First Aid for the USMLE Step 2 CS

Section 3. Minicases

Dysphagia

Key History

Solids or liquids vs. both solids and liquids, ± progression, occurring at the beginning or middle of swallow; constitutional symptoms (especially weight loss); hoarseness, drooling, regurgitation of liquids vs. undigested food, odynophagia, GERD symptoms; medications; HIV risk factors; history of anxiety, smoking, Raynaud’s phenomenon.

Key Physical Exam

Vital signs; head and neck exam; heart, lung, and abdominal exams; skin exam (for signs of scleroderma/CREST).

Presentation

Differential

Workup

■ 75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 15 lbs (6.8 kg) within the past 4 months.

Esophageal cancer

Achalasia

Esophagitis

Systemic sclerosis

Esophageal stricture

Amyotrophic lateral

sclerosis

CBC

CXR

Upper endoscopy with

biopsy

Barium swallow

CT—chest

■ 45 yo F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue, and a craving for ice and clay.

Plummer-Vinson syndrome

Esophageal cancer

Esophagitis

Achalasia

Systemic sclerosis Mitral valve stenosis

CBC

Serum iron, ferritin, TIBC

Barium swallow

Upper endoscopy

Video fluoroscopy

■ 48 yo F presents with dysphagia for both solids and liquids that has slowly progressed in severity within the past year. It is associated with difficulty belching and regurgitation of undigested food, especially at night. She has lost 5.5 lbs (2.5 kg) in the past 2 months.

Achalasia

Plummer-V inson

syndrome

Esophageal cancer

Esophagitis

Systemic sclerosis

Mitral valve stenosis

Esophageal stricture

Zenker’s diverticulum

CXR

Upper endoscopy

Barium swallow

Esophageal manometry

XR—neck

■ 38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.

Esophagitis (CMV, HSV,

HIV, pill-induced)

Systemic sclerosis

GERD

Esophageal stricture

Zenker’s diverticulum

CBC

Upper endoscopy

Barium swallow

HIV antibody and viral load

CD4 count

 

Neck Mass

Key History

Onset, size, location, mobility, pain, movement with swallowing; obstructive symptoms (dysphagia, shortness of breath); other masses; associated symptoms (constitutional, hematologic, GI, endocrine, pulmonary); ill contacts.

Key Physical Exam

Vital signs; HEENT exam; exam of lymph nodes, spleen, and tonsils; heart, lung, and abdominal exams.





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