General Medicine - 7
10 November, 2022
A 29 YEAR OLD FEMALE CAME WITH COMPLAINTS OF SHORTNESS OF BREATH.
Hi, I am Dussa Sri Snehitha, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:-
Renal function test:
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 her 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.
Later, 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 in the hospital in mumbai 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 dialysis.
Past history:
- Patient is a known case of;
- SLE since 5yrs
- Hypertension since 1month
- Orthopnea since 1month
- Pedal edema since 1month (aggravated by increased activity and releived on rest)
- No history of DM, TB, Asthma, Epilepsy
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 and nourished
Pallor- present
No icterus
No cyanosis
No clubbing of fingers
No generalised lymphadenopathy
Pedal edema- present
INVESTIGATIONS:
Complete blood picture:
Provisional Diagnosis:
Chronic kidney disease.
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