Postgraduate medicine
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Oropharyngeal and esophageal dysphagia involve different phases of swallowing, have different causes, and can usually be distinguished by a thorough patient history. Initial evaluation of patients with suspected oropharyngeal dysphagia includes patient history, physical and neurologic examination, and careful videofluoroscopic study of pharyngeal dynamics. Initial evaluation of patients with suspected esophageal dysphagia includes patient history and barium swallow with esophagography. Lesions such as Schatzki's ring or peptic stricture may not be detected unless the esophagus is sufficiently distended and the patient is given a bolus challenge.
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Almost three quarters of patients with cancer have severe pain, from invasion of the cancer itself, from effects of therapy, or from causes unrelated to the cancer (but often exacerbated by it). With the proper pain-management strategy, however, pain can be controlled in most patients. The analgesic ladder for pain control, promoted by the World Health Organization, begins with a nonnarcotic agent, progresses to a weak narcotic plus a nonnarcotic, and finally reaches a strong narcotic. ⋯ The most common reasons for inadequate pain control in cancer patients are incorrect narcotic dosing and incorrect switching from one narcotic to another and from one route of administration to another. Factors that influence pain management (eg, fear, anxiety, sleep disturbance) should be treated as well with appropriate medications, behavioral therapy, counseling, hypnosis, and other supportive techniques. These points are illustrated in the case report (see box, page 328).