MLA Domain 5 · Presentation
Swallowing problems
21 conditions in Finalist present this way. Work down the list and ask what would separate each one from the next — that discriminator is the exam question.
classic presentation · 10
Older patient with rapid weight loss and short history → exclude PSEUDOACHALASIA (tumour at the GOJ) with endoscopy
Severe distress, rising respiratory/heart rate then a falling rate and drowsiness/cyanosis = exhaustion → impending obst
Acute food-bolus impaction unable to swallow own saliva → urgent endoscopic disimpaction (do NOT push the bolus blindly
Hoarseness, fixed/hard nodule, rapid growth, cervical nodes, or stridor → suspected cancer pathway / urgent
ALARM features → urgent endoscopy: Anaemia (iron-deficiency), Loss of weight, Anorexia, Recent-onset/progressive symptom
A persistent, firm, fixed neck lump in an ADULT (especially with smoking/alcohol, dysphagia, hoarseness, or an HPV risk)
ANY dysphagia → urgent (2-week-wait) endoscopy
Trismus + "hot-potato" voice + uvular deviation → quinsy; drooling/stridor/unable to swallow → epiglittitis/airway; unil
Progressive dysphagia/weight loss -> exclude oesophageal cancer (endoscopy)
Features raising malignancy concern: rapid growth, a hard/fixed nodule, hoarseness (recurrent laryngeal nerve), cervical
recognised feature · 8
Any stridor, drooling or tripod posture = impending airway obstruction → do NOT lie the patient down, examine the throat
Para-oesophageal hernia with acute severe pain/obstruction → strangulation/gastric volvulus — surgical emergency
Respiratory compromise (FVC), bulbar dysfunction with aspiration; weight loss
Myasthenic CRISIS — respiratory muscle weakness (monitor FVC), bulbar weakness with aspiration; certain drugs trigger it
Underlying malignancy (especially with dermatomyositis) → age-appropriate cancer screen
Persistent unilateral parotid enlargement/lymphadenopathy → exclude B-cell (MALT) lymphoma (markedly increased risk)
Scleroderma renal crisis: accelerated hypertension + acute kidney injury → urgent ACE INHIBITOR (the treatment of choice
Established tetanus (spasms, laryngeal/respiratory involvement, autonomic storm) → ICU emergency
differential of the above · 3
Any Airway/Breathing/Circulation compromise = anaphylaxis → IM adrenaline now; biphasic reaction (recurrence hours later
Airway compromise, inability to swallow saliva/drooling, spread to a parapharyngeal/retropharyngeal abscess → urgent ENT
Rapidly growing hard fixed mass, hoarseness, stridor/dysphagia (compression), cervical nodes → urgent ENT/endocrine