Medical

1. Cases

2. Case 1
• A 58-year-old man has had increasing
difficulty swallowing for the past 6 months
and has lost 5 kg. No abnormal physical
examination findings are noted. Upper GI
endoscopy reveals a nearly circumferential
mass with overlying ulceration in the mid
esophageal region. Biopsy of the mass reveals
pink polygonal cells with marked
hyperchromatism and pleomorphism.

3. Questions
• What is the most likely diagnosis?
• What are the most likely risk factors for
development of his disease?

4. Case 2
• A 37-year-old female presents with a chief
complaint of difficulty swallowing. She reports
that she feels as if food gets stuck in her
midchest. She notices no difference between
liquids or solids but does note that the symptoms
worsen when she eats hurriedly. She has had a
15-lb weight loss and reports regurgitation of
undigested food after eating. The patient
undergoes barium swallow.

5. Case 2
Barium Swallow

6. Questions
• What is the most likely diagnosis?
• The pathophysiology of this process involves?
• What are the treatment options?

7. Case 3
• A 42-year-old male presents for evaluation of
recurrent sharp substernal chest pain that occurs
primarily at rest and radiates to both arms and
the sides of the chest. He notes that the pain is
worse with eating and emotional stress. The pain
lasts approximately 10 min before resolving
entirely. He has undergone a full cardiac
evaluation, including negative exercise
echocardiography for inducible ischemia. You
suspect diffuse esophageal spasm and order a
barium swallow for further evaluation.

8. Question
• Which findings would best correlate with your
suspected diagnosis?
• What is another diagnosis test of choice?
• How would you manage the patient?

9. Case 4
• A 35-year-old HIV positive woman known has
had pain on swallowing for the past week. No
abnormal physical examination findings are
noted. Upper GI endoscopy is performed.
There are 3 sharply circumscribed, shallow,
'punched out' 0.3 to 0.8 cm ulcers in the
lower esophagus.

10. Questions
• She is most likely to have infection with which
organisms?
• What is the first treatment options?
• What is second treatment option?

11. Case 5
• A 32-year-old man presents to the emergency department
at 2 am rather inebriated. He had been to an end of
examinations party that evening, followed by a Chinese
meal. He began to feel unwell around 11.45 pm and
vomited twice, brought up his meal and several pints of
lager and initially felt better. Over the next hour or so he
retched violently on several occasions and around 1 am
vomited up bright red blood. He says that he noticed just a
small amount of blood on the first occasion but
considerably more the second time. There is no relevant
previous medical history or family history. He smokes 10
cigarettes a day, takes occasional marijuana and drinks 2–3
units of alcohol a week.

12. Examination
• He seems a little drunk. There is some dried
blood around his mouth. The pulse is 102/min
and the blood pressure 134/80 mmHg lying,
with no change on standing and no other
abnormalities in the cardiovascular or
respiratory system. In the abdomen there is a
little tenderness in the epigastrium.

13. Quesrions
• What is the likely diagnosis?
• What is the appropriate management?