ACID PEPTIC DISEASE [ACIDITY]
Pateint ID : 2467/ 45 Years/ Male
Address : Rachi / Ranchi/ Jharkhand/ India/ 834001
Occupation : Biology Lecturer
Patient Category : New
Patient Presentation : Patient visited Dr. Sohan Lal Clinic and inform Dr. Anand Kumar that he is diagnosed with chronic acid peptic disease. Duration of illness is 3 years.
Chief Complaints : Chief Complaint-
Recurrent abdominal pain- which has three notable characters-
1-Localisation to the epigastrium.
2-Relationship to food
*Epigastric pain- pain is referred to epigastrium, and is so sharply localised that he can locate the site with one finger (pointing sign).
*Hunger pain- occurs on empty stomach (hunger pain) and is relieved by food or antacids.
*Night-pain-Typically the pain wakes him from sleep around 2-3 AM (night pain) and is relieved by food, milk or antacids.
*Pain relief-Pain is usually relieved by food, milk, antacids, belching or vomiting.
**Periodicity (episodic pain) Pain occurs in episodes, lasting 1-3 weeks every time, 3-4 times a year. Between episodes, he is perfectly well. In the initial stages, the episodes were short in duration and less frequent. As his disease progressed, the episodes become longer in duration and more frequent. He is more symptomatic during winters.
His other complaints were excessive salivation (water-brash), heart burns, loss of appetite and vomiting.
Personal history-Smoking & Alcohol intake
Family History : -
Treatment History : Patient is on antacids.
Follow up 1-There is not much relief. Dr. Anand Kumar advised him to take the following general measures-
*Avoid smoking-As it would increase his abdomen pain and relapses are more common in smokers than in non- smokers.
*Avoid asprin and non-steroidal anti-inflammatory drugs.
*Alcohol to be moderated.
He is advised for a double contrast barium meal test.
Follow up 2-His abdominal pain decreased 60% and his night pain had also decreased. His barium meal test showed multiple ulcers in stomach.
Follow up 3-Abdominal pain decreased by 90%. He had less salivation and heart burns. His appetite had improved and he had stopped taking antacids.
Follow up 4- He experienced spontaneous increase in his abdominal pain which was controlled by increasing the frequency of the medicines.
Follow up 5-Patient is responding well to his treatment. Dr. Anand Kumar had to council him; he explained that peptic ulcer is a chronic condition with a natural history of spontaneous relapses and remissions lasting for decades or even life.
Follow up 6-Patient has a mild relapse of his abdominal pain which is controlled by the medicines. He is sleeping well at night as he did not have any night pains.
Follow up 7-Patient has abdominal pain for short duration. His treatment is revised as his symptoms increase during winters.
Follow up 8-Patient is happy with his treatment as he is hopeful to be cured of his chronic acidity.
Follow up 9-Patient is asymptomatic in winters and is leading a normal life. Dr. Anand Kumar informed him that he would require intermittent treatment if his symptoms relapse 4 times a year.
Result : Patient achieved outstanding recovery. Our treatment will control the excessive acid production and heal the ulcers.;