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Author: C.E. Pope ♦ Download Chapter ♦ Download Lecture Slides & Notes

J. Case Histories

Case I

A 60-year old widow presents to her family doctor with a six months’ history of frequent heartburn, epigastric pain, and regurgitation of sour material into her mouth. Her symptoms are particularly troublesome lying in bed at night, and on several occasions she has awakened with chest tightness, coughing and wheezing. She denies difficulty in swallowing or vomiting. Her weight has increased by 5 kg in the preceding six months.

Ten years ago, she was told that she had a hiatal hernia. Several times a week she attends a social club for drinks, five or six whiskeys on each occasion. In addition, she has smoked 20 cigarettes a day for many years.

On examination, she is obese but otherwise appears healthy. No abnormalities are discernable on general exam. Routine blood count, serum electrolytes, and liver function tests are normal.
  1. What is your diagnosis and how would you proceed to prove it?
  2. What four factors mentioned in the case history may be relevant to her complaint of heartburn?
  3. What is the significance of her respiratory problems at night?
  4. What would you recommend to her?
Case II

A 40-year-old gentleman presents with a five-year history of dysphagia for solids and for liquids, and recent regurgitation of undigested food. He remembers that chest pain was present at the beginning of his illness, but this pain is no longer present. He does not complain of heartburn. Recently he has begun to awake at night with coughing and wheezing. His appetite has been maintained, and he has not lost weight.

On examination, he looks well and is slightly overweight. Respiratory, cardiovascular and abdominal exams are within normal limits. Routine blood tests and electrocardiogram show no abnormality. A chest x-ray shows a widened mediastinum.
  1. What is the most likely diagnosis?
  2. What further investigations would you request?
  3. How would you treat this condition?
Case III

This 62-year old man presents complaining of dysphagia. He has a long history of alcohol abuse and has smoked one pack a day for the past 40 years. Over the past six months, he has noted a gradual increase in difficulty swallowing. Initially, he only had trouble swallowing solids such as meat, but gradually the difficulty progressed to the time of presentation when he was only able to swallow liquids.

What diagnostic tests would you consider in evaluation of this patient? How long is it appropriate to wait to initiate the work-up?


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