A 30 Y male presented with vomitings and epigastric pain

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:

30 years male patient came with chief complaints of vomitings since 2 days associated with epigastric pain. Patient was apparently asymptomatic 2 days back then after eating spicy food (green chillies)he had first episode of vomiting which was non projectile contains food particles, non foul smelling. He took alcohol 3 days back (90 ml) that night he had multiple episodes of vomitings (8 episodes) he went to a rmp near by he gave some inj and vomitings were not relieved and was taken to local hospital and  and some treatment was given not recorded in between he had 3 episodes of vomitings and then next morning again he took alcohol 90 ml and had  vomitings which were associated with epigastric pain which was burning type and came to our hospital 
 Epigastric pain was relieved after 3 episodes of vomitings 
Not a k/c/o diabetes, hypertension, asthma, tuberculosis, epilepsy, cardiovascular diseases. 
No h/o fever, chest pain, palpitations, pedal edema, cough, loose stools, pain abdomen and dysuria. 
Patient is chronic smoker (20 beedis/day)  and alcoholic (90 ml/ 3 days). 
No simiar complaints in the past. 
On examination:
Patient is conscious, coherent and cooperative
General physical examination
No pallor,icterus,cyanosis,lymphadenopathy,
pedal edema
Vitals:
Temperature: 98.6 F
Pulse: 88 bpm
Respiratory rate: 22 cpm
Blood pressure: 110/70 mm hg
Sp02 : 98 % @room air
CVS: S1, S2 Heard, no murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Soft, non tender
Bowel sounds heard
CNS:
GCS:  E4V5M6
No abnormality detected.
Investigations 
Day 0
Treatment 
Inj pan 40 mg iv od
Intravenous fluids 1 unit of NS and 1 unit of RL at the rate of 75 ml/ he
Inj zofer 4 mg iv tid
Day 1
Patient c/o diffuse pain in chest which is non radiating and twisting type of pain
O/E 
Patient is conscious, coherent and cooperative
Vitals:
Temperature: 98.6 F
Pulse: 78 bpm
Respiratory rate: 22 cpm
Blood pressure: 110/70 mm hg
Sp02 : 98 % @room air
CVS: S1, S2 Heard, no murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Soft, non tender
Bowel sounds heard
CNS:
GCS:  E4V5M6
No focal deficit
Advised ecg 

Treatment 
Inj pan 40 mg iv od
Intravenous fluids 1 unit of NS and 1 unit of RL at the rate of 75 ml/ he
Inj zofer 4 mg iv tid
Day 2 
Patient had no fresh complaints
O/E 
Patient is conscious, coherent and cooperative
Vitals:
Temperature: 98.6 F
Pulse: 80 bpm
Respiratory rate: 22 cpm
Blood pressure: 110/70 mm hg
Sp02 : 98 % @room air
CVS: S1, S2 Heard, no murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Soft, non tender
Bowel sounds heard
CNS:
GCS:  E4V5M6
No focal deficit
Treatment 
Tab pan 40 mg od 
Tab mvt tid
Tab zofer 4 mg sos


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