This is an online E logbook to discuss our patient’s de-identified health data shared after taking his signed informed consent.
Here we discuss our individual patient’s problems through series of inputs from the global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence-based inputs.
This E-logbook reflects my patient-centered online learning portfolio.
CHIEF COMPLAINT : 47 y/o businessman with palpitations since last 5 days.
PRESENT HISTORY :
Pt was apparently asymptomatic 5 days ago after which he experienced sudden onset awareness of his heart beat accompanied by impending sense of doom, which was irregular and forceful in nature ; occurring intermittently over the course of past 5 days, (irrespective of rest/active) - lasting a duration of 5-10 minutes and regressing spontaneously ; perceived more during evening ;
Associated with difficulty in breathing even at rest / not strenuous activity
It is not associated with any triggers like strenuous exercise/ intake of anti-diabetic medication or fasting / consumption of tea and coffee / vomiting and diarrhoea
No h/o associated dizziness , headache, chest pain and fainting / tingling in hands and face / polyuria
He is not sure if it is associated with sweating, he describes himself as someone who is almost always perspiring.
He gives a h/o significant weight loss in the last 1 month
H/o anxiety wrt health and stress about family issues - sent for a psychiatry referral which indicated towards a probable panic attack
PAST HISTORY :
Pt was diagnosed with B/L CAP with ARDS 1 month ago, for which he was on ventilator for 20 days during which he had an acute MI.
He was given medication for one week following discharge which was discontinued immediately for reasons unknown
K/c/o HTN and DM since 10 years, on medication.
FAMILY HISTORY :
Mother is k/c/o HTN and DM
PERSONAL HISTORY :
- Diet - Mixed
- Appetite - Normal
- Bowel & Bladder - Regular
- Sleep - Markedly reduced after discharge from hospital, sleeps only with sleeping pills.
- Addictions - None
- Drug / Food Allergies - H/o anaphylaxis to Valproate ( DICORATE ER)
Currently the patient is on
- Antiplatelets
- Statins
- Anti-Arrhythmics
- Benzodiazepine
- Anti-HTNives
- OHAs
- CARDIAC - ?MI (as a post MI complication)
- METALBOLIC - ?Hypoglycaemia
- ENDOCRINE -
- ?Thyroid Dysfunction
- ? Pheochromocytoma
- PSYCHIATRY - ?Anxiety Disorder
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