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
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