32yr/male, c/o occasional discomfort in the sternal regional ( chest tightness and breathing difficulty) . this episode lasts for half to one hour.c/o lightheadedness ( last for nearly an hour). c/o epigastric discomfort +.c/o sweating.C/o indigestion and belching (severe ) for past 1 month.No c/o vomting/nausea/ chest pain / headache.No c/o fever. His CBG , Blood pressure were normal at the time of incidence. he is known smoker but stopped for 3 months.His CBC ,ECG, THYROID PROFILE , CHEST X RAY WERE NORMAL.On examination CVS, RS WERE NORMAL. Bowel and bladder habits were normal.per abd-soft and BS +. the above complaints relieved by antacids and for PPI. eventhough he is on antacids he is still have the same problem . Now patient is on HP KIT BD for 10 days,Tab.nexito 10mg half HS for 5 days,tab. ativan 1mg hs for 10 days. tab. Revotril 0.5 mg half tablet twice a day for 10 days,tab.domstal BD for 20 days. he has been admitted in private hospital and treated there for 3 days and discharged with above medications .Again patient is having the similar complaint from today early morning. all his vitals were stable .kindly suggest me how to proceed further and what all are the medications to be added or any other investigation that we need to do for this patient. what suggestions can we give to the patient.I am posting all the investigations that done to the patient till date.kindly interpret the patient PFT. only rearrangement in LFT.

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Looks like Cardiol problem angina. However possible gerd. Do trop I. Tmt. Urine 5hiaa to rule out carcinoid. Pft shows very low volumes. Either restrictive lung or non cooperatives patient. Lft is ok mild hyperbilirubinemia. Continue ppi anxiolytics. Plan endoscopy later

Possible causes in this case only- Neurogenic- Anxiety, nicotone withdrawal symptom Local- Bronchitis, starting of COPD, Asthma, Emphysema Cardiac- Angina pectoris Digestive- Hiatus Hernia, starting of Non- alcoholic fatty liver disease Since the patient has little relief with the antacids and PPIs, it could be a case of Hiatus Hernia. Advise a Barium meal Xray/ endoscopy and TMT for Angina Suitable Ayurvedic medicones for this patient for my Ayurvedic forum- Br Vaat Chintamani Ras+ sootshekhar Ras+ prawal panchamrit Ras+ Naag bhasm with Arjun chhal sheer paak BD Dashmollarisht BD and avipatthi churna at night.

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Labs & ECG- WNL Spirometry shows Bronchial Asthma Adv- inhaled short acting beta agonist bronchodilator to start with. If symptoms continue add long acting inhaled combined bronchodilators.

Advice TMT

Patient should be advised to undergo TMT and if reqd Echocadiography and Coronary angiography

It can be Hpylori go for Iga Igg .In addition to ppi can start clarithromycin ,tinidazole, and nortriptyline .

PFT s/o severe obstruction, so put him on inhalational therapy sos psychiatrist opinion should be taken if no relief

Get gastroscopy and ECG.

Go for TMT 2DECHO. Endoscopy

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