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Mr. A. M. M. visited Santacruz clinic on 29th August 2013. He was sixty years old retired gentleman. He had complaint of GERD since past eighteen years. It had increased since past four to six months. The symptoms were bloating sensation, empty eructation, belching, and flatulence. Occasionally he would feel nausea and vomiting. The bowels were normal and regular. The complaints would remain for a complete night. He would take 'home remedies' as and when required. He would also take antacid – Tablet Pan D ( pantoprazole + domperidone) for relief.
His patient identification number is 21556.
He had mild and seasonal eczema on the feet which would recover with application of moisturizers.
He would get left knee pain while ascending stairs. The general physician had prescribed calcium supplements.
He had sleeplessness since past six to eight months. The sleep would be disturbed. He would wake up every hour without any reason.
His diet was vegetarian. His appetite had reduced due to constant feeling of bloating of abdomen. He had liking for all food taste like sweets, spicy and sour. He would drink just four glasses of water per day. He could not tolerate warm weather.
He had retired from work fifteen years back. At present as a hobby he would do business of antique art work. His family consisted of wife and two daughters. His wife was a home maker. The elder daughter was working in an esteemed bank in London. The younger daughter was working in another reputed bank in Mumbai. Both the daughters were single, which was a kind of stress to him.
He was clever and had learnt advanced technology from Germany. He was generally calm and quiet but at times would get intense anger. He could not meet his ambitions as his degree was not much valued in India. His daughters were earning well and settled as single, did not wanted to get married.
He had suffered from kidney stones twice and had taken laser treatment.
His father and brother had the same complaints of acidity.
He was having mild blood pressure and was advised by local doctor to start with conventional medicines but did not start. He wanted to keep the medicines to minimum as possible.
Dr. Shah prescribed him Lycopodium Clavatum 30c along with few research based medicine for six weeks.
He visited on 7th October for first follow up. He was finding improvement of around 10 – 15% in belching and eructation. The flatulence did not find any change. He took tab pan d thrice in past six weeks. He also got few attacks of vertigo and took tab vertin for relief. The knee joint pain was better. The sleep was same. Dr. Shah upgraded his prescription and gave Sulphur 30c single dose.
He visited on 18th November for second follow up. There was further improvement in GERD. His days were much better and appetite had improved. The fullness and bloated sensation of abdomen was not there. He observed that his vertigo was more when there was more flatulence. The knee pain was further better. The sleep had also improved. The same prescription was repeated by Dr. Shah.
He visited on 30th December for third follow up. His complaints had become stable. There was no further improvement in GERD. His knee pain was minimal. His sleep had improved by 30%. He had recurrent mouth ulcers since past few months. Dr. Shah reviewed the case and made necessary changes in the medicines.
He visited on 11th February for his next follow up. The flatulence and eructation had increased since a week. The complaints were more in the night. He had to take tab pan d after a long time. His appetite was still better. The vertigo was relieved by 50%.
He visited on 26th March for feedback. He was glad to report around 80% improvement with last six weeks medicines. He was absolutely symptom free for almost a month. He had Punjabi food at night and it triggered the flatulence and belching in night. The rest of his month was fine. His sleep had also improved by 70%. The mouth ulcers were also nil.
He visited on 22nd April to inform about his wonderful recovery. He was happy and satisfied to be treated effectively by Dr. Shah.
Uploaded on 7th May 2014 by Dr. M. N. P.