Date 14/05/08

Identification Data
Name: w/ro Lubaba Abe
Age :30 years
Marital status :Married
Religion: Orthodox
Occupation :farmer
Comes from shewarobit and arrive to DBRH at 5 oclock (14/05/08) and admitted to gynecological ward bed number 03.
History is taken from herself

Mode of arrival :-by the support of her husband

Previous Admission:She was admitted to DBRH in 2006 E.C with a compliant of anemia for
two weeks and she was treated with iron sulphate and also given 4 units of blood .she was
discharged with good improvement.

Chief Complaint :Blurring of vision of for 8 days duration

History of Present pregnancy :This is a 30 years old gravid 2 para 1 known HIV positive
mother whose LNMP ,EDD and GA is unknown but on 14/05/08 E.C she has ultrasound at
nearby hospital from shewarobit and said that the pregnancy was 9 months.
Her menstruation had stoped following delivery of her first child in 2006 E.C.She was taken oral
contraceptive pills for 5 months to correct her menestration but ther was no improvement and
hence she discontinue.
Following this,she had gone to shewarobit health center to check her pregnancy status because of
her missed menses, before 5 months of her current visit at DBRH and her urine pregnancy test

Date 14/05/08

was positive.Starting on the day of pregnancy confirmation ,she starts ANC from shewarobit
health center for three times (3 visits)four weekly and on each visit she was told about her
weight,height and blood pressure and was smooth.
General examination was done and blood was taken and requested to laboratory and the result
was good but her serostatus to HIV which was positive.
She was given TT vaccine and oral tablet one per day possibly iron sulphate .She didnt
appreci-ate her first fetal movement.
Now she comes to our hospital with a compliant of blurring of vision for 8 days duration. She is
a well known sero positive patient and hence she is on HAART .She has also tinnitus ,vertigo ,
palpitation,easy fatigability ,drying of mouth,sore throat,difficulty of swallowing ,nausea and
vomiting . she has also dizziness while she stands from sitting position.she was treated for
malaria before two weeks and and also she was diagnosed as anemic and treated .
She has no:

headache

loss of consciousness

right upper quadrant pain

acute and chronic blood loss

orthopnea

projectile vomiting

paroxysmal nocturnal dyspnea

cough

polyuria

diarrhea

ployphagia

hemoptysis

past obstetrics history

she has one baby born in 2006 E.C at term from DBRH through vaginal delivery
with episiotomy . the labor was prolonged but didnt know which stage was and
the baby is male and alive and his weight was unknown.
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Date 14/05/08

Past gynecological history

She has seen her first menses when she was 16 years and it is regular in cycle and
the amount was moderate and the flow lasts for 3-5 days .

She has no history of abortion and STI

Contraceptive :-see HPI

Past surgical history

She has no previous surgical procedure.

Past medical history

She has no history of diabetes mellitus,hypertension,epilepsy ,asthma

Personal and social history

He was born from Afar region of farmer family and grew there well by helping
her parents by beaking and cooking.now she is living with living with her
husband and has adequate income.she is living in a well ventilated and clean
house that is free from vermin and insect.she has good social interaction with her
neighbours and her husband .she doesnt take alcohol and dont chew chat and
dont smoke ciggarte

Family history

Her father had died17 years by hemorrhoid but her mother is alive and healthy
and there is no history of daibetus mellitus , hypertension, epilepsy and asthma.

Review of Systemic
H.E.E.N.T

Head: no head injury and headache

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Date 14/05/08

Eyes: no blurring of vision, pain, lacrimation, itching and photophobia

Ears: no loss of hearing, discharge,earache

Nose: no nasal bleeding or discharge and sinusitis

Throat: no sore throat, tongue, hoarseness, bleeding from the gums and
gingivitis

Glands:

No swelling around the neck, axillae or groins.

No discharge from nipple

No lumps in the breast

Respiratory System: see HPI

Cardiovascular system:

No swelling of the leg and feet

No syncope

The other mentioned on HPI

Gastrointestinal system:

has no heart burn

no abdominal pain

no hemorrhoid

no jaundice

no black tarry stool

Date 14/05/08

Genitourinary system

no flank pain

no urinary urgency,frequency and hesitancy

no blood tinged urine

no urinary incontinence

no dysmenorrhea

no post coital bleeding

Integumentary system: no rashes, ulcers, changes in hair distribution and
change in finger nail.

Musculo Skeletal system: no muscle weakness, joint pain and swelling ,

backache, function loss of limbs and bone deformity

Allergy :- no asthma and no history of drug sensibility

Central nervous system: no forgetfulness, seizure, change in mood,
attention, dizziness , vertigo and insominia.

PHYSICAL EXAMINATION
General Appearance
The patient is alert and lying at about 400angle. She looks chronic sick looking.
Vital signs
BP: 90/50mmHg, left arm, supine position on brachial artery
Pulse Rate: 110 beats/min, regular, full in volume left radial artery
RR: 14/min, normal rhythm
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Date 14/05/08

Temperature: 35.80c, auxiliary, mid-day

H.E.E.N.T
Head: normal size, shape and hair distribution, no scar ,no hair loss.

Eyes:

pale conjunctiva,

no per-orbital edema,

ptosis,exophthalmoses or strabismus,non icteric sclera.

Ears:

normal contour of pinna;

Clear external ear canal;

no discharge

No mastoid tenderness

Nose:

nasal septum is not deviated or /and perforated

no polyp or unusual discharge

Mouth and throat:

dry buccal mucosa ,painful throat

Date 14/05/08

no fissure, ulceration or herpes, no ulceration on the gum, no dental caries , extractions,

dentures or filling.

The tongue is pink and doesnt show any atrophy

No gingival swelling and angular stomatitis

Lymphatic and glandular system

No lymphadenopathy all over the accessible lymph nodes (anterior and posterior cervical,
sub-mandibular, sub-mental, post and pre auricular, occipital, auxiliary, supra-clavicular,
epitrochlear and inguinal area with ulceration on the right and left anterior cervical).

No breast tenderness

No nipple discharge

No mass on the breast

Respiratory System
Inspection: no cyanosis or clubbing of the fingers .The palms is pale. The chest
is symmetrical. No deformities, surgical scars. No use of accessory muscle.
Palpation: The trachea is located centrally. There is no tenderness over the
anterior or posterior chest. Tactile fremitus is

normal in lung field. Chest

expansion is symmetrical.

Percussion: Both right and left side of anterior chest is resonant.

Diaphragmatic excursion is 5 cm.

Auscultation:

There is mormal air entry

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Date 14/05/08

. Breath sounds over other lung areas vesicular.

No wheezing and friction rub.

Cardiovascular system
Arterial Examination:
There is no hardening of the vessel wall.
No radio-femoral delay.
No bruit over the carotid or femoral artery.
Veinous Examination:
There are no distended veins over the neck area.

Hepato-jugular reflux positive and JVP is not raised

Precordium Examination:
Inspection:
There is no precordial bulge, precordium is quiet.
The apical impulse is visible at the fourth intercostal space along the mid
clavicular line (7cm from the sternum).
Palpation:

Date 14/05/08

The point of maximum impulse is visible. It has a diameter of 2.5 cm and it is

tapping. There is no parasternal or apical heave. There is no thrill.
Percussion: no cardiomegally,no dextrocardia.

Auscultation: Both heart sounds(S1 and S2) are normal over the valve areas.
There are no added heart sounds (split, gallop) or murmurs.

Gastrointestinal system
Inspection:

The abdomen is round, symmetrical and moves with respiration. The flank is full.
There are no dilated veins, surgical scars or masses but there are stretch marks and
linea nigra . The umbilicus is inverted. No hernia at the (epigastric, umbilical,
inguinal, femoral ) sites. No visible pulsation or peristalsis.

Auscultation:
The bowel sound is normo-active 12/minute. There is no bruit over renal artery,
abdominal aorta, iliac or femoral areas. No friction rub over the liver or the
spleen.
Palpation:
v Superficial palpation: There was no muscle spasm, or superficially palpable mass. There
was also no tenderness.
v Deep palpation: The liver is palpable up to 3 cm below the right costal margin but it
wasnt tender, not sharp, regular edge, not firm, smooth and not nodular. The spleen is not
palpable. No rebound tenderness.
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Date 14/05/08

Percussion:

Shifting dullness negative , no fluid thrill and rebound tendernessl. The total
vertical span of the liver along the right mid-clavicular line is 10 cm. Tympanic on
percussion over the abdomen.

Leiopold maneuver

The fundus is occupied by breech

Fundal heght 36 weaks

Fetal lie is oblique

Presentation is cephalic

Genitourinary System
Inspection

Pubic hair is inverted triangle

No laceration

No discharge

No urethral discharge

No bleeding

Dry skin

No purpura

Nail clubbing

No ulcer

palpation

No costovertebral angle tenderness,

no suprapubic tenderness.

Integumentary System

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Date 14/05/08

No pigmentation

No baldness

11

 Musculo Skeletal System

There is no muscle tenderness or spasm.

There is no bone deformity or tenderness.

There is no stiffness and swelling of the joint.

No lordosis ,scoliosis ,gibbus

Nervous system
Mental Status:
She knows what day is today, where he is and what his name is. Orientation
She remembers whats he ate for breakfast. She also remembers where she used to live.
Memory
She speaks in a normal voice but there is no hesitancy or gaps in the flow and rhythm of
his words. Speech
She denies any hallucinations or delusions.
She speaks fluently, good comprehension, she knows the meaning of words, she can
repeat what we say. Language

Cranial Nerves:
N-I: Smells alcohol via each nostril.
N-II: She can differentiate 2 fingers at about 4 meters. (Visual Acuity)

She sees waggling of finger approximately 1000 from axis of eye. (Visual Fields)

she differentiates green and red colors. (Color Appreciation)

 N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia.
The pupils are round, regular in outline and equal in size. They react to light directly and
consensually and accommodate normally.
N-V: she identifies cold, hot, light touch and pin prick over the mandibular, maxillary
and ophthalmic areas of the face. she closes his eyes at the touch of the cornea with a
cotton swab. Contraction of the temporal and masseter muscles is symmetrical and
strong. she can taste salt over the anterior 2/3 of the tongue.
N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising
the eye brows). she can close both eyes equally and forcefully.
N-VIII: she hears rubbing of the fingers on both ears. Rinnes test reveals air conduction
better than bone conduction in each ear, and Webers test is not lateralized.
N-IX & X: The soft palate rises in the midline when saying ah!. The gag reflex is intact
and no dysphagia and dysphonia.
N-XI: The Sternocleidomastoid and trapezius muscles contract on turning the head and
on shrugging the shoulder against resistance, respectively.
N-XII: The tongue protrudes in the midline and shows no fasciculation or atrophy.
Motor:

No involuntary movements.

Musclebulk: There is no muscle bulk difference between the left and the right side. There
is also no spontaneous as well as induced fasciculation.

Muscle tone and power.

Right

TONE

POWER

Upper

Lower

Upper

Lower

Normo-

Normo-

 Left

tonic

tonic

Normo-

Normo-

tonic

tonic

0 no active contraction 1 - flickering movements

2 - movement in horizontal axis 3

- movement against gravity only 4 - movement against gravity + mild resistance

5-

normal power
Coordination:
Finger to nose, heal to shin and rapid alternating movement of the arm were done without
any abnormalities.

Pronator Drift test was negative.

Reflexes:

Superficial reflexes: All the plantar, abdominal, cremastric & corneal reflexes are intact.

Deep tendon reflexes:

Righ

Bice

Trice

Supin

ps

ps

++

++

++

++

++

++

++

++

++

++

ator

Patell

Ankl

ar

t
Left

Clonus: No clonus

Sensory:

He identifies light touch, temperature, pressure, position sense and vibration and pin

prick over the extremities and trunk.

He appreciates the form of a key by means of only touch (Stereo gnosis)

He recognizes writings of different numbers on his palm (Graphesthesia)

He is able to differentiate 2 pin pricks up to 4 mm apart over the finger tips (2 pt

discrimination).

Meningeal Sign:

No neck stiffness.

Kernings Sign is negative.

Brudezinskis Sign is negative.

Summary
Subjective
A 30 years old gravida 2 para 1 mother presenting with blurring of vision for 8 days
duration.she also has palpitation,tinnitus,dizziness,difficulty of swallowing ,easy
fatigability,sorethroat ,dryness of mouth,nausea and vomiting..

Objective

 Chronic sick looking . Blood Pressure: 90/50mmHg, Pulse: 110/min, Respiratory Rate:
14 breaths/min, pale conjunctiva,dry buccal mucosa ,painful throat,cyanosis of lips and
dry skin

Differential Diagnosis
1

.Anemia secondary to:

1,1 .HIV
1.2 malaria

2.diabetes mellitus
3.hypoglycemia
4.acute blood loss
5.hookworm infection

Discussion of Differential Diagnosis

1.

Even

if our patient has blurring of vision that may be caused by blood seeking

hookworm infection,she has no cough and diarrhea and hence it is less likely to be the
diagnosis
2.

Even if our patient has blurring of vision that may be caused by acute blood loss,she has
no history of acute and chronic blood loss so it is less likely

3.

Our patient has no loss of consciousness even if she has blurring of vision and hence
hypoglycemia is less likely to be the cause

4.

our patient has blurring of vision but she doesnt have poly symptoms and hence it is less
likely to be the cause.

5.

our patient has blurring of vision and she is a known seropositive patient and also
comes from malarious area and treated for malaria before two weaks and hence the
blurring of vision may be secondary to anemia which is probably secondary to HIV or
malaria.

Final diagnostic impression

Anemia secondary to HIV/AIDS

Anemia secondary to malaria

Possible investigation
Blood film : Blood film to detect the protozoal parasite
Peripheral smear : to see RBC morphology
PCR to know the viral load.
Blood group and Rh antigen if she requires blood transfusion
Organ function test :liver and kidney
CBC: Hct,Hgb
FBS
Blood gas analysis

Management principle
Treat anemia conservatively
Adherence to HIV/AIDS treatment
Treat malaria accordingly

Treat the complication