40years old male c/o pain in abdomen since 1day
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• cheif complaint:-
C/o pain in abdomen since 1day
• History of present illness:-
Patient is apparently asymptomatic 15yrs back then he developed left side pain(Renal calculi) for which PCNL surgery was done 4 months back pt developed yellowish discoloration of eyes and pain abdomen for which he admitted in hospital and managed conservatively
Now since 1day patient c/o pain in abdomen in right hypochondrium region,non radiating insidious onset not associated with vomitings,fever,since 2days low grade intermittent type relieved by medication
• History of past illness:-
H/o DM since 6months
No h/o asthma, epilepsy,CAD, Hypertension, cervical lymphadenopathy
• Personal history:-
Martial status:- married
Occupation:- Daily wage labour
Appetite -Normal
Diet:mixed
Bowels-Regular
Micturition -Normal
No known allergies
• Habits/Addictions
Alcohol-occasional
Tobacco -No
betel nut- No
betel leaf-No
drug use-No
• Family History:
No history of DM, CAD, Asthma and thyroid disorders in the family
• General Examination:
Vitals:
Temp: Afibrile
Respiratory rate:16bpm
Pulse:80bpm
Blood pressure:110/79mmhg
Sp O2 :96%
• Systemic Examination:
Cardiovascular Examination:
Thrills:no
Cardiac sounds:S1,S2 heard
Cardiac murmurs:no
• Respiratory system:
Dysponea:no
Wheeze:no
-Abdomen:
Shape of abdomen: Scaphoid
Tenderness:no
Palpable mass:no
Henias orifices:normal
Free fluid:no
Bruits:no
-Liver:not palpable
-Spleen:not palpable
-Bowel sounds:yes
-Central Nervous system:
Pt is conscious
Speech: normal
Signs of meningitis:no
Cranial nerves: normal
Motor and sensory system:normal
-Provisional Diagnosis:
Acute pancreatitis secondary to cholelithiasis
-Investigation:
Treatment:Medication
Inj pan 40mg IV od
Inj zofer 4mg IV sos
Inj tramadol in 100ml NS100mg IV bd
Inj vit k in 100ml NS 10mg od
Inj thiamine 100ml Ns 10mg IV bdI
Inj hai SC tid
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