Browse categories and answer follow-up questions to refine your symptom profile.
History
HPI overview
Presentation characterization
Dysphagia
Odynophagia
Globus sensation
Regurgitation
Food sticking location perception
Oropharyngeal pattern
Difficulty initiating swallow
Coughing or choking with swallow
Nasal regurgitation
Voice change with swallowing
Esophageal pattern
Sensation of food sticking after swallow
Retrosternal discomfort with bolus passage
Bolus and consistency pattern
Solids only
Solids then liquids
Solids and liquids from onset
Pills
Liquids worse than solids
Onset
Time course
Sudden onset
Subacute onset
Gradual onset
Intermittent
Progressive
Triggering event
Meal related onset
After vomiting or retching
After endoscopy
After new medication
After caustic exposure
Provocation/Palliation
Exacerbating features
Specific foods
Dry foods
Cold liquids
Hot liquids
Supine position
Stress
Relieving features
Water sips
Carbonated beverages
Upright posture
Slow eating
Smaller boluses
Quality
Symptom quality
Pain with swallowing
Burning
Sharp pain
Pressure
Sticking sensation
Pattern modifiers
Worse at start of swallow
Worse mid swallow
Worse after swallow
Pain independent of bolus
Region/Radiation
Anatomic localization
Throat
Neck
Retrosternal
Epigastric
Radiation
To back
To shoulder
To jaw
Severity
Functional severity
Able to swallow solids
Able to swallow liquids only
Unable to tolerate liquids
Drooling
Complete obstruction symptoms
Consequences
Weight loss
Dehydration
Aspiration events
Timing
Temporal pattern
Constant
Episodic
Postprandial
Nocturnal
Progression
Stable
Worsening days
Worsening weeks
Worsening months
Associated symptoms
Airway and aspiration symptoms
Dyspnea
Stridor
Cough with swallow
Recurrent pneumonia
Esophageal and GI symptoms
Heartburn
Regurgitation
Chest pain
Hematemesis
Melena
Nausea
Vomiting
Symptom context and triggers
Infectious and immune context
Fever
Sick contacts
Recent antibiotics
Immunocompromised state history
Trauma and iatrogenic context
Recent intubation
Recent neck procedure
Recent thoracic procedure
Foreign body ingestion risk event
Prior episodes and baseline
Prior similar symptoms
Prior food bolus impaction
Prior esophageal dilation
Prior aspiration events
Baseline swallowing function
Prior stroke deficits
Neuromuscular disease baseline
Dentition and chewing baseline
Functional impact
Intake limitation
Reduced oral intake
Avoidance of solids
Avoidance of pills
Safety impact
Aspiration risk at home
Supervision reliability
Ability to follow instructions
Alarm Features
First 5 minutes critical patient workflow
Immediate threats
Airway compromise
Inability to handle secretions
Stridor
Severe respiratory distress
Shock physiology
Immediate actions and targets
Continuous pulse oximetry
Cardiac monitoring if unstable
Two large bore IV if unstable
NPO
Escalate to resuscitation bay for airway concern
Vital sign danger thresholds
Concerning vitals
SpO2 less than 92 percent on room air
RR greater than 30 per minute
SBP less than 90 mmHg
HR greater than 120 per minute
Temperature 38.5 C or higher with toxicity
Escalation triggers
Persistent hypoxia despite oxygen
Rising work of breathing
Altered mental status
High risk historical triggers
Time critical etiologies
Complete esophageal obstruction
Button battery ingestion
Multiple magnets ingestion
Caustic ingestion
Recent forceful vomiting with severe chest pain
High risk populations
Immunocompromised with odynophagia
Known esophageal stricture with impaction symptoms
Prior head and neck cancer
High risk exam findings
Airway and neck
Drooling
Trismus
Toxic appearance
Neck swelling
Neck crepitus
Muffled voice
Chest and systemic
Subcutaneous emphysema
Severe chest tenderness
Peritonitis
Immediate escalation triggers
Airway pathway activation
Stridor or impending obstruction
Unable to swallow secretions
Surgical or GI emergent pathway activation
Suspected esophageal perforation
Suspected mediastinitis
Suspected impacted sharp foreign body
Medications
Current medications relevant to symptoms
Medication reconciliation focus
Anticholinergics
Opioids
Calcium channel blockers
Nitrates
GLP1 receptor agonists
Pill esophagitis risk medications
Doxycycline
Bisphosphonates
Potassium chloride
NSAIDs
Iron supplements
Immunosuppression and infection risk medications
Immunosuppressive therapies
Systemic corticosteroids
Calcineurin inhibitors
Biologics
Chemotherapy
Anti infective exposures
Recent antibiotics
Antivirals
Antifungals
Anticoagulation and bleeding risk
Antithrombotics
DOACs
Warfarin
Antiplatelets
Implications
Higher risk GI bleeding source
Procedure planning considerations
Medication contraindications to likely therapies
Sedation and procedure risk modifiers
Chronic benzodiazepine use
Severe OSA history
Drug interaction traps
QT prolonging agents with azoles
Warfarin interaction with azoles
Diet
Recent intake and hydration
Intake pattern
Last solid intake time
Last liquid intake time
Ability to swallow medications
Hydration markers
Reduced urine output
Dizziness on standing
Trigger exposures
Caustic and thermal exposures
Household cleaners
Industrial chemicals
Hot liquids burns
Food exposures
Meat bolus
Fish bones
Shell fragments
Reflux and irritant exposures
Reflux promoting factors
Large late meals
High fat meals
Irritants
Tobacco
High caffeine intake
Review of Systems
HEENT
Upper airway and oral cavity
Sore throat
Hoarseness
Oral ulcers
Thrush
Dental pain
Neck symptoms
Neck pain
Neck stiffness
Cardiopulmonary
Respiratory symptoms
Dyspnea
Cough
Wheeze
Hemoptysis
Cardiac symptoms
Chest pain
Palpitations
Syncope
GI
Esophageal and gastric
Heartburn
Regurgitation
Early satiety
Bleeding and bowel
Hematemesis
Melena
Hematochezia
Neurologic
Bulbar and stroke symptoms
Dysarthria
Facial droop
Limb weakness
New gait instability
Neurodegenerative features
Tremor
Rigidity
Constitutional and infection
Systemic symptoms
Fever
Chills
Night sweats
Weight and appetite
Unintentional weight loss
Anorexia
Collateral History and Family History
Collateral sources and reliability
Source
Family
Caregiver
EMS
Reliability considerations
Baseline cognition
Language barriers
Family history relevant to dysphagia
Malignancy and GI conditions
Esophageal cancer (C15)
Gastric cancer (C16)
Neurologic and neuromuscular
ALS family history
Myasthenia gravis family history
Exposure and household context
Infectious exposures
Sick contacts
Tuberculosis exposure history
Supervision and safety
Ability to adhere to aspiration precautions
Availability of follow up support
Risk Factors
Mechanical obstruction risk
Structural disease risk
Prior esophageal stricture
Prior radiation to chest or neck
Known eosinophilic esophagitis
Malignancy risk
Age over 50 years with progressive dysphagia
Tobacco use
Heavy alcohol use
Infection risk
Immunocompromise
HIV risk
Transplant history
Chemotherapy
Local infection risk
Poor dentition
Recent pharyngitis
Foreign body and caustic risk
Ingestion risk
Denture use
Alcohol intoxication
Psychiatric disease history
Caustic exposure risk
Occupational chemical exposure
Household cleaner access
Neurologic and aspiration risk
Aspiration predisposition
Prior stroke
Parkinson disease (G20)
Dementia (F03.90)
Neuromuscular disease
Myasthenia gravis (G70.00)
ALS (G12.21)
Procedure and device related risk
Iatrogenic risks
Recent endoscopy
Recent NG tube placement
Airway adjuncts
Recent intubation
Tracheostomy
Differential Diagnosis
Life threatening
Airway and deep neck space
Epiglottitis (J05.1)
Stridor
Drooling
Tripod positioning
Retropharyngeal abscess (J39.0)
Neck stiffness
Trismus
Toxic appearance
Peritonsillar abscess (J36)
Uvula deviation
Hot potato voice
Esophageal emergencies
Esophageal perforation (K22.3)
Severe chest pain after vomiting
Subcutaneous emphysema
Fever or shock
Complete food bolus impaction (T18.1)
Inability to swallow liquids
Persistent drooling
Button battery ingestion (T18.9)
Pediatric presentation
Rapid tissue injury risk
Neurologic emergencies
Acute ischemic stroke (I63.9)
New focal deficits
Sudden oropharyngeal dysphagia
Common
Reflux and inflammatory
GERD with esophagitis (K21.0)
Heartburn
Regurgitation
Pill induced esophagitis (K20.8)
Odynophagia after new pill
Inadequate water with pills
Structural
Peptic stricture (K22.2)
Progressive solids then liquids
Longstanding reflux history
Schatzki ring (K22.2)
Intermittent solid food dysphagia
Meat bolus episodes
Motility
Achalasia (K22.0)
Dysphagia to solids and liquids from onset
Regurgitation of undigested food
Less common
Eosinophilic esophagitis (K20.0)
Atopy history
Recurrent food impactions
Esophageal malignancy (C15)
Progressive dysphagia
Weight loss
Zenker diverticulum (K22.5)
Regurgitation of undigested food
Halitosis
Mimics and distinguishing clues
Oropharyngeal versus esophageal clues
Oropharyngeal clues
Choking with swallow
Nasal regurgitation
Immediate cough
Esophageal clues
Delayed sticking sensation
Retrosternal localization
Mechanical versus motility clues
Mechanical clues
Solids worse than liquids
Progressive course
Motility clues
Solids and liquids from onset
Intermittent with stress
Past Medical History
Prior GI and esophageal disease
Prior diagnoses
GERD (K21.9)
Barrett esophagus (K22.70)
Eosinophilic esophagitis (K20.0)
Prior interventions
Prior esophageal dilation
Prior EGD findings
Neurologic history
CNS disease
Prior stroke (I63.9)
Multiple sclerosis (G35)
Neuromuscular disease
Parkinson disease (G20)
Myasthenia gravis (G70.00)
Infectious and immune history
Immunocompromise
HIV
Transplant
Long term steroids
Recurrent infections
Recurrent oral candidiasis
Recurrent pneumonia
Surgical and procedural history
Head neck and thoracic
Neck surgery
Esophageal surgery
Iatrogenic risk procedures
Recent endoscopy
Recent dilation
Physical Exam
General and vitals
General appearance
Toxic appearance
Dehydration signs
Ability to speak full sentences
Vital sign interpretation
Fever pattern
Tachycardia with pain versus sepsis
Airway and HEENT
Oral cavity and pharynx
Thrush
Ulcerations
Tonsillar asymmetry
Airway risk signs
Drooling
Stridor
Muffled voice
Neck
Neck exam
Tenderness
Swelling
Trismus
Subcutaneous emphysema
Crepitus palpation
Chest wall extension
Chest and cardiopulmonary
Respiratory exam
Increased work of breathing
Focal crackles
Wheeze
Aspiration indicators
Hypoxia
New focal findings
Abdomen
Abdominal findings
Epigastric tenderness
Peritonitis
GI bleeding stigmata
Melena on exam when applicable
Hemodynamic instability
Neurologic
Cranial nerve and bulbar
Dysarthria
Palatal elevation asymmetry
Gag reflex asymmetry
Focal neurologic deficits
Facial droop
Limb weakness
Lab Studies
Core labs guided by severity
Basic labs
CBC for infection and anemia
Electrolytes for dehydration
Creatinine for contrast planning
Inflammatory and perfusion labs when toxic
Lactate for shock physiology
CRP when deep infection suspected
Infection focused labs
Sepsis evaluation when indicated
Blood cultures before antibiotics if febrile and toxic
Venous blood gas if respiratory distress
Immunocompromised evaluation
HIV testing when risk factors
CD4 count if known HIV and unclear status
Bleeding and procedure planning labs
Hemostasis and anemia assessment
INR when on warfarin or liver disease
Type and screen if GI bleeding concern
Pitfalls and limitations
Normal labs do not exclude critical disease
Early perforation may have minimal leukocytosis
Early deep neck infection may have modest fever
Timing considerations
Antibiotics before cultures reduces yield
Steroids may blunt fever and WBC
Imaging
Scoring Systems
Swallow and aspiration screening tools
Bedside swallow screen
Intended for stroke and suspected oropharyngeal dysphagia
Failed screen triggers NPO and speech language pathology pathway
EAT 10 symptom score
Patient reported symptom burden tracking
Not a rule out tool for obstruction
Neuro risk tools when stroke suspected
NIH Stroke Scale
Severity stratification to support urgent stroke pathway
Not a substitute for imaging
MRI
MRI brain and brainstem
Indications
Suspected posterior circulation stroke with nondiagnostic CT
Suspected demyelinating disease flare
Limitations
Time to scan may delay airway focused care
Motion artifact in agitated patients
CT
CT neck with IV contrast
Indications
Suspected deep neck space infection
Suspected retropharyngeal abscess
Interpretation pearls
Rim enhancing collection supports abscess
Air tracking supports perforation or necrotizing infection
CT chest with IV contrast
Indications
Suspected esophageal perforation
Suspected mediastinitis
Pitfalls
Early perforation may have subtle findings
Consider water soluble esophagram when CT nondiagnostic and suspicion remains
Ultrasound
Neck ultrasound
Indications
Superficial neck abscess localization
Cervical lymphadenitis evaluation
Limitations
Poor visualization of deep spaces
Negative study does not exclude retropharyngeal abscess
Lung ultrasound
Indications
Aspiration pneumonitis screening adjunct
Pleural effusion assessment in toxic patients
Pitfalls
Early aspiration may be normal
Operator dependent findings
Special Tests
Bedside functional tests
Swallow safety tests
Bedside swallow screen when stroke suspected
Suction readiness for secretion management
Airway visualization adjuncts
Flexible nasolaryngoscopy by trained clinician when airway stable
Avoid agitation provoking maneuvers when epiglottitis suspected
Radiographic contrast studies
Esophagram contrast sequence
Water soluble contrast first when perforation suspected
Barium follow through if water soluble negative and suspicion persists
Diagnostic pearls
Aspiration during study supports oropharyngeal dysfunction
Bird beak appearance supports achalasia
Endoscopic evaluation
EGD indications
Food bolus impaction without perforation suspicion
Progressive dysphagia with alarm features
Contraindications and precautions
Unstable airway without airway plan
Suspected perforation requires surgical input and imaging first
Physiologic tests
High resolution esophageal manometry
Indications
Suspected achalasia after structural causes excluded
Persistent dysphagia with normal EGD
Limitations
Not an ED test
Requires outpatient planning and availability
ECG
Indications in dysphagia presentations
ECG triggers
Chest pain
Syncope
Significant electrolyte abnormality risk
Monitoring use cases
Sedation planning
Sepsis associated tachyarrhythmia
High risk patterns to not miss
Ischemia patterns
STEMI criteria
New ischemic ST depression
Arrhythmias and conduction
Atrial fibrillation with RVR
High grade AV block
Assessment
Pattern based localization
Oropharyngeal dysphagia likely
Difficulty initiating swallow
Coughing or choking with swallow
Nasal regurgitation
Esophageal dysphagia likely
Food sticking after swallow
Retrosternal localization
Solids and liquids characterization guides mechanical versus motility
Severity and risk stratification
High risk category
Unable to swallow secretions
Respiratory compromise
Suspected perforation
Moderate risk category
Able to swallow liquids only
Significant dehydration
Immunocompromised with odynophagia
Working diagnosis candidates with codes
Mechanical obstruction suspected
Peptic stricture (K22.2)
Malignancy (C15)
Motility disorder suspected
Achalasia (K22.0)
Esophageal spasm (K22.4)
Complications to actively exclude
Aspiration
New hypoxia
New focal chest findings
Perforation and mediastinitis
Chest pain with systemic toxicity
Subcutaneous emphysema
Plan
Stabilization and immediate precautions
Airway and aspiration precautions
NPO for high risk presentations
Upright positioning
Suction setup for drooling
Analgesia and symptom control
Acetaminophen 1000 mg PO once
Hydromorphone IV 0.5 mg once for severe pain
Diagnostic sequencing
Time critical pathways
If airway concern, ENT and anesthesia early
If suspected perforation, CT chest with contrast and surgery consult
Non critical pathways
If progressive dysphagia without instability, urgent GI referral for EGD planning
If stroke suspected, stroke protocol with neuroimaging
Targeted therapies by suspected etiology
Deep neck space infection suspected
Ampicillin sulbactam IV 3 g every 6 hours
If MRSA risk, add vancomycin IV 15 mg per kg every 12 hours
Dexamethasone IV 10 mg once for significant airway edema local protocol dependent
Epiglottitis suspected
Ceftriaxone IV 2 g daily
If MRSA risk, add vancomycin IV 15 mg per kg every 12 hours
Avoid agitation provoking interventions until airway plan in place
Candida esophagitis suspected
Fluconazole 400 mg PO or IV once
Then fluconazole 200 mg to 400 mg daily for 14 to 21 days
HSV esophagitis suspected
Acyclovir 400 mg PO five times daily
If severe or unable PO, acyclovir IV 5 mg per kg every 8 hours
CMV esophagitis suspected
Ganciclovir IV 5 mg per kg every 12 hours
Specialist consultation recommended
Pill induced esophagitis suspected
Stop offending agent if possible
PPI therapy example pantoprazole 40 mg PO daily
Food bolus impaction suspected and stable airway
Glucagon IV 1 mg once local protocol dependent
GI consult for endoscopic removal when persistent obstruction
Monitoring and reassessment loop
Reassessment timing
Repeat airway assessment every 15 to 30 minutes if borderline
Repeat vitals after analgesia and fluids
Deterioration triggers
New stridor or increased drooling
Rising oxygen requirement
New fever or hypotension
Disposition
ICU criteria
ICU level indications
Airway compromise or impending obstruction
Sepsis with vasopressor requirement
Esophageal perforation with shock
Inpatient admission criteria
Admission indications
Unable to tolerate oral intake with dehydration
Deep neck space infection
Immunocompromised with suspected infectious esophagitis and poor intake
Observation pathway criteria
Observation appropriate
Partial dysphagia tolerating liquids with stable vitals
Symptom control achieved and urgent outpatient testing arranged
Discharge criteria
Discharge appropriate
Stable airway and no drooling
Tolerating oral fluids
No concern for perforation or deep neck infection
Follow up plan reliable
Follow up timing
Follow up targets
GI follow up within 72 hours to 2 weeks depending on severity
ENT follow up within 24 to 72 hours if persistent throat symptoms
SLP referral for oropharyngeal dysphagia when stable
Discharge Instructions
Copy discharge instructions
Summary
You were seen for trouble swallowing or pain with swallowing
Your exam today did not show signs of an emergency airway problem
Diet and activity
Soft foods and small bites
Sit upright for meals and for 30 minutes after eating
Avoid alcohol and very hot liquids until improved
Medications
Take medicines exactly as prescribed
If given a reflux medicine, take it daily as directed
If antibiotics or antifungals were prescribed, complete the full course
Follow up
Arrange follow up as instructed
If an endoscopy or swallowing study was recommended, schedule it as soon as possible
Return to the emergency department now for
Trouble breathing
No ability to swallow saliva
Drooling
New or worsening chest pain
Fever with worsening throat or neck pain
Vomiting blood
Black stools
New weakness of face arm or leg
Safety notes
Do not drive if you received sedating medications today
Avoid eating alone if you have choking episodes
References
Guidelines and core references
Dysphagia evaluation and management guideline American Society for Gastrointestinal Endoscopy 2014
Endoscopy role in dysphagia evaluation
Food bolus and impaction management principles
Esophageal physiologic testing clinical guideline American College of Gastroenterology 2020
Manometry indications
Functional lumen imaging probe context
Ingested foreign body and food bolus impaction guideline European Society of Gastrointestinal Endoscopy 2016
Emergent removal indications
High risk objects
Caustic ingestion management guideline European Society of Gastrointestinal Endoscopy 2017
Early endoscopy timing considerations
High risk ingestion features
Candidiasis guideline Infectious Diseases Society of America 2016
Fluconazole first line for esophageal candidiasis
Alternative agents for refractory disease
Surviving Sepsis Campaign adult guideline 2021
Early antibiotics in septic shock
Lactate guided resuscitation principles
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.