Download A. Medical History

CLINICAL EVALUATION OF SWALLOWING
Patient Name:
Date:
Patient DOB:
Clinician:
Patient Weight:
Height:
Gender: Male Female
PU
R
PO
SE
S
A. Medical History
FO
Date of Onset:
Medications:
Medical Diagnosis(es):
Surgical History
(include approximate
dates):
N
O
C
T
O
N
O
D
R
ED
U
C
AT
IO
Concern on referral:
Primary Patient
Complaint:
PY
AL
Referral Source:
___ Antidepressant; ___ Antipsychotic; ___ Sedative; ___ Antihistimine; ___ Diuretic; ___Mucosal
anesthetic; ___ Anticholinergic (please list medications below):
CLINICAL EVALUATION OF SWALLOWING
Related Medical
History:
Cardiac:
SE
S
Gastroenterology (GI):
Pulmonary:
PO
Neurological:
PU
R
Otolaryngology (ENT):
N
Speech-Language Pathology:
FO
R
Respiratory Status:
O
C
T
O
N
O
ED
U
Occupation:
D
Primary language(s):
C
AT
IO
Social/Family:
Hearing Status:
PY
AL
Dental:
YES NO Ventilator Dependent?
YES NO Tracheostoma without tube?
YES NO Tracheostomy Tube (If Yes, identify type:____________________________________)
___ Cuffed ___ Uncuffed ___ Fenestrated ___ Passy Muir valve ___ Finger occluded
Other pertinent information (e.g. duration of placement, progression in transitioning to
independent breathing, hygiene status, etc.):
CLINICAL EVALUATION OF SWALLOWING
B. Patient Status and Observations
YES
The patient is alert and oriented to time and place
The patient is attentive and responds appropriately to questions
SE
S
The patient appears confused, disoriented, or unable to respond
appropriately to questions
PO
The patient appears ___ lethargic ___ sedated ___ unresponsive
R
The patient is cooperative
PU
The patient is uncooperative
AL
The patient is able to sit upright ___ independently ___with assistance
O
IO
N
PY
The patient is unable to sit upright without assistance
C
C
AT
The patient is able to ambulate ___ independently ___with assistance
O
T
The patient is immobile ___requires a wheelchair ___bedridden
N
ED
U
The patient is able to feed themselves independently
O
D
FO
R
The patient requires adapted eating utensils or products to feed
independently
The patient is eating an oral diet ___without modification ___with
modification or restriction
The patient is not eating an oral diet ___NG ___NJ ___PEG ___TPN
The patient is able to maintain oral hygiene ___independently ___with
assistance
The patient exhibits poor oral hygiene
OTHER OBSERVATIONS:
NO
CLINICAL EVALUATION OF SWALLOWING
YES
C. SIGNS AND SYMPTOMS:
Increased duration of meals
Frequent or excessively dry mouth
SE
S
Coughing/choking associated with eating
Food or pills get stuck (ask them to point to location):
PO
Food remains in the oral cavity when eating, or pockets between the teeth and
inside of the cheek(s)
Food or liquid come out of the nose
N
Feel a burning sensation
PY
AL
Food or liquid spill from the mouth while eating
PU
R
Sensation of a lump in the throat
O
IO
Experiences heartburn, indigestion, or burning in the chest associated with
eating
C
C
AT
Experiences a wet or gurgly voice quality associated with eating
T
N
ED
Difficulty swallowing liquids
O
U
Experiences an increased body temperature, or spikes a fever within an hour of
eating a meal
O
D
R
Difficulty swallowing thicker foods that are not solid such as applesauce,
mashed potatoes, or cooked vegetables
FO
Difficulty swallowing solid foods such as meat or raw vegetables
Frequent throat clearing associated with eating
Changes in smell (describe):
Changes in taste sensation (describe):
Onset of eating and swallowing problems was ___Sudden ___ Gradual
(describe duration of onset):
Swallowing problems occur during specific meals: ___Breakfast ___Lunch
___Dinner ___Snacks
Swallowing problems occur during specific times of day: ___Morning
___Afternoon ___Evening ___Waken during the night
OTHER SIGNS AND SYMPTOMS:
NO
CLINICAL EVALUATION OF SWALLOWING
D. OROPHARYNGEAL SENSORY MOTOR EXAMINATION
SENSE OF SMELL (CN I): Ask the patient to close their eyes and to tell you if and
when they smell each of the following (do not tell them what you are offering, ask them).
Indicate which of the following they correctly identified:
Chocolate
Coffee
Peppermint
PO
SE
S
Orange rind
FACE & LIPS (CN VII):
I
II
III
IV
PU
R
If asymmetrical at rest, identify the abnormal facial quadrant
Using the diagram to the right: QUADRANT I II III IV
O
C
T
O
U
C
AT
IO
N
PY
AL
Describe abnormal appearance:
N
O
D
ED
SENSORY MOTOR EXAMINATION OF THE OROPHARYNGEAL MECHANISM FOR EATING
FO
R
FACE & LIPS (CN V & CN VII)
RESTING OBSERVATION
The face is symmetrical at rest:
Lip tremor observed:
Adequate lip closure at rest:
YES NO
L/R
Strength
Sensation
ROM Impaired Impaired
Impaired (1 =
(1 = mild, 2 = (1 = mild, 2
mild, 2 = mod,
mod, 3 = severe) = mod, 3 =
3 = severe)
severe)
CLINICAL EVALUATION OF SWALLOWING
FACE & LIPS (CN V & CN VII)
YES NO
L/R
Strength
Sensation
ROM Impaired Impaired
Impaired (1 =
(1 = mild, 2 = (1 = mild, 2
mild, 2 = mod,
mod, 3 = severe) = mod, 3 =
3 = severe)
severe)
SE
S
MOVEMENT ASSESSMENT
Lift the eyebrows, or try to look at the ceiling
to wrinkle the forehead:
PO
Close eyelids tightly against resistance:
Smile widely so that the teeth show:
PU
R
Pucker the lips as though kissing:
Alternate smiling and puckering the lips as fast
as possible for 7 seconds:
O
IO
Puff out the cheeks and hold air in the mouth:
N
Frown while showing teeth (grimace):
O
O
D
ED
FO
R
N
U
Move mouth from side to side:
Say the sound, "ooh." (lip rounding during
speech):
Say the sound, "ee." (lip spreading during
speech):
Alternate saying "ooh ee ooh ee…" as quickly
as possible for 7 seconds:
C
T
C
AT
Puff out the cheeks and hold air in the mouth
against pressure applied to each cheek and
then both cheeks:
Repeat the sound, "puh," as quickly as
possible for 5 seconds (5-7 syllables/sec =
norm for adults):
Does the patient exhibit imprecise articulation
of /p/?
SENSORY ASSESSMENT
Using a cotton ball, or Q-tip, gently touch the
regions of the 3 regions of the face supplied
by CN V and also the upper and lower lips
and note any areas of reduced sensation:
PY
AL
Smack the lips:
CLINICAL EVALUATION OF SWALLOWING
JAW & TONGUE (CN V, XII, VII, IX)
YES
NO
ROM
Strength
Impaired Impaired
L / R (1 = mild, 2 (1 = mild, 2
= mod, 3 = = mod, 3 =
severe)
severe)
SE
S
RESTING OBSERVATION
Does the jaw appear symmetrical at rest?
PO
Does the jaw appear symmetrical at rest?
R
Does the jaw exhibit a tremor?
PU
Does the jaw hang lower than normal?
PY
O
C
O
D
R
Does the tongue exhibit a scalloped appearance
around the edges (impressions from teeth)?
Does the tongue or other oral mucosa appear dry,
or exhibit signs of xerostomia?
FO
N
O
ED
U
Does the tongue exhibit unilateral grooves,
symmetric grooves, or furrows on the surface of
the tongue evidencing atrophy?
T
C
AT
IO
N
Does the patient have adequate and healthy
dentition and oral hygiene?
Does the patient exhibit poor oral hygiene and
dentition status?
Open the mouth widely - does the tongue appear
symmetrical?
Does the tongue exhibit fasciculations (the tongue
must be positioned at rest in the mouth for this
observation)?
AL
Is the patient edentulous?
Does the tongue exhibit tremor in its rest position?
Are there secretions, or signs of pocketed food
within the oral cavity or under the tongue?
Sensation
Impaired
(1 = mild,
2 = mod, 3
= severe)
CLINICAL EVALUATION OF SWALLOWING
JAW & TONGUE (CN V, XII, VII, IX)
YES
ROM
Strength
Impaired Impaired
L / R (1 = mild, 2 (1 = mild, 2
= mod, 3 = = mod, 3 =
severe)
severe)
NO
SE
S
MOVEMENT ASSESSMENT
Open mouth as wide as possible:
PO
Try to close your mouth against resistance:
R
Try to open your mouth against resistance:
PU
Now move the jaw to each side (left and right):
N
Does the patient exhibit a normal occlusion during
the bite? Or malocclusion (describe):
PY
Clench the jaw together (i.e. bite):
AL
Open and close your mouth as quickly as possible
for 7 seconds:
C
O
IO
Ask the patient to stick out their tongue and hold it
for 2 seconds or more:
FO
O
D
Lick the periphery of the lips (along the vermillion
border):
With the mouth open, place the tongue tip behind
the upper front teeth:
With the mouth open, reach the tongue tip toward
the nose:
With the mouth open, place the tongue tip behind
the lower front teeth:
With the mouth open, reach the tongue tip toward
the chin:
Retract the tongue as far into the mouth as
possible:
R
N
O
ED
U
Rapid repetitive lateral motion of the tongue
between the left and right cheeks for 7 seconds
(with the mouth held open):
T
C
AT
Rapid repetitive lateral motion of the tongue
between the left and right angles for 7 seconds
(with mouth held open):
Trace the tongue along the hard palate from behind
the teeth to as far back as possible (with the mouth
held open):
Does the patient move the tongue without needing
to move the jaw?
Sensation
Impaired
(1 = mild,
2 = mod, 3
= severe)
CLINICAL EVALUATION OF SWALLOWING
JAW & TONGUE (CN V, XII, VII, IX)
(movement assessment, contin)
YES
NO
ROM
Strength
Impaired Impaired
L / R (1 = mild, 2 (1 = mild, 2
= mod, 3 = = mod, 3 =
severe)
severe)
Sensation
Impaired
(1 = mild,
2 = mod, 3
= severe)
Using a tongue blade, ask the patient to push the
tongue tip against the tongue blade during tongue
protrusion (i.e. against resistance):
SE
S
Ask the patient to push their tongue against the
inside of their left cheek against the resistance of
your finger. Repeat tongue lateral strength testing
with the right cheek:
Using a tongue blade, apply pressure to the tongue
dorsum and ask the patient to try to elevate their
tongue tip against it:
R
PO
Using a tongue blade, apply pressure to the left and
then right sides of the tongue and ask the patient to
try to resist their tongue being moved:
PU
Repeat the sound, "tuh," as rapidly as possible for
5 seconds (5-7 syllables/sec = norm for adults):
Appy the Q-tip to the hard palate and soft palate
regions along the midline while the patient keeps
their eyes closed and raise their hand when they
sense touch:
Using a Q-tip and while the patient keeps their eyes
closed, place it in a solution of 10% NaCl (salt)
and touch it to the left side of the patient's
protruded tongue and wait to see if they signal
tasting it, then test the right side of the tongue in the
same way:
Using a Q-tip and while the patient keeps their eyes
closed, place it in a solution of 10% glucose
(sugar) and touch it to the left side of the patient's
protruded tongue and wait to see if they signal
tasting it, then test the right side of the tongue in the
same way:
FO
O
C
T
O
N
D
R
ED
Using a Q-tip, apply light touch to the anterior left
and right sides of the tongue while the patient
keeps their eyes closed and raise their hand when
they sense touch:
O
U
Using a Q-tip, apply light touch to the posterior left
and right sides of the tongue while the patient
closes their eyes and raise their hand when they
sense touch:
PY
N
C
AT
SENSORY ASSESSMENT
IO
Does the patient exhibit imprecise articulation of
/t/?
Does the patient exhibit imprecise articulation of
/k/?
AL
Repeat the sound, "kuh," as rapidly as possible for
5 seconds (5-7 syllables/sec = norm for adults):
Repeat combinations of "puh tuh," "tuh kuh," and
"puh tuh kuh" as rapidly as possible for 5 seconds
(5-7 syllables/sec = norm for adults):
CLINICAL EVALUATION OF SWALLOWING
HARD/SOFT PALATE, PHARYNX, LARYNX (IX, X, XI)
YES
NO
ROM
Strength
Sensation
Impaired Impaired (1 Impaired (1
(1 = mild, = mild, 2 = = mild, 2 =
2 = mod, 3 mod, 3 =
mod, 3 =
= severe)
severe)
severe)
L/R
RESTING OBSERVATION
SE
S
Do the palatal arches appear symmetrical?
Does the hard palate appear intact? (If no, note cleft side, etc)
PO
Does the vault of the hard palate appear normal? (If no, note
abnormality)
Does the soft palate appear symmetrical?
R
Does the soft palate exhibit rhythmic or arrythmic movements
characteristic of a myoclonus?
PU
Do the palatal arches appear symmetrical?
Do you hear audible inhalation (i.e. stridor) or wheezing?
Does the voice sound hoarse?
ED
D
O
Does the voice sound excessively breathy?
Does the voice sound wet and gurgly?
R
C
T
O
N
U
C
AT
Say the sound, "ah," loudly (not yelling, however) 5 times and note
soft palate elevation consistency and symmetry:
Do you observe lateral or posterior pharyngeal wall constriction during
sustained or repeated production of "ah"?
Is the patient's resonance normal? Or do you hear hypernasality or
hyponasality?
O
IO
N
Does the palate elevate symmetrically during sustained phonation of
"ah" (ask the patient to open their mouth wide - you may need to use a
tongue blade to hold the tongue down to get a good look at the soft
palate)
PY
AL
MOVEMENT ASSESSMENT
FO
If the voice sounds wet and gurgly, ask the patient to clear their throat
and sustained the sound, "ah," again: Does it still sound wet and
gurgly?
Ask the patient to take a deep breath and then bear down while holding
their breath - can they hold their breath? Or do they exhibit air leakage
during this task?
Ask the patient to hold their breath for as long as possible and time
how long they can do this (30-60 seconds is average):
CLINICAL EVALUATION OF SWALLOWING
HARD/SOFT PALATE, PHARYNX, LARYNX (IX, X, XI)
(Movement Assessment, continued)
YES
NO
ROM
Strength
Sensation
Impaired Impaired (1 Impaired (1
(1 = mild, = mild, 2 = = mild, 2 =
2 = mod, 3 mod, 3 =
mod, 3 =
= severe)
severe)
severe)
L/R
SE
S
Ask the patient to perform a sharp cough - rate the cough using these
descriptors:
a. The cough was brisk with sharp hard onset of voicing followed by a
strong audible exhalation
PO
b. Mildly weak cough
c. Moderately weak cough
R
d. Severely weak cough
PU
e. Unable to produce a voluntary cough
Do you feel elevation of the larynx during a dry swallow?
AL
SENSORY ASSESSMENT
O
IO
N
PY
Does the patient gag or show sensitivity to touch of a tongue blade or
Q-tip to the posterior 1/3 of the tongue?
Does the patient gag or show sensitivity to touch of a tongue blade to
the posterior oropharynx?
C
C
AT
E. Respiratory Assessment:
ii)
Ability to complete a dry swallow during quiet breathing without discomfort:
N
O
T
Record the number of breaths taken per second: ______ (norm = 12 – 16)
U
i)
R
O
Duration of breath holding (instructed above):
FO
iii)
D
ED
___YES ___NO (If no, describe the breathing pattern relative to swallowing)
F. Food Assessment:
If the patient has been NPO before now, make sure they have completed oral hygiene
cleaning before administering anything orally.
If the patient has been eating orally, ask them to bring food they are currently eating, or
observe during their meal time.
FO
O
C
T
O
N
O
D
R
ED
U
C
AT
IO
N
PY
AL
PU
R
PO
SE
S
CLINICAL EVALUATION OF SWALLOWING
CLINICAL EVALUATION OF SWALLOWING
G.
Recommendations:
Oral versus Non-Oral nutrition and hydration:
Regular PO diet (unrestricted diet)
PO with modification or dietary restrictions (Specify):
SE
S
Water protocol between meals only (requires oral hygiene)
Liquids only (broth, nutritional supplements, milkshakes)
PO
Puree (specify runny versus thicker viscosity)
R
Soft and moist solids (easy to chew and easy to digest – avoid dry,
PU
dense, and stringy foods)
NPO
O
C
C
AT
Positional Strategies:
IO
Compensatory Strategies
N
Without supplemental oral intake
PY
AL
With supplemental oral intake (specify):
T
Chin tuck
O
N
U
Head turn Right vs Left (circle one)
O
ED
Lean or tilt to the Right vs Left (circle one)
D
OTHER:
FO
R
Swallowing Maneuvers:
Multiple swallows per bolus
Breath hold prior to swallow
Mendelsohn maneuver
Effortful swallow
Audible exhalation after the swallow
OTHER:
Adaptations or Compensations:
Assistance with feeding
CLINICAL EVALUATION OF SWALLOWING
Verbal cues
Food placement on plate
Complete feeding assistance by other person
Adaptive feeding device or method (refer to OT)
Alternate liquids with food
SE
S
Reduce rate of eating
Temperature of food (specify cold, room, hot):
PO
Small and more frequent meals
R
Additional Testing Needed:
PU
Gastroenterology consultation
Neurology consultation
AL
Otolaryngology consultation
N
O
IO
Dietitian consultation
C
C
AT
Home Health referral
T
Social Work assistance
O
O
Videofluoroscopy
N
U
Radiology referral
ED
PY
Occupational Therapy consultation
FO
D
R
Chest X-Ray (with physician input)
MRI (with physician input)
CT (with physician input)
Scintigraphy (with physician input)
Flexible Endoscopic Evaluation of Swallowing (FEES)
Flexible Endoscopic Evaluation of Swallowing and Sensory Testing
(FEESST)
Form taken from: Barkmeier-Kraemer J & Leonard R. (2014) Chapter 8: Clinical Swallow Evaluation. In:
Dysphagia Assessment and Treatment Planning Workbook: A Team Approach (3rd Edition), 2013. Plural
Publishing, San Diego, CA.