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Abstract: The patient, a 52-year-old male, was admitted to the hospital with the main symptom of erratic reflux with no obvious cause 7 days ago. After 3 days, the patient’s symptoms subsided and he was discharged from the hospital in stable condition.
Basic information】Male, 52 years old
Disease Type】Reflux esophagitis
Hospital】The First Hospital of China Medical University
Date of consultation】April 2021
Treatment plan】Medication (pantoprazole sodium for injection, pain and blood capsule, glucose injection, vitamin C injection, sodium chloride injection, aluminum thioglycollate suspension gel, rehabilitation new liquid)
[Treatment period] 3 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】The symptoms of eruption disappeared, the condition was stabilized and the ulcer surface was reduced at the follow-up.
I. First interview
The patient is a male, complaining of erratic symptoms about 7 days ago with no obvious cause, no nausea, vomiting, no acid reflux, heartburn, no abdominal distension, abdominal pain, pain in the throat after coughing in the last 2 days, no fever, chills, no special treatment outside, since the onset of the disease, clear consciousness, mental health, normal urine and stool. Today, he came to our hospital for physical examination and did not see any abnormality. During the gastroscopy, he saw several bands of erosion with blood oozing in the lower part of the esophagus near the dentate line, and the dentate line was not clear, so the preliminary diagnosis was reflux esophagitis and possible cardia mucosal tear. The patient was admitted to the hospital for further treatment.
II. Treatment history
After the patient was admitted to the hospital, he was given primary care, temporary dietary abstinence, and communicated with the patient that the case was mainly treated with medication, and the patient and family members were given answers about the medication needed and the effect of the medication. After the symptoms were relieved, the patient was discharged from the hospital and continued to take thiosemicarbazone suspension gel to protect the gastric mucosa, pain and blood capsule to stop bleeding, and rehabilitation solution to reduce inflammation and promote the healing of ulcer surface.
III. Treatment effect
After the patient was admitted to the hospital and given acid suppression and hemostatic treatment, the patient was checked 2 days later, and the patient’s erratic rebellion was reduced, no nausea and vomiting, no abdominal distension and abdominal pain, no chest tightness and chest pain, all the physical examination was normal, and gastrointestinal microscopy was performed, which showed esophageal erosion and inflammation, no active bleeding, and could be changed to a liquid diet. The pathological results were normal, and the patient was discharged from the hospital for continuous drug treatment. 1 month after the initial consultation, the patient’s gastroscopy showed that the ulcer surface was reduced and the treatment was effective.
IV. Precautions
The patient went to the hospital in a timely manner with erratic discomfort, and no malignant lesion appeared on examination, and the inflammatory lesion was treated and discharged. At the same time, I advised the patient to pay attention to a reasonable diet after discharge, avoiding overheated or hot food, spicy and stimulating food, and alcohol to avoid stimulating the esophageal erosion site and causing vasodilatation and bleeding. And pay attention to reasonable arrangement of rest, pay attention to proper exercise in daily life, avoid sitting or lying down for a long time after eating. In addition, attention should be paid to outpatient follow-up within 1 month and regular review of gastroscopy to avoid malignant lesions in long-standing gastroesophagitis and timely hospital consultation in case of discomfort.
V. Personal insight
In this case, the patient came to the clinic for 7 days with erratic reflux. Fortunately, the examination was only for reflux esophagitis, which usually improves with medication. In clinical practice, there are many patients who do not take nausea and regurgitation seriously and do not seek medical attention when there are no other symptoms and signs, but the appearance of erratic reflux with no known cause suggests that there are abnormalities in the gastrointestinal digestive system, and prompt hospital examination is needed, and regular gastroscopy is recommended for people who have irregular diets, or who drink alcohol regularly and smoke for a long time. In addition, reflux esophagitis is often slow to heal and requires long-term adherence to a healthy diet.