NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
DIAGNOSIS : ACUTE GASTRITIS WITH LOWER ESOPHAGEAL SPHINCTER
49 year old female born by natural delivery on 05-06-1973. Born and bought up in coochbihar North Bengal.
Milestones achieved normal.
Childhood was pleasant. Went to school by walk 1.5kms near to home. Comes back home and played games like coco, jumping,running, finishes homework and goes to bed.
She lives with her family - 9 siblings,parents and grandparents all live together
At age 11 she lost her father due to heart stroke secondary to hypertension.
She is very close to her younger brother during her childhood but the same relationship wasn’t maintained after he got married.
She had evening tuitions in 9th standard, fell in love with the teacher. Family was against to this and her elder brother physically tortured her. She came out of the house and married the love her life at age 17.After marriage she had mental torture from her in laws but the relations became smooth after the birth of first baby. Within an year of marriage she got pregnant but keeping the age in mind and after mutual decision she aborted the baby.
She completed her +1 and +2 in arts after marriage
At age 19 that is in 1993 she gave birth to a baby girl by normal delivery.
In 1997 her husband was appointed as forest officer and they moved to staff quarters and lived happily.
In 1999 she gave birth to her second daughter by normal delivery.
In 2001 she had facial puffiness, edema of both upper and lower limbs, went to hospital and was diagnosed with Hypothyroidism.
In 2008 she had insomnia, burning sensation in feet and legs, slow healing of wounds and diagnosed with type 2 DM and was started on medication.
In 2010 she went for a routine checkup and doctor advised her for fasting lipid profile. Found her cholesterols levels were high and she started on medication tab atorvastatin 10mg
In 2010 her husband was diagnosed with cad which worried her so much and took lot of stress but eventually came out of it believing in god.
Marital life was good and they haven’t had age difference issues in their life. Her husband has anger outbursts occasionally and small quarrels on differences for example she likes to have fast food but he likes to stay healthy etc. she is very much interested to do a job but her husband had different views on it and doesn’t like girls stepping out of home and hence she remained as house wife took care of household chores and looked after family.
In 2000 she had pain abdomen was diagnosed with cholelithiasis and cholecystectomy was done.
In 2021 she lost her mother due to natural age related causes. But since it was covid time she wasn’t allowed to go near the body or was allowed to touch her for which she felt very sad
In 2023 She married of her elder daughter which made her so sad and also happy at the same time to send her to in laws home.
Had dust allergy since three years
Daily routine- usually wakes up by 7.30-8am cooks breakfast like moori,chichire,Chura and have breakfast with tea at 10am, fruit at 11am. Cooks and have lunch around 2pm rice with non veg everyday like chicken fish mutton or egg. Takes rest for 30 minutes. Wakes up and have a cup of green tea after which she goes for an evening walk for 1-2 hours for 5-6kms. Comes back home, have snacks and take rest for a while, cooks dinner and have roti around 10pm. Occasionally have very little amount of alcohol but she feels abdominal burning sensation and so she avoided it in recent times. She had a habit of eating pan after every meal.
The routine is almost the same since her marriage and wasn’t changed or affected till date.
Bowel- had constipation since long time - pass stools once in 3 days and is on herbal medicine
Family history
Mother’s elder brother and her elder brother are known diabetics
Father, mother and grandfather are known hypertensives
Menstrual history
Age of menarche-12 years
Menstrual cycle initially 7/25 days past 3/25days
Menopause attained 2 years ago
Course in the hospital
49 year old female admitted with complains of abdominal burning sensation since three months.
Diffused abdominal burning sensation, on and off, gradually progressive in frequency aggreviates on empty stomach or on having spicy foods and relieves on eating and defecation. Not associated with pain abdomen, belchings, nausea, vomitings.
gastro opinion was taken and endoscopy was done in view of abdominal burning sensation
Diagnosed as acute gastritis with lower esophageal sphincter
Day 1
16/2/23
Unit 5
Ward SS
DOA : 15/2/23
49 Y /F WITH ACUTE GASTRITIS
K/C/O HYPOTHYROIDISM SINCE 20 YRS
K/C/O DM TYPE 2 SINCE 15 YRS
S
STOOLS PASSED
SLEEP NORMAL
NO HEADACHE
O
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
VITALS
TEMP- 97.6F
BP- 120/80 MMHG
PR- 80 BPM
RR- 18CPM
GRBS -215 MG/DL @ 8AM
-200MG/DL @ 2AM
-298MG/Dl @4PM(on 15/02/23)
SYSTEMIC EXAMINATION:
P/A : SOFT , NON TENDER
RS: B/L AIR ENTRY PRESENT,NVBS HEARD
CVS : S1,S2 HEARD ,NO MURMURS
CNS : HIGHER MOTOR FUNCTIONS INTACT
A:
ACUTE GASTRITIS
P:
* MEDITATION
*TAB.THYRONORM 75 MCG PO /OD
*TAB.PAN 40 MG PO/BBF
*TAB.METFORMIN GLIMIPERIDE 1000/4
*TAB .SITAGLIPTIN METFORMIN 100/1000
*TAB.ATORVASTATIN 10 MG PO/HS
Investigations
FBS-186mg/dl
PPBS-216mg/dl
HBA1C- 7.2%
Lipid profile:
Total cholesterol - 192mg/dl
Triglycerides - 203mg/dl
HDL - 42mg/dl
LDL - 96mg/dl
VLDL - 40.6mg/dl
Thyroid profile:
T3 - 0.86 ng/ml
T4-13.03micro g/dl
TSH - 3.82 micro Iu/ml
USG abdomen
Opthalomology referal for fundus examination in view of any diabetic retinopathic changes.
No diabetic retinopathic changes were seen but was advised to change spectacle for near vision.
Advice at discharge
*TAB.THYRONORM 75 MCG PO /OD
*TAB.PAN 40 MG PO/BBF
*TAB.METFORMIN GLIMIPERIDE 1000/4
*TAB .SITAGLIPTIN METFORMIN 100/1000
*TAB.ATORVASTATIN 10 MG PO/HS
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