Speech Language Pathology – Swallowing Assessment
Initial Summary: FORMTEXT Mrs. Illtoe is a 67-year-old female. She is married and has three adult children. Mrs.Illtoe's past medical history includes bilateral ptosis (drooping eyelids) and fatigue with no specified diagnosis. Oral Mechanism Examination: FORMTEXT The oral mechanism examination revealed appropriate strength and mobility throughout. Left droop and right droop assymetries reference her bilateral ptosis. Cranial Nerve V (Lip Sensation) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve V (Ant. Lingual Sensation) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve VII (Lip Seal) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve VII (Ant. Lingual Taste) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve VII (Facial Symmetry) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve IX (Post. Lingual Sensation) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve IX & X (Velar Movement/Gag) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve X (Voice) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereCranial Nerve XII (Lingual strength & motility) FORMCHECKBOX WFL FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereAssymetries FORMCHECKBOX Left droop FORMCHECKBOX Right droopHyolaryngeal Excursion FORMCHECKBOX WFL FORMCHECKBOX Mild (3/4”) FORMCHECKBOX Moderate (1/2”) FORMCHECKBOX Severe (<1/2”)Clinical Bedside Swallow Evaluation: Oral Prep/Oral Phase: FORMTEXT Mrs. Illtoe revealed appropriate strength and mobility during the oral mechanism examination per clinician observation. Her swallowing structures involved within the oral preperatory and oral phases appeared within functional limits. However, mild to moderate delay of the pharyngeal swallow was noted. Pharyngeal Phase: FORMTEXT Initial presentations indicated adequate hyolaryngeal functioning within functional limits. However, Mrs. Illtoe's hyolaryngeal excursion decreased over the course of multiple presentations. Mrs. Illtoe presented with a consistent cough following the swallow of densely textured solids. Coughing may be an indication of residuals with the pharyngeal cavities.Esophageal Phase: FORMTEXT The patient reported no feelings of pain or tightness in the throat or chest, indicating esophageal functioning within functional limits.Summary: FORMTEXT This clinical bedside swallow evaluation was not representative of a normal swallow. The patient demonstrated mild oral dysphagia and moderate pharyngeal dysphagia. Initially, Mrs. Illtoe's voice was clear and well articulated, which may relate to her intact oral strength and mobility during the oral mechanism examination. However, her articulatory precision declined throughout the session, which may demonstrate decreased endurance and increased fatigue of the oral structures over time. Changes in Mrs. Illtoe’s voice were noted thoughout the presentations of liquids and solids. Her voice following thin liquids was clear, indicating effective pharyngeal clearance. Her voice became wet and gurgly following the swallows of nectar to honey thick liquids. This change in resonance may be due to residuals within the pharyngeal cavity following presentations of thick liquids. Dense solids were consistently followed by a cough, which may be another indication of pharyngeal residuals. A decline in her hyolaryngeal excursion and a delay in pharyngeal swallow onset was also noted thorughout the assesment. Coughing and declined hyolaryngeal excursion also raises concerns of potential penetration and/or aspiration. The esophageal phase appears to be within functional limits.Videofluroscopic Swallowing Evaluation:Oral Prep/Oral Phase: FORMTEXT The oral preparatory phase and the oral phase are within functional limits. The patient demonstrated efficient oral transit.Pharyngeal Phase: FORMTEXT The pharyngeal phase became increasingly impaired over time, resulting in a moderate impairment. Mrs. Illtoe demonstrated effective pharyngeal transit and complete clearance over the first several presentations. As the study progressed, nectar to honey thick liquids left mild pharyngeal residuals. Initially, solids left mild pharyngeal residuals as well. During following presentations, Mrs. Illtoe demonstrated moderate to severe pharyngeal residuals with dense solids and moderate residuals with honey thick liquids. Upon swallow completion, Mrs. Illtoe penetrated both liquid and solid residuals to the level of the vocal folds. Penetration lasted for an extended period of time. Trace aspiration was noted. Esophageal Phase: FORMTEXT The patient's esophageal phase (upper 1/3) was within functional limits.Summary Table:BolusOral PhasePharyngeal PhaseEsophageal PhaseAspiration-PenetrationThin FORMTEXT n/a FORMTEXT n/a FORMTEXT n/a FORMTEXT n/aNectar FORMTEXT WFL FORMTEXT Mild pharyngeal residuals FORMTEXT WFL FORMTEXT n/aHoney FORMTEXT WFL FORMTEXT Moderate pharyngeal residuals FORMTEXT WFL FORMTEXT (6) Trace residual material entered airway, contacted the vocal folds for an extended duration despite coughing, and then passed belowPuree FORMTEXT n/a FORMTEXT n/a FORMTEXT n/a FORMTEXT n/aBanana FORMTEXT n/a FORMTEXT n/a FORMTEXT n/a FORMTEXT n/aCake FORMTEXT WFL FORMTEXT Moderate to severe pharyngeal residuals FORMTEXT WFL FORMTEXT (6) Trace residual material entered airway, contacted the vocal folds for an extended duration despite coughing, and then passed belowCookie FORMTEXT WFL FORMTEXT Moderate to severe pharyngeal residuals FORMTEXT WFL FORMTEXT (6) Trace residual material entered airway, contacted the vocal folds for an extended duration despite coughing, and then passed belowSummary: FORMTEXT Mrs. Illtoe demonstrated moderate to severe pharyngeal dysphagia. Results indicate an overall dyscoordination of the patient’s swallowing mechanism. The worsening nature of the impairment is a result of factors contributing to weakness of the pharyngeal structures and musculature. This results in paitent fatigue.Penetration and trace aspiration of honey-thick and dense solid residuals was observed. Compensatory strategies of the effortful swallow and the liquid wash were examined during the videofluroscopy. The effortful swallow was intially effective to clear oral and pharyngeal residuals, but quickly increased Mrs. Illtoe's fatigue and decreased her swallowing safety. Mrs. Illtoe would only benefit from the effortful swallow if used sparingly (1-2x per meal) and continuation of the strategy should based on her response. The liquid wash strategy effectively eliminated honey-thick and dense solid residuals from the pharyngeal cavity. It is recommended Mrs. Illtoe use the liquid wash strategy during each meal to increase swallowing safety. Mrs. Illtoe would also benefit from alternating food textures throughout each meal to facilitate the clearing of any residuals. Specifically, a dysphagia mechanically altered (NDD 2) diet with thin liquids is reccommended. Minimal to no assistance is needed. This information should be considered alongside her diagnosis before treatment and intervention begins. For a complete evaluation, Mrs. Illtoe is being referred to neurologist Dr. Jerry Hoepner to rule out any neurological disorders related to her increasing fatigue and weakness.Recommendations/Goals: FORMTEXT Diet:Long Term: Mrs. Illtoe will tolerate a least restrictive diet during each meal, for a minimum of two weeks to ensure swallowing safety.Short Term: Mrs. Illtoe will tolerate a NDD 2 diet with thin liquids, for a minimum of two weeks to ensure swallowing safety. FORMTEXT Compensatory Strategies:Long Term: Mrs. Illtoe will independently implement the swallowing strategy "liquid wash" during each meal to increase swallowing safety by clearing residuals, per self report.Short Term: Mrs. Illtoe will implement the swallowing strategy "liquid wash" following staff and/or a trained family member cues during each meal to increase swallowing safety by clearing residuals for at least two weeks. FORMTEXT Patient and Family EducationLong Term: After prompted by the clinician, Mrs. Illtoe and family will demonstrate an understanding of her current swallowing status, diet modifications, and compensatory strategies to facilitate swallowing success by verbally sharing information and answering questions.Short Term: Mrs. Illtoe and family will be provided with information on Mrs. Illtoe's current swallowing status, diet modifications, and compensatory strategies to facilitate swallowing success in a variety of modalities (e.g., both verbal and visual information) over two consecutive weeks. FORMTEXT ????? FORMTEXT ?????Speech Language Pathologist: FORMTEXT Piper Doering ................
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