A 77-year-old man is brought to the office by his daughter because of weight loss and poor appetite. The patient denies having any problems and states that his daughter worries unnecessarily. The daughter agrees that she has become overly concerned about her father's health since his stroke three months ago. According to her, he has lost 10-15 pounds since then and sometimes takes a long time to finish his meals. He also suffers from coughing spells during his meals which usually lasts a couple of minutes. She has not noticed any other symptoms except for some slurred speech.
His medical history is significant for an ischemic stroke, hypertension, diabetes mellitus, arthritis, and depression. He had a recent hospitalization for pneumonia 1 month ago. He is currently taking atenolol, baby aspirin, insulin, and trazodone. He intermittently takes over-the-counter naproxen. His dentist started him on an unknown antibiotic 5 days ago. He has a 20-pack-year smoking history, but quit smoking 30 years ago. He stopped drinking alcohol after the stroke, but otherwise says he has enjoyed a glass of wine everyday of his life.
Physical examination shows a thin-built elderly man. His blood pressure is 152/72mmHg, pulse is 55/min, and BMI is 19 kg/m². He has some halitosis, decaying molars bilaterally, and dry oral mucosa. Minimal crackles are heard at the right lung base. There is trace peripheral edema on both lower extremities.
Which of the following is the best next step in evaluating this patient?

Question

Quizplus · Accepted Answer

In this elderly patient with a history of stroke, recent pneumonia, and symptoms of coughing spells after liquid intake, concern for oropharyngeal dysphagia is high. Oropharyngeal dysphagia is caused by disrupted neuromuscular coordination required for deglutition and is commonly seen in stroke patients. The main symptoms of oropharyngeal dysphagia are: coughing/choking spells, nasal regurgitation, prolonged swallowing effort, or difficulty in initiation of swallows with a feeling of obstruction at the level of the neck. 11ec193a_97f0_5495_853d_93bd541f3555_MD0002_00 Oropharyngeal dysphagia is best diagnosed/assessed by a modified barium swallow (MBS) or videofluoroscopy performed in the presence of an expert speech pathologist and radiologist. It is important to diagnose it early as failure to do so can lead to aspiration pneumonia, which carries a high morbidity and mortality. This patient has already had an episode of pneumonia, thus making it even more important to diagnose and treat oropharyngeal dysfunction. (Choice A) Various mechanical factors (e.g., osteophytes, Zenker's diverticulum, etc.) could cause oropharyngeal dysphagia. In the presence of a classic history, the next step would be to confirm oropharyngeal dysfunction before working up the etiology. Additionally, these mechanical factors may be discovered on the MBS itself and would not require a CT of the neck/chest. (Choice C) Dietary adjustments may be required, but confirmation of the diagnosis and assessment of the aspiration risk is essential to determine the needed consistency of a modified diet (e.g., thick, mechanically soft, puree diet, etc.) as well as the route of administration (e.g., oral, PEG tube, etc.). (Choice D) Endoscopy is good tool to assess esophageal abnormalities, but it would not help with oropharyngeal dysphagia. (Choice E) Pill-esophagitis is possible given the patient's new-onset chest pain, but stopping the antibiotic without confirming its role in causation would not be recommended. Furthermore, this does not explain the high aspiration risk. Educational objective: Oropharyngeal dysphagia is commonly seen after a neurologic injury such as a stroke, and is best diagnosed with a modified barium swallow (MBS). Prompt diagnosis is essential to prevent aspiration pneumonia, which carries high morbidity and mortality rates. __________ References: Dysphagia in stroke patients (http://www.ncbi.nlm.nih.gov/pubmed/16754707)

A 77-Year-Old Man Is Brought to the Office by His