A 50 year old female with chest pain since 2weeks

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A 50 year old female came to opd with

Chief complaints of

PATIENT CAME TO THE OPD WITH C/O CHEST PAIN SINCE 2 WEEKS

C/O HEADACHE SINCE 10 DAYS

C/O BODY PAINS SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 WEEKS BACK THEN SHE DEVELOPED CHEST PAIN OF INSIDIOUS ONSET, DULL ACHING TYPE, NON RADIATING, GENERALISED WEAKNESS+, NOT ASSOCIATED WITH SOB, PALPITATIONS, COUGH, SWEATING. NO AGGREVATING AND RELIEVING FACTORS. NOT ALTERED WITH FOOD INTAKE. BELCHING BLOATING+.

HEADACHE OF INSIDIOUS ONSET.IN THE FRONTAL REGION, DULL ACHING TYPE. NO H/O PHOTOPHOBIA, PHONOPHOBIA, VOMITINGS, NAUSEA, BLURRING OF VISION.

FEVER.

NO H/O ABDOMINAL PAIN, DIARRHEA, CONSTIPATION, DECREASED URINE OUTPUT.

PAST HISTORY:

NOT A K/C/O DM II, HTN, CVA, CAD, TB, EPILEPSY. HYSTERECTOMISED 5 YEARS BACK

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS COHERENT,COOPERATIVE NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

BP-100/70 MMHG PR-88 BPM

RR-16CPM

SPO2-99%

CVS S1S2 HEARD, NO MURMURS

RS: NVBS, BLAE+

CNS: NFND

P/A: SOFT, NON TENDER

Investigation

HB-11.8

TLC-6000 NIL/E/M/B-54/35/2/9/0

PCV-36.1

RBC-4.33

PLT-3.31

CUE

SUGARS-NIL

EPITHELIAL CELLS:2-3

PUS CELLS 2-3

RBC-NIL ALB-TRACE

LFT:

TB-0.5

DB-0.2

SGOT-19

SGPT-20

ALP-153

ALB-39

TP68 AG-142

RFT:

UREA-17

SR.CREAT-0.7

CA-3.7 SODIUM-138

POTASSIUM-4:0

CHLORIDE-101

SEROLOGY NEGATIVE

BGT-A POSITIVE

Provisional diagnosis

GERD 
Tension type headache

Treatment

1.T PANTOP 40MG PO/OD/BBF

2T ULTRACET FORD 3.T NAPROXEN 250 MG POVSOS

4.T MVT PO/OD

5.SYP SUCRALFATE 10ML PO/TID

6 adviced to avoid spicy food