1 November 2024
Re: John Smith - Suspected Dysphagia
Dear Dr. Eleanor Vance,
John was referred to SLT for a swallowing assessment following reports of coughing and choking when drinking thin liquids. He was seen in clinic on 30 October 2024 (accompanied by his wife, Mrs. Sarah Smith).
PMHx
- Hypertension
- Type 2 Diabetes
- Recent mild stroke (2 months prior)
John Smith reports increased difficulty swallowing, particularly with thin liquids, leading to frequent coughing and occasional choking episodes. He describes these episodes as occurring mainly during meals and while drinking water, causing him significant anxiety and reducing his fluid intake. There is also a sensation of food sticking in his throat, predominantly with dry or crumbly foods. This primarily started approximately two months ago, following his recent stroke. He denies any significant weight loss but acknowledges a change in his diet to softer, pureed foods to avoid swallowing difficulties.
Swallowing Assessment
Cranial Nerve Exam
- Lips: Symmetrical at rest, good range of motion, competent labial seal.
- Tongue: Appears normal in size and colour, good protrusion, lateralisation, and elevation. No fasciculations noted.
- Palate: Symmetrical elevation of the soft palate upon phonation. Gag reflex present.
- Jaw: Full range of motion, strong bite.
Oral Trials
During oral trials, John exhibited difficulty controlling a sip of thin water, resulting in an immediate cough reflex and a wet vocal quality. He managed thickened fluids (honey consistency) without overt signs of aspiration, though a slight delay in the swallow reflex was observed. With soft solid foods (puréed apple), he demonstrated good oral preparation and a clear swallow, but with crumbly biscuit, multiple swallows were required, and some residue was noted in the oral cavity. His wife confirmed these observations, noting similar patterns at home.
Impression
John Smith presents with signs and symptoms consistent with oropharyngeal dysphagia, likely secondary to his recent cerebrovascular accident. This is characterised by impaired control of thin liquids, delayed swallow reflex, and reduced efficiency with certain solid food textures, leading to aspiration risk and anxiety around eating and drinking. There is also evidence of reduced oral residue clearance with specific textures. This primarily impacts his ability to safely consume a varied diet and maintain adequate hydration, necessitating intervention and dietary modification.
Plan:
- Recommend a modified diet: thickened fluids (honey consistency) and soft, moist solid foods.
- Provide education on safe swallowing strategies, including small sips/bites, slow pace, and chin tuck manoeuvre.
- Referral to Dietetics for nutritional assessment and guidance.
- Schedule follow-up dysphagia therapy sessions to improve swallow function and safety.
- Review instrumental assessment (VFSS/FEES) if symptoms persist or worsen.
Should you have any further questions regarding the above patient, please do not hesitate to contact me.
Sincerely,
Miss Emily Carter
Speech and Language Therapist
Reg No: SLT12345
Contact: 020 7946 0123 / emily.carter@hospital.org
