Thank you for seeing Ms Hall, a 45-year-old secondary school teacher, who has features suggestive of gastro-oesophageal reflux with a possible stricture. I am writing to refer Ms Hall to you for further investigation and definitive diagnosis.
Ms Hall is divorced and has two children. She has stopped smoking since her children were born, but she drinks alcohol socially (mainly spirits). Ms Hall is an overweight, however she has lost 2kg recently. She has a family history of peptic ulcer, and she had dyspepsia 6 years ago. Ms HallHall's coffee consumption has been increased.
Today, Ms Hall presented with dysphagia for solids, which has started 2two weeks ago, after she had an upper respiratory tract infection, for which she took OTC Chinese herbal product with unknown contents.Examination The examination showed epigastric pain radiated to the back, at the level of T12. However, there were no sensation of a lump and no obvious anxiety. As a result, I advised her to stop OTC productproducts and to decrease her coffee intake. Also, Pantoprazole 40mg was prescribed.
In light of the above, I would greatly appreciate Ifit if you could provide her with a definitive diagnosis.
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