Question

A 50-year-old man with a past medical history of hyperlipidemia presents with a recurrent "bitterness and sour sensation in his mouth" and a nonproductive cough; both have been occurring over the last year. There is associated progressive dysphagia and odynophagia to solid foods, but not to liquids; as a result, he has lost 15 pounds over the past 5 months. He admits to drinking 1 to 2 beers per week, but he denies additional alcohol use. He also denies cigarette smoking and illicit drug use.

He denies fever, chills, sputum production, chest pain, palpitations, dyspnea, shortness of breath, wheezing, peripheral edema, abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, and changes in bowel habits.

The physical exam reveals normal vital signs. Oropharyngeal, neck, cardiopulmonary, and abdominal exams are normal.

What is the most appropriate initial intervention for this patient at this time?

1 Perform a chest X-ray
2 Upper endoscopic evaluation
3 Prescribe a trial of esomeprazole
4 Barium esophagography
5 Ambulatory esophageal pH monitoring

Answer 1

An upper endoscopic evaluation is the most appropriate initial intervention for a patient presenting with symptoms suggestive of a significant gastrointestinal disorder, especially with dysphagia to solids and considerable weight loss.

Step-by-step explanation:

The most appropriate initial intervention for a 50-year-old man presenting with recurrent bitterness and sour sensation in the mouth, nonproductive cough, progressive dysphagia, odynophagia to solid foods, and significant weight loss is option 2 Upper endoscopic evaluation.

This patient's symptoms are suggestive of an underlying gastrointestinal disorder that warrants direct visualization to assess for structural abnormalities, inflammatory changes, lesions, or potential malignancy. Dysphagia, particularly when it comes to solid foods, and significant weight loss are especially concerning and upper endoscopy is considered a standard diagnostic approach in evaluation of these symptoms. While GERD (gastroesophageal reflux disease) could be considered, given the chronicity and progression of symptoms, a more thorough evaluation through endoscopy is necessary before prescribing treatments such as esomeprazole, which is a proton pump inhibitor.