Alcohol induced oesophagitis

 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 patients 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 comment box is welcome



35 year old male patient came to causality with 

the chief complaints of vomitings 3days back (10episodes), associated with blood

HISTORY OF PRESENTING ILLNESS:-

 Patient was apparently asymptomatic 3days back then he developed vomiting (10episodes) associated with blood,h/o alcohol consumption 3dyas back

no history of bleeding per rectum, 

no history of abdominal  distension, 

no history of pedal edema.

Past History:Not a known case of DM,HTN,TB,Asthma,CVA,CAD,Epilepsy

Personal history: 

Diet:-Mixed

Sleep-Adequate

Addictions-Occasional alcoholic since 10years 


General examination:-

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

No signs of pallor/Icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

Temp-afebrile

PR- 100bpm

RR-24/min

BP-130/110 mmhg

Spo2- 98%at RA

GRBS-140 mg/dl

CVS- S1 S2 +,No murmurs

RS- Bilateral air entry present;normal vesicular breath sounds heard.

P/A- soft, non tender 

CNS- No focal neurological deficits


















Provisional diagnosis:-

OESOPHAGEAL ULCER 2° TO REFLUX OESOPHAGITIS ( ALCOHOL INDUCED)



TREATMENT;-

NBM TILL FURTHER ORDER

IV 0.9&DNS WITH 1AMPOULE OPTINURON/IV/OD

INJ.PAN 200mg IV IN 50CC@2CC/HR (8mg/hr)

INJ.VITAMINE K 1AMPOULE /IV/OD

INJ.TRANEXA 500mg /IV/BD

T.HP KIT/BD (OMEPRAZOLE +AMOXICILLIN +TINIDAZOLE)



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