OLD MALE PRESENTING WITH DIFFICULTY SWALLOWING
AT OUTPATIENT CLINIC WITH LABORATORY AND
IMAGING CAPABILITIES
,PATIENT INFORMATION
Name: Don Payne
Age: 72 years
Sex: Male
Height: 5′10″ (178 cm)
Weight: 180.0 lb (81.8 kg)
Location: Outpatient clinic with laboratory and imaging capabilities
Reason for Encounter: Difficulty swallowing
Don Payne is a 72-year-old male who presents with progressive difficulty
swallowing (dysphagia) that has been worsening over time, leading to weight
loss and concerns about his ability to eat safely and maintain nutrition.
, REASON FOR ENCOUNTER
The patient presents with dysphagia — the inability to swallow solids and/or
liquids comfortably — which has progressively interfered with oral intake, led
to choking episodes, and contributed to decreased appetite and unintended
weight loss.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Difficulty swallowing (dysphagia)
Onset Gradual, over several weeks
Duration Persistent, worsening
Location Throat and esophageal region
Feeling of food sticking, choking episodes, coughing
Characteristics
while eating
Aggravating factors Swallowing solids or liquids
Relieving factors Small sips of water, rest between bites
Associated Unintended weight loss, occasional coughing during
symptoms meals
Systemic concerns No fever, night sweats
Patient goals Identify cause, restore safe swallowing, prevent aspiration