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[Dysphagia] A Case Study


  • Subject: [Dysphagia] A Case Study
  • From: chcky619@bellsouth.net (Ralph and Patti)
  • Date: Mon, 10 Nov 2003 22:37:03 -0500

I would ask this listserve to review this case study and send thoughts and
possible interventions for this patient:


> Here is the information on the patient I have been working with.
> History and Physical taken from chart:
> History:  74 black female with the following past medical history:  HTN,
> anemia, CHF, Non-Insulin dependent diabetes mellitus, recent
thyroidectomy,
> secondary to thyromegaly.  The pt has a seizure disorder for which she
takes
> Dilantin and Tegretol.  Some concern that the patient may have
> schizophrenia.
> Reason for Admission:  Dysphagia, secondary to local compression from
> thyromegaly (though now reason unknown), osteoarthrits, history of
epilepsy,
> S/P CVA in the distant past, S/P recent thyroidectomy.
> Brief History:  Pt admitted to rehab hospital for assessment of
improvement
> in swallowing.  The patient had a great deal of dysphagia secondary to
> compression by her thyroid gland.  The pt began c/o difficulty swallowing
> 06/03 and PEG placement 07/03 due to pt unable to swallow secretions.
PLF-
> pt was consuming reg diet with thin liquids.  The patient underwent
thyroid
> resection without any complications.
> Medications:  Cardura, Tegretol, Plavix, Cozaar, Prednisone, Lopressor,
> Reglan, Norvasc, Dilantin, Iron, Albuterol, Xopenex, and Atrovent
> nebulizers.
>
> Psychosocial HX:  Resides at nursing home.  Pt does not smoke, abuse
drugs,
> or alcohol.
>
> Review of Systems:
> Constitution:  Pt has had significant weight loss over the past 6 months
> secondary to her dysphagia.  Denies any recent fevers, chills, or shakes.
> Gastrointestinal:  Pt has had several dilations of the esophagus to
> facilitate her swallowing.  These have worked at times but her problem
> returned and this is why she underwent the thyroidectomy.
> Neurological:  The pt was alert and oriented X3.  Cranial nerves II-XII
> grossly intact.
>
> Impression:A recent 74-year-old black female recently status post thyroid
> resection for thyromegaly.  The pt's pathological report was negative for
> malignancy.  The pt has a great deal of odynaphasia and dysphagia.  The pt
> is now being assessed for improvement for her swallowing mechanism.
>
> Above report dated 10/10/03 and the initial eval and tx performed by
another
> SLP who recommended a MBSS.
>
> MBSS results:oral preparatory stage:WFL, Prolonged Pyriform pooling.  Only
> one consistency given - Thin Liquid.  Posterior spillage of the bolus to
the
> pyriform sinuses was noted.  The bolus remained in the pyriform sinuses as
> the pt. attempted to swallow.  "For some unknown etiology, the bolus
> remained in the pyriform sinuses until the pt. eventually emitted the
bolus
> through the oral cavity.  There was no visible stricture or constriction.
> The airway remained well protected during the series of attempted
swallows.
>
> Consult for an Upper GI given by physician.  That was today in which
> physician was unable to pass the scope through the pharynx (around the
area
> of the pyriform sinuses).  There was a large ?growth? which was for the
most
> part obstructing the pharynx with a passage way only to the vocal folds.
>
> My experiences with pt.  Pt began c/o difficulty swallowing in June of
this
> year and states that since July swallow has remained the same and she has
> been unable to swallow secretions.  When asked to swallow, pt attempts
> multiple times where she states the bolus just "stays there" While trying
to
> swallow, crackling sounds can be heard almost like small burps, but a
higher
> pitch.  Her voice also has a harsh/hoarse vocal quality though pt can
> sustain /s/, /z/, and ah for a reasonable amount of time.
>
> Following the upper GI consult, I spoke to the GI physician who began
saying
> he did not know what the obstruction was and requested the results of the
> MBSS.  He rescheduled her appointment for a dilation at another date in
the
> hospital.  I consulted her primary physician who suggested she get a MRI
and
> a consult to an ENT.
>
> Any thoughts?  All would be welcomed.  When we went to the MBSS and the GI
> appointment, people just kind of stand around and look at this
"obstruction"
> and throw their hands in the air.  We know its there, but the pt is
wanting
> whatever it is out or fixed.  She has a h/o pysh which I've never seen s/s
> of nor have any nurses (It was stated to have been when she had a
> miscarriage of her first child) but the other day she was crying in her
room
> stating "God, I know I'm being punished for something I have done.  You
must
> be very angry at me."  I'm telling you, cognitively she may have a mild
> impairment with abstract information/reasoning, but she has the memory of
a
> normal adult.  Her dysphagia is causing a lot of depression and feelings
of
> hopelessness.
>
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