30 Year Old Male - Alcoholic Gastritis

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A 30 year old male patient, resident of Nerupala,, driver by occupation came to the Medical OPD with

Chief Complaints

Vomiting everyday since 3 months 

Stomach Pain since 3 months 

History of Present Illness: 

Patient was apparently asymptomatic till 3 months ago, then he developed vomiting, which occurs daily mostly in the morning, contains food particles, non-bilious, non-blood containing, aggravated during morning and relieved by drinking alcohol. 

Stomach Pain which is dull and burning and progressive since 3 months.

Chest heaviness at intermittent intervals. 

History of bilateral lower limb swelling, associated with burning and tingling pain at the extremities. 

Colour change of Urine from yellow to red at intermittent intervals.

Past History: 

Known case of hypertension since 2 years.

Known case of diabetes since 2 years. 

Diagnosed with fatty liver grade 2, 1 month ago 

Was diagnosed with Axonal Neuropathy secondary to DBM

Was diagnosed with Polycythemia Vera in NIMS Hyderabad for which 8 Phlebotomies were done during span of 1 year during which he abstained from alcohol and smoking 

Then he reverted back to drinking alcohol and smoking cigarettes since 3 months 

N/K/C/O Epilepsy, Tuberculosis, Thyroid Disorder

Personal History: 

Loss of appetite since 1 month 

Bowel Moments normal 

Urine is discoloured from yellow to red at irregular intervals 

Chronic Alcohol Drinker since 10 years (14 units)

Chronic Smoker - Cigarettes (6-10)

Family History:

Father is a known case of hypertension and has paralysis of right side including both limbs and face.

Treatment History:  

On medication for Hypertension - Telma 20 Mg

Not on medication for Diabetes 

Phlebotomies done

General Examination: 

Patient is conscious coherent and cooperative and we'll oriented to time place and person 

Vitals

Conscious, coherent, co-operative 

BP: 130/100 mmhg

RR: 18 

PR: 90-100 bpm

Temperature: 98.6* F

GRBS: 148 mg/dl 


Pallor: Mild Pallor  

Icterus: Absent

Cyanosis: Absent 

Clubbing: Present 

Koilonychia: Absent

Lymphadenopathy: Absent 

Edema: Absent 


Systemic Examination: 

CVS: 

S1 S2 Heard 

No murmurs heard

Respiratory System: 

Vesicular Breath Sounds Heard 

Trachea Position Central 

No wheeze No Dyspnoea 

Abdomen: 

Inspection:

No scars seen 

Hernial orifices are Normal

No striations 

No distended veins 

Flanks are full

Umbilicus central and everted 


Palpation: 

Temperature Normal 

Liver Tender


Percussion: 

No fluid thrill 

No shifting fluid 


Auscultation: 

Bowel sounds heard

No bruits heard 


Central Nervous System:

Conscious, Coherent, Co-operative 

Motor : Normal

Sensory: Normal 



Provisional Diagnosis: Alcoholic Gastritis


Treatment :

1st day 

Inj. Thiamine - 200 mg - intravenous 

Tab. Nicardia - 10 mg - oral


2nd day 

Inj. Thiamine in 100 ml saline - 200 mg - intravenous 

Inj. Pantop - 4 mg - intravenous 

Inj. Zofer - 40 mg - intravenous 

Tab. Lorazapam - 2 mg - oral

Tab. Nicardia - 10 mg - oral

Tab. Telma - 20 mg - oral

Percussion: 

No fluid thrill 

No shifting fluid 



Auscultation: 

Bowel sounds heard

No bruits heard 



Central Nervous System:

Conscious, Coherent, Co-operative 

Motor : Normal

Sensory: Normal 





Provisional Diagnosis: Alcoholic Gastritis



Treatment :

1st day 

Inj. Thiamine - 200 mg - intravenous 

Tab. Nicardia - 10 mg - oral



2nd day 

Inj. Thiamine in 100 ml saline - 200 mg - intravenous 

Inj. Pantop - 4 mg - intravenous 

Inj. Zofer - 40 mg - intravenous 

Tab. Lorazapam - 2 mg - oral

Tab. Nicardia - 10 mg - oral

Tab. Telma - 20 mg - oral



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