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S2D: The Symptom to Diagnosis Podcast - Episode 32: Dysphagia
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S2D: The Symptom to Diagnosis Podcast - Episode 32: Dysphagia
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2023-06-03T00:00:00.0000000
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Language: EN.
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[upbeat intro music] [upbeat intro music] [upbeat intro music] [Dr. Cifu] I'm Adam Cifu. [Dr. Stern] And I'm Scott Stern. [Dr. Cifu] And we're here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms.
We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves and other random pearls of knowledge. The cases that we discuss are drawn from our clinical experience, but because protecting patient privacy is part of our oath, we never discuss actual patients.
What are we talking about today, Scott? [Dr. Stern] Today, we're talking about dysphagia. [Dr. Cifu] Dysphagia. - [Dr. Stern] Dysphagia. - [Dr. Cifu] I like it. So you are the expert of the day. You got a case for me? [Dr. Stern] I do. I remember this pseudo-patient well. [both chuckle] [Dr. Stern] He was a 70-year-old man who came in complaining that he was having trouble swallowing.
He actually called me first on the phone and said he's having trouble swallowing and said he'd lost 20 pounds in a month. And I said "That's not possible. You better come in." [Dr. Cifu] I would say that's also not good. [Dr. Stern chuckles] You're right about that. [Dr. Cifu] Okay. Are you going to give me anything else, or? [Dr. Stern] So his past medical history's pretty unremarkable. Hypertension controlled and I'll just say on physical exam, the only notable thing was that he'd lost 20 pounds.
- [Dr. Cifu] Got it. - [Dr. Stern] But otherwise, his exam was not contributory as they say. [Dr. Cifu] So this, as I said, this sounds bad. I'd be worried about this, right? And I think the things that I'd be worried about is this is an older guy with dysphagia who's lost weight. And I'll actually take a step back. I love dysphagia because pretty much when I see dysphagia, what I think is this guy needs an endoscopy.
[Dr. Stern chuckles] [Dr. Cifu] And so you can kind of put your thinking hat aside, make the management decisions, but then kind of go through the process of like, what is the endoscopy going to show? So anyway, so I'm assuming this did not start acutely, so we're not dealing with like simple food impaction- [Dr. Stern] Right. [Dr. Cifu] -which would be a nice outcome.
[Dr. Stern] Right, and as you know, that normally presents like that day. - [Dr. Cifu] Exactly. - [Dr. Stern] Right. [Dr. Cifu] And then it sounds like he's not having pain. - [Dr. Stern] Correct. - [Dr. Cifu] So it's not odynophagia, it's really dysphagia. [Dr. Stern] Correct. [Dr. Cifu] And then what I usually ask people, you know, because they're having trouble swallowing, do they cough, does it come out their nose, do they feel like it went down the wrong pipe?
And that's kind of going for oropharyngeal dysphagia. - Nothing like that? - [Dr. Stern] No. [Dr. Cifu] Okay. And then I think this, I don't know if this is even helpful, but I was always taught to, you know, point to where you feel the dysphagia and if it's not oropharyngeal, people usually kind of just point somewhere in their chest where they first- [Dr. Stern] Right. His is clearly chest.
[Dr. Cifu] Okay, okay. And I guess my last question is, maybe two questions, happen all the time or kind of intermittent and is it with everything, liquids and solids, or just solids? [Dr. Stern] So it's all the time now. And it started with solids and now it's hard getting almost - anything down. - [Dr. Cifu] Okay. This sounds like a terrible history. So I- [Dr. Stern] Not a terrible historian.
And I just want to clarify that remark rather bad- [Dr. Cifu] So hearing all of this, I think everything is pointing to me that this guy's got like anatomic obstruction of his esophagus. The fact that this is kind of slowly progressive, includes liquids and solids, that he's lost weight, and unfortunately, given that he's an older man, esophageal cancer has to be high up. It could be adenocarcinoma, it could be squamous.
I didn't ask about smoking, drinking, all that kind of stuff. And there is the potential that it's something not as bad, that he's got kind of a complication of long-standing reflux or maybe this guy had radiation in the past or something, which has bothered his esophagus. But I think he needs an endoscopy and- [Dr. Stern] Well, that's a good place to- Why don't we leave it there? And we'll come back to show what that says.
[Dr. Cifu] Sounds good. So that brings us to your five points. I'm curious about your five points, so- [Dr. Stern] Well, you hit - not surprisingly - many of them. So, it is true that when someone says to me that they are having trouble swallowing, the first thing that goes through my mind is an endoscopy, but let's be more systematic. So the first step is to distinguish whether it's odynophagia from dysphagia, and you mentioned this.
Odynophagia though, to be clear, is when people have pain swallowing, and dysphagia is other difficulty swallowing. Like it's hard to get things down. [Dr. Cifu] Yeah. [Dr. Stern] Odynophagia really has a similar, but slightly different differential diagnosis. If people have odynophagia, you want to know where it hurts. [Dr. Cifu] Right.
[Dr. Stern] If it hurts in the posterior pharynx, it's really a different differential diagnosis than if it hurts lower. [Dr. Cifu] Right. [Dr. Stern] Actually we don't even think of odynophagia when people complain of it all the time, when they have a sore throat. You know, people with a sore throat all the time say it hurts to swallow and that's odynophagia.
So a whole bunch of pharyngeal infections from strep throat to epiglottitis can cause odynophagia. And lower down, of course, esophagitis can cause odynophagia. [Dr. Cifu] Right. It's neat. You like sort of picture of Venn diagram, right? [Dr. Stern] Right. [Dr. Cifu] Where there's some overlap, but then there are also things which are just odynophagia and then a lot of things, most of which we're talking about today, which is just - dysphagia. - [Dr. Stern] Just dysphagia, - exactly. - [Dr. Cifu] Let me ask you one thing I just thought of. Globus sensation, which is, I think of that as a painless feeling of like something in the throat, which is often a weird symptom- [Dr. Stern] Right.
[Dr. Cifu] -it can actually be psychological, it can actually be something there which is not obstructing yet. We should probably just say that, like that's a thing and that's kind of separate from what we're talking about. [Dr. Stern] Right. And I don't know of any reliable way to distinguish when it is just a psychological thing from when it's anatomical.
You're kind of stuck looking. [Dr. Cifu] Yeah. Oh yeah, no question. - No question. - [Dr. Stern] Right. [Dr. Cifu] Okay, so point one, differentiate odynophagia from dysphagia because those things really have different though overlapping differential diagnoses. - [Dr. Stern] Correct. - [Dr. Cifu] Okay. [Dr. Stern] So point two is where is the dysphagia? So most of the time, because this is why you and I think of and EGD first, most of the time, it's an esophageal problem, and we want to look at the esophageal problem and know whether it's motor or neuromuscular, but there are a large group of people who have trouble swallowing because of problems in the mouth.
They either have dysmotility in their mouth, such as from a prior stroke, or they don't have enough hydration in their mouth, some people have very dry mouth. So you want to know whether the problem is initiating to swallow and they're, like you say, coughing, having problems with that, or they swallow fine, and then there's the problem. [Dr. Cifu] Right.
[Dr. Stern] And the workups and the differentials - are different. - [Dr. Cifu] Right. And I don't think that it's a terribly difficult thing to figure out. Right? I mean, people will- Either the person or sometimes, actually the partner will talk to you about, you know, the person chews a lot, it's like, seems like it's hard for them to get down. There's certainly, you know, the coughing, if they aspirate, there's the stuff coming out of their nose, if- - Right? - [Dr. Stern] Right.
[Dr. Cifu] So it's kind of obvious. [Dr. Stern] And people not having dentures. I mean, sometimes people are just chewing the whole time. [Dr. Cifu] Right. Right. [Dr. Stern] And it's kind of gross, but it is what it is. [Dr. Cifu] I looked up the differential of this kind of pharyngeal dysphagia, because I think, like you, I don't spend a whole lot of time thinking about that because I think most of the dysphagia I see is esophageal.
I looked this up on UpToDate and like always, UpToDate's, you know, their differential diagnosis is ridiculous. Right? It has everything. I sort of think neurological problems. Right? Is that same with you? [Dr. Stern] Right. It's definitely what I see the most of. - For sure. - [Dr. Cifu] Right. And it could be stroke, it could be ALS you know, generally- - [Dr. Stern] Right. - [Dr. Cifu] -bad things.
I found it interesting that looking on UpToDate, you know, the things they list are really quite broad, iatrogenic injuries, infections, which are a lot of things you already talked about with some crazy things like diphtheria and botulism. Metabolic things, amyloid I thought was interesting. Myopathic I guess, kind of what we talked about and then some structural things like a Zenker's diverticulum, cervical webs, things like that, but for me, I always focus on the neurological illness causing it.
[Dr. Stern] I mean, clearly in the hospital, we see this all the time and it's almost inevitable in the hospital that it's a result of some sort of brain phenomenon. [Dr. Cifu] Right. [Dr. Stern] I mean there's people who've had ENT surgery. - Right? - [Dr. Cifu] Right. [Dr. Stern] For cancers and whatnot in the head and neck and they always have trouble swallowing, but certainly in the hospital we see so many people who are encephalopathic or have had strokes, and they're the majority of people I see with oropharyngeal dysphagia.
[Dr. Cifu] That's a really good point. And that's like, let's have speech and swallow, see the person. [Dr. Stern] Right. [Dr. Cifu] And then often we have speech and swallow see the person every other day, because as their delirium lifts, you know, their oropharyngeal swallowing dysmotility, whatever, gets better. [Dr. Stern] Which is actually a great point. Right?
Because you don't want to put a G-tube into someone when they're going to get better. Right? I mean, if the oropharyngeal dysmotility is severe and people can't swallow, there's a temptation to jump and put in another way to feed them, but if it's going to be 72 hours or a week, - that might not be- - [Dr. Cifu] Yeah. [Dr. Stern] -a great idea. [Dr. Cifu] Let's not get into the G-tube discussion.
[Dr. Stern] Into the what? Oh yeah, well, okay. [Dr. Cifu] Okay. So point two, you sort of differentiated the oropharyngeal dysphagia from the esophageal dysphagia, right? So, point three? [Dr. Stern] Point three is one of the questions you asked, which is you really want to distinguish whether this seems like an obstruction or a motor problem. And the best question for that is simply, what's hard to swallow?
So if people are having trouble swallowing meats, typically the harder the meat, the harder it is to swallow, versus liquids, that really sounds like a mechanical problem. The liquids can slide by this obstruction and the meat can't; versus if it's both, you tend to think of the less common, but motor problems. [Dr. Cifu] Right. [Dr. Stern] Now complete obstructions can interfere with liquid and solid, but that's typically a progression of an obstruction that started usually as a mechanical obstruction to meat.
[Dr. Cifu] Got it. Got it. I got nothing else to say about point three. - [Dr. Stern chuckles] Okay. - [Dr. Cifu] Point four? [Dr. Stern] Well point four then is who needs an endoscopy or barium swallow? And which of those to choose, I think, depends a little bit on the center that you're at. Here at the university, I think we tend to err towards endoscopy because it allows for biopsy, it allows for visualization of the mucosa in case there's esophagitis, and neither of those are going to be very effectively done with barium swallow.
But indications for doing that would be one, it sounds like it's an obstruction, like this guy does, or if there're other alarm features onset over 50, anemia, GI bleeding, weight loss, or vomiting, and patients with odynophagia, especially if they don't get better with a brief course of a PPI. [Dr. Cifu] Great, great. And it is probably worthwhile, there are some people who you should go to barium swallow preferentially, and those are the people where it really does sound oropharyngeal as a problem.
Those are people who've maybe had procedures and you're worried about very proximal, you know, obstructions, abnormalities, things like that, where actually an EGD might be dangerous. - Right? - [Dr. Stern] Right. Sure, because you have to sedate people pretty heavily for an EGD. [Dr. Cifu] Yes. Yes. [Dr. Stern] And then the fifth point is simply if it sounds like it's a motor problem, that's where your manometry can be helpful to you, which I have to say, I don't remember the last time I ordered that.
So the mechanical problems are so much more common. When did you order that last? [Dr. Cifu] Right. I mean, you know, when I think about the people in my practice, who've either I've ordered manometry or they've ended up getting manometry after they've sort of gotten out of my hands, it's mostly, and I think this is what you read, right? It's mostly people who you do the upper endoscopy, you don't find anything on there, and so then there's a real suspicion of, "Boy, is this a motor problem?" Because the person clearly has dysphagia with at least a grossly normal esophagus.
[Dr. Stern] I've also seen it where people have a very tight lower esophageal sphincter, and they're trying to sort out, is this achalasia or what's going on with that? [Dr. Cifu] Right, right. Okay, so it sounds like our kind of clinical practice patterns as not esophagalogists- clinical practice patterns as not esophagalogists- - [both chuckle] - [Dr. Stern] Great word. [Dr. Cifu] -which I'm sure I just made up is sort of similar, is that you think about, you know, upper tract, but that's seldom the problem.
It's usually lower tract, you're usually going EGD first and then kind of fall back on manometry if you haven't then made the diagnosis. [Dr. Stern] Right. I think that's absolutely correct. [Dr. Cifu] Okay. So let's get back to the case. I left this 70-year-old man, who's lost a lot of weight going to endoscopy. I'm just going to read you here because I feel like I, Adam Cifu, know Scott Stern so well, I feel like this case you're presenting me is not just going to be tragic esophageal cancer.
I'm sort of thinking that there's something not so bad just because of the way you're looking at me. [Dr. Stern] That would be incorrect. [Dr. Cifu chuckles] Ah! [Dr. Stern chuckles] It was what you thought. I mean, it was unfortunately esophageal cancer. Very aggressive. He passed away within a month of the time of diagnosis. It was pretty horrible.
[Dr. Cifu] Yeah. It's a terrible disease. And what do you want to tell me? Adenocarcinoma? Squamous cell carcinoma? [Dr. Stern] No, he was not- You know, as you know, but just for the audience, squamous cell carcinoma is more typically seen in patients who have used tobacco and alcohol. Adenocarcinoma is thought to be more a complication of long standing reflux and Barrett's esophagus, and then the transition into esophageal carcinoma, and his was an adenocarcinoma.
[Dr. Cifu] Okay. I have an interesting side point that I'm not even going to say because I'm not entirely confident in my knowledge of it. So I'm going to tweet it with the podcast for a little follow-up for people so they can look into it themselves. [Dr. Steen chuckles] Wow, that's really mean, so stay tuned for the tweet, okay. [Dr. Cifu] Exactly. Okay. So let's move on to our favorite part, the fingerprints, common misconceptions, pet peeves and other random pearls of knowledge.
I'm pretty sure there are no fingerprints here. [Dr. Stern] That's right. There's not a single fingerprint I could find. Do you know of any fingerprints? [Dr. Cifu chuckles] Absolutely not. [Dr. Stern] All right. So common misconceptions. I think I'll start you off. [Dr. Cifu] Go. [Dr. Stern] The one that I think people have to be aware of, is that odynophagia, pain swallowing, is not the same as heartburn.
Heartburn, GERD is typically pain that occurs after meals as the food and the acid refluxes back up. Now it is true, if you have enough acid reflux over time, you'll get esophagitis and then you'll have odynophagia as well, but odynophagia is different and really brings to mind a host of other diagnoses and not simply heartburn. [Dr. Cifu] Yeah. I think that's a great point. You know, heartburn is overwhelmingly heartburn and sometimes people with heartburn could progress to odynophagia, but that's rare, uncommon, less common, whatever.
So mine is, this is a little bit getting into the weeds, but one of the causes of intermittent dysphagia are esophageal rings and esophageal webs, right? Which are kind of similar, they're generally kind of mucosal, I don't know, like redundancies in the esophagus, rings clearly circumferential where webs are usually kind of one sided. And you'd kind of think of those as being anatomic, they're going to cause chronic dysphagia, but in fact, for reasons that I think I don't understand that well, they're really mostly intermittent and people will do well most of the time, and then occasionally, you know, they'll sit down, they'll eat, it's often at the beginning of eating and the food will kind of get stuck there.
They'll often need to sort of stop, take a deep breath a couple of times, you know, try to like get the food down. They might actually regurgitate up food and saliva for a bit and then it'll pass and they'll feel better. That's often one of those things in the clinic where you'll get that history and you'll be like, this sounds like a web, you know, or this sounds like a ring. It still doesn't matter.
The person still needs endoscopy to make the diagnosis, and often actually to treat it, I guess that's a misconception, is that even though those are anatomical abnormalities, they tend to cause intermittent dysphagia. [Dr. Stern] You know, that made me think of another entity I wasn't going to bring up, but we should, which is esophageal spasm. [Dr. Cifu] Ah, yeah.
[Dr. Stern] So esophageal spasm occurs when someone swallows funny and it's not that food is stuck, it's that the esophagus literally cramps. [Dr. Cifu] Yeah. [Dr. Stern] And the story is so characteristic as to be almost pathognomonic. Somebody swallows, they get an "Um," I've had this, so I know what this feels like, and incredibly intense cramp in middle the chest. If it didn't go away, you'd be in the emergency room in about 10 minutes.
And then they know to just wait and over a period of a minute or two, it lets go and they can swallow again. [Dr. Cifu] Right. And esophageal spasm is one of the things that actually undermines the predictive value of response to nitrates for chest pain- [Dr. Stern] Oh fascinating. [Dr. Cifu] -which, and this is old literature, you know, this is like sort of from the 1970s when it was like, oh, someone's in the emergency room, let's give a nitrate.
And if they respond, it's angina, and if not, it's not, turns out it doesn't work very well, and it's probably because of esophageal spasm. [Dr. Stern] So the nitro relieves the esophageal spasm. So I'm just going to keep some of those at home. [Dr. Cifu] I think that would be good. Your spasm would go away, but you'd pass out because your blood pressure's bubbling like 90- [Dr. Stern chuckles] Then I'd call you for that.
[Dr. Cifu] Wonderful. [Dr. Stern] Okay. Pet peeves. I don't have any. I'm sure you do? [Dr. Cifu] I do. And interestingly, this comes from, you've talked about your history with esophageal spasm, I'll talk about my history with food impaction. And so my pet peeve is dithering when there's acute dysphagia. Okay? So if somebody calls you and they say, you know, "I was just eating dinner and I was eating in this order," it turns out "beef, chicken or turkey" are the main causes, "and all of a sudden, I couldn't swallow anymore, you know, I couldn't vomit, nothing was happening.
And I just kept on going to the bathroom and like spitting up a lot of like saliva and mucus and stuff," that person's got a food impaction. Okay? And that person needs to go to the emergency room where they're going to get glucagon first, which might relax the esophagus and let them pass the food impaction through, or they need an endoscopy. Waiting on that, making the person wait till the next morning, making the person go to urgent care, total waste of time.
Just treat the damn person. [Dr. Stern chuckles] I bet I know what time of the year turkeys get stuck, can you imagine in the emergency room? Oh it's Thanksgiving, we're going to have turkey impactions. [Dr. Cifu] That sounds like a bad night. [Dr. Stern] Oh my God. All right. Pearls, go ahead. [Dr. Cifu] Pearls. I think we may have a bunch of these. [Dr. Stern] We have a list here.
[Dr. Cifu] Okay. So this, I just wanted to restate, I said this at the beginning and I say this all the time when I've got students working with me, dysphagia is one of those few concerns that like just always calls for an evaluation. You know, the only time that you'll see dysphagia and you'll be like, "Eh, dysphagia," is when you've already worked it up, right? And I got a lot of people with esophageal spasm, with esophageal webs, things like that, who are like, "I'm done with the evaluation of this, I don't want to go through it again.
I've learned how to live with it, leave me alone." But if it's someone presenting new, you got to work that up. [Dr. Stern] Right. I totally agree with that. And so my next one you've actually mentioned, but I'll reiterate it, which is if you get somebody who's having dysphagia and they're coughing at the time, then you think of oropharyngeal disorders because that obviously suggests that they're having trouble getting it past the trachea, and you want to look for a swallowing study in that patient.
[Dr. Cifu] Great. I want to throw out for clinical pearls, a couple of zebras, and these are not total zebras, these are actually things that I've taken care of in the last, I don't know, let's say three to five years. One is called dysphagia aortica, okay? And that's where, because of an aortic aneurysm, you actually put pressure on the esophagus and people have trouble swallowing because of external compression from the aorta, like how scary is that?
[Dr. Stern] So the good news, Mrs. Jones, is that you don't have cancer of the esophagus. The bad news is you have an aneurysm- - [Dr. Cifu] Right. - [Dr. Stern] -that's ready to explode in the middle of your chest. Is that what you're saying? [Dr. Cifu] Exactly. We pretty much need to go directly to the vascular surgeon. [Dr. Stern] Oh, My God.
[Dr. Cifu] And the other one, which is actually more common, is compression of the esophagus from cervical osteophytes. I guess you could see this in, you know, regular osteoarthritis, but it's much more common in people with DISH, diffuse idiopathic skeletal hyperostosis, right? Where you get that sort of flowing extra bony growth over the spine, and that can become bulky enough that it can actually compress the esophagus and cause dysphagia.
[Dr. Stern] That sounds hard to fix. [Dr. Cifu] Yeah. That's really hard to fix. Often it's figuring out like, is there also something easier to fix anterior to the esophagus, which is pushing the esophagus back? So maybe the esophagus is sort of squeezed, you know. [Dr. Stern] Just move the heart maybe? [Dr. Cifu] It's often like substernal thyroid behind, bone in front, and it's a whole lot easier to get the thyroid out of the way than the bony growths.
[Dr. Stern] My next one you've touched on this as well earlier but there are certain underlying conditions that really increase the likelihood of very specific problems with the esophagus. Prior radiation makes stricture much more likely as does a prior caustic injury. I have to say, I don't think in my whole career have I ever seen a caustic injury to the esophagus, but certainly mentioned a lot in the literature.
[Dr. Cifu] Yeah. I've taken care of one person in my career, very sad case, who had a suicide attempt with a caustic substance, which this person survived, but then, you know, had a really sort of morbid time afterwards because of the esophageal injury. [Dr. Stern] Hm. [Dr. Cifu] I guess maybe my next one kind of builds on that, is think about medications, right? And the two that I think come up all the time are doxycycline, the antibiotics, and the class bisphosphonates, which can cause really bad pill esophagitis, where if people either have a motility disorder to begin with, or maybe they just have a dry mouth and they're lazy and they don't drink a lot and the pill gets hung up in the distal esophagus that can really cause bad esophagitis, which can cause dysphagia, odynophagia, you know, can be kind of miserable.
[Dr. Stern] Yeah. My last one, I just want to remind everybody that there are a variety of HIV-associated immunocompromised infections of the esophagus where patients might present with dysphagia, you know, HIV-related Candida esophagitis, HIV-related herpes simplex virus, esophagitis all can make people miserable. We don't tend to see as much of it these days because more patients with HIV are diagnosed earlier in the course, but if someone's not been screened, it is conceivable that someone will present not knowing they have HIV disease, and would present with odynophagia.
So again, take odynophagia seriously. [Dr. Cifu] Some day, like 30 years from now, when you're dead and gone, and I'm still doing the podcast with somebody new- [Dr. Stern chuckles] [Dr. Cifu] -that person's always going to be bringing up COVID and I'm going to be like, "Jesus, you know, first Scott was always bringing up HIV from 20 years ago, now you bring up COVID from 20 years ago, it's going to be rough for me.
[Dr. Stern] I can't wait to see your successor. Of course, I'll be dead, But from wherever I am, I'm going to be watching. [Dr. Cifu] I just wanted to cut in when you were talking about the underlying diseases, which will sort of push something up on your differential diagnosis. You talk about this a lot when you talk about sort of your- This'll sound bad, I don't mean it to sound bad, but kind of how you think in a very organized kind of algorithmic thinking through things, because it is so true that, you know, when you're seeing someone with GI bleeding, right?
If that person is on aspirin a day, you know, that changes your differential diagnosis. And it's kind of the same with dysphagia, that there are things which given the person's past medical history will jump into a differential diagnosis that just wouldn't even be there otherwise. [Dr. Stern] Right. [Dr. Cifu] What are the terms you use for that? [Dr. Stern] So a couple of things, what I try to encourage the students to do, is once they have a differential, is what we say is to explore the differential.
And what I want them to remember is for everything on their differential, think about the risk factors for that disease and the associated symptoms, as well as the science. And what I find is, many of us know the risk factors and symptoms and signs of a disease, but we don't think to ask them of the patient when it's on the differential, but like you just said, if the script concurrence, that's our lingo for that, shows that they have those things, it does make them much more likely on a differential.
So training ourselves to look for those specifically can be very helpful. [Dr. Cifu] That's a great point. So it's almost like you develop a symptom specific review of systems, right? So it's like, okay, I know 50,000 things I could ask in a review of systems, but I have a specific dysphagia review of systems, which includes some kind of cooky things that I wouldn't - usually ask. - [Dr. Stern] Right.
[Dr. Cifu] So you're going to turn that up. Great, thanks. So we hope that you found this episode of S2D, the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our textbook, Symptom to Diagnosis An Evidence-Based Guide, takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places, on your mobile device and also available and fully searchable via the AccessMedicine website available worldwide from McGraw Hill.
The music for the S2D podcast is courtesy of Dr. Maylyn Martinez. [Dr. Stern] Thank you. [upbeat outro music] [upbeat outro music]