ZANZIBAR SCHOOL OF HEALTH
DEPARTMENT OF HEALTH AND ALLIED SCIENCES
INDIVIDUAL TASK
MODULE NAME: COMMUNICABLE DISEASES
MODULE CODE: CMT 05101
NAME: SAID KHALFAN SAID
REGISTRATION NUMBER:S0309/0090/2017
FACILITATOR NAME: DR MAHAFUDHA
STARTING DATE: 13TH JUNE 2022
DEADLINE 19TH JUNE 2022
Issue date: 13TH JUNE 2022
Submission date: …………………………………………
TASK
COMMUNICABLE CLARK SHEET
DEMOGRAPHIC DATA
NAME: Moh’d mwinyi kondo
AGE: 59yrs
SEX male
ADDRESS kisauni
DATE OF ADMISSION
DATE OF CLERKED
CHIEF COMPLAINT
Difficult in breath 1/52
Fever 1/52
HPI
Patient was apparent well until one week started to experience difficulty in breathing which was
gradual onset increasing with severity with time more marked when laying flat but occur in all
positions and relieved when resting using 2 up to 3 pillows it aggravating when walking
associated with cough which produces white colors no blood stained sputum which has bad smell
but now no bad smell. And also Patient has on and off Fever that increasing as time goes on
released by taking paracetamol with no aggravating factor associated with blurred vision and
loss appetites, no history of headache, neither history of colvusion nor loss conscious
Has decrease weight due to the clothes Don fit well as normally
Has history of sweeting at night and wet the bed
Neither history of treated tb previously nor living with tb patient
Live in well ventilated room
ROS
Gus-no history of pain urination no history of blood in urine no history of low urine output
MSS_ no history of joint pain,no joint swelling no history of muscle pain and swelling
PMHx
Second admission where 1st admitted to arahma hospitals with same problem
No history of blood transfusion, no history of chronic illness,no history of drug allergy no history
of surgical
FAMILY AND SOCIAL HISTORY
Married live with wife,no children, no history of alcoholism no history of cigarette smoking no
history of chronic illness in the family
GENERAL EXAMINATION
Concious, afebrile, pale no jaundiced no cyanosed, no dehydrated
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Bilateral lower limb non pitching oedema up to the ankle no lymph node enlarged
Vital signs
BP:95/56Mmhg
RR:22/m
PR:100/m
Temp 36.6°C
SPO:93% on RA
SYSTEMATIC EXAMINATION
R/S: chest symmetrical move with respiration no therapeutic mark, trachea is central location,
normal chest expansion, tactile vocal fremitus, resonance note on percussion but dull on right
lower zone vesicular breath sound and course crepitating at right lower zone with fine crepitating
at left lung
CVS: capillary refills <2sec no finger climbing pulse rate normal synchronicity no pulse collapse
(PR 1min) no precordial hyperactivity no thrill no heave apex beat S1 and S2 heard, no added
sound
P/A normal abdominal contour move with respiration no surgical marks no therapeutic marks no
obvious mass
Had generalized tenderness on superficial deep palpation no organoomegally, tyrannical note on
percussion bowel sound heard
CNS Concious GSC 15/15(E4C5M6) No sign of meningial irritation short and long term
memory intact cranial nerve are intact normal sensations reflexes normal bulkiness power of
both upper and lower limb
INVESTIGATION
FBP RFT LFT SERUM ELECTROLYTE lipid profile
CHEST X-RAY
BLOOD CULTURE
COVID-19 TEST
URINALYSIS
3
RBG
SPUTUM FOR GENE EXPERT
MRDT
ECG and ECHO
PITC
PROVISIONAL DIAGNOSIS
Chronic Bronchial pneumonia
Pulmonary tuberculosis
DIFFERENTIAL DIAGNOSIS
Pneumocystis carinii pneumonia
COPD
Pulmonary
Malaria
Rheumatic heart fever
MANAGEMENT
Supportive treatment
IV fluid crystalloid
Resting
Sanction
Analgesics
Major treatment
Give antibiotics respectively to cause
If pneumonia we give benthylpenicillin 500,000 I.U STATE
GIVE TAB AMOXILLIN 500MG EVERY 8 hourly IN 7 DAYS
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If TB START TB MEDICATION. TB treatment is divided into two phases:
•
Initial /intensive phase, which consists of:
•
RHZE for 2 months - new and re-treatment cases
•
Continuation phase, which consists of:
•
RH for 4 months - new and re-treatment cases
•
RH for 10 months for severe forms
COMPLICATIONS
Heart disorder
Liver damage
Renal failure
Malnutrition
OUTCOMES
DEATHS
PROGNOSIS
The patient has difficulty in breathing with on and off Fever but if the patient use the medication
given by health care provider properly and follow proper care in prevention, he will improve well;
otherwise, the condition will continue to be worse.
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