A 33 yr old patient

A 33 year old patient resident of Suryapet,electrician by occupation ,presented to casuality with chief complaints of  
          -Nausea and vomitings since Sunday 4pm
          - Epigastric pain since Sunday 2 pm 
          -Induced vomiting
          - Throat pain

HISTORY OF PRESENT ILLNESS
Patient is Chronic alcoholic since 20yrs. Due to issues with his wife he consumes alcohol since 1 yr.For the last 7 days he is drinking without eating food.
He has complaints of Epigastric pain since yesterday ,burning type and radiating to back and gradually progressive.
Nausea and Vomiting is seen ( vomitis in black colour)after retching ,non bilious,non projectile
Complaints of burning sensation in throat

PAST HISTORY
Similar episode of binge drinking, 2 episodes in last 1yr
N/C/K/O DM
K/C/O Hypertension since 5yrs, On medication ,irregular
H/O Hernial surgery (Rt) 10 yrs back

 PERSONLA HISTORY
 - Married
 -Mixed diet
 -Apettite less since 1yr
 -Bowel movements - Regular
 -Micturition - Normal
 -Sleep - Irregular since 10 yrs ,sleepi induced only on intake of alcohol or sleeping pills 
If not taken medication he experiences sudden awakenings with frightening,sweating,Increase heart rate and BP 
 - Chronic Alcoholic since 20 yrs
 - Beetle leaf(pan) since 20 yrs initially 5-6 packs which gradually increased to 10 packs 
 - Gutka for 2yrs 

FAMILY HISTORY 
Not Significant

GWNERAL EXAMINATION
Pt is c/c/c
No Pallor,Icterus,Cyanosis,Clubbing,Lymphadenopathy,Edema
VITALS
Temperature: Afebrile
Respiratory rate: 24/ min
Pulse rate: 125/min
BP: 90/60
GRBS: 209mg%

 SYSTEMIC EXAMINATION
CVS: S1,S2 +
RS: BAE +
PA: Soft
CNS: NAD

PROVISIONAL DIAGNOSIS
ACUTE GASTRITIS/ ALCOHOLIC GASTRITIS
PHARYNGITIS? REACTIVE TO VOMITINGS
TREATMENT
INJ. PAN 40 mg/ IV/ BD
INJ. ZOFFER 4mg/TID
INJ. TRAMADOL1Ampoule in 100 ml NS/IV/SOS
IVF NS/RL@125 ml/hr
INJ. THIAMINE 1 Ampoule in 100 ml NS/IV/TID
INJ.OPTINEURON 1 Ampoule in 100 ml NS/IV/OD
VITALS MONITERING

ADVICE AT DISCHRGING 
T.PAN 40 mg PO/OD BBF 5 DAYS
T.AZITHROMYCIN 500 mg PO/OD
SYP. MUCAIN GEL 10 ml PO/
REVIEW AFTER 3 DAYS

Comments

Post a Comment

Popular posts from this blog

final exam long case

Image
This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome.    Chief complaint -  A 54 yrs old male patient of resident suryapet, shop keeper by occupation came to opd with chief complaint of pedal edema from 1 month and fever from 4 days.  History of present illness- Patient was apparantly asymptomatic 6months months back and then he developed  fever   associated with chills , rigor and vomitings. He was admitted in local hospital and was found to have raised creatinine levels and diagnosed as renal failure. He was under observation for 10days and treated . He was on
Read more

27 yr old male patient with Acute gastro enteritis

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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.  Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival )  5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing
Read more

a 45 yrs old male patient

Image
 A patient who is 45 yr old male came to OPD with chief complaints of fever since 2 days and slurring of speech since 1 day and pain in both lowerlimbs . HISTORY OF PRESENT ILLNESS     Patient is a daily wage worker by occupation . Patient was apparently asymptomatic 2 years back then his appetite increased( about 5- 6 times a day ) for which he came to KIMS hospital and diagnosed with Diabetes.He used oral hypoglycemic drugs for first 6 months.Then from past 1.5 years he is on insulin.He was a chronic alcoholic since 25 yrs. He consumes more than 180ml / day . Urine output increased since 2 years about 10 times a day.Decreased weight about 25kg since 2 years. Then since 2 days he developed fever which was high grade, continuous and associated with chills and rigor and also presence of neck stiffness and burning Micturition.Patient was also anemic for which he received blood transfusion   He developed slurring of speech since 1 day then he came to hospital the next day HISTORY OF PA
Read more