30YR old MALE with Pain Abdomen and Vomitings
1801006059-Short case
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
HOPI: Patient was apparently asymptomatic 2 yrs back, later he developed burning type of pain in epigastric region when he consumes alcohol and on eating spicy food. He also had 1 or 2 episodes of vomitings along with pain which were clear or sometimes yellowish in color .
He came to our hospital around 6 to 8 times in 2 years for the above complaints and has been treated for the cause and was advised to stop consuming alcohol.
3 months back ,he had an episode of vomiting with smal amount of clots(1- 2 ) with severe epigastric pain -stabbing type, non radiating and severe burning sensation in the throat after the episode of vomiting.
He came to the hospital with 7 to 8 episodes of vomit with blood clots in a day which were black in color with pain abdomen which was severe stabbing and non radiating type.
He also had a single episode of vomiting which was greenish in color on the same day.
*Symptoms aggravated by intake of spicy food and alcohol.
No H/O -Fever,headache,diarrhoea,blood in stool,body pains, burning micturition.
PAST HISTORY:
No H/O - DM,HTN,T.B,Epislepsy,Asthma,Syphilis,CAD,and CKD.
No known history of drug allergies.
FAMILY HISTORY -Nothing Significant.
PERSONAL HISTORY
**Diet: Vegetarian Bland food .(Since the episodes of vomiting and pain)
**Appetite: Decreased
Bowel and Bladder movements :Regular
Sleep: Adequate
**Addictions: Alcohol intake of 90-190ml /day since past 10 years And Tobbacco chewing since
9years.
ON EXAMINATION
Patient was conscious, coherent, cooperative and we'll oriented to time place and person
GENERAL PHYSICAL EXAMINATION
Pallor-absent
Icterus- absent
Cyanosis- absent
Clubbing- absent
Generalized lymphadenopathy- absent
**Vitals**
Temperature- Afebrile
Pulse rate -80bpm
Respiratory Rate - 18cpm
Blood pressure-128/85mmHg
sPo2 97% at room temperature
SYSTEMIC EXAMINATION
CVS: Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscaltation-
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS
Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
PER ABDOMEN
On inspection:
Abdominal distention - absent
All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars,dilated veins, prominent Venous pulsations and visible peristalsis.
On palpation::
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity
#TENDERNESS felt over left hypochondrium and epigastrium region
On percussion::
Tympanic note - heard
No shifting dullness
On auscaltation::
Bowel sounds heard
PROVISIONAL DIAGNOSIS::
Upper GI bleed.
Known case of Chronic pancreatitis and
Alcoholic gastritis.
INVESTIGATIONS:
Heamogram::
Hb-14.5gm/dl
TLC-6700 cells/cumm
Lymphocytes-38
Eosinophils-**10**
Platelet count-1.40lakhs/cumm
TREATMENT::
Inj.PANTOP 80mg in 40ml of NS
Inj.THIAMINE 200mg
Inj. ZOFER 4mg
Inj. TRENIXA 500mg
Inj.Diclofenac.
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