29 year old female came to opd with chest pain

 OPD case

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29 year old female labourer by occupation came to OPD with cheif complaint of chest pain since 1 week

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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