Mock Patient Case – Dysphagia

🗂 Mock Patient Scripts – Dysphagia

Explore real-world inspired scenarios to practice your clinical reasoning in English. From progressive dysphagia with weight loss to neuromuscular causes and food impaction, these cases help you prepare for OSCEs and real consultations. Use them to build confidence in history taking, differential diagnosis, and patient communication.


📘 Case 1 – “It feels like food just gets stuck halfway down.”

🚪 Doorway Information

  • Age/Gender: 64-year-old male
  • Chief Complaint: Difficulty swallowing solid food
  • Vital Signs: T 36.8°C / HR 82 / BP 138/84 / RR 16 / SpO₂ 98%

🩺 Shoreline

“For the past couple of months, I’ve had more and more trouble swallowing solid foods. It started with meats and bread, but now even rice is hard to get down. I sometimes have to drink water to push it through.”

🗣️ Structured History

  • Opening: “I came because eating has become a real struggle.”
  • Onset & Course: “It started gradually about 2–3 months ago. At first, I thought I was just eating too fast, but it’s clearly getting worse.”
  • Associated Symptoms: “I haven’t had much appetite, and I’ve lost about 5–6 kg. No chest pain, but sometimes I feel like food is stuck behind my breastbone.”
  • Mood / Function / Appetite / Sleep: “I get frustrated with meals. I eat less now. I sleep okay but wake up hungry sometimes.”
  • Medical History / Medication: “I have high blood pressure. I take amlodipine. No other major problems.”
  • Family & Social History (PAM HITS FOSS):
    • Past Medical History: Hypertension
    • Allergy: None
    • Medication: Amlodipine 5 mg/day
    • Hospitalization / Injury / Trauma / Surgery: None
    • Family History: Father had esophageal cancer in his 70s
    • OBGYN: N/A
    • Sexual History: Heterosexual, monogamous
    • Social History: Smoked 1 pack/day for 30 years (quit 5 years ago), drinks alcohol occasionally
  • Concerns & Questions: “Could this be something serious like cancer? I’m really worried.”

🔍 Physical Examination

  • General: Appears slightly underweight, mild temporal wasting
  • HEENT: No cervical lymphadenopathy, oral mucosa normal
  • Chest: Normal breath sounds, no rales
  • Abdomen: Soft, non-tender
  • Neuro: No focal deficits

🧠 Differential Diagnosis

Most likely diagnosis: Esophageal cancer (SCC)

  • Supporting: Progressive dysphagia (solids → liquids), weight loss, age >60, smoking history, family history
  • Contradictory: No overt bleeding, no cervical lymphadenopathy

Other possibilities:

  • 2nd – Esophageal stricture (peptic or post-inflammatory): History of GERD would support, but none reported
  • 3rd – Achalasia: Usually involves both solids and liquids early; absent chest pain; less likely here

💭 Clinical Reflection

Any older adult with progressive dysphagia and unintentional weight loss should be considered for urgent endoscopy. His smoking and family history elevate the risk of malignancy.

💡 Clinical Pearls

  • “Solids first” dysphagia suggests mechanical obstruction (e.g., tumor, stricture)
  • “Liquids and solids from the start” suggests motility disorder (e.g., achalasia)
  • Weight loss is an alarm symptom—never ignore it
  • Don’t forget to ask about smoking, alcohol, and family cancer history

❓ Challenging Questions

Q1: “Do you think I have cancer?”
A: “That’s one possibility we need to consider, especially given your symptoms. But we won’t know until we do further tests like an endoscopy. Whatever it is, we’ll guide you through it step by step.”

Q2: “Will I need surgery?”
A: “That depends on what we find. If it is a tumor, treatment options might include surgery, radiation, or medication depending on the stage. Let’s first focus on confirming the cause.”

📝 SOAP Note

S: 64-year-old male with 2–3 months of progressive dysphagia, starting with solids and now affecting softer foods. Reports 6 kg weight loss. No heartburn, nausea, or fever. Ex-smoker, family history of esophageal cancer.

O: Vitals stable. Mild temporal wasting. No lymphadenopathy. Chest and abdomen unremarkable. No neuro deficits.

A:
# Progressive dysphagia (solids → liquids)
# Unintentional weight loss
# Family and smoking history positive

ddx): Esophageal cancer, esophageal stricture, achalasia  
r/o): GERD (no typical symptoms), infectious esophagitis (no immunocompromise)

→ High suspicion for malignancy. Needs urgent upper endoscopy and biopsy.

P:
- Refer for EGD (esophagogastroduodenoscopy)
- CBC, LFTs, and basic metabolic panel
- CT chest and abdomen if mass found
- Nutritional support, dietitian consult
- Cancer center referral if confirmed

📚 Case inspired from:

  • UpToDate. Clinical evaluation of dysphagia in adults. [Accessed 2025]
  • Case Reports Gastroenterol. 2019;13:464–469. PMID: 31417847

⚠️ Case 2 – “Sometimes I cough up food hours after eating.”

🚪 Doorway Information

  • Age/Gender: 75-year-old male
  • Chief Complaint: Regurgitation and chronic cough
  • Vital Signs: T 36.6°C / HR 76 / BP 130/82 / RR 18 / SpO₂ 97%

🩺 Shoreline

“Over the past few months, I’ve been coughing more after meals and sometimes even bring up food I ate earlier. It feels like something’s stuck in my throat.”

🗣️ Structured History

  • Opening: “It’s been happening more and more—I’m coughing during meals, and food seems to come back up hours later.”
  • Onset & Course: “It started subtly maybe 5–6 months ago. Now it’s almost daily.”
  • Associated Symptoms: “I sometimes hear a gurgling sound in my neck. I don’t choke exactly, but food just sits there. No weight loss, no chest pain.”
  • Mood / Function / Appetite / Sleep: “I still eat, but slower. It’s a bit embarrassing, especially when I cough up food in public.”
  • Medical History / Medication: “I take a statin and aspirin. I had a TIA two years ago. No known allergies.”
  • Family & Social History (PAM HITS FOSS):
    • Past Medical History: TIA, hyperlipidemia
    • Allergy: None
    • Medication: Atorvastatin, aspirin
    • Hospitalization / Surgery: None recent
    • Family History: Unremarkable
    • Social History: Lives with spouse, non-smoker, no alcohol
  • Concerns & Questions: “Could it be something serious like cancer? Or am I just getting old?”

🔍 Physical Examination

  • General: Alert and cooperative
  • HEENT: No cervical lymphadenopathy, mild pooling of saliva
  • Chest: Intermittent cough noted, clear breath sounds
  • Neck: Gurgling sound heard on palpation during swallowing
  • Neuro: CNs II–XII grossly intact

🧠 Differential Diagnosis

Most likely diagnosis: Zenker’s diverticulum

  • Supporting: Elderly male, regurgitation of undigested food, gurgling noise, cough after meals, no weight loss
  • Contradictory: No overt neurological deficits

Other possibilities:

  • 2nd – Esophageal motility disorder: May cause similar symptoms but usually affects both solids/liquids and lacks regurgitation of undigested food
  • 3rd – GERD with laryngopharyngeal reflux: Possible, but less likely without heartburn or acidic taste

💭 Clinical Reflection

In elderly patients, Zenker’s diverticulum should be considered when regurgitation and cough occur without heartburn or weight loss. The “gurgle + cough + food coming back up” triad is a classic clue.

💡 Clinical Pearls

  • Zenker’s diverticulum is a pharyngoesophageal pouch, not a true esophageal disease
  • May be diagnosed via barium swallow (more sensitive than endoscopy)
  • Endoscopy carries risk of perforation in large diverticula
  • “Gurgling in the neck” is a highly specific symptom

❓ Challenging Questions

Q1: “Is this cancer of the throat?”
A: “That’s a fair concern, but your symptoms actually fit a benign condition called Zenker’s diverticulum. It’s not cancer, but it can cause significant discomfort. We’ll confirm with imaging and talk through options.”

Q2: “Why does food come back up after hours?”
A: “That’s because food can get trapped in a small pouch near your throat. When you move or lie down, it can come back up. It’s not related to your stomach, but rather to this structural issue in the upper esophagus.”

📝 SOAP Note

S: 75-year-old male with 5–6 months of regurgitation and post-meal cough. Gurgling in neck, undigested food returns hours later. No weight loss or pain. No GERD symptoms. History of TIA.

O: Vitals normal. Gurgling in left lateral neck. No focal neuro signs. Lungs clear.

A:
# Regurgitation and cough after meals
# Elderly male with possible Zenker's diverticulum
# No constitutional symptoms or weight loss

ddx): Zenker’s diverticulum, esophageal dysmotility, GERD-related cough  
r/o): Cancer (no weight loss or dysphonia), neuromuscular causes (no deficits)

→ Most likely Zenker's. Proceed with barium swallow and ENT/GI referral.

P:
- Order barium esophagram
- ENT/GI referral for evaluation
- Swallowing precautions
- Consider modified diet
- Educate about aspiration risk

📚 Case inspired from:

  • BMJ Best Practice. Dysphagia. [Accessed 2025]
  • Clin Geriatr Med. 2021;37(2):287–297. PMID: 34294326

🔍 Case 3 – “Even water seems to go the wrong way lately.”

🚪 Doorway Information

  • Age/Gender: 68-year-old female
  • Chief Complaint: Difficulty swallowing liquids and slurred speech
  • Vital Signs: T 36.9°C / HR 74 / BP 132/78 / RR 17 / SpO₂ 97%

🩺 Shoreline

“Over the past few weeks, I’ve been choking on water and soup. Even speaking feels more effortful than usual.”

🗣️ Structured History

  • Opening: “I’ve started coughing while drinking water and people say I sound different.”
  • Onset & Course: “It began maybe a month ago. It was subtle at first—just occasional coughing. But now it’s hard even with small sips.”
  • Associated Symptoms: “My voice sounds nasal at times. I feel like I can’t move my tongue as well. No numbness or limb weakness yet.”
  • Mood / Function / Appetite / Sleep: “I eat less because I’m afraid of choking. I feel embarrassed at meals. No changes in sleep.”
  • Medical History / Medication: “No major illnesses. Takes calcium for osteoporosis.”
  • Family & Social History (PAM HITS FOSS):
    • Past Medical History: Osteoporosis
    • Allergy: None
    • Medication: Calcium carbonate
    • Hospitalization / Surgery: None
    • Family History: No neurodegenerative disease
    • Social History: Retired teacher, lives alone, no tobacco or alcohol
  • Concerns & Questions: “Is something wrong with my brain? I’m scared I’ll choke to death.”

🔍 Physical Examination

  • General: Thin but alert and cooperative
  • HEENT: Mild pooling of saliva, no masses
  • Neuro: Tongue shows fasciculations and mild atrophy; slight dysarthria; no limb weakness
  • Cranial Nerves: CN IX–XII partially affected; soft palate elevation weak on left
  • Other: No abnormal reflexes or limb findings

🧠 Differential Diagnosis

Most likely diagnosis: Bulbar-onset ALS (amyotrophic lateral sclerosis)

  • Supporting: Age >65, dysarthria, tongue atrophy/fasciculations, oropharyngeal dysphagia, progressive course
  • Contradictory: No limb weakness yet (but early stage)

Other possibilities:

  • 2nd – Stroke (brainstem): Would expect abrupt onset and possible focal deficits
  • 3rd – Myasthenia Gravis: May cause bulbar weakness but symptoms fluctuate, often improves with rest

💭 Clinical Reflection

This is a classic presentation of bulbar-onset ALS, which can be missed early if no limb involvement is present. Fasciculations and tongue atrophy are red flags.

💡 Clinical Pearls

  • Bulbar-onset ALS affects speech and swallowing first, before limb weakness
  • Tongue fasciculations are highly suggestive of motor neuron disease
  • EMG and MRI brainstem are part of initial work-up
  • Early diagnosis can improve access to supportive care and planning

❓ Challenging Questions

Q1: “Is this a type of stroke?”
A: “I understand why you’re worried, but your symptoms have developed gradually, not suddenly like a stroke. They suggest a different type of condition affecting the nerves. We’ll do tests to clarify exactly what’s happening.”

Q2: “Will I stop being able to speak or eat?”
A: “These symptoms can affect those abilities over time, but we now have ways to support swallowing and communication. We’ll involve a multidisciplinary team to keep you safe and supported through every step.”

📝 SOAP Note

S: 68-year-old female with 4–5 weeks of oropharyngeal dysphagia, especially with liquids. Noted slurred speech, nasal voice, mild tongue movement difficulty. No limb weakness or pain. Lives alone.

O: Vitals stable. Tongue fasciculations, mild atrophy. Weak soft palate elevation. No sensory deficits. No limb findings.

A:
# Oropharyngeal dysphagia and dysarthria
# Fasciculations and tongue atrophy
# Bulbar-onset neurodegenerative disease suspected

ddx): ALS (bulbar onset), brainstem stroke, myasthenia gravis  
r/o): Stroke (gradual course), MG (no fluctuation, no ptosis)

→ High suspicion for ALS. Needs neuro workup including EMG, MRI, and neurologist referral.

P:
- Refer to neurologist
- Schedule EMG and brain MRI
- Swallowing assessment (speech therapist)
- Nutrition consult
- Family meeting for support planning

📚 Case insoired from:

  • UpToDate. Evaluation of oropharyngeal dysphagia in adults. [Accessed 2025]
  • Neurology Clin Pract. 2019;9(2):152–154. PMID: 30992073

🧩 Summary – Clinical Takeaways on Dysphagia

  • Progressive dysphagia for solids followed by liquids, along with weight loss, is highly concerning for malignancy (e.g., esophageal cancer).
  • In elderly patients with regurgitation, gurgling, and cough, consider Zenker’s diverticulum—especially if food comes back up undigested.
  • Neurological causes (e.g., bulbar-onset ALS) should be suspected in patients with dysarthria, tongue fasciculations, or liquid aspiration.
  • Distinguishing between oropharyngeal and esophageal dysphagia is key in forming an appropriate diagnostic pathway.
  • Always evaluate for alarm features: weight loss, anemia, aspiration, and family history of malignancy.

🧠 VITAMIN CDE Approach – Differentials in Dysphagia

Category Example Diagnoses
Vascular Brainstem stroke, subclavian steal syndrome
Infectious Candida esophagitis, CMV, HSV esophagitis (esp. immunocompromised)
Traumatic Esophageal injury post-endoscopy, foreign body ingestion
Autoimmune Myasthenia gravis, systemic sclerosis (CREST), dermatomyositis
Metabolic Hypothyroidism, diabetes (autonomic neuropathy)
Iatrogenic Radiation-induced esophageal stricture, pill-induced esophagitis
Neoplastic Esophageal cancer, oropharyngeal SCC, mediastinal mass
Congenital Esophageal web, tracheoesophageal fistula (in infants)
Degenerative ALS (especially bulbar), Parkinson’s disease
Endocrine Thyromegaly causing extrinsic compression

🔗 Related Articles


📚 References

  • UpToDate. Clinical and diagnostic evaluation of dysphagia in adults. [Accessed 2025]
  • Case Reports Gastroenterol. 2019;13:464–469. PMID: 31417847
  • Clin Geriatr Med. 2021;37(2):287–297. PMID: 34294326
  • Neurology Clin Pract. 2019;9(2):152–154. PMID: 30992073

Leave a Comment

Your email address will not be published. Required fields are marked *

Scroll to Top