A 61-year-old woman presents to her primary care physician because for the last 4 weeks she has had difficulty swallowing solid food and a feeling of food "getting stuck in the chest." She also reports having nausea, mild epigastric pain, and heartburn. She denies having fevers, chills, night sweats, weight loss, vomiting, diarrhea, hematochezia, or melena.
Medical historyFor the past 20 years, she has had gastroesophageal reflux disease (GERD), intermittently treated with a proton pump inhibitor. She also has arthritis, hyperlipidemia, hypertension, and asthma, and she has undergone right hip replacement for a hip fracture. She has no known allergies.She lives in the Midwest region of the United States and is on disability due to her arthritis. She is divorced and has three children.She quit smoking 3 years ago after smoking half a pack per day for 30 years. She drinks socially; she has never used recreational drugs.She recalls that an uncle had cancer, but she does not know the specific type.
Physical examinationThe patient's temperature is 96.7°F (35.9°C), heart rate 86 per minute, blood pressure 150/92 mm Hg, respiratory rate 16 per minute, and oxygen saturation 100% on room air.She is alert and oriented to time, place, and person. Her sclera are white, her lymph nodes are not palpable, and her heart and lungs appear normal. Her abdomen is tender in the area of the stomach and in the left upper quad-rant, there are no signs of peritonitis, the liver and spleen are not enlarged, and no masses can be palpated. She has no asterixis. Results of her complete neurologic examination are normal. Her extremities are normal with no edema. Her laboratory values are shown in TABLE 1.