A 20year old with Headache,Vomiting and neck stiffness
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P.Manogna, Roll no.120
CASE REPORT
A 20 year old female came to the OPD with
On 1/12/22
chief complaints of:
Headache since 3days
Vomitings since 3days
Neck Stiffness since 3days
History of presenting illness:
Patient was apparently asymptomatic 3months back, she came to our hospital with complaints of bilateral pedal edema,hyperpigmented macules,fever,cough,SOB,decreased urinary output,abdominal distention and loss of ability to speak- she was diagnosed with SLE and treated accordingly all the above symptoms were relieved and was discharged.
She again came to the hospital 3days back with complaints of headache,neck stiffness and vomiting.Headache which was sudden in onset,diffuse, dragging type of pain associated with neck stiffness with pain,which was present throughout the day,she had vomitings 3-4 episodes which was after consuming food, non-bilious, non-projectile,food as content not associated with any abdominal pain Or abdominal discomfort.
No fever,altered sensorium,blurring of vision,
No history of trauma
Past history:
No similar complaints in past.
Not a k/c/o diabetes,hypertension, asthma,TB,epilepsy
Family history:
No significant family history
Personal history:
She wakes up at 5:00Am and sleeps at 9:00pm,from recovery she is not doing any work.She was on I.V fluids the first two days, on 3rd day she had fruits(grapes)for breakfast, afternoon milk and rice and curd for dinner, on 4th day she had rice and curd for breakfast, afternoon had rice with bottle guard curry and dinner rice with curd.
Diet:mixed
Appetite: normal
Sleep:adequate
Bowel and bladder movements:regular
General examination:
Patient is conscious,coherent,cooperative and well oriented with time,place,person.
She is moderately built and nourished
Pallor is present
Facial puffiness is present with stary look
Previous rashes susbsided
No signs of clubbing,cyanosis,generalised lymphadenopathy
Vitals:
Temperature- Afebrile
Pulse rate- 76bpm
BP- 140/100mmHg
RR-16cpm
GRBS-140mg/dl
On local examination:
CNS:
Reflexes:
https://youtube.com/shorts/uX5VmkJl-dI?feature=share
Abdomen:soft,non tender no organomegaly
CVS: s1,s2 heard no added murmurs
Respiratory:bilateral airway entry is present,vesicular breath sounds heard
Investigations:
On 1/12/22:
Treatment:
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, tranexemic acid
Reference blog of 1st admission:
https://chandanaracharollno128.blogspot.com/2023/03/1801006137-short-case.html
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