Case history
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Date of administration :29-10-2021
A 35 year old male who is lorry driver by occupation came to the opd with chief complaint of stomach ache since 4 days
History of present illness :
Patient was apparently asymptomatic 4 days back, then the patients complaints of pain in the upper abdomen since 4 days, had 2 episodes of vomiting.
Past history :
Patient give history of similar pain 4 years back, he visited a local hospitalized for 2 weeks then he was diagnosed as pancreatitis.
Not a known case of hypertension, DM, asthama
Personal history :
Appetite :normal
Diet : mixed
Sleep:adequate
Bowel & bladder movements : normal
Additions : patient was alcoholic since 6 year back then he stop consuming alcohol 4 years back .
Family history:
No relevant family history
General physical examination :
Patient is conscious, coherent, co-operative
He is well oriented to time place and person
He is moderately build and nourished
No pallor
No icterus, cyanosis, clubbing, generalized lymphadenopathy
Vitals :
Temperature:Afebril
BP :100/70mmhg
PR:90bpm
Respiration rate: 20cpm
Systemic examination :
Cardiovascular system :
S1 and S2 heard
Respiratory system :
BAE - positive
Per abdomen :
Tenderness present in RIF
CNS :
No abnormality directed
Investigations :
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