Acute Gastritis

 Sai Charitha

Roll 115

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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

Ihave been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 40 years male, resident of chityala, field assistant by occupation came to the opd with chief complaints of vomitings Since 6:00pm yesterday;

History of presenting illness:

Patient was apparently asymptomatic 1 day back when he started developing vomitings ( 18 episodes uptil today evening)

Non bilious, non projectile, non blood stained in nature with watery consistency and is associated with squeezing feeling in the epigastrium region each time preceeding the vomiting episode.

No history of associated symptoms like fever, diarrhoea, abdominal pain, abdominal distension, constipation, headache, giddiness.

History of diabetic foot ulcer

No h/o chest pain

Past history:

History of diabetic ulcer on the heal since 2 months( healing) and on great toe since 1 month.

History of diabetes mellitus since 6 months( on medication)and hypertension since 2 months( not on medication).

No history of asthma,CAD,copd,Tuberculosis and epilepsy.

Treatment history:

Patient was on metformin 500mg since 6 months.

Family history:

History of diabetes mellitus in mother( since 15 years ) and elder brother( since 10 years).

Personal history:

Diet: mixed

Appetite: normal

Sleep: Adequate but interrupted( during nights when he gets up to micturate)

Bowel movements: normal

Bladder movements: Interrupted urine flow

Addictions: Alcohol( everyday 180ml) for 10 years stopped since 2 months.

General examination:

Patient is conscious coherent well oriented to time place and person

Moderately built and Moderately nourished 

Vitals:

Temp: Afebrile

Pulse: 72 bpm

Rr: 15cpm

Bp: 120/80 mm Hg

No pallor, icterus, koilonychia, clubbing, generalised lymphadenopathy, pedal edema

Systemic examination:

CVS : s1 s2 heard. No murmurs

CNS: No focal deficit. All reflexes are normal.

RS: Bilateral air entry.  No vesicular breath sounds

ABDOMEN:

Shape: scaphoid

soft, nontender, no organomegaly Normal Bowel sounds. No visible scars/sinuses/engorged veins.

Hernia orifices normal

Genitals: Normal

Investigation:

Food piosioning 

Acute Gastritis

Provisional diagnosis

Gastritis?

Food piosioning?

Chronic pancreatitis?

Treatment:

Day1

Inj.PANTOPREZOLE 40 mg

Inj.ZOFER 4mg

Inj.METOCLOPROMIDE iv stat