30/M with epigastric pain

 This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Interns:

Dr Archana

Dr Kalyan 

Dr Jeeharika

Dr Sreeja

Dr Harsha


Dr Raveen PGY1

Dr Aashitha PGY2

Dr Aravind PGY3

Dr Vamshi PGY3

Dr Hareen SR

Dr Praveen Naik Ass Prof

DR. RAKESH BISWAS HOD


Here is a case i have seen:

Admission under unit 3 on 24/02/2021



30yr man presented to the casualty at 9pm complaining pain abdomen since yesterday, vomitings since yesterday.


Patient works as a painter at hyderabad. He got married 9 years back and has a daughter,who is 4 yrs old.He has been an alcoholic since the past 13yrs of around 90ml/day along with toddy consumption ocassionally.

Last intake was 2 days back nearly 2litres of toddy. He was admitted 1 yr back with the complaints of chest pain along with vomitings, he was admitted for 2 days and was told that it was because of alcohol. He also chews 1 pack of zarda per day. His wife tells that he was been having similar complaints since the past 5 yrs with recurrent episodes of vomitings along with pain abdomen.


Since yesterday he has been having Epigastric pain along with vomitings of around 3 episodes since yesterday. Vomitings are non projectile, non bilious, watery ,containing food.

His pain abdomen isn't relieved on bending forward.He says it is a constant,burning type of pain in the epigastrium.


The patient says his appetite has lost since the past 5 years

His pulse is at 78bpm

Bp at 120/70mmg

Afebrile

RR 19cpm

Spo2 at 99%

Grbs - 121 mg/dl


Cvs - S1, S2 +

Lungs clear on auscultation

Per Abdomen - Tenderness + in epigastrium



Investigations: 

















Day 3 haemogram: 



Psychiatric referral taken I/v/o alcohol dependance, tab lorazepam and inj thiamine was added. 


Provisional diagnosis:

Alcoholic gastritis with alcohol dependence syndrome


Treatment : 

1. IVF 

2. Inj. Thiamine 

3. Inj. PANTOP

4. Inj. ZOFER

5. Inj. TRAMADOL

5. Tab. LORAZEPAM














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