General Medicine E-log (3)

Hi, I'm Danush Varkur (roll:29), 3rd sem medical student. This is the 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 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. 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 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 

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

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

Medications prescribed-

General examination:

                          Pallor- present;

                          Pedal edema- present;

Rash on her nose and cheeks;

Rash behind her ear;

Alopecia;

Investigations:

Provisional diagnosis:

Chronic kidney disease