a patient with abdominal pain

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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:

CT scan reports :- 

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