Onset of Dysphagia

Case 14 (This is everything you will need to know about the patient)
A 65-year-old man named Charlie Champion presents to your office complaining of difficulty swallowing.

Vital Signs:
Temperature 98.6°F
Blood pressure 100/70 mmHg
Heart rate 88 beats per minute
Respiratory rate 12 breaths per minute
Examinee’s Tasks
⦁ Obtain a focused and relevant history.
⦁ Perform a focused and relevant physical examination.
⦁ Discuss initial diagnostic impressions with the patient.
⦁ Discuss follow-up tests with the patient.
⦁ After seeing the patient, complete paperwork relevant to the case.

History of Present Illness. The Examinee:
asked if there was “real dysphagia,” i.e., a feeling of food sticking in the chest (“Yes, that describes what I’m feeling.”)
asked about the onset of dysphagia (“It started about 2 months ago.”)
asked specifically about difficulty swallowing solid foods (“I definitely can’t swallow anything solid.”) asked specifically about difficulty swallowing liquids (“Not in the beginning, but now it’s getting to the point where swallowing water is becoming a problem.”)
asked about painful swallowing, i.e., odynophagia (“No.”)
asked about weight loss (“Yes. I’ve lost 20 pounds in the last month.”)
asked about alcohol use (“I used to be a heavy drinker—a pint of whiskey a day for 25 years; I stopped drinking 2 months ago, when this problem started.”)
asked about tobacco use (“Yes. I’ve smoked two packs of cigarettes per day for over 25 years.”)
asked about a previous history of gastrointestinal problems, i.e., reflux (“No.”)
asked about a history of lye ingestion (“No.”)
asked about any hoarseness (“No.”)
Physical Examination. The Examinee:
looked inside my mouth for obstructive lesions (normal mouth and pharynx).
checked my neck for an enlarged thyroid gland or other obstructive masses (none evident).
checked for either axillary or supraclavicular nodes (a 3-cm fixed left supraclavicular node is palpable).
Communication Skills. The Examinee:
explained the possible diagnosis (esophageal carcinoma, achalasia, stricture).
 explained that risk factors for the disease include tobacco and alcohol use.
 explained the next step in the workup (blood work, esophagogram, gastroenterology consultation for
possible endoscopy).
explained that the supraclavicular node was probably due to cancer.
stated that I would need nutritional support either in the hospital or at home.
inquired about my support system (“I have a wife at home; no children.”)
offered to help me tell my wife (“Oh, that would be a big help, Doctor.”)
demonstrated empathy for my situation.
discussed prognosis (this is a serious problem).
asked me if there was anything not covered in the discussion.

HISTORY—Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint.
DIFFERENTIAL DIAGNOSIS—In order of likelihood, write no more than five differential diagnoses for this patient’s current problems.
DIAGNOSTIC WORKUP—Immediate plans for no more than five diagnostic studies.

HISTORY—Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history.
Mr. Charlie Champion is a 65-year-old man with a 2-month history of dysphagia. He feels as if the food he eats is getting stuck in the middle of his chest. Two months ago, the dysphagia was occurring only with solids, but it has now progressed to liquids to the point where the patient is having difficulty swallowing water. Mr. Champion denies odynophagia but admits to a 20-pound weight loss over the last month. He is a former drinker of a pint of whiskey daily for 25 years but stopped 2 months ago. He has smoked 2 packs of cigarettes per day for over 25 years. He has no previous history of gastrointestinal problems, such as reflux, and has no history of lye ingestion. He denies hoarseness.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint.
Cachectic male looking older than his stated age in NAD. Patient is not hoarse. HT = 72 in. WT = 140 lb.
BP = 100/70 mmHg and HR = 88 beats/min lying down.
BP = 100/70 mmHg and HR = 88 beats/min standing.
Afebrile. RR = 12 breaths/min.
HEENT: Mouth without lesions or masses. Thyroid normal.
3-cm fixed nontender left supraclavicular node.
No cervical, submandibular, occipital, or submental lymphadenopathy. No axillary lymphadenopathy.
Heart, lungs, and abdominal exams normal.
DIFFERENTIAL DIAGNOSIS
In order of likelihood, write no more than five differential diag- noses for this patient’s current problems.
⦁ esophageal carcinoma
⦁ stricture
⦁ achalasia
⦁ Schatzki’s ring

DIAGNOSTIC WORKUP
Immediate plans for no more than five diagnostic studies.
1. barium esophagogram
2. endoscopy with biopsy and histology
3. CBC
4. electrolytes
5. liver function tests

LEARNING OBJECTIVE FOR MR. CHAMPION
APPROACH TO THE PATIENT WITH DYSPHAGIA
Mr. Champion presents with the chief complaint of dysphagia, initially to solids then progressing to liquids (progressive dysphagia), accompa- nied by anorexia and rapid weight loss. It is important to inquire about the symptoms of dysphagia (food sticking implies real dysphagia). Dysphagia accompanied by odynophagia (painful swallowing) may indicate mediastinal invasion by tumor. Other symptoms of esophageal cancer may include cough, hoarseness, choking, fever, and aspiration pneumonitis. The patient has a long history of alcohol and tobacco abuse, which predisposes him to developing esophageal carcinoma. Other risk factors for esophageal cancer include chronic gastric reflux causing a Barrett’s esophagus, achalasia, and lye ingestion. The differ- ential diagnosis for dysphagia in this patient would include a stricture and achalasia.
On physical examination, Mr. Champion has a normal-sounding voice. Tumor involvement of the recurrent laryngeal nerve would cause hoarseness. The mouth and neck examinations reveal no obstructive lesions responsible for the dysphagia. A careful search for metastatic lymphadenopathy reveals a fixed node in the left supraclavicular area. In most cases, the physical examination in patients with esophageal carcinoma is unremarkable.
The workup for Mr. Champion includes admission to the hospital for nutritional support to prevent further weight loss. A barium esophagogram is the first step in the workup of any patient with dysphagia. If a lesion is seen radiographically, further evaluation with endoscopy, biopsy, and histologic assessment is warranted to confirm the diagnosis. Patients with poor nutritional intake should be evaluated with a complete blood count and electrolytes. Elevated liver function tests may be representative of metastasis to the liver.
The treatment for esophageal carcinoma is palliative when the disease is metastatic. The goal of therapy is to relieve the dysphagia if possible and maximize the quality of life for each patient.
Patient Note Pearl: The differential diagnosis for esophageal dysphagia is as follows:
Solid food dysphagia (mechanical problem) Intermittent: lower esophagus (Schatzki’s ring) Progressive: stricture (has heartburn),
cancer
Solid or liquid dysphagia (neuromuscular problem) Intermittent: diffuse esophageal spasm (has chest pain) Progressive: scleroderma (has heartburn), achalasia (may have respiratory symptoms)

I. Data Gathering (DG) /MY CHECKLIST: These are the questions you will be asking the patient as provided in the case study

A. Subjective: (4 points)
Chief Complaint:
History of Present Illness. The Examinee:
1.__________________________________________________________________________2.___________________________________________________________________________ 3.___________________________________________________________________________ 4.___________________________________________________________________________ 5.___________________________________________________________________________
Past Medical History:
6.__________________________________________________________________________7. __________________________________________________________________________ Family History:
8.________________________________________________________________________
9.__________________________________________________________________________ Social History:
10. ________________________________________________________________________
11._______________________________________________________________________
Review of Systems:
12._______________________________________________________________________ 13._______________________________________________________________________
Physical Examination. The Examinee: (Here you list how you do the physical assessment for each system)
14._________________________________________________________________________15._________________________________________________________________________16._________________________________________________________________________17._________________________________________________________________________18._________________________________________________________________________
Communication Skills. The Examinee: (Here you list what you provide to the)
19._________________________________________________________________________20._________________________________________________________________________ 21.__________________________________________________________________________

II. Required elements/grading rubric of the Patient Note
1.Subjective
State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation.
a. History of Present Illness: All symptoms related to the problem are described using the following cue descriptive categories:
Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).
Associated symptoms
Quality of all reported symptoms including the effect on the patient’s lifestyle
Temporal factors (date of onset, frequency, duration, sequence of events)
Location (localized or generalized? does it radiate?)
Sequelae (complications, impact on patient and/or significant others
Severity of the symptoms
b. Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations.
c. Family History includes family members’ health history.
d. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships.
e. Review of Systems relevant to the chief complaint/presenting problem is included.

Include pertinent positives and negatives.
ROS: (whatever is not included in the case study is considered a normal finding..see examples)
Optha: (i.e. no eye pain, no eye discharge, no blurry vision)
Otolaryngo: (i.e. no ear pain, no sore throat)
Respiratory:
Cardio:
Gastro:
Musculoskeletal:
Endocrine:
Neuro:

2. Objective
a. Using problem-focused examination re: inspection, palpation, percussion, and auscultation, the examiner evaluates pertinent systems associated with the subjective complaint including applicable systems which may be causing the problem, or which will manifest or may potentially manifest complications and records positive and pertinent negative findings.
General:
Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
Chest:
Heart:
Abdomen:
Extremities:

b. Performs appropriate diagnostic studies if equipment is available.
c. Records results of pertinent, previously obtained diagnostic studies.
d. Use Handout Guidelines to Physical Examination.

3. Assessment
a. Diagnosis/es with pathophysiology is (are) derived from the subjective and objective data
b. Differential diagnoses with pathophysiology are prioritized – (minimum of 2)
c. Diagnosis/es come(s) from the medical domain
d. Assessment includes health risks/needs assessment
4. Plan
a. Appropriate diagnostic studies with rationale
b. Therapeutic treatment plan with rationale
c. Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required?
d. Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding.
e. What community resources are available in the provision of care for this client?
f. Referrals initiated (including to whom the patient is referred to and the purpose)
g. Target dates for re-evaluating the results of the plan and follow up.

5. References

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