20 Yr old female with headcahe and neck pain

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December 01, 2022

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 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 

https://drive.google.com/uc?export=view&id=1DI8ulqsKMXY7Fw5ApkrvrqINJ5UK9sc_https://drive.google.com/uc?export=view&id=1AMfhhiUp02eVUaxGyBZoXbDfT6-Pdvtx
https://drive.google.com/uc?export=view&id=1Ck12IFP1KeQxJL8buGljeDWSI9XseNHy
https://drive.google.com/uc?export=view&id=1ru552FX12vrgufwuWzh2dGEMIEHEt_8g
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:
https://drive.google.com/uc?export=view&id=13ge1w1_J-5wGMyMvxrDG4M746ikHfX_w

Serum electrolytes: Normal 
Serum Creatinine normal 
Blood sugar- normal 
"Blood urea is elevated":64 mg/dl(12 to 42 mg/dl)

LFT : https://drive.google.com/uc?export=view&id=10zdPSjgeXEMjf832BlxO6Ej-vNm395qq
Elevated alkaline phosphate-123 IU/L (42-98 IU/L)
ABG : 
https://drive.google.com/uc?export=view&id=1hI8oi3_j-cvzie1dCH1UTa3PtHZK3Ro3
HEMOGRAM :
https://drive.google.com/uc?export=view&id=16QGfORkpk1bKjaqWUfvDxTmP64oqg052

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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