27 yr old male presented with stomach pain

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 27yr old male resident of vellanki Mason by occupation came with chief complaints of stomach pain since 2 days

An episode of vomiting just before presentation

HOPI:


Patient was apparently asymptomatic 3days ago then he developed stomach pain in epigastric area which is insidious in onset pricking and shooting type of pain radiating to back (lumbar region) gradually progressive in nature aggregated on not having food and no relieving factors

7-8 episodes of non projectile and non bilious vomiting

History of fever 10days ago 

History of weight loss, loss of appetite, insomnia, fatigue 

No complaints of chest pain, palpitations, SOB, headache, burning micturition,loose stools, giddiness

SEQUENCE OF EVENTS



PAST HISTORY

He is known alcoholic since 5 years with a daily intake of 160ml

No history of DM,TB, ASTHMA,HTN, EPILEPSY, THYROID DISORDERS, ALLERGIES 

FAMILY HISTORY

No relevant family history

PERSONAL HISTORY 

Diet mixed 

Appetite reduced

 Bowel and bladder movements regular

Addiction alcohol regular and smoke occasionally until 3yrs back

TREATMENT HISTORY




GENERAL PHYSICAL EXAMINATION

On examination, patient is conscious, coherent, cooperative

patient is moderately built and moderately nourished

No pallor,icterus, cyanosis, clubbing, lymphadenopathy, edema







Vitals

Fever chart



Temperature- afebrile

Pulse rate -64/min

Respiration rate-20/min

BP-130/100mm/Hg


SYSTEMIC EXAMINATION:

Abdominal examination:





Inspection 

Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.

Palpation 

 Soft, non tender, no organo megaly.

Auscultation 

Bowel sounds Heard


Cardio vascular examination:

No visible pulsations, scars, engorged veins. No rise in jvp 


Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

Respiratory system :


Shape of chest is elliptical, b/l symmetrical.


Trachea is central. Expansion of chest is symmetrical


 Bilateral Airway Entry - positive


 Normal vesicular breath sounds


CNS examination: No neurological deficit found.


Gait: normal.



INVESTIGATIONS

USG



Serum electrolytes



ECG



PROVISIONAL DIAGNOSIS

Alcoholic gastroenteritis 


TREATMENT AND FOLLOW UP 



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