30 year male patient with hematemesis /Upper GI bleed secondary to mucosal tear -? Mallory weiss
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TRAETMENT GIVEN
1. IVF NS, RL, DNS AT 100ML/HR
2. INJ. THIAMINE 200 MG/ IV/OD
3. INJ. ZOFER 4MG/IV/ TID
4. INJ. TRANEXA 500 MG/IV/STAT F/B SOS
5. INJ. PANTOP 80 MG IN 40 ML NS IV AT 4ML/HR
6. INJ. DICLOFENAC 1AMP/IM/STAT F/B SOS
7. NBM TILL FURTHER ORDERS
8. BP/PR/TEMP/Spo2 monitoring.
30 year old male patient complains of pain abdomen and bloody vomitings since the morning that day.
HOPI
Patient was apparently asymptomatic till the morning that day when he developed pain abdomen.
c/o vomitings 7-8 episodes since the morning that day associated with blood clots. 1 episode of greenish colored vomitings.
H/O similar episodes in the past and diagnosed with chronic pancreatitis with alcoholic gastritis.
N/K/C/O HTN, DM, CVA
Chronic alcoholic 90-100 ml whisky daily.
Last binge 3 months back - due to spiritual rituals.
No known treatment history.
Personal history:
Patient consumes 90-100 ml whisky/day.
Last binge 3 months back
Patient is a known tobacco chewer.
Family history:
No significant family history.
PHYSICAL EXAMINATION
HOPI
Patient was apparently asymptomatic till the morning that day when he developed pain abdomen.
c/o vomitings 7-8 episodes since the morning that day associated with blood clots. 1 episode of greenish colored vomitings.
H/O similar episodes in the past and diagnosed with chronic pancreatitis with alcoholic gastritis.
N/K/C/O HTN, DM, CVA
Chronic alcoholic 90-100 ml whisky daily.
Last binge 3 months back - due to spiritual rituals.
No known treatment history.
Personal history:
Patient consumes 90-100 ml whisky/day.
Last binge 3 months back
Patient is a known tobacco chewer.
Family history:
No significant family history.
PHYSICAL EXAMINATION
No Pallor ,Icterus, Cyanosis,Clubbing ,Lymphadenopathy
TEMPERATURE - AFEBRILE
PULSE RATE - 73 BPM
RR-18 CPM
BP- 140/90 MM HG
SPO2- 98 % AT RA
GRBS - 72 MG/DL
SYSTEMIC EXAMINATION
CVS - S1 ,S2 heard , No murmurs
RS - BAE +
P/A - Soft ,Non tender
CNS - NAD
TEMPERATURE - AFEBRILE
PULSE RATE - 73 BPM
RR-18 CPM
BP- 140/90 MM HG
SPO2- 98 % AT RA
GRBS - 72 MG/DL
SYSTEMIC EXAMINATION
CVS - S1 ,S2 heard , No murmurs
RS - BAE +
P/A - Soft ,Non tender
CNS - NAD
INVESTIGATIONS
Usg abdomen
TRAETMENT GIVEN
1. IVF NS, RL, DNS AT 100ML/HR
2. INJ. THIAMINE 200 MG/ IV/OD
3. INJ. ZOFER 4MG/IV/ TID
4. INJ. TRANEXA 500 MG/IV/STAT F/B SOS
5. INJ. PANTOP 80 MG IN 40 ML NS IV AT 4ML/HR
6. INJ. DICLOFENAC 1AMP/IM/STAT F/B SOS
7. NBM TILL FURTHER ORDERS
8. BP/PR/TEMP/Spo2 monitoring.
