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

B KRISHNA (INTERN)

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



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