38 yr old male with Alcoholic gastritis , Pre renal AKI and Alcohol withdrawal with dependence.

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Case presentation:

A 38 yr old Male patient came to casualty on 1/12/2020 at 5:10 pm with cheif complains of pain abdomen in epigastric region since 6 days 

Followed by Alcohol intake for continuous 10 days

Pain abdomen is burning type, continuous , non radiating, aggrevated on intake of food and water 

Associated with Vomiting 1 episode 4 days back , non bilious 

H/O loose stools - 3 days back , black coloured stools, subsided spontaneously, no mucous or pus discharge ,no foul smell 

No H/o constipation , fever, cold , cough , burning micturition 

PAST HISTORY

H/O Similar complaints 1 yr back for which pt got hospitalized and diagnosed as acute pancreatitis

H/O Appendicectomy at 10 yrs of age

No H/O DM, HTN, Epilepsy, Asthama, CVA, CAD 

PERSONAL HISTORY

Diet :mixed

Sleep :adequate 

Bowel and bladder :regular

Appetite:normal

Addictions - H/O alcohol intake regularly since 15yrs ( 90-180ml / day)

H/O smoking since 10 yrs occasionally

FAMILY HISTORY

No H/O DM, HTN, Epilepsy, Asthama, CVA, CAD 

GENERAL EXAMINATION

PT is conscious, coherent, cooperative

No pallor,icterus,cyanosis,clubbing,

lymphadenopathy,no edema

Vitals:

Temperature:98.6F

Pulse:78bpm

Blood pressure:180/90mm of hg

Respiratory rate:16cpm

SpO2:96%at room air

PER ABDOMEN

Distended abdomen no tenderness,no massN

No organomegaly

CVS 

S1S2 heard

No murmurs

RESPIRATORY SYSTEM

Bilateral air entry present

No added sounds

CNS

No abnormality detected

PROVISIONAL DIAGNOSIS

Alcoholic gastritis

Pre renal AKI

Alcohol withdrawal with dependence 

INVESTIGATIONS

DAY 1

HAEMOGRAM

LFT

RFT

CUE

SERUM AMYLASE

SERUM LIPASE

ULTRASOUND ABDOMEN

CHEST X RAY

ECG

DAY 2

HAEMOGRAM

X RAY ERECT ABDOMEN

URINE PROTEIN AND CREATININE RATIO

HRCT CHEST

2D ECHO

DAY 3

HAEMOGRAM

SERUM CREATININE

HIV 1/2 RAPID TEST

HBsAG RAPID

Anti HCV Antibodies RAPID

FASTING LIPID PROFILE

DAY 4

HAEMOGRAM

RFT

ENDOSCOPY

ECG

RT PCR FOR COVID 19

SPUTUM CULTURE

DAY 5 

SERUM CREATININE

DAY 6

HAEMOGRAM

SERUM CREATININE

TREATMENT

INJ OPTINEURON 1AMP IN 100ML NS IV OD 

INJ THIAMINE 1 AMP IN 100ML NS IV BD.

INJ MONOCEF 1G IV BD

TAB LORAZEPAM 2MG ( 1 - x- 2) FOR 2 DAYS

TAB PAN 40MD PO/OD

TAB ZOFER 4MG PO/OD

TAB BACFEN -XL 20MG OD

SYRUP MUCAINE GEL 10ML TID

NICOTEX GUMS 2MG/SOS

TAB  NICARDIA 10 MG PO/ BD

KETOCONOZOLE CREAM FOR TOPICAL USE FOR 4 WEEKS