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














Comments

Post a Comment

Popular posts from this blog

60/M with ?CVA

Image
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 Jeeharika Dr Sreeja Dr Harsha Dr Kalyan 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 03/03/2021 60/M with  C/O : inability to speak since evening (around 6pm.) Deviation of angle of mouth to left side since evening (around 6pm) Patient was apparently alright till evening, suddenly he was unable to speak (?slurring) w
Read more

Bimonthly assessment for the month of February 2021

Image
  Bimonthly assessment for the month of feb 2021 February 22, 2021 This is my submission for the Bimonthly internal assessment for the month of February. The questions to the cases being discussed can be viewed in the following link :  https://medicinedepartment.blogspot.com/2021/02/medicine-paper-for-february-2021.html?m=1 1Q.   50 year man, he presented with the complaints of Frequently walking into objects along with frequent falls since 1.5 years Drooping of eyelids since 1.5 years   Involuntary movements of hands since 1.5 years  Talking to self since 1.5 years    https://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.html?m=1 https://youtu.be/kMrD662wRIQ a. What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings? This is our unit case, and I’ve got the opportunity to prepare the blog for this. I’ve read about Parkinsonism plus syndrome in my final year MBBS, and seeing one i.e., P
Read more

Right sided hemiplegia

Image
  34yr old man , as a working driver presented  in swallowing since 5am   Weakness in Right UL and LL since 5am   Deviation of mouth to left since 5 am  Slurred speech since 6am .  Pt developed sudden onset of  difficulty in swallowing while he tried drinking water followed by he suddenly developed weakness of rt upper limb and rt lower limb .  His attendant later observed deviation of mouth towards left side and slurring of speech.  H/o ? 1episode of GTCS 3years back, the patients attendant says they were also told that he had a heart problem back then.   He has been an occasionally  alcoholic since 20years .  Not a known case of Htn ,Dm type2, Thyroid disorder,  Asthma.  No history of any past surgeries.  On examination  A well nourished and obese individual with no pallor, Icterus, clubbing, cyanosis or lymphadenopathy Though he had bilateral pitting type of pedal edema extending upto his knees His Abdominal girth measured around 96cms He had no neurocutaneous markers Spine is norma
Read more