40 year old male complaints of pain abdomen

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40 year old male came to the casualty with c/o pain abdomen since 5days,a/w vomitings ,non bilious ,non projectile.
HOPI-
Patient was apparently asymptomatic 5days back then she developed pain abdomen -diffuse(more in lower abdomen ),burning type ,radiating to back , aggravated with food ,relieved with medication a/w h/o vomitings since 1day ,4to5  episodes ,watery non bilious ,non projectile,a/w intake of food .
No h/o fever /constipation/loose stools /burning micturition/dysuria/trauma.
Last passed stools 1day before ,passing flatus.
No h/o previous abdominal surgeries.
PERSONAL HISTORY-
Loss of appetite+,takes mixed diet ,bowel and bladder movements were regular .
H/o alcohol consumption since 20 years , cigarette smoking 5to6 /day since 20years .
ON EXAMINATION-
Patient  is conscious ,coherent ,co operative
Temp-98f
PR-77BPM
RR-18CPM
BP-140/100mmhg
Spo2-98@RA
CVS-S1S2+
RS-BAE+,NVBS+
P/A- Shape-flat,tenderness+ (diffuse),left hydrocele +.
CNS-NAD

INVESTIGATIONS:



DIAGNOSIS- LEFT RENAL CALCULUS

 
TREATMENT-
1)IVF -NS,DNS@80ML / HR
2)INJ.BUSCOPAN IM /STAT
3)INJ.DICLO 75MG /IM/STAT
4)INJ.PAN 40 MG /IV/STAT

SOAP NOTES DAY 2

S:

Pain abdomen decreased

No vomitings

O:

PR: 82bpm

Bp: 160/100mmhg

Temp: 99F

RR:20cpm

Cvs:s1,s2heard

Rs:BAE+

CNS:NFD


A:

Acute pancreatitis (2°to alcohol)with De novo HTN?


P:

1)INJ.PAN 40MG/IV/BD

2)IVF.NS RL @150ml/hr

3)INJ.ZOFER 4MG/IV/BD

4)INJ.TRAMADOL 1 AMP IN 100ML NS/IV/ BD

5)INJ.OPTINEURON 1AMP IN 100ML IV/OD

6)Tab.CILNIDIPINE 10MG/BD

7)GRBS MONITORING 4TH HRLY

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