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Case scenario:
Sunita, Indian lady of 52-year-old presented to her General Practitioner with pain & burning
sensation in the chest & upper abdomen which radiated to the neck for about 4 months.
PATIENT INFORMATION SHEET 1
The pain appeared when lying on bed with full stomach. She had some trouble in swallowing
food and the food seemed to get stuck on its way down in the lower part of throat. She could
not take adequate food the last few days. For this, the GP suggested her to take antacid, which
relieved a little bit of her problem.
Family history:
Nil of significant
Physical Examination
General Examination:
Anaemia: ++ Jaundice: Nil
Cyanosis: Nil Oedema: Nil
Dehydration: Nil
Height: 135 cm Weight: 60 kg
Vital Signs:
Blood pressure: 140/80 mmHg
Pulse rate: 80 per minute, regular rhythm
Respiratory rate: 16 per minute
Temperature: 36.9°C
Systemic Examination
Abdominal exam: No scars, no striae, Tenderness (++) at the epigastric region. No hernia,
no bruit, normal bowel sound, no hepatosplenomegaly, non-ballotable kidney.
Laboratory Investigations:
Comment on PBF: ?
Cardiac enzymes:
AST 10 IU/L 5-43 IU/L
LDH 150 IU/L 140-280 IU/L
Barium swallow esophagus- mild narrowing of esophagus, also there is evidence of hiatal
hernia.
She was subsequently referred to a gastroenterologist for her problem. The gastroenterologist
then performed endoscopy of esophagus & stomach to view the extent of the lesion and took
biopsy.
1. Endoscopic finding:
The lining of the oesophagus is inflamed (esophagitis) with superficial erosions and ulcers.
2.Histopathological study of the biopsy (taken from affected oesophageal lesion):
antacids
proton pump inhibitor
prokinetic drugs
The patient was advised to modify her lifestyle by the gastroenterologist. The risk factor for
developing this problem was discussed and informed her of the importance of knowing these
factors.
She was informed to come to the clinic for periodic check-up with endoscopic examination
for further evaluation. There is some chance of developing carcinoma at the lesion involved.