30Y/M with epigastric pain and bloody Vomitings

February 27 , 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

CHIEF COMPLIANT : 30Y/M and tractor driver by occupation came to OPD with C/O epigastric pain and Bloody vomitings since 2 days

HISTORY OF PRESENT ILLNESS :
 ▪️Patient was apparently asymptomatic 5-6  years back.Initially he was an occasional alcoholic but due to family disputes patient started drinking excessively around 90-180ml of alcohol daily.
▪️One day he developed pain abdomen associated with Bloody vomitings then he got admitted in outside hospital and told to stop alcohol completely.
▪️2 such admissions in 5-6 years.
▪️2 months back he again had abdominal pain and Bloody vomitings,got admitted and treated accordingly.
▪️2 days back he again binged on alcohol because of his daughter's wedding since then he had pain abdomen epigastric region a/w bloody vomiting-dark coloured,10 episodes since yesterday

HISTORY OF PAST ILLNESS:
Not a k/c/o Diabetes mellitus
Not a k/c/o Hypertension,TB,Bronchial Asthma,Epilepsy

PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
He is an regular alocholic (90 ml whisky)
And have a habit of smoking

FAMILY HISTORY: No similar history in the family

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-Mild dehydration 
 
VITALS :
Temperature - 98.3 F
Pulse rate - 85 bpm
Respiration rate - 20 cpm
BP - 110/70 mmhg
Spo - 98%

SYSTEMIC EXAMINATION:

▪️CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard


▪️RESPIRATORY SYSTEM 

-BAE present

▪️CNS

-HMF intact

INVESTIGATIONS:
Na+: 140
K+: 3.4
Cl: 99
Sr.Creat: 1.1
Blood urea: 40
Sr.Lipase: 34
Sr.Amylase: 107

 
    
   USG abdomen: 
   impression - Hepatomegaly
DIAGNOSIS:
Upper GI bleed under evaluation

TREATMENT:
1. Inj. PAN 40mg IV/BD
2.Inj. ZOFER 4mg /IV/ SOS
3.Inj. THIAMINE 1amp in 100ml NS/OD



 



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