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
Investigations
- Barium swallow
- Scope if any red flags
Note:
- Plummer-Vinson or Patterson Kelly – esophageal web associated with iron deficiency (increased risk of cancer)