A 30 yr old man came to OPD with abdominal pains and bouts of vomiting.

FEBRUARY 16 ,2022

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Mamta Agrawal

Roll no. 42

A 30 yr old male patient who is painter by occupation since 10 yrs came to opd yesterday night with chief complaints of abdominal pain and repeated episodes of vomiting since 2 days. 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 years back. Then he developed pain in abdomen at the epigastric region which is non radiating, intermittent , dragging like, moderate pain which is aggravated after having spicy food and when he drinks alchol on empty stomach in the morning and decreased with medication ( whose name he doesn't know and he didn't bring it to hospital) 

He also had 2-3 episodes of vomiting which was non bilious non projectile and had food as it's contents. 

He had similar complaints in the past 2 yrs for nearly 6-7 times. He had alcohol every day but stopped consuming alchol for the 3-4 months in between(religious reasons and no withdrawal) after which he was hospitalised was a month ago he had abdominal pain similar to the one he had before and 5-7 episodes of vomiting which was non bilious non projectile and food as it's contents and was blood tinged. - He was advised to have endoscopy which the patient didn't do and? medication. 

He resumed his alchol after the discharge last time and he at present had similar abd pain and 8-10 episodes of vomiting without any blood contain. 

His symptoms are aggravated generally after he drink in the morning on empty stomach. 

He has mild intermediate tremors which doesnt interfere with his day to day activities. 

He had no history of nausea, loss of appetite,diarrohea Or constipation.

He had no history of any seizures or sudden loss of consciousness. 

PAST HISTORY:

He is not a known case of diabetes mellitus, hypertension, thyroid, asthma, TB, epilepsy, leprosy. 

FAMILY HISTORY:

Mother is a known hypertensive. 

PERSONAL HISTORY:

Diet - Mixed

Appetite - Normal

Sleep - Normal

Bowel and bladder movements - Regular

No known allergies

Addictions - alcohol (whisky) intake since 10 yrs (180 ml/day) daily . Increased intake during holidays and weekends. 

Patient started on alcohol because of occupational stress with half the quatity as of now and gradually the amount of intake increased. 

His general alcohol consuming routine  constitutes of having it in the evening and then after 2- 3 hours he has his dinner. Occasioally he has his alchol in the morning on empty stomach which leads to pain abdomen. 

His last drink was 3 days back and he shows no alcohol withdrawal as of now. 

Smoking since 6 yrs occasionally. 

GENERAL EXAMINATION:

Patient is examined under well lit room and adequate ventilation with his consent taken

Patient is conscious , coherent and cooperative well orientated to time, space and person. He is moderately built and well nourished. 

No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema. 

Vitals:

Temperature: afebrile

Pulse:62 bpm

Respiratory rate: 16cpm

Blood pressure: 170/110 mm Hg

SpO2 at room air: 98%

GRBS:mg/dl

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard ,no murmurs 

Respiratory system:

Central position of trachea 

Vesicular breath sounds

No wheeze,no dyspnoea

Central Nervous System:

No focal neurological defecits is present. 

Abdomen:

Scaphoid shape

Umbilicus - everted

On palpation soft and no scars or pigments present. 

No tenderness

No palpable masses

No organomegaly

Bowel sounds present

Abdominal grith - 36 inches

Investigations -

ECG -

USG -

It shows bulky body of pancreas with altered echo texture. 

Summary -

PROVISIONAL DIAGNOSIS-

? Alcoholic Gastritis

? Pancreatitis (Acute/Chronic) 

? Upper GI bleed secondary to PUD

TREATMENT:

Infusion - RL, NS - @ 100 ml/hr

Injection pantaprazole 40 mg IV/OD

Injection Zofer 4 mg IV/TID

Injection Thiamine 1 amp in 100 ml NS IV/OD

Injection Tramadol 1amp in 100 ml NS IV/TID

BP/HR/Temp - monitor 4th hourly

GRBS monitor 12 th hourly.