30yr Old Male with Alcoholic Gastritis

QA 30 yr old Male patient came with chief complaints vomiting with clots and abdominal pain.

HOPI:

Patient was asymptomatic 2 years back.Then he developed abdominal pain in the epigastric region which is Stabbing type when he consumes more amount of alcohol and on eating spicy food.

He also had 1 to 2 episodes of vomitings along with pain which were clear and yellowish. 

He came to KIMS about 6 times since 2 yrs for the above complaints and has been treated for it and was advised to stop consuming alcohol.

3 months back: He had a mild blood clots in vomiting.

On 31/1/22  : He again had blood clots in his vomiting about 7 to 8 episodes .And single episode of vomiting which was greenish in colour with severe epigastric pain which was stabbing type  and burning sensation in throat. 

Then he came to KIMS on 31/1/22.

* Symptoms aggravated on taking spicy food.

No history of fever , burning micturition, diarrhoea, blood in stool, Body pains.

PAST HISTORY

No history of hypertension, Diabetes mellitus ,TB , Asthma , Epilepsy.

No known history of drug allergies.

No significant family history.

PERSONAL HISTORY

*Diet: Bland diet ( since the episodes of vomiting and pain.)

*Appetite : Decreased 

Bowel and bladder movements: Regular

*Sleep: inadequate 

*Addictions: Chronic alcoholic

 Alcohol intake around 90 to 180 ml per day since 10 years.

Tobacco chewing since 10 years .

ON EXAMINATION

Patient was conscious, coherent, cooperative and we'll oriented to time place and person and moderately built.

GENERAL PHYSICAL EXAMINATION

Pallor-absent 

Icterus- absent

Cyanosis- absent

Clubbing- absent

Generalized lymphadenopathy- absent

**Vitals**

Temperature- Afebrile

Pulse rate -78bpm

Resp rate - 16cpm

Blood pressure-126/84mmHg

sPo2 98% at room temperature

SYSTEMIC EXAMINATION

CVS:

 Inspection 

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line .

Auscultation

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

*Position of trachea- central

*Bilateral air entry, normal vesicular breath sounds are heard

*No added sounds

CVS

*Patient is conscious

*Speech normal

*No signs of meningeal irritating

*Motor and sensory system- Normal

*Reflexes - present

*Cranial nerves - intact

PER ABDOMEN

On inspection::

*Abdominal distention - absent

*All quadrants are moving equally with respiration

*Umbilicus - central and inverted

*No scars,dilated veins, prominent Venous pulsations and visible pulsations.

On palpation::

Superficial palpation- No Local rise in temperature and no tenderness

Deep palpation- No guarding, rigidity

*TENDERNESS felt over left hypochondrium and epigastrium region

Percussion:

Tympanic note - heard 

No shifting dullness

On auscaltation::

Bowel sounds heard 

PROVISIONAL DIAGNOSIS::

Upper GI bleed secondary to esophageal varices 

Known case of Chronic pancreatitis and 

Alcoholic gastritis.

INVESTIGATIONS

Heamogram::

Hb-14.5gm/dl

TLC-6700 cells/cumm

Lymphocytes-35

*Eosinophils :10

Platelet count-1.40lakhs/cumm

TREATMENT::

Inj PANTOP 80mg in 40ml of NS

Inj THIAMINE 200mg

Inj ZOFER 4mg

Inj TRENIXA 500mg

Inj Diclofenac