A 33year male, came with complaints of Vomitings, Blood in stools,Chest pain and Loss of Appetite..

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 33yr male,resident of Gattupal who is a scrap recycle  shop owner came with c/o vomitings since 10 days which was bilious, daily (1-2 episodes)
Blood in the stools since 10 days
Chest pain (diffuse) since 10 days which is non radiating
Loss of appetite since 2-3 months
HOPI : Pt was apparently asymptomatic 10 days back then developed vomitings which was bilious, during morning (5-7am only).
The frequency of episodes increased on intake of alcohol which he consumed previous night and is not associated with any pain abdomen,but has diffuse chest pain and pt also had bleeding per rectum since 10 days which was relieved now and pt diagnosed to have (Fissure in Ano)

Past History :H/o weight loss present (95kg 1yr ago to 65kg now)
No H/o similar episodes in the past 
No H/o DM TB HTN ASTHMA EPILEPSY,CVA,CAD
H/o RTA 10yrs back

Personal History:
Diet-Mixed
Appetite-Normal
Sleep-Adequate
Bowel and bladder movements-Regular
Alcoholic - Daily quarter (180ml) since 10 years
Non smoker

General examination : pt is conscious, coherent, co-operative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy,pedal Oedema

Vitals
Temperature-afebrile
PR-84bpm
BP-130/90
Spo2-84%
RR-23cpm

CVS -
S1&S2 heard, no murmurs
RS- trachea - central, BAE+,NVBS heard.
Per Abdomen - inspection: shape of abdomen- normal, all quadrants moving equally with respiration, hernial orifices are intacts, no visible pulsations.
Palpation:  soft, non- tender, no-organomegaly.
Percussion: tympanic note heard over all the quadrants of abdomen.
Auscultation : bowel sounds heard.

20/1/21
21/1/21
Endoscopy :
Mild erythromatous gastritis

Ultrasound Report

Diagnosis
Alcoholic gastritis with hypokalemia

Treatment :
Inj PAN 40mg IV / BD
Inj OPTINEURON 1Amp IV / OD.
Syp SUCRALFATE 10ML / PO/ TID
Vitals monitoring 4th hrly

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