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[Dysphagia] A Case Study
- Subject: [Dysphagia] A Case Study
- From: email@example.com (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
> secondary to thyromegaly. The pt has a seizure disorder for which she
> Dilantin and Tegretol. Some concern that the patient may have
> Reason for Admission: Dysphagia, secondary to local compression from
> thyromegaly (though now reason unknown), osteoarthrits, history of
> S/P CVA in the distant past, S/P recent thyroidectomy.
> Brief History: Pt admitted to rehab hospital for assessment of
> 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.
> pt was consuming reg diet with thin liquids. The patient underwent
> resection without any complications.
> Medications: Cardura, Tegretol, Plavix, Cozaar, Prednisone, Lopressor,
> Reglan, Norvasc, Dilantin, Iron, Albuterol, Xopenex, and Atrovent
> Psychosocial HX: Resides at nursing home. Pt does not smoke, abuse
> 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
> 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
> 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
> through the oral cavity. There was no visible stricture or constriction.
> The airway remained well protected during the series of attempted
> 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
> of the pyriform sinuses). There was a large ?growth? which was for the
> 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
> 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
> swallow, crackling sounds can be heard almost like small burps, but a
> 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
> 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
> hospital. I consulted her primary physician who suggested she get a MRI
> 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
> and throw their hands in the air. We know its there, but the pt is
> 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
> stating "God, I know I'm being punished for something I have done. You
> 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
> normal adult. Her dysphagia is causing a lot of depression and feelings
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