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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:
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
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