40 YEAR OLD MALE WITH SEVERE 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

November 17,2021

40 YEAR OLD MALE WITH SEVERE EPIGASTRIC PAIN

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 A 30 year old gentleman painter by occupation resident of Hyderabad came to OPD with chief complaints of vomiting and loose stools since 2 days and pain abdomen since 1 day 

Patient was apparently asymptomatic 3 days ago when he developed sudden onset vomiting,7-8 episodes since past 2 days which were non bilious and non foul smelling and contained undigested food material

 Patient also had 6 episodes of loose stools since 2 days  which were watery in consistency 

 Colicky and burning type of Pain in the epigastrium which was sudden in onset, persistent aggravated on consuming oily,spicy food and on  alcohol consumption. Relieves on taking medication(meftalspas). But this time it didn’t decrease on taking medication 

SOB(grade-II) since 2 days

History of Alcohol binge 4 days back

He had similar complaints in the past for which he was admitted in our hospital 4 times in past 1 year.

No h/o fever 

Not a k/c/o HTN, CAD, CVA, Asthma,DM

Personal History :

Diet- mixed 

Sleep- adequate 

Appetite- normal

Bowel and bladder movements- regular ,mild burning during micturition

Addictions- none


Family history : Insignificant 


General examination:

No pallor 
No cyanosis 
No icterus 
No lymphadenopathy 

No edema

Vitals:

Temperature- afebrile

BP- 120/70

PR- 76beats / min

RR- 16 cpm


Cvs:s1s2+

Respiratory :BAE present

P/A:soft ,tenderness in epigastrium, no organomegaly 

CNS:NAD 

INVESTIGATIONS: USG abdomen,ECG,amylase,electrolytes 

  

ECG



 HEMOGRAM:

          Hb:14.7gm/dl

          TLC:8,200 cells/

          PCV:40.7

          PL:1.5


  CUE:

        Albumin:nil

        PC:2-3

        EC:2-3

        RBC:nil


Serum lipase -38 IU/L

Serum amylase-41 IU/L

Serum creatinine-1.1mg/dl 

Sodium :147 mEq/L

Potassium :3.8 mEq/L

Chloride:98 mEq/L

Calcium:8.9

Phosphate :2.7

ALP:132

ALT:20

AST:24

TP:5.5

A/G:2.85


PROVISIONAL DIAGNOSIS: alcoholic gastritis, pancreatitis


TREATMENT :

IVF  NS,RL @75ml/hr


Inj. PAN 40/iv/BD


Inj.ZOFER 4mg/iv/SOS


Inj. TRAMADOL 1amp in 100Ns/SOS


Inj.OPTINEURON 1amp in 100ml NS/iv/OD


Inj.THIAMINE -100 1amp in 100ml NS/iv/OD


Moniter vitals 


GRBS 12th hourly



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