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 SURGERY

NAME:ISACK OMWANGA SOTI

REGISTRATION NO NS5362/0027/2018
LEVEL……………………………………6
ACCADEMIC YEA 2023

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TABLE OF CONTENTS

Summary/abstract………………………………………………………………3

Acknowledgement……………………………………………………………………3

Introduction…………………………………………………………………………4

PART ONE Patient history

Patient demographic
data………………………………………………………………………………………
5…
Chief complaint and
duration…………………………………………………………………………………5…
History of presenting
illness…………………………………………………………………………………
6……
Review of other
system…………………………………………………………………………………
6……
Past medical
history………………………………………………………………………………6…
Family and social
history…………………………………………………………………………………6
PART TWO Physical examination

General
examination………………………………………………………………………………
7…
Local examination…………………………………………………………….7
Abdominal examination…………………………………………………………
7………….
Respiratory system examination……………………………………………………………
7……………………
Cardiovascular system
examination………………………………………………………………7………………
Nervous system examination………………………………………………………………
8……………….
PART THREE Diagnosis

Provisional diagnosis……………………………………………………………………
8…………….
Differential diagnosis…………………………………………………………8………..
Finaldiagnosis…………………………………………………………………9

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 Investigation ordered with their
results……………………………………………………….9
PART FOUR Treatment plan

Follow up……………………………………………………………9

PART FIVE

Discussion in relation to the final diagnosis

PART SIX Conclusion and remarks

Conclusion
Lesson learnt
Recommendation
References

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 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.HERMAN and 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 SUMMERY

The case is all about acute appendicitis according to the presentation of the patient acute appendicitis is
the inflammation appendix this can be caused by constipation and nature of food or food which lack fiber
so mostly are likely to cause inflammation of the appendix.

INTRODUCTION

The consent was obtained from the patient and confidentiality was assured

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DEMOGRAPHIC DATA

Name; AGNESS A KIMALO

Age; 29YEARS

Sex; Female

Occupation; BUSNESWOMEN

Marital status; Married

Address; kamwene

Tribe; CHAGA

D.O.A; 17/5/2023

Date hx taking; 18/5/2023

Referral status; Self referral from home

CHIEF COMPLAINT

Right lower abdominal pain 3/7

HISTORY OF PRESENTING ILLNESS

Patient was apparently well untill 3 days before admission when she started to experience right lower
abdominal pain of gradual onset colicky in nature that initially started around the umbilicus and later
shifted to the right lower abdomen which is non radiating, associated with vomiting in which vomitus was
yellowish in color, non-projectile, large in amount she vomited 7 episodes per day. Pain was relieved
when laying flat and aggravated when moving and coughing, pain increased in intensity with time and
became more severe. Patient denied history of difficulty passing stool, loss of appetite, painful
swallowing, passing loose stool, painful urination, difficulty in passing urine, blood in urine, no
abnormal vaginal discharge.

Patient reported having a tendency of eating non food material (Pemba), she eats 40 pieces for two days
and that when Pemba is not available she peels soil from house bricks and she eats, she has a poor dietary
fibers in take.

On admission she was given oral medications and intravenous fluids, currently she is still in pain.

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REVIEW OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM

 No history of air hunger at night

 No history of difficulty in breathing when laying flat
 No history of dizziness
 No history of lower limb swelling
 No history of heartbeat awareness

CENTRAL NERVOUS SYSTEM

 No history of dizziness
 No history of headache
 No history of blurred vision
 No history of convulsions
 No history of loss of consciousness

RESPIRATORY SYSTEM

 No history of cough
 No history of difficulty in breathing
 No history of shortness of breath

MUSCLESKELETAL SYSTEM

 No history of muscle pain

 No history of muscle swelling
 No history of joint pain

EAR, NOSE AND THROAT

 No history of nose and ear discharge

 No history of ear and nose bleeding

PAST MEDICAL HISTORY

 This is her second admission, first admission was on 01/03/2023 at Mlimba HC with a diagnosis
of U.T.I in which was treated and was discharged. No history of blood transfusion, no history of
surgery, no history chronic illness and no known history of drug and food allergies.

FAMILY AND SOCIAL HISTORY

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 They live a total of 10 people in an extended family, they get together for meals and also they eat
mostly carbohydrates, they eat less vegetables and fruits. No history of similar illness to any
family member and no history of familial diseases.

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PHYSICAL EXAMINATION

GENERAL EXAMINATION

 Patient is conscious, with normal hair texture, distribution and color, no pallor per conjunctiva, no
jaundice per sclera, no ear and nose discharge, no lymph nodes enlargement no central cyanosis,
no angular cheilitis, no palmar pallor, capillary refill is <2 seconds, cannulated on the right hand
and no lower limb edema.
VITAL SIGNS
 Temperature= 36.4°C
 Pulse rate= 78bpm
 Blood pressure= 120/85 mmHg
 Respiratory rate= 18cycles per minute

LOCAL EXAMINATION

 Normal abdominal contour, rebound tenderness positive, Rovsing sign positive and positive
pointing sign at McBurney's point.

PER ABDOMEN

 Normal abdominal contour, abdomen moves with respiration, no surgical scar and traditional
marks, no visible mass.
 Tenderness and no palpable mass on superficial palpation. Kidneys not ballotable, liver and
spleen were not palpable.
 Tympanic note was noted
 Bowel sounds were heard.

RESPIRATORY SYSTEM

 Normal chest cage, chest moves with respiration, no surgical scar and traditional marks, no
visible mass.
 Trachea is centrally located, normal tactile vocal fremitus, chest is bilateral symmetrical and no
tenderness on palpation.
 Resonant note was noted.
 Vesicular breathing sounds were heard.

CARDIOVASCULAR SYSTEM

 Warm extremities, capillary refill is less than 2 seconds, no finger clubbing, pulse rate is 78 beat
per min, regular - regular, strong. Blood pressure 120/85 mmHg, jugular vein not distended.
 No hyperactivity on the precordial area. No bulging of the precordial area, no surgical scar and
traditional marks.
 Apex beat was felt on the 5th intercoastal space along left mid clavicular line.
 S1 and S2 were heard in all four ascultatory areas.

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CENTRAL NERVOUS SYSTEM

 Patient is ariented to people, place and time, long and short term memory were intact since she
was able to mention her birth year an she remembered what she had for breakfast. She can smell,
she can see, she can move eyes in all four plains, she can crunch teeth, she can smile, she can
hear, she can protrude tongue, uvula is centrally located, she can shrug shoulder against
resistance,

Motor examination

 Muscle tone was good

 Muscle bulkiness is good
 Muscle power is 5/5

Reflexes

 Deep and superficial reflexes were normal

SUMMARY

 A 26 years old female from kamwen who came with chief complaint of right lower abdominal
pain for 3/7 which was gradual onset, colicky in nature, initially started around the umbilicus and
later shifted to the right lower abdomen associated with vomiting 7 episodes per day, yellowish in
color and large in amount. On examination afebrile, tenderness on the right illiac fossa, Rovsing
sign, pointing sign and rebound tenderness were all positive. Other systems were uneventful.

PROVISIONAL DIAGNOSIS

 Acute appendicitis

Supportive features: pain on the right illiac fossa (McBurney's point), Rovsing sign was positive, rebound
tenderness was positive and pointing sign was positive and associated with vomiting.

DIFFERENTIAL DIAGNOSIS

 Ruptured ectopic pregnancy due to right lower abdominal pain.

 Acute peritonitis due to gradual onset of right lower abdominal pain.

INVESTIGATIONS

 Abdominal ultrasound to check for acute peritonitis.

 Hb level
 Blood grouping and cross-matching
 Pelvic ultrasound

TREATMENT

 Iv fluids 4 litres of Ringer's lactate

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  Urethral catheterization
 Diclofenac (IM) 75mg 8 hourly for 3 days
 Metronidazole (IV) 500mg 30 minutes before surgery
 Ceftriaxone (IV) 1 g 12 hourly for 5 days
 Refer for Appendicectomy

COUNSELLING MADE

 Patient was informed about the surgical procedure (appendectomy) and the reason to do so, and
also counseling about having a positive attitude about the surgery so as to accept the outcomes of
it.

MONITORING DONE

 Vital signs were monitored oftenly and bowel sounds were checked so as to ensure that appendix
has not ruptured which will lead to peritonitis which may also cause sepsis and eventually cause
death.

OUTCOME OF TREATMENT

 The outcome will be good, since the cause of the problem will be eliminated.

FOLLOW UP

 Before and after surgery for vital signs monitoring, when any new complications arise and 7 days
after discharge.

RISK FACTORS FOR PREDISPOSITION

 Eating of non food material (Pemba) which might have caused appecindal obstruction.
 Not eating enough dietary fibers.

OTHER FEATURES OF THE DISEASE

 Fever
 Muscle guarding
 Anorexia
 Obtructor's sign
 Constipation
 Persistent abdominal pain

OTHER INVESTIGATIONS

 Complete blood count; WBC leukocytosis >10000 cells/mm³, neutrophils greater than 75%
 Abdominal x-ray to rule out perforation
 Urinalysis

OTHER TREATMENT RECEIVED

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  Patient received all the required preoperative managements.

PROGNOSIS

Prognosis is good since the disease is early diagnosed and an intervention is done.

PREVENTION

 A proper diet especially the one rich in dietary fibers should be highly emphasized.
 Avoidance of non food material.
 Drinking plenty of water or uptake of plenty of fluids.

LESSON LEARNT

 Any foreign material inside the body can lead to serious health complications.

RECOMMENDATIONS

 People should eat a well nutritious meal rather than junk food and non food stuffs such as
charcoal, soil, chalk and ashes.

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REFERENCES

 Das, S. (2004). A Manual on Clinical Surgery: 6th Edition. (2004). Calcutta: SD Distributors
 Standard treatment guidelines (2021)

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