68year old male complaints of burning sensation in epigastric region

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A 68 year old male, resident of bengal, farmer by occupation came to the casuality last night with complaints of burning sensation in the epigastric region since 7 years relieved after medication, associated with loose stools ( after intake of spicy food), 5-6 episodes. 
Patient also complaints of lower back pain since 10 years, for which he got treated with medication from local hospital.
H/ o burning sensation in the lower abdomen since 1 year. No h/ o burning micturition, decreased urine output. 

Not a k/c/o diabetes, hypertension, asthma, tuberculosis, epilepsy, CAD
History of jaundice 50 years back, hospitalised and treated.
History of appendicetomy 32 years back. 

He is a chronic alcoholic, takes 80 ml/ day since 50 years, now stopped since 6-8 months.
Chronic smokers, 1 pack per day since 25 years.
Chews betel nuts since 50 years 

He takes mixed diet, appetite normal, sleep adequate( sleeps for 6-7 hours a day), bladder habits regular. 

On examination
Vitals: 
Temp: afebrile
PR: 80 bpm
BP: 100/70 mm hg
RR: 16cpm
Spo2: 98% at room air
GRBS: 117 mg/dl
No signs of pallor, icterus, cyanosi, clubbing, edema, lymphadenopathy 

CVS: S1 S2 +
RS: BAE+, NVBS+
PER ABDOMEN: SOFT, NON TENDER, BOWEL SOUNDS+
CNS: NAD
24/10/21

SOAP NOTES DAY 3

S: 
Burning sensation in epigastric region
decreased.
Loose stools subsided
No fresh complaints.

O:
Patient is c/c/c
Temp: afebrile
BP: 130/80mmhg 
RR: 20cycles / min
PR: 80Bpm 
CNS:NAD
CVS: S1 S2+ , no murmers
RS: NVBS + 
P/A: soft,non tender

P:

1.Tab.pan40mg/po/OD
2.Tab.zincovit/po/od
3.Tab.Pcm 650 mg od/sos
4.monitor BP,PR 4th hrly
25/10/21

 25/10/2021
SOAP NOTES DAY 4

68year old male patient in SSW

S: 
Burning sensation in epigastric region
decreased.
Loose stools subsided
No fresh complaints.

O:
Patient is c/c/c
Temp: afebrile
BP: 120/80mmhg 
PR: 75Bpm 
CNS:NAD
CVS: S1 S2+ , no murmers
RS: NVBS + 
P/A: soft,non tender

P:

1.Tab.pan40mg/po/OD
2.Tab.zincovit/po/od
3.Tab.Pcm 650 mg od/sos
4.monitor BP,PR 4th hrly

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