PAEDIATRIC CASE

DEMOGRAPHIC DATA

Name : Edson J kibiki

Age : 1 year and 4 months
Sex : Male
Tribe : benna
Religion: Christian
Adress: Igawa
Informant : mother
Date of admission: 15-07-2020

CHIEF COMPLAIN

Body swelling for 2 weeks

Loss of appetite for 5 days

HISTORY OF PRESENTING ILLNESS

Seen in the patient at paediatric ward with the complain of body swelling for 2 weeks which started
gradually by swelling in the face every morning for 4 days and then swelling disappear when the child is
awake and active, then the swelling started to the lower limbs there after the upper limbs.The body
swelling is associated with reduced volume of urine, the mother reported the child passes urine once
aday. no history of pain during micturation no history of blood in urine.no hx of fever no hx of dyspnoea
no hx of cough. The child was breast fed exclusively for 6 months where she was breast fed more than 8
times aday and on every demand even at night, he started taking porridge at 7 months plus crashed
potatoes, now the child eats home food 4 times aday.

He also complained of loss of appetite for 5 days which started gradually with reject of all kind of food,
no hx of abdominal discomfort no of hx diarhoea no hx of constipation no hx of vomiting.

On admission (day 1 ) the child was given 2 injection intravenous of which the mother doesn’t know the
names. The progress of the child was poor.

REVIEW OF OTHER SYSTEMS

Respiratory System

 No cough
 No. chest pain
 No. difficulty in breathing
Cardiovascular System

 No lwer limb oedema

 No palpitation
 No fatigability
Central Never System

 No. dizziness
 No convulsion

Muscle Skeletal System

 No muscle pain
 No joint pain

Ear Nose and Throat

 No ear discharge
 No nasal discharge

PAST MEDICAL HISTORY

This is the first admission. no history of chronic illness such as diabetic mellitus,epilepsy and bronchial
asthma. no known history of foods and drugs allergy. no history of any surgical procedure.

ANTENATAL HISTORY

Booking was at 4 months. she visited 3times.the mother was given haematenics which were ferrous
sulphate and folic acid also she was given mebendazole and sulphadoxine plus pyremethamine as
intermittent preventive treatment. the mother tested for HIV/AIDS and Syphilis and the results were
negative and non reactive respectively. no any complication developed to the mother during pregnancy.

NATAL HISTORY

A baby boy was born with 3.2kg at lujewa hospital ,full term baby by spontenous virginal delivery,a child
cried soon after delivery as mother reported,duration of labour was for 22hours,and the baby was able to
suck within one hour post delivery.

POST NATAL HISTORY

No any diseases a child suffered after delivery such as yellowish colouration of the skin and
convulsion.And the cord dropped after five days post delivery.

IMMUNIZATION HISTORY

Immunized as per age.

DIETARY HISTORY

Are as per history of presenting illness.

DEVELOPMENTAL MILESTONE

A child started to smile after 4 weeks, a child started to control her neck after 4 months,a child started to
sit without support after 4 months,achild started to sit with support after 6 months.and the child started to
walks with support after 12 months ,started to walk without support after 15 months and now the child is
able to run.

FAMILY AND SOCIAL HISTORY

The mother has only one kid,she lives with her husband,both parents are form four leavers,and both are
farmers,they are neither cigarrete smoking nor alcohol takers,they live in well ventilated house.no history
of familial diseases like asthma,diabetic mellitus and epilepsy.

PHYSICAL EXAMINATION

GENERAL EXAMINATION
The patient was alert not wasted not dyspnoeic with normal hair coulor and distribution.no jaundice per
sclera no palor per conjuctiva No angular keratis and stomatitis normal warmth of upper and lower
extremities. There is pitty oedema of upper and lower limbs and sacro oedema. No finger clubbing no
fungal nail infection.

VITAL SIGNS
Temp 36.7c
Pulse rate 84beats per min
Respiratory rate 26 breath per min

Anthropometric measurements
MUAC 15CM
Weight 7.5cm
height

SUMMARY
1year and 4 months old child came with the complaints of body swelling for 2 weeks and loss of apetite
for 2 days no history of dypnoea and no history of difficulty in breathing. No history vomiting and
constipation. On examination ill looking and generalized oedema, no palm pallor no jaundice per sclera.
MANAGEMENT

PROVISION DIAGNOSIS

Nephrotic syndrome with supportive features of oliguria morning puffiness and generalized oedema

DIFFERENTIAL DIAGNOSIS
Nephritic syndrome with supportive features of anasaca oedema and oliguria but feature against of
hypertension and haematuria.

Sever acute malnutrition with supportive features of weight loss and oedema but feature against of a
good dietary hx and MUAC of 15cm.

INVESTIGATIONS
Urinalysis for protein which reviled excess protein in urine of 7g and trace microscopic haematuria

DIAGNOSIS
Nephrotic syndrome

TREATMENT
On day 1
Admitte in the paediatric ward
Give iv Ampicillin 50mg per kg 6hry for 5 days
Give frusemide tabs 1mg bd for 3 days
Give spironolactone tabs 1omg bd for 3days
Hydrocortisone 100mg bd for 3 vdays
Encourage adequate protein intake
Reduce fluid intake
Reduce table salt intake

On day 2
During service ward round the following was done;-
Continue with prescribed medication

On day 3
The progress of the patient was poor up to 3 days in the ward , oedema did not subside and the child
continued being severlly ill looking. The following was done
Refer to higher center for further management and investigations.

DISCUSSION RELATED TO NEPHROTIC SYNDROME

Nephrotic syndrome is aclinical manifestation of glomerular disease characterized by heavy proteinuria.
It is characterized by with oedema/generalized oedema, proteinuria, hypoalbunemia and
hyperlipidermia.

Investigations
Urinalysis for protein
Renal function test
Intravenous urogram

Treatment of nephrotic syndrome

Steroids forexample hydrocortisone, predinsolone
Frusemide to subside oedema
Antibiotics if signs of inflammation.
 INTERNAL MEDICINE CASE

Among the ward that found at Mbarali hospital are medical ward, the ward have several
activities that are done there. The ward is divided into two which is male ward and female ward
and each ward divided into two potion which is A and B and within this two potion there is small
rooms for the patient who use HINF card. The most diseases to patient admitted in this ward
include; Gastro enteritis, Urinary tract infection (UTI), Burn, HIV/AIDS, TB, Diarrhea, sickle
cell, Asthmatic patient and epilepsy. The mostly drugs used in this ward includs Benzyl
penicillin injection, both Diclofenac,Paracetamol,AmoxycillinErythromycin,Cotrimoxazole, both
intravenous and tablets Metronidazole.

CASE REPORT
DEMOGRAPHIC DATA
Name: YOHANA KIPANDA
Age:58 years
Sex: Male
Tribe: Kinga
Address: lujewa
Days in the ward: 1hours
Date of taking history: 14-07-2020
Chief complain;
Fever for 2 days
Lower abdominal pain for 1 day

HISTORY OF PRESENTING ILLNESS

Seen the patient in medical ward with complain of fever for 2days of sudden onset, which
was on and off, marked all the time relieved when taking medication as reported associating with
general body weakness, headache. There is no history of convulsion, cough, chest tightness, no
history of hyperactivity and lower limb oedema.
Also the patient was complaining about lower abdominal pain for one day which was for
gradual onset, relived also when taking medication associating with loss of appetite, nausea,
increase in urination, painful in urination and there is recent history of travelling to malaria
endemic area, no history of joint pain, no history of vomiting, no history of diarrhea, no history
of drinking boiled water, no history of using ITN. On admission he was given injection
intravenous which the client doesn’t know the name. Progress of the patient is poor.

REVIEW OF OTHER SYSTEM

As per HPI
PAST MEDICAL HISTORY
No history of admission,
No history of chronic illnesses like HTN and DM
No known history of food and drugs allergy.

FAMILY AND SOCIAL HISTORY

He is standard seven level of education

He is married and lives with her wife in a well-ventilated house
He is alcohol taker but not cigarate smoker
He drinks boiled water

PHYSICAL EXAMINATION
GENERAL EXAMINATION (G/E)
The patient was alert , not dyspneic , normal hair color texture and distribution , no jaundice per
sclera , no pallor per conjunctiva , no ear and nasal discharge , no angular stomatitis and chelitis ,
no oral thrush , gingivitis , no palpable enlarged lymph nodes ,normal warmth of upper and
lower extremities no palm pallor , normal capillary refill , no fungal nail infection , no finger
clubbing, no lower limb edema .

VITAL SIGNS
BP 118/78 mmHg which is normal
PR 89 Beat/Minute which is normal
RR 17 Breath per minute which is normal
Body temperature 38C which is not normal

SYSTEMIC EXAMINATION (S/E)

PER ABDOMEN (P/A)
On nspection; The abdomen moves up and down with respiration, no distended veins , no
visible mass , no surgical scar , no traditional mark, no therapeutic mark
On palpation (superficial)no any area of tenderness,on deep palpation no palpable mass, liver
and spleen were not palpable and kidney were not ballotable

Percussion; tympanic note was heard, and on uscultation three bowel sound were heard in a
minute which which is normal.

RESPIRATORY SYSTEM (R/S)

On inspection; the chest moves systematical with respiration, no chest deformity such as
scoliosis, kyphosis and lordosis,there were traditional mark but no surgical scar, no any mass
was seen.
On palpation; trachea was centrally located, bilateral equal chest expansion, normal tactile
vocal fremitus, no any area of tenderness
On percussion; resonant percussion note was heard and on auscultation normal air entry
Vesicular breath sound was heard.

NERVER SYSTEM IN HIGHER CENTRE

The patient was oriented to people place and time, long term memory and short term was intact
since the patient was able to remember the name of the first president of Tanganyika and current
president of Tanzania.
Cranial nerves
The patient was able to detect the smell of soap for each nostril separated while the eyes are
closed , patient was able to differentiate blue color from red color, patient was able to rotate the
eye ball in four planes, patient was able to open mouth against resistance, patient was able to
smile symmetrically with facial expression, patient was able to hear the rubbed finger in each ear
separately, patient was able to swallow without regurgitation, ovula was centrally located, patient
was able to shrug shoulder against resistance, patient was able to protrude the tongue
symmetrically.

MOTOR EXAMINATION
Normal; muscle bulkiness, muscle tone, muscle power of upper limbs and lower limbs which
was 5 / 5.
Reflexes
Superficial reflex; abdominal reflex was intact and plantar reflex was intact since the patient was
able to plantar flex while deep reflex, triceps , biceps and knee reflex were intact

SENSORY EXAMINATION
The patient was able to detect pain when touched by safety pin.
COORDINATION EXAMINATION
Finger to nose coordination was intact but heel to shine examination was not intact.

CARDIOVASCULAR
On inspection; no bulging on precordial area , no hyperactivity on the precordial area,no
surgical mark , no traditional mark , no visible mass.
On palpation; blood pressure as per general examination, pulse rate as per general examination
strong in volume, regular regular , non-collapsing left radial pulse synchronize with right radial
pulse, the apex beat was located at the 5th intercostal pace along the left mid-clavicular line.
On auscultation; the first and second heart sound were heard with no any added sound.

SUMMARY
A58 years male from LUJEWA admitted in medical ward with complain of fever for two
days which was on and off and lower abdominal pain for one day, on examination all vital signs
were essentially normal except body temperature which was 38C also in systemic examination
were normal, on admission blood and urine samples was taken for laboratory investigation.

PROVISION DIAGNOSIS
 Un complicated malaria
 Urinary tract infection cyctitis

INVESTIGATION
Blood sample was taken for;
 mRDT…………………Positie
 PITC regular test…………negative
Urinalysis…………………..many pus cells and epithelia cells were seen
Stool analysis……………....NIL

Confirmed diagnosis was

Uncomplicated Malaria with supportive feture of;

 mRDT was positive also; fever, loss of appetite, general body weakness,
recently history of travelling to malaria endemic area, and no history of
using insecticide treated net.
 Urinary tract infection(UTI) with supportive features of laboratory result
also on history of presenting history patient were presenting with increase
in micturition, painful in micturition, lower abdominal pain and generar
body weakness.
TREATMENT; Artmetherlumefantrin(ALU) Tab 4 tab start then 8 hour from the first dose the
12 hourly for the remaining four doses, Tab ciprofloxacin 500mg every 12houry for 5days
plusParacetamol tab 1g 8 hourly whenever necessary.

COUNSELLING;Counselled the patient sleeping on insect side treated net, to drink boiled
water, to slash bushes around the house and to maintain other environmental sanitation.

PROGNOSIS;Prognosis of the patient will be good if the above prescribed management will be
adhered.

DISCUSSION IN RELATION TO FINAL DIAGNOSIS

MALARIA AND UTI

URINARY TRACT INFECTION

Introduction; Urinary tract infection (UTI): refers to an infection that affects the organs dealing
with urination, that includes; urethra, urinary bladder, ureters and finally to the kidneys. This
infection can be classified into two parts which as follows; Lower urinary tract
infection(Cystitis) affect urethra and urinary bladder and that of upper urinary tract infection
(pyelonephraitis) that affect ureter and kidney. All this types of infection have its clinical
presentation though pyelonephraitis is very complicated cystitis
.
CLINICAL FEATURES OF EACH
For lower urinary tract infection the patient may present with; increase in urination, burning
sensation on urination, lower abdominal pain, fever, headache and general body weakness. While
for upper urinary tract infection patient may present with those of lower urinary tract plus side
angled of the libs tenderness on examination.

All this type of urinary tract infection caused by most normal flora of the gastrointestinal tract
most one is Called EscerichiaColi, and other is cklebsiella and pseudomonas.
Risk factors; sex, female are more prone to have this condition due to his anatomical position of
the genetaria, Immunalsuppression, also the patient with problem in empting urine (urinary tract
obstraction.
THE DIAGNOSIS CRITERIA
The diagnostic criteria of this disease depend on;
 History taking and laboratory investigation.
For laboratory investigation include;
 Urine for culture and sensitivity
 Urine for microscopy.
Treatment; the treatment of the disease can be treated depends on the type of organ involved, is
treated by using oral or intravenous antibiotic drugs, this depend on the site which is affected. If
is cystitis give oral antibiotics and if pyelonephritis give intravenous antibiotics. All of the
patient they should be given ant pain.

References;
Internal medicine 2 student module
Standard treatment guidelines and national essential medicine list, Tanzania main land fifth
edition November 2017
 SURGICAL CASE
Name ; Joshua mwasunga
Age : 32 yeras
Sex : male
Tribe : Mnyakyusa
Religion ; Christian
Address : Igawa
Occupation : Diver
Next of kin; brother
Date of admission: 17-07-2020

CHIEF COMPLAIN
Upper right chest pain for 1 day

HISTORY OF PRESENTING ILLNESS

Seen the patient who was involved in a motor traffic car accident while driving on his way to
ubaruku trying to escape knoking a pedestrian and falled of the brige with the car and sustained
injury on the chest. No history difficult in breathing no history of coughing blood and history of
laceration and bleeding on the injured sight.

REVIEW OF OTHER SYSTEMS

Ear Nose and Throat{ENT}
 No ear and nasal discharge
 No ear and nasal bleeding
Gastro interstinal tract{GIT}
 No diarrhea, no nausea, no vomiting, no Hx of painful swallowing, no difficult in
swallowing.
Cardiovascular System

 No. swelling of lower limbs

 No palpitation
 No fatigability
Central Never System

 No. dizziness
 No convulsion
 No. blurring in vision
PAST MEDICAL HISTORY
This is the first admission, no hx of any chronic illness such as HIV, Diabetes mellitus, no hx of
known food and drug allergy.

General examination
The patient was alert not ill looking, not dynoeic with normal hair colour texture and
distribution. No palor per conjunctiva no jaundice per sclera. No angular keratis and stomatitis
no finger clabbing no bilateral lower limb oedema no fungal nail infection.
Vital signs
Bp 130/80 mmhg
Rr 24 breath/ min
Pulse rate 83 beats / min
Temp 36.7c
Local examination
Inspection
visible mass on the right sternoclavicular joint area
right upper limb is adducted at 45 degree to the chest
no any laceration or bruises at affected site.
Palpation
Tender palpable mass on the right sternoclavicular joint
No limb shortening
Neurovascular status
Normal warmth of the upper limbs
Normal sensation because the patient was able to sense touch by soft and sharp object.

SUMMARY
A 32 year old male from Igawa presnt with complain of pain on the right upper side of the chest.
No history loss of consciousness no history of active bleeding. On eaxamination the upper right
limb is on anatomical position, visible palpable tender mass on the right sternoclavicular joint.
All vital signs were essentially normal.
MANAGEMENT
Provision diagnosis
Dislocation of right sternoclavicular joint.

Differential diagnosis
Closed fracture of the proximal one third of the right clavicle.

Investigations
Chest x ray anteria posteria view and expose the right shoulder joint.
Results
x ray revealed dislocation of the right sternoclavicular joint.

Treatment
Diclofenac injection 150mg IM bid for 3 days.
Reduction to attain joint alignment the take a control x ray
Apply figure of 8 shoulder brace for 6 weeks

DISCUSSION OF THE DISLOCATION OF THE CLAVICO

Dislocation refers to displacement of joint allignment.
The clavicle can dislocate at two joints , from sternoclavicular joint and from the shoulder joint
(acromioclavicular joint) . the most common dislocation occurs at the sternoclavicular joint.
Diagnosis is made clinically by aid of x ray. With inconsideration of role of two in ordering the
x ray.
Treatment , since fracture and dislocation can occur at the same time exclude fracture of the
clavicle before attaining the dislocated joint.
Reduction by adequate force is the most preffered treatment. Antipain is necessary during
reduction.
Apply figure of 8 shoulder brace after reduction for 4 to 6 weeks.
However dislocation and fracture of the clavicle at alarger percentage heal with malunion.

.OBSTETRIC AND GYNAECOLGY

DEMOGRAPHIC DATA
Name; Bahati Lupenza
Age : 30yrs
Sex : female
Tribe; Mpangwa
Religion: Christian
Address : lujewa
Next of kin: mother
Occupation : peasant
Gravida5 Para4 living4
LNMP 02-11-2019
EDD 09-08-2020
GA 36 weeks
Date of admission : 10-07-2020

CHIEF COMPLAIN
Per vaginal leakage for 5 hours
Lower abdominal pain for 2 hours

HISTORY OF PRESENTING ILLNESS

Seen the patient at the antenatal ward who came with the complaint of per vaginal leakage for 5
hours, the leakage is large in amount and not thick reaching at level of the feet pass by the knee,
its clear like water not foul smelling not blood stained relived by prolonged bed rest. The
leakage is aggreviated by walking. No history of absent foetal kicks no history of fever no
history of per vaginal bleeding. No history of recent abdominal trauma.

She as well presented with the complaint of lower abdominal pain for 2 hoours which was
below the umbilicus colik in nature radiating to back relieved on walking agreviated by being
station. No history of vomiting no history of constipation no history of passing loose watery
stool, no history of pain during swallowing. There is history of frequent micturation no history of
pain during micturation no history of passing blood in urine.
On admission she was examined per vagina and told that the cervix has dilated by 5 cm and she
was given bed rest and told to avoid un necessary movements. Progress of the patient is poor.
REVIEW OF OTHER SYSTEM

Respiratory System
 No cough
 No. chest pain
 No. difficulty in breathing
Cardiovascular System
  No. swelling of lower limbs
 No palpitation
 No fatigability
Central Never System
 No. dizziness
 No convulsion
 No. blurring in vision
Muscle Skeletal System
 No muscle pain
 No joint pain
 No. joint ache

PAST MEDICAL HISTORY

This is her fifth admission in the obstetric ward all the past admission were diagnosed as normal
pregnancy at term and ware managed successfully. No hx of blood transfusion, no hx of any
chronic illness such as HIV, D.M, no hx of known food and drug allergy and no hx of any
surgical procedure. .

OBSTETRIC HISTORY

Previous prengacies
This is her fifth pregnancy, the first pregnancy was in 2008, the second one was in 2013, the
third one was in 2016 and the fourth one was in 2018, she delivered successfully with no
complication and all babies were born at term in hospital and they were able to cry immediately
after delivery. All her children are alive and doing well.

Index Pregnancy

Booking was at 4 month of pregnancy she attend at clinic 3 times, blood group is
“O”Rhesus positive, screening for HIV which was negative, haemoglobin level was 12g/dl,
weight was 52kg, height was 156cm, also was given ferrous sulphate,
sulphadoxineperimethamide (SP), mabendazole, tetanus toxoid not given.
GENERAL EXAMINATION
The patient was alert not wasted not dypnoeic in pain. Normal hair colour texture and
distribution no jaundice per sclera and pallor per conjunctiva no angular stomatitis and keratis
normal warmth of the upper extremities no figure clabbing no fungal nail infection, with bilateral
ankle oedema.
Vital signs
Blood pressure 115/78 mmhg
Pulse rate 138 beats per minute
Respiratory rate 20 breath per minute

SUMMARY
A 30 years old women present with per vaginal leakage for 5 hours and lower abdominal pain
for 2 hours no history of absent foetal quicks thers history of frequent micturation but no pain
during micturation. On examination alert afebrile the fundus is soft longitudinal lie cephalic
presentation foetal heart rate 125 beats per min. cervical dilatation 5cm. Adequate room and
spontenous vaginal delivery is expected. All vital signs were essentially normal.

MANAGEMENT
Provision diagnosis
First stage of labor in active phase with supportive features of lower abdominal pain and
cervical dilatation of 5 cm.

Differential diagnosis
Wrong date

Treatment
Admit in the labor ward
Continue monitoring the progress of labor by the parameters of patograph
Monitor foetal heart rates every after 30 min
Monitor uterin contractions every after 3o mins
Perform per vaginal examination to check cervical dilatation every after 4 hours

Counseling
Counseled the patient to avoid unnecessary movements
Counseled the patient on family planning
Follow up
At around 2:35am the client was able to deliver by sponteous vaginal delivery and she gave birth to a
live baby boy weighing 3.0kg. the bay cried immediately after delivery with APGAR score of 9 with in 1
minute and 10 after 5 minutes.

DISCUSSION OF THE DIAGNOSIS

Normal Labor is a physiological series of event characterized by the presence of regular uterine
contractions with effacement and dilatation of the cervix and fetal descent.
Labor is divided into first, second and third stage. The first stage if further classified in
latent and active phase. Latent phase involves regular uterine contractions and cervical
dilatation of up to 3cm, the active phase involves regular uterine contractions and cervical
dilatation of greater than 3cm. second stage of labor involves full dilatation of cervix and
delivery of the first shoulder. Third stage involves removal of placenta and clots from the
mother plus administration of oxytocin.

Management of labor in first stage at active phase

open a patograph and manage using the parameters of patograph
check cervical dilatation every after 4 hours
monitor vital signs uterine contractions and foetal heart rate every after 30 mins.