Case Studies

Patient : 45 year old male patient

Case History

Forty-five year old male patient came with chief complaints of severe burning pain in the abdomen for the last 7 days. The pain was related to food intake. The patient had a stressful job and was a chronic smoker. The complaints worsened at night time affecting the sleep pattern of the patient. He was not able to either fall asleep easily nor was he able to sleep peacefully throughout the night .

Examination Findings

General examination: The patient’s BP was 120/80mmHg. The other vital parameters were within normal limits.

The systemic examination of the cardiovascular system, central nervous system, and respiratory system did not reveal any abnormalities.

The examination of alimentary system confirmed the diagnosis of peptic ulcer disease.

Treatment

The patient was prescribed cap Omeprazole 40mg a day. He was asked to try and stop smoking. Tab. Zolpidem was added to the therapy at a dose of 10mg per day at bedtime. The patient was asked to follow up regularly.

Follow up

The patient followed up for examination after 30 days. The patient’s symptoms had regressed significantly. The patient felt decreased level of stress and improved work performance due to the therapy. The patient continued therapy for 6 months. At the end of 6 months, the treatment was discontinued. He did not complain of rebound insomnia or any alteration of the sleep pattern.