Dysphagia 2

Take a history from this 28 year old lady with a 3 month history of dysphagia. She has never smoked and does not drink alcohol. She admits that she is under stress with her job and marriage. There is no history of reflux and she is otherwise fit and well.

  1. Example answer

    History 

    • Onset
    • Duration
    • Level of dysphagia – can be useful to ask the patient to “point with one finger”
    • Timing of symptoms – difficulty initiating swallow (oropharyngeal – often neurological) or late (often mechanical aetiology) in swallow
    • Progression – rate of progression, intermittent/episodic or constant. Affecting ingestion of solids, liquids or both?
    • Exacerbating and relieving factors 
    • Associated symptoms – reflux, regurgitation (digested or undigested foods), halitosis, neck swelling, cough, choking
    • Predisposing events – trauma, previous surgery or endoscopy, self harm (e.g. imbibing corrosive substances)
    • Red flag symptoms – odynophagia, referred otalgia, dyspnoea, dysphonia, haemoptysis, haematemesis.
    • Constitutional symptoms – weight loss, malaise, anorexia, night sweats
    • Past Medical History – GORD, cancer, previous surgery or endoscopy, diabetes, HIV
    • Drug History – NSAIDs, steroids, immunosuppressants, PPI, over-the-counter antacids, medication allergies 
    • Social History – smoking, alcohol, occupation
    • Family History – Family history of cancer or neurological conditions
    • Systems review – Abdo (pain, vomiting and diarrhoea, PR bleeding, change in bowel habits) Neuro (slurred speech, muscle weakness, choking) 
    • Elicit the patient’s ideas, concerns and expectations 

    Conclusion

    • Summarise consultation
    • Thank patient
    • Offer appropriate differential diagnosis
    Differential diagnoses to consider*
    Neurological causes 

    • Parkinson’s disease
    • Myasthenia Gravis
    • Stroke
    • Multiple sclerosis
    • Muscular dystrophies

    Diseases of motility

    • Achalasia
    • CREST syndrome
    • Oesophageal spasm
    Mechanical causes 

    Intraluminal

    • Foreign body
    • Tumour

    Luminal 

    • Pharyngeal pouch
    • Strictures
    • Webbing

    Extraluminal

    • Thyroid goitre
    • Cervical spondylosis
    • Lymphadenopathy
    • Pleural/mediastinal swelling
    • Aortic aneurysm 
    Infective 

    • Candidiasis 
    Other

    • Globus pharyngeus
    • Anorexia
    • Bulimia

    *Table not exhaustive

    Management

    You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations. 

    Some examples are below:-

    Suspected diagnosisThe following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given
    TumourCT neck and thorax, MRI Neck, Panendoscopy
    RefluxTrial of PPI + gaviscon and review
    Pharyngeal pouch/achalasia/strictureBarium swallow
    Neurological disorderNeurological referral 
    Globus pharyngeusPatient education and reassurance
    If lymphadenopathy observedUltrasound +/- FNA
    GoitreTFTs, Ultrasound +/- FNA
    Oral candidiasisAntifungal treatment

    You may also mention that you would ask for a senior opinion and inform the patient of the outcome if you are unsure.

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