Hi doctor,
I am a 30 year old male working in a national insurance company. My height is 5 feet 11 inches and weight is 85 kg. I do not drink and I do not have any other habits. I eat mixed diet.
I am married and have one baby girl (two years of age). I am leading a stressless life both at home and office. I am a very calm and smooth going person.
My only concern is my health.
- I feel some pricking pain in the upper back side of the shoulder and left side of the chest. I feel very uncomfortable.
- I feel drowsy and unsteady throughout the day.
- When I am walking or sitting or sleeping I feel that I am pulling down to the ground and I feel extreme tiredness and pain in legs. At the same time, I feel air hunger and not able to breath comfortably.
- With all these pains and drowsiness I am doing my routine work.
- Also I feel pain in left side of head next to eye and I feel dull.
Two years back I underwent MRI cervical spine, CT chest and one year back I underwent CT coronary angiogram. I was diagnosed with sliding hiatus hernia last month. I underwent appendicitis operation one year back. I am attaching my recent reports for your reference.
As I am young, I am much worried about my present health condition. As I do not have the habit of regular exercise I keep gaining weight. I am not sure whether my diet is healthy and balanced. Please advice.
Hello,
Welcome to icliniq.com.
I have reviewed all your reports (attachment removed to protect patient identity). You seem to be having GERD (Gastroesophageal Reflux Disease) due to hiatus hernia. The GERD might cause the chest and back pain.
- I would advice you to take a combination of Pantoprazole and Domperidone for reflux.
- I would recommend you to take soft and bland diet.
- You should put a pillow below your head when you sleep.
- Make it a habit that you walk after every meal.
- More important here is to avoid alcohol and smoking in case you do.
- Always brush your teeth before you sleep.
- Your reports have serious issues with the raised cholesterol and that would pose a risk of heart attack. You should be started on a combination containing Atorvastatin and Fenofibrates to reduce cholesterol level.
- Take measures to reduce your weight.
- Avoid fatty food, alcohol, smoking, potato, rice and oil.
Get an ECG done to rule out any cardiac event. Stay healthy.
For further information consult a general medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/general-medicine-physician
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