24 years old with chief complaint of hematemesis

 A 24 years old mason came to hospital on 23.10.2021 with the complaint of 3 episodes of vomitings with blood previous nightwhich are non bilous and non projectile and only consist of water and alcohol (No episodes after admission)

After episodes of vomitings he had shorth ness of breath while walking and slight chest pain which is non radiating, pricking type with no postural variation

Before these episodes he had history of alcohol intake of 180ml × 6 ( 36 units) throughout the day with empty stomach

No H/o of fever, cough, stomach pain

PAST HISTORY 

 

No similar complaints in the past 

No h/o asthma, epilepsy, HTN,DM,TB, CAD,CVD

PERSONAL HISTORY

Appetite- decreased(since 4 days)

Diet- mixed

Sleep- adequate

Bowel and bladder movements- regular

Addictions- he is chronic alcoholic from 5 years ( drinks every day whiskey of 180ml × 3)

Allergies- No

FAMILY HISTORY- Insignificant 

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative and well oriented to time palce and person

He is thinly built and moderately nourished.

Pallor- present

Icterus- absent

Clubbing- absent

Edema- absent

Lymadenopthy- absent

Vitals

23.10.2021

Pulse rate- 82bpm ( palpation of radial artery) with regular rate and rhythm and normal volume and no radio-radial delay

RR- 18cpm

BP- 120/80 mmHg

Temperature- afebrile

SYSTEMIC EXAMINATION

23.10.2021

PER ABDOMEN- 

Inspection-

Shape of abdomen- scaphoid 

No scars,visible pulsations,engorged veins

Umbilicus- slightly retracted and inverted

Palpation- 

No palpable liver,spleen and kidney

No tenderness and rise of local temperature

Percussion-

Liver dullness- from 5th intercostal space to below right subcostal margin

No shifting dullness and fluud thrill

Auscultation

Bowel sounds are heard

Bruut absent 

CVS EXAMINATION-

Inspection 

Shape of chest- elliptical 

No engorged veins, scars

Palpation

Apex beat can be palpable in 5th inter costal space

No thrills can be felt

Auscultation

S1,S2 are heard, no murmurs

RESPIRATORY SYSTEM EXAMINATION-

Bilateral air entry present

Normal vesicular breath sounds are heard on ascultation

CNS EXAMINATION-

Normal higher motor functions

Normal gait

No signs of meningial irritation

Cranial nerve examintion- normal

Reflexes- all are elicited and normal

PROVISIONAL DIAGNOSIS-

Alcoholic gastritis with mallory wiess tear?

INVESTIGATIONS 

ECG

Hemogram

Hb- 15

TLC- 6,700

Platelets- 2.08

Serum electrolytes 

S.Na+: 140

S.K+: 4.4

S.cl-: 100

S.Creatinine: 0.8

Liver profile

Total bilurubin: 0.87

Direct bilurubin: 0.19

SGOT: 22

SGPT: 10

Alkaline phosphate: 193

*REFERED TO PSYCHIATRIST due to alcohol dependence 

TREATMENT

23.10.2021

IVF Normal saline 200ml/hr

Inj PAN 40mg IV/BD

Inj ZOFER 4mg/IV/BD

Inj TRANEXA 500mg IV/SOS

Inj THIAMINE 200mg in 100ml NS/IV/OD

Syp SUCRALFATE 15ml/PO/TID

BP, PR monitoring 4th timely

*UNDER EVALUATION