45 year old female with central chest pain
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CHIEF COMPLAINTS
45 year old female resident of Mallepally ,labourer by occupation came with the chief complaint of dysphagia to solid and liquids since 1 year
central chest pain since 1 year .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year ago when she developed difficulty in swallowing for both solid and liquids associated with a feeling of food stuck in the food pipe which was insidious in onset ,
central type of chest pain radiating Upto 4 cms below the suprastrenal notch to the xiphisternum ,it is a burning type of pain and aggravated on eating spicy food and eating in hurry (especially when dinning at a gathering or during early hours before going to work ) and relieved only on taking medication (antacids ) in order to prevent this from happening she tried to eat slower and by taking smaller quantities of food .
Also complaints of retching after intake of food ,to relieve from pain
vomit contains food taken prior
H/O of weight loss with preserved appetite
PAST HISTORY
patient is a known case of hypertension since 4 years ,
H/O of wheeze especially on exposure to cold climate
Not a known case of DM , TB ,asthma , epilepsy , thyroid abnormalities
MENTRUAL HISTORY
age of menarche 12
Duration of cycle 28 days
No of days of bleeding -6-7 days
No of pads used per day 2 pads /day
Not Associated with clots , pain
FAMILY HISTORY
no similar complaints in the family
TREAMENT HISTORY
patient has been prescribed telmisartan 40 mg OD in view of her high BP
SURGICAL HISTORY
patient was tubectomised after birth of her third child
MARITAL HISTORY
Age at marriage -14 years
Age at first child birth-14 years (6months after marriage )
mother of 3 male children each 3 years apart from each other
all were NVD
PERSONAL HISTORY
45 year old female ,labourer by occupation mother of 3 male children
DIET -mixed
APPETITE -decreased
BOWEL AND BLADDER -regular
SLEEP -adqueate
ADDICATIONS /ALLERGIES -none
GENERAL EXAMINATION
patient is conscious coherent and cooperative , well oriented to time place and person
Moderately built and moderately nourished
Pallor -absent
Icterus -absent
Cyanosis -absent
Clubbing -absent
Koilonychia -absent
Lymphadenopathy -absent
Pedal edema -absent
JVP not raised
VITALS
Temp -a febrile
Pulse rate -72bpm
Blood pressure -130/90mmHg
Respiratory rate -16cpm
spO2-98% on room temp
SYSTEMIC EXAMINATION
CNS EXAMINATION
Scaphoid
-No visible pulsations/engorged veins/sinuses
-Soft,non tender, no guarding and rigidity, no organomegaly
-Bowel sounds heard
INVESTIGATION
X ray findings
Impression:
few osteophytes noted at the bed of C5, c6
Thyroid cartilage calcification noted
UPPER GI ENDOSCOPY
impression:
Achalasia cardia under evaluation.
USG
Grade 1 fatty liver
HB -12.4
PCV-37.2
TLC-4100
RBC-3.96
PLATELETS-1.74
GRBS-96
S.CREATININE -0.7
S.Na-143
S.K-4.1
S.Cl-103
T Bilirubin.-0.65
D. Bilirubin-0.18
SGPT-19
SGOT-24
Alk. Phosphate-104
T. Proteins- 8.0
Albumin 3.7
A/G Ratio 0.90
Pus Cells 3-4
CUE-Normal
Provisional diagnosis
This is a case involving the gastrointestinal system probably a motor pathology probably Achalasia cardia (under evaluation )
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