36 MALE WITH BILE REFLUX GASTRITIS WITH HIATUS HERNIA WITH MILD PROLAPSING GASTROPATHY

Name: Meghana M

Roll no: 95 


This is online E log book to discuss our patient’s de-identified health data shared after taking   his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problms with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .


CHIEF COMPLAINTS:
patient  with c/o vomitings since 5 days
HOPI:
Patient was apparently alright 9 years back
He consumed pesticide for suicide and was taken to hospital where thorough stomach wash was done and he was discharged home.
From then onwards patient complaints of vomitings occuring for every 6 months bilious type, non projectile, which happens for  6 to 7 days for which he goes to local hospital and gets treated.
Last episode of vomitings were 1 year back.
Now he has c/o of vomitings since 5days.
He had 5 to 6 episodes per day, bilious, non projectile, preceded by nausea.
No h/o  fever, loose stools, pain abdomen
No h/o headache, retrosternal chest pain, regurgitation

PAST HISTORY:
N/K/C/O DM, HTN, EPILEPSY, CAD, asthma, TB
No h/o blood transfusions in past
 h/o thyroidectomy 17years back
PERSONAL HISTORY :
Appetite - normal
Bowel and bladder movements - regular 
Sleep - adequate 
No known drug and food allergies.
Addictions: alcoholic since 20 years.
GENERAL EXAMINATION :
Pt is conscious , coherent , cooperative 
Moderately built and nourished 
No pallor , icterus , clubbing , cyanosis , lymphadenopathy, generalised edema 
No signs of dehydration
no pallor
tongue moist
VITALS : 
PR-120bpm
BP-110/60mm of Hg
RR: 14cpm
SPo2 -99%. On room air

SYSTEMIC EXAMINATION :
CNS : NFD
CVS - 
S1 , S2 heard , no murmurs
RESPIRATORY SYSTEM :
Bilateral air entry present 
NVBS 

PER ABDOMEN :
Inspection: scaphoid abdomen
No scars, sinuses 
No engorged veins
No visible pulsations
No visible mass
Palpation:
No local rise of temperature
No local tenderness
No palpable mass
Percussion:
Resonant
Auscultation:
Bowel sounds heard

DIAGNOSIS :
BILE REFLUX GASTRITIS with hiatus hernia with mild prolapsing gastropathy



TREATMENT:
IV FLUIDS NS RL @ 100ml/hr
INJ PAN-D 40mg iv/od
INJ PROMETHAZINE 25mg/IV/BD
INJ OPTINEURON 1 amp in 500ml NS/IV/OD
INJ ZOFER 4 MG SOS
ADEQUATE FLUIDS

Comments

Post a Comment

Popular posts from this blog

52/F with pyrexia and body pains

Image
NAME: Meghana.M Roll no: 95 Batch: 2017  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" 52 year old, female farmer by occupation, came with complains of fever and cough since 14 days  Patient was apparently asymptomatic 15 days back. Then she tripped and had a fall in bus stop.  Injury to jaw and bled and had a suture.  loss of consciousness for 15 minutes.  Post ictal confusion is absent  Fever since 14 days low-grade associated with chills and Rigors intermittent insidious in onset, no diurnal variation, decreased...
Read more

MEDICINE CASE BASED LEARNING || Online assignment for the month of MAY 2021

MEDICINE BLENDED ASSIGNMENT  I have been given the following cases 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 diagnosis and come up with a treatment plan. This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  1. PULMONOLOGY:  CASE I: A) Link to patient details: https:// soumyanadella128eloggm. blogspot.com/2021/05/a-55- year-old-female-with- shortness-of.html Q&A: 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? A) The following is the event timeline of sympto...
Read more

55/M Pyrexia with ?Septic shock

Image
 NAME: Meghana.M Roll no: 95 Batch: 2017  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" 55 year old MALE daily wage laborer by occupation, resident of Mandapuram came with chief complaints of  Fever  since 10days,  Abdominal pain Since 10 days,  Patient was apparently asymptomatic 15 days back then he developed FEVER high-grade Intermittent, Insidious in onset, gradually progressive, decreased on using medications.  Since day 3 fever was associated With headache, chills and Rigors decreased sleep; decreased in...
Read more