SLT - Telephone Clinical Note

Specialty: Speech and Language Therapist Aim -To assess the patient's current communication abilities following a recent stroke and establish a preliminary treatment plan. Consent was obtained for the session and for the use of Heidi Ai Health Scribe. Family present: Mother (Sarah Smith), Husband (John Smith) -Patient's daughter, Maria, called regarding her 72-year-old mother, Mrs. Eleanor Vance, who recently had a stroke. Maria reported that her mother is having significant difficulty speaking and understanding others, which is causing her distress and isolation. She is also having difficulty swallowing thinner liquids. -Discussion focused on the specific communication challenges Mrs. Vance is experiencing (e.g., word finding difficulties, slurred speech, trouble following complex instructions) and her reported dysphagia symptoms (e.g., coughing during drinking). Clarification was sought regarding the timeline of the stroke and any prior speech or swallowing difficulties. Information was also gathered about Mrs. Vance's current living situation and support network. The potential impact of these difficulties on her quality of life was explored. -Advised Maria to keep a log of specific instances where Mrs. Vance struggles with communication or swallowing. Provided preliminary strategies for improving communication, such as speaking slowly, using short sentences, and visual cues. Recommended thickening agents for liquids and advised observation for signs of aspiration. Scheduled an in-person comprehensive assessment for Mrs. Vance next week. Impression - Diagnosis: Aphasia (likely expressive and receptive components) secondary to cerebrovascular accident (CVA); suspected Oropharyngeal Dysphagia. - Clinical impressions: Mrs. Vance presents with significant communication impairment impacting her ability to express needs and understand information, leading to frustration and social withdrawal. Her reported swallowing difficulties suggest a risk of aspiration, necessitating immediate dietary modifications and further assessment. Her family is highly supportive and motivated to participate in her rehabilitation. P/ -Follow-up actions: Comprehensive in-person Speech and Language Therapy assessment scheduled for 8 November 2024 at 10:00 AM at the clinic. Referral to Dietetics for swallowing management planning. Family to continue logging communication difficulties and use provided strategies. Will provide a home exercise programme following the assessment.