A 76-Year-Old Man with Multi-Infarct Dementia Comes to the Emergency

A 76-year-old man with multi-infarct dementia comes to the emergency department due to cough and low-grade fever.  He was treated for pneumonia twice in the last year.  For the past 6 months, he has had difficulty swallowing and has occasionally regurgitated undigested food.  The patient has a lengthy history of hypertension and chronic atrial fibrillation.  BMI is 22 kg/m².  Temperature is 38.5 C (101.3 F) , blood pressure is 150/95 mm Hg, pulse is 102/min, and respirations are 16/min.  Physical examination is notable for foul-smelling breath and a fluctuant mass in the left neck.  Auscultation shows crackles in the right lung base.  Chest x-ray shows an infiltrate without cavitation in the right lower lung field.  The patient is admitted to the hospital, sputum and blood cultures are sent to the laboratory, and antibiotics are started.  A few days later, the patient's condition is markedly improved.  Which of the following is the most appropriate next step in management of this patient?

A) Bronchoscopy
B) Contrast esophagography
C) Gastric feeding tube placement
D) Neck mass biopsy
E) Upper gastrointestinal endoscopy

Correct Answer:

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