Difficulty Swallowing Station

Presenting Complaint

• Patient reports difficulty in swallowing.

History of Presenting Complaint

• Site: Food gets stuck near his stomach
• Onset:  Gradually started 6 months ago and has progressively got worse
• Character:  At first food was difficult to swallow but over 6 months liquids have also become difficult to swallow. He has to blend all his meals and is very annoyed.
• Associated Features:
  • Patient has acid reflux and heartburn but manages with PPIs.
  • Patient has no bloating or pain and no ulcers. He also denies nausea and vomiting
  • Patient reports no changes in his bowel habits
• Timing: Patient reports this is constant and getting worse
• Severity: Patient reports this has progressively got worse

Systems Review

• Gastrointestinal: Patient reports nausea, vomiting and reflux
• Cardiovascular: Patient reports no chest pain, palpitations, dizziness.
• Neurological: Patient reports no fits, faints, funny turns, and no changes in vision, hearing, balance or sensation.
• Respiratory: Patient reports no shortness of breath, coughing, difficulty breathing or leg swelling.
• Red Flags: as below
  • Patient reports night sweats for 3 months.
  • Patient reports some weight loss but thinks it could be due to eating less food.
  • Patient reports no fatigue and fever
  • Patient reports no back pain
  • Patient reports no blood in stools, abdominal mass or change in bowel habits.

Previous Medical and Surgical History

• Hypertension
• Osteoarthritis
• GORD
• Appendix removed 40 years ago due to appendicitis

Drug History

• Omeprazole: Only if asked, the patient states this was started a year ago for heartburn and acid reflux.
• Ibuprofen for Osteoarthritis
• Ramipril: For high blood pressure which is well controlled.
• Patient takes all their medication on time and takes the correct doses

Allergies

• Penicillin: If asked about the nature of the allergy, the patient states he had anaphylaxis with a widespread rash and wheezing when given penicillin in hospital. He now never takes penicillin.

Social History

• Patient is a current smoker of 20 cigarettes a day for the last 10 years.
• Patient has never taken any recreational drugs.
• Patient drinks 2 cans of beer a week
• Patient has had No recent travel
• The patient is a retired lorry driver
• The patient lives with their wife at home.

Family History

• Patient’s family has a history of Hypertension and Type 2 Diabetes
• No history of cancer and gastrointestinal disease

ICE

• Ideas: Has no idea what causes his difficulty in swallowing.
• Concerns: He is worried that it is serious and due to his smoking?
• Expectations: He wants help to fix his swallowing and to help eat food normally.

Vitals

• HR: 75 bpm
• Blood pressure: 130/80 mmHg
• SpO₂: 98%
• Respiratory Rate: 12 breaths per minute

General Inspection

• General- appears comfortable at rest
• Hands- Koilonychia in both hands. Capillary refill time is under 2 seconds
• Face- Conjunctival Pallor

Head and Neck Examination

• Lymph Nodes - No lymphadenopathy in head and neck
• No abnormalities detected when inspecting the throat.

Abdominal Examination

• Inspection- No scars, no abdominal distention
• Palpation- Abdomen is soft and non-tender, no masses are palpable and no hepatomegaly or splenomegaly
• Percussion- Normal Percussion

Neurological Examination

• Cranial Nerves I-XII: All normal
• Upper Limb Exam: No scarring, muscle wasting, intention tremor or fasciculation. MRC Power is 5/5. Biceps, Triceps and Supinator reflexes present, and normal sensation in all dermatomes.
• Lower Limb Exam: No scarring, muscle wasting, intention tremor, fasciculation or clonus. MRC Power is 5/5. Quadriceps and ankle jerk reflexes present. Normal sensation in all dermatomes

1. What are your most likely differentials?

• GI Malignancy (Oesophageal): Red flag symptoms of progressive chronic dysphagia, weight loss and night sweats. GORD and smoking are also risk factors for GI malignancy.
• Achalasia: Presents with progressive chronic dysphagia and from solid to liquid. However typically will be in a younger patient and will not have the red flag symptoms of weight loss or night sweats.

2. What investigations would you request for this patient?

Bedside

• A basic set of observations and FIT test. A FIT will test for traces of blood and is a screening test of GI cancer. We will do a basic set of observations to help create a baseline for the patient and to calculate a NEWS score

Bloods

• FBC, Iron studies, U+E, LFT, CRP, ESR. Malignancy can cause iron deficiency anemia which will be shown in the FBC and Iron Studies. We do the U+E and LFT as a baseline set of bloods as some medication will interfere with liver and kidney function.

Imaging

• OGD -> will be useful to visualize and take a biopsy.

3. Given a diagnosis of Oesophageal Cancer, how would you manage this patient?

• Refer to the Cancer MDT
• Options include surgery, radiotherapy, chemotherapy, immunotherapy. This depends on the stage of the cancer, if there are any metastases and the functional status of the patient.