LMDS

1. INTERNAL MEDICINE HISTORY
 Name;SL
 Age;50yrs
 Sex;F
 Tribe;makua
 Religi on;muslim
 Occupation;peasant
 Marital status;devorced
 D.O.A ;22nd january 2013
 D.O.C;27th january 2013
 She stays 8 days in the ward
 A known case of hypertension since 2011 under anti-hypertensive
which she doesn’t know but its of two combination.

2. M/c
 Abdominal pain 2/52 prior to admission
 Difficult in breathing 6/7 prior to admission
Amplification
Apparently the patient was doing well until she started experience abdominal
pain for 2weeks,on the right upper quadrant, which was gradual onset,throbing
in nature, the pain accompanied with abdominal distention,fulness,nausea
,which was aggravated when taking food and relived when taking panadol. No
history of diarrhoea,vomiting,constipation,difficult during swallowing.
Also the patient has history of difficult on breathing for 6days which was gradual
onset worsen during the night on lying flat and on exertion accompanied by
chest tightness and associated with chest pain and dry cough which relived on
sitting position.
She had a history of taking alcohol and cigarette smoking approximately one
packet/day and quit after diagnosed as hypertensive case.

3. Cont...............
On admission the patient was diagnosed heart failure
secondary to hypertension and managed as follows;
IV Lasix start 80mg then 40mg bd,Tabs Losatan 25mg od
14/7,Aldometone 250mg od 14/7 also patient was
catheterized.
REVIEW OF OTHER SYSTEM
CENTRAL NERVE SYSTEM
No loss of consciousness
No dizziness

4. Cont............
MUSCLOSKELETAL SYSTEM
No muscle pain
No joint pain
No neck stiffness
URINOGENITAL SYSTEM
Small amount of urine output
No pain during micturation
Urine not stained with blood
No abnormal vaginal discharge

5. PMH
 This is the 4th admission; 1st on 2009 & 2nd on 2010 both
was due to severe malaria was treated and cured at sokoine
hospital, 3rd admission on 2012 was due to abdominal
pain was treated but not cured at Nyangao hospital.
 No known history of drug allergy
 No history of surgical intervation
FSH
She lives with her 4 children (3female &1male). Has history
of asthma in her family, no history of, chronic disease .she
lives in a house of two rooms with one window at each
room

6. ON GENERAL EXAMINATION
 Afabrile on touch
 Good hair distribution texture and colour according to her
age
 No conjuctival and palmer pallor
 No nasal eye and ear discharge
 No angular stomatitis
 No cyanosis
 No oral thrush
 No lymphadenopathy
 Has lower limb pitting oedema

7. VITAL SIGNS
BP;100/60mmHg normal
PR;92b/min strong and regular
RR;23c/m normal
T;36.8c normal
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
Inspection
 Slightly distended abdomen
 Moves with respiration
 No distended vein

8. Cont............
palpation
Superficial palpation
 No tenderness
 No palpable mass
Deep palpation
 Soft tender hepatomegally
percusion
 Dullness heard
 Shifting dullness positive

9. Cont......
Auscultation
 Bowel sound present
RESPIRATORY SYSTEM
inspection
 Bilateral symmetrical and elliptical in shape
 No therapeutic or surgical mark
Palpation
 Trachea is centrally located
 Normal tactile vocal fremitus
 No tenderness
 No mass

10. Cont........
Percussion
 Normal resonant sound was heard
Auscultation
 Anterior and posterior bilateral fine crackles were
heard on the base of the lung
CARDIOVASCULAR EXAMINATION
Inspection
 Normal pericardial area

11. Cont.............
Palpation
 Apex beat is located on the 5th intercostal space on the
left side away from midclavicular line
Auscultation
 S1&S2 were heard and added sound (murmur)
CENTRAL NERVE SYSTEM
 Full concious oriented with people ,place and time
 All cranial nerves are intact

12. SUMMARY
Patient SL aged 50yrs ,female from Likwaya,came with
complaint of abdominal pain for 2weeks and difficult
in breathing for 6days. On examination, tender
hepatomegally, shifting dullness, fine crackles at the
base of the lung. On vital sign
PR:92b/min,RR;23c/min;BP;100/60mmHg,T;36.8c

13. DIAGNOSIS
 Congestive cardiac failure secondary to hypertension
DDX
 Pulmonary hypertension
 Pulmonary oedema
INVESTIGATIONS
 Chest x-ray-heart size moderate cardiomegaly, right atrium right
ventricle and left ventricular hypertrophy, alveolar infiltrate
 FBP
 Electrocardiograph
 Echocardiogram

14. MANAGEMENT
 Monitoring of vital signs
 Frusemide 40mg od for 3/7
 Losatan 25mg od for 7/7
 Juniour asprin 75mg od for 5/7