Difficulty swallowing (initiation difficulty usually neurological)

History of Presenting Illness

  • Timing/Location (oropharynx vs esophageal)
  • Type of food – Solid versus liquid (obstruction versus neuromuscular)
  • Intermittent vs progressive
  • Odynophagia
  • Associated symptoms: wt loss, cough, choke, regurgitation (nasal), drool, hoarse, slur, dysarthria, hiccups, other neuro signs, nausea/vomiting
  • Other: risks, History of foreign body ingestion
    • Smoking – lung ca, esophageal ca
    • NG tube, recent intubation (irritation, ulcers)
    • Cancer – hematemesis, B symptoms (fevers, sweating, weight loss)


Review of Systems

  • General: weight loss, night sweats, appetite, fever, fatigue
  • Resp: cough, aspiration, halitosis (Zenker’s)
  • CVS: chest pain
  • GI: cough, choke, regurgitation, heartburn, odynophagia, hematemesis

Past Medical History

  • GERD (reflux, burning, pain, waterbrash, when, stricture)
  • Neurological conditions (MS, ALS, strokes – usually more initiation)
  • Scleroderma
  • Cancer
  • Radiation Therapy

Family History

  • Cancer
  • Scleroderma
  • Achalasia

Differential Diagnosis

  • Cancer (esophageal, lung)
  • Peptic ulcer disease
  • Stricture
  • Neurologic
  • Scleroderma (CREST)
  • Esophageal spasm (Presby, Nutcracker – provoke with tensilon and Tx with nitrates, CCB)
  • Achalasia (increased LES tone)
  • Diverticulum (Zenker’s)

Physical Exam

  • Oral cavity (dentition, lesions, masses)
  • CN exam
  • Cervical LN
  • Masses
  • Thyroid
  • Neuro
  • Skin changes


  • Barium swallow
  • Scope if any red flags


  • Plummer-Vinson or Patterson Kelly – esophageal web associated with iron deficiency (increased risk of cancer)

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