I.

T MUKWENYA

OUTLINE FOR CONTENTS OF WARD CLERKING

PATIENT DETAILS: Name, Age, Sex, Occupation, Address, Place of birth

HISTORY

Presenting Complaints List with main complaint first, patient’s words

e.g., 1. Cough for two weeks

2. Ankle swelling for five days

History (details) of Presenting Complaints

Main complaint first

Patient’s words

Duration, timing (chronology)

Details of each presenting complaint in full

Systems Review

General fever, thirst

CVS and CHEST dyspnea, (on exertion, paroxysmal nocturnal orthopnea), wheeze.

chest pain, (ankle) swelling, palpitations, cough, sputum, hemoptysis

claudication, varicose veins

GIT appetite, weight, dysphagia, heartburn, nausea/vomiting, abdominal pain

dyspepsia, abdominal swelling, masses, change in bowel habit

(diarrhea, melena, blood, mucus, steatorrhea, pale stools, worms,

constipation), jaundice

URIRANARY frequency (day/night)- any change, dysuria, appearance, hesitancy,

 Stream, dribbling quantity, hematuria

GENITAL Female: last menstrual period, cycle, discharge, dysmenorrhea,

Menarche, post- menopausal bleeding

Male: discharge, impotence, ulcers, glands

Both: libido, warts, itching

CNS headache, loss of consciousness (fit/faint), recent head injury, change in

vision (acuity, diplopia), hearing, smell, taste, difficulty with gait, hands

(clumsy), speech, chewing, memory, calculation, mood, sleep pattern/

disturbance, paresthesia, pain, numbness/ weakness in the limbs, neck

or back pain or stiffness

MUSCULOSKELETAL back pain/stiffness, swelling, tenderness or loss of movement of

any

joint, muscle pain, weakness, wasting

SKIN itching, rash, nodules, bruising, weeping, blisters, pain

PAST MEDICAL HISTORY serious illness (admissions, injuries, chronic illness, allergies,
drug

reactions.

PRESENT MEDICATION includes over the counter, traditional “alternative” e.g.,

homeopathic

FAMILY HISTORY parents, siblings, spouse, and children

: age and health (or cause of death), chronic illness

: current or recent infectious disease

SOCIAL HISTORY present and past occupations, home circumstances, diet, alcohol,

cigarettes, recreational drugs, (how much/often for each), exercise,

recreation, sexual habits or partners, recent travel

EXAMINATION

GENERAL

sick/distressed (how e.g., wasted, restless, comatose)

level of consciousness (Glasgow), orientation, mood, speech

temperature, body build, facies, posture/position

eyes (pallor, jaundice, cyanosis, plethora, pigmentation

skin, fluid state (dry or oedema), nutrition, hands, nails

lymph nodes, other lumps, thyroid, breasts, breath (odor)

bruising, scars, traditional marks

CARDIOVASCULAR

Pulse (rate, rhythm, character), pulses: radial, brachial, central, femoral, popliteal, posterior tibial,

dorsalis, left and right, blood pressure

jugulovenous pressure (cm), neck pulsations

PRAECORDIA

Inspection: shape, scars, pulsations, deformity

Palpation: apex beat (position, character), palpable sounds, thrills

Auscultation: heart sounds (loudness, character, dominance)

added sounds, murmurs (site, timing, grade)

character, radiation, change with respiration and position

RESPIRATORY

Inspection: Respiratory rate, character, chest shape, expansion, sputum description if available

Palpation: Position of trachea, apex beat, chest expansion, vocal fremitus

Percussion: (area of dullness: mild, moderate or stony)

Auscultation: breath sounds (vesicular or bronchial)

 added sounds (crackles, wheezes, pleural rub)

vocal resonance

GIT

Inspection: Mouth, tongue

ABDOMEN

Inspection: shape, scars, masses (visible), veins, peristalsis

Palpation: Tenderness, masses, organomegaly

Percussion: Masses, shifting dullness, fluid thrill

Auscultation: bowel sounds, bruits, venous hums, rectal examination, hernias

GENITOURINARY

Men: external genitalia (ulcers, discharge, testes)

Female: external genitalia, vaginal examination

NEUROLOGICAL

1. No symptoms in the nervous system

Higher functions: conscious, oriented, alert

Cranial nerves: visual acuity, fields, pupils, external ocular movements, fundoscopy, facial sensation,
symmetry, expressions, power, hearing, palatal movements, taste, cough, tongue
movements

Upper limb and Lower limb: Inspection: (wasting, fasciculation, posture, deformity, trophic).

Tone: (2 joints, both sides), power; (2 movements per joint)

Reflexes (table, BJ/TJ, KJ/AJ/plantar), sensation 2 modalities: light touch or

pin prick coordination (limb dysmetria, ataxia, fast alternating moves)

gait, neck stiffness, punch tenderness, dorsal spine

2. Symptoms or signs referable to nervous system (may sometimes exclude chronic headache)
Higher functions: mini mental test (score/30), specific test for each lobe (e.g., two-point for parietal, pouting
for frontal), depressed?

Cranial nerves I: change in sense of smell (both nostrils)

II: visual acuity; Snellen (6/60) or N score

: visual fields; confrontation

: pupillary reflexes

: fundoscopy

III & IV: external ocular movements, ptosis, nystagmus

V: facial sensation, jaw muscles, corneal reflexes

VII: facial power, symmetry, anterior taste,

VIII: hearing

IX: palatal sensation, movements, cough reflex, gag

XI: sternocleidomastoid and trapezius

XII: tongue movements

UPPER LIMBS & LOWER LIMBS

Inspection: wasting, fasciculation, posture, deformity

tone (3 joints, both sides), power (all muscle groups)

reflexes

R B
BJ
TJ
SJ
RJ
AJ
PR
sensation 5 modalities (light, touch, proprioception, vibration sense, pain and temperature)

coordination (limb dysmetria, ataxia, fast alternating movements)

gait, neck stiffness, punch tenderness, dorsal spines

Cerebellar?

Autonomic?

MUSCULOSKELETAL inspection, palpation, ranges of movement of symptomatic

URINE: dipstick and microscopy for all patients

BLOOD: film for malaria parasites if symptomatic

SUMMARY

Not a repetition of all findings: group symptoms and signs into syndromic e.g., left heart failure: One
sentence

DIAGNOSIS/ DIFFERENTIAL DIAGNOSIS

PRESENTATION OF TYPED CASE REPORTS IS INDIVIDUAL

WORK COMPULSORY

MEDICAL CASE REPORT

Name: Innocent Mukwenya Age: 27 Sex: Male

C/F Number 272663 Ward: C10 Parirenyatwa

Admission date: 07.09.23 Discharge date; 26.09.23

Consultant: Dr. Kamba

Dept of Medicine

University of Zimbabwe

Diagnosis: Lower lobe pneumonia

1. Presenting complaints (P/C) left sided chest pain- 2 days
Cough – 2 days
Shortness of breath- 2 days
2. History of presenting complaint (HPC)
The patient was well 2 days ago when he noticed a sudden onset of sharp stabbing left sided chest
pain which was aggravated by coughing and deep breathing and associated with a cough. At first
the cough was dry but later he began to cough up about a teaspoonful of brownish red sputum per
day. He had no shortness of breath or wheezing but could not breathe deeply because of pain.
On the day of admission, he had noted sores on the lips which were painful and irritating
There was no history of immobilization or prolonged bed rest. He had no history of unconscious or
recent drunkenness or vomiting.
3. System Review
General- fever and shivering on the night before admission
Resp- HPC
CVS- No orthopnea, no paroxysmal dyspnea
No ankle oedema
No palpitations
No central chest pains
No claudication
No varicose veins
GIT- Loss of appetite: 2 days
No loss of weight
No problem swallowing or chewing
No vomiting/nausea/heartburn/hematemesis
No abdominal pain
No abdominal distension
No hernia
Opens bowels- twice a day, No pain, No recent change, No bleeding, No diarrhea
No constipation
No jaundice
GUS- No dysuria frequency x 3 Nocturia x 1 (D/N- 3/1)
Normal stream, no color of urine
No incontinence
Fully potent
 No discharge, no genital ulcers/warts, no groin lumps
CNS- Headache: Yes
Eased by simple stop pain
No recent head injury
Vision normal, no glasses, no diplopia, smells well
Hearing good, No dizziness
No neck or back pain/stiffness
No paresthesia/ muscle weakness
No fits/faints or loss of consciousness
Normal gait, no change in speech, memory, mood
No problem with chewing
Normal sleep pattern
MSS No joint pain, No joint stiffness
No joint swelling
SKIN No skin rashes
No observed lumps/swellings

4. Past Medical History

No previous operations
No hospitalization
Unsure of details of vaccination, but remembers getting BCG at school
No insurance medicals
Has had ‘bilharzia’ not treated for this
Has not attended clinic for any ill-health over 5 years
Does not visit n’anga
5. Drug History
Not on any drugs. No drug allergies known to the patient
6. Family History
Youngest of 7 siblings
All alive and well
Eldest brother (age 45) has ‘BP’
Eldest sister (age 42) has ‘Sugar disease’
Both take tablets from clinic
Parents take tablets from clinic
 Parents- father died 2002 cause not known
Mother- well
No serious illness he is aware of uncles and aunts
No history of asthma/mental illness/epilepsy
Patient is married with 3 children alive. Youngest child (born 6/12 ago0 died soon after birth with
yellow eyes. Doctors could not treat her. Died in Harare hospital.
Surviving children are alive and well. No children had illness in the last 2 or 3 weeks.
7. Social History
Employed as a carpenter by a furniture manufacturing company. Worked there since leaving school
7 years ago. Educated to form 2. Lodges with a family in Glen Norah. Single room for all 5 in
family. Municipal water and sewage. No recent travel to communal area. Patient does not take
alcohol and is a non-smoker.

EXAMINATION

General: Ill distressed, tachypneic and agitated. Fully conscious, well oriented in time, place, person.
Febrile 39 degrees Celsius. Herps simplex sores on both lips. Tinge of jaundice, central cyanosis. No
plethora or anemia. Well hydrated, no wasting. No lymphadenopathy. No skin rashes, bruising, scars.
Thyroid- normal gland and apparent function. Throat- mild inflammation. No oedema

CVS: Pulse- 120 beats per minute, regular, normal volume and character. Peripheral pulses present R and
L. BP- 140/90 mmHg. JVP-2cm

Precordium- Inspection: Chest is of normal shape, no scars, no abnormal pulsations. Palpation: Apex 5th
ICS, MCL; normal character, no thrills, no parasternal heave

Auscultation- Normal heart sounds, no added sounds, no murmurs

RS- Rusty colored sputum

Inspection: Respiratory rate- 42/min, Alar flare present

Using respiratory accessory muscles

Movements equal, R and L and shallow (2cm expansion)

Palpation: Trachea central, No tug

Apex beat 5th ICS MCL

Percussion: Increased tactile fremitus (L) lower zone posteriorly movement equal L and R
 Dullness to percussion left lower zone posteriorly. Not stony dull

Auscultation: Bronchial breathing heard over same area. Increased vocal resonance left lower zone
posteriorly. Pleural rub head over same area. No crackles/wheezes

GIT- Mouth and tongue normal

Inspection: No distension/ scars/ hernias, no visible veins, no visible peristalsis. Moves well with
respiration.

Palpation: Tender in right lower zone posteriorly. Not stony dull

Auscultation: Normal bowel sounds, no bruits or venous hums. PR normal

CNS Mental state: Fully oriented in time, place and person

Good recall- remote and recent

Intellect normal

Fully conscious

Cranial nerves

II Pupils equal and react briskly to light. Both discs seen and appeared normal

Visual fields normal. Visual acuity normal

III, IV, V Normal eye movements and reactions

VI Normal sensational

VII Normal hearing

IX, X

XII No deviation

Upper limbs and lower limbs: Bulk. No wasting of any muscle, no fascination, no contractures or deformity.
Power equal and normal in all limbs. Tone

Reflexes BJ TJ SJ KJ AJ P

L
Sensation light touch and pinprick normal

Cerebellar function normal coordination R and L

No punch tenderness over the dorsal spine, no neck stiffness

Gait: normal

GUS Genitalia normal

MSS No deformities, No joint tenderness

Normal range of movement (ROM) in all joints

SUMMARY

A 27-year-old previously well male patient with a 2-day history of pleuritic chest pain, shortness of breath
and cough productive of rusty sputum who on examination is febrile with tachypnoea and signs of
consolidation on the left lower zone.

CLINICAL DIAGNOSIS

Primary lobar pneumonia of the left lower lobe with pleurisy

DIFFERENTIAL DIAGNOSIS

1. Other types of pneumonia e.g.

a. atypical
b. inhalational
c. tuberculosis
2. Pulmonary embolism
3. Underlying factors e.g
a. foreign body
b. tumour

INVESTIGATIONS

(Normal Range)

1. FBC ESR Hb 14.06g/dL M 14-18g/Dl

WCC 22 x 103 g/L 4.5-10.5 x 103 g/L
P 87% 40-75%
L 13% 20-45%
 Others 0%
Platelets 250 x 103/L 150-400 x 103/L
MCV normal
MCH 27-32 pg
ESR 56 mm/hr 0-10 mm/hr
2. Solutum microscopy
H&S stain polymorphs and RBC
Gram Stain gram -ve diplococci
Ziehl-Neelsan: No AAFB’s seen
3. Urinalysis
Protein- glucose -ve
No WC/RC/casts
Bilirubin -ve
4. Chest X-ray
Hazy shadowing (L) lower zone with air bronchogram
Normal heart size
5. Liver function test
(Normal Range)

Bilirubin 270mmol

Conjugated 210mol/l

AST 34u/L 5-44u/L

APT 42iu/L 5-44iu/L

ALP 96/l 34-140iu/L

Total protein 66g/l 50-86g/l

Albumin 36g/l 28-53g/l

6. Blood gases PO2 46mmHg

PCO2 32mmHg 80-100
PCO3 36mmol/L 35-45
pH 7.526 7.35-7.45

NOTE: U/E, VDRL, Stool routine were not done as they were not indicated
 7. Blood Culture: Grew streptococcus pneumonia, sensitive to penicillin

DISCUSSION OF THE DIFFERENTIAL DIAGNOSIS

Lobar Pneumonia

The acute onset pleuritic chest pain and cough with rusty sputum a primary lobar pneumonia and thus
supported by the fever and signs of consolidation of the left lower lobe. The presence of herpes labialis
favors pneumococcal pneumonia. The gram stain suggests this is pneumococcal pneumonia.

The high white cell count indicates bacterial infection, although occasionally this leukemia reaction to a
viral or tube infection. This might also indicate a true position in 25 – 30 % of pneumonias and should
always in severe pneumonia

The mild proteinuria is compatible with acute fever. The bilirubin indicates that the jaundice is obstructive.
Mild cholestatic jaundice is described in severe pneumonias. Other mechanism of jaundice in pneumonia
includes hemolysis in G6PD deficiency and cold agglutinin hemolysis in mycoplasma pneumonia.

The chest X-ray confirmed left lower pneumonia. In spite of the clinical signs of consolidation it was
decided this was a necessary investigation in view of the other possible differential diagnoses.

The liver function test was a wasted test as only the bilirubin was necessary for this particular case

Other types of Pneumonia

Atypical pneumonia was unlikely. Prominent clinical signs of consolidation and the chest X-ray findings
were against this diagnosis.

The absence of a history of unconsciousness or epilepsy makes an inhalational pneumonia unlikely. The
full blood count and sputum findings are also against the diagnosis of a typical pneumonia.

Pulmonary Embolism

The arterial blood gases show hypoxemia, hypocapnia and alkalosis. This is compatible with pneumonia or
pulmonary embolus. The high fever, herpes labialis and lack on an obvious source of embolism e.g., DVT
are against this diagnosis. Mild jaundice however does occur in pulmonary embolism.

Underlying Factors

Tumor is unlikely in a patient of this age and with these signs. In addition, there is no clubbing and the
patient is a non-smoker

DEFINITIVE DIAGNOSIS
Acue (L) lower lobar pneumonia

This was reached after the high WCC confirmed infection and the organism (pneumococcal) was seen in
the sputum smear. Mild obstructive jaundice (rather than hemolytic) is a feature of pneumococcal
pneumonias as are herpes simplex sores and cyanosis, the pleural rub indicates extension of the
inflammatory process into the pleura.