Information
A patient has been referred on an urgent basis by his GP
to the gastroenterology clinic. You are the doctor seeing the patient. Please
read the referral letter and take a history from the patient.
Letter
Dear
Doctor,
Kindly
see Mrs. X (65 years) who complains of dysphagia for the last 6-8 weeks. She
has lost weight and is concerned that she may have a cancer.
Thanking
you,
Yours
sincerely,
Dr. Y
History
Use the method described in
ACES for PACES chapter 4. The mnemonic I
passed by employing aces will help you
remember to take a complete history without any omissions
Identification
Begin with an introduction of oneself and clarify the
identity of the patient.
Analysis of Symptoms
Use the method described in ACES
for PACES chapter 4 . Use the mnemonic "Please Carefully Question These
Methods For Reliability and Resilience" to help you
analyse symptoms.
The patient complains of difficulty in swallowing. She
describes this as food getting stuck and the site at which it gets stuck is
the lower part of her chest.
This affects solids and liquids go down without any
difficulty. She can swallow semi-solids and small pieces of solid food if she
chews it a lot. She finds that drinking water with her meals helps her to
swallow. Change in posture does not help.
There is no pain on swallowing. She does not have
heartburn now as she has been using omeprazole for the last one year but did
have heartburn, acid regurgitation and belching until she was started on this
drug by her GP.
She has lost weight. She does not know how much but her
clothes are becoming loose.
There has been no nausea, vomiting or haematemesis.
The difficulty in swallowing was of insidious onset and
has been steadily getting worse. She says that this has been going on for 6-8
weeks but feels that there may have been minor difficulties for longer than
that. There have been no periods in which symptoms have abated.
Review of systems
GIT
Appetite normal, no difficulty with mastication
No abdominal pain
Bowel movements have decreased in frequency; the patient
attributes this to here eating less.
No jaundice, itch or swelling of her abdomen.
E&M
Loss of weight already known
No excess sweating, feels lack of energy
IS
No rash
CVS
No history of cold extremities or fingers going blue
RS
No hoarseness of voice
No cough, breathlessness
KUS
No problems with micturition
No polyuria
RAG
Post menopausal
HS
No swelling of glands
Nil else
CNS
No problems with vision or speech
Nil else
LMS
No stiffness of joints
Past Illnesses
She gives a history of asthma
No history of ischaemic heart disease or cerebrovascular
disease
Drug History
She takes salbutamol and steroid inhalers for asthma
Omeprazole 40 mgs daily
Drug Intolerance
No intolerance to any drug
Allergies
No known allergies
Personal History
Diet- has been unable to eat a normal diet, has been
restricted to taking semi-solids and liquids.
Exercise- does no exercise
Smoking- does not smoke
Alcohol – 2- 4 units per week
Family History
No family history of cancer
Social History
She is married, has a married daughter and 3
grandchildren.
She is a housewife
Husband retired
She is able to undertake all activities of daily living
independently.
Beliefs
She thinks she may have cancer.
She has heard from friends that cancer of the gullet is a
very serious illness and one is unlikely to survive
Expectations
She feels she will have to undergo a camera test to look
at her gullet (the GP has told her about this and so have her friends)
She knows that if the test result is not good that she
may have to undergo an operation
Anxieties
She is afraid that this may be hereditary and that her
family might be affected.
She has promised to look after her grandchildren for
three months whilst her daughter and son-in-law go abroad on an assignment in
relation to their work. She is afraid she will not be able to fulfil this
obligation.
She is also afraid that she will die of this illness and
that she does not have long to live.
Analysis
♥
Dysphagia may be due to a number of causes
(ACES for PACES Page 285)
ª
Low dysphagia would make a pharyngeal pouch or bulbar palsy less
likely
¨
Solids being affected more than liquids would make it likely
that the cause is a stricture rather than a motility disorder
§
The absence of reflux symptoms and the fact that the patient is
on a proton pump inhibitor would make oesophagitis and a benign stricture less
likely. The associated loss of weight is in keeping with the diagnosis of a
malignant stricture.
♥
The time span too would favour a malignant stricture. Food bolus
obstruction is definitely not likely.
ª
The absence of symptoms in relation to the CVS, RS, IS, LMS,
CNS, HS make external compression and systemic causes of dysphagia unlikely.
¨
The absence of major associated illness is a benefit, as this
would allow surgery to be performed if the patient does have a malignant
stricture.
§
The fact that she has well-controlled asthma would not be a
contraindication to surgery.
♥
The fact that she is not eating well and is losing weight is an
indication for dietary intervention to help maintain her nutritional status
until definite treatment may be instituted.
Diagnosis
ª
Stricture of the oesophagus
¨
Most likely malignant
§
Nutritional failure
♥
No contraindication to surgery
Other Factors
ª
Belief that she has cancer and the outlook would be poor
¨
Expectation of endoscopy for diagnosis of cancer and operative
treatment if this diagnosis is concerned
§
Anxieties regarding the cause and whether it is hereditary
♥
Anxieties regarding effects of the disease and treatment in
relation to her obligations to her daughter
ª
Anxieties regarding survival
Planning
(ACES for PACES
chapter 18)
Management
Control
♥
Surgery
ª
Chemotherapy
♥
Radiotherapy
Symptomatic Relief
§
Stenting for palliation (if not suitable for surgery or radical
chemo-radiotherapy)
Support
♥
Nutritional support would be required in view of dysphagia
Discussion
ª
Discuss the two types of oesophageal cancer (squamous carcinoma
and adenocarcinoma) and the risk factors for the two types
¨
Discuss above investigations and management
§
Discuss alternative arrangements to look after her grandchildren
and suggest further discussion with her daughter in the light of definitive
investigations, which would give a clearer idea of treatment and prognosis
