imed(1).pptx .

health science

1. INTERNAL MEDICINE

2. Demographic Data Clerk Date &Time: 20) 01/2025: 09:0 0hrs Name: Ms F.P Age: 27 years Sex: Female Marital Status: Single Religion: Christianity Occupation: Business woman Residential Address: New Kanyama Informant: Self and sister Date of Admission and Time: 1 2/01 /2025: 1000hrs Language: English

3. Presenting Complaints Weight loss 1/12 Cough 1/12 Difficulty in breathing 2/7

4. History of Presenting Complaints Weight loss started 1/12 , associated with loss of appetite , nausea , denies vomiting , abd pain and no constipation, no diarrhea and no jaundice . Cough started 1/12 , dry , no fever association , no chest pain, associated with drenching night sweats . Difficuly in breathing started gradually then worsesned 2 days before admission, accompanied with generalized body weakness , racing heart, easy fatigability and denies swollen legs / body. Positive hx of dizziness during the day associated with double vision . Denies headaches, seizures and syncope .

5. Review of systems GU S No hematuria or pain No vaginal dischrage No urinary incontinence MSS no joint pain no joint swelling No rash

6. P ast M edical and Drug Hx No History of hospital admi ssion N ewly diagnosed RVD-R upon admission has not yet commenced on H AA RT No history of Diabetes mellitus, Epilepsy, Asthma, Sickle cell anaemia / disease, hypertension , TB No history of herbal medical No known drug allergies

7. M enstural and Obstetric Hx L MP: 19/01/2025 He r period lasts for 4 days and she uses three pads per day. H er cycle is regular , denies dysmenorrhea. No hx of contraceptives. S he has two children: 1st child at 15 years and was delivered via cesarean section indication was CPD S he attended all her antenatal visits and received all hematinic s and IPT . She was RVD- NR and she delivered a 3.5kg baby who cried at birth 2 nd child at 17years via SVD, the baby was 2.8kg and cried upon delivery .

8. Family history M other is a diabetic N o TB, Asthma, SCD, Epilepsy, HTN No history of similar presentation .

9. Social history H as two child ren , claims to have one sexual partner and rarely uses protection. S he claims to take alcohol over the weekend to relax, beverage called castle lite at least 4 bottles/day . Started taking at the age of 18 till a month ago when her illness started. Does not smoke E ducational level: Grade 1 2. And she's a business woman Li ving in a 3 roomed house with 5 occupants , not well ventilated U se tap water within the yard Use a pi t latrine N o recent history of travel outside Lusaka

10. Summary FP 27 years female Newly diagnosed RVD-R who presented with weight loss, loss of appetite , dry cough , drenching night sweats and generalized body weakness for a month ,difficulties in breathing , palpitations and fatigue two days before admission with hx of dizziness and blurry vision . F P denies fever,chest pain, vomiting.

11. Impression pulmonary tuberculosis in an RVD-R

12. Differential diagnosis COVID Influenza P eumocystic pneumonia Mycobacterium Avium Complex Anemia of Chronic Diseases

13. Physical examination C onsent to examine the patient was obtained: Chaperon ( Female Med student) and exposed from neck to waist. GENERAL EXAM Young female. FP w as lying supine at 45 degrees, oriented, go PPT, of poor nutritional state, ill looking and in resp distress , with a nasal prone and 18 guage cannula in situ on left hand. GCS 15/15

14. Physical examination VITALS ON ADMISSION Temperature- 37.2 C Resp rate - 26 bpm Pulse - 94 bpm BP - 120/76 mmHg O2 SAT - 60% off oxygen and 92% on oxygen VITALS WHEN CLERKED Temperature- 36.4 C Resp rate - 2 8 bpm Pulse - 126 bpm BP - 121/78 mmHg O2 SAT - 30% off oxygen and 79% on oxygen

15. Physical examination HANDS Cold hands to touch, no finger clubbing, CRT> 3 sec, No leukonychia or kolionychia No palmar pallor , no nicotine stains, Radial pulse was regular , nonbounding , full volume and R-R synchronicity No epitrocheal and axillary lymphadenopathy.

16. Physical examination HEAD AND NECK No conjuctiva pallor , no jaundice , no cyanosis. No cervical lymphadenopathy, oral thrush, had moist membranes,

17. Physical examination CHEST Normal overlying skin, no sacrs Symmetrical chest, non tender, no masses, apex beat palpable. afebrile to touch Bilateral stoney dull sounds on percussion Bilateral bronchial sounds, coarse crakles on inspiration and expirration,no noted air entry on left miiddle and lower lobes. S1and S2 normal and regular, no additional sounds

18. Physical examination ABDOMEN Overlying skin normal, no scars , moving with respiration Soft and non tender, no distension, no masses, no enlarged organs palpable Bowl sounds every 14 seconds. MUSCKULOSKELETAL Muscle tone - normal Muscle power - 3/5 Muscle bulkness - general wasting No swelling / rash or sores

19. Summary F.P a young fe male who was in respiratory distress at rest , on oxygen, of poor nutritiona state. On auscultation bilateral coarse crackles heard and stoney dull sounds on percussion. No abdominal distension and no lymphadenopathy. Impression : Pulmonary TB in RVD-R or Pt with acute resp failure Differential Diagnosis Pneuminia in RVD-R Pleural effusin in RVD-R PCP Malignancy

20. Impression Pul monary tuberculosis in an RVD-R

21. Differential diagnosis Mycobacterium Avium Complex Acute Respiratory failure P eumocystic pneumonia

22. Management: Investigations Labs BLOOD Full blood count CD4 count CAT RPR URINE Urine LAM STOOL M/C/S

23. Management: Investigations Imaging IMAGING Chest X- ray

24. Management: Non-Pharmacological Bed rest Small frequent meals Health education on condition Psychological support Adherence support

25. Management: Pharmacology & Therapeutic O2 therapy 4-6 l/min ATT STAT Cotrimoxaxol Azithromycin Ceftriaxone Pyridoxine Hydrocortisone Fluconazole Benzathine penicillin

26. MAY HER SOUL REST IN PEACE