A 45 year old male came with complaints of vomitings, nausea and dark coloured stools since 5 days.

Unit II admission on 09/02/2021 

DR. AMULYA ( INTERN) 
DR. YAMINI ( INTERN) 
DR. SURYA PRADEEP ( INTERN) 
DR. ASHA KIRAN ( INTERN)
DR. JAYANTH ( INTERN) 
DR. VAMSHI ( INTERN)
DR. ISMAIL  (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI 

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Here is a case I have seen: 

A 45 year old male who is a farmer by occupation came to OPD with 
1) C/o vomitings since 5 days
2) C/o nausea since 5 days
3) C/o dark coloured stools since 5 days
Patient was apparently asymptomatic 1 month back when his mother passed away, after which he started his consumption of alcohol increased by double /day , with decreased intake of food associated with belching. No h/o outside food intake , insidious onset of non projectile bilious vomitings containing food mixed with blood , 4-5 episodes per day. Not associated with pain abdomen, headache, neck pains. Inspite of which patient continued to consume alcohol and was brought here by his brother for further management.

History of past illness:- 
1)known case of DM type 2 since 10 years on T. Glimi-M2 OD
2)known case of HTN since 10 years on T. Telma 40 mg OD 
3) known chronic alcoholic since 10-15 years consuming 180 ml/ day , daily intake( including yesterday) 
Not a smoker
No h/o CAD, asthma, TB, epilepsy.

 Personal history :-  decreased appetite since a month.

ON EXAMINATION
BP :- 160/100 mm Hg
PR :- 82 BPM
SpO2 :-98% on RA
GRBS :- 110 mg/dl
 No signs of pallor, icterus, cyanisisu, ckubbiu, lymphedenopathy, edema.
No signs of malnutrition or dehydration.
 Systemic Examination :-
CVS - S1 S2 heard, no thrills , no murmurs
RS - BAE present. Trachea central in position. Vesicular breath sounds. No dyspnea or wheeze.
Per abdomen -  scaphoid shape. Tenderness only on deep palpation in peri umbilical area. No palpable mass, hernial orifices normal . No free fluid or bruits. Bowel sounds present.
CNS -  conscious with normal speech. No signs of meningeal irritation.  No motor, sensory and cranial nerve deficits.
 PROVISIONAL DIAGNOSIS 
 Alcoholic gastritis with alcohol dependence syndrome with known case of HTN and DM2

Treatment on day of admission
1.) IVF N and RL @50ml/ hour
2.) Inj thiamine 1amp in 100 ml NS IV TID
3.) Inj pantop 40 mg IV OD
4.) Inj zofer 4mg IV TID
5.) Strict I/O charting
6.) BP/PR/Temp hourly
7.) GRBS 6th hourly pre meal
8.) Inj . HAI SC after informing resident in charge
9.) T. Telma 40 mg OD
10.) W/H all OHA till further orders.

*Day 1 (10-02-2021)
S - subjectively feeling better. No new complaints.
O- pt is conscious and coherent. Fine resting tremors present. 
A- alcoholic gastritis with ? Upper GI bleed with chronic alcoholic liver disease with known case of DM2 and HTN

 Treatment 
 1.) IVF N and RL @50ml/ hour
2.) Inj thiamine 1amp in 100 ml NS IV TID
3.) Inj pantop 40 mg IV OD
4.) Inj zofer 4mg IV TID
5.) Inj. Vit K 10mg IMOD
6.) T. Librium 25 mg for 2 days
7.) GRBS 6th hourly pre meal
8.) Inj . HAI SC after informing resident in charge
9.) T. Telma 40 mg OD
10.) T. Bacfen XL 20 mg
11.) T. Ben XL
12.) Inj. Lorazepam 4mg SOS
 
*Day 2 (11-02-2021) 
S- subjectively feeling better. No new complaints.
O- pt is conscious and coherent. 
A- alcoholic gastritis with ? Upper GI bleed with chronic alcoholic liver disease with known case of DM2 and HTN

 Treatment 
1) IVF N and RL @50ml/ hour
2.) Inj thiamine 1amp in 100 ml NS IV TID
3.) Inj pantop 40 mg IV OD
4.) Inj zofer 4mg IV TID
5.) Inj. Vit K 10mg IMOD
6.) T. Librium 25 mg for 2 days
7.) GRBS 6th hourly pre meal
8.) Inj . HAI SC after informing resident in charge
9.) T. Telma 40 mg OD
10.) T. Bacfen XL 20 mg
11.) T. Ben XL
12.) Inj. Lorazepam 4mg SOS
13.) T. Glimi -M2 OD / 8 am
 

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