 Welcome back to our MedSmarter question of the week where we're taking a smarter approach to preparing future physicians. Before we get started, if you'll take just a quick minute and click that like button and also subscribe and turn the bell on so that you'll be notified when we post new videos. Let's get right to that question. As always, we start with the last sentence of the vignette and then we'll go back and read the rest. Which of the following actions is most likely absent in this patient? A 30 year old woman presents to her physician complaining of chest pain and difficulty swallowing. Results of the ECG and X-ray of the chest were normal, but the following image was seen during a barium swallow study. So which of the following actions is most likely absent in this patient? So before we get to the answer choices, let's take a look at this picture because this is what we're going to be referring from. So what we see here is the esophagus coming down here to the lower esophageal sphincter and we're seeing what we call a birds beak appearance there. So the barium is getting to that bottom and it's hitting on bottleneck. So let's now see and figure out what is the problem going on in this specific situation. So take a minute, read the answer choices, go back over the question again, come up with your answer and put it in the comment box below. Alright, so let's go through these answer choices together. A contraction of the lower esophageal sphincter. So we want to know what is absent. So if there is no contraction of the lower esophageal sphincter, then this would be wide open. You wouldn't see much barium. It would go through no problem at all. So we're not seeing that in this case. So A is not our issue that we're dealing with. B contraction of the upper esophageal sphincter. So if we have an absent contraction of the upper esophageal sphincter will still allow that barium to come through. We won't see that birds beak appearance. So therefore B is not our correct answer. C initiation of swallowing in the oropharynx. So difficulty swallowing would not be something that we have issues with down in the esophagus stomach area. So that's just completely out. D relaxation of the lower esophageal sphincter. So if we have an absence of relaxation of the lower esophageal sphincter, that can cause this. So what we're dealing with would be achalasia. So achalasia is a failure of relaxation of the lower esophageal sphincter. So therefore D I think is probably our answer. Let's double check and make sure E is not the right answer. E relaxation of the upper esophageal sphincter. The upper esophageal sphincter isn't affected with achalasia, which is what we're dealing with here. So therefore E is not my choice. So D is my final answer. And D is the correct answer. So this barium study is showing us the birds beak appearance as we pointed out earlier. That's that contraction. It looks like a birds beak coming to a point there down in the distal esophagus. And that is characteristic of achalasia. So what we are dealing with is achalasia. So you have difficulty swallowing, abnormal contraction of the esophageal muscles, absence of peristalsis, and absence of relaxation of the lower esophageal sphincter are the characteristic hallmarks of achalasia. If you found this material helpful for your studying, please like and consider subscribing to the channel. Also share this video so that more people can benefit from it like you have.