HUBERT KAIRUKI MEMORIAL UNIVERSITY

FACULTY OF MEDICINE
DEPARTMENT OF INTERNAL MEDICINE

COURSE TITLE: INTERNAL MEDICINE

CORSE CODE: IM500
FACILITATOR: DR. THERESIA KIPASIKA
DATE OF SUBMISSION: 1 MARCH 2024
HISTORY TAKING AND PHYSICAL EXAMINATION ASSESMENT
GROUP C 2 MEMBERS

NAME REGISTRATION NUMBER SIGN

BERNADETHA KIMARIO HK/MD/21/2854

BENARD MGWENO HK/MD/21/2855

 FIONA KAZIMOTO HK/MD/21/2856

SALMON CHIWANGU HK/MD/21/2857

PATIENT PARTICULARS
Name: SALOME SHAURI
Age:61 years
Sex:Female
Address: Ukonga
Tribe: Sambaa
Occupation: Retired teacher
Religion: Christian
Education level: Diploma in education
Marital status: Married
Date of admission:
Date of clerkship:1/03/2024
Duration of stay:15 days post adimission
CHIEF COMPLAINT
Vomiting for two hours
HISTORY OF PRESENTING ILLNESS
The patient reported to have experienced vomiting for two hours which was persistent
that started suddenly in the afternoon upon bringing her daughter in law to the hospital
for delivery, it was associated with nausea, and body weakness which was neither
aggreviated nor relieved by any factors.

REVIEW OF OTHER SYSTEMS

Genitourinary system: There was no increased frequency of micturition or increased
volume of urine, no painful micturition, there was no genital rash, genital itching or
abnormal genital
discharge.
Cardiovascular system: no easy fatigability, no peripheral edema, no chest pain,no
syncope, no
breathlessness, no palpitations
Respiratory system: no chest pain, no cough, no hemoptysis, no breathlessness, no
productin of sputum
.
Endocrine system: no heat or cold intolerance, no excessive sweating, no unexpected
weight gain or unexpected weight loss.
Hematological system: No easy bruising or bleeding tendencies, no pallor,
Integumentary system: no rash, no itching, no redness, but presented with pain and
swelling
Central nervous system: No headache, no blurry vision, no loss of consciousness, no
dizinness,no confussion,no numbness and tingling no convulsions.
6. Past Medical History :
This is the patients first admission
She had been attending multiple diabetes mellitus and hypertension clinics.
The patient had a history of one surgery due to ceasarian section upon delivery of her
last born twenty two years ago.
She has no history of blood transfusion.
She had no any food or drug allergies.
The patient reached menopause sixteen years ago.
7. Family Social History :
The patient is married and lives with her husband who is a marketing manager.
The patient has four children three sons and one daughter who areall alive.
The patient reported not to use alcohol and does not smoke.
The patient reported using clean water and sleeping under insecticide treated net.
The patient reported a history of hereditary familial illnesses which are diabetes mellitus
and hypertension.

Summary 1:
This is 61 years old female, known hypertensive and diabetic patient who presented
with persistent vomiting for two hours. The patient reported not to have experienced
diarrhea, heart burn, gastrointestinal reflux.

GENERAL EXAMINATION

The patient was not ill looking, she had tremors

• She had evenly distributed grey colored hair
• She was not pale , not jaundiced and not cyanosed
• Has normal ears with no discharges.
• No nasal blockage, no nasal discharge.
• No angular cheilitis, normal dental formula
• She had atrophic glossitis and no oral thrush
. She had a decayed molar tooth
.She had no palpable,Cervical,axillary or inguinal lymph nodes
.She had no finger clubbing, no koilonychia, no Leukonychia, no splinter hemorrhage,
normal capillary refill of less than 2 seconds, no palmar erythema, no Osler’s
nodes, no Janeway lesions ,no peripheral lymphadenopathy, no lower limb
edema.

VITALS
Temperature :37.2°C
Pulse Rate:94 beats per minute
Respiratory Rate:20 breaths per minute
Oxygen Saturation: 96%

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM EXAMINATION

Inspection
•Her Chest was moving with respiration
• The chest was bilaterally symmetrical
• No surgical scars or traditional marks.
• There was symmetrical chest movement during respiration with a respiratory rate of
20
breaths per minute
• There was no use of accessory muscles in breathing

Palpation
• There was no tenderness, no superficial palpable lymph nodes
• No swelling/mass
The trachea was centrally located
• Apex beat palpable at the left fifth intercostal space midclavicular line
• Symmetrical chest expansion on both sides of the lungs
. Tactile fremitus was normal

Percussion
● Both the lung fields were resonant on percussion

Auscultation
●Normal vesicular breath sounds were heard in all the lung fields
●No added sounds such as wheezes, crackles.
•Vocal fremitus was normal

CARDIOVASCULAR SYSTEM EXAMINATION

● The capillary refill on the right hand was <2 seconds.
● The radial pulse of right hand was 94 bpm: regular rhythm, non-collapsing in nature,
strong volume, symmetrical to peripheral pulses( radial-radial, radial - carotid and
radial-femoral synchronicity), and the arterial walls were smooth.
● The Blood pressure= 123/70 mmHg.
. No visible pulsations on the neck.
.No jugular vein distension
• Jugular venous pressure was 7cmH20 (not elevated

Precordial examination

Inspection

No surgical scars or traditional marks.

No precordial bulging
●
No precordial hyperactivity

Palpation
● Apex beat felt at the left fifth intercostal space midclavicular,
normal character.
● No palpable murmurs(thrills)
● No left parasternal heaving
Auscultation
● Heart sounds S1 and S2 heard at the mitral, tricuspid, pulmonary
and aortic areas.
● No murmurs were heard.
● No systolic clicks and opening snaps.
● The lung bases were clear.
A 61-year-old female, known hypertensive and diabetic patient who presented at kairuki hospital with
vomiting for 2 hours before admission associated with nausea and general body weakness, on review of
other system there was no any positive findings.

On physical examination the patient vitals were normal, and on examination of cardiovascular system
and respiratory system were normal