Transcript Slide 1

Medical Grand Rounds
Clinical Vignette
Wednesday, April 1st, 2009
Daniel Frenkel, PGY-3
Chief Complaint
57 year old male presents with complaints of
epigastric burning and a bitter taste in his
mouth after eating for the past 4 months.
History of Present Illness
• The patient is originally from Mexico and you first saw
him 5 years ago when he presented with epigastric
burning and a bitter taste in his mouth after eating.
• At that time, esomeprazole 40mg daily was prescribed
for a presumed diagnosis of gastroesophageal reflux
disease.
• His symptoms were relieved with this medications.
• However, over the past 4 months, his symptoms have
recurred.
• He also reports a sensation of food getting stuck in his
throat, requiring a glass of water to “move” the food.
• He has gained 25-30 pounds in the past year.
Additional History
• Past medical history:
– hypertension
– hyperlipidemia
• Past surgical history: none
• Family history: non-contributory
• Social history:
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Married with 2 children
Works in a restaurant
Has a 20 pack-year tobacco history
No other toxic habits
• Allergies: none
• Medications:
– Hydrochlorothiazide 25mg daily
– Simvastatin 40mg at bedtime
– Aspirin 81mg daily
– Esomeprazole 40mg daily
Physical Exam
General: No acute distress, centrally obese
Vital Signs: BP: 128/82, HR: 84, T: 98.4,
Ht: 5 feet 8 inches. Weight 200 pounds
The remainder of the physical exam was
unremarkable
Laboratory Results
• Complete blood count was within normal
limits
• Basic metabolic panel was within normal
limits
• Hepatic function panel was within normal
limits
Working Diagnosis
• Gastroesophageal reflux disease
Follow-Up
• The patient was counseled on diet and exercise to
help with weight loss and recommended to avoid
spicy food and caffeinated beverages.
• The patient was counseled on smoking cessation.
• Esomeprazole was increased to 40mg twice daily
• The patient was referred to gastroenterology for
further evaluation and management and is
currently scheduled for EGD.