A 29 yr old female with complaints of shortness of breath since 3 days

A 29 yr old female with complaints of shortness of breath since 3 days 


July 15, 2023

 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.


29 yr old female came to hospital with complaints of shortness of breath since 3 days .

History of presenting illness:
Patient was apparently asymptomatic since last year. In november then she has loss of hair and rashes and have pedal edema and renal biopsy was done and 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  had medications 
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 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 that is 7 yrs 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 

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