Makindo Medical Notes

🩺 OSCE Station – Dysphagia

Candidate Instructions 📋

You are the medical student in an outpatient clinic. A 58-year-old patient has been referred by their GP with swallowing difficulties. Take a focused history, identify possible causes, and outline your initial management plan. You do not need to perform a physical examination. You have 8 minutes.

Key OSCE Learning Points 🔑

• Dysphagia = difficulty in swallowing, a red-flag symptom 🚩.
• Must distinguish between oropharyngeal vs oesophageal dysphagia.
• Causes: benign (stricture, achalasia, GORD) vs malignant (oesophageal cancer).
• Urgent referral (2-week wait) if malignancy suspected.

History Framework 📝

• Onset & Progression: Sudden or gradual? Intermittent or worsening?
• Site: Difficulty initiating swallow (oropharyngeal) vs food sticking (oesophageal).
• Solids vs Liquids: Solids → progressive = mechanical obstruction. Solids & liquids = motility disorder.
• Associated Symptoms: Weight loss, regurgitation, odynophagia (painful swallowing), cough, aspiration, heartburn, hoarseness.
• Past Medical History: GORD, Barrett’s, neurological disease (stroke, Parkinson’s, MS), autoimmune disease.
• Red Flags: Weight loss, anaemia, haematemesis, smoking/alcohol, progressive symptoms.
• Impact: Nutrition, hydration, QoL, psychosocial impact.

Examiner Role-Player Prompts 👩‍⚕️

• Patient says swallowing started being “awkward” 3 months ago and is getting worse.
• Initially solids stuck, now both solids and liquids feel stuck in the chest.
• Reports 5 kg weight loss, increasing fatigue, occasional regurgitation of undigested food.
• No history of stroke or neurological disease. Past history of reflux.
• Smokes 20/day, drinks 4 beers nightly.

Differential Diagnosis ⚖️

• Oesophageal cancer (progressive, red flags) 🚨
• Benign stricture (e.g., GORD, caustic ingestion)
• Achalasia (solids & liquids, regurgitation)
• Neurological (stroke, Parkinson’s, MS)
• Oropharyngeal pathology (tonsillar mass, pharyngeal pouch)

Investigations 🔬

• Urgent Oesophagogastroduodenoscopy (OGD) with biopsy – first-line for suspected malignancy.
• Barium swallow – motility disorders, pharyngeal pouch.
• Manometry – if achalasia suspected.
• CT chest/abdomen – staging if cancer confirmed.
• Bloods: FBC (anaemia), U&E (hydration, renal function).

Management 🚑

• Red-flag referral: Urgent 2-week wait OGD 🚨.
• Supportive: Dietitian referral, nutritional support (soft diet, supplements, NG/PEG if severe).
• Specific causes:
  • Cancer → oncology/surgical MDT, stenting, resection, chemo/radiotherapy.
  • Achalasia → balloon dilatation, Heller’s myotomy, botulinum toxin injection.
  • Strictures → dilatation, PPI for reflux.
  • Neurological → SALT referral, swallowing rehabilitation.

Examiner’s Marking Guide 📋

• Introduces self, gains consent, explores symptom onset, solids vs liquids, red flags.
• Asks about systemic features (weight loss, anaemia, PMH, lifestyle).
• Considers malignancy and arranges urgent referral.
• Explains plan clearly and safely to patient.
• Demonstrates holistic care: dietitian, SALT, psychosocial support.

References 📚

• NICE CKS – Dyspepsia & Upper GI Symptoms
• British Society of Gastroenterology – Oesophageal Cancer Guidelines.