Tikur Anbessa Hospital Hospital No.

Addis Ababa

Name: Age: Sex: Occupation: Religion:

Address: Date of Admission:

Department: Ward: Bed No: Marital Status:

Date of Clerking: Historian:

Previous Admission:

She has no previous admissions.

Chief complaint

Difficulty of swallowing of 6 months duration.

History of present illlness

This is a 61 year old female patient from ambo who was relativelly well 6 months back at which time
she started presenting with difficulty of swallowing. The difficulty to swallow started abruptly, initially
she presented with difficulty to swallow the normal food she eats daily, mainly bread and injera. So she
begin to use water everytime she eats. However in 4 months it progressed and made her unable to
swallow liquid. From 2 weeks before admission she also couldn’t swallow her saliva.she feels that the
food is stuck at the lower sternum. She has regurgitations of the ingested matter everytime after she
eats. But it doesn’t contain blood. There is associated burning type retrosternal pain, mostly on the
afternoon aggravated by taking food with no relieving factor, that doesn’t radiate.

She has history of choking from a month ago, which comes every 2 or 3 days at first but in the last 2
weeks it was frequent. It occurs both day and night.In the last 6 months she has lost about 6 kilos from
52 kilos to 46 kilos upon admission.

This led her to seek medical attention at Geldu health center where the doctors were unable to treat
her and referred her to tikur anbessa Hospital a months ago.

She has history of taking spicy foods and drinking hot coffee. She also drinks local beverages on
occasions.But she has no history of smoking,corrosive intake, radiation therapy , previous surgery or
taking aspirin.
She has no history of loss of appetite,abdominal pain,vomiting, diarrhea or constipation.she has no
history of headache,tinnitus and blurring of vision. There is no history of fever, cough,night
sweats,shortness of breath,orthopnea,PND or syncope.There is no history of hoarsness of voice,
swelling in any part of the body,heat and cold intolerance, bone pain,or yellow discoloration of sclera.

She has no hx of chronic illnesses including DM,htn,asthma.She has no history of contact with a known
TB patient and she is seronegative for HIV. There is no similar illness in her family. There is no family
history of DM,or hypertension. There is no smoker in the family.

There is no color change in the skin observed by the patient .She is weak and easly tired.She came to the
hospital walking supported by her children.

Past Illnesses

No chicken pox, mumps, small pox or any other childhood diseases.

Functional Inquiry

H.E.E.N.T

Head: see HPI,no trauma

Ears:No loss of hearing, discharge, earache, vertigo or tinnitus

Eyes: Good vision, no pain, strain, lacrimation, photophobia or itching

Nose: No epistaxis or discharge.

Mouse and throat: no dental pain or bleeding from the gums. Intact tonsils.

Glands:see HPI

Respiratory System:SEE HPI

Cardiovascular system: see HPI.

Gastrointestinal system:SEE HPI.

Genitourinary system: No flank pain, dysuria, urgency, hesitancy, dribbling or pyuria.Her last
menstruation was 10 years back.

Integumentary system: Moist skin, no rashes or ulcers, no changes in hair distribution or pigmentation.

Allergy: No asthma, drug sensitivity, or food allergy.

Locomotory system: see HPI, No bony deformities, no joint pain

Central nervous system: Good memory. No seizures, nervous breakdown or insomnia.

Personal History

Early Development: The patient was born in Geldu near Ambo where she lived all her life. she spent a
healthy childhood.

Education: she did not attend school.

Habits: SEE HPI.

Marital Status: she is married and has 4 children. All are healthy and living well.

Family history

Father and mother: Both her parents passed away at an old age.

Siblings: She has 6 brothers and 2 sisters. All are alive and well.

Family Diseases: There is no family history of tuberculosis, allergy, diabetes mellitus, hypertension, or
asthma.

Physical Examination

General Appearance

The patient is chronically sick looking. She appears weak and malnourished. She is fully cooperative but
look depressed. She frequently spits whitish sputum. But she is not in respiratory distress.

Vital signs

BP: 110/70mmHg, right arm, supine position Pulse: 88/min,radial artery, regular

RR: 18/min, regular rhythm T0: 36.50c, axillary,in the afternoon

Weight: 46 kgs Height: 162cms

H.E.E.N.T

Head: Proportional size, shape and normal hair distribution, No scar.

Ears: Normal contour of pinna. No tenderness or lesions.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus.The conjunctivae

are pale. The sclerae are not icteric.

Nose: The nasal septum is not deviated. There are no enlarged turbinates or unusual discharge

Mouth and throat: The lips are dry. They show no fissure or ulceration. The gums are intact and show
no ulceration. . There are no extractions, dentures or filling. The tongue is pink, doesn’t show any
atrophy. The tonsils are intact.

Lymphatic and glandular system

There are no enlarged lymph nodes over the occipital, posterior and pre auricular, anterior and
posterior cervical, sub-mandibular, sub-mental, supra-clavicular, axillary, inguinal and epithrochlear
areas.

The thyroid is not enlarged. No tremor or lid lag.

Respiratory System

Inspection: There is no cyanosis or clubbing or the finger nails.The palms are pale. Breathing is of
regular rate. The chest is symmetrical. There are no deformities, surgical scars, visible pulsation
or dilated vessels.

Palpation: The trachea is central. There is no tenderness over the entire chest. The total circumferential
chest expansion is 3 cm along the 4th ICS on deep inspiration. Tactile fremitus is normal over the
entire lung field. Chest expansion is symmetrical.

Percussion: Both the right and left chest are resonant. Diaphragmatic excursion is 3 cm.

Auscultation: The breath sounds are vesicular over the entire the lung field. No wheezing, crepitations,
stridor or pleural friction rub.

Cardiovascular system
Arteries: BP and pulse (see under vital signs). There is no hardening of the vessel wall. Pulse volume can
be tabulated as follow:

Carotid Axillary Brachial Radial Femoral popliteal PT DP

Right +++ ++ ++ ++ +++ ++ ++ ++
Left +++ ++ ++ ++ +++ ++ ++ ++

No radio-femoral delay detected.

No bruit over the carotid or femoral artery.

Veins: There are no distended veins over the neck, chest wall, or leg. JVP observed at an inclination of
450 is 3cm above the angle of Louis.

Precordium:

Inspection: The precordium is Quiet. The apical impulse is not visible.No deformities.

Palpation: The point of maximum impulse is felt at the left fifth intercostal space along the mid
clavicular line. It is localized. It’s 8 cm from mid sternum.

Auscultation: Both s1 and s2 are normal over the valvular areas. There are no added heart sounds or
murmurs.

Gastrointestinal System

Inspection: The abdomen is scaphoid, symmetrical and moves with respiration. The flanks are not full.
There are no surgical scars, masses or dilated veins over abdomen. The umbilicus is inverted. Hernia
sites are free. No visible pulsation or peristalsis. No caput medusae.

Palpation:

 Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was
also no direct or rebound tenderness.
 Deep palpation: The liver was not palpable below the right costal margin. The spleen is also not
palpable.
Percussion: There is no shifting dullness, fluid thrill or flank dullness. The total vertical span of the liver
along the right mid-clavicular line is8 cm.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or
liver areas.

Locomotory System

There is no muscle tenderness or spasm. There is no bone deformity or tenderness. There is no

tenderness of the joints. There is no edema.

Nervous system

Mental Status: The patient is conscious, fully cooperative doesn’t seem to be depressed. She is well
oriented in person, place and time. She denies any hallucinations or delusions.

Cranial Nerves:

N-I: Smells orange via each nostril.

N-II: Normal visual acuity and good visual fields.

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are
round, regular in outline and equal in size. They react to light directly and consensually.

N-V: Pain and touch are intact over the face. Contraction of the temporal and masseter muscles is
symmetrical.

N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising the eye brows).

N-VIII: She hears rubbing of the fingers on both ears.

N-IX & X: The soft palate rises in the midline when saying ‘ah!’

N-XI: The Sternocleidomastoid and trapezius muscles contract on turning the head and on shrugging the
shoulder against resistance, respectively.

N-XII: The tongue protrudes in the midline and shows no fasciculation or atrophy.
Motor: There is muscle bulk reduction in all extremities and there is also no bulk difference between
the left and the right sides. There is no spontaneous as well as induced fasciculation. She has normal
Muscle tone and power.

Coordination: Finger to nose, heal to shin and rapid alternating movement of the arm were done
without any abnormalities.

Reflexes: Superficial reflexes-Abdominal reflex is present both in upper and lower quadrants. Corneal
reflex is intact in both eyes. Plantar reflex is down going on both sides.

Deep tendon reflexes-Both right and left biceps, triceps, patellar and ankle reflexes are also
intact.

Clonus: No clonus

Sensory: She identifies light touch, pain and temperature sensations. She appreciates the form, size and
shape of a coin. Passive movements and position sense are also well appreciated.

Meningeal Sign: There is no neck stiffness.

Summary

Subjective

A 61 year old female patient presenting with a progressive dysphagia of 6 months duration, from initial
solid to now difficulty to swallow saliva, food being stuck at the lower sternum, regurgitation of ingested
matter, burning type of retrosternal pain that doesn’t radiate, frequent chocking, significant weight loss.

Objective

 Malnourished body
 Pale conjuctivae and pale palms.
 Dry lips and tongue.
 Scaphoid abdomen.

Differential diagnosis
1. esophageal Ca

2. proximal gastric ca

3. chronic reflux secondary to GERD

Discussion of the Differential Diagnosis

3.chronic reflux due to GERD

It is caused by loss of competence of LES. As a result of reflux of gastric acid extensive inflammation of
the lower esophagus occurs which results in esophagitis. Dysphagia is a long term result of GERD as
result of stricture esphagitis due to repeated reflux, ulcer and fibrosis.

Though GERD mostly occurs in young and middle aged, it can occur at this age, the presence of
dysphagia at the lower sternum, retrosternal pain,choking, and history of alcohol and spicy food intake
can support this diagnosis. On the physical examination the finding of anemia can also add to the
diagnosis.

However the presence of regurgitation. The early presentation of dysphagia, the absence of dyspeptic
symptoms. Also the presence of dysphagia is less likely in patients with GERD.

So this diagnosis is less plausible for this patient.

2. proximal gastric ca

Gastric ca is more common in developing countries like ours, the incidence is more common in males.
Adenocarcinoma is more common, it has two types according to lauren’s classification- the intestinal
and diffuse type. The diffuse type is more common in women at young age. The intestinal type increases
with increasing age.

The presence of food being stuck at the lower sternum can suggest one complication of proximal gastric
ca which is obstruction at cardio-esophageal junction. The age of the patient, the presence of
retrosternal pain and significant weight loss can support this diagnosis. But the presence of
regurgitation, the sex of the patient and absence of abdominal pain, vomiting and other dyspeptic
symptoms.
The presence of anemia and cachectic body on physical examination can support this diagnosis.

Endoscopic and other investigative modalities are needed to make this diagnosis complete.(the
investigations modalities are listed below).

1. esophageal carcinoma

Has two main types- squamous cell carcinoma and adenocarcinoma. The squamous variant is more
common representing the 90% of cases. And the incidence of this carcinoma is increasing in our setup.

The age of the patient and the progression of the dysphagia from solid to liquid and then saliva in about
6 months strongly suggests this disease. In addition she has some risk factors including taking hot meal,
spicy foods and alcohol intake. She also presents with retrosternal pain, regurgitation and significant
weight loss that also adds to this condition.

From the physical examination- the presence of pale sclera and palor on the skin,signs of dehydration o
n the lips and tongue, the physique of the patient which is very cachetic, frequent spitting of saliva are in
the favor of this diagnosis.

Though these reasons strongly suggest this disease we can’t be sure until some important investigations
are done(they are listed below)

INVESTIGATIONS

 Complete blood count-Hb,Hct-because we suspect anemia,

 Blood group-because she may need blood transfusions
 Serum electrolyte-mainly for potassium,
 PT,PTT,INR
 Liver function test-if there are secondaries in the liver
 Barium swallow-
 Endoscopy-is the majory diagnostic modality. We can also take biopsy
 Endoscopic ultrasound-for staging
 CT-to detect local infiltration,
 Chest X ray-to rule out aspiration pneumonia
 Bronchoscopy-to rule out involvement of bronchus.