Dysphagia 3

Take a history from this 75 year old man with Parkinson’s disease. He has noticed worsening dysphagia over the past 12 months (medication adherence has been poor).

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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