29 year old female came to opd with chest pain
OPD case
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History of presenting illness
Patient was apparently asymptomatic 1 week ago then she developed chest pain in epigastric region which was insidious in onset,non progressive, continuous, burning type,non radiating, aggravated on work ,no releiving factors.
History of one episode of vomiting 2 days ago contents are food
History of belching is present
No h/o of nausea, abdominal pain,sob
Past history
History of similar complaints 8 months ago,then treated with sucralfate and pantop
History of laparotomy surgery 3 years ago due to small bowel obstruction
Personal history
Diet mixed
Appetite normal
Sleep altered
Bowel and bladder regular
No addictions
GENERAL. EXAMINATION
Patient is examined in a well light room after taking the consent.
Patient is conscious, coherent and cooperative, moderately built and moderately nourished.
Mild pallor is present
There are no signs of icterus , cyanosis , clubbing , koilonychia , lymphadenopathy.
Vitals
Temparature afebrile
BP- 110/80 mmHg
Pulse- 86 bpm regular,normal volume
RR- 18cpm
Per abdomen examination
Inspection
Shape of abdomen scaphoid
Umbilicus inverted
Skin normal
No dilated veins
A vertical scar is present
No visible gastric paralysis
Palpation
No local rise of temperature
No tenderness
No palpable swellings
Percussion
No abnormal finding
Auscultation
Normal Bowel sounds are heard
Respiratory system :- trachea is central, normal vesicular breath sounds heard.
CVS S1,2 heard no murmurs
CNS no focal neurological deficit
Provisional diagnosis
Epigastric pain 2° due to acid reflux?
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