Dysphagia Assessment Note

Reason for Referral

• Referred on 14/05/2024 due to coughing on thin fluids and difficulty clearing oral residue following a recent right MCA infarct.

Background Information

• 78yo male (Arthur Pendelton, DOB: 12/08/1945, NHS: 482 910 3847) admitted to Stroke Unit on 10/05/2024. PMH: HTN, AF, T2DM. Current meds: apixaban 5 mg PO BID, amlodipine 5 mg PO OD, metformin 500 mg PO BID. Previously independent with normal diet and fluids (IDDSI 7 / IDDSI 0). Currently nil by mouth (NBM) with NG tube in situ.

Summary of Assessment

• Mild-moderate oropharyngeal dysphagia characterised by reduced left labial seal, delayed pharyngeal swallow trigger, and overt signs of aspiration on thin fluids (IDDSI 0). Safe swallow demonstrated on mildly thick fluids (IDDSI 2) and minced and moist diet (IDDSI 5) with postural adjustments.

Case History

• Nursing staff failed bedside water swallow screen on admission due to immediate cough and wet voice quality. Chest auscultation prior to assessment clear; SpO2 97% on RA, RR 16 bpm, HR 78 bpm. Patient alert, sitting out in chair, keen for oral trials.

Oro-Motor Skills Assessment

• CN VII: Mild left lower facial weakness, asymmetry on smile, reduced left labial seal.
• CN V: Mandibular ROM and strength WNL.
• CN XII: Tongue protrusion deviates slightly to left; reduced lateralisation and strength against resistance on left side.
• Palatal elevation symmetrical.
• Voluntary cough present but moderately weak; vocal quality mildly hoarse at baseline. Oral mucosa dry, coated tongue noted.

Food Assessment

• IDDSI 4 (Pureed): 3 x 5 ml tsp trials. Adequate bolus formation, timely AP transit, prompt laryngeal elevation. Clear voice post-swallow, nil cough, nil oral residue.
• IDDSI 5 (Minced and Moist): 3 x 5 ml tsp trials. Mildly prolonged oral prep phase; trace pocketing in left lateral sulcus, cleared spontaneously with verbal prompt. Laryngeal elevation adequate. Nil overt signs of aspiration.
• IDDSI 6 (Soft and Bite-Sized): Not trialled due to masticatory fatigue noted on IDDSI 5.

Drinks Assessment

• IDDSI 0 (Thin): 5 ml tsp x 2. Anterior spillage from left labial commissure. Delayed swallow trigger, immediate weak cough post-swallow, wet/gurgly vocal quality. Cleared with prompted double swallow and throat clear.
• IDDSI 1 (Slightly Thick): 5 ml tsp x 2 and single sips from open cup. Nil anterior loss, delayed trigger persists, throat clearing post-swallow on cup sips.
• IDDSI 2 (Mildly Thick): Single sips from open cup. Adequate labial seal, timely swallow trigger, nil cough, clear voice post-swallow. SpO2 stable at 97%.

Recommendations

• Environment: Quiet, distraction-free environment during all mealtimes; turn TV off.
• Positioning: Upright at 90 degrees in chair or bed with trunk supported midline and slight chin tuck on liquids. Remain upright for 30 mins post-intake.
• Food and Texture (IDDSI level): IDDSI Level 5 (Minced and Moist).
• Drinks (IDDSI level): IDDSI Level 2 (Mildly Thick) via open cup, single sips only. No straws.
• Assistance: Supervision required. Verbal prompts to pace intake and clear left cheek pocket.
• Communication: Give short, clear instructions one at a time; ensure spectacles and hearing aids are worn.
• Oral Hygiene: Strict oral care QDS using a small, soft toothbrush and chlorhexidine 0.2% mouthwash sponge swabs, paying close attention to clearing the left lateral sulcus before and after meals.
• Sensory Issues: Provide cold or strongly flavoured boluses where possible to facilitate sensory input and trigger timely swallow reflex.
• Cognitive Issues: Prompt patient to put spoon down between mouthfuls to reduce impulsivity and rapid feeding rate.

Intervention Plan and Next Steps

• Commence oral trials on IDDSI 5 diet and IDDSI 2 fluids as above; maintain NG tube for top-up hydration and non-crushable medications. Pharmacy to review meds for liquid/dispersible alternatives. Monitor chest status, temperature, and oral intake charts daily. Review on ward in 48 hours with view to upgrade textures if chest remains clear.