35 year old female with left sided headache

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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.

A 35 year old female patient who is housewife,Resident of Nakrekal came to OPD with Chief complaints of

Fever since 1 week 

Headache on left side since 3 days

History of presenting illness:

 Patient was apparently asymtomatic 10 year back then she developed  unexplained weight gain and fatigue for which she went to local hospital where she found to be Hypothyroidism and she was on thyroxine medication.

Six years back  she developed lower back ache she was found to have renal stones where treated conservatively.

Two years back her Thyroxine dose is increased to 75mcg daily.

 One week back she developed Fever which is intermittent in nature relieved on medication.Not associated with nausea, vomiting,rashes,bodypain.

History of Unliateral left sided headache since 3 days .It was severe headache,Throbbing type of pain,which is radiating to neck.Not associated with Vomiting,Blurring of vision,Lacrimation,Photophobia.There are no aggrevating factors and releived on medication.

History of burning micturation since 5 days.

Daily routine:

She wakes up at 5am and does her daily household work and have breakfast at 9am and then sleeps for some time and then she cooks lunch and watch tv from 2pm to evening then she have tea in the evening and later she prepares dinner and eat at 9pm and sleeps at 9:30pm.

Past History:

Known case of Hypothyroidism since 10 years

Not a known case of Diabetes,TB,epilepsy,CAD,Asthma, Hypertension.

Personal history:

Diet-mixed

Appetite -Normal

Sleep-inadequate

Bowel and bladder regular

No addictions.

Family history:

No relevant family history

General examination:

Patient is consicous,coherent,cooperative.

Pallor-present

Icterus - absent

Clubbing - Absent

Cyanosis- Absent

Lymphadenopathy- absent

Edema - absent.

Clinical pictures:

Vitals -

RR:18cpm 

PR:80bpm

Bp:110/70mmhg

Temp:99F

Systemic Examaination:

CNS:

She is Right handed person 

HIGHER MENTAL FUNCTION

Counsious ,oreinted to time place person

Speech normal

Behaviour normal

Memory intact 

Intelligence normal 

Sensory system: Normal

 

Motor System:

Bulk of muscles are normal

Tone of limbs are normal

Power of limbs are normal

Reflexes:

                 Right           Left

Biceps     2+                2+

Triceps    2+                2+

Knee        2+                2+

Ankle       2+                2+

meningeal signs:

No neck stiffness

Kernigs and Brudzinski's signs are negative.

Per abdomen:

Inspection

shape-normal

No scars seen

Umbilicus is central in postion and inverted

No dilated veins seen.

visible peristalsis,no visible pulsations.

Palpation:

No local rise of temperature 

No tenderness

No organomegaly.

Percussion:Tympanic note ,No Shifting dullness,Fluid Thrill.

Ascultation:Bowel sounds heard

 

CVS:

Appear normal

Trachea is central.

 No palpable murmurs 

S1; S2heard

Respiratory system:

Trachea  is central

Bilateral Airway present

Resonant on peecussion

Normal breath sounds heard.

Diagnosis

Migraine? Fever with headache.

Investigations:

USG report:

Treatment:

Inj-optineuron 1amp in 100ml of NS OD

IvF-@70ml/hr

Tab nitrofurantoin 100mg

Tab pantoprozale

Tab naproxen  250mg

Bp,temp,RR,PR check 4th hrly

Tab thyronorm   25mcg