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Carafate and non acidic reflux


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Acid reflux for over 1 year

Name of Student clinician: Minjung Shin Name of supervisor: Mei

Age : 50 years Gender : Female

Chief Complains : Acid reflux for over 1 year

Description (4 diagnostic methods)

A) Asking

- Present illness history : She has suffered from the acid regurgitation for over 1 year. It started with stress from work. It generally gets worse at night and after taken greasy and oily food. She has takes 2 tablets of “ Losec ” everyday after have dinner, it makes her feel better.

Accompanying symptoms are stiffness of shoulder ( tenderness on the Jianjing – both side ), nape ( Fengchi ), anxiety and nausea. Also, she is infected with a Hepatitis C virus for a long time and the side effect symptoms that are suspected to be related with the HCV are orange color urination and hair falling down.

- Present Symptoms : Good appetite, No chill and fever, No abnormal

sweating, No feels thirst and prefers warm drink ( Mixed for cold and hot water ), Sleeping is good with vivid dreams ( dreams about busy things, feels tired after wakes up, sleeping 7 hours – 11pm~6am ), Urine ( normal amount, orange color of urine without foam, fish smell ), Loose stool ( 1~2 times per day, strong smell without indigested food, no abdominal pain ), Myopia, Nausea, Acid reflux, Cold foot and hands, Stressful, Emotional, Irritability, Depression, Tinnitus ( right side ), Dry eyes.

- Past history : Currently infected with Hepatitis C Virus

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