This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Chief Complaints:
29 yr old female came to hospital with complaints of shortness of breath since 6 days
History of presenting illness:
Patient was apparently asymptomatic since last year november then she had loss of hair and rashes and has pedal edema.When renal biopsy was done she was diagnosed with lupus nephritis and was on conservative management.
Patient was initiated with dialysis since February this year and was on maintainance hemo dialysis.
History of past illness:
K/C/O HTN since february and is on medication.
Not a K/C/O DM/Asthma / Epilepsy/ CAD.
Personal History:
Diet-Vegetarian
Appetite normal
Sleep adequate
Bowel : Constipation
No Addictions
No known allergies
Family History:
Her mother is a known case of DM and HTN . No other significant family history.
Menstrual History:
LMP = Dec 2022
Menstrual cycle= Duration of cycle / no of days of breeding = 4/28
Gynaeclogy problems - she had two abortions in the past which was 7 years back.
Obstetric History:
Obstetric formula - G3 P1 L1 A2
No of Abortions:2
Birth History: Normal Delivery
No birth Asphyxia
Immunization Status : upto mark
General Examinations:
Pt is conscious coherent and cooperative
Pallor present
No Icterus, cyanosis, clubbing generalized lymphadenopathy
She has pedal edema which is of pitting type.
Vitals :
Temp- Afebrile
Bp 130/90 mm Hg
PR- 75 bpm
RR-16 cpm
Systemic examination
CVS:
No thrills and murmurs
S1 and s2 felt
Respiratory System:
No dyspnoea and wheeze
Centrally placed trachea
Vesicular breath sounds heard
No adventitious sounds
Abdomen:
Scaphoid abdomen
No tenderness and no palpable mass hypochondrium and left flank region
No free fluid
Liver not palpable
Spleen not palpable
Bowel sounds -No
CNS:
Conscious and coherent
Normal speech
No neck stiffness
No kerning sign
Cerebellar signs:
Finger nose in co-ordination - No
Knee heel in co-ordination - Not
Investigations :
Diagnosis: CKD on hemodialysis
K/C/O Lupus nephritis
K/C/O HTN since 6 months
