ALCOHOLIC GASTRITIS ALCOHOL DEPENDENCE SYNDROME K/C/O HYPERTENSION SINCE 3 YEARS

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42YR OLD MALE WITH C/O VOMITINGS SINCE 7 DAYS

C/O PAIN ABDOMEN SINCE 3 DAYS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC1 WEEK BACK , THEN HE DEVELOPED VOMITINGS,MULTIPLE EPISODES (10-15) PER DAY NON BILIOUS NON PROJECTILE

H/O NAUSEA

PAIN IN EPIGASTRIC REGION,BURNING SENSATION,NON RADIATING

H/O LOOSE STOOLS,WATERY IN CONSISTENCY,NON FOUL SMELLING

PAST HISTORY:

K/C/O HTN SINCE 2 YEARS ON IRREGULAR MEDICATION

K/C/O CAD SINCE 2.5 YRS, UNDERWENT ANGIOGRAPHY I/V/O CHEST PAIN PT WAS KEPT ON ECOSPIRIN +CLOPIDOGREL+ATORASTATIN

N/K/C/O DM,SEIZURES,THYROID DISORDERS,CVA

GENREAL EXAMINATION:

PT IS CCC

NO SIGNS OF PALLOR,CYANOSIS,CLUBBING,LYMPHADENOPATHY

PR 76 BPM

BP 130/80 MMHG

SPO2 98

RR 22 CPM

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD

RS BAE+

CNS NFND

GIT NT SOFT

PSYCHIATRY REFERRAL WAS DONE ON 15/12/23 I/V/O ALCOHOL WITHDRAWL

IMP: ALCOHOL DEPENDENCE SYNDROME

TREATMENT ADVISED-

T. LORAZEPAM 2 MG PO/TID

T. BACLOFEN XL 20 MG PO/BD

T. BENFOTHIAMINE 100 MG PO/BD

INJ. LORAZEPAM 4MG/2ML/1 AMP IM/SOS

HEAD END ELEVATION

INVESTIGATION:

LIVER FUNCTION TEST (LFT)   16-12-2023 05:10:AM   Total Bilurubin 2.25 mg/dl 1-0 mg/dl  Direct Bilurubin 0.65 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 455 IU/L 35-0 IU/L  SGPT(ALT) 391 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 133 IU/L 128-53 IU/L  TOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dl  ALBUMIN 4.03 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.70	RFT   16-12-2023 05:10:AM   UREA 43 mg/dl 42-12 mg/dl  CREATININE 0.8 mg/dl 1.3-0.9 mg/dl  URIC ACID 5.15 mg/dl 7.2-3.5 mg/dl  CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 2.3 mg/dl 4.5-2.5 mg/dl  SODIUM 120 mEq/L 145-136 mEq/L  POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L  CHLORIDE 98 mEq/L 98-107 mEq/L
RFT   17-12-2023 11:33:AM   UREA 24 mg/dl 42-12 mg/dl  CREATININE 0.9 mg/dl 1.3-0.9 mg/dl  URIC ACID 3.9 mg/dl 7.2-3.5 mg/dl  CALCIUM 9.2 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 1.9 mg/dl 4.5-2.5 mg/dl  SODIUM 128 mEq/L 145-136 mEq/L  POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L  CHLORIDE 92 mEq/L 98-107 mEq/L

DIAGNOSIS:

ALCOHOLIC GASTRITIS

ALCOHOL DEPENDENCE SYNDROME

K/C/O HYPERTENSION SINCE 3 YEARS

TREATMENT:

INJ METROGYL 400MG/PO/TID

INJ LORAZ 2CC IV/SOS

INJ ZOFER 8MG IV/TID

INJ PAN 40 MG IV/BD

INJ THIAMINE 200MG IV IN 100ML NS/BD

TAB SPOROLAC PO/TID

TAB OFLOX PO/BD

TAB LORAZEPAM PO/TID

TAB BACLOFEN XL 20 MG PO/BD

TAB BENFOTHIAMINE 100MG PO/BD

ADVICE AT DISCHARGE:

TAB SPOROLAC PO/TID

TAB OFLOX PO/BD X 1 DAY

TAB LORAZEPAM PO/TID

TAB BACLOFEN XL 20 MG PO/BD

TAB BENFOTHIAMINE 100MG PO/BD

TAB PAN 40 MG PO/OD X 1 DAY

TAB METROGYL 400MG PO/BD X 1 DAY