A 30 year male with Acute epigastric pain CBBLE UDHC similar cases

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Chief complaints

A 30 year labour male came to casualty with history of epigastric pain and vomiting since 2 days

History of presenting illness

Patient was apparently asymptomatic 2 days ago then developed 

epigastric pain which is not radiating to back aggravating with alcohol,  relieved with medications, 

history of 20 episodes of vomiting which are nonbilious non projectile and food particles as contains. 

No history of fever, burning mituration, shortness of breath

History of alcohol binge 3 days back

Past history

History of 7-8 admissions in the past 5 years last admission was one month back with complaints of pain in abdomen in epigastric region associated with 4-5 episodes of vomiting with food particles mixed with blood and then was diagnosed upper GI bleed secondary to peptic ulcer disease or mallory Weiss tear and patient was advised endoscopy but refused to get it done.

NOT A KNOWN CASE OF DM, HTN, THYROID DISEASE, EPILEPSY, 

PERSONAL HISTORY :

DIET - MIXED

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ALCOHOL ADDICTION, LAST BINGE 3 DAYS BACK 60 ML WHISKY

FAMILY HISTORY - 

NAD

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 98.1

PULSE RATE - 80 BPM

BLOOD PRESSURE - 100/70 MM OF HG 

RESPIRATORY RATE - 16

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

Clinical images

INVESTIGATIONS

LFT

TB - 3.56

DB - 0.98

AST - 26

ALT - 10

ALP - 127

TP - 6.3

ALB - 3.7

RFT

UREA - 25

CREATININE - 0.9

Uric acid 6.8

NA - 140

K - 4

CL - 98

S.AMYLASE - 32

S.LIPASE - 24

FBS - 90

HEMOGRAM

Chest X-ray

X-ray erect abdomen

ECG

USG abdomen

Pancreas bulkey with altered echotexture

No evidence of cholelithiasis

No evidence of ascitis

Plan

IV fluids NS/RL AT 75ML/HR

INJ. PAN 40MG IV OD

INJ. TRAMADOL 1AMP IN 100ML NS IV TID

INJ. ZOFER 4MG IV TID

INJ. THIAMINE 1AMP IN 100ML NS IV OD

SOAP NOTES DAY 1

S

C/O ABDOMINAL PAIN DECREASED

No episodes of vomitings

No SOB

O

TEMP - 98.4' F

PR - 72

BP - 120/80

RR - 16

SPO2 99 ON RA

CVS - S1, S2 +

RS - BAE +, B/L NVBS

P/A - SOFT, NT

CNS - NAD

HB - 15.3

TLC - 7,600

Plt - 1.5 lac

LFT

TB - 3.56

DB - 0.98

AST - 26

ALT - 10

ALP - 127

TP - 6.3

ALB - 3.7

RFT

UREA - 25

CREATININE - 0.9

Uric acid 6.8

NA - 140

K - 4

CL - 98

S.AMYLASE - 32

S.LIPASE - 24

FBS - 90

BISAP - 0

Modified Marshall score - 0

A - acute ABDOMINAL pain secondary to alcoholic gastritis

P

IV fluids NS/RL AT 75ML/HR

INJ. PAN 40MG IV OD

INJ. TRAMADOL 1AMP IN 100ML NS IV TID

INJ. ZOFER 4MG IV TID

INJ. THIAMINE 1AMP IN 100ML NS IV OD

Upper GI ENDOSCOPY

Psychiatrist referal

Alcohol dependence syndrome, currently in withdrawal, and Tobacco harmful use

Advise:

Inj. LORAZEPAM 2mg IM HS

Inj. THIAMINE 100 mg SLOW IV OD