Topic 21. Management of the patients with dysphagia, heartburn and
functional dyspepsia
Clinical task
Case #1
A 52-year-old man presents to the office with approximately 2 weeks of upper
abdominal pain. His symptoms are difficult for him to describe, but include some
“discomfort” in the epigastric region that comes and goes. He has had some
“heartburn” and nausea, but no vomiting or diarrhea.
He has noticed that his stool looks darker than it used to, but he has not seen any
blood. He feels full quickly after eating. He tried taking some over-the-counter
antacid, which helps a little bit. His only other medication is an over-the-counter
nonsteroidal anti-inflammatory drug that he takes “once or twice” a day because of
arthritis in his knees. He does not smoke cigarettes or drink alcohol. On
examination, he is pale appearing, but in no acute discomfort. He is afebrile, his
blood pressure is 120/80 mm Hg, his pulse is 95 beats/min, and his respiratory rate
is 14 breaths/min. Head, ears, eyes, nose, and throat examination is notable only
for pale conjunctiva. Cardiac and pulmonary examinations are normal. His
abdomen has normoactive bowel sounds and tenderness in the epigastrium. There
is no mass, rebound, or guarding. Rectal examination reveals normal tone, no
masses, and dark black stool that is strongly fecal occult blood test positive. The
remainder of his examination is unremarkable.
Questions:
1. Make a rationale for diagnosis.
2. Make a clinical diagnosis.
3. Make a differential diagnosis with proving of your choice.
4. Assign additional investigation according to a protocol.
5. Make a rationale for patient`s treatment (Group of drugs, pharmacological
name, dosage, route, time a day).
Case #2
A 73-year-old woman described a 2-year history of solid foods “getting stuck”
once or twice per week. The sensation was not progressive, and she denied
heartburn, regurgitation, weight loss, fever, hemoptysis and melena. She did not
drink or smoke and had no history of muscle weakness or respiratory illness. On
physical examination she appeared well nourished and was not jaundiced. Head,
neck, respiratory and abdominal examinations were unremarkable. She had no
lymphadenopathy, rash or focal neurologic findings.
Questions:
1. Make a rationale for diagnosis.
2. Make a clinical diagnosis.
3. Make a differential diagnosis with proving of your choice.
4. Assign additional investigation according to a protocol.
5. Make a rationale for patient`s treatment (Group of drugs,
pharmacological name, dosage, route, time a day).