A 30 year old female with chest pain and pain in the right lumbar

 

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CASE:

A 30 year old female came with chief complaints of 

-Chest pain since 2 years

- Pain in the right lumbar region since 6 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 years ago.She  complained of chest pain (substernal region)which was insidious in onset.Initially 2 years ago,pain was present only during the day but at present the pain is present during day and aggravates at night. 

Pain is radiating to the back (interscapular region) and is intermittent,dragging in nature and tenderness on touch.

Each episode lasting for 15-20 mins during the day and it gets aggravated during the night everyday while lying down on bed or while bending down. 

It relieves spontaneously.

She complained of pain and tenderness in the right lumbar region which is intermittent (4-5 times a week) since 6 months.It aggravates after she has spicy and oily food.

 It is of prickly and burning type of pain which is associated with bloating,nausea,headache and dizziness for which she takes pantop for temporary relief.

She has belching and bitter after taste.

She also complained of black colour stools 4-5 episodes since 6 months.

DAILY ROUTINE:

Patient wakes up by 8am in the morning.She is a home maker and makes breakfast for the family.

She has tea,biscuit and roti for breakfast.

She does her daily chores and has lunch by 2pm (rice and vegetables).

She takes a nap for 1-2 hours.

In the evening she looks after her child’s studies and makes dinner by 10pm.

She goes to bed at 11pm.

PAST HISTORY:

Patient is not a known case of HTN,DM,Asthma,Epilepsy,Tuberculosis and thyroid abnormalities.

PERSONAL HISTORY:

Sleep:Normal 

Apetite: decreased since 6 months

Diet: mixed

Bowel and bladder: regular

Addictions: paan, (supari) areca nuts daily since 3-4 years.

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative, moderately built and moderately nourished.

Pallor: mild pallor

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: 98 degree farenheit

Pulse: 92 beats/minute

Blood pressure:120/70mm Hg

Respiratory rate: 18 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

Respiratory: bilateral vesicular breath sounds are present

CNS: no focal neurological deficits

Abdomen: soft and tenderness is present only when there is pain

INVESTIGATIONS:

Ultrasound report:

X ray:

PROVISIONAL DIAGNOSIS:

Chronic gastritis

TREATMENT:

Tab Pantop 40mg PO/OD

Tab Brufen 400mg PO/BD