GERD Presented by Reg. No:

SUBJECTIVE Patient Demographics: Name: G N Age/ Sex: 43/M DOA: 08/01/2015 I.P. No: Unit/ Ward: S1/19 DOD:13/01/2015 Chief Complaints: Heart burn, dysphagia for 6 weeks. Vomiting for past 3 days.

OBJECTIVE On Examination: Patient conscious, oriented, afebrile BP 130/85mm of Hg PR 70/min GI endoscopy : Inflammation of Gastric Mucosa (Gastritis)

Laboratory data : S.NoParameterObserved valueReference value 1Haemoglobin13gm/dl gm/dl 2Blood Sugar(R)96 mg/dl mg/dl 3Serum Urea19mg/dl8-25mg/dl 4Serum Creatinine1.0 mg/dl mg/dl 5ESR20mm/hr0-15mm/hr 6WBC11000cells/mm cells/mm3 7platelet300000/mm /mm3

ASSESMENT Diagnosis: GASTROESOPHAGEAL REFLUX DISEASE

PLAN SL N O DRUG NAMEDOSEROAFREQDURATION T.ALUMINIUM HYDROXIDE[ALUDRO X] IV Fluids 500mg 20mg p/o iv p/o bid od √√√√√√ √√√√ √√√√ √√√√ √√√√ 3 T.Lansoprazole (T Prevacid) 4T. Domperidone10mg`p/obid√√√√√

Drugs on discharge INTERVENTION The given prescription was found to be rational,since there is no adverse drug reaction or drug interaction found.Drugs on discharge should be taken for 2 weeks.Review after 2 weeks. Sl.no DRUGSDOSEROUTEFREQU ENCY DURATION 1.T.Lansoprazole20 mgp/ood2 weeks 2.Susp.aluminiu m hydroxide 320mg /5ml p/oHS2 weeks 3T.domperidone10mgp/oSos2weeks

EDUCATION PATIENT COUNSELLING: Drug based Follow up the medication correctly. Do not stop medication without doctors recommendation as symptoms may rebound Strictly avoid using NSAIDs such as aspirin, ibuprofen, and birth control pills Non responders to PPI’s should be consulted with the doctor Disease based Don’t skip meals. Don’t take rest immidiatly after taking food. Reduce fatty diet intake. Maintain ideal body weight. Take minimum of six hours sleep. Avoid citrus containing diet like orange, lemon. Avoid emotional stress.

Lifestyle Modification: Maintain a healthy weight Quit smoking Avoid alcohol consumption Avoid stress and other related problem Avoid spicy and irritating food Include fibre containing food

Thank you.