Acid peptic disease

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.

A 45 year old female patient is a labourer by occupation, resident of Mallepally has come to the casualty with

Chief complaints:

C/o difficulty in swallowing since 1 year.

C/o pain in epigastrium since 1 year.

History of Present Illness:

Patient was apparently asymptomatic 1 year back then she developed difficulty in swallowing of both solids and fluids.

Pain in the epigastrium - burning type of pain after consuming spicy food.

Regurgitation of food taken.

H/o intermittent headache, chest pain, and tightness.

No h/o fever, cough, hematemesis, palpitations, burning micturition and diarrhoea.

History of Past Illness:

She had h/o high grade fever and shortness of breath for which she got admitted in the hospital and treated.

K/c/o HTN since 4 years.

N/k/c/o DM, Epilepsy, Asthma, TB, CVA, CAD.

Family History:

No similar complaints in the family.

Personal History:

Marital status- Married 

Occupation- Labourer 

Appetite- Normal 

Diet- Mixed

Bowel and Bladder movements- Regular 

Micturition- Normal 

Known Allergies- No

Addictions- No

Physical Examination:

A) GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

No pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy, no pedal oedema.

No malnourishment.

No dehydration.

—VITALS:

Temperature- afebrile 

Pulse rate- 86/min

Respiratory rate- 20/min

BP- 130/90 mmHg

Systemic Examination:

B) CVS

Cardiac sounds- S1 and S2 heard.

Cardiac murmurs- No

C)RESPIRATORY SYSTEM:

Dyspnoea- No

Wheezing- Yes

Position of trachea- Central 

Breath sounds- Normal vesicular breathing sounds 

B/L air entry- Normal 

D) ABDOMEN:

Shape- Scaphoid 

No abdominal distension, no visible pulsation, no scars, no swellings.

Tenderness- absent (on palpating)

Palpable masses- No organomegaly 

Liver- not palpable; Spleen- not palpable 

Bowel sounds- Yes 

E) CNS:

Level of consciousness: conscious, coherent and cooperative.

Speech- Normal

No signs of meningeal irritation (Neck stiffness, Kernig’s sign)

Cranial nerves- Normal

Motor system- Normal

Sensory system- Normal

Reflexes-             Rt.           Lt. 

Biceps                 ++           ++

Triceps                ++           ++

Supinators           ++           ++

Knee                    ++           ++

Ankle                   ++           ++

Gait- Normal

INVESTIGATIONS:

Haemogram

PROVISIONAL DIAGNOSIS:

       Acid Peptic Disease

TREATMENT:

1) Tab. PAN 40mg PO/OD

2) Syp. SUCRALFATE 15ml PO/TID   30 minutes before food.

3) Neb. IPRAVENT  6th hourly

8/4/23  8:00a.m

  45/F

S-   Chest pain and tightness decreased

O-   O/E  Pt is c/c/c

Temp- afebrile 

PR- 82/min

BP- 130/80 mmHg

CVS- S1 S2 heard, no murmurs 

RS- BAE+

P/A- soft, non-tender 

CNS- NAD

A-  Acid Peptic Disease, k/c/o HTN, ?Asthma.

P-   1) Tab. PAN 40mg PO/OD 30 minutes before food 

       2) Syp. SUCRALFATE 15ml PO/TID 30 minutes before food

       3) Neb. IPRAVENT 6th hourly 

       4) Monitor vitals 

       5) Tab. TELMA 40mg PO/OD

Advice: ENT opinion for - Oropharyngeal dysphagia to both solids and fluids.

No hoarseness.

Frequent regurgitation episodes.

Unable to visualise soft palate ——Plan for ENDOSCOPY for GERD on Tuesday.

Auscultation- Lungs clear.

9/4/23  8:00 a.m

   45/F

S-   Wheezing decreased; Regurgitation and burning sensation decreased.

O-   O/E  Pt is c/c/c 

Temp- afebrile 

PR-69/min

BP-120/80 mmHg

RR-20/min

CVS- S1 and S2 heard; no murmurs.

RS- BAE+ ; NVBS

P/A- soft, non-tender.

CNS- NAD

A-   Acid peptic disease with dysphagia. K/c/o HTN,  ?Asthma.

P-   1) Tab. PAN 40mg PO/OD 30 minutes before food (7 am).

       2) Syp. SUCRALFATE 15ml PO/TID 30 minutes before food

       3) Neb. IPRAVENT 6th hourly 

       4) Tab. TELMA 40mg PO/OD (9 am)

       5) Monitor vitals

10/4/23  8:00 a.m

    45/F

S-   Regurgitation decreased; Burning in epigastrium decreased.

O-   O/E  Pt is c/c/c

Temp- afebrile 

PR- 82/min

RR- 20/min

BP- 90/60 mmHg

CVS- S1 and S2 heard, no murmurs 

RS- B/L AE + ; NVBS

P/A- soft, non-tender

CNS- NAD

A-  Acid peptic disease with dysphagia. K/c/o HTN since 4 years.

P- 1) Tab. PAN 40mg PO/OD

     2) Syp. SUCRALFATE 15ml PO/TOD 30 minutes before food 

     3) Tab. TELMA 40mg PO/OD