Blood Pressure:
138/76
Pulse:
80
Weight:
74.8
Temperature:
36.9
Glucose:
History
known with HPT on treatment.
history of acute abdominal pain,1 day history,sharp stabbing pain radiates to the back and left upper quadrant,history of vomiting x2 episodes,no hematemesis,good bowel habits.
no smoking, occasional alcohol intake
dipstick :nad
abdomen, tender on epigastric and right upper quadrant, plus gaurding, no peritonism
Diagnosis
inspecific abdominal pain? pancreatitis?PUD
Medication
buscopan 20mg imi stat
and refer to HGRH for xray and possible ultrasound
tto
buscopan 1tab tds
tramadol 10mg tds
tto
Sick Leave
0