A question for you: dysphagia
A 70yM with PMH CAD, GERD, and tobacco use disorder (50+ pack-year history) presents to clinic with 3 months of progressive difficulty swallowing. He reports that he feels like food is getting stuck in his chest and has lost 10 pounds as a result of the decreased oral intake. He is able to tolerate liquids. He denies cough or congestion. His past surgical history includes R inguinal hernia repair. His home medications include aspirin, rosuvastatin, metoprolol, and omeprazole, and he reports that his GERD has been well controlled on a PPI for many years.
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In this older patient with progressive esophageal dysphagia to solids only, and unintentional weight loss, the most concerning diagnosis is an esophageal malignancy. He does have risk factors (GERD and smoking). The most important next step is to order an endoscopy (b) to assess for an obstructing lesion and obtain tissue samples. CT scans (a) will be part of the workup/staging if he is ultimately diagnosed with an esophageal cancer, but would not be the first step in diagnosis. pH monitoring (c) is used to diagnose GERD. Manometry (d) is used to diagnose esophageal motility disorders, not obstructive disorders. Adding an H2 blocker like famotidine (e) is unhelpful diagnostically, and his dysphagia is very concerning for a new malignancy, rather than being a symptom of his GERD.