Dysphagia OSCE History Checklist

1. Introduction

• Wash hands, introduce yourself, confirm patient identity.
• Explain: “I’d like to ask some questions about your swallowing difficulty.”
• Obtain consent.
• Check if the patient is comfortable and able to speak.
• Start open: “Can you tell me about the problem with swallowing?”

2. Presenting Complaint and History of Presenting Complaint

Define the symptom

• What do you mean by difficulty swallowing?
• Is it:
  • Difficulty initiating a swallow?
  • Food or drink sticking after swallowing?
  • Pain on swallowing (odynophagia)?
  • A lump sensation without true difficulty swallowing (globus)?

Onset and course

• When did it start?
• Sudden or gradual onset?
• Is it intermittent or constant?
• Is it getting worse? Over what time period?
• Was there a preceding event, such as stroke, surgery, radiation, caustic ingestion, or a food bolus becoming stuck?

Oropharyngeal vs oesophageal dysphagia

• Is it difficult to start the swallow?
• Do you cough or choke when eating or drinking?
• Does food or fluid go down the “wrong way”?
• Any nasal regurgitation?
• Any wet or gurgly voice after swallowing?
• Recurrent chest infections, aspiration, or fever?
• Do you need repeated swallows to clear food?

• Does food feel as if it gets stuck after you swallow?
• Where does it feel stuck? Note that perceived site may not accurately localise the lesion.
• Does it occur with solids, liquids, or both?

Solids versus liquids

• Solids only initially, then progressing to liquids: suggests a mechanical narrowing, such as stricture or malignancy.
• Solids and liquids from the onset: suggests a motility disorder, for example achalasia.
• Is it worse with particular foods, such as meat or bread?
• Any episodes of complete food impaction requiring emergency care or endoscopy?

Severity and functional impact

• Can you swallow saliva?
• What is the consistency of food you can manage: normal food, soft diet, purée, liquids only?
• Have you changed how you eat, for example smaller mouthfuls, avoiding food, or drinking water with meals?
• How long does a meal take?
• Any reduced oral intake, dehydration, or inability to take medication?

3. Associated Symptoms

Upper gastrointestinal symptoms

• Heartburn or acid regurgitation?
• Sour taste in mouth?
• Belching?
• Chest or retrosternal pain?
• Painful swallowing?
• Nausea or vomiting?
• Regurgitation of undigested food, especially at night?
• Haematemesis or coffee-ground vomit?
• Black stools or rectal bleeding?

Malignancy red flags

• Unintentional weight loss?
• Loss of appetite or early satiety?
• Fatigue, dizziness, or symptoms of anaemia?
• Persistent vomiting?
• Hoarse voice or chronic cough?
• Neck lump or supraclavicular swelling?

Aspiration and respiratory symptoms

• Coughing/choking with food or fluid?
• Breathlessness during meals?
• Recurrent aspiration pneumonia or chest infections?
• Fever?
• Change in voice after swallowing?

Neurological symptoms

• Recent stroke or transient neurological symptoms?
• Limb weakness, facial droop, speech difficulty?
• Parkinsonian symptoms: tremor, slowness, rigidity?
• Memory problems or dementia?
• Symptoms of motor neurone disease, such as progressive weakness, dysarthria, or fasciculations?
• Myasthenic symptoms: fatigable weakness, ptosis, diplopia?

4. Risk Factors and Aetiology-Focused History

Gastro-oesophageal disease

• Previous reflux disease?
• Previous oesophagitis, Barrett’s oesophagus, peptic ulcer disease, hiatus hernia, or strictures?
• Previous endoscopy or oesophageal dilatation?

Eosinophilic oesophagitis

• History of asthma, eczema, hay fever, food allergy, or atopy?
• Recurrent food impaction?

Cancer risk

• Smoking history, including pack-years.
• Alcohol intake.
• Previous head and neck or oesophageal cancer.
• Previous radiotherapy to the neck or chest.
• Family history of upper gastrointestinal cancer.

Mechanical injury or exposures

• Previous caustic ingestion.
• Previous prolonged nasogastric tube, intubation, or oesophageal surgery.
• Neck, mediastinal, thyroid, or cervical-spine surgery.
• Foreign-body ingestion.

Medication history

• Current and recent medications, especially:
  • Bisphosphonates
  • Doxycycline/tetracyclines
  • NSAIDs
  • Potassium tablets
  • Iron tablets
  • Anticholinergics, opioids, or drugs causing dry mouth
• Ask how tablets are taken: with little water? immediately before lying down?
• Immunosuppressants, chemotherapy, steroids, or HIV risk, which increase risk of infectious oesophagitis.

5. Past History

• Previous dysphagia, food impaction, reflux, peptic stricture, or oesophageal disease.
• Neurological disease: stroke, Parkinson disease, multiple sclerosis, dementia, motor neurone disease.
• Diabetes or connective-tissue disease, especially systemic sclerosis.
• Head and neck disease, thyroid enlargement, goitre, or mediastinal mass.
• Previous surgery, radiotherapy, intubation, or endoscopy.
• Allergies.

6. Family History

• Oesophageal, gastric, head and neck, or bowel cancer.
• Neurological disease.
• Atopy or eosinophilic oesophagitis where relevant.

7. Social History

• Smoking and alcohol.
• Diet, appetite, and recent weight change.
• Living situation and support with meals.
• Ability to prepare food and maintain hydration.
• Occupational impact.
• For aspiration risk: needs help eating? altered diet? speech and language therapy input?

8. Systems Review

• ENT: mouth ulcers, sore throat, hoarseness, neck lump.
• Respiratory: cough, recurrent pneumonia, dyspnoea.
• Neurological: weakness, sensory loss, altered speech, gait or cognition.
• Autoimmune: Raynaud phenomenon, skin tightening, joint pain.

9. Summarise and Close

• Summarise key points, including:
  • Site/type of dysphagia
  • Solids versus liquids
  • Progression
  • Aspiration symptoms
  • Weight loss and other alarm features
  • Relevant neurological, reflux, cancer, and medication history
• Ask: “Is there anything else you feel may be relevant?”
• Thank the patient.
• State that you would proceed to examination, including nutritional status, oral cavity, cranial nerves, neck/chest examination, and neurological examination as appropriate.

One-line OSCE discriminator

Dysphagia OSCE History-Taking Marking Scheme

Essential points expected

• Oropharyngeal dysphagia: difficulty initiating swallowing, cough/choke immediately after swallowing, nasal regurgitation, aspiration.
• Oesophageal dysphagia: food sticking after swallowing.
• Mechanical obstruction pattern: progressive difficulty, usually solids before liquids.
• Motility pattern: dysphagia for solids and liquids, often intermittent.
• Urgent concerns: inability to swallow saliva, food bolus obstruction, aspiration, significant weight loss, bleeding, anaemia, persistent vomiting, or rapidly progressive symptoms.

Global Rating Scale

Major safety concerns

1. Inability to swallow saliva or acute food bolus obstruction
2. Aspiration, choking, or recurrent aspiration pneumonia
3. Weight loss or rapidly progressive dysphagia
4. GI bleeding, anaemia symptoms, or persistent vomiting
5. Odynophagia in an immunocompromised patient