A 40 years old male with hematemesis

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I have been given this case in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 40 year old male patient who is a resident of Choutuppal tractor driver by occupation came with

 CHIEF COMPLAINTS :

- c/o blood in vomiting since yesterday afternoon

( 10-20 episodes)

HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal till yesterday afternoon then he developed blood in vomiting which was sudden in onset, non projectile, non progressive with no aggravating and relieving factors.

- There were about 20 episodes of vomiting few of which were with blood and food particles as content.

- No history of fever, headache, weakness, loose stools, burning micturition, neck stiffness, constipation.

Daily routine of patient -

- The person wakes up at around 7:30 am goes to work at 8am . As the patient is a tractor driver he does the farm work with it.

- He does his lunch at 1pm and continues with his work and returns home by 6:30pm takes some rest and have dinner at 8:30 pm and goes to bed by 9pm.

- But the patient had 90 ml of alcohol (OC) on the previous day i.e, on 8 Aug as he had body weakness due to excessive work load on that day as suggested by his friends.

- Then he had rice, chicken for dinner and went to bed.

- Next day morning i.e, 9 Aug he ate upma as breakfast and went to work. In the afternoon he had vomiting so returned home early than usual.

- The vomiting episodes continued so he came to the hospital on 9 Aug evening.

PAST HISTORY :

He had similar complaints in the past and admitted in KIMS , Nkpt.

Diabetes - No

Hypertension - No

TB - No

Asthma - No

Epilepsy - No

CVD - No

CKD - No

Chemo/Radiation Exposure - No

Surgical history -

- Appendectomy was done 30 years ago

FAMILY HISTORY : Nil significant

PERSONEL HISTORY :

Diet - Mixed

Appetite - Normal

Bowel and bladder - Normal

Allergies - No

Addictions - No

GENERAL EXAMINATION :

Temperature - 98.4 °F

Pulse - 80 beats/min

BP - 120/80 mmHg

RR - 20 cycles/min

GRBS - 102 mg%

SPO2 - 99 %

Pallor - No

Icterus - No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular

BAE - +ve

ABDOMEN :

Shape - Normal ( Scaphoid )

No tenderness, palpable mass

Bowel sounds heard

CNS : Normal

- Patient is Conscious, Coherent well oriented to surroundings.

REFLEXES : Normal

INVESTIGATIONS : 

9/8/22  and 10/8/22 -

11/8/22 -

PROVISIONAL DIAGNOSIS :

Upper GI bleed Secondary to

? Oesophageal varices 

With Alcohol withdrawal syndrome.

TREATMENT :

9/8/22

- NBM till further orders

- IVF - 20 RL @ 100ml/hr

         - 20 NS @ 100ml/hr

- Inj Pan IV/OD

- Monitor vitals

- Inform SOS

- Inj Tranexa IV/BD

- Inj Zofer 4mg/IV/BD