14 MARCH 2011

Dr Aleena
CASE
AMC BOOK CASE page 81
A 26 year-old male presented with difficulty of swallowing. Task take history,
physical examination, diagnosis, investigation, and management.

GLOBUS HYSTERICUS
RED FLAG: Rule out organic cause
Cause of:
- Functional muscle tension
- Neurological stroke, myasthenia gravis
- Mechanical stricture, tumor, goiter
HISTORY
When and how did it start
Is it with liquid or fluid
Could you please tell me exactly what you feel? (I feel a lump)
At what level
What makes it better/worse
Any heartburn, any thickness of skin (scleroderma)
Does food come back again from your mouth or nose (regurgitation)
Have you noticed any weight loss, abdominal pain or cramps
Any nausea, vomiting, any blood in the vomitus
Any changes in bowel and waterworks
Any headache, weakness in your arms and legs
Any abnormal feeling numbness, tingling in your face, limbs
Past medical history
General health
Chronic condition
Thyroid problem
Any abdominal surgery
SADMA
Family history of similar condition or serious problem like stroke, cancer, mental
illness
Any stressful situation
Financial problem, job, family
What about your mood, sleep, appetite
Any thought of harming yourself
EXAMINATION
GA: pale
BMI

VS
Any skin changes scleroderma
Systemic
- Cranial nerve exam
- Oesophageal obstruction test: give a glass of water, put stethoscope on left
upper quadrant, ask to swallow, you will hear noise in 10 seconds no
obstruction, test (-)
- Throat inspection and laryngoscopy
EXPLANATION
All examination is normal which is good news
Most likely stress if causing these problems but we need to rule out organic cause
Id like to do some blood tests, chest X-ray
Ill refer you to specialist, you may need endoscopy
Laryngoscopy and pharyngoscopy will be done
Most likely all investigations will come back normal
This condition is not uncommon
The cause is unclear and Id like to refer you to a psychologist
He will help you to cope with your stress and overcome these problems
Let me assure you, it will settle down with time