20 Yr old female with headache and neck pain
March16,2023
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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..
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 with complaints of neck pain since 3 days, vomitings and headache since 1day..
HISTORY OF PRESENTING ILLNESS:
Pt was asymptomatic 3 days back then she developed neck pain.
Vomitings since 1 day with 4 to 5 episodes per day, non bilious type..
Headache with facial puffiness since 1 day 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 +
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)
LFT:
Elevated alkaline phosphate-123 IU/L (42-98 IU/L)
ABG :
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)
PROVISIONAL DIAGNOSIS:
SLE
TREATMENT :
Tab paracetamol 500mg PO/TID
Tab warfarin 5mg PO/BD
Tab HCQ 200mg PO/OD
Tab azathioprine 50mg PO/BD
Tab prednisolone PO/BD
Inject zofer 4mg iv/BD
syrup sucralfate 15ml PO/BD
Monitor vitals
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