Case 14 (This is everything you will need to know about the patient)<\/p>\n
A 65-year-old man named Charlie Champion presents to your office complaining of difficulty swallowing. <\/p>\n
Vital Signs: <\/p>\n
Temperature 98.6\u00b0F<\/p>\n
Blood pressure 100\/70 mmHg<\/p>\n
Heart rate 88 beats per minute<\/p>\n
Respiratory rate 12 breaths per minute<\/p>\n
Examinee\u2019s Tasks <\/p>\n
Obtain a focused and relevant history. <\/p>\n
Perform a focused and relevant physical examination.<\/p>\n
Discuss initial diagnostic impressions with the patient. <\/p>\n
Discuss follow-up tests with the patient. <\/p>\n
After seeing the patient, complete paperwork relevant to the case. <\/p>\n
History of Present Illness. The Examinee: <\/p>\n
asked if there was \u201creal dysphagia,\u201d i.e., a feeling of food sticking in the chest (\u201cYes, that describes what I\u2019m feeling.\u201d)
asked about the onset of dysphagia (\u201cIt started about 2 months ago.\u201d)
asked specifically about difficulty swallowing solid foods (\u201cI definitely can\u2019t swallow anything solid.\u201d) asked specifically about difficulty swallowing liquids (\u201cNot in the beginning, but now it\u2019s getting to the point where swallowing water is becoming a problem.\u201d) <\/p>\n
asked about painful swallowing, i.e., odynophagia (\u201cNo.\u201d)
asked about weight loss (\u201cYes. I\u2019ve lost 20 pounds in the last month.\u201d)
asked about alcohol use (\u201cI used to be a heavy drinker\u2014a pint of whiskey a day for 25 years; I stopped drinking 2 months ago, when this problem started.\u201d)
asked about tobacco use (\u201cYes. I\u2019ve smoked two packs of cigarettes per day for over 25 years.\u201d)
asked about a previous history of gastrointestinal problems, i.e., reflux (\u201cNo.\u201d) <\/p>\n
asked about a history of lye ingestion (\u201cNo.\u201d) <\/p>\n
asked about any hoarseness (\u201cNo.\u201d) <\/p>\n
Physical Examination. The Examinee: <\/p>\n
looked inside my mouth for obstructive lesions (normal mouth and pharynx). <\/p>\n
checked my neck for an enlarged thyroid gland or other obstructive masses (none evident). <\/p>\n
checked for either axillary or supraclavicular nodes (a 3-cm fixed left supraclavicular node is palpable). <\/p>\n
Communication Skills. The Examinee: <\/p>\n
explained the possible diagnosis (esophageal carcinoma, achalasia, stricture). <\/p>\n
\u00a0explained that risk factors for the disease include tobacco and alcohol use. <\/p>\n
\u00a0explained the next step in the workup (blood work, esophagogram, gastroenterology consultation for <\/p>\n
possible endoscopy). <\/p>\n
explained that the supraclavicular node was probably due to cancer. <\/p>\n
stated that I would need nutritional support either in the hospital or at home. <\/p>\n
inquired about my support system (\u201cI have a wife at home; no children.\u201d) <\/p>\n
offered to help me tell my wife (\u201cOh, that would be a big help, Doctor.\u201d) <\/p>\n
demonstrated empathy for my situation. <\/p>\n
discussed prognosis (this is a serious problem). <\/p>\n
asked me if there was anything not covered in the discussion. <\/p>\n
HISTORY\u2014Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history. <\/p>\n
PHYSICAL EXAMINATION\u2014Indicate only the pertinent positive and negative findings related to the patient\u2019s chief complaint. <\/p>\n
DIFFERENTIAL DIAGNOSIS\u2014In order of likelihood, write no more than five differential diagnoses for this patient\u2019s current problems. <\/p>\n
DIAGNOSTIC WORKUP\u2014Immediate plans for no more than five diagnostic studies. <\/p>\n
HISTORY\u2014Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history. <\/p>\n
Mr. Charlie Champion is a 65-year-old man with a 2-month history of dysphagia. He feels as if the food he eats is getting stuck in the middle of his chest. Two months ago, the dysphagia was occurring only with solids, but it has now progressed to liquids to the point where the patient is having difficulty swallowing water. Mr. Champion denies odynophagia but admits to a 20-pound weight loss over the last month. He is a former drinker of a pint of whiskey daily for 25 years but stopped 2 months ago. He has smoked 2 packs of cigarettes per day for over 25 years. He has no previous history of gastrointestinal problems, such as reflux, and has no history of lye ingestion. He denies hoarseness. <\/p>\n
PHYSICAL EXAMINATION\u2014Indicate only the pertinent positive and negative findings related to the patient\u2019s chief complaint. <\/p>\n
Cachectic male looking older than his stated age in NAD. Patient is not hoarse. HT = 72 in. WT = 140 lb.
BP = 100\/70 mmHg and HR = 88 beats\/min lying down.
BP = 100\/70 mmHg and HR = 88 beats\/min standing. <\/p>\n
Afebrile. RR = 12 breaths\/min.
HEENT: Mouth without lesions or masses. Thyroid normal.
3-cm fixed nontender left supraclavicular node.
No cervical, submandibular, occipital, or submental lymphadenopathy. No axillary lymphadenopathy.
Heart, lungs, and abdominal exams normal. <\/p>\n
DIFFERENTIAL DIAGNOSIS <\/p>\n
In order of likelihood, write no more than five differential diag- noses for this patient\u2019s current problems. <\/p>\n
esophageal carcinoma <\/p>\n
stricture <\/p>\n
achalasia <\/p>\n
Schatzki\u2019s ring <\/p>\n
DIAGNOSTIC WORKUP <\/p>\n
Immediate plans for no more than five diagnostic studies. <\/p>\n
1. barium esophagogram <\/p>\n
2. endoscopy with biopsy and histology <\/p>\n
3. CBC
4. electrolytes
5. liver function tests <\/p>\n
LEARNING OBJECTIVE FOR MR. CHAMPION <\/p>\n
APPROACH TO THE PATIENT WITH DYSPHAGIA <\/p>\n
Mr. Champion presents with the chief complaint of dysphagia, initially to solids then progressing to liquids (progressive dysphagia), accompa- nied by anorexia and rapid weight loss. It is important to inquire about the symptoms of dysphagia (food sticking implies real dysphagia). Dysphagia accompanied by odynophagia (painful swallowing) may indicate mediastinal invasion by tumor. Other symptoms of esophageal cancer may include cough, hoarseness, choking, fever, and aspiration pneumonitis. The patient has a long history of alcohol and tobacco abuse, which predisposes him to developing esophageal carcinoma. Other risk factors for esophageal cancer include chronic gastric reflux causing a Barrett\u2019s esophagus, achalasia, and lye ingestion. The differ- ential diagnosis for dysphagia in this patient would include a stricture and achalasia. <\/p>\n
On physical examination, Mr. Champion has a normal-sounding voice. Tumor involvement of the recurrent laryngeal nerve would cause hoarseness. The mouth and neck examinations reveal no obstructive lesions responsible for the dysphagia. A careful search for metastatic lymphadenopathy reveals a fixed node in the left supraclavicular area. In most cases, the physical examination in patients with esophageal carcinoma is unremarkable. <\/p>\n
The workup for Mr. Champion includes admission to the hospital for nutritional support to prevent further weight loss. A barium esophagogram is the first step in the workup of any patient with dysphagia. If a lesion is seen radiographically, further evaluation with endoscopy, biopsy, and histologic assessment is warranted to confirm the diagnosis. Patients with poor nutritional intake should be evaluated with a complete blood count and electrolytes. Elevated liver function tests may be representative of metastasis to the liver. <\/p>\n
The treatment for esophageal carcinoma is palliative when the disease is metastatic. The goal of therapy is to relieve the dysphagia if possible and maximize the quality of life for each patient. <\/p>\n
Patient Note Pearl: The differential diagnosis for esophageal dysphagia is as follows: <\/p>\n
Solid food dysphagia (mechanical problem) Intermittent: lower esophagus (Schatzki\u2019s ring) Progressive: stricture (has heartburn), <\/p>\n
cancer <\/p>\n
Solid or liquid dysphagia (neuromuscular problem) Intermittent: diffuse esophageal spasm (has chest pain) Progressive: scleroderma (has heartburn), <\/p>\n
achalasia (may have respiratory symptoms)<\/p>\n","protected":false},"excerpt":{"rendered":"
Case 14 (This is everything you will need to know about the patient) A 65-year-old man named Charlie Champion presents to your office complaining of difficulty swallowing. Vital Signs: Temperature 98.6\u00b0F Blood pressure 100\/70 mmHg Heart rate 88 beats per minute Respiratory rate 12 breaths per minute Examinee\u2019s Tasks Obtain a focused and relevant history. […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10],"class_list":["post-97972","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97972","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=97972"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97972\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=97972"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=97972"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=97972"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}