70 year old male with epigastric pain since 1 year and Dysnpnea

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CHIEF COMPLAINTS 

1. Dyspnea at rest since 2 years 

2.epigastric pain since 1 year 

3.water brash since 1 year 

HISTORY OF PRESENTING ILLNESS 

Patient is a resident of Nalgonda , a unskilled labourer by occupation for the last 50 years 

he was apparently leading a normal life until 2 years back when he developed shortness of breath on doing more than ordinary physical activity , (grade -2) , which currently progressed to (grade -4)even at rest .

Dysnpnea was not associated with orthopnea, PND ,bendopnea, trepopnea .

one year later 

patient started with a feeling of water brash , sour taste in his mouth immediately after eating food , as days passed by he even developed epigastric burning pain, radiating into the chest , gradually he lost his appetite.

(currently eats in fairly smaller portions and less frequently than before )

This continued for a month 

Concerned about his condition  , he was taken to RVM hospital where he underwent investigations in view of his epigastric pain 

He underwent upper GI endoscopy,CT scan  ,ECG and USG and blood work 

He was diagnosed with GERD, with multiple gastric erosions and USG showed b/l renal calculi 

Patient was even medication was his dyspepsia 

Though he took medication  his symptoms last till date 

since last 2 months  patient has also developed giddiness on walking 

For which he visited local hospital was prescribed 

Mutli- vitamins 

at this point , he was frustrated with his condition , multiple visits at the hospital and still no cure to his state 

he was brought to us today (16-08-2023) at 2:00pm 

PAST HISTORY 

not a known case of HTN , DM, epilepsy ,asthma , copd ,thyroid disorders , any psychiatric conditions .

PERSONAL HISTORY 

Patient is married, with one son and two daughters 

he has worked as a unskilled labourer for the last 50 years 

Stopped working 2 months ago 

his daily routine 

8:00 am - wakes up 

9:30 am - showers and has breakfast and takes his lunch box and leaves for work 

1:00pm- takes a break from work and has his lunch 

5:00 pm - continues to work until then , takes his daily wage and comes home 

7:30 pm - showers and performs his namaz for the day 

9:00pm - dinner is done by this time and lays to sleep 

( symptoms of epigastric pain are not aggravated on laying down , nor do they have any diurnal variation ) 

His meal time are always scheduled on time .

FAMILY HISTORY 

No similar complaints in family .

GENERAL EXAMINATION 

Patient is moderately built and moderately nourished well oriented to time , place , person 

patient has hoarse voice , and is Dyspnic even at rest .

VITALS 

TEMP -afebrile on touch 

PULSE RATE -86bpm

PULSE PRESSURE -120/80mmHg

RESPIRATORY RATE -22cpm

SYSTEMIC EXAMINATION 

CVS

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

RESPIRATORY SYSTEM

Upper respiratory tract normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas

CNS 

Higher mental functions

-Patient is conscious, coherent,co-operative.Oriented to time, place,person.

-Speech = Fluency,comprehension,repetition intact

-Memory =Recent,Remote,Immediate : Intact

Cranial nerve examination -

other cranial nerves are normal

Motor examination :

Bulk of muscle normal on both sides on inspection

Tone  

                          Right.             Left 

Upper limb.    Normal.           Normal

Lower limb.    Normal.           Normal

POWER

upper limbs and lower limbs  +5 in all proximal and distal muscles 

Reflexes:                          Right.             Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

Investigations 

provisional diagnosis 

Disease involving the gastrointestinal system , GERD ?LPR?with hoarness of voice indicating vocal cord destruction due to chronic stomach acid exposure ?dysnpnea due to ?