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

 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 patient's 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 the comment box is welcome. 




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


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