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Dysphagia
Assessment:
The patient reports difficulty swallowing, particularly with [solids/liquids], consistent with dysphagia. There are no signs of acute airway obstruction. The differential diagnosis includes esophageal stricture, achalasia, GERD, esophageal cancer, and neuromuscular disorders.
Plan:
Order an upper endoscopy (EGD) to evaluate for structural causes like strictures, masses, or inflammation. Consider a barium swallow or esophageal manometry if motility disorder (e.g., achalasia) is suspected. Recommend a trial of proton pump inhibitors (PPIs) if GERD is a likely contributor. Refer to gastroenterology for further evaluation and management. Advise the patient to modify diet (e.g., softer foods) to reduce symptoms while awaiting diagnostic workup. Follow up after testing to discuss results and treatment options. If any signs of aspiration or weight loss, refer to speech therapy for a swallowing evaluation.
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