Patient Name: Hazel Wood
Age: 72
Referral source: Dr. Jones, neurologist
Referral: "evaluate swallowing"
Pt status: acute inpatient
Medical History:
| Are you having any difficulty swallowing? | Yes |
| Tell me what kind trouble you are having. | Food sticks in my throat when I swallow |
| When did it start? | Last month when I had a cold |
| Did it come on gradually or suddenly? | All at once |
| Has it gotten any better or worse? | No, it's pretty much the same |
| Do you notice it all the time? | Pretty much |
| Show me where it sticks | (Points to right side of thyroid cartilage) |
| Do all things stick there? | It's worse with bread and muffins |
| Do you cough or choke? | no |
| Do you have any pain when you swallow? | no |
| Are liquids or solids easier for you? | I don't have any difficulty with liquids |
| Do have heartburn or reflux? | I take Zantac every day |
| Have you noticed any drooling or difficulty swallowing your saliva? | no |
| Does food ever go up into your nose when you swallow? | no |
| Do you have a dry mouth? | yes |
| Do you take any medications that dry your mouth? | My high blood pressure medication seems to make it worse |
| Have you lost any weight? | I wish |
| How is your appetite? | Fine |
| Have you noticed any changes in your voice? | I haven't fully gotten over this cold. I still have a frog in my throat. |
| Have you had any colds or congestion? | Yes, I had that cold a month ago and haven't gotten over it. |
Oral Mechanism Exam
| Target | Elicitation | Observations |
| Facial Symmetry | Have subject look straight at you | no asymmetries |
| Lips | Smile
Pucker Open Close tight Puff up cheeks, hold against resistance |
nl
nl nl nl nl |
| Tongue | Stick straight out
Left Right Left and Right quickly Elevation Retraction Protrusion & lateral movement against resistance (with tongue blade) |
nl
nl nl nl nl nl nl |
| Oral Cavity | Open wide | Upper and lower dentures
Jaw ROM wnl |
| Velum | Say "ah"
Elicit gag reflex by touching anterior faucial arches, posterior faucial arches, or base of tongue. Elicit gag on both sides |
not elicited |
| Voice | Maximum Phonation Time
s:z ratio Pitch glides |
"ah" = 16
"sss" = 15 "zzz" = 17 pitch assessed informally wnl vocal quality slightly hoarse and wet |
Bedside Swallowing Assessment
| Observation | Liquid (water, coffee) | Puree (applesauce) | Solid (bread, cookie) |
| Oral | |||
| Lip seal | nl | nl | nl |
| Bolus formation, chewing | nl | nl | prolonged |
| Retention | none | none | none |
| Reflex | prompt | prompt | delayed? |
| Pharyngeal | |||
| Laryngeal elevation | nl | nl | nl |
| Coordination (repeated swallows, 4 point test) | nl | nl | disrupted |
| Cough | none | none | none |
| Vocal quality | unchanged | unchanged | unchanged |