30YR MALE WITH VOMITINGS AND PAIN ABDOMEN
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Here is a case i have seen:
A 30yr male cloth merchant came with complaints of
Vomitings - 3 days
Pain abdomen - 2 days
Decreased urine output from 1 day
Patient was apparently asymptomatic 3 days back then he developed 1 episode of vomiting after a binge of alcohol (content : alcohol)
Next day he gradually developed pain abdomen and vomitings associated with food and water intake
Vomitings: 6 episodes per day, non bilious, non projectile, associated with food particles
Nausea - present
Pain abdomen: pain in epigastric region, burning type of pain, no radiation, aggrevated with vomiting, no relieving factors, no postural variation.
No h/o loose stools, fever, headache
Patient had a laceration on right forearm 5 days back
PAST HISTORY :
no history of DM, Htn, asthma, epilepsy, TB, CAD
PERSONAL HISTORY :
smoking since 10yrs - 5 cigarettes per day
Alcohol since 10yrs - 90ml per day, since 1yr he has increased to nearly 1litre per day
ON EXAMINATION:
Patient is conscious, coherent, not cooperative
GENERAL EXAMINATION :
Pallor- absent
Icterus - present
Clubbing - absent
Cyanosis- absent
Lympadenopathy - absent
Edema- absent
VITALS:
SPO2: 98% ON RA
TEMPERATURE : AFEBRILE
BP: 150/90 MMHG
PR: 117BPM
RR: 26 CYCLES /MIN
SYSTEMIC EXAMINATION :
Per abdomen:
soft, tenderness in epigastric region
No organomegaly.
CVS :
S1, S2 heard
No murmurs
RS:
B/L AE present
No added sounds
CNS:
No focal defici
DAY 1:
INVESTIGATIONS:
1.CXR:
. 2. ERECT ABDOMEN XRAY:
? ACUTE GASTRITIS
TREATMENT :
1. NBM TILL FURTHER ORDERS
2. IV FLUIDS - DNS, RL @ 125ML/HR CONTINUOUS
3. INJ. PAN 40MG IV BD
4. INJ. ZOFER 4MG IV TID
5. INJ. TRAMADOL 1AMP IN 100ML NS BD
6. INJ. THIAMINE 1AMP IN 100ML NS IV TID
7. INJ. OPTINEURON 1AMP IN 100ML NS IV . OD
8. RT ASPIRATION
9. I/O CHARTING
10. MAINTAIN TEMPERATURE, PR, BP, GRBS 4TH HOURLY.
