35 year old male patient came to causality with the c/o vomitings 3days back (10episodes), associated with blood

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 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 comment box is welcome


35 year old male patient came to causality with the c/o vomitings 3days back (10episodes), associated with blood


HOPl:-

 patient was apparently asymptomatic 3days back then he developed vomiting (10episodes) associated with blood,h/o alcohol consumption 3dyas back

no history of bleeding per rectum, abdomen distension, pedal edema,no other complaints.

Past History:

Not k/c/o DM,HTN,TB,Asthma,CVA,CAD,Epilepsy

Personal history: 

Occasional alcoholic since 10years 


O/E:

No pallor/Icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

Temp-afebrile

PR- 100bpm

RR-24/min

BP-130/110 mmhg

Spo2- 98%at RA

GRBS-140 mg/dl

CVS- S1 S2 +,No murmurs

RS- BAE+,nvbs +

P/A- soft, non tender 

CNS- NAD









Investigations:-

GI Endoscopy


Chest X ray


X ray abd


2D ECHO


USG


ECG



Provisional diagnosis:-

OESOPHAGEAL ULCER 2° TO REFLUX OESOPHAGITIS (GRADE || ) ALCOHOL INDUCED


TREATMENT;-

1)NBM TILL FURTHER ORDER

2)IVF 0.9&DNS WITH 1AMPOULE OPTINURON/IV/OD

3)INJ.PAN 200mg IV IN 50CC@2CC/HR (8mg/hr)

4)TAB.RANITIDINE 150mg /BD

5)INJ.VITAMINE K  1AMPOULE /IV/OD

6)INJ.TRANEXA 500mg /IV/BD

7)T.LEVOSULPRIDE  25 mg/BD

8)T.HP KIT/BD (OMEPRAZOLE +AMOXICILLIN +TINIDAZOLE)

9)SYP.MUCAINE GEL 10ml /PO/TID


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