The patient had been seen by this department for a clinical swallowing evaluation. At that time, he had reported 3 to 4 months of coughing with liquids, approximately one time per week. He had a barium swallow, which showed one episode of aspiration with appropriate cough response. Given the patient’s complaints of coughing with thin liquids and possible reflux related symptoms, an objective swallowing evaluation was recommended. However, the patient chose not to follow up for further objective testing at that time. The patient returns today reporting that dysphagia has persisted, and now, he feels as though he can cough or choke several times a day with either liquids or solids. He is on a regular diet. He takes his pills with water without difficulty. He has a reported 5 to 10 pound weight loss over the past several months that has been unexplained. His physician has asked him to gain some weight to improve his nutritional status. He has no recent history of pneumonia. The patient does complain of feeling as though he has sluggish passage of his meals and sometimes this will cause him to stop eating early. He has a feeling of increased mucus with frequent throat clearing throughout the day, and he complains of frequent heartburn. He is not on any proton pump inhibitor regimen at this time.
PAST MEDICAL HISTORY: Coronary artery disease requiring LAD stent placement, hypertension, hyperlipidemia, asymptomatic right carotid stenosis, chronic anemia due to renal disease, chronic renal insufficiency that is stable.
CLINICAL OBSERVATIONS: The patient arrives to today’s session with his daughter. He uses a walker due to knee trouble. He is fully alert and oriented, slightly hard of hearing. He is able to provide a comprehensive history. Good speech intelligibility. Vocal quality is slightly raspy, although otherwise within normal limits for age and gender.
ORAL PERIPHERAL EXAM: The patient has naturally present dentition, in poor condition. There is bilateral palatal elevation, good lingual and labial strength and range of motion, and good ability to maintain intraoral pressure. Cough is strong and unproductive. There is good hyolaryngeal elevation and excursion to palpation.
SWALLOWING EVALUATION: Administered p.o. trials of ice chips, thin puree, and particulate solid.
ORAL PHASE: The patient is able to self-feed appropriately. He has good bolus containment and timely anterior to posterior transit with mildly delayed trigger of pharyngeal swallow overall. Question premature spillage with multiple sips of thin liquids.
PHARYNGEAL PHASE: Audible and question slightly discoordinated swallowing pattern for multiple sips of thin liquids. One swallow required for single sips of thin, puree, and particulate solids. No overt clinical signs or symptoms of aspiration after any p.o. trial; although, the patient reports that he had slight difficulty with the initial sip of water, feeling like it might head down the wrong pipe.
SUMMARY AND IMPRESSION: The patient is a (XX)-year-old male with a several year history of reported dysphagia to solids and liquids. This can happen several times per day. Clinically, he does not show significant overt clinical signs of aspiration, although question discoordinated swallowing pattern for thin liquids, especially when given larger quantities. This is likely consistent with the one incidence of symptomatic aspiration on a barium swallow in the past. The patient also complains of multiple symptoms that appear consistent with laryngopharyngeal reflux, and these include increased mucus, throat clearing, and globus sensation. He reports frequent heartburn and sensation of slow esophageal passage. At this time, would recommend objective testing to further evaluate oropharyngeal swallowing mechanism to determine if coordination of swallowing pattern has been affected over time. Further differential diagnosis would be considerable reflux in current complaints. The patient may benefit from a proton pump inhibitor regimen if deemed appropriate by his physicians. At today’s session, discussed aspiration precautions, especially given that the patient self-reported drinks multiple sips at a time. In addition, reflux precautions were recommended, including sitting upright 90 degrees with all p.o. and for one hour after meals. The patient was also counseled to monitor his nutritional intake. If he is indeed shortening meals due to sensation of sluggish passage, would recommend multiple smaller meals a day rather than three large ones to allow for adequate nutritional intake. The patient understands all given recommendations and is in agreement for a followup with an objective swallowing test.
RECOMMENDATIONS:
1. Regular diet with thin liquids.
2. Medications one at a time with water.
3. Further objective testing via modified barium swallow.
4. Upright 90 degrees with all p.o. and for one hour after meals.
5. Decrease bolus size and rate of presentation.
6. Single bites and single sips.
7. Consideration of proton pump inhibitor regimen if reflux is deemed by the patient’s physicians to be playing a role in the patient’s current symptoms.
8. Further recommendations will be made pending outcome of objective study.
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