A 36 years old man with pain abdomen and vomitings.

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 36 years old man who is a biochemistry professor by occupation came to the opd with chief complaints of pain over the epigastric region since 4days and vomitings since 2days.

History of presenting illness :

Patient was apparently asymptomatic 7years back then he developed giddiness and fall so he went to local hospital there he was diagnosed as diabetic, from then he was on OHA(metformin) by taking OHA he was fine and his FBS,PLBS used to be control few years later he shifted to Glimy M1 and from 2-3 months ago he was on Glimy M2.

3years ago patient was on binge alcohol and had pain abdomen he went to hospital then he was diagnosed to have Acute pancreatitis 

3years ago he developed a corn and thickening on the planter aspect of greater toe ,patient himself used to cut the thickened part,which 1year ago it turned into ulcer for which he under went wound debriedment.

2years ago he has a h/o Organophoshorus poisoning for which he was admittted to hospital and got treated.

1 1/2year ago again he started binge drinking and had pain abdomen but he was not diagnosed to have acute pancreatitis.

1year ago he had a complaints of burning sensation of feet,tingling sensation of both lower limbs.

6days ago he has a h/o of fall from the bike and injured to lower rib,left side of hypochondriac region.

From 5days he is on binge alcohol drinking without taking any food and OHA.

From 4days he stated having pain in the epigastric region,dragging type of pain and it is radiating to left hypochondriac region and to the back.

He is having vomitings since 2days with contains food,non bilious,non projectile.

Past history:

No h/o hypertension, tuberculosis, asthma,epilepsy 

H/o diabetes since 7 years.

Family history:

Not significant.

Personal history :

He is totally alright till his 26years of age.

He is biochemistry professor,he goes to college for teaching carry on his daily activities normally.

He started consuming alcohol 10years ago and he got married and divorced after two year of marriage life after one year he got married again and divorced after 7years of marriage. So stared taking alcohol daily.

Physiological habits:

Diet-mixed 

Appetite-normal

Sleep-adequate 

Bowel and bladder movements-regular

Addictions-h/o taking alcohol from 10 years and binge alcohol in between.

General examination 

Patient is conscious,coherent,cooperative to time place and person.

Moderately built and moderately nourished.

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent 

Pedal edema-absent

Vitals:

Temperature-95.2F

Pulse rate-103bpm

Blood pressure-120/80mmHg

Respiratory rate:18cpm

Spo2-98%

GRBS-386mg%

Systemic examination:

CVS-S1S2 heard

RS-BAE+NVBS

P/A-soft,tenderness in the epigastric and left hypochondriac region.

CNS-NFND

Investigations:

Hemogram:

Hb-10.4gm/dl 

TLC-5,400

Pl-2.3

LFT:

TB-1.08

DB-0.24

AST-18

ALT-10

ALP-242

TP-7.3

ALB-4

A/G-1.23

RFT:

Creatinine:-1.0

Na+:138

K+:4.1

Cl-:99

CUE:

Amylase-74

Lipase-48

RBS-370mg/dl

Blood urea-15mg/dl

FBS-107mg/dl

Lipid profile:

Total cholesterol-217mg/dl

Triglycerides-438mg/dl

HDL-55mg/dl

LDL-122mg/dl

ECG:

Radiograph:

Left 11th ribe mild displaced fracture.

USG:

No sonological abnormality detected.

Provisional diagnosis:

Uncontrolled sugars

Diabetic ulcer

Diabetic neuropathy 

Alcoholic gastritis?

Treatment:

Inj HAI NPH

 Inj Pantop 40 mg IV OD

Inj Tramadol lamp + 100ml NS IV STat ->

Tab. Pregabalin 75mng po H/S.

Ulcer care, foot care

Inj Zofer 4mg IV TID

InjThiamine 100mg + 100ml NS IV BD