Dysphagia

Name

Age

Sex

Occupation

Residence

Marital status

Date of admission

C/o 

Difficulty in swallowing for 1 month

History of Present Illness

Dysphagia:   onset duration fluid or solid .level .progression q. Compensation.eating with water .valsalva maneuver . Eat small peace . Avoid social activity .slow eating Confined to liquids . Amount of fluid per day

Odynophagia Onset & Duration

Symptoms of Upper Oesphagus

Nasal regurgitation

Change in voice

Halitosis

Regurgitation

Chocking

Cough

Symptoms of Lower Oesphagus 

Heart burn : Onset, Duration , Day or Night , related to posture, relieving and aggravating factors 

Epigastric pain: Onset , Duration , Site, Relieving and Aggravating factors and radiation

Retro-sternernal chest pain

Hiccup

Bloating

Bleaching

Vomiting :Onset , Amount ,Times per day, Color , Frequency ,Containing old meal,  Projectile ,odor containing bile .

Haematemesis : Onset ,Colour, Amount , Number of times, containing blood clot and effect on the patients

Anorexia and nausea

Feeling hunger

Symptoms of Malignancy

Weight loss 

symptoms of anemia (Fatigability , SOB and palpitation on exertion ).

Symptoms of metastasis: 

● GIT :abdominal distension.

● CVS + Respiratory:cough with haemoptysis chest pain lower limb edema.

● CNS:loss of consciousness . Headache . Convulsion .

● Genitourinary:urine amount colour and frequency

● Menstrual cycle: menorrhagea

Fill the gap

●  e.g seen in x Centre received management .done endoscopy and biopsy

Past Medical History

 Hospitalization

 Surgical operation
Endoscopy  or colonoscopy : When ,How many time, Diagnostic take biopsy . Had  sclerotherapy. Post procedure complications followup and diagnosis .

Endoscopic Dilation

Travel

Corrosive

Chronic illnesses Dm, HTN and Asthma
 Blood transfusion
History of anemia
 History of schistosmiasis
 History of peptic ulcer disease

Family History 

- Similar condition
- Family history of other malignancies

Drug History 

Long term medication
Proton pump Inhebitors 

Aspirin. NSAID
Chemo- Radiotherapy

Social History

Home condition
Water and electricity
Level of education
Smoking
Alcohol abuser
Health insurance
Nutritional Habits

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