SECOND INTERNAL ASSESSMENT
GEN-MED E-log
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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