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Case Study : HYPER ACIDITY

History

  • A 34 year old male suffering from HYPERACIDITY since 2 years.
  • Burning in abdomen < eating after/empty stomach/afternoon.
  • Bloating of abdomen > flatulence.
  • H/O Hyperacidity 2 yrs ago took multiple treatment got better.
  • Endoscopy reveals GASTRITIS.
  • Also complaints of anger issues.
P/H & FH
  • H/O Injury on right wrist in 2016.
    F/H : DM+ HTN+
  • Thyroid disorder+ H/O T.b
PHYSICAL GENERALS
THERMALS
  • APPETITE : Hunger< (irritability)
  • LIKES : Warm food+/Mutton++/Sweets++/Tea++
  • DISLIKES : Chicken/Vegetables
  • THIRST : 2L/day
  • PERSPIRATION : Moderate/on upper body/N.S/N.O
  • SLEEP : On Right side
  • STOOL : H/O constipation (takes isabgol daily)/after eating
  • URINE : Normal
  • FAN- Not required
  • BATHING- Warm water
  • COVERING- In all seasons
  • SEASON- Cannot tolerate winter
  • LIKES- Rainy+
  • THERMALLY CHILLY+ Pt
MIND
TOTALITY
  • Hasty speech+
  • Anger at trifles+ – Hits / Abusive in anger
    Trembling of legs with anger
    Anger with repentance+
  • Fear of accidents+/darkness+(wants light on)/falling+
  • Anticipation+ something bad will happen
  • Impatient +
  • Fastidious+
  • Likes cricket/football
  • Weeps easily+ >weeping
  • O/O – Imprints of teeth on tongue
  • DREAMS – Snakes+/death+/dead relative+
  • Food- Tea+
  • >flatus
  • Warm food
  • >Rainy+
  • Fastidious+

PRESCRIPTION

Rx,
Hepar sulph 200(2p)
S.L 200(2d) 5-0-5
S.O.S Iris versicolor 30(1/2d) 3 pills
Date
Prescription
Follow up

14/08/21

Burning sensation > 50%
Stool twice a day
Sensation with urging
Rx,
Hepar sulph 200(3p)
S.L 200(1d)*3 5-0-5
6/09/21
Stool Improved
Rx,
Ct all×3 weeks
30/09/21
Stool Normal
Burning ->-
Rx,
Ct all×3 weeks
26/10/21
>>
Rx,
Ct all×3 weeks
18/11/21
Stool >>(not taking isabgol)/once a day
Burning in abdomen-o-
Rx,
Ct all×3 weeks
11/12/21
>>
Rx,
Ct all×3 weeks

1/1/22

>>
Rx,
Ct all×3 weeks
24/1/22
Burning in abdomen <->(H/O outside food)
Stool normal
One episode of bleeding P/R
Rx,
Ct all×3 weeks
7/2/22
Burning >
Fissure >
Rx,
Ct all×3 weeks
10/3/22
10/10/22
>>
Anger >>
Rx,
Hepar sulph 200(3p)
S.L 200