A 30 year old female patient came with chief complaints of shortness of breath.

November 08, 2022

E LOG GENERAL MEDICINE.

Hi, I am Anvitha, 3rd Sem Medical Student. This is an online e-log book to discuss our 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 as and when required
CASE SHEET.
Chief complaints and duration.
A 30 year old female patient who is a computer operator and a call executive by occupation came with the chief complaint of shortness of breath from one day.
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 years. 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 .

Medications prescribed-

General examination:
Pallor- present;

Pedal edema- present;
Rash on her nose and cheeks;
Rash behind her ear;
Alopecia;

Investigations:

Provisional diagnosis: lupus nephritis