57 yr old male farmer by occupation complains of abdominal discomfort since 6 months.
57 yr old male ,farmer by occupation complaints of Abdominal discomfort since 6 months
Induced Vomitings since 6months
Weight loss since 6 months .
H/O constipation 6 months one stool episode in 2-3 days.
HISTORY OF PRESENT ILLNESS:
Pt was apparently asymptomatic 6 months ago ,then first he developed loss of appetite (In the frst 3 months he used to take small amount of food later on he started avoiding food) and later on he developed abdominal discomfort so he himself induces vomiting by keeping finger inside the mouth , vomiting is non projectile , non foul smelling, contains food contents , non blood stained .
H/O weight loss in the past 6 months pt lost nearly 25kgs of weight .
H/O constipation since 6 months one stool episode in 2-3 days.
H/O PAST ILLNESS:
Not a known case of DM,HTN,BA ,EPILEPSY ,CAD,CBA ,TB.
PERSONAL HISTORY :
Appetite : decreased
Diet :Mixed (NON VEG EVERYDAY)
Bowels : Irregular
MICTURITION: Normal
HABITS :
Alcoholic he started drinking alcohol 27 yrs ago stopped 10yrs ago.
Smoker since his age was 30 yrs and last he took beedi 2-3 days . He regularly consumes 20 beedis in 24 hrs . Laat beedi 2-3 days ago
He consumes betel leaf daily .
On examination:
Pt was conscious , coherent and cooperative.
Ht : 172cms
Wt: 55kgs
Bmi : 18.6
Temp: Afebrile
Pr: 86bpm
Rr: 19cpm
BP:90/60 mmhg
No signs of pallor , icterus , cyanosis , koilonychia ,lymphadenopathy, edema.
Systemic examination:
Cvs : S1,S2 heard
Cns :NAD
RS: BAE
P/A: soft , non tender.
Investigations:
Hemogram:
Hb:10.7gm/dl
Total count :10,500
Plt:4.05lakhs
RFT:
Urea : 44
Creatinine :1.4
Uric acid : 5.4
Calcium :9.7
Sodium :138
Potassium:4.5
Chloride:99
Chest X-ray:
Ecg:
Upper GI endoscopy: Done by gastroenterologist from westbengal on 5/5/22
Histopathology report :
Done at pathology laboratories from westbengal on date 12/5/22.
S: No fresh complaints
O:
Vitals : Pt is C/C/C
Bp:110/70 mm hg
PR: 78bpm
RR:14 cpm
Systemic examination:
CVS : S1S2 heard
CNS : NAD
RS: BAE PRESENT
P/A : Soft , Non tender
On palpation : mobile perigastric lymphnodes palpable .
A: Gastric outlet obstruction
(Adenocarcinoma - pylorus )
P: CECT ABD N PELVIS
TAB . RANTAC 150 mg P/O BD
TAB METACHLOPROMIDE 10MG PO /OD
Cect abd n pelvis : 20/5/22
Soap notes day 2:
S: No fresh complaints
O: Pt is conscious,coherent and cooperative
Temp: Afebrile
PR: 76bpm
BP:100/70 mmhg
RR: 16 cpm
CNS : NAD
CVS: S1S2 heard
RS: BAE present
P/A : Soft , non tender
Passed tarry black stools
A: GASTRIC OUTLET OBSTRUCTION ( pylorus adenocarcinoma )
P:
Planning for oncosurgeon referral
1.Tab RANTAC 150mg /PO/BD
2.TAB METACLOPROMIDE 10mg PO/BD
3.DNS @80ml/hr
Onco surgeon refferal :
1.NBM
2.GASTRIC LAVAGE WITH 2 pint DNS EVERY 3 HRLY
3.FLUID N ELECTROLYTE BALANCE .
Soap notes day 3:
S: No fresh complaints
O:
Pt is conscious,coherent and cooperative
Temp: Afebrile
PR: 74bpm
BP:100/70 mmhg
RR: 15cpm
CNS : NAD
CVS: S1S2 heard
RS: BAE present
P/A : Soft , non tender
A: GASTRIC OUTLET OBSTRUCTION ( pylorus adenocarcinoma )
P:
1.Tab RANTAC 150mg /PO/BD
2.TAB METACLOPROMIDE 10mg PO/BD
3.DNS @ 80 ml/hr
Soap notes day 4:
S: No fresh complaints
O:
Pt is conscious,coherent and cooperative
Temp: Afebrile
PR: 74bpm
BP:100/60 mmhg
RR: 15cpm
CNS : NAD
CVS: S1S2 heard
RS: BAE present
P/A : Soft , non tender
A: GASTRIC OUTLET OBSTRUCTION ( pylorus adenocarcinoma )
P:
1.Tab RANTAC 150mg /PO/BD
2.TAB METACLOPROMIDE 10mg PO/BD
3.DNS @ 80 ml/hr
Provisional diagnosis :
Gastric outlet obstruction
