Alcoholic gastritis with infective pharyngitis
5/03/22
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Sanidha Singh
Roll no.- 206
CHIEF COMPLAINTS:
A 33 year old patient, electrician by occupation and resident of Suryapet came to the OPD on 28/02/22 with chief complaints of :
• Throat Pain since 27/02/22
• Pain Abdomen since 2pm on 27/02/22
• Nausea and Vomiting since 4pm on 27/02/22
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 7 days (26/02/22) back.
Then he had :
• Throat pain which was sudden in onset severe burning type non-radiating associated with difficulty & painful swallowing aggravated on eating food & drinking water with no reliving factors.
• epigastric pain since 27/02/22 which was burning type, gradually progressive & radiating to the back.
• Retching (+)
• nausea (+)
• vomiting (+) , non bilious, non projectile, Dark coloured with no food contents.
On 27/02/22 he was rushed to local physician and many tests were run on him & he was referred to our hospital.
Patient has h/o alcohol consumption since 20 years and use to drink (whisky- 90ml) only on occasions with his friends.
He got married last year in Sept 2021 & due to issues with his wife he has turned into a chronic alcoholic.
Before the onset of symptoms he was known to be binge drinking since 5 days on empty stomach.
In the past 1 year he had similar complaint once every 2 months on binge drinking on empty stomach for 4 to 5 days continuously & as the symptoms in the past episodes were not this severe & it use to subside on cessation of alcohol.
He has complaints of inadequate sleep (4-5 hrs) in the night since 1 year & experiencing people walking or falling over him or a bull hitting him. (Referred to Psychiatry)
Psychiatry History:
• Denies Tremors (-)
• When he wasn’t consuming alcohol due to health issue he started experiencing people walking and falling over him while he was going to sleep.
He consulted a physician and psychiatrist but there was no improvement. 1 and half years back he was kept on Tab. Etizola 0.5mg and there was significant improvement and discontinued later on.
• h/o hitting his head with a TV stabiliser after a fight with his wife leading to trauma to his brain
No h/o seizures, low mood, suicidal, suspiciousness, self talking.
ENT History:
• difficulty in swallowing
• painful swallowing
• mouth opening restricted
• poor Oral hygiene
PAST HISTORY:
He is known case of Hypertension since 5 years & has discontinued the medication.
No h/o DM, thyroid, epilepsy, TB, leprosy
FAMILY HISTORY:
NAD
PERSONAL HISTORY:
Diet- Mixed
Appetite- Reduced
Sleep- Inadequate
Bowel & Bladder- Regular
Alcohol consumption (whisky) occasionally (90ml) since 20 years and since past 1 year turned into a chronic alcoholic ( 3 units) due to marital problem.
Paan and tobacco consumption (Prabhat)
No h/o smoking
GENERAL EXAMINATION:
Patient was c/c/c. He is moderately built and moderately nourished.
No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Vitals-
Temperature - 98.1
Pulse Rate - 98 BPM
Blood Pressure - 120/80 MM OF HG
Respiratory Rate - 17
SPO2 - 100 % at room air
CVS : S1 & S2 Heard , No murmurs
Investigation:
Day 1 :
Day 2:
Day 3:
ECG:
Temperature Monitoring:
PROVISIONAL DIAGNOSIS:
Acute Gastritis or Alcoholic Gastritis with Infective Pharyngitis
TREATMENT:
Day 1 & 2:
IVF- NS/RL @125ml/hr
INJ. Pan 40mg /iv/BD
INJ. Thiamine 1AMP in 100 ml NS/IV/TID
INJ. Zofer 4mg / IV/ TID
INJ Optineuron 1 AMP in 100 ml NS/ IV/ OD
Tab. Azithromycin 500 mg PO/ OD
SYP. Mucain gel 10ml PO/ TID
Day 3:
Tab. Clonazepam 0.5 mg
Tab. Propranolol 20 mg
Nicotex gums 2mg
Follow up after 3 days for endoscopy
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