CASE 04

NAME: SALUM SULTAN MGUMBA (801492)

AGE: 44

SEX: MALE

ADDRESS: TABATA

TRIBLE: ZARAMO

OCCUPATION: HOUSE BUILDER

RELIGION: CHRISTIAN

M/STATUS: MARRIED

INFORMANT: RELATIVE (HALIMA HASSAN- his mother)

REFERRAL: FROM NGUVU KAZI HOSPITAL FOR FURTHER INVESTIGATION AND MANAGEMENT

DOA: 7/07/2024

DOC: 12/07/2024

5 DAYS POST ADMISSION

Known patient with hypertension for 5 years not in regular medications

M/C: Right sided body weakness 5/7

HISTORY OF PRESENTING ILLNESS

The patient was apparent well until 5days prior to admission when he started to experience weakness of
right side of the body that was of sudden onset, having no specific periodicity but progressive with time,
it had no aggravated factor or relieving factor. It associated with dizziness. However no fever, headache,
loss of consciousness, confusion, neck stiffness or pain. Also no history of muscle pain and spasms, joint
pain and stiffness. Positive history of using 3 units of beer per day and 5 cigarettes per day. At Nguvu
kazi hospital blood sample was taken for investigation management done was IV fluid provision so he
was referred to Amana hospital. After arriving at Amana hospital blood and urine sample was taken for
investigations, also CT scan, X ray and abdominal ultrasound was done. Management done so far is IV
fluid provision, antibiotics and physiotherapy.

REVIEW OF OTHER SYSTEM

GIT: No history of difficulty in swallowing, abdominal pain or distension, vomiting, nausea and difficult in
passing stool.

CVS: No history of heart palpitation, orthopnea, shortness of breath, difficulty in breathing on lying flat

GUS: No history of painful urination, frequent urination, blood in urine, urine retention

RS: No history of cough, chest pain and difficulty in breathing

MSS: No joint stiffness or pain, muscle spasms or pain

HEENT: No history of pain, bleeding or discharge

PAST MEDICAL HISTORY

Patient has no history of admission, no history blood transfusion, no history of trauma or surgical
intervention, no history of food and drug allergy, no history of chronic use of medications and herbs

FAMILY AND SOCIAL HISTORY

The patient is the first born in a family of 3 children on his maternal side there is history of
hypertension but no other any chronic disease or hereditary disease likes diabetes, heart disease The
patient takes 3 units of beer and 5 cigarettes per day .

DIATERY HISTORY

The patient takes meal three times a day morning, noon and evening. He has no habit of using
vegetables and fruits frequently and no allergy to any kind of food.

SUMMARY: 01

44 years old male presented with weakness of the right side of the body, it associated with dizziness but
no fever, headache, loss of consciousness, joint pain or stiffness, muscle spasms. No history of trauma,
positive history of using alcohol and cigarette smoking

PHYSICAL EXAMINATION

GENERAL EXAMINATION

The patient is ill looking, he is conscious, afebrile, not pale, not cyanosed, not jaundiced, no
dehydration, not dyspneic, no angular stomatitis, oral hair leukoplakia and oral ulcers, no finger
clubbing, presence nicotine stain, no edema, no lymphadenopathy

Temp: 36.7 Respiratory Rate 16 breaths/min

Blood pressure: 138/88mmHg SPO2:99% Pulse rate 86 beats per min

Pulse rate was 86 beats per minute, regular-regular, strong volume, non-collapsing, radial pulse was
synchronized with contralateral femoral pulse

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM EXAMINATION

HIGHER CENTERS

The patient has both short and long term memory, can orient to place person and time with GCS 15/15,
paying attention during history taking. He had good cognitive function. Presence slurred speech

CRANIAL NERVE

- Cranial VII: Abnormal facial expression

- Cranial XI: Can only rotate neck only one side
- The other cranial nerves were intact

MENINGEAL SIGNS

Neck stiffness, Brudzinski sign and kerning sign were negative

MOTOR SYSTEM

UPPER LIMB LEFT RIGHT

Bulk Normal normal
Tone Normal Hypo tonicity
Power 5/5 1/5
Reflex Normal abnormal
LOWER LIMB
Bulk Normal normal
Tone Normal Hypo tonicity
Power 5/5 1/5

Reflex Normal abnormal

SENSORY SYSTEM

Joint position Normal

Vibration Normal
Pin prick Normal
Temperature Normal
Soft touch Normal

CORDINATION AND GAIT

Rhomberg test was

Impaired walking in straight line test

PER ABDOMINAL EXAMINATION

INSPECTION: Normal abdominal contour, moves with respiration, umbilicus is centrally located and
inverted, no visible peristalsis, no traditional or surgical scars

PALPATION: no tenderness was observed on superficial palpation and on deep palpation no any
tenderness, or mass observed, kidney, liver and spleen were not palpable. No renal angle tenderness

PERCUSSION: Normal tympanic note was heard

ON AUSCULTATION: 3 bowel sounds/min, no abdominal bruits

CARDIOVASCULAR EXAMINATION

INSPECTION: normal shape of precordium, no visible cardiac impulse, Jugular veins were not prominent

PALPATION: No swelling or tenderness at precordium, apex beat was palpable at fifth intercostal space
along mid-clavicular line

AUSCULTATION: First and second heart sounds were heard at mitral, aortic, tricuspid and pulmonary
areas. No murmur

RESPIRATORY EXAMINATION

INSPECTION: The patient has normal chest shape, no scars and chest wall is moving with respiration and
symmetrically

PALPATION: The trachea is centrally located, normal tactile vocal fremitus in all lung fields anteriorly and
posteriorly

PERCUSSION: Normal resonant sound was heard

AUSCULTATION: There were vesicular breathing sounds in all lung fields

INTERGUMENTARY SYSTEM

Hair; well distributed hair, no alopecia, normal texture and color

Skin; No hypopigmentation, rashes, subcutaneous swelling sores and swelling

Nails; No koilonychias, bleeding from nail bed color change, shape change or pain

Mucous membrane; No bleeding, change in color or soreness

 SUMMARY: 2

44 years old male presented with weakness of the right side of the body, it associated with dizziness but
no fever, headache, loss of consciousness, joint pain or stiffness, muscle spasms. No history of trauma,
positive history of using alcohol and cigarette smoking. On examination presences of slurred speech, on
right side of both upper and lower limbs, there was abnormal gait and reflexes, power 1/5, hypo
tonicity. There was abnormal facial expression. Other systems were essentially normal.

PROVISIONAL DIAGNOSIS

Hypertension with ischemic stroke

DIFFERENTIAL DIAGNOSIS

Hemorrhagic stroke

Brain tumor

Hypertensive encephalopathy

INVESTIGATION

Full blood picture and serum electrolyte

RBG

Urinalysis

MRDT

CT scan

MANAGEMENT

Frequent monitoring of vital signs

IV fluid

Antihypertensive drugs (labetalol 10 -20 mg infusion 1-2min until BP is attained)

Acetylsalicylic acid (PO) 325mg 24 hourly for 4 weeks