華山論劍-專業案例挑戰/Case 2015-004

Date: 5 Apr. posted by 方律涵/湯道謙/曾政豪/李青泰/張吉仰/牟聯瑞醫師學術天地

73 years-old male with dysphagia for one year

73 year-old male with past medical/surgical history significant for cervical spondylosis and chronic kidney disease (eGFR:30, stage 3) without medical follow-up presented as a referral from outside hospital for evaluation of dysphagia. Symptoms started 1 year ago, without exacerbating or relieving factors, and associated with both liquid and solid food intake. Patient also experienced retro-sternal compression pain that might persist up to 4 hours. There was no radiation pain, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, heartburn, or fever.

Symptomatic treatments were provided, and patient initially reported a improvement of symptoms.

However, patient's symptoms worsened in recent two months, associated with body weight loss of 4~5 kilograms over two months and vomiting with/without oral intake. He was transferred to our hospital for further evaluation and management. Social history is significant for smoking 3PPD/day for 40+ years (quit for one year) and occasional alcohol consumption.

Vital signs: Body temperature: 36.9C, Pulse rate: 79/min, Respiratory rate: 20/min, Blood pressure: 105/70mmHg. Body weight: 55.6 Kilograms, body height: 162.6cm. BMI:21. Consciousness: alert and oriented. Physical examination: anicteric sclera, no palpable lymph nodes over neck and axilla, Chest: symmetric chest expansion, bilateral clear vesical breathing sound, Abdomen: soft and flat, normal active bowel sound, no abdominal tenderness, no rebounding paiN. Extremities: no legs pitting edema. Lab data: As (table 1). EKG (figure 1) showed sinus bradycardia (57/min). CXR (figure 2) showed bilateral mild increased infiltration and no cardiomegaly. Which diagnosis do you think of?

Laboratory examinations

Table1

Figure1

Figure2

What’s your Diagnosis?

Ready for answers?  CLICK HERE