60 year old patient came to hospital with pain in abdomen

This is an online e log book to discuss our de identified health data shared after taking his /her guardian signature on informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e log book also reflects my patient - centered online learning portfolio and your valuable inputs on the comment box. 

Chief complaint - pain in abdomen since 1 day 
History of present illness 
Patient was apparently asymptomatic 15 years back and then he developed left side pain ( renal caliculi) percutaneous nephrolithonomy surgery was done 4 months back patient developed yellowish discoloration of eyes and pain abdomen for which he admitted in hospital and managed conservatively. 
Now since one day patient complains of pain in abdomen in right hypochondrium region, non radiating, insidious onset not associated with vomiting, fever since 2 days which was relieved by medication. 
History of past illness
History of diabetes mellitus since 6 months 
No history of asthma , epilepsy, cad, hypertension, cervical lymphadenopathy. 
Personal history 
Married 
Occupation - daily wage labourer 
Appetite normal 
Diet - mixed 
Bowels - regular 
Micturition - normal
No known allergies 
Habits - alcohol occasional 
Family history 
No known family history 
General examination 
Vitals 
Temp - afebrile 
Respiratory rate - 16bpm 
Pulse -80bpm
Bp- 120/70mmHg
Spo2 96%
Systemic examination 
Cvs 
No thrills,  cardiac murmurs
S1s2+
Respiratory 
NOdyspnoea, wheeze
Abdomen 
Shape - scaphoid 
No tenderness, palpable mass, free fluid  , bruits 
Hernial orifice - normal
Liver and spleen not palpable
Bowels sounds - yes 
Cns 
Patient 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 

Inj. Pan 40mg iv od
Inj. Zofer 4mg iv sos
Inj. Tramadol in 100ml  ns 100mg iv bd
Inj. Vitk in 100ml ns 10mg od
Inj. Thymine 100ml ns 10mg iv bd
Inj. Hai sc  tid 





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