27 year old male presented with stomach pain .

 

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27 YR OLD MALE PRESENTED WITH STOMACH PAIN 

 27yr old male ,Mason by occupation resident of vellanki came with chief complaints of stomach pain since 2 days .

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 3 days ago then he developed stomach pain in epigastric region which is insidious in onset pricking and shooting type of pain radiating to back,gradually progressive in nature.

It aggrevated on not having food didn't relieve even on taking medication.

7-8 episodes of vomiting which is non projectile and non bilious ,with food contents in it.

History of fever 10 days ago 

History of weight loss, loss of appetite, insomnia, fatigue .

No complaints of chest pain, palpitations, SOB, headache, burning micturition,loose stools, giddiness

Dailyroutine:He usually wakes up in the morning around 7 am .He will complete his daily routine .He drinks tea around   and have breakfast around 8 am .He will go to his work(construction site) by 9 am .He will have lunch around 1pm with rice and vegetables in his meal.But most of the times he skips his lunch.He will get off from his work by 6pm. He drinks alcohol (160 ml)after getting of work daily.Then he comes home have dinner,play with his kids and go to bed by 11 pm.

PAST HISTORY :

He is known alcoholic since  with a daily intake of 160ml.

No history of Diabetes Mellitus, Tuberculosis, Asthma, Hypertension, Epilepsy, Thyroid Disorders.

FAMILY HISTORY :

No significant family history 

PERSONAL HISTORY :

Mixed diet 

Reduced Appetite

Regular Bowel and Bladder movements

Adequate Sleep 

Alcohol intake regularly around 160 ml (recent intake on 30/12/2022 around 6pm )

Used to be a smoker until 3 years ago.

TREATMENT HISTORY :

Tab.Sompraz 40

Mucaine gel 

Normodorm 25 mg 

GENERAL PHYSICAL EXAMINATION :

On examination, patient is conscious, coherent, cooperative

patient is moderately built and moderately nourished

No signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy, generalised edema.

Vitals

Fever chart

Temperature- afebrile

Pulse rate -64/min

Respiration rate-20/min

BP-130/100mm/Hg. 

SYSTEMIC EXAMINATION:

Abdominal Examination:

Inspection 

Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.

Palpation 

No local rise of temperature 

 Soft, tenderness present in the epigastric region,    lumbar region.

Percussion

Dullness 

Auscultation 

Bowel sounds Heard

Cardio vascular examination:

No visible pulsations, scars, engorged veins. No rise in jvp 

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

Respiratory system :

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

 Bilateral Airway Entry - positive

 Normal vesicular breath sounds

CNS examination: 

No neurological deficit found.

Gait: normal.

Provisional Diagnosis 

Alcoholic gastritis .

INVESTIGATIONS: 

Hemoglobin :15.7 mgdl 

Total leukocyte count : 9400 

Lymphocytes : 14 

PCV :45 

RBC :5.19 

PLT :3.1

SERUM ELECTROLYTES :

Sodium :136mEq/L

Potassium:3.6 mEq/L

Chloride:104mEq/L 

Ionised Calcium : 1.09 mmol/L 

LIVER FUNCTION TESTS :

Total bilirubin : 2.92 mg/dL

Direct Bilirubin:0.57mg/dL

SGOT 16IU/L 

SGPT 15 IU/L 

Alkaline Phosphate 338IU/L 

Total proteins : 8.0 mg/dL 

Albumin : 4gm/dL 

A/G ratio :1.0 

Serum Amylase 99IU/L

ECG 

Ultrasound 

Hepatomegaly:16.6 cm

DIAGNOSIS:

Alcoholic Gastritis.

Alcoholic Hepatitis.

Treatment:

IV Normal saline @75ml /hour 

INJ PAN 40 mg IV /stat 

INJ ZOFER4mg IV /stat 

INJ THIAMINE 1Amp in 100 m NS/BD 

INJ BUSCOPAN IV /SOS