odynophagia workup

Full Writeup

CC: odynophagia

HPI: Patient is a ___ year old ___ with no significant past medical history who presents with a chief complaint of odynophagia.

onset; quality; quantity; progression; triggering events; aggravates; alleviates;

Pertinent positives in clinical history include: odynophagia.

PMH: none
Meds:
Allergies:
FH:
SH: smoke, EtOH, illicit drugs, environment

10-point review of systems is negative other than those per HPI.

Physical exam:

Vitals:
Gen: NAD
HEENT: NCAT, PERRL, TM nonbulging, nasal mucosa pink, oropharynx without exudates
Neck: no lymphadenopathy
CV: RRR, no murmurs or gallops
Pulm: CTAB, normal work of breathing
GI: NTND, no organomegaly, no rebound
Ext: well perfused, nontender, nonedematous

Assessment & Plan:

In summary, patient is a ___ year old ___ with no significant past medical history who presents with odynophagia

Differential diagnoses:
Based on the symptoms, my differential includes: esophageal disease, esophagitis
There are also 11 diseases that can present with a chief complaint of odynophagia: Strep throat, sjogren syndrome, pemphigus vulgaris, mumps, ludwig angina, peritonsilar abscess, peritonsilar cellulitis, retropharyngeal abscess, oral cancer, oral candidiasis, aphthous stomatitis

After reviewing the signs and symptoms, I narrowed the differential to the following diseases: esophageal disease, esophagitis

# esophageal disease: I suspect this because of odynophagia. Will recommend: - barium swallow
- endoscopy (lesions, cancer, scleroderma, motility)
# esophagitis: I suspect this because of odynophagia. Will recommend: - omeprazole if due to GERD
- fluconazole if candida
- other ddx include pill esophagitis in kids / elderly, viral (herpes, CMV) in immunocompromised

Pertinent positives

Pertinent negatives

Differential diagnoses

Clinical suspicians

What to do next

HPI and Review of Systems

Physical Exam

Full Writeup

Common Chief Complaints