A 29 yr old female came to opd with shortness of breath
Hi I am, AnirudhManne (roll no:11), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.
CASE SHEET:-
Chief complaint;
A 29yr old female, resident of Mumbai, customer service executive by occupation came to OPD with chief complaints of
Increased sweating 4days ago
Shortness of breath 4days ago
Dizziness 4days ago
Vomitings 2episodes/day before the day of admission
History of present illness;
Patient was apparently asymptomatic 5yrs ago. Then she developed ulcers in mouth and painless rash on her face across her nose, hair loss and sensitivity to light on face.Then she went to a private hospital where she was referred to another doctor where she was diagnosed with SLE. She was given medication for it. Then, 1 month ago, she developed Shortness of breath and went to hospital where she was diagnosed with kidney disease. She was put on dialysis 4times before coming back to her native place. 4days ago, she again developed severe shortness of breath, vomitings, dizziness and increased BP due to which she arrived at the hospital where she developed seizure and was later put on dilaysis
Daily routine;
The daily routine of the patient didn't change after the diagnosis
She wakes up at 7am
Goes to work by 9am till 6pm
Comes home and does chores before going to bed by 10pm
Past history;
Patient is a known case of;
SLE since 5yrs
Hypertension since 1month
Orthopnea since 1month
Oedema since 1month aggrevated on increased activity and releived on rest
No history of TB, Asthma, Epilepsy,Diabetes
Personal history;
Diet- mixed
Appetite- Decreased
Sleep- Disturbed
Bowel and bladder movements- regular
No burning micturition
No addictions
Family history;
Mother is a k/c/o DM since 8 years
General examination;
Patient was conscious, coherent and cooperative
Moderately built
Moderately nourished
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema- present
Alopecia
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