20 Yr old female with headache and neck pain

December 02,2022 

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment  plan..

CHIEF COMPLAINTS :  

Patient was brought to casuality on 1/12/22 with complaints of neck pain since 4 days, vomitings and headache since 2 days.

HISTORY OF PRESENTING ILLNESS : 

Pt was asymptomatic 4days back then she developed neck pain. 

Vomitings since 2day with 4 to 5 episodes per day, non bilious type.. 

Headache  with facial puffiness since 2days which is of frontal type.

PAST HISTORY:

She was bought to this hospital 1 month back for fever, sore throat, dry cough, reduced urine output, shortness of breath, pedal oedema extended till knees and  hyper pigmented macules seen over the fore head and legs , diagnosed with SLE with anti ds DNA++ , anti histone antibodies positive..

N/k/c/o Diabetes, TB or asthma., CAD, epilepsy 

Addictions : none 

FAMILY HISTORY :  no significant family history 

Surgical history: No surgeries done in past. 

TREATMENT HISTORY : treated 1 month back with

INJ AUGMENTIN 

INJ LASIX 

BUDECORT 

BETADINE GARGLING

TAB AZITHROMYCIN

PERSONAL HISTORY:

Diet: mixed

Appetite : decreased

Sleep : inadequate

Bowel movements : regular 

GENERAL EXAMINATION : 

patient was examined after taking consent from the attenders

Pt is conscious cooperative and coherent 

Pallor - present 

Icterus- absent

Cyanosis- absent

Clubbing- absent

Koilonychia - absent

Lymphadenopathy - absent

Edema - absent 

SYSTEMIC EXAMINATION : 

CVS:

No thrills, no parasternal heave, 

S1, S2 +, no murmurs

RESPIRATORY SYSTEM : BAE + Trachea is central in position, no dyspnoea, no wheeze, vesicular breath sounds heard

ABDOMEN EXAMINATION : 

Non tender , bowel sounds heard

CNS :

 No focal neurological deficit 

Oriented to person,time and place 

Speech - normal

 Signs of meningeal irritation - not present

INVESTIGATIONS:

Serum electrolytes: Normal 

Serum Creatinine normal 

Blood sugar- normal 

"Blood urea is elevated":64 mg/dl(12 to 42 mg/dl)

ABG : 

LFT :

Elevated alkaline phosphate-123 IU/L (42-98 IU/L)

Hemogram:

Hemoglobin isReduced-10.2gm/dl (12-15 gm/dl) 

Lymphocytes are reduced-08% (20-40%) 

Neutrophils-82% (40-80%) 

-Normocytic normochromic anemia with neutrophilic leukocytosis..

MCHC is reduced-30.8%(31.5 - 34.5%) 

RDW-CV is raised - 17.8%( 11.6 - 14%) 

Rbc count is reduced-3.47millions/cumm(3.8-4.8)

FEVER CHART

APTT:

Follow up :- 

Right now ( today ) she is only suffering from headache ,while the neck pain and vomitings subsided .

 

Yesterday she was sent for mri scan and there is a suspicion of intra cranial hemorrhage.

And she is shifted to icu

And treated with tranaxmic acid and vit k . 

PROVISIONAL DIAGNOSIS:

Vomitings and headache secondary to sle

TREATMENT :

Tab paracetamol 500mg PO/TID Tab warfarin 5mg PO/BD Tab HCQ 200mg PO/ODTab azathioprine 50mg PO/BD Tab prednisolone PO/BD Inject zofer 4mg iv/BD syrup sucralfate 15ml PO/BD Monitor vitals