59 years old male with Large hiatus hernia and Zenkers diverticulum

E-LOGS MEDICINE 


Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centred approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.



CASE OF A 59-YEAR-OLD MALE


This is a case of a 59-year-old male who is a businessman in profession. This de-identified blog was created after taking informed consent from the patient.



CHIEF COMPLAINTS

  1.  Mild and occasional abdominal pain for 14 years.
  2. Gastric acidity for more than 10 years.
  3. Discomfort of throat.



History of Presenting Illness



The patient was reasonably well till 2006.

Then he developed abdoninal pain which was mild in nature. The pain occurred in an interval of 10/15 days and stayed for 1/2 days.


In 2009, he went to kolkata for endoscopy. His endoscopy report revealed ulcer. Doctor provided him 2 medicine for 1 year. One of which is gas tablet and the another one he couldn’t remember. From that time he is still continuing the gastric tablet.


Later in 2010, he again went to Kolkata for endoscopy. This time his report suggested that his ulcer was completely well but he was diagnosed with large hiatus hernia.


In 2015, he did endoscopy and it suggested his hernia got enlarged & doctor said to do operation.


His 2017 endoscopy report suggested stage 3 hiatus hernia.


In March 2022, he developed abdoninal pain and bladder pain which is sudden in nature and occurs once in a 10/12 days. He did USG, and the report was well.


In late November 2022, his endoscopy suggests Zenkers Diverticulum. There is a pouch beside his esophagus, in which food particles got stuck.

Doctor suggests operation for this.



History of Past Illness


No significant past history.


Family History 


His father was a known case of asthma.


Patient's Diet 


-Breakfast: potota, vegetables, tea.

-Lunch: rice, pulse,vegetable

-Dinner: porota, vegetable, tea



Personal History  :


Weight - 65 kg

Diet - mainly vegetables

Appetite - Normal

Bowel- Normal

Bladder movements - Urination not clear(incomplete).

Addiction - No smoking. Alcohol intake once in 2/3 years. Previously, betel nut intake for 8/10 years before 2006(25/30 betel nut per day)



Clinical Images: 






Clinical Reports: 






























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