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  A 39 YRS OLD WITH CKD ON MHD Chief complaints: Patient c/o SOB since 3 months HOPI : Patient was apparently asymptomatic 1 year ago then he developed blurring of vision and was diagnosed with hypertension and CKD with hypertensive changes in the right eye since then he was on conservative therapy stayed in hospital for 5 days in ICU . 3 months patient developed SOB grade II-III and pitting type of pedal edema ( b/l )and significant weight loss No H/o pyuria, palpitations, chest pain. H/o orthopnea, PND Then he underwent dialysis at NIMS punjagutta ( right IJV- 3 sessions) HISTORY OF PAST ILLNESS: k/c/o HTN since 1year N/k/c/o DM, epilepsy, asthma, CAD, TB, CVA, thyroid disorder. PREVIOUS HISTORY: No similar complaints in the past. PROVISIONAL DIAGNOSIS  CKD ON MHD PERSONAL HISTORY: Appetite:normal Diet:mixed Bowel and bladder:regular  Sleep: adequate  No addictions FAMILY HISTORY: K/c/o HTN in the family GENERAL EXAMINATION: Patient is conscious and coherent Moderately built and mode
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GEN-MED E-log

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  Hi, This is Vaishnavi Manga, an eighth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 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 a diagnosis and treatment plan. A 65yr old with DKA 2° to CAP with AKI Case: A 65year old male who is a resident of thurkapallem, shop keeper by occupation came to opd with Chief complaints:  Fever since 6days. Breathlessness since 3days. History of present illness: Patient was apparently asymptomatic 10days back then he developed cold and cough with expectoration which is greenish and mucoid, no aggaravating
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SECOND INTERNAL ASSESSMENT

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