Solve the Medical Riddle: Her 75-year-old Mother Has Trouble Swallowing, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient and her daughter told the doctor and how the doctor proceeded with the examination. Next week, a specialist will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the specialist will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient’s Daughter and the Patient Report the Symptoms

Mildred, age 75, recently noticed that she’s having some trouble swallowing. Her 50-year-old daughter, Lucy, is concerned and made an appointment for Mildred with her PCP. Lucy went with her mother for the doctor visit.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Lucy and Mildred told the doctor:

Lucy: “My 75-year old mother recently moved in with my husband and me and our two teenage sons. She had been living alone after my father died two years ago, but she got tired of taking care of a big house and yard so we all thought she’d be better off at our place. She sold the house, which was a huge relief to her. We love having her around! Until now, she hasn’t had any health problems. Then a week or so ago, she told me that she had noticed she was having some trouble swallowing. That sounds scary to me, like she might have a blockage or maybe could choke!”

Mildred: “I think my daughter is overreacting, but I don’t want her to worry. That’s why I agreed to come in today. All that happens is that when I eat certain foods, especially the high-fiber bran cereal I have every morning, I get the sensation that some of it is kind of stuck in the back of my throat and upper chest. If I drink water, I can eventually wash everything down just fine. It also helps when I chew gum! That seems to make extra saliva, although I could be imagining things. Anyway, I don’t think this is a big deal. I feel great overall. I just want you to put my daughter’s mind at ease!”

Mildred’s doctor was aware that older people often try to ignore symptoms because they’re afraid they’ll be hospitalized or lose their independence if a condition is discovered, so he began by assuring her that it was good she came. He said she should never consider that she is overreacting. Better safe than sorry! Although Mildred’s symptoms may not be cause for concern, they can be a sign of something more serious such as a blockage from cancer or could progress to a life-threatening problem such as aspiration at some point.

The doctor then questioned Mildred to explore possible causes of her swallowing issues. He asked about chronic reflux or heartburn that can lead to esophageal stricture, a narrowing caused by acid irritation. Mildred said she didn’t have that problem. She also didn’t have a chronic cough or asthma.

Then the doctor asked about medications that could cause mouth dryness and slow down swallowing a bit, including antidepressants that have anticholinergic activity, over-the-counter sleeping pills containing Benadryl, or even over-the counter cold or allergy pills containing sedating antihistamines. Mildred said she wasn’t taking anything prescription or over-the counter. She did say she had tried taking a multivitamin recently, but she found she had difficulty swallowing the pills so she stopped.

Next the doctor asked whether Mildred had dry eyes or dry mouth and Mildred said she didn’t think so. Finally, the doctor established that Mildred had never smoked, which would have been a risk factor for cancer. Mildred emphasized that food never actually got stuck and that she never felt as though she would choke.

The doctor moved on to a complete exam including a through neurologic assessment. Mildred’s lungs were clear and she had no neurologic or other findings on complete physical exam (Sondra – symptoms are subjective, signs or findings are ‘objective”). However, Lucy mentioned to the doctor that her mother couldn’t get up out of a chair without using her arms to push off.

The doctor scheduled Mildred for a modified barium swallow (MBS) at the radiology department of a hospital. MBS is the gold standard test for dysphagia, which is the medical term for difficulty swallowing.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn about Mildred’s MBS.

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.