A 20 YEAR OLD FEMALE WITH HEADACHE, VOMITING AND NECK PAIN
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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
A 20 year old female presented with chief complaints of
headache, neck pain since 4 days and
vomitings since 3 days
HOPI:- patient was apparently asymptomatic 4 days back the she developed headache which was sudden in onset, with dragging type of pain, diffuse, which worsened on following days, associated with neck pain, no aggravating and relieving factors.
Then she developed vomitings , 3 days back which was insidious in onset, with 3-4 episodes, non projectile, non bilious, food as content,not associated with pain abdomen and discomfort
No fever, no altered sensorium, No blurring of vision, No diplopia, No photophobia or phonophobia.
No history of trauma.
Past history:- diagnosed with SLE 2 months back.SLE with anti histone and anti ds DNA , anti antibodies positive.
,on tab. HCQ 200mg PO OD
Tab. Prednisolone 20mg PO BD ,tab.argoran 50 mg PO OD. No history of diabetes, hypertension, asthma
Family history:- father is diabetic
Personal history:- wakes up at 5am and sleeps early at 9pm doesn't perform any work, diet is mixed ,bowel and bladder movements are regular.
Dietary history:- took only grapes and milk following episodes of vomiting then admitted to ICu on 1-12-2022 , was on i.v fluids for two days, on 3rd for breakfast she had grapes , milk in afternoon and rice and curd for dinner, on 4rth breakfast and lunch had curd rice with bottleguard curry.
5 th break fast and lunch had curd rice with
Tomato curry
on 5-12-2022 she was shifted to Amc
GENERAL EXAMINATION:- on informed consent of patient, she was examined in a well lit area, patient was conscious, coherent, cooperative well oreiented to time place and person.
Head to toe examination:-Facial puffiness present with stary look. Previous rashes subsided.
Echymotic patch noticed on Rt knee.
Neck stiffness present associated with Pain.
No pallor, icterus, lymphadenopathy, facial puffiness present, no cyanosis, clubbing.
Vitals at admission :
Bp 170/110mmhg
Pr : 84
Spo2 : 99 on RA
RR : 18 cpm
Temp : Afebrile to touch.
On CNS examination:-HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
speech : normal
Behaviour: normal
Memory :intact
Intelligence:normal
No hallucinations or delusions.
Intelligence:normal
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
On 3rd December:- diplopia was present subsided by evening
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK:- Normal Normal Normal Normal
TONE:-normal hypotonia normal hypotonia
POWER 5 /5 5/5 5/5 5 /5
SUPERFICIAL REFLEXES:
CORNEAL:- present present
CONJUNCTIVAL :-present present
DEEP TENDON REFLEXES:
R L
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 2+ 2+
KNEE 3+ 3+
ANKLE 2+ 2+
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch :-present
pain:- present
temperature:- present
DORSAL COLUMN SENSATION:
Fine touch :- present
Vibration:- present
Proprioception:- present
CORTICAL SENSATION:
Two point discrimination :- present
Tactile localisation:- present
CEREBELLAR EXAMINATION:
Finger nose test :- coordination present
Heel knee test :-present
Dysdiadochokinesia
Speech:- normal
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT: normal
Per abdomen:- inspection :- no visible scars, no engorged veins, no visible peristalsis
Palpation :- no organomegaly, no local rise of temperature and no tenderness. On percussion resonant and on auscultation bowel sounds were heard.
Provisional diagnosis:-Vomitings, neck pain and headache secondary to SLE
Investigations:-
Ultrasound:
Follow up :Right now headache, vomiting,neck pain have subsided
Investigations:-24hr urine protein -1090 mg/dl (normal -less than 150mg/dl) on admission
Urine volume :-400 ml on admission
Blood urea :- 64
2nd December:- blood urea-84
4rth December:-blood urea- 73
On 4rth December:- urine volume was 150 ml
Treatment:-
On 1-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv BD
Tab prednisolone 20mg PO OD, 10mg PO OD
Syrup sucralfate 15ml PO BD
On 2-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv TID
Tab prednisolone 20mg PO OD, 10mg PO OD
Tramadal -1 amp IV
Normal saline -100ml IV
Syrup sucralfate 15ml PO BD
Injection mannitol-
100 ml IV
Injection monocef, trenexamic acid 2gm, injection vitamin K. 10 mg IV OD
On 3-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv TID
Tab prednisolone 20mg PO OD, 10mg PO OD
Tramadal -1 amp IV
Normal saline -100ml IV
Syrup sucralfate 15ml PO BD
Injection mannitol-15 mg
Dexamethasone -8mg IV TID
on 5-12 -2022
1.IV FLUIDS -NS
2.Inj MONOCEF 1gm IV BD
3.Inj PAN 40mg IV OD
4.Inj ZOFER 4mg IV TID
5. Inj DEXA 8 mg IV TID
6. Tab DOLO 650 mg PO TID
7. Tab HCQ 200mg PO OD
8. Tab AZATHIOPRINE 50 mg PO BD
9. Inj MANNITOL 20 gm IV TID
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