Case+History


 * Case History **

 (3;a, 3;b, 3;c)

The first step in the assessment of dysphagia is to take a full case history from the patient.

Although some of the information can be taken from the patient’s clinical notes (such as co-morbidites) it is still necessary to ask these questions of the patient. Information such as the patients values placed around food can also only be truly gathered this way (Nguyen et al., 2008)

This also provides the SLT the opportunity to make observations of the patient’s mood, general condition and other factors before beginning more formal assessments (Cichero, 2006).

The following pages will take you through a template form that can be used for taking a case history, or adapted as needed. There are prompts within this form and questions to ask which can be used as a guide.

Note: Before beginning the assessment process with the client note the physical and emotional capability of the patient to answer questions at the time. Post surgery patients may be disorientated, fatigued, drowsy, in pain, and have articulation difficulties post surgical removal of part of the tongue (Nguyen et al., 2008). If all other methods of alternative forms of communication have been tried with the patient medical information from the file, and more personal questions about the patient’s experiences/values around food may be obtained from family/friends of the patient.


 * **Adult Dysphagia Speech Language Therapy Case History** 5555555555555555 ||
 * Date completed/modified: ||||||  ||
 * Name:

Alternative/Preferred name: 55

5 || Date of birth: || Age: || Male/ female 55555555555555 ||
 * Address: |||||| Home phone: ||
 * ^  |||||| Work / mobile: ||
 * |||||| Email: ||
 * Carers: 5555555555555555555555555555 Relationships: ||
 * Ethnicity:

55

5 |||||| Languages spoken: ||

Although some of the above information can be taken from the patient’s medical records in this next section a full understanding of patients condition can only be gained through direct conversation with them (or a family member if it is not possible to talk to the patient).


 * ** HISTORY OF PRESENTING CONDITION **

Date of diagnosis:

5

Cancer location and staging:

(using TMN staging as explained here, or equivalent grading system) 55555555555555555555555555555555555555555

- Primary tumor

5

- Regional Lymph Nodes

5

- Distant Metastasis

5

Surgery:

(location, area of removal, needing further surgery?)

5

5

5

- Side effects

those noted in medical file (tracheostomy) (see below)

5

5

Have you noticed any of the following symptoms…..?

(numbness, pain, reduced mobility, difficulties with speech)

5

5 ||

Effects of the Surgery

Surgery of the neck and/or throat involves delicate anatomical structures involved in swallowing and speech. The following effects may be seen in patient’s following their surgery:

- swelling of mouth/throat (resulting in difficulty breathing) - impaired speech and/or voice - numbness in the face, neck or throat - reduced mobility in the neck and shoulder area - fatigue - A tracheostomy or gastrostomy [may have been preformed depending on the severity of the areas removed/anticipation of swallowing difficulties or edema causing airway narrowing]

(Groher & Crary, 2010)

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