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Fred is a 60-year-old healthy appearing man with a diagnosis of undifferentiated schizophrenia who is referred to your Outpatient Swallowing Clinic with complaints of “solid food sticking in his throat” and extreme “fear of choking.” By patient report, the problem has been present since he was 10-years old, following tonsillectomy surgery. There is no confirmation of this complaint in his medical record. He also expresses concerns regarding the government using x-rays to read his mind. From the list below, which of these subjective signs/symptoms would be most concerning and prompt you to proceed with a referral for additional examinations? A. Fred’s report of losing weight at the rate of 2-pounds over the last month—This reported degree of unexplained weight loss is reason to suspect dysphagia and warrants a referral to gastroenterology. B. A documented history of viral pneumonia—A history of any infection involving the lungs, combined with the patient’s report of food sticking would prompt a clinician to proceed with a radiological swallow examination. C. The patient’s complaint of a dry mouth, confirmed on oral inspection—Dry mouth could certainly be a major contributing factor to food sticking and fear of choking. A radiological swallow examination is warranted to assess oral and pharyngeal stages of swallowing and referral to otolaryngology is required to assess salivary gland function. D. D. Your perception of pronounced hyponasal resonance in the patient’s otherwise normal speech—Changes in resonance quality, particularly hypernasality, can be an indication of dysarthria. Hyponasality is not associated with dysarthria, but rather with a nasopharyngeal obstructive condition that requires further assessment

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