral lower limb
swelling , no facial puffiness, no difficult in breathing. on examination- elderly
patient, alert, conscious with a GCS OF 15/15,not pale, not jaundiced, has bilateral
pitting edema which is more on the right, no Palmer erythema VITALS- -T-
35.9BP-100/57PR-78RR-22 SPO2- 94 PA- distended abdomen, moves with
respiration, no visible veins, positive shifting dullness. other systems are
essentially normal. IN THE WARD: Investigations were done, FBC,
Electrolytes ,creatinine, blood urea nitrogen: hb-11.9 (10.2) g/dl, serum creatinine-
511 µmol/L,urea-5.88(17.85)mmol/L, potassium-4.51 (5.54) mmol/L,sodium-
137.69 (138.62) mmol/L ,AST- 10.34 U/l,ALT-11.00 U/l and USS abdomen shows
a shrunken liver and ascites, OGD showed features suggestive of Pan Gastritis and
he was treated with PPI's :Raberprazole Injection: 20mg iv od 3/7 and to continue
with oral PPIs the complaints of the patient resolved during his stay in the ward.
Doppler USS of the right foot was done and showed: No evidence of deep venous
thrombosis, impression was cellulitis but clinically there was no evidence of
cellulitis, during his stay in ward the patient was discharged temporarily twice to
go dialysis. At 4:00am the patient started gasping and was kept on high flow
oxygen where the blood pressure was 93/55mmhg, sat-44% and pulse was 35 bpm.
He was resuscitated with adrenaline 300mls, and the pulse came up to 96bpm with
saturation of 92% on oxygen. One hour later, his condition began to deteriorate
again, his vitals were unrecordable, pupils dilated non reactive to light, absence of
radial and carotid pulse, cold extremities. Death was certified around 5:45am.
PREVENTION
PRIMARY PREVENTION
1. Drink alcohol in moderation if fail to moderate its better to stop completely.
2. Avoid high potassium foods such as bananas, avocados, potatoes, fried cassava,
coffee not more than 1 cup per day, milk half pint per day(300mls).
3. Avoid large amount of salt in take in diet.
4. Quit smoking
5. Manage/control diabetes and hypertension if known or diagnosed
SECONDARY PREVENTION
1. The patient should be given medications to treat congestive heart failure and told
to strongly adhere to medications together with attending renal dialysis us
instructed with Renal team.
2. The patient should eat more vegetables and fruits, reduce raw salt intake and
high contents of fat diet. ALL DIET SHOULD BE STRICT US GUIDED BY
RENAL TEAM
TERTIARY PREVENTION
1. Psychological counselling on how to cope and live with his condition especially
about dialysis
2. The patient should be informed about possible complication from her problem
and for the case of Chronic kidney disease may need dialysis in future.
 KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY COLLEGE
INTERNAL MEDICINE DEPARTMENT
REG No: TUMA/KCMUCo/MD.2016/2017/TZ/1965
CASE 04
NAME: JOHN MIKAELI CHAMI (Ehms no. 58954)
AGE: 67 years old
RESIDENCE: Machame, Moshi
OCCUPATION: Small scale farmer
TRIBE: Chagga
RELIGION: Christian
DATE OF ADMISSION: 5TH December 2020

CHIEF COMPLAINT: difficult in breathing for 2/52

HISTORY OF PRESENTING ILLNESS:

The patient was well until 2 weeks ago where he started to experience gradual
onset of difficult in breathing which kept on worsening with time. The symptom
was aggravated when he walks or climb up the hills and relieved when at rest. He
was able to dress himself without assistance and associated with dry intermittent
cough with no periodic variation, awareness of heart beats at rest and on exertion,
air hunger at night, difficult in laying flat, swelling of both legs below the knee. He
also reports to have increased urinary frequency more than 4 times during night.
He denies any history of vomiting, diarrhea, abdominal pain, fever, night sweats,
loss of consciousness, or history of recent travelling.
REVIEW OF OTHER SYSTEMS:

Respiratory system: No difficulty in breathing, no cough, no hemoptysis

Central nervous system: No headache, no diplopia, no paresthesia, no

numbness, no limbs weakness, no loss of conscious, no convulsions no speech
changes.

Gastrointestinal system: no abdominal pain, no diarrhoea, no melena, no vomiting

Musculoskeletal system: No joint pain, No muscle pain, No joint swelling

Genitourinary system: No nocturia, no polyuria, no dysuria, no urethral discharge

PAST MEDICAL HISTORY

This is his first admission he is a known hypertensive patient for 10 months and
currently on medication but he doesn’t either remember the names or carry them
with him. He once diagnosed with diabetes mellitus back in February this year
was on medication for 3 months and then stopped the reason being blood glucose
was controlled.

There is no history of blood transfusion, no history of surgery, no any drugs

allergies known.

FAMILY AND SOCIAL HISTORY

He lives with his wife and has 12 children, his level of education is primary
education, he was a small-scale farmer (peasant) stopped after sickness start
getting worse, he now depends on his wife and children for financial support .

He has no any history of drinking alcohol or cigarettes smoking.

GENERAL EXAMINATION

 The patient is elderly man, ill looking, tachpoenic, conscious, alert, well
oriented to time place and people, afebrile

 Well nourished

 Not pale

 Not jaundiced

 No cyanosis

 Not dehydrated

 No finger clubbing

 No lymphadenopathy

 Pitting lower limb edema grade III below the knee same on both limbs
equally

Vitals signs: on admission

Blood pressure: 160/80 mmHg

Temperature: 35.7c

Respiratory rate: 20br/min

Pulse rate: 75bpm

SPO2:  98% in Ra

RBG: mmol/L.
CARDIOVASCULAR SYSTEM

Peripheries

 The pulse rate was 90 beats/min, regular rhythm, normal character, normal
volume, radial to radial synchronized and radial femoral synchronized.

 Blood pressure was 160/80 mmHg on laying position and mmHg on sitting
position.

 Raised jugular venous pressure 7cm from the sternal angle.

 The carotid pulse was palpable with no bruits

Inspection

 No visible pericardial activity

 No chest deformity

 No any surgical scar

 No any traditional marks

Palpation

 No any chest tenderness on the chest

 Apex beat palpable left side midclavicular 5th intercostal space

 No any thrills

 No heaves were felt.

Auscultation

 Normal s1 and s2 sounds heard, no abnormal sounds were heard

  No murmurs were heard

RESPIRATORY SYSTEM

Inspection

 No chest deformity

 No scars or traditional marks both anteriorly posteriorly and lateral to the

chest

 Symmetrical chest movement on respiration

 Respiratory rate: 20 breaths/min

 Audible wheezes accompanied with difficult in breathing

Palpation

 No chest wall tenderness.

 Palpable trachea centrally located.

 Tactile vocal fremitus vibrations lateralized both sides normal

 Symmetrical normal chest expansion about 4cm on measurements.

 No palpable supraclavicular lymph nodes.

Percussion

 Normal resonance was heard on percussion both anteriorly, laterals and

posteriorly
Auscultation

 Vesicular breath sounds were heard supra-mammary on both sides of the

lungs

 Reduced breath sounds intra and infra-mammary on the both lungs

 Coarse crackles/crepitations were heard infra-scapular bilaterally from

posterior auscultation.

 Normal vocal fremitus was heard on both sides of the lungs

ABDOMINAL EXAMINATION

Inspection

 Distended abdomen

 The abdomen moves symmetrical with respiration

 The umbilical is inverted

 No any visible peristalsis

 No visible pulsation

 No visible prominent veins

 No scars or traditional marks.

Palpation

 Non tender abdomen with no any palpable mass on superficial palpation

 Non tender abdomen

 Spleen and kidneys were not palpable

  The liver was not palpable due to distension of the abdomen

Percussion

 The fluid thrills were present

 Normal tympanic note was heard from mid-umbilical line toward right side
up-to lumbar region, mid-clavicular line where it changed to dullness then
patient laid on her left lateral tympanic note was heard and dullness shifted
towards umbilical. Hence positive Shifting dullness.

 Liver span was 7cm measured on mid clavicular line.

Auscultation

 3 bowel sounds were heard in a minute 2cm right from umbilical

 There were any bruits on renal or abdominal aorta

GENITALIA

Inspection

 Well defined diamond shaped hair pattern, shaved and circumcised.

 Normal position of urethral meatus and glans penis.

 No swelling on scrotal region and hypopigmentation.

Palpation

 No palpable induration

 Both testes are palpable in respective to hemi scrotal region.

 Spermatic cord firm and non-tender.

DIGITAL RECTAL EXAMINATION (DRE);

 Normal anal ridge and tone.

 Mobile anal mucosa.

 Grade 1 and firm prostate.

 Fecal matter on gloves after withdrawal.

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher centers

Conscious with the GCS of 15/15, oriented to person, place and time, pupils were
both normal and reactive to light, both short- and long-term memory were intact,
normal speech.

Cranial nerves
Cranial nerve I: Can smell different scents

Cranial nerve II: There was normal visual acuity and visual field

Cranial nerve III, IV, VI: all extraocular muscles are intact, there was movement of
eye muscles in response to the ‘H’ sign

Cranial nerve V : No loss of sensation on the face, the patient could open and close
his mouth without difficulties. Could resist force against his mouth closing and
opening movements

Cranial nerve VII: normal bilateral facial expression and no loss of taste

Cranial nerve VIII: there was no hearing loss on both Rinne’s and Weber test
Cranial nerve XI and X: symmetrical and normal movement of uvula at the midline

Cranial nerve XI: Can shrug shoulders against resistance, can move neck freely.

Cranial nerve XII: Can protrude tongue and move in all directions

Motor functions

RIGHT
LEFT
Upper Lower Upper Lower
Tone Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Sensation Normal Normal Normal Normal
Babinski Down going Down going
Clonus Negative Negative

MUSCULOSKELETAL SYSTEM

Gait - Patient could walk

Arms - Normal Bulk, Normal skin color, Free movement

Legs- Could flex

Spine - Normal Spinal curve

SUMMARY
67 years old, presented with DIB 3/12, worse on exertion and on lying flat ass/w
progressive lower limb swelling, awareness and easy fatigability. Background
history of HTN on medication that he doesn’t remember, also diabetic for 7
months, not on any hypoglycemic agents.
O.E: An elderly man, dyspnoeic, pale, has LLE to the level of the knee, not
jaundiced RS: normal chest shape, an audible wheeze, reduced bilateral vesicular
breath sounds, with no added sound. CVS: Apex beat at 5th ICS left to the
midclavicular line, S1 and S2 heard no added sounds P/A abdomen is of normal
contour, mild ascites with positive shifting dullness, no organomegaly. 
PROVISIONAL DIAGNOSIS
1. Congestive heart failure, New York Heart Association Class 3 Secondary to
hypertension
Differential: Acute Kidney Injury

2. Chronic kidney disease secondary to hypertension

Differentials: Acute Kidney Injury, Chronic Liver Failure

3. Diabetes mellitus type 2

Differential: Late Onset Diabetes in Adults

4. Non allergic asthma

Differential : Allergic asthma
INVESTIGATIONS
Labs investigations
1. Full blood picture
 Erythrocyte count………...2.06 x 10^9 cells/L (Low)
 Haemoglobin ……………. 6.2 g/dL (Low)
 HCT………………………19.5% (Low)
 MCHC……………………31.9 g/dL (High)
 With normal Leucocyte Count, MCV, MCH and RDW

Normal Platelets count and normal differential

2. Renal function test

 Estimated GFR (eGFR) ......... 6 ml/min
 S-Creatinine ........................... 831 μmol/L (H)
 Serum Na+.............................. 131.8 mmol/L (L)
 Serum K+……………………5.71 mmol/L (H)
 BUN.........................................33.24 mmol/L (H)

3. Serology
 HBsAg………………...…...Negative
 Hep. C Antibody test………Negative
 HIV Elisa…………………..Negative
Imaging studies
1. Chest X-ray
 X-Ray Chest – PA
Comments:
 In comparison to the study done on 8 December 2020 the condition
remained stable.
 Cardiothoracic ratio is within normal limits.
 Normal pulmonary vasculature.
 Unfolded and elongated aorta
 Both costophrenic and cardio phrenic angles appear normal.
 Lung fields are clear.
 Bony thorax and soft tissue look normal.
 Persistent right-sided central line

2. ECHO
 MITRAL VALVE: Normal
 TRICUSPID VALVE: Mild TR
 AORTIC VALVE: Normal
 PULMONARY VALVE: Normal
 RV Function: Normal
 CONCLUSION: Diastolic Dysfunction Grade I With Mild Tricuspid
Valvular incompetence
3. ECG
 Normal sinus rhythm, Left axis deviation, Anterior infarct , age
undetermined, Abnormal ECG.

MANAGEMENT
NON-PHARMACOLOGICAL THERAPY
1. Low protein diet (0.6-0.75g/kg/day)
2. Fluid intake restriction
3. Weight maintenance and if obesity effort to lose weight is important.
MEDICAL THERAPY
 Hydrocortisone Powder for injection IV  200mg 6 hourly in 24 hours
 Furosemide (Lasix) Injection 80mg stat
 Salbutamol Nebulizer 5mls.
 Captopril 12.5mg po od 3/7
 Isosorbide dinitrate 10mg od po 3/7
 Insulin Injection: soluble 10iu in 30mls d50% 4 hourly x 24hrs.
 Nifedipine Retard 20mg BD 3/7
 Soluble Aspirin 75mg OD 1/12

FOLLOW UP
05th December 2020
Conscious, severely dyspneic, mildly pale, febrile on touch, Massive LLE BP-
142/78 PR-65, SPO2-100 RBG-14.4
CVS-Irregularly irregular, distended neck veins, bilateral basal crackles. r/s-
diffused wheezes prolonged expiratory phase. P/A: Positive shifting dullness.
CXR-Flattening hemidiaphragms.
Review of a 67y/o male, M/C: SOB x2/52, worse on exertion and on lying flat
ass/w progressive lower limb swelling, awareness and easy fatigability.
Background hx of HTN on medication that he doesn’t remember, also diabetic for
7 months, not on any hypoglycemic agents.
Give furosemide 80 mg, ISD 10mg,Captopril 12.5mg, to do Total protein, albumin,
ECHO and ECG

06th December 2020

Continue with Lasix 80mg tds, Hyperkalemia protocol. Do pre-dialysis panel and
consult renal team and counsel on dialysis.
07th December 2020
Patient is still experiencing DIB with an audible wheeze, to be nebulized and use a
salbutamol inhaler PRN, awaiting to do renal panel
08th December 2020
Patient is still sick, On Nebulizer
O/E: Sick, Dyspneic, Audible wheeze Output 1400mls Vitals:Temp-36.1C BP-
126/101mmHq PR-79b/min RR-19breath/min SPO-99% on a RA RS: Diff Ronchi
Start dialysis today, nebulize 4hourly with 2.5mg Salbutamol and 0.5 Ipratropium
& Hydrocortisone 200mg start then 100mg tds for 24hours. Do ECG

DISCHARGE NOTES
JOHN CHAMI, 67 year old male diagnosed with hypertension for 10 months on
regular medication with c/c of DIB 3/12 the patient was apparently well until 3
weeks ago when he started experiencing DIB which got worse with time a/c a dry
non productive cough, shortness of breath which causes the patient to wake up at
night due to air hunger, awareness of heart beat, easy fatigue, and long standing
lower limb swelling for about 10 months now, no history of fever, no headaches,
no blurry vision, no convulsions, no LOC, abdominal pain, no vomiting or nausea,
no change in urine frequency as per fluid intake, no change in bowel movements.
O.E An elderly man, dyspnoeic, pale, has LLE to the level of the knee, not
jaundiced.
Vital signs: T-36.5, BP-188/96, PR-76, RR-22, SPO2-97%, FBG 9.6mmol/L
RS: normal chest shape, an audible expiration wheeze, reduced bilateral air entry,
vesicular breath sounds no added sound.
CVS: Apex beat at 5thICS left to the midclavicular line,s1 and s2 heard no added
sounds P/A abdomen is of normal contour ,mild ascites with positive shifting
dullness, no organomegaly
CXR: features suggestive of pulmonary edema.
Labs Cr-786 K-6.14 Hepatitis C surface antigen Negative and HIV Elisa- negative
ECG-Normal sinus rhythm, Left axis deviation, Anterior infarct , age
undetermined, Abnormal ECG.
He started dialysis on 0/12/2020, his condition has improved after dialysis
sessions, and today he has no new symptoms with vitals BP-159/94, PR- 91, RR-
20, and SPO2-99 on room air. Therefore, we are discharging him home through
dialysis with his Lasix tabs 80mg BD 1/12, Isosorbide dinitrate 10mg po OD 1/12,
Nifedipine 20mg BD 1/12, Aspirin 75mg OD 1/12, Captopril 12.5mg OD 1/12,
salbutamol inhaler to use PRN.

PREVENTION
PRIMARY PREVENTION
1. Drink alcohol in moderation if fail to moderate its better to stop completely.
2. Avoid high potassium foods such as bananas, avocados, potatoes, fried cassava,
coffee not more than 1 cup per day, milk half pint per day(300mls).
3. Avoid large amount of salt in take in diet.
4. Quit smoking
5. Manage/control diabetes and hypertension if known or diagnosed
SECONDARY PREVENTION
1. The patient should be given medications to treat congestive heart failure and told
to strongly adhere to medications together with attending renal dialysis us
instructed with Renal team.
2. The patient should eat more vegetables and fruits, reduce raw salt intake and
high contents of fat diet. ALL DIET SHOULD BE STRICT US GUIDED BY
RENAL TEAM
TERTIARY PREVENTION
1. Psychological counselling on how to cope and live with his condition especially
about dialysis
2. The patient should be informed about possible complication from her problem
and for the case of Chronic kidney disease may need dialysis in future.
 KILIMANJARO CHRISTIAN MEDICAL UNIVERSITY COLLEGE
INTERNAL MEDICINE DEPARTMENT
REG No: TUMA/KCMUCo/MD/1965
CASE 05
NAME: PATRIC BAREOMAYO NDOSSY (Ehms no. 91723)
AGE: 50 years old
SEX: MALE
RESIDENCE: Hai, Kilimanjaro
OCCUPATION: Retired bus driver
TRIBE: Chagga
RELIGION: Christian
DATE OF ADMISSION: 16th November 2020
INFORMANT: His brother (BENSON NDOSSY)

CHIEF COMPLAINT: Non projectile vomiting for 2/7

HISTORY OF PRESENTING ILLNESS:
The patient was well until last 2 day where he started to experience vomiting
which was of sudden onset progressively with time the vomitus was of recent eaten
food approximately 10 episodes in last 48 hours with 2 episodes out of 10 mixed
with blood stain. It was associated with nausea, abdominal pain with no change in
bowel habits, easy fatigability at rest and on exertion, excessive sweating with no
periodicity, increase urinary frequency of more than 3 times during night, there
was no positive history of travelling, diarrhea, fever or loss of consciousness. He
also denies difficult in breathing, awareness of heart beats, air hunger at night and
lower limb edema. His symptoms were aggravated with dry cough while sitting at
rest and drinking locally-made oral rehydration therapy couldn’t relieve the
condition.
REVIEW OF OTHER SYSTEMS:

Respiratory system: No difficulty in breathing, no cough, no hemoptysis

Cardiovascular system: No easy fatigue, no awareness of heart beat, no orthopnea,

no paraxomal nocturnal dyspnea

Musculoskeletal system: no joint pain, no muscle pain

PAST MEDICAL HISTORY

There is no history of blood transfusion

There history of minor surgery to construct fistula for dialysis

No any drugs allergies known.

FAMILY AND SOCIAL HISTORY

He lives with his wife and has 3 children he is a retired chairperson of school board
in Masama. He has no any history of drinking alcohol or cigarettes.
ON EXAMINATION

GENERAL EXAMINATION

 The patient is ill looking average man, alert oriented to time place and
people, dyspnoeic and afebrile.
 Slightly wasted
 Not pale
 No jaundice
 No cyanosis
 Finger clubbing grade 2.
 No lymphadenopathy
 No lower limb edema

Vitals signs: on admission

Blood pressure: 123/74 mmHg
Temperature: 36.7C
Respiratory rate: 30br/min
Pulse rate: 92bpm
SPO2:  99% on RA
RBG: 11.2mmol ,

ABDOMINAL EXAMINATION
Inspection
 Scaphoid abdomen
 The abdomen moves symmetrical with respiration
 The umbilical is inverted
  No any visible peristalsis
 No visible pulsation
 No visible prominent veins
 No scars or traditional marks.
Palpation
 Soft non tender abdomen with no any palpable mass on superficial palpation
 No tenderness on deep palpation
 Spleen and kidneys were not palpable
 The liver edge could feel on inspiration.
Percussion
 Normal tympanic note was heard in all 9 quadrants.
 Liver span was 6cm measured on mid clavicular line.
Auscultation
 3 bowel sounds were heard in a minute 2cm right from umbilical
 There were any bruits on renal or abdominal aorta

GENITALIA
Inspection
 Well defined diamond shaped hair pattern, shaved and circumcised.
 Normal position of urethral meatus and glans penis.
 No swelling on scrotal region and hypopigmentation.
Palpation
 No palpable induration
 Both testes are palpable in respective to hemi scrotal region.
 Spermatic cord firm and non-tender.
DIGITAL RECTAL EXAMINATION (DRE);
 Normal anal ridge and tone.
 Mobile anal mucosa.
 Grade 1 and firm.
 Fecal matter on gloves after withdraws.

RESPIRATORY SYSTEM
Inspection
 No chest deformity
 No scars or traditional marks both anteriorly posteriorly and lateral to the
chest
 Symmetrical chest movement on respiration
 Respiratory rate:27 breaths/min
Palpation
 No chest wall tenderness.
 Palpable trachea centrally located.
 Tactile vocal fremitus vibrations lateralized both sides normal
 Symmetrical normal chest expansion about 5cm on measurements.
 No palpable supraclavicular lymph nodes.
Percussion
 Normal resonance was heard on percussion both anteriorly, laterals and
posteriorly

Auscultation
 Vesicular breath sounds were heard supra-mammary on both sides of the
lungs
  Slightly reduced vesicular breath sounds infra-mammary on the both lungs
 Normal vocal fremitus was heard on both sides of the lungs

CARDIOVASCULAR SYSTEM
Peripheries
 The pulse rate was 92 beats/min, regular rhythm, normal character, slightly
decrease in volume, radial to radial synchronized and radial femoral
synchronized.
 Blood pressure was 123/74 mmHg on laying position and 115/70 mmHg on
sitting position
 Jugular venous pressure 4cm from the sternal angle
 The carotid pulse was palpable with no bruits

Inspection
 No visible pericardial activity
 No chest deformity
 Surgical scar
 No any traditional marks
Palpation
 No any chest tenderness on the chest
 Apex beat palpable left side midclavicular 5th intercostal space
 No any thrills
 No heaves were felt.
Auscultation
 Normal S1 and S2 sounds heard, no abnormal sounds were heard
  No murmurs were heard

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher centers

Conscious with the GCS of 11/15, oriented to person, place and time, pupils were
both normal and reactive to light, both short- and long-term memory were intact,
normal speech.

Cranial nerves
Cranial nerve I: Can smell different scents

Cranial nerve II: There was normal visual acuity and visual field

Cranial nerve III, IV, VI: all extraocular muscles are intact, there was movement of
eye muscles in response to the ‘H’ sign

Cranial nerve V : No loss of sensation on the face, the patient could open and close
his mouth without difficulties. Could resist force against his mouth closing and
opening movements

Cranial nerve VII: normal bilateral facial expression and no loss of taste

Cranial nerve VIII: there was no hearing loss on both Rinne’s and Weber test

Cranial nerve XI and X: symmetrical and normal movement of uvula at the midline

Cranial nerve XI: Can shrug shoulders against resistance, can move neck freely.

Cranial nerve XII: Can protrude tongue and move in all directions

Motor functions

RIGHT
 LEFT
Upper Lower Upper Lower
Tone Normal Normal Normal Normal
Reflexes Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Coordination Normal Normal Normal Normal
Sensation Normal Normal Normal Normal
Babinski Down going Down going
Clonus Negative Negative

MUSCULOSKELETAL SYSTEM

Gait - Patient could walk

Arms - Normal Bulk, Normal skin color, Free movement

Legs- Could flex

Spine - Normal Spinal curve

SUMMARY
60-year-old patient presented from renal clinic with complain of non projectile
vomiting for 2 days started gradual and kept worsening10 episodes a day,
sometimes blood-stained, projectile in nature associated with nausea, awareness of
heart beats and abdominal pain no diarrhoea. He is a known with DM2 since 2013
(started using metformin and chlorpropamide) and HTN on 2019 not on
medication and recently diagnosed with CKD, not on Renal replacement therapy.
He has several admissions from nausea and vomiting
O.E alert and fully conscious, T-36.9, BP-172/94, PR-103, RR-22br/min, RBG-
24.8mmol/L on repeat 17mmol/l, SPO2-98% on Room air, ketones negative,
protein ++ and glucose ++ on dipstick, PA -NAD. CVS- NAD, no edema, clubbed
fingers bilaterally and cyanotic tongue.
PROVISIONAL DIAGNOSIS
1. Diabetes mellitus type 2
 Differential: Late Onset Diabetes in Adults, Acute gastritis

2. Chronic kidney disease stage 5 secondary to hypertension

Differential: acute kidney injury, hypokalemia

INVESTIGATION
Labs investigations
4. Full blood picture
 Erythrocyte count………...2.9 x 10^9 cells/L L
 Haemoglobin ……………. 8.1 g/dL L
 HCT………………………23.6 % L
 With normal Leucocyte Count, MCV, MCHC, MCH and RDW
 Normal differential

Platelet Count .................................529 x 10^9/L H

5. Renal function test

 Estimated GFR (eGFR) ......... 9 ml/min
 S-Creatinine ........................... 589 μmol/L H
 Serum Na+.............................. 126.77 mmol/L L
 BUN.........................................26.60 mmol/L H
 Normal serum K+ level
6. Normal liver enzymes AST and AST

MANAGEMENT
NON-PHARMACOLOGICAL THERAPY
4. Low protein diet (0.6-0.75g/kg/day)
5. Fluid intake restriction
 6. Weight maintenance and if obesity effort to lose weight is important.

MEDICAL THERAPY
 Insulin Human injection (ACTRAPID) 10 IU stat
 Nifedipine Retard 40mg stat and then 20mg po OD 3/7
 Pantoprazole tabs 40mg PO OD 3/7
 Metoclopramide 10mg PRN

FOLLOW UP
05th December 2020
Patient likely with uremic gastritis, give actrapid 5 IU tds but measure RBG before
giving. give PP1 and observe for 24 hours. minimize fluids to oral intake 1.5L /day
for 24 hours orally. As discussed with second on call we stopped insulatard and
reduce act rapid to 5IU tds and measure glucose before administering since he has
CKD and CKD Patient ais at high risk of hypoglycemia.

06th December 2020

Patient, today has no new complaint conscious, afebrile
With vitals T- 35.9c BP-172/119 Pr-112 RR-20 RBG-22.2mmol/l SPO2-99 on RA
Continue close monitoring of his BP and blood glucose

07th December 2020

Seen patient during service ward round today has no new complaint but patient and
relatives wants to go home to send him to church for prayers 
Conscious, afebrile, not dyspnoeic with vitals of T=35.9c BP=172/119 mmHg
PR=112bpm RR=20Br/min RBG=22.2mmol/l SPO2=99 on RA
Patient relative agree to take their patient with written documents despite the
doctors counselling on the critical condition of the patient ,and agree that anything
happen to their patient will be under them and not under their doctors.
DISCHARGE NOTE
50 years, known DM for 7 years and started DM medications on MAY 2019,
Hypertensive for one year and chronic kidney disease in November 2020 at
KCMC, came with the chief compliant of vomiting eaten food material for two
days which was immediately after eating and sometimes when he has not eaten
anything, had approximately 10 episodes in which 2 to 3 was blood stained .
Associated with nausea, abdominal pain , no change in bowel habits, no heart burn
and reports normal urine output. Vomiting was aggravated with cough and had no
relieving factors. He also reports to have easy fatigability at rest and on exertion
where he can not walk unguided , associated with awareness of heart beat , no
difficult in breathing, no air hunger at night, no lower limb edema. ROS-NAD
PMHX- three past admissions , first at KIBONG'OTO for TB where he was
admitted for 2 weeks, and remaining at KCMC secondary to the same compliant.
no hx of psychiatry illness . FSHX- Married living with his wife , has two
children , retired bus driver, depends on his wife and son financially, not insured,
has a hx of using alcohol occasionally ten years ago, no hx of smoking. no hx of
chronic disease in the family. O/E conscious, GCS 15/15, afebrile, not tachypneic,
not pale, not jaundiced, not cyanosed, no lower limb edema, Vitals- T- 36.9 BP-
172/94PR-103RR-22RBG-24.8mmol/l SPO2-98% on ra RS- bilateral vesicular
sound, no added sound PA - Soft abdomen, moves with respiration, no
organomegaly. His urine dipstick showed negative ketones, protein ++ and
glucose. His labs workups; HB 8.7g/dl, creatinine 589. We gave 5IU Actrapid and
monitored his blood glucose but there's was no improvement and so we increased
dose to 8IU tds and it dropped to RBG of16mmol/l. Vomiting has stopped. We
have counselled patient on starting dialysis and to remain in the ward until his
glucose is controlled but due to financial problem they have opted to go home and
seek prayers. We are discharging him through diabetic on Wednesday 9/12/2020
and renal clinic  after two weeks.  And he is moved to insulin actrapid 15 IU am
and 10 IU pm.

PREVENTION
PRIMARY PREVENTION
1. Drink alcohol in moderation if fail to moderate its better to stop completely.
2. Avoid high potassium foods such as bananas, avocados, potatoes, fried cassava,
coffee not more than 1 cup per day, milk half pint per day(300mls).
3. Avoid large amount of salt in take in diet.
4. Quit smoking
5. Manage/control diabetes and hypertension.
SECONDARY PREVENTION
1. The patient should be given medications to treat his DM type 2 and congestive
heart failure and told to strongly adhere to medications together with attending
renal dialysis us instructed with Renal team.
2. The patient should eat more vegetables and fruits, reduce raw salt intake and
high contents of fat diet. ALL DIET SHOULD BE STRICT US GUIDED BY
RENAL TEAM
TERTIARY PREVENTION
1. Psychological counselling on how to cope and live with his condition especially
about dialysis
2. The patient should be informed about possible complication from her problem
and for the case of Chronic kidney disease may need dialysis in future.