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Case 20 🔥
A 52-year-old gentleman comes to your office with a history of intermittent difficulty swallowing solid food. His symptoms have been present for the past 5 years. He points to his supraclavicular notch when describing where the food feels stuck, although he is able to chew his food and transfer it into his posterior pharynx without difficulty. He does not choke or cough while eating. Drinking water will usually relieve his symptoms, although on several occasions he has self-induced vomiting. His symptoms are slightly worse
now than they were several years ago, which prompted to￾day’s visit.
ADDITIONAL HISTORY
His symptoms typically happen shortly after swallowing solid food, particularly when he is eating fast and takes alarge bite of food such as bread or meat. He does not have difficulty swallowing liquids. The longest he has had food stuck has been 30 minutes, during which time he had severe pain in his chest. He reports rare episodes of heartburn and regurgitation, which have been relieved with antacids. He denies smoking or excessive alcohol use.

Explanation case 20



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He has esophageal (rather than oropharyngeal) dysphagia. He has no difficulty with liquids, suggesting that his symptoms are most likely due to a mechanical obstruction rather than a motor disorder such as esophageal spasm or achalasia. He has had only occasional episodes of heartburn or regurgitation to suggest acid reflux disease, and therefore, although possible, it less likely that he has a peptic stricture of his distal esophagus. Likewise, esopha￾geal cancer is less likely because his symptoms have been present for approximately 5 years and, despite this, he has not lost a significant amount of weight. Patients with esophageal rings usually have intermittent dysphagia to solids, particularly foods greater than 13 mm in diameter. The episodes of dysphagia are usually associated with chest discomfort and relieved by regurgitating the obstructing food bolus. Acute impaction of the esophagus may require endoscopic intervention to remove the food
bolus

Case 21
A 66-year-old woman with type 2 diabetes mellitus comes to the physician because of a severely painful right ear with discharge for 10 days. The ear pain was acute in onset and is constant. She has been using over-the-counter eardrops but her symptoms have continued to worsen. Her only medication is insulin, which she uses inconsistently. Her temperature is 39°C (102.2°F), pulse is 108/min, and blood pressure is 130/90 mm Hg. Examination of the right ear shows a swollen pinna and lobule and malodorous purulent discharge; the ear is tender to touch. Posterior auricular lymphadenopathy is present. There is mild hearing loss of the right ear. Otoscopic examination shows a swollen ear canal with granulation tissue. Laboratory studies show:
Hemoglobin13.3 g/dL
Hemoglobin A1c12.2%
Leukocyte count18,300 mm3Segmented
neutrophils76%
Eosinophils1%
Lymphocytes20%
Monocytes3%
SerumGlucose212 mg/dL
Creatinine1.7 mg/dL
A CT scan of the head shows severe thickening and enhancing of the soft tissue of the external auditory canal with patchy destruction of the temporal bone. Culture results of the ear drainage are pending. Which of the following is the most appropriate pharmacotherapy?

#case 22
A 60-year-old woman with heart failure and normal renal function is started on furosemide (Lasix) 80 mg/day. She notices a good diuretic response every time she takes the medication.A few weeks later, she is feeling unwell because of fatigue and muscle weakness, but her heart
failure symptoms are better.

Explanation




Hypokalemia can result in paralytic ileus,rhabdomyolysis, weakness, and cardiac repolarization abnormalities. It is a common complication along with hyponatremia of starting
patients on diuretics. (

Case 23
You see a 40-year-old woman with throbbing headaches. She reports that the symptoms began approximately 2 months ago and have gradually worsened. They are always on the right side. On one occasion, she had a prolonged visual aura of zigzag lines that lasted for one day
and persisted after the headache had resolved. Which of the following features is not an alarm symptom that should prompt concern for a serious cause of headache?

Answer and explanation case 23

The patient has old headaches (ie, they are the same in character as her usual headaches, albeit more severe). Therefore, the diagnosis for her headaches remains the same. Cervico￾genic headache is generally a disease of middle-aged or older patients and is uncommon in young women. Occasionally, it can occur in younger patients after whiplash-type neck injuries. It is most commonly a burning or dull pain in the occiput
and forehead. Brain tumor is a new headache. The character
and description of her pain have not changed, as one would
expect if a new source, such as brain tumor, were the cause of
the headache.
The unilateral, throbbing nature of the headaches is typical of migraine. The occasional visual aura and associated
nausea confidently establish the diagnosis of migraine with
great certainty. These 2 features most accurately distinguish
migraine from tension-type headache. She has no alarm
symptoms. The challenge is to determine why the headaches
are more severe and frequent now. Her headaches are likely
worse due to a change in her lifestyle including triggers of
irregular sleep and excessive caffeine.

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