University Medical Center Lubbock, TX 79415 Date: November 2014
Clinician: Chris Bolinger
A 58 year old Hispanic male admitted to the hospital for hepatic encephalopathy after being found minimally responsive in his vehicle. Co-morbidities include: alcoholic liver cirrhosis, elevated LFTs, erosive esophagitis, hypertension, seizure due to alcohol withdrawal, and Wernicke’s encephalopathy. Chest x-ray on admission revealed possible pneumonia. Patient was oriented to person, but not place and time. Patient exhibited difficulty following commands and was not initially a candidate for therapy.
Dysphagia evaluation completed on day 3 of hospital admission. Evaluation revealed profound dysphagia characterized by the following: poor management of secretions, overt s/s of aspiration following all PO trials, inability to clear pharynx following PO trials as evidenced by continued coughing and throat clearing resulting in poor oxygen saturation. Patient required sedation on day 4 and day 5; therefore, swallow rescreen was not attempted. Patient continued to be inappropriate for swallow therapy secondary to altered mental status. Swallow was rescreened on day 6, no improvement noted. Patient continued to exhibit s/s of aspiration of secretions and all PO trials. Patient’s mental status improved on day 7 and day 8. Swallow was rescreened on day 9. Mild improvement in hyolaryngeal movement was noted. Patient exhibited a functional swallow for puree and honey-thick liquids on day 10. Patient continued to exhibit deficits in hyolaryngeal movement and demonstrated s/s of aspiration with thin and nectar thick liquids. Patient started completing oropharyngeal exercise regimen independently on day 10. Day 11 of hospital admission, clinician completed oropharyngeal exercises with patient.
Swallow was rescreened on day 12 for potential advancement to thinner liquid consistencies. Patient explained that he was discharging home on this date and was not going to use thickeners in his liquids, despite any recommendations. Patient was educated regarding risks and consequences of aspiration. Patient verbalized understanding. A clear SafeStraw for thin liquids was utilized to determine patient’s ability to safely consume thin liquids. No s/s of aspiration were noted with the small controlled sips of thin liquids. After educating patient regarding usage and cleaning of SafeStraw, patient stated that “this is so much better.” Patient is unfunded and unable to be discharged to a skilled nursing facility for further treatment. Current treatment plan is to discharge home with daughter and utilize home health. Clinician was concerned with the potential for aspiration and possible re-admission secondary to pneumonia. Patient is now able to be discharged with the oropharyngeal exercise regimen to independently complete to improve strength of swallow and able to safely consume PO diet of his choice with the usage of the SafeStraw.