A 30 year old female with SOB

November 10 , 2022

E LOG GENERAL MEDICINE 

Hi, I am G.Akshara , 3rd Sem Medical Student. This is an online e-log book to discuss my  patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG.

Chief complaint.

A 30 year old female patient who is a computer operator and a call executive by occupation came with the chief complaints of

 Shortness of breath from 4 days associated with sweating.

Vomitings 2 episodes / day before the day of admission.

History of present illness.

Patient was apparently asymptomatic 6 years ago then she developed generalised body pains and joint pains which involved joints of elbow and knee and associated body aches.

She noticed hair loss from past five Tara’s. After multiple hospital visits she was diagnosed with auto immune disorder SLE. She was on medication but her joint pains and hair loss was not improved so she had multiple hospital visits.

2 months back she had pedal oedema and sudden onset of shortness of breath initially and became worse even at rest. She was diagnosed with hypertensive emergency admitted and discharged with anti hypertensive drugs.

Since ten days patient stopped all her medication except the anti hypertensives. Since the day before administration in our hospital she experienced shortness of breath which became worse even on rest.

History of past illness.

K/C/O SLE since 2017

K/C/O hypertension since 1 month

N/K/C/O DM , asthma , epilepsy, Tb

Personal history.

Appetite normal

Bowel movements regular

Micturition - burning type 

No addictions 

Family history.

Mother is a K/C/O diabetes since four years.

PHYSICAL EXAMINATION.

A. General Examination 

Pallor is present.

Icterus is absent

No cyanosis

No clubbing of fingers

No lymphadenopathy

No malnutrition 

No clubbing of fingers

No oedema of feet and hands.

SYSTEMIC EXAMINATION

B. Cardiovascular system 

No thrills 

No cardiac murmurs

Cardiac sounds: S1 and S2

C. Respiratory system

dyspnea present

No wheezing

Vesicular breath sounds .

Position of trachea - central

D. Abdomen

Abdomen is scaphoid

No tenderness

No Palpable mass 

Bowel sounds anew present 

No bruits

No free fluids

E. Central nervous system

The patient was conscious coherent and cooperative.

Speech is normal .

General examination:

 

Pallor- present

Pedal edema : present 

Rash on nose and cheeks

Rash behind ear 

Alopecia

Investigations : 

Provisional diagnosis:

Lupus nephritis