2.a 27 years old man presented to the hospital with the complaints of painful vesicels on the left side of the face for 3 days. This was protected by intestine itching of the area but currently non- itch .on examination febrile with vesicles involving the left side of the face along the veclometome with periobital oedema some of the vesicles have ruptured, HIV test reactive .

(a) what is diagnosis:  HIV/AIDS stage II with Herpes Zoster
Reasons: HIV positive patient with Vesicular skin lesions that are painful and do not close the midline
Dx: Chicken Pox (read the differences against Herpes zoster)


(b) outline treatment plan
For sake of knowledge: Herpes zoster is viral infection caused by varicella zoster virus,therefore treatment will be giving anti-viral medication commonly acyclovir either cream or tabs
1. T. acyclovir 800mg 5times a day x 7/7

Because some vesicles are ruptured this can be a route of infection therefore we need to give wound care medications

Mupirocin cream 12hrly 


But probably this is a HIV Naïve patient (I mean not on Rx) therefore we need to link to CTC team for initiation of ART

Do baseline investigations i.e FBP,LFT and RFT and Initiate antiretroviral medications preferably TLE


For sake of knowledge: We Do baseline investigations because some ARTs cause anaemia, some cause liver and renal damage so we need to ensure someone is clinically stable before initiating such toxic drugs


3. A 55 years woman was brought to dispensary with the hx of severe headache and inability to move the right upper and lower limbs for past 32 hrs. On examination consciousness GLS 14/15.muscle power grade 2 both limbs ,left and lower limb group of muscles vital signs T=37.4°c, PR =102b/m and BP= 200/110 mmhHg

(a)what is diagnosis.  Hypertensive emergency with Cerebrovascular Event/ Stroke
Reasons: Elevated BP and severe headache and Decreased muscle power

(b) outline management of the patient
For Sake of Knowledge
Before outlining the management of a stroke patient there are two principles to remember
1. There are two types of Stroke i.e. Ischemic stroke and Hemorrhagic stroke and to diagnose these you need to do CT scan i.e. Computed Tomography Scan and if its Ischemic the patient will need to be given Junior Aspirin to dissolve the thrombus that caused ichaemia
2. In stroke we do not want to rush into lowering blood pressure in first 24hrs because few hours after stroke BP is false positively elevated and if we do so we will reduce Brain perfusion and exacerbate(worsen) brain damage!
You can lower BP in first 24 if BP is greater than 220/120mmHg

With the above concept my management options will be as follows
1. Cannulation of the patient because he will need IV anti-HTN
2. Give IV anti-Hypertensive because first 24hrs have elapsed since the stroke event
example we commonly give IV hydralazine 5mg every 30 minutes
But we should not decrease the BP below 25% because aggressive reduction of BP will take you back to the Hypoperfusion concept

3. Catheterization of the patient because he cannot walk
3. Referral for CT scan and Physiotherapy

4. List features which point to mania during hx taking and mental examination of patient at dispensary level

1. Elevated mood /extreme happiness

2. Irritability

3. Increased energy/activity

4. Talkativeness

5. Reduction in the need for sleep

6. Grandiose and/or religious delusions

5. A 35 years old women sero converted for 3 years with poor ART adherence presents to the hospital with hx of DIB and dry cough for 3 days an examination dysponic and chest in dear

(a) what is the diagnosis : HIV stage IV with PCP/PJP

reasons: HIV/AIDs pt with DIB + clear chest

(b)outline treatment plan for the pt .
Points of learning
One thing to remember about PJP is that the chest is always clear and even you do a chest Xray you may not find any feature on Xray!
PJP is a fungal infection and HIV AIDS opportunistic infection of lungs that causes very severe lung inflammation so treatment should focus on giving anti-inflammatory e.g Predinisolone or Hydrocosrtisone and Giving Anti-fungal medical that is effective for opportunistic infection in AIDS patient i.e Septrin or Cotrimoxazole
T. Cotrimoxazole 1920mg 6hrly x 21/7
IV hydrocortisone 200mg start then Tabs Prednisolone 40mg OD x 14/7 

Linking a patient to CTC team for Counselling the patient to adhere to ART and the danger of Treatment failure and ART resistance

6. A 27 yrs old women presented to the hospital with complaints of severe chest pain list differential diagnosis of this condition
The question doesn’t localize the site of chest pain it could be generalized chest pain probably due to a pulmonary disease or from Left side hence signifying Heart disease
i) Pulmonary Tuberculosis
ii) Myocardial infarction
iii) Lung cancer
v) Pneumothorax

7. A 31 yrs old man brought to the hospital with complaints of abnormal behavior for 4 hours . No hx of trauma ,convulsion or fever .this characterized by restless ,aggression beliving that he is the president and also second a lion on the sky .RBG and vitals are normal MRDT is negative

(a) list differently diagnosis:  1) Acute Manic Mood Disorder
                                                      2) Narcistic Personality disorder i.e personality disorder full of grandiosity

Add up your Ddx! J

(b) outiline treament plan
0) Hospitalization in a psychiatric unit
1) Pharmacological management with a Tranquilizer e.g Tabs Haloperidol 1.5-3mg
STG says you can use Carbamazepine 600mg nocte…You can choose what u have tought in class

In psychiatry pharmacological Rx is not enough

2) Patient may need Psychotherapy
3) Family therapy
4) Occupational therapy 

8. Outline specific aims of TB treatment in Tanzania .
This seems to be a public Health or political Question and am not MPH guy J  so take care with my points
1)  Reduce prevalence and deaths due to TB by 50% compared with the 1990 baseline
2) Eliminate TB as a public health problem by 2050
3) Prevent vulnerable populations from TB and Drug resistant TB

Read more about WHO Stop TB strategy which is currently used by Ministry of Health in eradication of TB

9. A 28 years old woman professional to the health centre with complaints of severe central chest pain. list down differential diagnosis .
1) Myocardial infarction
2) Peptic Ulcer disease
3) Pericarditis

Add yours am exhausted J 

10. A 40 yrs old women present to the hospital with complaints of abdominal pain for 1 week, The pain is more severe during night that it usually wakes her from sleep and usually relieved by taking food. Describe the management of this patient .

Dx: Peptic Ulcer disease
Reason: Abdominal pain associated with meals
Will include Investigations, Pharmacological and Non Pharmacological management

Its worthy to remember that more than 90% of PUD are due to Helicobacter Pylori infection which is usually transmitted thru the fecal-oral route!


Non-Invasive and diagnostic tests
1) H. Pyroli test (Non specifc test)
2) Fecal stool antigen (very specific and Good for follow up after treatment)

N: B All the above investigations will confirm if the PUD is H.Pyroli associated or not

Invasive test 
 1. OesophagealGastroduodenalscope (OGD) which is Golden standard

Other test like barium meal are Old school investigations and will probably be used when you suspect Complications of PUD

Pharmacological Management!
Give a Proton Pump inhibitor e.g. Omeprazole or pantoprazole or Esomeprazole etc.
Proton pump inhibitors reduce HCL acid secretion
Cheap but effective is Omeprazole
 T. Omeprazole 20mg BID for 8 weeks

if H.pyroli test or Fecal H.pyroli stool antigen comes out to be positive then we will need to add two antibiotics for eradication of this bacteria(Some books will mention Metronidazole. Amoxicillin and clarithromycin)

caps Amoxycillin 1g BID x 14/7
Metronidazole 400mg BID x 14/7

Do not be surprised with the dosage above e.g. we give Metronidazole TDS but in PUD we give BID these are wonder of medicine J 

Non Pharmacological
1. Maintaining Good hygiene because H.Pyroli is transmitted in the fecal oral route

For my level and my Knowledge and other studies/researches  they do not support the idea of  foods as the aggravating factor to abdominal pain in PUD!
But for your level you can add this as a non-pharmacological management e.g Many Tanzanians think Beans  is an example of aggravating factor of PUD abd. Pain


Follow up!
After the 2 weeks of treating with antibiotics we need to follow up this patient and repeat the Fecal stool antigen test but remember H.Pyroli antibody test can remain positive even after successful eradication!
If Fecal Stool antigen test because Negative then we have successfully treated the disease!
But the pt will have to continue with a Proton Pump inhibitor i.e. Omeprazole

Post a Comment