40 y old Female

 Hello all this is G Jagadeesh,INTERN of 2019 batch .This E Log depicts the patient centered approach to learning  

This is an 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 centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

40 Year old female resident of Nalgonda farmer by occupation presented to the OPD with c/0

Watering from left eye since 2 years

Swelling on the inner aspect of left eye since 6 months

History of presenting complaints

Patient was apparently asymptomatic 9 years back in 2015 she developed watering from left eye which was insidious in onset and gradually progressive which was clear and non foul smelling, which was associated with photophobia and itching and not associated with pain, redness, blurring of vision, No aggravating and relieving factors for which she went to local ophthalmologist for which they advised spectacles

In 2018 she developed swelling of size 1x1cm in the inner aspect of left eye which was insidious in onset and gradually progressive to size 3x4cm which was associated with itching, and pain. Pain which is intermittent and gradually progressive which aggravates on exposure to sunlight and long time open eyes and reliever by watering from eye after applying some pressure over the swellings for which she went to local suryapet hospital for which she had given medications and had subsided

There was increased size of swelling since 6 months which is associated with pus discharge which is purulent non-foul smelling and non blood stained which is associated with itching watering and pain

4/0 trauma to left eye in 2014

No h/o redness, burning sensation,nystagmus, decrease of vision

Sequence of events

In 2022, there was a h/0 polymenorhogia for 4 months, the cycles were regular 28 days cycle and has bleeding for 7-8 days, she used 2pads/day and associated with pain and not associated with clots and whitish discharge, patient also has c/0 easy fatiguability for which she has been diagnosed as severe anaemia with hb - 6 gm/dl

She has c/o polyarthralgia which was associated with vomitings and no h/0 fever for which she has been treated by oral steroids

In august 2022 she had developed fever of high grade with generalised body pains and loss of appetite -

Generalised clonic tonic seizures of 4-5 episodes in her home for which she had admitted in sigma hospitals for the evaluation of seizures on 13/08/22 where on investigations she was found to have hyperkalemia and serum creatinine of 9.7mg/dl for which she was referred to SVR kidney hospital for further management 

On admission to SVR hospital she was in post ictal confusion state with serum creatinine of 10mg/dl for which she underwent hemodialysis of 3 consecutive sessions with blood transfusion following which her sensorium improved on USG abdomen and pelvis revealed bilateral bulky kidneys for which they have referred to Nims Hyderabad to get a kidney biopsy done 

Past history 

H/o similar complaints in the past

K/c/o HTN since 10 years 

2 episodes of seizures in 2022 and on leviteracetam 

N/K/C/O DM ,TB ,asthma, CAD, CVA

Family history

No similar complaints in the family

Personal history 

Mixed diet normal appetite 

Bowel and bladder movements are regular 

Sleep adequate

No known addictions 

Allergic history 

No known allergies 

General examination

Patient is conscious coherent and co operative 

Moderately built and nourished

Mild pallor present

No signs of , icterus, cyanosis, clubbing, lymphadenopathy and oedema

Vitals

Temperature- afebrile

 BP - 130/90mmhg

PR - 82bpm

RR - 18 cpm

SPO2 - 98% at room air

Systemic examination 

CVS 

S1S2 heard no murmurs

RS

Trachea central

BAE+

NVBS heard no added sounds 

CNS

NFND

P/A

Soft and non tender 

No organ palpable 

Bowel sounds heard and normal

Local examination

Examination	Right eye	Left eye
Lids	Normal	A 6x4mm swelling present at medial canthus and periorbital swelling associated with discharge at medial canthus
Eyelashes	Normal	Matting of lashes present
Bony orbit	Normal	Normal
Conjunctiva	Quiet	Erythematous
Cornea	Clear	Clear
anterior chamber	Normal depth and clear	Normal depth and clear
Iris	Normal and brown pigmented	Normal and brown pigmented
Pupil	Normal size and reacting to light	Normal size and reacting to light
Lens	Clear	Clear
IOP	16	14

Provisional diagnosis 

Chronic kidney disease

Left sided dacryocystitis

Investigations 

Renal biopsy report

Immunoflourecense 

Ultrasound abdomen

Final diagnosis 

Rapidly progressive glomerulonephritis

Chronic dacryocystitis on left side