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A good clinical history and physical exam are critical when evaluating all patients with dysphagia. Along with the timing and location of the dysphagia, it is important to elicit: (i) the type of food (solid or liquid) that produces symptoms; (ii) the frequency of symptoms (if symptoms are consistent, progressive, or intermittent); (iii) the onset of symptoms (acute or gradual over time); (iv) the duration of symptoms; and (v) the presence of any associated symptoms such as weight loss, regurgitation, or oropharyngeal symptoms. Taking a thorough medication history is essential, as medications such as nonsteroidal anti‐inflammatories (NSAIDs), potassium supplementation, vitamins, and bisphosphonates are all well‐known to cause pill esophagitis [17]. In patients with suspected eosinophilic esophagitis, it is also important to ask about a history of asthma, eczema, or any known food or environmental allergies. A short duration of symptoms, in the setting of significant weight loss, is suggestive of a malignant etiology.

When obtaining a patient history, it is important to remember that patients with chronic conditions often develop compensatory strategies and techniques to help ease their symptoms. This is often the case for patients with dysphagia. Patients may avoid their most troublesome foods, eat more slowly or consistently be the last person to finish a meal, or dunk solids into liquids to moisten them prior to swallowing. Some patients may report that they do not have any difficulty swallowing, but a more detailed dietary history will reveal that they are avoiding entire groups of foods. In addition, some patients may avoid social situations such as family meals or meals with colleagues at work, due to embarrassment at their symptoms. Often, accompanying family members help to provide key portions of a patient’s history, as the patient may have consciously or subconsciously adapted to their symptoms [18].

While often unremarkable, a good physical exam is important in all patients with dysphagia, especially those with suspected oropharyngeal dysphagia. A neurologic exam, including an examination of the cranial nerves, should be performed to evaluate for potential underlying neurologic etiologies. This includes assessing for any asymmetry, dysarthria, tongue fasciculation, tremor, and cognitive dysfunction. An oral exam is important to assess for poor dentition or if a patient is edentulous, as well as for buccal lesions, which may suggest lichen planus. The neck should be palpated for lymphadenopathy and an enlarged thyroid. Patients should also be examined for calcinosis, Raynaud’s phenomenon, sclerodactyly (thickness or tightness of the skin), and telangiectasias, which will suggest CREST syndrome and concomitant esophageal dysmotility.