30/F with chest pain and pain in the right hypochondrium

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CASE:

A 30 year old female has come with chief complaints of chest pain since 2 years and pain in the right hypochondrium region since 6 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 years ago, then she complained of chest pain which was insidious in onset, intermittent, dragging type and radiating to the back.

Initially she had pain only during the day but now she has pain during the day and aggravates at night. 

She complains of pain and tenderness in the right hypochondrium region since 6 months which is intermittent, pricking and burning type, associated with bloating, nausea and headache. 4-5 episodes per week. It aggravates on having spicy and oily food. Relieved temporarily on taking medication (Pantop).

She also complained of black coloured stools (4-5 episodes) since 6 months which was solid in consistency. No pain while defecating. 

DAILY ROUTINE:

She wakes up by 8 am in the morning and does her morning routine. She cooks breakfast for the family (she’s a home maker).

For breakfast, she has tea with roti or biscuits. 

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

She takes a nap for 1-2 hours after lunch.

She has her dinner by 10 pm (mostly rice/ roti with curry) and goes to bed by 11 pm.

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:  Supari (areca nuts) daily since 3 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: Afebrile

Pulse: 82 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

PROVISIONAL DIAGNOSIS:

? Chronic gastritis

INVESTIGATIONS:

TREATMENT:

Tab Pantop 40mg PO/OD

Tab Brufen 400mg PO/BD