Case History

Question 1

What kind of information do you want to gather?

Answer 1

1. background information 2. general observations 3. Communication, Cognition and Behaviour 4. Medical history 5. Swallowing history

Question 2

to probe via case history

Answer 2

1. Onset of swallowing problem o Sudden vs. gradual o Progressive vs. improving o Fluctuating vs. stable 2. Pain associated with swallowing (odynophagia) 3. Duration of meals 4. Consistencies that are difficult vs. easier to swallow o Solids, liquids, medications 5. Characteristics of dysphagia: o Main symptoms/difficulties o Factors that exacerbates the problem o Factors that alleviates the problem 6. Diet/fluid modifications o Food or drink currently being avoided or modified to aid swallowing 7. Food preferences (cultural, religious, personal)

Question 3

the goals of a dysphagia case history

Answer 3

• To gather information about the medical diagnosis, current medical status, nutritional status and complexity of the problem • To establish if there is a swallowing problem, and if so, the nature and extent of the dysphagia • To determine any causal factors that may be contributing to the dysphagia • To determine the clients functional abilities and impairments, with attention to adaptations and compensations that exist • To gather info about the clients cultural, educational, religious and vocational background • To determine the level of stress or concern regarding the swallowing/ feeding problem

Question 4

Background information

Answer 4

• Age/gender • Relevant medical history/diagnosis • Current medical status/ recent illness • Current chest status • Current nutritional status/ needs • Recent change in medications • Previous speech pathology assessment/management • Any other client specific information e.g. cultural

Question 5

General Observation

Answer 5

(environment, medical status, mood, mobility, non-physiological factors with potential to impair, compromise or impact swallowing function and safety) • Alertness, Awareness and insight • Mobility status/ posture/ positioning • Habitual head position • Ability to manage oral secretions • Ability to self feed • Endurance/ fatigue • Respiratory status • Presence of tubes • Client state (e.g. agitation/distress) and Ability to participate/ comply • Support system/family

Question 6

Communication, Cognition and Behaviour

Answer 6

• Ability to follow instructions • Visual and auditory skills (e.g. glasses, hearing aids) • Need for communication device/support • Insight, awareness and compliance • Need to involve family/ care staff