A 20 year old female with Headache, Neck pain and Vomitings

A 20 yr old female resident of chottupal, was brought to our OP with cheif complaints of neck pain since 4 days vomitings and headache along with swelling of face since 2 days.


HISTORY OF PRESENTING ILLNESS :-
Patient was asymptomatic 4 days back then she developed neck pain which was sudden in onset, after 2 days she developed Headache with facial puffiness and this headache is in the frontal region and Vomitings since 2 days with 4 to 5 episodes per day and is of non bilious type.

The pain in head and neck didnt subside from the time she arrived to our hospital and she is facing severe discomfort because of that.

PAST HISTORY :-

She was brought to this hospital 1 month 15 days back for dry cough, reduced urine output, shortness of breath, fever, sore throat, decreased platelet and WBC count, pedal oedema extending till knees and hyper pigmented macules were seen over the fore head and legs , diagnosed with SLE with anti histone and anti ds DNA , anti antibodies positive.

Not a known case of Diabetes, TB or asthma., CAD, epilepsy  

Surgical history: No surgeries were done in past. 


TREATMENT HISTORY :- treated 1 month back with
INJ AUGMENTIN 
INJ LASIX 
BUDECORT 
BETADINE GARGLING
TAB AZITHROMYCIN

FAMILY HISTORY :- no significant family history 

PERSONAL HISTORY :-
Diet: mixed
Appetite : decreased
Sleep : inadequate
Bowel movements : regular 
Addictions : nil

GENERAL EXAMINATION :- 
Pt is conscious cooperative and coherent 

VITALS :
PR - 84 bpm
RR - 26 cpm
Temp - 98 deg F
BP - 120/80 hgmm


Pallor - present 
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy - absent
Edema - absent 


SYSTEMIC EXAMINATION :-

CVS : 
No thrills, S1, S2 +, no murmurs

RESPIRATORY SYSTEM :
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 Present.

INVESTIGATIONS :-

Blood urea - 64 mg/dl (N: 12 - 42)

RBS - 105 mg/dL (N: 100 - 160)

Serum electrolytes - sodium - 135 mEq/L (N: 136-145)

Blood grouping - A, rh positive

LFT -
alkaline phosphate - 123 (N: 42 - 98)
Total protein - 6.2 gm/dl (N: 6.4 - 8.3)

Serum creatinine - 0.8 mg/dl (N: 0.6 - 1.1)

ECG -
On 2 dec, APTT - more than one min (N : 24 - 33sec)

Haemogram - 
Haemoglobin - 8.9 gm/dl (12 - 15)
Total count - 12000 cells/cumm (4000 - 10000)
Neutrophils - 84 % (40 -  80)
Lymphocytes - 6 % (20 - 40)
PCV - 27.6 vol % (36 - 46)
Rbc count - 2.99 millions/cumm (3.8 - 4.8)


FOLLOW UP - Right now she is only suffering from headache while the neck pain and vomittings subsided.

Yesterday when she was sent for MRI, the provisional diagnosis came out as Intracranial Haemorrhage.

For that, She has been given tranaexemic acid and vit K.

PROVISIONAL DIAGNOSIS:-
Vomittings, neck pain 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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