A 24 old male with Alcohol gastritis with ?Mallory weiss tear

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OCTOBER 23, 2021

 This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

K.TEJA SREE , ROLL NO:54 ,  9th SEM

CASE

A 24 year old male, construction worker by occupation came to the casuality with chief complaints of blood vomitings since 1 day.

HOPI :

patient was apparently asymptomatic 1 day back . Yesterday night he had 5-6 episodes of vomitings after consuming alocohol continuously for 2days (180ml , 6times)  and last 3 episodes was associated with blood. It was non bilious and non projectile. 

No vomitings since admission.

He had chest pain which is of pricking type and no postural variation.

No history of fever, diarrhea.

HISTORY OF PAST ILLNESS:

not a case of diabetes, hypertension, CAD

no history of TB. epilepsy, asthma

PERSONAL HISTORY:

Appetite :  decreased since 2days

Diet : mixed

Bladder & bowel movements : regular

Sleep :adequate

Addictions :he is an alcoholic ( 180ml/day)

no allergies 

FAMILY HISTORY:

insignificant

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative 
he is moderately built and moderately nourished.
he was examined after taking consent

  • Pallor  : absent
  • Icterus  : absent
  • Cyanosis : absent
  • Clubbing  : absent
  • Lymphadenopathy  : absent
  • Edema  :  absent

Vitals

  • Pulse rate  : 99bpm
  • Bp  : 120/80mmhg
  • Temperature : afebrile
  • Respiratory rate  : 22cpm
  • SpO2  : 98% at room air

        SYSTEMIC EXAMINATION

  • RESPIRATORY SYSTEM

            -position of trachea: central

            - normal vesicular breath sounds   

            -no dyspnea,wheeze                                                         

  • CARDIOVASCULAR SYSTEM   : S1, S2 heard and no thrills and no murmurs

  • PER ABDOMEN : soft non tender non distended.
  • CNS: higher motor functions are intact.
INVESTIGATIONS :

  • ECG



PROVISIONAL DIAGNOSIS   :
  • Alcohol gastritis with ? Mallory weiss tear.
TREATMENT  :
On 23/10/2021
  • Inj. PAN 40mg IV/BD
  • Inj. ZOFER 4mg/ IV/BD
  • Inj.TRANEXA 500mg IV
  • Inj. THIAMINE 200mg in 100ml NS/IV/OD
  • Syp. SUCRALFATE 15ml/PO/TID
  • BP, PR monitoring 4th hourly
On 24/010/2021

  • Inj. PAN 40mg IV/BD
  • Inj. ZOFER 4mg/ IV/BD
  • Inj.TRANEXA 500mg IV
  • Inj. THIAMINE 200mg in 100ml NS/IV/OD
  • Syp. SUCRALFATE 15ml/PO/TID
  • BP, PR monitoring 4th hourly
On 25/10/2021: discharged

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