Medical Mystery: What caused woman’s unusual swallowing trouble?

I saw Mrs. M for an office visit only a few weeks after she was sent home from the hospital where she was treated for a bowel obstruction. We try to see patients in our primary-care office soon after discharge, to ensure that they understand their condition and that it is improving, and to review any new medications or treatments.

This patient, however, had a mysterious new problem to report. Shortly after returning home, Mrs. M complained of trouble swallowing. She had already been back to her gastrointestinal specialist since discharge, but the cause of her swallowing difficulty remained elusive.

It was time to take a step back and reassess her symptoms, listen carefully to her story, and try to unravel the cause.

As part of her hospital treatment, Mrs. M required placement of a nasogastric (NG) tube. This is a thin, plastic, lubricated tube that was inserted through her nose and threaded down into her stomach, and then attached to suction. The NG tube helped remove fluid from her stomach and intestines, relieving her bloating, pain and nausea until the blockage resolved. After a few days, her bowels began to move again, and the tube was removed. She was initially allowed to drink liquids, which she could sip though a straw, but when her diet was advanced to include solid food, she ate only some small bites.

Her care team was concerned about her apparently poor appetite, but expressed confidence that it would improve once she returned home. She knew that her appetite wasn’t the problem. But she thought if she mentioned her trouble swallowing, she’d be stuck in the hospital. She really longed to get home.

“Tell me what it is like for you, when you try to eat solid food,” I said.

What she described was not so much a mechanical struggle, but a sense of terror as soon as she put food in her mouth. When I asked her to tell me more about her experience in the hospital, she was quick to say that her doctors had an unusually difficult time placing this NG tube, and how thankful she was to eventually have it removed. The tube had tangled in her throat twice, which caused her to gag, and feel as if she couldn’t breathe.

She was not physically injured in the process, but had been emotionally traumatized by her experience with the NG tube. After acknowledging how terrifying this was for her, her symptoms eventually resolved with reassurance, close phone follow-up, and a small dosage of anti-anxiety medicine.

Primary care physicians (PCPs) are trained to see patients not as a collection of signs and symptoms, but as multifaceted people with feelings, values, connections, stories, and circumstances. Other specialists share these concerns, but have competing obligations to provide highly focused assessment in a narrow area.

Physicians must all collaborate effectively, and it is the PCP’s foremost charge to understand our patients in the most complete possible way. We may see you in exam rooms, hospitals, and sometimes even procedure suites and operating rooms. But our most productive work spaces are relationships. Mrs. M is a patient who needed both a wide angle and a narrow focus.

Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices at Penn Medicine.