The document is a case report from Mlimba Institute of Health and Allied Sciences regarding a patient named Isack Omwang Soti. It includes sections on the patient's history, physical examination, diagnosis, treatment plan and follow up. The patient, a 32 year old female, presented with abdominal pain and painful urination. The physical examination revealed mild abdominal tenderness but no other abnormalities. The provisional diagnosis was cystitis based on the symptoms. The treatment plan included IV antibiotics, IV fluids and oral antibiotics.
The document is a case report from Mlimba Institute of Health and Allied Sciences regarding a patient named Isack Omwang Soti. It includes sections on the patient's history, physical examination, diagnosis, treatment plan and follow up. The patient, a 32 year old female, presented with abdominal pain and painful urination. The physical examination revealed mild abdominal tenderness but no other abnormalities. The provisional diagnosis was cystitis based on the symptoms. The treatment plan included IV antibiotics, IV fluids and oral antibiotics.
The document is a case report from Mlimba Institute of Health and Allied Sciences regarding a patient named Isack Omwang Soti. It includes sections on the patient's history, physical examination, diagnosis, treatment plan and follow up. The patient, a 32 year old female, presented with abdominal pain and painful urination. The physical examination revealed mild abdominal tenderness but no other abnormalities. The provisional diagnosis was cystitis based on the symptoms. The treatment plan included IV antibiotics, IV fluids and oral antibiotics.
The document is a case report from Mlimba Institute of Health and Allied Sciences regarding a patient named Isack Omwang Soti. It includes sections on the patient's history, physical examination, diagnosis, treatment plan and follow up. The patient, a 32 year old female, presented with abdominal pain and painful urination. The physical examination revealed mild abdominal tenderness but no other abnormalities. The provisional diagnosis was cystitis based on the symptoms. The treatment plan included IV antibiotics, IV fluids and oral antibiotics.
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THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH TANGANYIKA MEDICAL TRAINING BOARD MLIMBA INSTITUTE OF HEALTH AND ALLIED SCIENCES CASE REPORT FOR CONTINUOUS ASSESSMENT- ASSIGNMENT II APPRENTICESHIP IN INTERNAL MEDICINE
NAME:ISACK OMWANGA SOTI
REGISTRATION NO:NS 5362/0027/2018
LEVEL……………………………………. 6 ACCADEMIC YEAR 2022/2023
1 TABLE OF CONTENTS Summary/abstract………………………………………………………………3 Acknowledgement………………………………………………………………3…… Introduction………………………………………………………………………3… PART ONE Patient history Patient demographic data…………………………………………………………………………4……… Chief complaint and duration………………………………………………………………………4……… History of presenting illness…………………………………………………………………………4……… Review of other system…………………………………………………………………………4…… Past medical history……………………………………………………………………………5… Family and social history…………………………………………………………………………… 5………… PART TWO Physical examination General examination………………………………………………………………………6… Abdominal examination…………………………………………………………………….6 Respiratory system examination………………………………………………………………………6… Cardiovascular system examination…………………………………………………………………6 Nervous system examination……………………………………………………………………6…. PART THREE Diagnosis Provisional diagnosis………………………………………………………………………… 7……. Differential diagnosis……………………………………………………………… 7….. Finaldiagnosis…………………………………………………………………8 Investigation ordered with their results……………………………………………………….8 PART FOUR Treatment plan Follow up……………………………………………………………….8 PART FIVE Discussion in relation to the final diagnosis PART SIX Conclusion and remarks Conclusion
2 Lesson learnt Recommendation References
3 ACKNOWLEDGEMENT I would like to thanks Arlmighty God for giving me the ability of participating and learning during the rotation in the obstetrics and gynecology ward. Also much thanks to MIHAS management for providing information and directions toward the completion and achievement of my goals fore most to the Principal DR Mwakanyamale and academic DR Myembe Also great full thanks to hospital management for allowing me to conduct rotation in the hospital for the purpose of learning Much thanks to Dr.HERMANand Dr, ALLERN for taking their time and joining with us at the clinical area, teaching and implementing some knowledge to us. Also much thanks to nurses supervisor in pediatrics ward for being with me during my learning in the ward Thanks to the class representatives CRs for their contribution on providing with information on what to do at the certain time
ABSTRUCT AND INTRODUCTION
Cystitis have been being a case not mostly but can be caused by various causes like infection trauma and urine obstruction but also kidney stone This have discussed about cystitis and how it complicates if not treated and also sexual transmitted infection can cause it.
The consent was obtained from the patient and patient confidentiality was assured to the patient.
4 PATIENT’S IDENTIFICATION
NAME; hamisa mbughi
AGE; 32 years SEX; FEMALE ADDRESS; msimbazi RELIGION; Christian TRIBE; BENA OCCUPATION; peasant DATE OF ADMISION; 23/05/2023 DATE OF HISTORY TAKING; 24/05/2023
MAIN COMPLAINT(S): Abdominal pain 3/7
HISTORY OF PRESENTING ILLNES
A patient was apparently well until 3 days ago when she experienced an acute onset of lower abdominal pain that was radiating from the suprapubic area toward the back. The pain had no periodicity but it is aggravated by bending forward and is relieved when she sleep. The pain was associated with mild fever, loss of appetite mild lower back pain and general body weakness. But no diarrhoea, no constipation, no vomiting. The second day she noted painful during mituraton that was also acute onset increasing in severity as time goes. The pain was burning in nature with no periodicity other than during urination. The pain has unknown aggravating and relieving factors. But no haematuria, no urine retention.
REVIEW OF OTHER SYSTEM
Central nervous system;
No head ache, No conversion, No dizziness, Cardiovascular system; No swelling of lower limb, No palpitation, No chest pain
Respiratory system; No cough, No difficulty in breathing, No chest tightness,
5 Musculoskeletal system; No joint pain, No muscle pain, No joint swelling
PAST MEDICAL HISTORY
The patient had no history of previous admission but she had history of the same symptoms as she have now. She used flagily from pharmacy for one week and she recovered. This is the first admission. She had no surgical history and any previous pelvic inflammatory diseases.
FAMILLY & SOCIAL HISTORY.
She is not marred, she live with her parents, she is not doing any job, her level of education is form four. She not using any alcohol drinks also she not using a cigarette. Her father is a watcher man but her mother is house wife. There is no any inherited diseases to their family such as; sickle cell, Diabete mellitus, epilepsy, except hypertension where by her mother is suffering for about six years and she is on regular medication.
PHYSICAL EXAMINATION GENERAL EXAMINATION; She is alert, she have normal hair colour distribution and texture. Her eyes have no signs of anaemia and jaundice. No angular stomatitis, Her skin is normal with no rashes, no cyanosis no pustules No discharge or redness from the ears, no oral thrash, No enlargement of lymph nodes , no lower limb swelling her palm are not pale, no finger clubbing, the capillary refill also is good.
SYSTEMIC EXAMINATION Abdominal examination. The stomach moves with respiration, The umbilicus is inverted , No engorgement of vein , No visible peristalsis, No visible mass. Palpation
6 No palpable mass, No tenderness , No enlargements of abdominal organ such as liver, kidney, spleen and pancreas but she experience a mild lower abdominal pain during deep palpation.
Percussion On percussion tympanic note was heard , Auscultation On auscultation a bowel sound was heard
Central nevous system
She is alert, oriented to people,place and time The short and long memory is good. She can speak , can hear, can move, and she can swallow. Also she can see,can shrug her shoulder,her muscle tone,muscle buck and muscle power are good Generally no abnormality detected.
Respiratory system Inspection
The chest is symetry,
Move with respiration, Have no any mark such as surgical mark or traditional mark ,
No any visible mass and scars.
Palpation
Trachea is centrally located,
No palpable mass, No tenderness, The tactile vocal fremitus is normal (is not increased or decreased). Percussion On percussion resonance sound was heard Auscultation The vesicular sound was head with no any added sound like crackles sound.
Cardiovascular system Inspection
No any protruded blood vessel such as deep and superficial jugular vein No swelling of lower limbs Palpation The apex beat is located at 5th intercostal muscles of left clavicular line.
7 Auscultation Heart sound 1 and 2 heard normal No added sound such as murmurs.
SAMMARY R/ M. 31years old came with complaints of lower abdominal pin for 2/7 and painful during urination for 1/7 which are associated with general body malaise, mild lower back pain plus loss of appetite and mild fever. On examination no any positive finding.
PROVISSION DIAGNOSIS The provisional diagnosis is cystitis. This is because of these features; Painful during urination, mild fever, lower abdominal pain.
DIFFERENTIAL DIAGNOSIS. Pelvic Inflammatory Diseases (P.I.Ds) Trichomoniasis and Interstitial cystitis and Vaginitis due to candida
Intravenous(IV) antimicrobial therapy, ceftriaxone 1g BD for 2 days IV fluid 2l ringers lactate for resuscitation to restore appropriate circulatory volume and promote adequate urinary flow. Also she can use antibiotic such as Amoxicillin 500mg PO 12hr for 5 days. Antipyretics is needed to relieve fever PO paracetamol 2g TDS for 5 days FOLOW UP Routine supervision and review a patient for a new complait(s). If a new complaint(s) arise, treat them in early stage to prevent complication and deformities. RISK FACTORS • Previous history of UTI • Catheterization • Age (adults are at increased risk of developing UTI) • Sex , being female increase risk to UTI • changes in immune system FEATURES NOT DEMOSTRATED BY THE PATIENT • Unexplained argue to urinate • Flank pain • Nausea and vomiting • Fever and chills RELEVANT INVESTIGATIONS
PROGNOSIS The prognosis will be good if she will adhere to the medication given and if she will follow the prevention ways here under.
PREVENTION Proper personal hygiene To seek medical help when she experience any abnormal signs and symptoms at early stage to prevent development of disease Health education is also more important for people to protect themselves against squaring diseases.
CONCLUSION Is essential to report common conditions like UTIS as they are contradicted with other sexual transmitted diseases like chymidia, fungal, herpes virus, infection which presents with pain urination LESSON LEARNT I have learnt that some patients have no tendency for regular health check-up which increases the chronicity of the disease also other patients have poor conception regarding u.t.i and other sexual transmitted infection Also now am able to manage and diagnose the diseases and to educate the society on how to be free from the disease RECOMMENDATIONS I recommend home safe practises may aid to prevent urinary tract infections Such practise are hygiene, drinking plenty of fluid especially water , emptying bladder often, urinating soon after sex and wipe front to back
9 REFFERENCE
Braunwald, E. & Fauci, A.S. (2001). Harrison’s Principles of Internal Medicine.
McGraw Hill. Cumming A.D. (2003). Davidson’s Principles and Practice of Medicine. Edingurgh,Oxford: Elsevier Saunders. MOHSW (2005). Tanzania National Formulary. Dar es Salaam, Tanzania: Ministry of Health and Social Welfare. Kumar, P. & Clark, M. (2007). Clinical Medicine (6th ed.). Edingurgh, Oxford: Elsevier Saunders.
