45M OPD with burning sensation in throat and chest, chest pain since 5 years

This is an online e log book to discuss our patient's deidentified health data shared after taking his/her guardian's signed informed consent. Here we discuss our individual patient's problems with collector's current best evident input.This eblog also reflects my patient centered online learning portfolio and your valuable inputs in the comment box are welcome.

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment.

A 45 year old male came to the OPD with

Chief complaint: burning sensation in the throat and chest, chest pain since 5 years

HOPI :Patient was apparently asymptomatic 5 yrs ago and then developed pain in the throat and chest which was insidious in onset and gradually progressive,intermittent, non-radiating, not associated with any other pain and aggravated on eating cold items, relieved on taking medication.

 Pain is associated with SOB since 2 yrs which is aggravated on excercising and relieved on taking rest.

Burning sensation in throat and chest since 5 yrs which is insidious in onset,gradually progressive, intermittent, aggravated on eating cold items, relieved on taking medication.

Negative history:No history of trauma,neck pain, abdominal pain, nausea, vomiting, back pain.

Past history:No history of DM, HTN, Tb, asthma, Thyroid, CAD, CVA, no surgical history. Patient was on medication for 6 months 1 yr ago details of which are not known.

Personal history:

-Diet is mixed

-Appetite is normal

-Sleep is adequate

-Bowel and bladder movements are regular

-No known allergies or addictions.

Family history:No significant family history

General examination:

Conscious, coherent and cooperative

Moderately built and nourished 

-No pallor

-No icterus

-No cyanosis 

-No clubbing

-No lymphadenopathy 

-No edema

Vitals:

PR:88 bpm

RR:12 cpm

BP:110/80 mm Hg

Temp: Afebrile

Attached below are clinical images of the patient taken after taking his consent:

Out patient slip: