Case 22: Problems with swallowing

Opening scenario

Eva Garcia, a 60-year-old female; , comes to the doctor's office because of trouble swallowing.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 120/80 mm Hg
• Heart rate: 62/min
• Respirations: 15/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are not aware of the meanings of medical terms (e.g., barium swallow) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Be honest with me – do you think I have cancer?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have problems swallowing food.
• Onset
• It started around 6 months ago.
• Constant/intermittent
• It is not there all of the time, but most of the time it is an issue, especially if I try to swallow bigger chunks of food.
• Precipitating events
• None.
• Progression
• It is getting worse. First, I only had problems with solid food, but liquids have also become more difficult to swallow over the past month.
• Previous episodes
• Well, I have reflux. So at the beginning I thought that this was my reflux disease.
• Frequency
• Pretty much always when I eat things like meat and do not carefully chew. And sometimes with other food and drinks, too.
• Alleviating factors
• I have to eat slowly and chew carefully.
• Aggravating factors
• If I do not eat slowly.
• Associated symptoms
• I have had chest pain while eating for the past few weeks.
  • Location
  • Right in the middle, behind my chest bone.
  • Intensity (on a scale from 0–10)
  • Maybe a 3–4.
  • Quality
  • It is like someone is sitting on my chest.
  • Pain during exercise/pain without trigger
  • It has never happened when I climb the stairs or exercise, no! And it has only happened when I eat something and never in other situations.

Review of systems specific to dysphagia

• Recent travel
• I went to Vietnam 8 months ago.
• Nausea/vomiting
• No.
  • Regurgitation
  • From time to time, I have to cough up some food.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• Yes, I have been feeling more tired these past 2 months.
• Cough
• No.
• Bowel problems
• No.
• Appetite
• Normal.
• Weight changes
• Yes, I have lost 8 pounds over the past 6 months. Not bad, right? I was not even trying.
• Recent infections
• No.
• Hoarse voice
• No.
• Lumps on neck/swelling of neck
• No.

Past medical history, family history, and social history

• Past medical history
• I have had reflux for the past 18 years.
• Allergies
• None.
• Medications
• I take Tums®.
• Hospitalizations
• Never.
• Past surgical history
• None.
• Family history
• My mother has a problem with her large bowel, it is called something like “diverticle”, “diverticula.” Yes, as you say, it is called diverticulosis.
• Work
• I work as a cashier.
• Home
• I live alone. I am divorced.
• Alcohol
• I have maybe 1-2 beers on the weekends.
• Recreational drugs
• None.
• Tobacco
• Yes, I have smoked half a pack a day for the past 32 years.
• Diet
• I love cured food and bacon. Fresh foods like fruits and veggies are not really my thing.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
  • Inspection of the oropharynx
• Neck examination
  • Inspection of the neck
  • Palpation of the lymph nodes of the head and neck
• Cardiovascular examination
  • Palpation of the apical impulse
  • Auscultation of the heart
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee offered counseling on support options for weight and diet changes.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Garcia, I understand your concern that your symptoms may be due to a serious underlying condition. Many things can cause difficulty swallowing, including cancer, but it can also be caused by less serious conditions such as muscle dysfunction in your esophagus or a long history of reflux. I would like to run some tests to determine what exactly is causing your symptoms. I can assure you that we are a very experienced team here and that we will do our best to treat you. I will be with you every step of the way and I am always available for any questions or concerns you might have. Does that sound okay?”

Patient note

Differential diagnoses

1. Esophageal cancer: Dysphagia that progresses from solids to liquids and is associated with fatigue and/or unintentional weight loss should always raise concern for esophageal cancer. The condition is more common in men and has a peak incidence of 60–70 years of age. This patient has a number of risk factors for both adenocarcinoma (smoking history, history of long-standing untreated GERD) and squamous cell carcinoma (smoking history, diet low in fruits and vegetables, nitrosamine exposure), making esophageal cancer the most likely diagnosis.
2. Achalasia: Intermittent dysphagia to both solids and liquids that is associated with retrosternal chest pain, regurgitation, and weight loss is characteristic of achalasia. The condition occurs most commonly in individuals 25–60 years of age. As with this patient, careful chewing or eating slowly is often reported to alleviate symptoms. Although this patient's findings are all consistent with achalasia, her multiple risk factors for esophageal cancer make it only the second most likely diagnosis in this case.
3. Esophageal ring: Esophageal rings, most commonly Schatzki rings, can cause dysphagia and occur as a result of long-standing GERD. However, dysphagia is usually limited to solids and does not progress or progresses only slowly, making it the least likely of the three diagnoses.

Diagnostic studies

• ECG: should be performed in all patients with chest pain to rule out life-threatening cardiac causes
• Barium swallow: best initial test for suspected esophageal rings and achalasia
  • Shows “bird-beak appearance” and delayed emptying in achalasia or narrowing of the esophagus (often at the gastroesophageal junction) in esophageal rings
  • Esophageal cancer manifests as asymmetrical and irregular borders of the esophagus with stenosis and proximal dilatation (apple core lesion).
• Esophagogastroduodenoscopy (EGD) with biopsies: best initial and confirmatory test in esophageal cancer, as it allows for direct visualization of the tumor and biopsy of suspicious lesions
• Esophageal manometry: confirmatory test in achalasia; shows lack of peristalsis in the lower two-thirds of the esophagus, incomplete or absent relaxation of the lower esophageal sphincter, and increased resting pressure

Other differential diagnoses to consider

• Zenker diverticulum
• Diffuse esophageal spasm
• Nutcracker esophagus
• Hiatal hernia
• See also “Overview of causes of dysphagia” and “Esophageal motility disorders.”

Dysphagia BITES: Blocked esophageal lumen, Intrinsic narrowing, Throat/mouth disease, Extrinsic compression, Smooth/striated muscle disorders.