What is the best course of action for a 39-year-old male, 6 ft 4 in, with a history of chronic Gastroesophageal Reflux Disease (GERD) on daily Nexium (esomeprazole), elevated cholesterol, and recent significant weight loss of 30 lbs in one week, who presents with severe chest pain upon oral intake after being treated with Augmentin (amoxicillin/clavulanate) for flu-like symptoms?

Immediate Emergency Department Evaluation Required

This patient requires immediate emergency department evaluation for suspected medication-induced esophageal injury (pill esophagitis) from Augmentin, with urgent upper endoscopy indicated within 2 weeks due to the presence of alarm symptoms: severe odynophagia (chest pain with oral intake) and significant weight loss. 1

Critical Red Flags Present

This patient has multiple alarm symptoms that mandate urgent evaluation:

• Odynophagia (severe chest pain with swallowing) - a cardinal alarm symptom requiring endoscopy 1
• Unexplained weight loss (30 lbs in one week is physiologically implausible and likely represents inability to eat/drink due to severe odynophagia) - another alarm symptom 1
• Medication history highly suspicious for pill esophagitis - Augmentin (amoxicillin/clavulanate) is a known cause of medication-induced esophagitis 1
• Tall stature (6'4") increases risk for pill esophagitis due to longer esophageal transit time 1

Immediate Cardiac Exclusion Required First

Despite the obvious esophageal etiology, cardiac causes must be excluded immediately before attributing symptoms to gastrointestinal disease: 1, 2, 3, 4

• Obtain 12-lead ECG within 10 minutes to exclude acute coronary syndrome, as cardiac ischemia commonly presents as "burning" and can mimic reflux 2, 3, 4
• Measure cardiac troponin immediately - the 39-year-old male with elevated cholesterol and recent flu-like illness has cardiac risk factors, and post-viral myocarditis can present with chest pain and troponin elevation 3
• Normal vital signs do NOT exclude cardiac disease - patients with diabetes, women, and elderly frequently present with atypical symptoms 2

Most Likely Diagnosis: Augmentin-Induced Pill Esophagitis

The combination of severe odynophagia immediately following Augmentin therapy in a tall patient with chronic GERD on PPI is pathognomonic for medication-induced esophageal injury: 1

• Antibiotics (particularly doxycycline, but also amoxicillin/clavulanate), NSAIDs, potassium supplements, iron, and bisphosphonates are the most common causative medications 1
• Patients on chronic PPI therapy may have pre-existing esophageal pathology that increases susceptibility to pill-induced injury 1
• The temporal relationship (symptoms began after Augmentin initiation) strongly supports this diagnosis 1

Urgent Upper Endoscopy Indicated

Upper endoscopy should be performed urgently (within 2 weeks, ideally sooner given severity) rather than empiric therapy: 1

• The presence of odynophagia and weight loss are Class 2a indications for early endoscopy 1
• Endoscopy will identify the extent of esophageal injury, exclude complications (stricture, perforation, Barrett's esophagus), and rule out other serious pathology 1
• Empiric acid suppression trial is NOT appropriate when alarm symptoms are present 1

Immediate Management Pending Endoscopy

While arranging urgent endoscopy:

• Discontinue Augmentin immediately 1
• Continue Nexium (esomeprazole) but consider increasing dose - PPIs are the most effective treatment for esophageal injury and GERD complications 1
• Initiate liquid diet or soft foods to minimize mechanical trauma to injured esophagus 1
• Avoid lying flat after eating - maintain upright position for 2-3 hours post-meals 1
• Consider sucralfate suspension for mucosal protection, though evidence is limited 1

Critical Pitfalls to Avoid

Do not assume this is simply GERD exacerbation: 1

• The acute onset of severe symptoms immediately following antibiotic therapy distinguishes this from chronic GERD 1
• The severity of odynophagia (preventing oral intake) is atypical for uncomplicated GERD 1
• Weight loss of this magnitude suggests complete or near-complete dysphagia/odynophagia requiring urgent intervention 1

Do not use nitroglycerin response as a diagnostic criterion: 2, 4

• Esophageal spasm and other non-cardiac conditions also respond to nitroglycerin 2, 4
• Relief with nitroglycerin does not exclude cardiac disease 2, 4

Do not delay endoscopy for empiric PPI trial when alarm symptoms are present: 1

• Empiric acid suppression is only appropriate for patients WITHOUT dysphagia, odynophagia, bleeding, anemia, weight loss, or recurrent vomiting 1
• Delaying endoscopy risks missing serious pathology including malignancy, stricture, or perforation 1

Disposition Algorithm

If cardiac workup is negative (ECG normal, troponin negative):

1. Arrange urgent GI consultation for upper endoscopy within 2-7 days 1
2. If patient cannot tolerate oral intake, admit for IV hydration and nutritional support 1
3. If patient can tolerate liquids, discharge with strict return precautions and expedited outpatient endoscopy 1

If any high-risk cardiac features develop:

• Activate ACS protocol immediately 1, 2, 3
• Do not attribute symptoms to gastrointestinal causes until cardiac disease is definitively excluded 2, 3, 4