Medical Grand Rounds Clinical Vignette Wednesday, April 1 st, 2009 Daniel Frenkel, PGY-3

57 year old male presents with complaints of epigastric burning and a bitter taste in his mouth after eating for the past 4 months. Chief Complaint

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.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.At that time, esomeprazole 40mg daily was prescribed for a presumed diagnosis of gastroesophageal reflux disease. His symptoms were relieved with this medications.His symptoms were relieved with this medications. However, over the past 4 months, his symptoms have recurred.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 also reports a sensation of food getting stuck in his throat, requiring a glass of water to “move” the food. He has gained pounds in the past year.He has gained pounds in the past year.

Additional History Past medical history:Past medical history: –hypertension –hyperlipidemia Past surgical history: nonePast surgical history: none Family history:non-contributoryFamily history:non-contributory Social history:Social history: –Married with 2 children –Works in a restaurant –Has a 20 pack-year tobacco history –No other toxic habits Allergies: noneAllergies: none Medications: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 limitsComplete blood count was within normal limits Basic metabolic panel was within normal limitsBasic metabolic panel was within normal limits Hepatic function panel was within normal limitsHepatic 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 diet and exercise to help with weight loss and recommended to avoid spicy food and caffeinated beverages. The patient was counseled on smoking cessation.The patient was counseled on smoking cessation. Esomeprazole was increased to 40mg twice dailyEsomeprazole was increased to 40mg twice daily The patient was referred to gastroenterology for further evaluation and management and is currently scheduled for EGD.The patient was referred to gastroenterology for further evaluation and management and is currently scheduled for EGD.