NAME: LEOCADIA CASTRO TINDWA (801519)

AGE: 52

SEX: FEMALE

ADDRESS: SINZA

TRIBLE: CHAGA

OCCUPATION: INTERPREUER

RELIGION: CHRISTIAN

M/STATUS: SINGLE

INFORMANT: HIMSELF

REFERRAL: FROM INDUMANDARIN HOSPITAL FOR FURTHER INVESTIGATIONS AND MANAGEMENT

DOA: 12/07/2024

DOC: 12/07/2024

4HOURS POST ADMISSION

Known patient with DM for 13 years not in regular medications

M/Abdominal pain 3/7

HISTORY OF PRESENTING ILLNESS

The patient was apparent well until 1 day prior to admission when she started to experience abdominal
pain that was of sudden onset colicky in natured, non – radiating, no specific periodicity, no relieving
and aggravating factor, it associated with nausea, loss of appetite, early satiety and vomiting that was of
sudden onset, non-projectile containing food particles, having 4 episodes per day, each episodes is
approximated ½ of cup of tea (100ml) having no specific periodicity, no aggravating or relieving factor.
However, no history of difficult in swallowing, abdominal distension, passing of loose stool. At
indumandarin hospital blood and urine sample were taken for investigations, management done was
provision of IV fluid and antibiotics, then referred to Amana hospital. At Amana hospital blood and urine
sample was taken for investigation, management done so far is IV fluid provision, antibiotics. she is now
improving
 REVIEW OF OTHER SYSTEM

RSS: No history of cough, chest pain, difficulty in breathing

CVS: No history of awareness of heartbeat, shortness of breath, difficulty in breathing on lying flat

CNS: No history of fever, loss of consciousness, headache, problem in vision, Tingling

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

MSS: No history of muscle weakness, pain/ s

HEENT: No history of pain, bleeding or discharge

PAST MEDICAL HISTORY

Patient has history of admission 2 months ago because of peptic ulcer disease and she was cured, 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 third born in a family of 6 children on her paternal and maternal side she said there is
no history of any chronic disease or hereditary disease likes diabetes, heart diseases and hypertension.
The patient does not use alcohol and cigarettes smoking. Her education level is standard seven living in
her own house.

DIATERY HISTORY

The patient takes meal three times a day morning, noon and evening, in regular interval. She does use
vegetables and fruits frequently.

SUMMARY: 01

52 years old male known patient with DM presented with abdominal pain that associated with nausea,
loss of appetite, early satiety and vomiting.

PHYSICAL EXAMINATION

GENERAL EXAMINATION

The patient is ill looking, she is conscious, a febrile, not pale, not cyanosed, not jaundiced, not
dehydrated, not dyspneic, no angular stomatitis, oral hair leukoplakia and oral ulcers, no finger clubbing,
no nicotine stain, no Jane way lesions and osseous node, no edema, no lymphadenopathy
Temp: 36.7 Respiratory Rate 18 breaths/min.

Blood pressure: 128/84 mmHg SPO2:98% PR 92 beats per min

Pulse rate was 92 beats per minute, regular-regular, strong volume, non-collapsing, radial pulse was
synchronized with contralateral femoral pulse

SYSTEMIC EXAMINATION

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 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.

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 field.

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

CENTRAL NERVOUS SYSTEM EXAMINATION

HIGHER CENTERS
The patient has both short and long term memory, can orient to place person and time GCS15/15,
paying attention during history taking. Having good cognitive function.

All cranial nerves were intact

MOTOR SYSTEM

Patient can stand up from lying and sitting positions without difficulties, no muscle wasting, no hyper
tonicity or hypo tonicity of limbs, no spasticity and rigidity of both limbs.

SENSORY SYSTEM

Patient was able to feel the light touch of my index finger also able to feel two point discrimination

Patient was able to sense on different positions and able to sense vibrations and pain

REFLEXES

Deep tendon reflexes; There was no hypoflexia or hyperflexia elicited at patella ankle and triceps

Superficial reflexes; Babinski’s extensor plantar response was negative

Meningeal signs; kerning sign and brudzinski sign were negative

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

52 years old female known patient with DM presented with abdominal pain that associated with
nausea, loss of appetite, early satiety and vomiting. All systems were essentially normal.

PROVISIONAL DIAGNOSIS

Diabetic mellitus type 2 with diabetic gastropathy

DIFFERENTIAL DIAGNOSIS

Peptic ulcer disease

Gastroesophageal reflux disease

Gastroparesis

INVESTIGATION

Full blood picture and serum electrolyte

RBG

Urinalysis

Abdominal ultrasound

GI endoscopy

MANAGEMENT

Frequent monitoring of vital signs

IV fluid (Normal saline)

Metoclopramide, domperidone and erythomycin