grand round 4

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HUBERT KAIRUKI MEMORIAL UNIVERSITY.

• GRAND ROUND PRESENTATION.
  PRESENTERS- EDWIN
  MNGONGO-HK/MD/19/2382
• RAMADHAN
  MLUNZA-HK/MD/20/2541
• MWAJUMA
  MNEDAH-HK/MD/20/2621
• ISABELLA
  MNYITAFU-HK/MD/21/2951
• GIFT MNYINGI-HK/MD/19/2474
• FACILITATOR-DR. SARAH AND DR. CONSOLATHA.

2
PATIENT PARTICULARS

• Name Hawa Siwa Rashid.
• Age 20 years old.
• Sex Female.
• Address Kigogo Mwisho.
• Tribe Mrangi.
• Religion Muslim.
• Informant Herself.
• Date of Admission 17/11/2023.
• Date of Clerkship 21/11/2023.
• Duration of stay at the hospital 5 days.

3
CHIEF COMPLAINT

• Left sided body weakness for 1/7

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HISTORY OF PRESENTING ILLNESS.

• The patient was apparently well until 1 day prior
  admission
• She started experiencing left sided body
  weakness.
• of sudden onset
• with no specific periodicity
• non progressive
• It is associated with
• Slurred speech for 1 day which was sudden
  on onset and difficulty in swallowing for both
  solid and liquids for 1 day not associated with
  vomiting, diarrhoea, constipation, loss of
  consciousness, headache, numbness, convulsion,
  muscle pain , joint pain.

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REVIEW OF THE OTHER SYSTEMS

• Genital-urinary System
• No Genital discharge
• No Genital itching
• No Genital rash
• Painful urination associated with abdominal pain
  more marked below the umbilicus sudden on onset,
  sharp pain in nature and also associated with
  urine mixed with blood.
• No change in urinary frequency
• Respiratory System
• Cough that was productive with yellowish sputum
  associated with chest pain.
• No difficulty in breathing.
• No hemoptysis.

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REVIEW OF THE OTHER SYSTEM

• Cardiovascular System
• No awareness of heartbeats.
• No lower limb swelling.
• No breathlessness when lying flat.
• Endocrine System
• No excessive thirsty.
• No heat intolerance.
• No cold intolerance.
• No neck enlargement.
• No loss of libido.

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REVIEW OF THE OTHER SYSTEM

• Hemopoetic system.
• No easy bruising.
• No bleeding tendency.
• Integumentary system.
• No skin itch.
• No skin rashes.
• No skin swelling.

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REVIEW OF THE OTHER SYSTEM

• Ear,Nose, Throat.
• No abnormal ear discharge.
• No abnormal nasal discharge.
• No difficulty in swallowing.

9
PAST MEDICAL HISTORY

• This is her first admission , no past admissions.
• No history of Blood Transfusion.
• No history of trauma/surgery.
• She has no allergy to drugs.
• She is a known patient with HIV/AIDS since birth
  on regular Tenofovir ,Lamivudine ,Dolutegravir
  medication OD.

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FAMILY HISTORY

• She is a third born out of 4 children , 3 of them
  are alive, well and have no history of HIV/AIDS.
• Her mother is alive and a known HIV/AIDS patient.
• Her father is alive and has no history of
  HIV/AIDS.
• No history of sudden death.
• Negative family history for other chronic illness
  such as Hypertension, Diabetes Mellitus.

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SOCIAL HISTORY

• She is a student with certificate level.
• She is single with no extra marital affairs.
• She has no child.
• No history of smoking.
• No history of alcohol use.
• No history of illicit drug use and abuse.

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DIETERY HISTORY

• She takes three meals per day.
• Morning she takes tea and maandazi.
• Afternoon she takes cooked rice with meat or
  beans or vegetables.
• Evening she takes cooked rice with either meat or
  beans or vegetables.
• She takes fruits such as water melon or banana.
• she drinks reasonable amount of water gt1000ml per
  day.
• She takes a balanced diet.

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SUMMARY 1.

• Female patient, 20 yrs Old from Kigogo Mwisho
  Known patient with HIV/AIDS since birth on
  Tenofovir, Lamivudine and Dolutegravir with Chief
  Complaint of left sided body weakness for one
  day associated with slurred speech and dysphagia.
  Also reported abdominal pain associated with
  hematuria and dysuria. Patient had a productive
  cough, yellowish in nature which was associated
  with chest pain.She has no history of chronic
  illness such as hypertension,Diabetes Mellitus.

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CLINICAL DIAGNOSIS BASED ON HISTORY.

• 1. STROKE.
• Reason for
• Left sided body weakness.
• loss of power in left arm.
• Immunocompromised patient.

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• Differential Diagnosis
• 1. Space Occupying Lesions.
• Reasons for
• Left sided body weakness
• Hemiplegic gait.
• Reasons against
• No vomiting.
• No headaches.
• No behavioural changes.

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• Other Diagnosis.
• 1. Pulmonary Tuberculosis
• Reasons for
• Productive cough.
• Immunocompromised.
• Reasons against
• No night sweats.
• No fever.
• Sudden onset.
• No hemoptysis.

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• 2.Urinary Tract Infection.
• Reasons for
• Haematuria.
• Painful urination.
• Abdominal pain.
• Reasons against
• No history of fever.
• 3. Community Acquired Pneumonia.
• Reasons for
• Chest pain.
• Productive cough yellow in nature.
• Reasons against
• No fever.

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PHYSICAL EXAMINATION.

• GENERAL EXAMINATION.
• Ill looking,wasted with blue cannula on her right
  hand and she was catheterized.
• She had black coloured hair well distributed with
  normal texture.
• Face is symmetrical.
• Pale eyes ,not jaundiced and cyanosed.
• No Xanthelasma,No cornea arcus.
• Normal ear set position with no abnormal
  discharges.
• No nasal blockade , no nasal discharge.
• No oral thrush no any palpable lymph nodes.
• No finger clubbing , no koilonychias, no
  leokonychia , no splinter hemorrhage.
• Normal capillary refill of less than 2 seconds,
  no palmar erythema.

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VITALS.

• Temperature 37.5 0C. (normal)
• Blood pressure 105/68 mmHg.(normal)
• Respiratory Rate 20 bpm. (normal)
• Pulse Rate 108 bpm. (tachycardia)
• SpO2 92 on room air. (normal)

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SYSTEMIC EXAMINATION.

• NERVOUS SYSTEM EXAMINATION.
• Higher Center.
• Patient was alert,fully conscious with GCS 15/15.
• Oriented to person,place and time.
• Long term memory and short term memory were
  intact.
• Normal intelligence, concentration and slurred
  speech.

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• Cranial Nerves.
• CN 1 (Olfactory)
• She has normal sense of smell
• CN 2 (Optic)
• Normal visual acuity
• Normal visual field
• Normal colour vision
• CN 3,4 6 (Occulomotor,Trochlea,Abducent )
• Normal eye ball movement

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• CN 5 (Trigeminal)
• Normal sensory function
• Normal jaw opening and closing
• CN 7 (Facial)
• Normal facial expressions.
• CN 8 (Vestibulocochlea)
• Positive Rinnes test
• Positive Webers test
• CN 9 (Glossopharyngeal)
• Normal gag reflex

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• CN 10 (Vagus)
• Patient had dysphagia for both solid and liquid
  hence vagus nerve was not intact
• CN 11 (Accessory)
• Patient can normally turn her head against
  resistance
• Patient can shrug her right shoulder but not the
  left shoulder
• CN 12 (Hypoglossal)
• Patient could not articulate words well (slurred
  speech)

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• PERIPHERAL NERVOUS SYSTEM.
• Motor system examination.
• The muscle bulkiness was normal .
• There was no any involuntary movement.
• There was normal tone for 3 limbs , No tone on
  the left arm.
• She had hemiplegic gait with normal
  coordination.
• Power was reduced to 1 , trace of contraction was
  seen.
• Biceps,triceps,patellar and Achilles tendon
  reflexes was normal on the 3 limbs , No biceps
  and triceps reflexes on the left arm.
• Sensory system examination.
• On sensory system there was normal sensation to
  sharp touch,light touch,vibration sense, joint
  position sense.

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• ON RESPIRATORY EXAMINATION
• On inspection
• The chest was symmetrical in morphology, there
  was no any therapeutic or surgical scars ,the
  chest movement was symmetrical with respiratory
  rate of 20 beats per minute.
• There was no use of accessory muscles in
  breathing.
• On palpation
• No tenderness and superficial palpable lymph
  nodes, the trachea was placed in the midline and
  the cardiac apex beat was felt on the left 5th
  intercostal space mid clavicular line,no
  superficial palpable mass.There was normal
  tactile vocal fremitus and symmetrical chest
  expansion on both sides of the lungs.
• On percussion Both the lung fields were
  resonant on percussion.

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• On auscultation
• Normal vesicular sounds were heard with fine
  crackles on the right mid infra scapular.
• ON CARDIOVASCULAR EXAMINATION.
• The Radial pulse was 98 beats/minute,regular ,
  strong with normal character and synchronous with
  contralateral pulses with blood pressure
  105/68mmHg at supine lying position heard at 1st
  and 5th Korotkoff phase.The Jugular venous
  pressure was increased with no hepatojugular
  reflux.
• On precordial examination
• On inspection There was no precordial
  hyperactivity or any bulging,there was no
  surgical or traditional scar
• On palaption The cardiac apex beat felt at the
  5th intercostal space mid clavicular line with
  normal character.There was no palpable thrills or
  parasternal heaves.
• On percussionThere was dull percussion note
  heard over the area of the heart.
• On auscultation Normal S1 and S2 were
  heard.There were no any added sounds and no extra
  sounds were heard.Fine crackles were heard at the
  base of the lungs.

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• ON GASTRO INTESTINAL SYSTEM EXAMINATION
• Per abdomen
• On Inspection
• There was normal abdominal contour and
  symmetrical in shape with normally inverted
  umbilicus , there was no any surgical or
  traditional scars.
• On palpation
• On superficial palpation there was no tenderness
  or any palpable mass.
• On deep palpation there was abdominal tenderness
  below the umbilicus.
• On percussion
• There was a tympanic note heard on the
  abdomen.
• On auscultation
• There were normal bowel sounds.

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SUMMARY 2.

• Female patient , 20yrs Old from Kigogo Mwisho
  known patient with IDS since birth on Tenofovir,
  Lamivudine and Dolutegravir with chief complaint
  of
• Left sided body weakness for 1/7.
• On examination revealed
• Slurred speech , loss of tone and reflexes on
  the left arm, No shrug of the left shoulder,
  abdominal pain below the umbilicus.She had no
  numbness on her left arm hemiplegic gait and
  dysphagia for both solid and liquid

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• 1. STROKE.
• Reasons for
• Slurred speech.
• Loss of tone on the left arm.
• No shrug of the left shoulder.

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• Differential Diagnosis.
• 1. Space Occupying Lesions.
• Reasons for
• Left sided body weakness
• Hemiplegic gait.
• Reasons against
• No vomiting.
• No headaches.
• No behavioural changes.

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• Other Diagnosis.
• 1. Pulmonary Tuberculosis.
• Reasons for
• Productive cough.
• Immunocompromised.
• Reasons against
• No excessive night sweats.
• No fever.
• Sudden onset.
• No hemoptysis.

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• 2 Community Acquired Pneumonia
• Reasons for
• chest pain
• productive cough yellow in nature
• Reasons against
• No fever.
• 3 Urinary Tract Infection
• Reasons for
• Painful urination.
• Blood mixed with urine.
• Reasons against
• No fever.

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INVESTIGATIONS.

• ROUTINE INVESTIGATIONS.
• Investigation done in the ward.
• 1 Full blood picture
• Anemia - low Hb, low MCH and low RBC due to
  hematuria.
• Leukocytosis pre-dominant neutrophilia that show
  signs of infection.
• 2 Random Blood Glucose
• To rule out DM
• 3 Lipid profile
• Increased LDL, decreased HDL signs of
  hyperlipidemia.

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INVESTIGATIONS.

• 4. Urinalysis
• Hematuria
• leucocytes
• 5. ESR
• Raised - inflammation which will show signs of
  infection
• 6. Serum electrolytes
• To chek for electrolyte levels - hypokalemia
• RELEVANT INVESTIGATIONS.
• 1 Renal Function Test
• Normal serum creatinine and Blood Urea
  Nitrates - to ruleout renal diseases.
• 2 Liver Function Test
• To check liver enzymes AST,ALT,Serum
  Bilirubin-to ruleout liver diseases.
• 3 Sputum analysis for Gene Xpert.
• To ruleout pulmonary tuberculosis

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• SPECIFIC INVESTIGATIONS.
• Imaging studies.
• 1 Non Contrasted Brain CT scan
• To check for Hemorrhaghic or Ischemic Stroke
• 2 MRI Brain Angiography
• To confirm presence of Ischemic stroke
• 3 Chest Xray
• To ruleout cardiac deseases ,cardiomegally
• To ruleout lung diseases,pneumonia.
• 4 Electrocardiogram
• To ruleout cardiac arrythmia, myocardial
  Infarction
• 5 Echocardiography
• To ruleout mitral valve diseases ,endocarditis
  and thrombus

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TREATMENT.

• Pharmacological.
• Continue ART medication.
• IV Infusion RL 500ml start.
• Hyoscine Butyl Bromide
• 20mg inj
• Anticoagulant.
• Low Molecular Weight Heparin prophylaxis against
  DVT
• Enoxaparin 40mg inj
• Antiplatelet.
• Low dose Aspirin , 75mg tabs.
• Statin.
• Lovastatin 20mg oral OD.
• Ambroxol cough syrup
• Co-Trimoxazole 480g, for prophylaxis against
  opportunistic infection.

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TREATMENT.

• Non-pharmacological.
• Physiotherapy.

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