ISLAMIC UNIVERSITY IN UGANDA

HABIB MEDICAL SCHOOL

NAME: MOHAMED HASSAN

REG NO: 217-083011-09720

COURSE: MBChB 3

FACULTY: HEALTH SCIENCE

DEPARTMENT: INTERNAL MEDICINE

TASK: INTERNAL MEDICINE CASE WRITE UP.

LECTURER: DR NSEREKO CHRISTOPHER

CASE: I present Jenifer 44 year old female from Nampunge. She is a

newly diagnosed HIV seropositive patient, not yet on Art, coming in
with the complains of:

1. Generalized abdominal pain- 4/7

2. Fever- 4/7
 BIODATA

NAME: Jenipher

AGE: 44 years

ADRESS: Nampunge

OCCUPATION: Housewife

TRIBE: Mganda

RELIGION: Christian

NEXT OF KIN: Elizabeth {mother}

DATE OF ADMISSION: 10TH / 01/ 2020

DATE OF DISCHARGE: 13TH /01/2020

PRESENTING COMPLAINTS

- Generalized abdominal pain- 4/7

- Fever- 4/7
HISTORY OF PRESENTING COMPLAIN
Jenipher was well until 4 days prior to admission when she developed generalized abdominal pain with
gradual onset. The pain was intermittent, dull in nature and not radiating, with no known aggravating or
relieving factors, however it was associated with Diarrhea and unexplained weight loss. There is no
history of, Dysphagia, Constipation, Odynophagia or Vomiting.

She also developed fever which was high grade, intermittent in nature, with no known aggravating or
relieving factors but it was associated with Headache. However, there are no history of Seizure, loss of
consciousness, photophobia, blurry vision and hearing loss.

REVIEW OF OTHER SYSTEMS

Respiratory system: She reports no history of Cough, chest pain, D.I.B, Hemoptysis and Nasal
Discharges.

Cardiovascular System: There are no history of chest pain, palpitation, easy fatigability and Body
swelling.

Genitourinary system: There was no Dysuria, frequency, hesitancy, haematuria or Urethral Discharges.

Musculoskeletal system: There was no muscle pains, joint pains, Bone pain or inability to use one limb.
 PAST MEDICAL HISTORY

This is her index admission; she has no known food and drug allergy history. She is a known HIV
serostatus patient and has no known history of chronic illnesses like hypertension, Diabetes mellitus,
and sickle cell disease.

PAST SURGICAL HISTORY

She reports no history of any surgical procedure carried out on her, and no blood transfusion history as
well.

FAMILY HISTORY

Jenipher is married and has 6 children and all are alive and healthy. There is no history of any chronic
illnesses like diabetes, hypertension, and sickle cell disease.

SOCIAL HISTORY

She stays in 2 rooms, sleeps under a mosquito net, get water from a Borehole and drink it boiled, put
rubbish in a rubbish pit.
She has no history of alcohol consumption and tobacco smoking

SUMMARY

Jenipher 44 year old female from Nampunge, a newly Diagnosed seropositive patient, coming with the
complains of Generalized abdominal pain for 4/7 which was associated with Diarrhea and unexplained
weight loss and Fever of 4/7 which was associated with Headache. However there are no history of
vomiting, Chest pain, Orthopnea, Seizure and she repots normal Micturition habit.

PHYSICAL EXAMINATION

GENERAL

A sick looking young woman, she is febrile with axillary temperature of 38 degrees Celsius, lying supine
in bed, fully conscious and alert, well oriented in time, place and person, not in respiratory distress, with
evidence of wasting. However there are no pallor, Lymphadenopathy, Dehydration or Cyanosis.

SYSTEMIC
RESPIRATORY SYSTEM

Respiratory rate was 21 breath/min, labored breathing but regular, chest was moving symmetrically
with respiration, no swellings or chest deformity, normal percussion elicited in all lung fields anterior
and posterior, there was equal air entry, normal vesicular breath sound heard and no added sound.

CARDIOVASCULAR
Pulse rate was 100b/min, regular, normal strength and volume, blood pressure 90/60 mmHg, no raised
JVP, precordium not hyperactive, apex beat located in the 5 th intercostal space mid clavicular line, heart
sounds S1 and S2 heard normally, no murmurs or added sounds.

PER ABDOMEN

Abdomen was of normal fullness moving with respiration, umbilicus inverted, no visible blood vessels or
peristaltic movements, there was superficial tenderness in the left hypochondriac region, no enlarged
organs palpable. Tympanic percussion elicited in all quadrants, bowel sounds heard and were normal.

CENTRAL NERVOUS SYSTEM

Patient fully alert and conscious, well oriented in time place and person, all cranial nerves intact, normal
muscle bulk power and tone, normal superficial and deep tendon reflexes noted.

PROBLEM LIST

- Generalized abdominal pain

- High Grade Fever
- Unexplained Weight loss
- Left hypochondriac tenderness
- HIV seropositive patient

IMPRESSION

. Abdominal TB

DIFFERENTIAL DIAGNOSIS

-acute Gastritis in the view of abdominal pain.

MANAGEMENT
Admit her and do:
Investigations

1. Abdominal ultrasound scan

2. Routine counseling and testing
3. Blood slide for malaria done and it was negative
4. Respiratory function tests not done
5. CT scan
6. CBC

Treatment
 1. Analgesic tabs Paracetamol 1g TDs
2. Antibiotics IV ceftriaxone 1g OD

FOLLOW UP

11th /01/2020

Note above history and findings. Most of the investigations have not been done.

General examination: The patient appear weak though clinical afebrile with temperature of 37.3 0c. Has
no pallor, Cyanosis, Dehydration and lymphadenopathy.

Respiratory system: Respiratory rate was 19 breath/min, the chest was moving symmetrically with
respiration, no swellings or chest deformity, normal percussion was elicited in all lung fields anterior and
posterior, there was equal air entry and no added sounds.

Cardiovascular System: Pulse rate was 98beats/min, regular, normal strength and volume, blood
pressure 112/69 mmHg, no raised JVP, precordium not hyperactive, apex beat located in the 5 th
intercostal space mid clavicular line, heart sounds S1 and S2 heard normally, no murmurs or added
sounds.

Abdominal System: Abdomen was of normal fullness moving with respiration, umbilicus inverted, no
visible blood vessels or peristaltic movements, there was superficial tenderness in the left
hypochondriac region, no enlarged organs palpable. Tympanic percussion elicited in all quadrants,
bowel sounds heard and were normal.

Nervous System: Patient fully alert and conscious, well oriented in time place and person, all cranial
nerves intact, normal muscle bulk power and tone, normal superficial and deep tendon reflexes noted.

IMPRESSION
Abdominal TB

PLAN

1. Do PCR Test
2. Do abdominal ultrasound scan?
3. Give a Corticosteroid
4. Give an ant tuberculous Drug

12th /01/2020
Note above history and findings
General Exam:
The patient appear weak though clinical afebrile with temperature of 36.8 0c. No pallor, Cyanosis,
Dehydration and lymphadenopathy.
Respiratory system: Respiratory rate was 17 breath/min, the chest was moving symmetrically with
respiration, no swellings or chest deformity, normal percussion was elicited in all lung fields anterior and
posterior, there was equal air entry and no added sounds.

Cardiovascular System: Pulse rate was 102beats/min, regular, normal strength and volume, blood
pressure 112/69 mmHg, no raised JVP, precordium not hyperactive, apex beat located in the 5 th
intercostal space mid clavicular line, heart sounds S1 and S2 heard normally, no murmurs or added
sounds.

Abdominal System: Abdomen was of normal fullness moving with respiration, umbilicus inverted, no
visible blood vessels or peristaltic movements, the superficial tenderness in the left hypochondriac
region is subsiding, no enlarged organs palpable. Tympanic percussion elicited in all quadrants, bowel
sounds heard and were normal.
Nervous System: Patient fully alert and conscious, well oriented in time place and person, all cranial
nerves intact, normal muscle bulk power and tone, normal superficial and deep tendon reflexes noted.

IMPRESSION

Abdominal TB
PLAN

1. Abdominal ultrasound scan not done yet?

2. Continue Corticosteroid
3. Continue an ant tuberculous Drug

13th /01/2020

She reports symptoms have improved and the sister requested to be discharged.

General Exam: She is clinically afebrile with temperature of 36.8 0c Per Axilla and there are no
signs of Respiratory Distress. There are No Jaundice, Cyanosis, Dehydration, Lymphadenopathy
and edema.

Respiratory Exam: There are no signs of Respiratory distress and the respiratory rate is 21
breath per minute. The chest was Clear with Normal Broncho vesicular heard and no added
sound.

Abdominal Exam: Abdomen was of normal fullness, soft, non-tender with no organomegally.

Cardiovascular System: She has a pulse rate of 89 beats per minute. On auscultation normal
heart sound S1 and S2 heard and no added sound.

CNS: She conscious and alert and her GCS Is 15/15. No Craniopathy Observed. Her Sensory,
motor and cerebellar function are intact.

IMPRESSION
Abdominal TB
PLAN
1. Culture done but the result are not yet ready.
2 Abdominal ultrasound scan done but the results not yet received.

Discharge her on initial 1st line Anti tuberculous drug such as Isoniazid along with pyridoxine (Vit B6),
Pyrazinamide, Rifampicin and Ethambutol for 2 months.

Continue Isoniazid along with Pyridoxine, Rifampicin and ethambutol (avoid résistance) for 4 months

Continue Corticosteroids.

DISCUSSION

Tuberculosis or TB is a common and often deadly infectious disease caused by various strains of
mycobacteria, usually Mycobacterium tuberculosis in humans. Tuberculosis usually attacks the lungs but
can also affect other parts of the body. It is spread through the air, when people who have the disease
cough, sneeze, or spit. Most infections in humans result in an asymptomatic, latent infection, and about
one in ten latent infections eventually progresses to active disease, which, if left untreated, kills more
than 50% of its victims.
With the advent of HIV/AIDS Tb cases have been noted to have increased rapidly.

The classic symptoms are a chronic cough, night sweats, and weight loss, which the patient presented
with, there by aiding us to the diagnosis of PTB. However, through diagnosis relies on radiology
(commonly chest X-rays), a tuberculin skin test, blood tests, as well as microscopic examination and
microbiological culture of bodily fluids. The x ray did suggest features of milliary TB, the ZN stain was
negative, but that is usually expected on the first sample, we would have required other 3 or 4 samples
but we weren’t able to do them since the patient left quite earlier, therefore no other tests were done.

I would have wanted to do further ZN stains, With TB being so much associated with HIV/AIDS of which
we suspected he had we would have wanted to do a thorough examination ascertain the TB and start
him on the anti-tuberculosis drugs, therefore I would conclude by saying we could have managed the
patient better had he been cooperative.

ABDOMINAL TUBERCULOSIS
Swallowing of the Infected Sputum, Hematological spread and rarely ingestion of milk cows infected
with Bovine strain are pathological mechanism involved in TB of GI Tract.
In Intestinal TB, Terminal ileum and cecum are most commonly involved. Abdominal pain, chronic
Diarrhea, Malabsorption, intestinal obstruction can result in Intestinal TB.
Barium studies may indicate ulceration and intestinal obstruction.
Biopsy obtained by Laparotomy or laparoscopy is often needed for Diagnosis.
In Peritoneal Tuberculosis, Tuberculous peritonitis results either from direct spread of tubercle bacilli
from a raptured lymph nodes or by Hematogenous spread. Fever, pain and ascites may develop.
Peritoneal Biopsy is often needed to establish Diagnosis.

REFERENCES

- Kumar and Clarke-Clinical Medicine 6 th edition

- Davidson
- Textbook of Mohammad Inam Danish.