Videofluorscopic swallow study report

Videofluoroscopic Swallow Study Report: Patient Information: - John Doe - Date of Birth: 05/12/1950 - Medical Record Number: 123456789 - Date of Study: 10/15/2023 Indication for Study: - Recurrent aspiration pneumonia, difficulty swallowing, and history of stroke. Procedure: - The procedure was conducted using 20 ml of barium sulfate contrast material. The patient was seated upright and instructed to swallow various consistencies of barium. Findings: - Oral Phase: Mild delay in oral transit time with reduced tongue control. - Pharyngeal Phase: Delayed swallow initiation with mild residue in the valleculae. - Esophageal Phase: Normal esophageal clearance. - Presence of aspiration or penetration: Trace penetration observed with thin liquids. - Compensatory strategies attempted and their effectiveness: Chin tuck maneuver was attempted and found to be effective in reducing penetration. Impression: - The study indicates mild dysphagia with risk of aspiration on thin liquids. Compensatory strategies were effective in managing symptoms. Recommendations: - Dietary modifications: Recommend thickened liquids to nectar consistency. - Swallowing strategies or exercises: Encourage chin tuck during swallowing. - Further evaluations or referrals: Follow-up with a speech and language therapist in 4 weeks. Signature: - Dr. Emily Smith, SLP - Date of Report: 10/16/2023