
CC/HPI:
Mrs X is a 13 year old female who presents to the clinic with a chief complaint of "difficulty swallowing".
The onset has been gradual and over the past year.
It is intermittent and associated with specific foods: chocolate and some meats,
though her recollection is shoddy at best.
She has GERD, and has since she was a baby. Her mother reports she always spit up as an infant.
She knows this difficulty swallowing is different from the GERD she has experienced in the past.
She takes omeprazole 20mg daily and has for years.
The sensation, she reports, is a very different feeling.
She further reports that she has not experienced GERD in years and that attacks of
GERD do noT precede dysphagic episodes.
When she points to the location that the difficulty seems to arise she indicates her
midline at the level of the first intercostal space.
It has recently lead to a burning (5/10 when it happens) sensation and a need to vomit.
It is non-bilious vomit and looks exactly like what she just swallowed.

There is no associated difficulty breathing.
Sometimes taking a deep breath to "make more room in her chest helps" the offending food to go down.

She has noted some allergic reactions that have led to lip and mouth swelling and have necessitated
benadryl use per her mother.
These have included various foods, most notably chocolate.
Her dad recalls for her that it is most notably milk and milk chocolate.
The picture is not entirely clear.
She is unable to recall any other foods at this time, though she knows there are others.
So do her parents. They cannot recall either. She denies dysphagia associated with liquids.

She denies odynophagia. She denies new medications or taking any new pills. She has no other
complaints today.


Assessment and Plan:
Mrs X is a well appearing cheerful young woman in no acute distress.
Her vital signs are stable. She has an unremarkable physical exam.
Her history is significant for long standing GERD, a risk factor for esophageal stricture/ring/web.

However, she has been on omeprazole and the dysphagia is increasing.
Further, she seems to clearly differentiate the long standing GERD from the dysphagia and is familiar
with her symptoms enough to state clearly that one does not precede the other.
One would think that she would have noticed increasing GERD in the last year. Her food related allergies
that seem to localize around her lips and mouth raise a concern for EoE (eosinophilic esophagitis).
In any of the cases, the next step in her management should be consultation with a specialist.
This would likely lead to either a pH probe, a trial of increased PPIs, or more to the point perhaps,
an upper endoscopy with biopsy.

