30 YEAT OLD MALE WITH PAIN ABDOMEN UNDER EVALUATION

30yr old male patient came to the OPD with the chief complaints of
 Painabdomen since 1 week
Vomitings since  1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 week back then she developed pain abdomen which is squeezing type,non radiating.It is associated with vomitings non projectile,mucoid with food particles as contents.
PAST HISTORY
He is a k/c/o DM TYPE-2 since 3 years.he is on medication GLIMAX 500.
He is known case hypertension since 3 years and he is on medication (unknown)
No history of asthma,tb,cad,stroke 
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:regular
Addictions:regular alcoholic since 3 years
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:108b/m
Respiratory rate:22c/m
BP:160/110mmhg
Spo2:99
Grbs:187mg%

Pallor: no
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:no
SYSTEMIC EXAMINATION:
Shape:scaphoid
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
Tenderness present
No local rise of temperature
DEEP PALPATION:
liver:palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CARDIOVASCULAR SYSTEM:
S1,S2 Heard
 no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact
PROVISIONAL DOAGNOSIS:
PAIN ABDOMEN UNDER EVALUATION.
WITH HYPERTENSION AND DIABETES SINCE 3 YEARS

TREATMENT:
1.SOFT DIET
2.IV FLUIDS NS,RL(@100ML/HR
3.INJ.PAN 40MG/IV/OD
4.INJ.ZOFER 4MG/IV/SOS
5.INJ.THIAMINE 1AMP IN   100MLNS/IV/BD
6.OPTINEURON 1 AMP IN 100 NS/IV/BD
7.TRAMADOL 1 AMP IN 100ML NS/IV/SOS
8.TAB.ULTRACET 1 TAB PO/BD
9.TAB.AMLODIPINE 5 MG PO/OD
10.TAB.AMLODIPJ E 5MG PO/OD
10.BP,GRBS,PR,TEMP CHARTING 2ND HOURLY
11.I/O CHARTING

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