Note: All identifying information removed for patient confidentiality.
Speech Therapy
Evaluation
Pt presents with with mild-moderate oral pharyngeal dysphagia c/b decreased lingual
coordination resulting in premature spillage into the pharynx with all consistencies and
mild oral residue along the tongue with all consistencies. Delayed triggering of
pharyngeal swallow resulted in pooling in the valleculae with all consistencies with
continued pooling to the piriform sinuses with pudding and peaches. Decreased
hyolaryngeal elevation/excursion resulted in penetration to the true vocal folds during
self regulated sips of thin liquids through a straw only. No aspiration noted. Decreased
BOT retraction and epiglottic inversion noted which resulted in mild vallecular residue
s/p 10cc, 20cc, and self regulated sips of thin liquids; moderate vallecular residue with
5cc sips of thin and 1 inch bite of graham cracker; severe vallecular residue with 1 tsp
bite of pudding . Decreased pharyngeal wall constriction resulted in mild residue along
the posterior pharyngeal wall with 10cc thin, 1tsp pudding, 1 tsp peaches, and 1 inch bite
of graham cracker. Pharyngeal residue was cleared with multiple effortful swallows and
liquid rinses. Recommended at this time: 1. Thin liquids 2. Dental soft 3. No straws 4.
Alternate sips and bites 5. Multiple effortful swallows 6. Seated upright for meals 7. F/u
with ST for dysphagia therapy and diet f/u.
07/16/15 1045
Speech Time Calculation
Speech Start Time 1045
Speech Stop Time 1105
Speech Total (min) 20 min
General Information
SLP Treatment
00/00/15
Date
Referring Physician XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
General
Pt alert, communicative. Seated upright in swallow study chair for MBSS
Observations
Pertinent History of
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Current Problem
Moderate bilateral lower lobe atelectatic versus consolidative change overlying
Chest X-ray results
bilateral pleural fluid left greater than right.
CT/MRI results
none on file
Current Respiratory
nasal cannula
Status
General
standard;fall;aspiration
Precautions
Current Diet
Current Liquid
Nectar Thick
Consistencies
Subjective
Patient states
Removed for patient confidentiality
Family states
none present
Pain/Comfort
Pain Rating
no pain
Pain Comment
No complaints
Oral Musculature Evaluation
Oral Musculature
WFL
Dentition
rarely or never uses dentures to eat
Mucosal Quality
adequate
Mandibular
Strength and
WFL
Mobility
Oral Labial Strength
WFL
and Mobility
Lingual Strength
WFL;functional protrusion;functional anterior elevation;functional lateral
and Mobility
movement;functional strength
Velar Elevation
WFL
Buccal Strength
WFL
and Mobility
Volitional Cough
elicited
Volitional Swallow timely
Voice Prior to PO
clear
Intake
MBS Evaluation
Additional
Yes
Documentation
MBS Eval: Thin Liquid Trial
Mode of
Presentation, Thin cup;straw;self fed
Liquid
Volume of Thin
5cc, 10cc, 20cc sips; self regualted sips from cup and straw
Liquid Presented
Oral Prep/Phase,
premature spillage
Thin Liquid
Oral Residue, Thin back posterior tongue;mid posterior tongue;other (see comments)
Liquid
(BOT residue noted on 20cc sip)
decreased base of tongue retraction;decreased pharyngeal wall
Pharyngeal Phase, contraction;delayed pharyngeal swallow;no epiglottic inversion;premature
Thin Liquid
spillage;pyriform sinuses stasis;reduction in laryngeal elevation;reduced
hyolaryngeal excursion;scattered pharyngeal residue;vallecular stasis
Rosenbeck's 8(4) Material enters the airway, contacts the vocal folds, and is ejected from the
Point Penetrationairway.
Aspiration Scale,
(with straw sips)
Thin Liquids
Penetration/Aspirati Penetration to the vocal folds noted with straw sips. Cleared before entering the
on, Thin Liquid
airway.
Successful
Strategies Trialed
effortful swallow;multiple swallows
During Procedure,
Thin Liquid
Diagnostic
Statement
Pt presented with moderate oral pharyngeal dysphagia c/b decreased BOT
reraction, decrease hyolaryngeal elevation/excursion, and decreased epiglottic
inversion.
Additional
Okay to consume thin liquids. No straws
Comments
MBS Eval: Pureed Trial
Mode of
spoon;self fed
Presentation, Puree
Volume of Puree
1tsp bite of pudding
Presented
Oral Prep/Phase,
premature spillage
Puree
decreased pharyngeal wall contraction;delayed pharyngeal swallow;no epiglottic
Pharyngeal Phase, inversion;premature spillage;pyriform sinuses stasis;reduction in laryngeal
Puree
elevation;reduced hyolaryngeal excursion;scattered pharyngeal residue;vallecular
stasis
Rosenbeck's 8Point Penetration(1) Material does not enter airway.
Aspiration Scale,
Pureed
Penetration/Aspirati
No penetration or aspiration noted
on, Pureed
Successful
Strategies Trialed
effortful swallow;multiple swallows
During Procedure,
Puree
Pt preseted with moderate oral pharyngeal dysphagia c/b decreased BOT
Diagnostic
retraction, decreased pharyngeal constriction, decreased hyolaryngeal
Statement
elevation/excursion, decreased epiglottic inversion
Additional
Okay to consume with aleternating sips/bites and multiple effortful swallows.
Comments
MBS Eval: Soft Solid Trial
Mode of
Presentation,
spoon;self fed
Semisolid
Volume of
Semisolid Food
1 tsp bites of peaches
Presented
Oral Prep/Phase,
premature spillage
Semisolid
decreased base of tongue retraction;decreased pharyngeal wall
Pharyngeal Phase, contraction;delayed pharyngeal swallow;premature spillage;pyriform sinuses
Semisolid
stasis;reduction in laryngeal elevation;reduced hyolaryngeal excursion;scattered
pharnygeal residue;vallecular stasis
Rosenbeck's 8Point Penetration(1) Material does not enter airway.
Aspiration Scale,
Semisolid
Penetration/Aspirati
No aspiration or penetration noted
on, Semisolid
Successful
Strategies Trialed
effortful swallow;multiple swallows
During Procedure,
Semisolid
Pt preseted with moderate oral pharyngeal dysphagia c/b decreased BOT
Diagnostic
retraction, decreased pharyngeal constriction, decreased hyolaryngeal
Statement
elevation/excursion, and decreased epiglottic inversion
Additional
Okay to consume with aleternating sips/bites and multiple effortful swallows.
Comments
MBS Eval: Solid Food Texture Trial
Mode of
self fed
Presentation, Solid
Volume of Solid
1 inch graham cracker square
Food Presented
Oral Prep/Phase,
premature spillage
Solid
decreased base of tongue retraction;decreased pharyngeal wall contraction;no
Pharyngeal Phase,
epiglottic inversion;premature spillage;pyriform sinuses stasis;reduction in laryngeal
Solid
elevation;reduced hyolaryngeal excursion;vallecular stasis;vallecular pooling
Rosenbeck's 8Point Penetration(1) Material does not enter airway.
Aspiration Scale,
Solid
Penetration/Aspirati
No aspiration or penetration noted
on
Successful
Strategies Trialed
effortful swallow;multiple swallows
During Procedure,
Solid
Pt preseted with moderate oral pharyngeal dysphagia c/b decreased BOT
Diagnostic
retraction, decreased pharyngeal constriction, decreased hyolaryngeal
Statement
elevation/excursion, and decreased epiglottic inversion
Additional
Okay to consume with aleternating sips/bites and multiple effortful swallows.
Comments
Recommendations
NPO
No
Solid Diet Level
Dental Soft
Thin
Liquid Diet Level
(no straws)
Additional
1. Upright for meals 2. Alternating sips and bites 3. multiple effortful swallows 4. no
Recommendations straws
Plan
Plan
Dysphagia Therapy;Patient Education
Therapy Frequency minimum of 3 times a week
Plan of Care
00/00/15
Expires on
SLP Follow-up
SLP Follow-up?
Yes
SLP - Next Visit
00/00/15
Date
Treatment/Billable Minutes
Motion Fluoro
20
Swallow, Cine/Vid
Total Time
20
Katherine Kampen, B.S.
Speech Pathology Graduate Clinician
LSUHSC