30Y/M with Epigastric pain and Bloody vomitings

CBBLE UDHC SIMILAR CASES

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


30Y/M came to OPD with C/O epigastric pain and Bloody vomitings since 2 days
HOPI:
Patient was apparently normal 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
Past History:
Not a k/c/o DM,HTN,Asthma
Family History:
No family history of HTN, DM, bronchial asthma, epilepsy
 
General examination:- 

Patient is conscious,coherent , cooperative,Oriented to time,place and person
No signs of pallor,icterus,cyanosis,lymphadenopathy&pedal edema

Vitals:
Temp:- 98.3 F
BP:- 110/70 mmhg
RR:- 20 cpm
PR:- 85 bpm
Systemic examination:-
CVS- S1, S2 heard,
RS: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:?Peptic Ulcer Disease

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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