20 Yr old female with neck pain and headache
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General examination: patient was examined after taking consent from the attenders
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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:
20 yr old 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 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, hyper pigmented macules over forehead, shortness of breath, pedal oedema extended till knees and 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- ab7sent
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
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 :
Vomitings and headache secondary to 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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