36yr old male with vomitings

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 A 36yr old male  lecturer by occupation came with cheif complaints of abdominal pain

since 7days and vomitings since 3days.

HOPI 

Patient was apparently asymptomatic 7yrs ago then he had episode of dizziness  for which he went to the hospital there he diagnosed with dm and metformin was given

2yrs ago  again he had episode of dizziness then his medication has changed to gm1 

Then 2months back again he had episode of dizziness then he shifted to gm2

3yrs ago he used to consume alcohol occasionally 

3yrsago patient  had consumed too much of alcohol continuously then he had vomitings and abdominal pain for which he went to the hospital where he diagnosed with acute pancreatitis and he got treated. 

He also noticed callus over left big toe which turned in to ulcer and 1year back  went to the hospital where debridement was done .

Since 1year he is experiencing tingling sensation and burning sensation over the calf and feet

Since 2yrs he is consuming alcohol for every 3-4days and for 4days

when ever he consumes alcohol he vomit.  he complained of vomitings since 3days which is non bilious and non projectile and blood stained.

Past history: 

He was diagnosed with Diabetes mellitus 7 years back and was started on Metformin initially, then on Tab, GLIMI MV1 and now since 2-3 months is using Tab. GLIMI MV2. 

Vitals on admission: 

Temp: 98°F

PR: 104bpm

RR: 18 cpm

BP: 120/80 mm hg

SpO2: 98% on RA 

GRBS: High (>400mg%)

On examination, 

pallor present. 

No icterus, cyanosis, clubbing, lymphadenopathy. 

  

Pedal edema present upto ankle in Left foot. 

Systemic examination*

Abdominal examination:

Inspection 

Abdomen is flat

Soft 

Palpation 

Tenderness over epigastric and right hypochondriac region

No organomegaly

Percussion 

No shifting dullness

No fluid thrill

Ascultation 

Bowel sounds heard

Respiratory examination

Inspection:

Shape of the chest -elliptical

Chest bilaterally symmetrical, all quadrants

moves equally with respiration

Palpation:Trachea central, chest expansion normal

Percussion: Resonant all over the areas

Auscultation:

 B/l equal air entry

NVBS

CVS examination:

Inspection: Apical impulse

visible

Palpation: apex beat feltin 5th intercostal space 1cm medial to midclavicular line.

Ascultation: S1 S2 are heard, No murmur

CNS:

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Serum creatinine: 1.0

Serum urea: 15

Hemogram: 

Hb: 10.5

TLC: 5,400

N:65

L: 28

PLT: 2.30

 

Na: 138

K: 4.1

Cl: 99

Diagnosis: 

Alcoholic gastritis

Uncontrolled sugars 

Diabetic ulcer on left lower limb 

Diabetic neuropathy

Treatment: 

1. Inj. HAI 6U given STAT

2. Inj. NS . 2 bolus given 

3. Inj. PANTOP 40mg IV OD

4. Tab. PREGABALIN 75mg OD H/S

5. Inj. TRAMADOL 1 amp in 100ml NS IV

6. Inj. ZOFER 4mg IV TID

7. Inj. THIAMINE 100mg + 100ml NS IV BD 

8. Tab. ULTRACET 1/2 PO/ QID 

9. Inj. HAI 10 units—x—6 units  pre meal and Inj. NPH 6 units BD