Dysphagia Assessment - Note

Reason for Referral: - The patient was referred due to persistent coughing and choking during meals, raising concerns about potential dysphagia. Background Information: - The patient is a 72-year-old male with a history of stroke six months ago, which has affected his swallowing abilities. Summary of Assessment: - The assessment revealed moderate dysphagia with difficulties in managing both solids and liquids, particularly thin liquids. Case History: - The patient has a history of hypertension and type 2 diabetes, and he experienced a left-sided stroke, which has impacted his speech and swallowing. Oro-Motor Skills Assessment: - The assessment showed reduced tongue strength and coordination, with delayed swallow initiation. Food Assessment: - The patient struggled with chewing and swallowing solid foods, requiring multiple swallows per bite. Drinks Assessment: - The patient exhibited coughing and throat clearing with thin liquids, indicating aspiration risk. Recommendations: - Environment: Ensure a quiet and distraction-free environment during meals. - Positioning: The patient should be seated upright at a 90-degree angle during meals. - Food and Texture (IDDSI level): Recommend soft and moist foods (IDDSI Level 5) to facilitate easier swallowing. - Drinks (IDDSI level): Recommend thickened liquids (IDDSI Level 2) to reduce aspiration risk. - Assistance: Supervision during meals to ensure safe swallowing practices. - Communication: Use simple, clear instructions to guide the patient during meals. - Oral Hygiene: Encourage regular oral hygiene to prevent infections. - Sensory Issues: Monitor for any changes in taste or texture preferences. - Cognitive Issues: Provide reminders and cues to aid in meal completion. Intervention Plan and Next Steps: - Initiate a swallowing therapy program focusing on strengthening exercises and safe swallowing techniques. Schedule follow-up in four weeks to reassess swallowing function and adjust the care plan as needed.