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

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