Printable Course Bookn : I."

Table of Contents
Master Keys
Clinical Swallow Evaluations 4-9
Videofluoroscopic Swallow Studies 10-12
Flexible Endoscopic Evaluations of Swallowing 13-14
Templates
Clinical Swallow Evaluations 16
Sample Reports
Clinical Swallow Evaluations 22-165
Bonus Documents
Abbreviation Glossary 271-274
Phraseology 275-284
8-Point Penetration-Aspiration Scale 285
Yale Pharyngeal Residue Severity Rating Scale 286
Murray Secretion Scale 287
Dysphagia Outcome and Severity Scale 288
Kelsey Day, MS, CCC-SLP 2

Master Keys

Clinical Swallow Evaluation (CSE) Sample Report Master Key
FILE PREDISPOSING RISK CHRONIC DYSPHAGIA PRECIPITATING RISK ADDITIONAL

NAME FACTORS SIGNS FACTORS FEATURES DIET REC OTHER RECS
CSE 1 COPD N/A PNA, respiratory failure NPO VFSS
Hypopharyngeal cysts, Respiratory failure,
CSE 2 achalasia N/A intubation NPO GI, VFSS
CHF, PNA, CPA, respiratory
CSE 3 SCI N/A failure, intubation, HFNC NPO FEES
Reported symptoms,
CSE 4 Tobacco weight loss N/A Dysphonia NPO FEES, ENT, dietitian
AMS, encephalopathy,
CSE 5 Unknown PNA rhabdomyolysis, drug OD Somnolent NPO Clinical f/u
Weight loss, respiratory DNR,
CSE 6 COPD, lung CA failure Respiratory failure dysphonia NPO FEES
Reported symptoms,
CSE 7 COPD PNA Intubation NPO VFSS
Penetrating neck injury,
CSE 8 N/A N/A intubation Dysphonia NPO Clinical f/u, FEES
CSE 9 N/A Weight loss H&N CA/mass, TVC paralysis Dysphonia IDDSI 7/0 FEES
(Undiagnosed myotonic PNA, weight loss, Muscular
CSE 10 dystrophy) malnutrition Generalized weakness dystrophy NPO FEES, VFSS
Esophageal/g
astric GI, upper GI series,
CSE 11 Diabetes N/A DKA, encephalopathy dysfunction IDDSI 7/0 dietitian
Chiari malformation,
cervicooccipital fusion, CVA vs. progressing Chiari
CSE 12 CVA Dysphagia per VFSS malformation Dysphonia NPO FEES, Neurosurgeon
Weight loss, reported
symptoms, malnutrition,
CSE 13 N/A PNA N/A Dysphonia NPO FEES
CSE 14 N/A N/A TBI, intubation NPO FEES
TBI, intubation, chest tube,
CSE 15 N/A N/A HFNC Dysphonia NPO NGT, clinical f/u
Somnolent,
absent NGT, clinical f/u, f/u w/
CSE 16 N/A N/A CVA, AMS swallow NPO Neurologist

CSE 17 VP shunt N/A AMS IDDSI 4/0 Clinical f/u
TBI, intubation, cervical Stridor,
CSE 18 N/A N/A injury somnolent NPO NGT, clinical f/u
CSE 19 N/A N/A AMS, encephalitis IDDSI 7/0 No f/u
Respiratory
CSE 20 SCI N/A ACDF distress NPO NGT, clinical f/u
Respiratory
distress,
ACDF, intubation, aspiration absent PEG, clinical f/u, airway
CSE 21 SCI N/A PNA swallow NPO monitoring
CSE 22 N/A N/A CVA IDDSI 7/0 No f/u
CSE 23 N/A N/A Angioedema IDDSI 7/0 No f/u
CSE 25 N/A N/A PNA, intubation, HFNC Dysphonia NPO FEES
NGT, ENT laryngoscopy,
Pulmonologist
Respiratory failure, PNA, bronchoscopy,
CSE 26 N/A PNA encephalopathy Stridor NPO Neurologist
Poor
CSE 27 COPD N/A Intubation cooperation NPO Clinical f/u
Thyroid/neck/mediastinal
CSE 28 mass Reported symptoms Dyspnea Dysphonia IDDSI 4/0 FEES, VFSS
Recurrent PNA, Tachypnea, respiratory Poor Defer to FEES, re-consult SLP if
CSE 29 COPD, GERD malnutrition failure cooperation pt/MD change in motivation
Ingestion of caustic FEES, GI consult, EGD
CSE 30 CVA Reported symptoms substance Dysphonia Full liquid and/or Esophagram
Lung CA, COPD, brain DNR/hospice/
CSE 31 mass N/A Vasogenic cerebral edema comfort care IDDSI 7/0 No f/u
Peritonsillar
mass/malignancy vs. Clear
CSE 32 N/A N/A abscess/phlegmon liquid ENT, airway monitoring
CHF exacerbation,
CSE 33 CHF N/A intubation NPO FEES
CSE 34 CVA N/A CO poisoning, AMS, HFNC Somnolent IDDSI 4/0 Clinical f/u, titrate HFNC
Severe IDDSI 4/0 Clinical f/u, titrate HFNC,
CSE 35 N/A PNA Tachypnea, PNA, HFNC tachypnea vs. NPO, NGT

pending
RR
Pharyngeal abscess,
CSE 36 N/A N/A epiglottitis Trach NPO Clinical f/u
PNA, reported Oral aversion,
CSE 37 Dementia symptoms PNA refusal IDDSI 3/0 Clinical f/u
CSE 38 N/A N/A Intubation, UGIB Dysphonia NPO NGT, FEES
CSE 39 N/A Reported symptoms TBI Dysphonia IDDSI 7/0 FEES
TBI, intubation, cervical
CSE 40 N/A N/A injury Dysphonia NPO NGT, clinical f/u
Esopahgeal candida,
esophagitis, esophageal Weight loss, reported
CSE 41 dysmotility symptoms N/A Full liquid GI, no f/u
Full liquid
CSE 42 N/A N/A Tonsillitis ADAT No f/u
CSE 43 N/A N/A ACDF Full liquid Clinical f/u
Cervical myelopathy,
CVA, gastritis, hiatal
CSE 44 hernia Reported symptoms ACDF NPO VFSS
CSE 45 H&N CA Weight loss Tracheotomy Aphonia NPO VFSS
Weight loss, reported
CSE 47 H&N CA symptoms N/A IDDSI 4/0 VFSS
CSE 48 N/A N/A Intubation, lung resection Trach/vent NPO FEES
CSE 49 N/A PNA Septic shock NPO VFSS
CSE 50 MS N/A Sepsis IDDSI 7/0 No f/u
Reported symptoms,
CSE 51 Thyroidectomy weight loss N/A Dysphonia Full liquid FEES + VFSS, ENT, GI
CSE 52 N/A N/A CVA vs. CN V/VII palsy IDDSI 7/0 Neurologist, no f/u
CSE 53 N/A N/A Penetrating neck injury, trach Trach NPO VFSS, trach change
CSE 54 N/A N/A TBI, intubation, HFNC Dysphonia NPO FEES
Reported symptoms, FEES, VFSS and/or
CSE 55 Smoking PNA, weight loss N/A Dysphonia NPO Esophagram
Suspect
aspiration of
CVA, white matter disease gastric
CSE 56 vs MELAS, epilepsy Recurrent PNA PNA, AMS content NPO VFSS, GI

CSE 57 N/A N/A Penetrating oral injury, trach Trach NPO VFSS
Peritonsillar
CSE 58 N/A N/A abscess/phlegmon Dysphonia Full liquid Clinical f/u
CSE 59 N/A N/A TBI, intubation, trach/vent Trach/vent NPO Clinical f/u
Stridor,
CSE 60 Vocal fold lesion, H&N CA Weight loss N/A dysphonia IDDSI 7/0 FEES, ENT, dietitian
CSE 61 Myopathy N/A N/A IDDSI 6/0 Outpatient VFSS & tx
Confirmed dysphagia
CSE 62 Parkinson's hx COVID-19, seizure NPO Clinical f/u
CVA vs. blunt head/neck
CSE 63 N/A N/A trauma NPO Clinical f/u
Confirmed dysphagia
CSE 64 Dementia, CVA hx Sepsis, aspiration PNA IDDSI 4/2 Caregiver education
Reported symptoms,
CSE 65 H&N CA PNA, weight loss PNA Dysphonia Full liquid FEES
CSE 66 CHF Reported symptoms N/A IDDSI 4/0 VFSS
Lupus, PRES, lupus
CSE 67 cerebritis, seizure N/A Encephalopathy NPO Clinical f/u
CSE 68 Dementia, COPD PNA HFNC NPO VFSS
CSE 69 Chronic L frontal SDH PNA Intubation, encephalopathy NPO Clinical f/u
CSE 70 COPD, CHF N/A Intubation Dysphonia IDDSI 7/0 FEES
(Undiagnosed
paraneoplastic Reported symptoms, Proximal
CSE 71 dermatomyositis) weight loss N/A weakness Full liquid FEES
CSE 72 Brain mass Reported symptoms N/A Dysphonia IDDSI 7/0 FEES
Acute neurological
CSE 73 N/A Reported symptoms symptoms NPO VFSS
Intubation, PNA, HFNC,
CSE 74 N/A N/A encephalopathy Dysphonia NPO Clinical f/u
CSE 75 Unknown N/A CVA, intubation NPO VFSS, PT, OT
PNA, weight loss,
CVA, bifrontal SDH, malnutrition, chronic
CSE 76 tobacco use dyphonia Encephalopathy Dysphonia NPO FEES + VFSS
Angioedema, endotracheal
CSE 77 N/A N/A intubation Dysphonia IDDSI 7/0 Clinical f/u
CSE 78 N/A N/A SCI s/p ACDF NPO VFSS

COVID-19, encephalopathy,
intubation, trach, critical Clinical f/u, trach change,
CSE 79 N/A N/A illness myopathy Trach NPO then FEES
CSE 80 N/A N/A COVID-19, ARDS, intubation Dysphonia NPO Clinical f/u
Malnutrition,
dehydration, weight
CSE 81 Dementia loss, food refusal ALOC Hospice IDDSI 4/0 No f/u
ALS (undaignosed), "CVA" Acute neurological
CSE 82 (misdiagnosed) Reported symptoms symptoms Misdiagnosis NPO FEES, Neurologist
Recurrent PNA, Acute respiratory failure, Dysphonia,
CSE 83 CVA, intubation reported symptoms HFNC, tachypnea HFNC NPO FEES
CSE 84 COPD PNA Respiratory failure NPO VFSS
Respiratory failure,
CSE 85 COPD, CHF, dementia Respiratory failure tachypnea Tachypnea NPO Clinical f/u
Encephalopathy, intubation, Dysphonia,
CSE 86 COPD Respiratory failure tachypnea tachypnea NPO Clinical f/u
Encephalopathy, intubation,
tracheostomy, ventilator- Clinical f/u, optimize for
CSE 87 COPD Respiratory failure dependency Trach/vent NPO FEES (PMV in-line)
COVID-19, ARDS, PNA,
CSE 88 N/A N/A intubation Dysphonia NPO FEES, PT
Miller Fisher GBS, intubation,
CSE 89 N/A N/A trach trach NPO FEES
Confirmed dysphagia COVID-19, ARDS, intubation, Trach, poor Clinical f/u, VFSS vs. FEES
CSE 90 Dementia, CVA hx tracheostomy participation NPO when pt participates
COVID-19, ARDS, CVA,
encephalitis,
encephalopathy, intubation, Clinical f/u, optimize for
tracheostomy, ventilator- FEES (trach downsize +
CSE 91 N/A N/A dependency Trach/vent NPO PMV in-line)
Undiagnosed
CSE 92 (Undiagnosed MG) Reported symptoms Generalized weakness chronic dx IDDSI 7/0 FEES, VFSS, Neurologist
Poor
secretion
CSE 93 COPD, HIV N/A Esophageal food impaction management NPO FEES

(Undiagnosed
disseminated Weight loss, reported
CSE 94 histoplasmosis) symptoms, PNA Generalized weakness IDDSI 7/0 VFSS
Dog bite w/ MRSA infection
& L supraclavicular
lymphadenopathy, HFNC, Stridor,
CSE 95 N/A N/A PNA dysphonia NPO FEES
(Undiagnosed
esophageal/mediastinal Weight loss, reported Stridor,
CSE 96 cancer) symptoms N/A dysphonia NPO FEES
Blunt neck trauma,
CSE 97 N/A N/A tracheotomy Trach NPO FEES
FEES, GI, outpatient High
Resolution Esophageal
Suspected esophageal Manometry and/or Barium
CSE 98 dysmotility, thyroid cancer Reported symptoms Thyroidectomy Dysphonia NPO Esophagram
Overdose, encephalopathy,
CSE 99 N/A N/A seizure IDDSI 5/0 Clinical f/u
Penetrating neck injury,
CSE 100 N/A N/A intubation Dysphonia NPO VFSS + FEES

Videofluoroscopic Swallow Study (VFSS) Sample Report Master Key
FILE PREDISPOSING PRECIPITATING PENETRATION-ASPIRATION SCALE (PAS) DOSS DIET REC ADDITIONAL
NAME RISK FACTORS RISK FACTORS IDDSI 0 IDDSI 2 IDDSI 3 IDDSI 4 IDDSI 7 INFORMATION
VFSS 1 Mediastinal/neck Angioedema vs. 1 N/A N/A 1 1 5 IDDSI 6/0 Mediastinal tumor,
tumor, vocal fold facial abscess esophageal deviation,
paralysis cardiothoracic surgery
& ENT evals
VFSS 2 N/A N/A; pt endorses 1 N/A N/A 1 1 6 IDDSI 7/0 Abnormal esophageal
dysphagia screening, GI eval, high
symptoms resolution esophageal
manometry, barium
esophagram, 24 hr pH
monitoring
VFSS 3 N/A GSW to 8 8 8 1 N/A 1 NPO Rec'd trach downsize &
head/neck, trach repeat exam
VFSS 4 N/A GSW to 1 1 1 1 N/A 5 IDDSI 4/0 F/u exam (comparison
head/neck, trach to VFSS 3)
VFSS 5 Chronic L frontal Intubation, 8 7 N/A 1 N/A 3 IDDSI 4/2 F/u VFSS or FEES
SDH encephalopathy
VFSS 6 N/A None known; 1 N/A N/A 1 1 7 IDDSI 7/0 Abnormal esophageal
dysphagia screening, GI eval, high
symptoms of resolution esophageal
unknown etiology manometry, barium
esophagram, 24 hr pH
monitoring
VFSS 7 N/A N/A; pt endorses 1 N/A N/A 1 1 6 IDDSI 7/0 GI eval, outpatient ENT
dysphagia laryngoscopy,
symptoms outpatient SLP
videostroboscopy
VFSS 8 CVA, diabetic ACDF, PCDF 4 1 N/A 1 2 3 IDSSI 4/0 Dietitian eval, swallow
peripheral tx, repeat instrumental
neuropathy
VFSS 9 CVA, dementia, Aspiration PNA, 1 N/A N/A 1 N/A 5 IDDSI 4/0 Aspiration PNA (suspect
epilepsy sepsis r/t gastric content),
avoid PEG
VFSS 10 CVA, dementia Acute CVA, sepsis 7 8 N/A N/A N/A 1 NPO 95-year-old; end-of-life;
repeat VFSS in 3-7 days
VFSS 11 N/A TBI, intubation, 4 N/A N/A 1 N/A 3 IDDSI 4/0 Dietitian eval, swallow
trach tx, repeat instrumental
VFSS 12 N/A Oropharyngeal 2 N/A N/A 1 1 7 IDDSI 7/0 Trach downsize, d/c
abscess, swallow goal
epiglottitis, trach
VFSS 13 Anterior cervical PNA, intubation 7 6 N/A 1 N/A 3 IDDSI 4/2 Osteophytes,
osteophytes compensatory
(unknown/undiagn strategies, swallow tx,
osed), COPD, CHF repeat VFSS in 4 weeks
VFSS 14 Unknown/undiagn PNA, intubation 7 N/A N/A 7 N/A 1 NPO 97-year-old; end-of-life;
osed sources for end-of-life;
hospice
VFSS 15 CVA, COPD, PNA 8 8 8 8 N/A 1 NPO Hospice eval; end-of-
dementia life; sources for end-of-
life
VFSS 16 Undiagnosed N/A 2 N/A N/A 1 1 4 IDDSI 7/0 Neurologist f/u;
paraneoplastic hematology/rheumatol
dermatomyositis ogy consult; dietitian
consult; swallow tx
VFSS 17 N/A SCI, ACDF 1 N/A N/A 1 N/A 2 IDDSI 0 Swallow tx, f/u VFSS in
3-5 days
VFSS 18 N/A CVA, intubation 8 1 N/A 1 N/A 5 IDDSI 4/2 Swallow tx
VFSS 19 Dementia Intubation, trach 8 2 2 1 N/A 4 IDDSI 4/2 Swallow tx, trach
downsize
VFSS 20 N/A Miller Fisher GBS, 2 N/A N/A 2 N/A 2 IDDSI 0 Swallow tx, repeat
intubation, trach outpatient VFSS in 4-8
weeks
VFSS 21 N/A Miller Fisher GBS, 6 N/A N/A 1 1 5 IDDSI 7/0 Defer solid diet to
intubation, trach pt/MD/treating SLP, f/u
w/ outpatient SLP
VFSS 22 Undiagnosed N/A 2 N/A N/A 1 1 3, 4 IDDSI 7/0 Swallow tx, f/u w/
Myotonic Neurologist for
Dystrophy dysphagia workup
VFSS 23 Undiagnosed ALS N/A 1 N/A N/A 1 1 4 IDDSI 1 Full liquid diet, ADAT,
(misdiagnosed as f/u w/ Neurologist for
chronic CVAs) dysphagia workup

VFSS 24 CVA, R frontal N/A 7 1 N/A 1 1 5 IDDSI 7/0 Unrestricted diet
craniotomy, despite aspiration,
seizures outpatient swallow
therapy for chronic
dysphagia
VFSS 25 Undiagnosed Generalized 4 N/A N/A 1 1 3 IDDSI 7/0 CT Soft Tissue Neck,
disseminated weakness Infectious Disease
histoplasmosis and/or Rheumatology
consults, swallow tx

Flexible Endoscopic Evaluation of Swallowing (FEES) Sample Report Master Key
FILE PREDISPOSING PRECIPITATING PENETRATION-ASPIRATION SCALE (PAS) DOSS DIET REC ADDITIONAL
NAME RISK FACTORS RISK FACTORS IDDSI 0 IDDSI 2 IDDSI 3 IDDSI 4 IDDSI 7 INFORMATION
Laryngologist
evaluation,
laryngoscopy, swallow
COVID PNA/ARDS, tx, repeat FEES in 2-4
FEES 1 N/A intubation 7 8 1 1 1 3 IDDSI 7/3 weeks
Chiari
malformation, Worsening
occipital neurological Neurosurgery
FEES 2 craniotomy, CVA symptoms 4 N/A N/A 1 4 3 IDDSI 7/0 evaluation, swallow tx
Dog bite w/ L
supraclavicular ENT consult, CT Soft
FEES 3 N/A lymphadenopathy 1 4 N/A 1 1 4 IDDSI 7/2 Tissue Neck, swallow tx
Undiagnosed
esophageal/media ENT consult, CT Soft
FEES 4 stinal cancer SOB 8 N/A N/A 7 N/A 1 NPO Tissue Neck, swallow tx
Medical management
of edema, short-term
nutrition route, repeat
FEES q1week until oral
FEES 5 N/A Blunt neck trauma 5 N/A N/A 5 N/A 1 NPO diet, swallow tx
Undiagnosed Neurology,
paraneoplastic Rheumatology, swallow
FEES 6 dermatomyositis N/A 3 N/A N/A 1 1 3 IDDSI 7/0 tx
Repeat FEES in 2-3
FEES 7 COPD, CVA PNA, intubation 7 8 8 2 N/A 2 NPO days, trial swallow tx
COPD, ENT laryngoscopy &
undiagnosed H&N biopsy, Dietitian,
FEES 8 CA N/A 8 N/A N/A 1 1 5 IDDSI 7/0 swallow tx
STAT GI consult 2/2
Esophageal food suspected esophageal
FEES 9 COPD, HIV impaction N/A N/A N/A N/A N/A 7 NPO food impaction
FEES 10 Undiagnosed ALS N/A 1 N/A N/A 1 N/A 1 NPO Neurology, swallow tx
Intubation, 1 Repeat FEES after trach
FEES 11 SCI, PCDF trach/vent N/A N/A 5 N/A 2 NPO downsize
Intubation, Swallow tx, repeat FEES
FEES 12 SCI, PCDF trach/vent 3 1 N/A 1 1 5 IDDSI 7/2 in 1-2 weeks
PT, Dietitian, ENT,
repeat FEES in 1-2
FEES 13 CVA PNA, intubation 8 3 1 1 N/A 3 IDDSI 4/3 weeks
Undiagnosed Neurology,
myotonic Rheumatology, swallow
FEES 14 dystrophy N/A 2 N/A N/A 1 2 3 IDDSI 7/0 tx, VFSS
GBS, intubation, Swallow tx, FEES vs
FEES 15 N/A trach 7 7 N/A 7 N/A 1 NPO VFSS in 4 weeks
COVID PNA/ARDS, PT, OT, repeat FEES
intubation, trach, after cuff deflation/PMV
FEES 16 CVA CVA 8 1 1 1 1 5 IDDSI 5/2 use
Mediastinal tumor, Cardiothoracic surgery,
FEES 17 vocal fold paralysis N/A 1 N/A N/A 1 1 5 IDDSI 4/0 ENT, VFSS
ENT, repeat FEES after
FEES 18 N/A GSW, trach 8 8 1 1 N/A 4 IDDSI 3/0 ENT
COVID PNA/ARDS, PT, OT, swallow tx,
FEES 19 N/A intubation 7 7 7 1 N/A 2 NPO repeat FEES in 4-5 days
Cardiac arrest,
FEES 20 trach, dysphagia N/A 2 N/A N/A 1 1 6 IDDSI 7/0 ENT
PT, OT, Dietitian, trach
downsize, swallow tx,
COVID PNA/ARDS, repeat FEES in 2-4
FEES 21 N/A intubation, trach 3 3 N/A 1 1 4 IDDSI 4/2 weeks
FEES 22 N/A GSW, trach 1 N/A N/A 1 1 6 IDDSI 7/0 OMFS, ENT
GSW to mandible, ENT laryngoscopy,
FEES 23 N/A emergent trach N/A N/A N/A N/A N/A 1 NPO swallow tx
Laryngoscopy,
videostroboscopy w/
COPD, CHF, SLP, outpatient
(suspected voice/swallow tx, repeat
FEES 24 PVFMD) N/A 5 N/A N/A 1 1 5 IDDSI 7/0 FEES in 4-6 weeks
PT, OT, swallow tx,
TBI, intubation, FEES vs VFSS in 2-3
FEES 25 N/A HFNC 8 1 N/A 1 1 4 IDDSI 4/2 weeks

Templates
Clinical Swallow Evaluation
HPI
PMHx
O Predisposing dysphagia risk

factors
Clinical signs of possible
chronic dysphagia
Precipitating dysphagia risk
factors
Temp SpO2
Vitals/labs
RR WBCs
CN V
CN VII
Cranial nerve exam
CN IX/X
CN XII
Secretions S/Z ratio
Laryngeal function exam VQ Pitch range
MPT Cough
Ice IDDSI 5
IDDSI 0 IDDSI 6
IDDSI 2 IDDSI 7
PO trials
IDDSI 3 3 oz water
IDDSI 4 Standardize
Notes
P Instrumentation
Diet recommendation
Risk management
Specialist referrals
Ancillary tests
Therapy
Goal

Videofluoroscopic Swallow Study
HPI
PMHx
O Videofluoroscopic Swallow Study was conducted in the lateral & anterior-to-posterior projections by Speech-
Language Pathologist Kelsey Day, in collaboration with Radiologist Dr. Fluoro, to evaluate oropharyngeal
swallow function.
Anatomic view under
fluoroscopy
P.O. barium contrast trials Varibar thin liquid, Varibar pudding, solid coated in Varibar pudding
Lip closure
Tongue control
Oral phase findings Bolus preparation
Bolus transport
Oral residue
Initiation of swallow
Velar elevation
Laryngeal elevation
Anterior hyoid excursion
Epiglottic movement
Pharyngeal phase
Laryngeal vestibule closure
findings
Pharyngeal stripping wave
Pharyngeal contraction
PES opening
BOT retraction
Pharyngeal residue
Esophageal findings Esophageal clearance
Thin liquid
Mildly-thick liquid
8-point Penetration-
Moderately-thick liquid
Aspiration Scale (PAS)
Pudding
Solid
Compensatory Swallow
Strategies
Dysphagia Outcome and
Severity Scale (DOSS)

A
P Diet recommendation
Risk management
Ancillary tests
Therapy
Goal
Follow-up exam

Flexible Endoscopic Evaluation of Swallowing
HPI
PMHx
O Flexible Endoscopic Evaluation of Swallowing (FEES) conducted by SLP Kelsey Day at pt’s bedside under order
from Dr. Scope. The flexible endoscope was passed transnasally to evaluate the anatomy and physiology of
swallowing.
P.O. trials Ice chips, thin liquid, mildly-thick liquid, moderately-thick liquid, puree, & solid
Nasopharyngoscopic Velopharyngeal function
findings Anatomic findings
Secretions
Pharyngoscopic & Vocal fold motion
laryngoscopic findings Sensory integrity
Anatomic findings
Posterior containment
Oral phase findings Mastication
Clearance
Initiation of swallow
BOT retraction
Epiglottic movement
Pharyngeal phase
Pharyngeal contraction
findings
Laryngeal vestibule closure
PES opening
Other findings
Thin liquid
Mildly-thick liquid
Moderately-thick liquid
Pudding
Solid
Yale Pharyngeal Residue Valleculae
Severity Rating Scale Pyriform sinuses
Murray Secretion Scale
Compensatory Swallow
Strategies
Dysphagia Outcome and

A
P Diet recommendation
Risk management
Ancillary tests
Therapy
Goal
Follow-up exam

Sample Reports

Clinical Swallow Evaluations

Clinical Swallow Evaluation 1
HPI 86yoM admitted w/ dyspnea. + Influenza A, PNA, acute hypercapnic respiratory failure. H/c: BiPAP
dependent x2 days. CXR reveals coarse lung markings c/w fibrosis, left pleural effusion, subtle right basilar
opacification that may represent airspace disease or atelectasis.
PMHx COPD, tobacco use
S Pt alert, oriented x4. Participated well in exam.
O Predisposing dysphagia risk COPD

factors
Clinical signs of possible None
chronic dysphagia
Precipitating dysphagia risk PNA, influenza, acute hypercapnic respiratory failure
factors
Temp WNL SpO2 90-95% on 2L via NC
Vitals/labs
RR 12-16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions WNL S/Z ratio 1.1
Laryngeal function exam VQ Clear Pitch Range WNL
MPT 10 secs Cough Perceptually weak
Ice Throat clear IDDSI 5 N/A
IDDSI 0 Throat clear IDDSI 6 N/A
IDDSI 2 N/A IDDSI 7 N/A
PO trials
IDDSI 3 N/A 3 oz water N/A
IDDSI 4 No s/s of aspiration Standardized N/A
Notes Further trials deferred for instrumentation
A Clinical signs of oropharyngeal dysphagia in the context of PNA + acute respiratory failure in pt w/ + historical
dysphagia risk factor (i.e., COPD). Instrumental swallow exam is indicated to define swallow physiology. Given
pt’s acuity of illness & reduced physical mobility, pt may be at increased risk for aspiration-related complication
& is not judged safe for oral diet until instrumental swallow study results.
P Instrumentation VFSS today

Diet recommendation NPO except critical p.o. meds crushed in puree until VFSS results
Risk management Oral hygiene q4h. Encourage physical mobility as tolerated.
Specialist referrals N/A
Ancillary tests N/A
Therapy Pending VFSS results
Goal Pt will participate in VFSS to define swallow physiology & therapy program.

HPI 58yoM underwent planned microlaryngoscopy/biopsy of small hypopharyngeal cysts (x3), c/b intra-
operative aspiration of esophageal content (likely r/t achalasia) w/ post-operative respiratory failure s/p re-
intubation & extubation. CXR reveals dilated esophagus.
PMHx Remote hx of achalasia s/p dilation 20 years ago; pt denies any f/u w/ GI or repeated dilatations since.
Outpatient identification of small hypopharyngeal cysts by ENT during flexible laryngoscopy for globus
sensation.
S Pt alert, very pleasant for exam. States he feels “okay.” Endorses long-term hx of dysphagia symptoms (primarily
to solids), which he attributes to his achalasia. States he hasn’t visited GI in “20 years.”
O Predisposing dysphagia risk Hypopharyngeal masses x3, achalasia (s/p dilation reportedly 20 years ago)
factors
Clinical signs of possible Pt endorses chronic dysphagia to solids, including globus sensation, chest pain
chronic dysphagia w/ meals, & occasional solid food regurgitation
Precipitating dysphagia risk Post-operative respiratory failure 2/2 intraoperative aspiration of esophageal
factors content s/p re-intubation/extubation
Temp Febrile SpO2 94% on 2L via NC
Vitals/lab
RR 20-22 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam:
CN IX/X Intact b/l
CN XII Intact b/l
Laryngeal function exam VQ Clear Pitch Range Perceptually WNL
MPT 10 secs Cough Perceptually WNL
Ice No s/s of aspiration IDDSI 5 N/A
IDDSI 0 No s/s of aspiration IDDSI 6 N/A
PO trials
IDDSI 4 N/A Standardized N/A
Notes Further trials deferred 2/2 achalasia, pending GI eval
A Clinical signs of primary esophageal dysphagia 2/2 hx of achalasia, which correlates w/ pt’s intra-operative
aspiration of esophageal content & dilated esophagus on chest imaging. No evidence of post-extubation
pharyngeal dysphagia or laryngeal dysfunction; SLP will sign off. Pt’s primary esophageal dysphagia requires
evaluation/intervention by Gastroenterologist.
P Instrumentation N/A
Diet recommendation NPO except ice chips until GI evaluation
Risk management Oral hygiene q4h. HOB upright as tolerated.
Specialist referrals Inpatient GI consult; f/u w/ outpatient ENT
Ancillary tests Consider EGD 2/2 hx of achalasia
Therapy N/A
Goal N/A

HPI 52yoF admitted w/ dyspnea, acute respiratory failure, PNA, volume overload, cardiopulmonary arrest. H/c:
endotracheal intubation x3 days, weaned to HFNC.
PMHx CHF, cervical spinal stenosis
S Pt alert, cooperative for exam w/ encouragement. Requesting to remove NGT & to eat by mouth. Mother at
bedside. Increased work of breathing on HFNC at 40 L/min.
O Predisposing dysphagia risk CHF, cervical spinal stenosis

factors
Clinical signs of possible Hospitalization w/ RML/RLL PNA (aspiration PNA not excluded)
chronic dysphagia
Precipitating dysphagia risk Volume overload; PNA; cardiopulmonary arrest/respiratory failure s/p
factors endotracheal intubation x3 days; iatrogenic high pharyngeal pressure on HFNC
Temp WNL SpO2 90-95% on HFNC 40
Vitals/lab L/m
RR 16 WBCs Elevated on admission
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Unable to exclude CN X branch involvement 2/2 dysphonia
CN XII Intact b/l
Secretions Mildly impaired S/Z ratio 1.2
Laryngeal function exam VQ G2R2B1A1S1 Pitch Range Perceptually reduced
MPT 2-5 secs 2/2 dyspnea Cough Perceptually weak
IDDSI 0 Cough, + regurgitation IDDSI 6 N/A
PO trials
Notes Regurgitation of blood-tinged mucous after water
A Clinical signs of pharyngeal dysphagia, likely temporary post-extubation dysphagia, compounded by iatrogenic
high pharyngeal pressure on HFNC at 40 L/min. In the context of pt’s recent CPA/respiratory failure, PNA, high
ventilatory requirement, & limited physical mobility 2/2 cervical stenosis, risk for aspiration-related pulmonary
complication appears high. Instrumental swallow study is indicated to evaluate swallow physiology prior to oral
diet initiation.
P Instrumentation FEES tomorrow

Diet recommendation NPO except ice chips (1 at a time) w/ RN assist for swallow stim/QOL; continue NGT
Ancillary tests N/A
Therapy Pending FEES results
Goal Pt will participate in FEES to define swallow physiology & therapy program.
HPI 60yoF presented to ED for report of dysphagia & dysphonia x3 weeks; pt states she is now unable to
swallow
PMHx Tobacco abuse
S Pt alert, very pleasant/cooperative for exam in ED; expressing concern regarding voice & swallow changes.
Spouse at bedside.
O Predisposing dysphagia risk Tobacco abuse

factors
3 weeks of progressive dysphagia symptoms, odynophagia, & weight loss;
endorses intermittent coughing on liquids & “choking” on solids; states she can
manually extract foods when stuck & gestured to level of hyoid; states
chronic dysphagia
swallowing improves “when I squeeze here” (gestured to thyroid); endorses
stridor & dyspnea on exertion
Precipitating dysphagia risk None known
factors
Temp WNL SpO2 98% on RA
Vitals/labs
RR 14 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
IDDSI 0 Odynophagia IDDSI 6 N/A
PO trials
Note Pt declined further trials 2/2 odynophagia; agreeable to FEES
A Clinical signs of pharyngeal dysphagia & laryngeal dysfunction/pathology, reportedly subacute (x3 weeks,
progressive). In the context of concomitant dysphonia + tobacco abuse, high clinical concern for potential
pharyngeal/laryngeal pathology. Patient requires endoscopic swallow study with direct visualization of
pharyngeal/laryngeal anatomy.
P Instrumentation FEES ASAP

Diet recommendation NPO except small sips of water until FEES results
Risk management Oral hygiene q4h. Encourage physical mobility as tolerated.
Specialist referrals ENT for laryngoscopy. Dietitian 2/2 weight loss.
Ancillary tests Consider CT Soft Tissue Neck, pending FEES & laryngoscopy results
Goal Pt will participate in FEES to define swallow physiology & determine therapy program.

HPI 63yoM found down, altered w/ drug overdose. + tox screen for methamphetamines & opiates.
PMHx Unknown medical hx; patient currently unidentified
S Pt somnolent; difficult to sustain wakefulness for exam. Responded verbally “yes” to all yes/no questions.
Oriented x0.
O Predisposing dysphagia risk Unknown

factors
LLL PNA (suspected aspiration PNA); suspect likely isolated non-dysphagia
related aspiration event, given + overdose, though unable to exclude chronic
chronic dysphagia
dysphagia/aspiration as medical hx unknown
Precipitating dysphagia risk Encephalopathy, rhabdomyolysis
factors
Vitals/labs
RR 18 WBCs WNL
CN V Pt did not follow commands for assessment
CN VII Pt did not follow commands for assessment; no overt asymmetry
Cranial nerve exam
CN IX/X Pt did not follow commands for assessment
CN XII Pt did not follow commands for assessment
Secretions WNL S/Z ratio Unable to test
Laryngeal function exam VQ G1R1B0A0S0 Pitch Range Unable to test
MPT Unable to test Cough Weak spontaneous
IDDSI 0 Multiple swallows/bolus IDDSI 6 N/A
PO trials
Notes Further trials deferred 2/2 LOA
A Clinical signs of oropharyngeal dysphagia, likely r/t current AMS/somnolence 2/2 encephalopathy. Unknown
historical dysphagia risk factors, as medical hx unknown at this time. + LLL PNA, possibly aspiration-related; this
likely reflects an isolated/non-dysphagia related aspiration event, though unable to exclude potential chronic
dysphagia sequalae. Pt does not appear safe for oral diet at this time 2/2 current LOA. Will defer
instrumentation until clinical improvement in alertness/encephalopathy.
P Instrumentation VFSS vs. FEES, pending clinical improvement

Diet recommendation NPO except critical meds crushed in puree
Ancillary tests N/A
Therapy SLP will f/u x5/week for diagnostic swallow tx
Goal Pt will tolerate least-restrictive p.o. diet w/out acute dysphagia-related aspiration PNA.

HPI 70yoM admitted w/ SOB/respiratory failure. Chest imaging & w/u during h/c revealed stage IV R lung
malignancy; R lung mass w/ extension to bronchus/trachea/chest wall.
PMHx HTN, tobacco abuse, Bell’s Palsy. Endorses chronic/progressive dysphagia symptoms x3 months.
S Pt received asleep on NRB; roused easily to verbal stim. Sustained alertness, very pleasant for exam. Pt
appeared highly aware of his dysphagia symptoms. Verbal pain scale 0.
O Predisposing dysphagia risk COPD, undiagnosed R lung malignancy

factors
Clinical signs of possible Weight loss, SOB, respiratory failure, dysphagia symptoms x3 months
chronic dysphagia
Precipitating dysphagia risk Respiratory failure on NRB
factors
Temp WNL SpO2 95% on NRB 15 L/min
Vitals/labs
RR 20 WBCs WNL
CN V Intact b/l
CN VI Signs of LMN R CN involvement c/w hx of Bell’s Palsy
Cranial nerve exam CN IX/X: Suspect R RLN involvement, given R lung malignancy w/ extension
to bronchus/trachea/chest wall, in context of dysphonia
CN XII Intact b/l
Secretions Mildly impaired S/Z ratio 2.5
IDDSI 0 Wet vocal quality IDDSI 6 N/A
PO trials
Notes Further trials deferred for FEES
A Clinical signs of pharyngeal phase dysphagia & laryngeal dysfunction, which appear chronic/progressive x3
months. In the context of severe dysphonia & stage IV R lung malignancy, high clinical suspicion for R RLN
involvement. Given pt’s respiratory failure, risk for immediate deterioration w/ aspiration event appears high;
suspect chronic pharyngeal dysphagia w/ likely aspiration as probable component of pt’s current respiratory
failure. Endoscopic swallow study is indicated prior to any PO intake. Appreciate pt’s code status change to
DNR; discussed pt’s goals of care & pt stated he would like to preserve lung function as long as possible & is
agreeable to potential diet modifications that may impact QOL; pt agreeable to temporary NPO status pending
FEES.
P Instrumentation FEES
Diet recommendation NPO, pending FEES results
Risk management Oral hygiene q4h. HOB upright as tolerated. Encourage physical mobility as tolerated.
Specialist referrals Cardiothoracic surgery 2/2 lung/mediastinal mass w/ suspected R RLN involvement
Ancillary tests N/A
Goal Pt will participate in FEES to define swallow physiology & assess therapy need.
HPI 68yoM admitted w/ cough, hypoxia, SOB 2/2 PNA. H/c involved endotracheal intubation x12 hrs.
PMHx COPD, DM
S Pt alert, very pleasant for exam. Pt eager to eat/drink by mouth. Son arrived at bedside.

factors
Admission w/ PNA; chronic dysphagia symptoms; states that for weeks “little
Clinical signs of possible granules go down the wrong way” & endorses coughing during meals; reports
chronic dysphagia completing swallow study at OSH “many years ago” & being advised to
alternate liquids/solids
Precipitating dysphagia risk Endotracheal intubation x12 hours
factors
Temp WNL SpO2 95-100% on 30 L/min
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Adequate S/Z ratio Unable to test
Laryngeal function exam VQ G1R1B0A1S0 Pitch Range Perceptually WNL
MPT 6 secs Cough Perceptually intact
Ice No s/s of aspiration IDDSI N/A
IDDSI 0 Delayed cough, wet VQ IDDSI 6 N/A
PO trials
Notes Deferred for instrumentation
A Clinical signs of pharyngeal phase dysphagia in pt w/ known chronic (COPD) & acute (endotracheal intubation)
dysphagia risk factors admitted w/ respiratory failure/PNA. Pt endorses chronic/progressive dysphagia
symptoms. Instrumental swallow study is indicated; given pt’s acuity of illness, pt does not appear safe for oral
diet until instrumental swallow study results.
P Instrumentation VFSS
Diet recommendation NPO except critical meds crushed in puree, pending VFSS results
Risk management Oral hygiene QID
Ancillary tests N/A
Goal Pt will participate in VFSS to define swallow physiology & determine therapy program.

HPI 30yoM admitted as level I trauma s/p penetrating R neck injury (stab wound). Respiratory failure requiring
endotracheal intubation x2 days.
PMHx None
S Pt alert, very pleasant for exam. Eager to eat/drink s/p extubation. SLP phoned Trauma Surgeon to receive
verbal clearance for PO trials; surgeon stated no clinical concern for pharyngeal/esophageal perforation or
subsequent extravasation of material into soft tissues & gave clearance for p.o. trials as tolerated.
O Predisposing dysphagia risk None

factors
chronic dysphagia
Precipitating dysphagia risk Penetrating R neck injury; endotracheal intubation x2 days
factors
Temp Critically high SpO2 100% on 3 L/min
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to exclude possible CN X branch involvement 2/2
dysphonia
CN XII Intact b/l
Secretions + coughing, suctioning S/Z ratio 2.25 (norm <1.4)
Ice Delayed cough IDDSI 5 N/A
PO trials
Notes Further trials deferred for pt’s airway protection
A Clinical signs of pharyngeal phase dysphagia marked by severe laryngeal dysfunction; most likely post-
extubation dysphagia w/ excellent prognosis for spontaneous recovery, however, unable to exclude potential R
RLN injury r/t R penetrating neck wound. Pt does not appear safe for PO diet at this time, given severity of
laryngeal dysfunction & impaired secretion management. Pt will benefit from endoscopic swallow study in 1-2
days, pending clinical progress.
P Instrumentation FEES in 1-2 days, pending clinical progress

Diet recommendation NPO except ice chips (1 at a time) w/ RN assist for swallow stimulation
Risk management Oral hygiene QID. HOB upright as tolerated. Yankauer suction PRN.
Ancillary tests N/A
Therapy SLP following x7/week for diagnostic swallow tx.
HPI 62yoM admitted w/ weight loss and dyspnea. New dx of R neck mass involving R RLN w/ subsequent R TVC
paralysis; CT Soft Tissue Neck reveals a mass that involves cricoid cartilage, “tracheoesophageal groove”, &
is “abutting the epiglottis.” CXR clear.
PMHx Tobacco use, ETOH use, HTN
S Pt alert, very pleasant for exam. Received eating breakfast EOB.
O Predisposing dysphagia risk R neck mass w/ associated R TVC paralysis (presumably chronic/progressive,
factors though newly identified)
Clinical signs of possible Weight loss per pt report (pt unable to quantify)
chronic dysphagia
Precipitating dysphagia risk N/A
factors
Temp WNL SpO2 95-100% on RA
Vitals/labs
RR 20-22 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X R RLN involvement w/ R TVC paralysis, per laryngoscopy
CN XII Intact b/l
Secretions Adequate S/Z ratio 2
MPT 8 secs Cough Perceptually intact
IDDSI 2 N/A IDDSI 7 No s/s of aspiration
PO trials
IDDSI 3 N/A 3 oz water Fail
Notes Pt denied difficulty swallowing
A High risk for pharyngeal dysphagia in the setting of R neck mass w/ laryngeal/pharyngeal & RLN involvement w/
subsequent R TVC paralysis. Instrumental swallow exam is indicated to define swallow physiology & generate
swallow tx plan. As suspected dysphagia etiology is chronic/progressive & respiratory status is stable, chest
radiography clear, no leukocytosis, & pt afebrile, pt appears safe to continue oral diet until FEES results.
Diet recommendation Continue IDDSI 7/0 diet until FEES results
Risk management Oral hygiene QID. Encourage physical mobility as medically feasible.
Specialist referrals F/u w/ ENT
Ancillary tests N/A

HPI 25yoM admitted for cough, dyspnea, hypoxia, fever, & generalized weakness 2/2 PNA.
PMHx PNA x3 this year, cachexia/malnutrition
S Alert & participated in exam, but w/ notably flat affect. Pt denies concern for difficulty swallowing, despite
education on his clinical symptoms of dysphagia.

factors
Clinical signs of possible Recurrent PNA in gravity-dependent lung zones, severe malnutrition/cachexia,
chronic dysphagia sepsis, chronic cough
Precipitating dysphagia risk Generalized weakness
factors
Temp Critically high, trend ¯ SpO2 88% on adm, now WNL
Vitals/labs
RR 30 on adm, now WNL WBCs on adm, now WNL
CN V Intact b/l
CN VII b/l LMN vs. neuromuscular involvement
Cranial nerve exam
CN IX/X Possible b/l involvement; + hypernasality & dysphonia
CN XII Possible b/l involvement; perceptually reduced b/l lingual strength
Secretions Impaired, coughing S/Z ratio 1.6
Laryngeal function exam VQ Mildly hoarse Pitch Range Perceptually reduced
Ice Multiple swallows/bolus IDDSI 5 N/A
PO trials
Notes Swallowing appeared effortful but pt denied difficulty
A Clinical signs of oropharyngeal dysphagia (i.e., malnutrition/cachexia, RLL PNA, atypical CNE w/ potential b/l
LMN vs. muscular involvement, clinical laryngeal dysfunction). No known historical dysphagia risk factors in this
25-year-old patient, however, complete workup for possible chronic dysphagia of undiagnosed etiology is
indicated based upon this pt’s symptomatology. Given current PNA, risk for aspiration-related complication
appears increased; advise NPO until instrumental swallow study results.
P Instrumentation FEES + VFSS today

Diet recommendation NPO until VFSS/FEES results
Risk management Oral hygiene QID. Encourage physical mobility as medically feasible.
Specialist referrals Pending VFSS/FEES results
Ancillary tests Pending VFSS/FEES results
Therapy Pending VFSS/FEES results
Goal Pt will participate in VFSS/FEES to define swallow physiology & therapy program.
HPI 23yoM admitted w/ AMS & hyperglycemia. CT Head & MRI Brain unremarkable.
PMHx Type 1 DM
S Pt alert, pleasant for exam. Limited verbal responses initially, however, this appeared largely cultural; pt’s
responses improved as clinical-patient rapport improved, & also when familiar family member arrived at
bedside.
O Predisposing dysphagia risk DM

factors
Clinical signs of possible N/A
chronic dysphagia
Precipitating dysphagia risk DKA, encephalopathy
factors
Vitals/labs
RR 18 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Adequate S/Z ratio 1.2
MPT WNL Cough Perceptually intact
IDDSI 0 No s/s of aspiration IDDSI 6 No s/s of aspiration
PO trials
Notes Early satiety & nausea w/ meals, c/w possible GI dysmotility
A No clinical signs of oropharyngeal dysphagia. Signs of possible esophageal and/or gastric dysfunction (e.g.,
reduced esophageal motility, delayed gastric emptying), given pt’s report of nausea & early satiety w/ meals,
which may be c/w pt’s uncontrolled diabetes. Pt will benefit from GI consult but does not require further SLP
intervention.
Diet recommendation IDDSI 7/0. Meds whole w/ thin liquid.
Risk management Consider 6 small meals per day. Behavioral reflux precautions.
Specialist referrals GI consult 2/2 possible GI dysmotility; Dietitian consult 2/2 poor appetite
Ancillary tests Consider upper GI series to evaluate esophageal/gastric motility
Therapy SLP will sign off, as pt will not benefit from behavioral swallow tx
Goal N/A
HPI 41yoF admitted w/ right-sided weakness, drooling, dysphagia, dysphonia, headache.
PMHx Chiari malformation s/p VP shunt & midline low occipital craniotomy with cervical fusion, CVA w/ residual R
weakness, mild pharyngeal dysphagia (per VFSS 2016)
S Pt alert, pleasant for exam. Pt endorses 3 days of progressive dysphagia & dysphonia. Pt highly educated on her
medical hx & appeared to be an excellent historian; aware of her mild oropharyngeal dysphagia since 2016.
O Predisposing dysphagia risk Chiari malformation s/p VP shunt; low occipital craniotomy w/ cervical fusion; hx
factors of CVA
Clinical signs of possible Mild oropharyngeal dysphagia, per VFSS in 2016 (images personally reviewed
chronic dysphagia by this clinician today)
Precipitating dysphagia risk Exacerbated dysphagia symptoms x3 days concerning for possible acute CVA
factors vs. complication r/t Chiari malformation
Temp WNL SpO2 >94% on RA
Vitals/labs
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
CN IX/X Signs of R CN involvement, marked by impaired R velar elevation,
Cranial nerve exam hypernasality, dysphonia, & absent gag response; new since 2016
CN XII Signs of LMN impairment of R CN XII; severe
atrophy/fasciculations of R tongue w/ R deviation, which is chronic
per 2016 records
Secretions Coughing; pt endorses S/Z ratio 1.4
drooling, though not
Laryngeal function exam observed
VQ G2R2B0A1S0 Pitch Range Perceptually reduced
Ice Multiple swallows, IDDSI 5 N/A
coughing, globus
PO trials IDDSI 2 N/A IDDSI 7 N/A
A Clinical signs of oropharyngeal dysphagia, acute (progressive x3 days) on chronic (known mild oropharyngeal
dysphagia since 2016 r/t Chiari malformation). In the context of acute R CN X involvement & worsening
dysphagia symptoms, immediate instrumental swallow study is indicated to define swallow physiology.
P Instrumentation FEES today

Diet recommendation NPO except ice chips, pending FEES results
Specialist referrals Neurosurgery f/u 2/2 progressive dysphagia in context of Chiari malformation
Ancillary tests N/A
Therapy Swallow tx plan pending FEES results
Goal Pt will participate in FEES to define swallow physiology & therapy need.

HPI 72yoF admitted for cough, dyspnea, hypoxia, fever, AMS 2/2 PNA.
PMHx FTT, malnutrition, dehydration, weight loss
S Pt alert, very pleasant/cooperative for exam. Pt appears frail/cachectic & deconditioned.
O Predisposing dysphagia risk None known

factors
Clinical signs of possible Progressive weight loss x6 months; dysphagia symptoms to both liquids &
chronic dysphagia solids; failure to thrive/malnutrition/dehydration; PNA
Precipitating dysphagia risk None
factors
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Unable to exclude mild b/l weakness of velum/pharynx
CN XII Mildly reduced lingual strength b/l; no deviation
Secretions Impaired S/Z ratio Pt declined
MPT Pt declined Cough Perceptually weak
Ice Multiple swallows/bolus, IDDSI 5 N/A
coughing, globus
IDDSI 0 Multiple swallows/bolus, IDDSI 6 N/A
nasal regurgitation
Notes Further trials deferred for instrumentation; pt endorses swallowing
is mildly painful, worse w/ solids
A Clinical signs of oropharyngeal dysphagia of unknown etiology. In the setting of progressive weight loss x6
months & hospitalization with PNA in gravity-dependent lung zone, there is concern for possible
chronic/undiagnosed oropharyngeal dysphagia. Immediate instrumental swallow studies are indicated prior to
oral diet initiation.

Diet recommendation NPO pending FEES results
Specialist referrals Pending FEES results
Ancillary tests N/A

HPI 33yoM admitted s/p BHT w/ R SDH/SAH & subsequent respiratory failure requiring endotracheal intubation
x1 day.
PMHx None
S Pt awake, minimal verbal responses. Pt handcuffed to ICU bed, in LAPD custody w/ 2 officers at bedside.

factors
chronic dysphagia
Precipitating dysphagia risk BHT w/ R SDH/SAH; endotracheal intubation 12/10-12/11 (x1 day)
factors
Vitals/labs
RR 22 WBCs WNL
CN V Pt did not follow commands to assess
CN VII Pt did not follow commands to assess; no overt facial asymmetry
Cranial nerve exam
CN IX/X Pt did not follow commands to assess
CN XII Pt did not follow commands to assess
Secretions Adequate S/Z ratio Unable to elicit
Laryngeal function exam VQ Unable to elicit Pitch Range Unable to elicit
MPT Unable to elicit Cough Perceptually weak
IDDSI 0 Wet/congested cough IDDSI 6 N/A
PO trials
A Clinical signs of oropharyngeal dysphagia. In the setting of multiple acute dysphagia risk factors (i.e., TBI w/ R
SAH/SDH, endotracheal intubation), instrumental swallow study is indicated prior to initiation of p.o. diet.
P Instrumentation FEES immediately to follow

Diet recommendation NPO pending FEES results
Ancillary tests N/A

HPI 39yoM admitted s/p auto vs. ped accident w/ BHT, femur fracture, liver laceration, pneumothorax, splenic
laceration. CT Head revealed post-traumatic bleeding in L frontal/temporal/parietal scalp. H/c involved
endotracheal intubation x8 days, hip fracture repair + revision, chest tube,. Repeat CT Head revealed b/l
gliosis or sequalae of axonal shearing injury.
PMHx None
S Pt awake/alert, oriented x3 but confused. Tachypneic on HFNC at 50L/min.

factors
chronic dysphagia
BHT/TBI w/ bifrontal axonal shearing injury; endotracheal intubation 12/10-
12/18 (x8 days); HFNC at 50 L/min; pneumothorax/chest tube w/ tachypnea;
factors
critical illness
Temp Febrile SpO2 94% on 50L via HFNC
Vitals/labs
CN VII Pt did not follow commands to assess; unable to exclude UMN
involvement of L CN XII vs. limited facial ROM r/t facial lacerations
Cranial nerve exam
edema
Secretions Impaired S/Z ratio Unable to assess
Laryngeal function exam VQ G2R2B1A1S0, wet Pitch Range Unable to assess
MPT 2 secs Cough Absent volitional
Ice N/A IDDSI 5 N/A
PO trials
Notes Trials deferred 2/2 current tachypnea (RR 40-50 on HFNC at 50
L/min) & impaired secretion management; elicited spontaneous
swallows x3 after oral hygiene
A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t TBI + likely laryngeal dysfunction s/p
endotracheal intubation + critical illness w/ PNA/tachypnea + iatrogenic high peak pharyngeal pressures on
HFNC at 50 L/min. Swallow prognosis is good for improvement w/ intensive swallow rehabilitation. Pt is not safe
for p.o. intake at this time.
P Instrumentation Instrumental swallow study (VFSS vs. FEES) in 1-3 days, pending clinical progress.
Diet recommendation Strict NPO w/ short-term enteral feeding route (e.g., NGT)
Ancillary tests N/A
HPI 84yoM brought by EMS for AMS & dysarthria, possible CVA.
PMHx DM, HTN, L eye blindness
S Pt awake/alert but confused; grandson at bedside in Emergency Room

factors
chronic dysphagia
Precipitating dysphagia risk Possible acute CVA
factors
Temp Febrile SpO2 98% on RA
Vitals/labs
CN V Pt unable to follow commands for assessment
CN VII Intact b/l
Cranial nerve exam
CN IX/X Pt unable to follow commands for assessment
CN XII Intact b/l
Secretions Impaired S/Z ratio Unable to assess
Laryngeal function exam VQ G2R2B1A1S2, wet Pitch Range Perceptually reduced
Ice Absent oral transit & IDDSI 5 N/A
swallow trigger (bolus
visualized w/ open
mouth posture)
A Clinical signs of oropharyngeal dysphagia, despite no focal cranial nerve involvement appreciated by this
clinician. Dysphagia appears r/t pt’s current AMS. Pt does not appear safe for oral intake at this time. Given pt’s
current mental status, anticipate at least several days prior to sufficient LOA for instrumental swallow exam.
P Instrumentation Instrumental swallow study (i.e., VFSS vs. FEES), pending clinical progress.
Diet recommendation Strict NPO. Medications alternate route. Consider short-term enteral feeding route
(e.g., NGT).
Specialist referrals F/u w/ Neurologist
Ancillary tests N/A
HPI 55yoF admitted for AMS 2/2 complication with VP shunt
PMHx VP shunt for hydrocephalus
S Pt awake but lethargic; sustained attention w/ cueing. Confused & perseverative, restless in bed.
O Predisposing dysphagia risk VP shunt for hydrocephalus

factors
chronic dysphagia
Precipitating dysphagia risk AMS/delirium 2/2 hyperglycemia
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Adequate S/Z ratio Unable to assess
Laryngeal function exam VQ Clear Pitch Range Unable to assess
MPT >10 secs Cough Perceptually WNL
PO trials IDDSI 3 N/A 3 oz water Pass
Notes Reduced mastication skill 2/2 absent dentition + AMS; daughter
states pt typically uses dentures, which she will bring from home
A Clinical signs of oral phase dysphagia r/t AMS/delirium; no evidence of pharyngeal phase dysphagia. Impaired
safety for solid foods at this time 2/2 reduced LOA combined w/ absent dentition. Temporary solid diet
modification appears indicated while mental status remains altered.
Diet recommendation IDDSI 4/0 diet. Meds whole w/ thin liquid.
Risk management Aspiration precautions: 1:1 feeding assist; feed only when fully alert & upright
Ancillary tests N/A
Therapy SLP will f/u x2/week for swallow tx to advance solid diet as mental status improves.
Goal Pt will tolerate least-restrictive p.o. diet w/out dysphagia-related aspiration PNA

HPI 42yoM w/ BHT/TBI s/p auto vs. bicycle accident. GCS 3 on arrival. C7 vertebral fx. H/c involved
PMHx None
S Pt awake, tracking visually. Not following verbal-only commands well. No nonverbal signs of pain.

factors
chronic dysphagia
Precipitating dysphagia risk TBI (SAH/SDH); endotracheal intubation x3 days; C7 fracture; cervical collar
factors
Temp WNL SpO2 98% on 2L via NC
Vitals/labs
RR 18 WBCs WNL
CN VII Pt did not follow commands to assess
Cranial nerve exam
Secretions Severely impaired; S/Z ratio Aphonic
significantly wet breath
sounds; mild inspiratory
Laryngeal function exam stridor & expiratory
wheezing
VQ Aphonic Pitch Range Aphonic
Ice Elicited oral-motor IDDSI 5 N/A
movements; elicited
swallow triggers
Notes Increase in wet laryngeal breath sounds & stridor post-trials w/
profoundly weak spontaneous coughing
A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t TBI + laryngeal dysfunction s/p endotracheal
intubation. Given acuity of illness, pt does not appear safe for any p.o. intake at this time. Pt will require
instrumental swallow study to define swallow physiology, once LOA improves.
P Instrumentation Instrumental swallow study pending improved LOA.

Diet recommendation Strict NPO. Short-term enteral feeding route (e.g., NGT).
Ancillary tests N/A
HPI 54yoM admitted w/ AMS, fever, cervical stiffness/rigidity, leukocytosis.
PMHx HTN, a-fib, BPH, DM, AKA
S Pt awake/alert but confused; extended b/l UEs (which appeared rigid) for duration of exam; demonstrated
repetitive grinding of TMJs. Sitter at bedside.

factors
chronic dysphagia
Precipitating dysphagia risk AMS/delirium, possible influenza encephalitis, r/o meningitis
factors
Vitals/labs
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
MPT Unable to assess Cough Perceptually WNL
PO trials
IDDSI 3 N/A 3 oz water Pass
Notes N/A
A No clinical signs of oropharyngeal dysphagia, despite altered mentation. No SLP swallow services indicated.
Risk management 1:1 feeding assistance 2/2 AMS
Ancillary tests N/A
Therapy No swallow rehabilitation indicated at this time
Goal N/A
HPI 78yoM admitted w/ L weakness & difficulty ambulating 2/2 cervical myelopathy. H/c involved C3-C7 ACDF
& C2-T1 posterior laminectomy/fusion + revision.
PMHx Progressive L weakness, cervical spinal stenosis, cervical myelopathy, HTN
S Pt received awake, in apparent mild respiratory distress; + use of accessory muscles & rib cage flaring during
respiration, RR 30-35. Copious secretion production audible in upper airway requiring Yankauer or
nasopharyngeal suction q1 min. Severely wet/gurgly vocal quality & breath sounds.
O Predisposing dysphagia risk Progressive L weakness x1 month 2/2 C3-C4 cervical stenosis
factors
chronic dysphagia
Precipitating dysphagia risk C3-C7 ACDF on 12/11; C2-T1 posterior laminectomy/fusion on 12/10; C2-T1
factors posterior laminectomy/fusion revision on 12/11; respiratory distress
Temp Critically high SpO2 >95% on 2L via NC
Vitals/labs
RR 30-35 WBCs WNL
Cranial nerve exam
Secretions Copious secretion S/Z ratio Unable to assess
production requiring
Laryngeal function exam near constant suctioning
VQ Severely wet/gurgly Pitch Range Unable to assess
MPT Unable to assess Cough Perceptually weak
Ice N/A IDDSI 5 N/A
PO trials
Notes Wet/congested laryngeal breath sounds; all trials deferred 2/2
suspected inability to protect the airway & apparent mild
respiratory distress.
A Clinical signs of oropharyngeal dysphagia s/p C2-C7 ACDF (POD #2). Severely impaired secretion management
& laryngeal function at this time. Pt does not appear to protect the airway; signs of respiratory distress at time of
SLP evaluation (i.e., RR 30-35, use of accessory muscles, rib cage flaring). Presumable pathology is severe post-
op edema of the prevertebral soft tissue, +/- comorbid laryngeal dysfunction.
P Instrumentation Pt will require instrumental swallow study via VFSS and/or FEES, once respiratory status
stable.
Diet recommendation Strict NPO. Short-term enteral feeding route per MD discretion. Anticipate potential
complications w/ NGT placement 2/2 presumed prevertebral soft tissue. Large bore
NGT may also exacerbate current dysphagia. Consider use of small-bore NGT (e.g.,
Dobhoff); consider use of fluoroscopic guidance to avoid laryngeal/pharyngeal trauma.

Risk management Close airway monitoring 2/2 suspected gross aspiration of secretions. Oral hygiene
q4h.
Ancillary tests N/A

HPI 78yoM admitted w/ L weakness & difficulty ambulating 2/2 cervical myelopathy. H/c involved C3-C7 ACDF
& C2-T1 posterior laminectomy/fusion + revision. C/b post-operative respiratory failure 2/2 dysphagia &
aspiration PNA, requiring endotracheal intubation x2 days, s/p extubation.
PMHx Progressive L weakness, cervical spinal stenosis, cervical myelopathy, HTN
S Pt received alert, restless & confused. In wrist restraints s/p extubation, stating he is ready to walk outside & go
home. Severe wet/gurgly vocal quality.
O Predisposing dysphagia risk Progressive L weakness x1 month 2/2 C3-C4 cervical stenosis
factors
chronic dysphagia
C3-C7 ACDF on 12/11; C2-T1 posterior laminectomy/fusion on 12/10; C2-T1
posterior laminectomy/fusion on 12/11; post-op dysphagia w/ aspiration PNA,
factors
respiratory failure, sepsis w/ endotracheal intubation 12/20-12/22 (x2 days)
Temp Critically high SpO2 >94% on 4 L via NC
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
Secretions Severely impaired; S/Z ratio Unable to assess
severely wet/gurgly
vocal quality &
coughing w/ secretion
production (requiring
constant Yankauer
Laryngeal function exam
suctioning)
VQ Severely hoarse/wet Pitch Range Unable to assess
MPT <1 sec Cough Absent volitional
cough; peak expiratory
flow rate (PEFR) <60
L/min
Ice Absent swallow trigger IDDSI 5 N/A
to palpation
PO trials
Notes Absent swallow trigger to palpation w/ saliva >30 mins; unable to
elicit swallow trigger to palpation w/ max cues

A Clinical signs of oropharyngeal dysphagia s/p C2-C7 ACDF (POD #12). Hospital course complicated by post-op
dysphagia w/ aspiration PNA resulting in sepsis & respiratory failure w/ 2-day endotracheal intubation. Severely
impaired secretion management & laryngeal function at this time. Pt does not appear to protect the airway;
absent swallow at this time. Presumable dysphagia pathology is now multifactorial, including post-op edema of
prevertebral soft tissue, +/- comorbid laryngeal dysfunction (r/t possible intra-operative RLN injury and/or
laryngeal trauma from endotracheal tube). Given severity of dysphagia symptoms & aspiration-related
pulmonary complication, early consideration of long-term enteral feeding route may be indicated for this
patient.
P Instrumentation Pt will require instrumental swallow study via VFSS and/or FEES, once respiratory status
stable & pt appears to trigger swallow.
Diet recommendation Strict NPO. Consider long-term enteral feeding route (e.g., PEG), given severity of
symptoms & poor recovery post-operatively.
Risk management Close airway monitoring 2/2 suspected gross aspiration of secretions. Consider
percussive chest therapy followed immediately by nasopharyngeal suctioning to assist
w/ secretion management.
Ancillary tests N/A

HPI 43yoM admitted w/ left hemiparesis & facial droop 2/2 acute R pontine hemorrhagic CVA.
PMHx HTN
S Pt received alert. Appeared emotionally distressed regarding his left-sided weakness. Required extensive
counseling for emotional support & coping with his deficits.

factors
chronic dysphagia
Precipitating dysphagia risk Acute R pontine hemorrhagic CVA
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Signs of UMN involvement of L CN VII
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes N/A
A No clinical signs of oropharyngeal dysphagia. + UMN involvement of L CN VII, however, CN IX/X/XII appear
spared bilaterally. Appreciate L facial droop, however, this does not appear to impact pt’s speech/swallowing
function.
Risk management N/A
Ancillary tests N/A
Therapy No SLP service indicated at this time; SLP will sign off
Goal N/A

HPI 50yoM admitted for facial/lingual angioedema.
PMHx HTN, a-fib, angioedema x2
S Pt alert, very pleasant for exam. Expressing his worry regarding unknown cause of lip/face swelling; stated, “this
is the 3rd time in the past several weeks”

factors
chronic dysphagia
Precipitating dysphagia risk Angioedema
factors
Vitals/labs
RR 14 WBCs WNL
CN V Intact b/l
CN VII Reduced b/l lower facial movement, likely r/t overt facial edema
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes N/A
A No clinical signs of oropharyngeal dysphagia. No evidence of lingual/pharyngeal edema or peripheral nerve

involvement at time of SLP exam.
Risk management N/A
Ancillary tests N/A
Goal N/A

HPI 65yoM admitted w/ L hand paresthesia, r/o CVA.
PMHx DH, HTN, CAD
S Pt received alert, very pleasant for exam in ED. Endorsing L hand numbness.

factors
chronic dysphagia
Precipitating dysphagia risk Possible acute CVA
factors
Vitals/labs
RR 18-22 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes N/A
A No clinical signs of oropharyngeal dysphagia or CN involvement in pt w/ possible acute CVA. No SLP swallow
service indicated at this time.
Risk management N/A
Ancillary tests N/A
Goal N/A
HPI 71yoF admitted w/ AMS, cough, fever, dyspnea 2/2 CAP & sepsis. H/c involved respiratory failure s/p
endotracheal intubation x7 days, extubated to HFNC at 40 L/min.
PMHx Depression, anxiety, HTN
S Pt alert, very pleasant for exam. Followed all commands & participated well. Received w/ severely wet/gurgly
vocal quality on HFNC.

factors
chronic dysphagia
Precipitating dysphagia risk CAP w/ respiratory failure & septic shock, endotracheal intubation x7 days,
factors iatrogenic high pharyngeal pressure 2/2 HFNC at 40 L/min
Temp Febrile SpO2 94% on HFNC 40 L/min
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Severely impaired S/Z ratio Unable to assess
VQ Severely wet/gurgly Pitch Range Perceptually reduced
MPT 2 secs Cough Perceptually weak;
PEFR 110 L/min
Ice Wet VQ IDDSI 5 N/A
PO trials
A Clinical signs of pharyngeal dysphagia & laryngeal dysfunction, likely r/t 7-day endotracheal intubation &
iatrogenic high pharyngeal pressure (on HFNC at 40 L/min). Impaired secretion management s/p extubation
today. Moderate-severe dystussia. In the context of pt’s critical illness & reduced physical mobility, pt is at high
risk for dysphagia-related aspiration PNA & does not appear safe for oral diet until endoscopic swallow study.

Diet recommendation Strict NPO pending FEES results
Risk management Oral hygiene q4h
Ancillary tests N/A
HPI 48yoF admitted w/ respiratory failure, PNA, & methamphetamine overdose.
PMHx Polysubstance abuse
S Pt received asleep on HFNC w/ significant expiratory stridor/wheezing. Roused to tactile stim. Suspected clonus
in LUE/bicep 2/2 involuntary, rhythmic contraction of LUE/elbow flexion; passive movement of elbow into
extension elicited rigidity & rhythmic contractions c/w clonus.

factors
Clinical signs of possible Admission w/ PNA/respiratory failure
chronic dysphagia
Precipitating dysphagia risk Acute respiratory failure w/ pleural effusions & PNA, acidosis, encephalopathy;
factors CT Head unremarkable
Vitals/labs
CN VII Pt did not follow commands for assessment
Cranial nerve exam
Secretions Severely impaired; + S/Z ratio Unable to assess
drooling, wet VQ/upper
airway sounds,
moderate-severe
expiratory
stridor/wheezing
VQ Wet/gurgly Pitch Range Unable to assess
MPT Unable to assess Cough “Barking” cough
Ice N/A IDDSI 5 N/A
IDDSI 0 1 mL water via tsp IDDSI 6 N/A
elicited poor oral
awareness of bolus &
PO trials wet vocal quality

A Clinical signs of oropharyngeal dysphagia & laryngeal obstruction; expiratory stridor/wheezing, “barking”
cough, & mild tachypnea concerning for possible partial upper airway obstruction. Additional neurological
signs, including possible clonus. Risk for dysphagia/aspiration-related complication appears high. Pt is not safe
for p.o. intake at this time.
P Instrumentation Instrumental swallow study (i.e., VFSS vs. FEES) pending clinical progress.
Diet recommendation Strict NPO. Short-term enteral feeding route (e.g., NGT), per MD discretion.
Specialist referrals ENT and/or Pulmonologist consult to r/o upper airway obstruction. Neurologist consult
for suspected clonus.
Ancillary tests Consider laryngoscopy and/or bronchoscopy to r/u upper airway obstruction.
Goal Pt will participate in VFSS/FEES to define swallow physiology & therapy need.

HPI 55yoM admitted by LAFD w/ severe respiratory distress/failure & hypoxemia (SpO2 55%) s/p endotracheal
intubation x2 days.
PMHx COPD, smoking hx, substance abuse, possible psychiatric disorder
S Pt alert but confused, initially cooperative but became agitated w/ poor participation during exam.

factors
chronic dysphagia
Precipitating dysphagia risk Respiratory failure 2/2 COPD exacerbation s/p endotracheal intubation x2 days
factors
Vitals/labs
RR 25-30 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Laryngeal function exam VQ G1R1B0A0S1 Pitch Range Unable to assess
PO trials
Notes Assessment limited 2/2 refusal of further trials
A Unable to exclude pharyngeal dysphagia in patient with acute-on-chronic dysphagia risk factors (i.e.,
endotracheal intubation, COPD). Multiple swallows per bolus may be c/w swallow dysfunction, though most
likely transient s/p extubation. Assessment limited 2/2 reduced pt cooperation.
P Instrumentation Pending clinical progress & improved participation

Diet recommendation NPO except ice chips (1 at a time) & meds crushed in puree.
Ancillary tests N/A
Therapy SLP will re-attempt swallow assessment in 2-4 hours, pending improved participation;
will f/u x5/week for diagnostic swallow tx
Goal Pt will tolerate least-restrictive p.o. diet w/out dysphagia-related aspiration PNA.
HPI 80yoM admitted w/ angioedema and/or facial abscess, chest pain, dyspnea, & dysphagia.
PMHx Mediastinal tumor, possible vocal fold paralysis
S Pt alert, very pleasant & cooperative for exam. Endorses chronic/progressive dysphagia to solids > liquids;
endorses hx of right-sided neck/mediastinal “non-cancerous” tumor & states he undergoes routine (q1-2 year)
outpatient VFSS at OSH. Pt breathing comfortably on room air but describes that, “Sometimes my throat just
closes up and I can’t talk.”
O Predisposing dysphagia risk Thyroid tumor extending to mediastinum

factors
Pt endorses chronic dysphagia symptoms (solids > liquids), marked by difficulty
“passing” solid food, globus sensation at level of sternal notch, & occasional
chronic dysphagia
solid/liquid regurgitation
Precipitating dysphagia risk Acute dyspnea, facial abscess
factors
Vitals/labs
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l; slightly reduced L facial mobility, which appears r/t L
Cranial nerve exam facial edema/abscess rather than CN involvement
CN IX/X signs of likely CN X branch involvement 2/2 severe dysphonia
CN XII Intact b/l
PO trials IDDSI 3 N/A 3 oz water N/A
Notes Trials limited to liquid & puree prior to instrumentation, given
reported increased dysphagia symptoms to solids
A Clinical signs of pharyngoesophageal dysphagia, presumably r/t thyroid/mediastinal mass w/ suspected

recurrent laryngeal nerve (RLN) involvement, given comorbid severe dysphonia. Suspect possible extrinsic
compression of pharynx and/or esophagus by large neck/mediastinal mass. Instrumental swallow study is
indicated to evaluate swallow physiology. However, given pt’s currently stable respiratory status & clear lungs (in
the context of the aforementioned chronic conditions), pt does appear safe to continue modified oral diet until
study results.
P Instrumentation FEES to evaluate laryngeal function as it relates to swallowing. VFSS to evaluate for
possible extrinsic compression of pharynx/cervical esophagus & exclude mechanical
obstruction contributing to dysphagia.
Diet recommendation IDDSI 4/0 diet until FEES results. Meds crushed in puree.

Ancillary tests N/A

HPI 80yoF admitted w/ SOB, cough, wheezing. Recent URI. Acute hypercapneic respiratory failure s/p NIPPV &
Solumedrol, weaned to nasal cannula for swallow eval.
PMHx COPD, asthma, HTN, spinal stenosis, chronic respiratory failure on home O2, HTN, hyperlipidemia, GERD,
depression
S Pt received awake on BiPAP. RT transferred pt to nasal cannula at 3 L/min for exam. Daughter at bedside. Pt
uncooperative & became increasingly agitated throughout exam & refused further SLP evaluation.
O Predisposing dysphagia risk COPD, GERD

factors
Pt appears significantly underweight & daughter endorses recent weight loss;
Clinical signs of possible pt reports occasional coughing w/ liquids; admitted w/ cough & respiratory
chronic dysphagia failure w/ bibasilar infiltrates (right > left); recurrent RLL PNA per radiographic
imaging at this facility in 2016, 2017, & 2019
Precipitating dysphagia risk Acute respiratory failure, tachypnea
factors
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Impaired; significant S/Z ratio Pt refused task
secretion production
VQ G1R1B0A1S1 Pitch Range Pt refused task
MPT Pt refused task Cough Perceptually weak
IDDSI 0 Wet vocal quality IDDSI 6 N/A
PO trials
Notes Pt became agitated & refused all further trials; educated
pt/daughter on concern for possible pharyngeal dysphagia,
however, resistant to education
A Inconclusive swallow evaluation 2/2 poor pt cooperation. Pt presents w/ chronic dysphagia risk factors (i.e.,
COPD, GERD) & signs of possible chronic dysphagia (i.e., recurrent lower lobe PNA, cachexia/malnutrition). In
the context of pt’s critical illness, there is increased risk for dysphagia-related complications. Unable to exclude
pharyngeal dysphagia without instrumental swallow study, however, pt refuses SLP services at this time.
P Instrumentation FEES, which pt refuses at this time.

Diet recommendation Defer nutrition/hydration POC to pt & physician.
Ancillary tests N/A

Therapy SLP will sign off, per pt request; please re-consult if change in pt motivation for
services. Recommend physician to educate pt on potential risk for aspiration-related
complications if swallow function not evaluated via instrumentation.
Goal N/A

HPI 57yoF admitted w/ acute dyspnea, odynophagia, increased BP, accidental overdose 2/2 ingestion of
caustic substance
PMHx Pt reports hx of CVA x2 (most recently 4 years ago), although this is not confirmed; pt endorses subjective
hx of dysphagia, which she attributes to her CVA hx
S Pt alert, very pleasant for exam. Notable hoarse vocal quality; pt endorsing mild throat pain.
O Predisposing dysphagia risk Pt reports hx of CVA x2 (although not confirmed)

factors
Pt reports hx of chronic dysphagia symptoms r/t reported old CVAs; pt reports
she feels her throat is always “closed” since the CVAs & that dry solids feel
chronic dysphagia
difficult to pass; pt endorses 1 week of productive cough
Precipitating dysphagia risk Accidental ingestion of caustic substance (per pt, she was attempting to take
factors cough medicine for her cough x1 week)
Vitals/labs
RR 20 WBCs WNL
CN V Intact b/l
CN VII Diminished b/l movement, which appears r/t b/l facial edema
CN IX/X Intact palatal elevation b/l; notable dysphonia, however,
Cranial nerve exam
concerning for possible direct laryngeal injury r/t caustic ingestion
CN XII Diminished b/l movement, which appears r/t lingual edema from
caustic ingestion
IDDSI 0 Throat clearing IDDSI 6 N/A
PO trials
Notes Pt endorses odynophagia w/ all trials
A Clinical signs of oropharyngeal dysphagia r/t ingestion of caustic substance, most likely direct oropharyngeal
mucosal injury; unable to exclude laryngeal injury. There is also risk for concomitant esophageal dysphagia r/t
ingestion of caustic substance. In the context of dysphonia + odynophagia + dysphagia symptoms, instrumental
swallow study is indicated.

Diet recommendation Continue full liquid diet, per physician order, until FEES results
Risk management Oral hygiene QID. HOB upright as tolerated.
Specialist referrals GI consult for clearance to begin oral diet, given risk for esophageal mucosal injury
Ancillary tests Consider EGD and/or Esophagram, per GI

HPI 80yoM admitted s/p fall. CT Head revealed L temporoparietal lobe mass w/ midline shift c/w
malignancy/metastases from known lung CA.
PMHx Lung CA, COPD, tobacco abuse
S Pt alert, very pleasant for exam. Expressing gratitude for basic cares, “Thank you so much.” Reporting
hunger/thirst. States his goal is for comfort/QOL.
O Predisposing dysphagia risk Lung CA, COPD, newly identified L brain mass
factors
chronic dysphagia
Precipitating dysphagia risk Vasogenic cerebral edema, sepsis
factors
Temp Febrile SpO2 >94% on 2L via NC
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes Pt edentulous & prefers softer solids w/out dentures
A Unable to exclude oropharyngeal dysphagia at bedside in pt w/ multiple dysphagia risk factors (COPD, lung
CA, L cortical brain mass). However, no overt s/s of aspiration or distress w/ p.o. trials. Given pt’s goals of care
(comfort measures/DNR), instrumental swallow exam is unlikely to alter POC; pt unlikely to benefit from direct
swallow rehabilitation if deficits were identified; pt pending hospice evaluation.
Risk management Aspiration precaution: eat/drink when RR <25
Ancillary tests N/A
Therapy SLP will sign off, given pt’s swallow is functional for current needs (comfortable p.o.
intake)
Goal N/A

HPI 43yoF admitted w/ throat pain, odynophagia x2 days. CT Soft Tissue Neck revealed L tonsillar mass vs.
abscess/phlegmon.
PMHx None
S Pt alert, very pleasant for exam. Denied throat pain after receiving pain meds this am. States she feels her L
face/neck swelling is worsening & moving in an inferomedial direction from the L mandible.

factors
chronic dysphagia
Precipitating dysphagia risk L tonsillar mass vs. abscess/phlegmon vs. malignancy
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Intact b/l; reduced L palatal elevation, however, this appeared
mechanical r/t very enlarged L palatine tonsil/faucial pillar
CN XII Intact b/l
Notes Pt declined further trials 2/2 odynophagia; pt requests to begin
with liquid diet & in agrees to advance solids as tolerated
A Clinical signs of oropharyngeal dysphagia w/ associated odynophagia r/t left peritonsillar mass w/ effacement of
left oropharynx. No signs of aspiration, airway obstruction, nor cranial nerve involvement at this time. There is
risk for swallow deterioration if mass enlarges to compress oropharynx or peripheral nerves. Pt self-restricts diet
2/2 odynophagia. Dysphagia/odynophagia are likely to resolve w/ medical/surgical interventions. However, SLP
will f/u until malignancy excluded; if + malignancy, pt may require long-term dysphagia intervention.
P Instrumentation Pending medical workup

Diet recommendation Initiate clear liquid diet. Advance solid diet as tolerated, per physician order.
Risk management Close voice/airway monitoring. If change in vocal quality or respiration, d/c p.o. diet.
Specialist referrals ENT consult
Ancillary tests N/A
Therapy SLP will f/u x2/week, pending further diagnostic results. If malignancy excluded, SLP
will sign off. If + malignancy, pt will require instrumental swallow study & long-term
dysphagia intervention.
HPI 61yoM admitted w/ chest pain, possible NSTEMI. H/c s/p angioplasty c/b post-op respiratory failure w/
PMHx ESRD on HD, HTN, CHF, a-fib, gout
S Pt alert, agitated, requesting to eat/drink. Requesting NGT removal. Agreeable to SLP evaluation.
O Predisposing dysphagia risk CHF

factors
chronic dysphagia
Precipitating dysphagia risk CHF exacerbation, endotracheal intubation 12/13-12/15 (x2 days)
factors
Vitals/labs
RR 20-25 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Impaired; significant S/Z ratio 1.5
secretion production,
gesturing to sternal
Laryngeal function exam notch & reporting
“phlegm”
VQ Mod hoarse Pitch Range Perceptually reduced
IDDSI 0 Delayed cough IDDSI 6 N/A
PO trials
Notes Pt reported globus sensation & gestured to sternal notch,
coughing & expectorating mucous after each bolus presentation;
further trials deferred for instrumentation
A Clinical signs of oropharyngeal dysphagia in pt with acute-on-chronic dysphagia risk factors (i.e., endotracheal
intubation, CHF) warranting instrumental swallow study. Given current acuity of illness, instrumentation is
recommended prior to initiation of oral diet.

Diet recommendation NPO except ice chips pending FEES results
Ancillary tests N/A
HPI 71yoM admitted w/ AMS 2/2 b/l globus pallidus ischemia c/w possible CO poisoning. CO2 critically high.
PMHx CVA in 2019 w/ residual R weakness & moderate cognitive-communication disorder, polysubstance abuse
S Pt received asleep after MRI. Roused to multimodal stim, but lethargic. Wet read of MRI Brain results phoned to
RN during SLP exam, which revealed acute L thalamic infarct.
O Predisposing dysphagia risk CVA (though VFSS post-CVA in 2019 revealed functional oropharyngeal
factors swallow)
chronic dysphagia
Precipitating dysphagia risk Acute b/l infarcts in basal ganglia/globus pallidus (c/w carbon monoxide
factors poisoning); + acute L thalamic infarct; reduced LOA; HFNC at 40 L/min
Temp WNL SpO2 98% on HFNC at 40
Vitals/labs L/min
RR 20-25 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Laryngeal function exam VQ Clear Pitch Range Perceptually reduced
IDDSI 2 N/A IDDSI 7 Deferred 2/2 LOA
PO trials
Notes N/A
A Clinical signs of oral phase dysphagia, which appears r/t reduced LOA. No evidence of CN involvement or
pharyngeal phase dysphagia. Iatrogenic high peak pharyngeal pressures r/t 40 L/min HFNC likely increase
intermittent aspiration risk; pt would benefit from titrating flow rate down for meals to reduce risk. Temporary
solid diet modification appears indicated 2/2 reduced LOA.
Diet recommendation IDDSI 4/0 diet. Meds crushed w/ puree.
Risk management Aspiration Precautions: 1:1 feeding assist; feed only when fully alert; titrate flow rate as
low as possible for meals, goal <20 L/min.
Ancillary tests N/A
Therapy SLP will f/u x3/week to advance solid diet as mentation improves

HPI 55yoM admitted w/ CP & SOB x2 days, cough, generalized abdominal pain w/ associated vomiting & non-
melenic diarrhea. Tremors s/p ETOH cessation.
PMHx ETOH abuse
S Pt received alert, severely tachypneic on HFNC (RR 50-60) at 50 L/min. RN reports pt just consumed lunch.
Abdomen appears distended.

factors
Clinical signs of possible PNA
chronic dysphagia
Precipitating dysphagia risk Current PNA w/ associated severe tachypnea (RR 50-60), requiring HFNC at 50
factors L/min
Vitals/labs RR 50-60 at rest; <30 w/ WBCs Elevated
coaching
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
MPT 1 sec r/t dyspnea Cough Perceptually weak
Notes All trials provided following long rest breaks & coaching to lower
RR <30; pt unable to sustain RR <30 for >1-2 mins
A Clinical signs of oropharyngeal dysphagia r/t pt’s current severe tachypnea & high pharyngeal/laryngeal
pressures (iatrogenic r/t HFNC at 50 L/min). High risk for aspiration events w/ RR >30 + increased pharyngeal
pressures w/ HFNC; pt unlikely to coordinate necessary swallow apneic period. Pt does not appear safe for p.o.
intake w/ current respiratory status, however, medical team expresses critical need for PO access for to pt’s
medication & blood glucose needs.
Diet recommendation IDDSI 4/0 diet, only if RR <30 & HFNC <40 L/min. If pt unable to meet these respiratory
requirements, advise NPO w/ short-term enteral feeding route (e.g., NGT).

Ancillary tests N/A
Goal Pt will tolerate least-restrictive p.o. diet w/out acute dysphagia-related pulmonary
decompensation.

HPI 30yoM admitted w/ oropharyngeal abscess, epiglottitis, dysphagia, dysphonia, & airway compromise s/p
tracheotomy.
PMHx None
S Pt awake but lethargic s/p tracheostomy this am. Brother at bedside. Significant bloody secretions at trach site.

factors
chronic dysphagia
Oropharyngeal abscess/epiglottitis w/ subsequent airway
compression/obstruction s/p emergent tracheotomy (POD #0), received w/
factors
Shiley #8 cuffed trach w/ cuff inflated on trach mask
Temp Febrile SpO2 94% on 6L via trach
Vitals/labs mask
RR 20 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions impaired; copious S/Z ratio Aphonic
bloody secretions at
trach site
VQ aphonic (iatrogenic r/t Pitch Range Aphonic
Laryngeal function exam emergent tracheotomy
today); pt endorses
dysphonia in hours
preceding tracheotomy
MPT Aphonic Cough Absent volitional
Ice N/A IDDSI 5 N/A
Notes all trials deferred 2/2 total pharyngeal/laryngeal obstruction
requiring emergent trach; now on Decadron & Vancomycin

A Tracheostomy voice evaluation on POD #0 revealed aphonia (multifactorial r/t epiglottitis/pharyngeal abscess +
inflated cuff + likely post-operative tracheal edema). Not yet safe for cuff deflation/PMV trials w/ copious bloody
secretions post-operatively. Presumable pharyngeal phase dysphagia r/t pharyngeal abscess w/ subsequent
pharyngeal obstruction/displacement. Not yet safe for oral intake at this time; pt will require instrumental
swallow study. Anticipate spontaneous swallow improvement w/ medical management of pharyngeal abscess.
P Instrumentation Instrumental swallow study pending clinical progress.

Diet recommendation Strict NPO. Continue use of NGT for nutrition/hydration.
Ancillary tests N/A
Therapy SLP will f/u x5/week for voice/swallow diagnostic tx.

HPI 95yoF admitted w/ PNA, productive cough.
PMHx CVA, dementia, bipolar disorder, DM, a-fib, HTN, hyperlipidemia
S Pt alert, confused. Combative w/ care. Pt’s daughter & hired caregiver at bedside.
O Predisposing dysphagia risk Dementia, CVA

factors
Clinical signs of possible Admission w/ PNA; caregiver reports frequent coughing during meals
chronic dysphagia
Precipitating dysphagia risk PNA
factors
Vitals/labs
RR 18 WBCs Elevated
Cranial nerve exam
Secretions Adequate S/Z ratio N/A
Laryngeal function exam VQ Mildly hoarse Pitch Range N/A
MPT N/A Cough Unable to assess
Ice Pt declined trials IDDSI 5 N/A
IDDSI 0 Pt declined trials IDDSI 6 N/A
PO trials IDDSI 4 Pt declined trials Standardized N/A
Notes Pt declined all trials for SLP; caregiver at bedside demonstrating
home feeding strategy, which involved providing p.o. bolus
despite pt’s nonverbal signs of refusal, to which pt became
combative
A Signs of oral aversion + chronic oropharyngeal dysphagia r/t dementia. Family endorses signs of aspiration
during meals at home. Pt admitted w/ PNA; in the context of dementia, suspect dysphagia-related aspiration
complication. Pt’s daughter states goal of care is for comfort/QOL; daughter declines all invasive procedures,
including PEG tube, & made informed decision to proceed w/ p.o. diet despite potential aspiration risk. Pt
unable to participate in swallow tx or instrumental swallow study at this time; instrumental swallow exam unlikely
to alter POC, given goals of care.
Diet recommendation Liquidized (IDDSI Level 3)/Thin Liquid (IDDSI Level 0) diet. Meds crushed in puree or
dissolved in liquid.

Risk management Careful hand-under-hand feeding via tsp. Upright position. Do not feed if signs of pt
refusal (i.e., no force feeding).
Ancillary tests N/A
Therapy SLP will f/u for caregiver training
Goal Caregiver will perform verbal teachback of recommended feeding strategies to
facilitate oral intake & reduce aspiration risk.

HPI 45yoM admitted w/ AMS, coffee ground emesis, & acute respiratory failure 2/2 acute UGIB & septic shock
2/2 aspiration PNA. H/c involved endotracheal intubation x5 days. EGD revealed distal esophageal varices
s/p band ligation x5.
PMHx ETOH abuse
S Pt alert, very pleasant for exam. Appears SOB on HFNC at 40 L/min. Stating he is hungry & wants to eat. Family
at bedside. NGT in situ.

factors
chronic dysphagia
Precipitating dysphagia risk Endotracheal intubation x5 days; PNA w/ tachypnea & HFNC (i.e., iatrogenic
factors high peak pharyngeal pressure); acute toxic-metabolic/hepatic encephalopathy
Temp Febrile SpO2 94% on HFNC 40L/min
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Impaired; mildly wet S/Z ratio N/A
vocal quality, throat
Laryngeal function exam clearing
IDDSI 0 Inconsistent cough IDDSI 6 N/A
Notes Further trials deferred at this time, given signs of dysphagia and
recency of extubation
A Clinical signs of pharyngeal dysphagia, likely acute/transient r/t laryngeal dysfunction s/p 5-day endotracheal
intubation, exacerbated by tachypnea & iatrogenic high peak pharyngeal pressures 2/2 HFNC. Swallow
prognosis appears excellent for spontaneous swallow recovery in the next several days, assuming no significant
laryngeal trauma. Given acuity of illness, pt will benefit from endoscopic swallow study to evaluate swallow
physiology prior to p.o. diet initiation.

Diet recommendation NPO except ice chips for swallow stim. Short-term enteral feeding route (e.g., NGT).
Risk management Oral hygiene q4h. HOB upright as tolerated for reflux precaution.
Ancillary tests N/A
Therapy SLP following x5/week for diagnostic swallow tx

HPI 79yoF admitted w/ AMS s/p GLF. CT Head revealed small acute R parafalcine SAH. CT C-spine
unremarkable.
PMHx HTN
S Pt received alert, very pleasant for exam. RN reports significant improvement in mental status since yesterday.

factors
Clinical signs of possible Pt reports approx. 1 month of dysphonia & dysphagia symptoms (onset prior to
chronic dysphagia admission) of unknown etiology
Precipitating dysphagia risk GLF w/ R SAH, acute encephalopathy
factors
Vitals/labs
RR 16-20 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions impaired; + throat S/Z ratio 1.5
clearing
VQ G3R3B2A2S2; Pitch Range Perceptually reduced
diplophonic, transient
wet VQ
MPT 5 secs Cough Perceptually reduced
IDDSI 0 Throat clear, wet VQ IDDSI 6 N/A
PO trials
Notes Pt reports globus sensation to solids & dysphonia x1 month
A Clinical signs of pharyngoesophageal dysphagia of unknown etiology. Overt laryngeal dysfunction. Pt endorses
symptoms are subacute x1 month. However, in the context of TBI w/ SAH, unable to exclude acute
onset/exacerbation of dysphagia. Instrumental swallow exam appears indicated.
Diet recommendation IDDSI 7/0 diet until FEES results. Meds whole w/ thin liquid.
Risk management Oral hygiene QID.
Specialist referrals Further recommendations pending FEES results
Ancillary tests N/A
Therapy SLP will f/u x5/week for swallow tx

HPI 59yo unidentified female admitted s/p auto vs. pedestrian accident w/ TBI (SDH/SAH), facial fracture,
cervical fracture, respiratory failure requiring endotracheal intubation x3 days.
PMHx None
S Pt awake, tracking visually. Not following verbal-only commands. No nonverbal signs of pain.

factors
chronic dysphagia
Precipitating dysphagia risk TBI (SAH/SDH), endotracheal intubation x3 days, C7 fracture in cervical collar
factors
Vitals/labs
RR 30 WBCs Elevated
Cranial nerve exam
Secretions severely impaired; S/Z ratio Aphonic
significantly wet/gurgly
vocal quality w/ mild
Laryngeal function exam inspiratory stridor &
expiratory wheezing
VQ Aphonic Pitch Range Aphonic
MPT N/A Cough Absent
Ice Elicited oral-motor IDDSI 5 N/A
movements; elicited
swallow triggers
PO trials
Notes Increase in wet laryngeal breath sounds & stridor post-trials w/
profoundly weak spontaneous coughing; further trials deferred for
pt’s airway protection
A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t TBI + laryngeal dysfunction s/p endotracheal
intubation + possible prevertebral soft tissue edema r/t C7 fracture. Given severity of clinical symptoms + critical
illness, pt does not appear safe for any oral intake at this time. Pt will require instrumental swallow study once
more stable respiratory status.
P Instrumentation Instrumental swallow study (VFSS vs. FEES), pending improved respiratory status.

Ancillary tests N/A
Therapy Pt following x5/week for diagnostic swallow tx.

HPI 67yoF admitted w/ poor oral intake, dysphagia, weakness.
PMHx CHF, gastric bypass, esophageal candida w/ severe esophagitis per EGD, presumed esophageal
dysmotility per GI (s/p Botox injection to GE junction approx. 4 weeks prior to admission)
S Pt alert, pleasant for exam. Reports difficulty swallowing.
O CHF, gastric bypass, esophageal candida w/ severe esophagitis per EGD,

Predisposing dysphagia risk
presumed esophageal dysmotility per GI (s/p Botox injection to GE junction
factors
approx. 4 weeks prior to admission)
Clinical signs of possible Progressive weight loss > 50 lbs
chronic dysphagia
factors
Vitals/labs
RR 18 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Notes GI team at bedside, who recommends full liquid diet 2/2 known
esophageal dysphagia; trials limited to liquids, per GI
A No clinical signs of oropharyngeal dysphagia. Pt w/ known esophageal dysphagia r/t esophageal candida &
severe esophagitis w/ presumable esophageal dysmotility s/p Botox. Pt requires further medical/surgical
management of esophageal dysphagia by GI team.
Diet recommendation Defer diet order to GI; at this time, full liquid diet
Risk management Behavioral reflux precautions, including upright position during + 90 mins after meals,
small sips, & slow rate of intake
Specialist referrals F/u w/ GI
Ancillary tests Consider high resolution esophageal manometry
Therapy SLP will sign off, as pt will not benefit from behavioral SLP intervention
Goal N/A

HPI 26yoF admitted w/ throat pain, odynophagia, dysphonia, strep throat
PMHx None
S Pt alert, very pleasant for exam. Reports her throat pain is improving & hoarseness is resolved.

factors
chronic dysphagia
Precipitating dysphagia risk Tonsillitis
factors
Vitals/labs
RR 16 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Notes Pt declined puree & solid trials; states she prefers liquids at this
time 2/2 odynophagia
A Odynophagia in the absence of oropharyngeal dysphagia symptoms in pt w/ strep throat/tonsillitis. No clinical

evidence of cranial nerve involvement or laryngeal dysfunction to warrant instrumental swallow study. Anticipate
odynophagia will resolve with medical treatment.
Diet recommendation Full liquid diet, per pt preference. Advance as tolerated to regular solids at pt’s
discretion.
Risk management N/A
Specialist referrals ENT for medical management of tonsillitis
Ancillary tests N/A
Therapy SLP will sign off, as pt will not benefit from behavioral SLP intervention
Goal N/A

HPI 53yoM admitted s/p mechanical fall (15 steps) w/ C2 fracture/odontoid fracture, proximal humeral fracture.
Hospital course involved C2 anterior instrumentation (odontoid screw placement & fixation).
PMHx Chronic R inferior frontal CVA (incidentally found on new CT Head, which is new w/ comparison to imaging
in 2017
S Pt alert, very pleasant for exam. Receiving sitting upright tin chair after breakfast; on clear liquid diet (per
Neurosurgeon order), w/ order to ADAT. Notable throat clearing upon SLP arrival to pt’s room. Pt endorses
dysphagia symptoms post-operatively, including throat clearing & globus sensation.
O Predisposing dysphagia risk Chronic R inferior frontal CVA (incidentally found on new CT Head, which is new
factors w/ comparison to imaging in 2017)
chronic dysphagia
Precipitating dysphagia risk Acute C2 fracture s/p C2 anterior instrumentation, now POD #1
factors
Vitals/labs
RR 14 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Throat clearing S/Z ratio 0.7
VQ Clear; intermittent mild Pitch Range Perceptually WNL
wetness, cleared w/
Laryngeal function exam spontaneous throat
clears
MPT 10 secs Cough Perceptually WNL;
PEFR 390 L/min
IDDSI 4 Multiple swallows/bolus Standardized N/A
Notes Pt declined solid trials, states he feels he can swallow thin liquids &
purees
A Clinical signs of pharyngeal dysphagia, which is expected POD #1 s/p C2 anterior instrumentation; presumable
pathology is prevertebral soft tissue edema, which should improve spontaneously over next days to weeks.
Cough appears effective w/ PEFR 390 L/min. No evidence of laryngeal dysfunction. Pt’s personal risk factors for
development of aspiration PNA are low (i.e., good oral hygiene, pt ambulatory/physically mobile, immune
function preserved). Instrumental swallow study is unlikely to alter POC at this time, however, pt requires
monitoring for anticipated swallow improvement; instrumental swallow study if pt’s recovery does not follow
anticipated trajectory.

P Instrumentation Instrumental swallow study via VFSS and/or FEES if symptoms not rapidly improving
over next several days
Diet recommendation Full liquid diet. SLP following to advance solid diet as clinical dysphagia symptoms
improve.
Risk management Control risk factors for aspiration PNA via (a) oral hygiene x4/day, (b) increasing
physical mobility as medically feasible
Ancillary tests N/A
Therapy SLP will f/u to monitor spontaneous swallow recovery x3/week

HPI 67yoM admitted w/ c/o lower back pain, BLE and BUE weakness, falls. + cervical and lumbar central canal
stenosis, pending cervical decompression surgery.
PMHx 3 mm CVA in R cerebellum 2019, diabetic peripheral neuropathy, cervical myelopathy, hiatal hernia, mild
gastritis
S Pt alert, oriented x4. Pt reports feeling well after ACDF yesterday; scheduled for posterior approach today. Pt
endorses 1 year hx of dysphagia to solids/pills prior to hospitalization, which he states improved slightly w/ PPIs.
O 3 mm CVA in R cerebellum 2019, diabetic peripheral neuropathy, cervical

myelopathy, hiatal hernia, mild gastritis
factors
Pt endorses 1 year hx of dysphagia symptoms to solids/pills, for which he

underwent EGD 4 months ago (which revealed mild gastritis & hiatal hernia);
chronic dysphagia
states his symptoms have been improving w/ PPIs
Precipitating dysphagia risk C3-C6 anterior instrumentation w/ PEEK cage (POD #1)
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Ice N/A IDDSI 5 N/A
PO trials
Notes Elicited volitional swallows of secretions; all trials deferred today
2/2 NPO for OR posterior cervical fusion
A High probability of temporary pharyngeal phase dysphagia in pt w/ cervical myelopathy s/p C3-C6 anterior
cervical instrumentation/PEEK cage placement (now POD #1); likely pathology is prevertebral soft tissue edema.
Laryngeal function appears intact. Pt also endorses 1 year of chronic dysphagia (likely esophageal), however,
unable to exclude chronic pharyngeal dysphagia r/t cervical myelopathy and/or CVA hx. Pt will require
instrumental swallow study, once medically stable s/p posterior cervical surgery.
P Instrumentation VFSS tomorrow

Diet recommendation Once alert/stable post-operatively today, recommend NPO except ice chips & small
sips of water until VFSS tomorrow
Ancillary tests N/A
Therapy Further recommendations pending VFSS results

HPI 75yoM admitted s/p assault w/ neck pain & L supraclavicular mass. CT showed exophytic L
laryngeal/supralaryngeal mass + multiple L cervical lymphadenopathy concerning for primary malignancy
w/ nodal mets. + new diagnosis of laryngeal SCC s/p tracheotomy.
PMHx Recent dx of laryngeal SCC of L pyriform sinus/aryepiglottic fold, arthritis, DM, visual deficit
S Pt alert, pleasant but appears confused. Pt w/ tracheostomy tube on trach mask. Communication limited 2/2
iatrogenic aphonia + poor upper airway patency, in combination w/ severe visual acuity deficits & overt
cognitive deficits. Appreciate GI & Oncology consult notes w/ plan for possible PEG; pt requires instrumental
swallow evaluation to confirm pharyngeal dysphagia & necessity of PEG. Oncology states pt may be a poor
candidate for chemo/XRT & may benefit from palliative/hospice evaluation, in which case goal would be
continue oral feedings for comfort/QOL.
O Predisposing dysphagia risk Newly diagnosed laryngeal/pharyngeal SCC (mass at L aryepiglottic

factors fold/pyriform/larynx), multiple L cervical lymphadenopathy w/ nodal mets
Clinical signs of possible Reported 10 lb weight loss prior to hospitalization
chronic dysphagia
Precipitating dysphagia risk Tracheotomy (POD #3)
factors
Temp WNL SpO2 95% on 6L via trach
Vitals/labs mask
RR 18 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Impaired; expectoration S/Z ratio 0.88
of secretions via trach
VQ Aphonic w/ open trach Pitch Range Perceptually reduced
tube; severely strained-
strangled phonation to
digital occlusion
MPT <1 sec to trach Cough Absent volitional
occlusion
Notes PT declined further trials despite encouragement & was unable to
communicate reason for refusal

A Presumable chronic pharyngeal phase dysphagia r/t newly diagnosed laryngeal/pharyngeal SCC, now s/p
tracheotomy. However, unknown severity of dysphagia. As pt was consuming full oral diet prior to
hospitalization, pt’s swallow physiology may be safe to support full or partial oral diet. Goals of care are currently
unclear; plan for chemo/XRT vs. possible palliative/hospice care may alter nutrition/hydration route decision-
making. Pt requires instrumental swallow study to first define swallow physiology, however, pt currently
confused & refusing p.o. trials.
P Instrumentation VFSS ASAP, when pt agreeable

Diet recommendation NPO except ice chips w/ RN assist for swallow stim, pending VFSS results. Defer
decision regarding long-term enteral feeding route (E.g., PEG) until VFSS results and/or
decision regarding plan for SCC management & goals of care.
Ancillary tests N/A
Therapy SLP following for voice/swallow tx x5/week

HPI 70yoM admitted w/ dizziness x3 days, headache 2/2 acute L thalamic/posterior limb of internal capsule ICH
PMHx HTN, DM
S Pt alert, pleasant & cooperative for exam.

factors
chronic dysphagia
Precipitating dysphagia risk Acute L thalamic/posterior limb internal capsule ICH
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes N/A
A No clinical signs of oropharyngeal dysphagia or CN involvement despite acute CVA.
Risk management N/A
Ancillary tests N/A
Therapy No swallow tx indicated at this time; SLP will sign off
Goal N/A

HPI 53yoM admitted w/ bleeding/pain in oral cavity + dysphagia/odynophagia.
PMHx Oral carcinoma s/p surgical resection (limited records available)
S Pt alert, pleasant & cooperative for exam. Endorses oral pain (8/10).
O Predisposing dysphagia risk Oral carcinoma s/p surgical resection (limited records available)
factors
Clinical signs of possible Pt endorses poor oral intake & weight loss
chronic dysphagia
factors
Vitals/labs
RR 20 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
CN IX/X Intact b/l
Cranial nerve exam CN XII Unable to assess 2/2 obstruction from massive sublingual mass,
which displaced oral tongue posteriorly into posterior oral cavity;
sublingual mass was black in color & large/obstructive to much of
the anterior oral cavity
Secretions Drooling S/Z ratio 1.1
IDDSI 0 Immediate cough in 1/5 IDDSI 6 N/A
trials
IDDSI 2 N/A IDDSI 7 Pt declined
PO trials
Notes Suspect impaired oral containment/bolus control r/t mechanical
posterior displacement of oral tongue 2/2 sublingual mass
A Oral phase dysphagia 2/2 mechanical displacement of oral tongue posteriorly due to massive sublingual
necrotic lesion. No clinical signs of pharyngeal phase involvement, given intact CN X function & perceptually
normal vocal quality. Risk for aspiration appears low. However, swallow appears inefficient r/t oral mass; solid
diet modification appears indicated.
Given pt’s oral cancer, pt will require instrumental swallow study for baseline & treatment planning. However, it
is preferred that this instrumentation be performed at higher level of care (location of planned surgery) for
continuity of care, given pending transfer.
P Instrumentation VFSS for baseline/treatment planning, preferably at HLOC

Diet recommendation IDDSI 4/0 diet.
Risk management Oral hygiene q4h.
Specialist referrals F/u w/ Oncologist & ENT
Ancillary tests N/A
Goal Pt will participate in VFSS to define swallow physiology & therapy need.

HPI 36yoM admitted w/ GSW to back, GCS 3, cardiac arrest, hemorrhagic shock s/p b/l thoracotomies w/
exploration + wedge resection of RUL, ex-lap. Endotracheal intubation x11 days, converted to
tracheostomy.
PMHx None
S Pt alert after sedation vacation this am. Followed commands & participated well. Received w/ trach on vent.

factors
chronic dysphagia
Precipitating dysphagia risk Endotracheal intubation x11 days s/p tracheostomy (POD #1; Shiley #8 cuffed
factors trach); RUL wedge resection
Temp Febrile SpO2 95% on vent in AC
Vitals/labs mode, FiO2 40%
RR 20 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Intact palatal elevation b/l; unable to assess CN X branch function
w/ cuff inflated on vent
CN XII Intact b/l
Secretions Impaired S/Z ratio Aphonic
Laryngeal function exam VQ Aphonic Pitch Range Aphonic
MPT Aphonic Cough Aphonic; cuff inflated
Ice Elicited swallow triggers IDDSI 5 N/A
Notes Further trials pending readiness for cuff deflation and/or
instrumental swallow study
A Presumable pharyngeal phase dysphagia due to 11-day endotracheal intubation/ventilator-dependency, now

s/p tracheotomy (POD #1). Pt will require instrumental swallow study, ideally, once cuff deflated & pt tolerates
one-way speaking valve in-line on vent. Swallow prognosis is good for improvement w/ rehabilitation. However,
risk for aspiration-related pulmonary complication appears high at this time.
P Instrumentation FEES in 1-2 days, preferably w/ cuff deflated & one-way speaking valve in-line on vent.
Diet recommendation NPO except ice chips w/ RN assist for swallow stim. Continue use of PEG for
nutrition/hydration.
Ancillary tests N/A
Therapy SLP following x5/week for voice/swallow tx.

HPI 62yoM admitted w/ cough, septic shock, PNA.
PMHx PAD, BPH
S Pt alert, smiling & very pleasant. Followed simple commands; nonverbal (which is reportedly pt’s baseline due
to developmental disability).

factors
Clinical signs of possible Admission w/ PNA in gravity-dependent lung zones + sepsis
chronic dysphagia
Precipitating dysphagia risk Septic shock
factors
Vitals/labs
RR 20 WBCs Low
Cranial nerve exam
Laryngeal function exam VQ Unable to assess Pitch Range Unable to assess
MPT Unable to assess Cough Unable to assess
Ice Immediate cough IDDSI 5 N/A
IDDSI 0 Immediate cough IDDSI 6 N/A
IDDSI 4 Immediate cough, Standardized N/A
PO trials
respiratory distress
(which resolved
spontaneously in <2
mins)
Notes
A Clinical signs of pharyngeal (probable) vs. esophageal (possible) dysphagia of unknown etiology. In context of
PNA in gravity-dependent lung zone + septic shock, pt does not appear safe for oral intake until instrumental
swallow study.
P Instrumentation VFSS ASAP

Diet recommendation Strict NPO pending VFSS results
Specialist referrals Further recommendations pending VFSS results
Ancillary tests N/A
Therapy Further recommendations pending VFSS results
HPI 64yoF admitted w/ lethargy, weakness 2/2 septic shock, dehydration, UTI.
PMHx MS
S Pt alert, very pleasant for exam. Reports feeling thirsty, eager to eat/drink.
O Predisposing dysphagia risk MS

factors
chronic dysphagia
Precipitating dysphagia risk Septic shock 2/2 UTO
factors
Vitals/labs
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes N/A
A No clinical signs of oropharyngeal dysphagia, despite hx of multiple sclerosis. Current lung opacities in apices
are unlikely due to dysphagia-related aspiration. No SLP swallow intervention is indicated at this time.
Risk management N/A
Ancillary tests N/A
Therapy SLP will sign off, as no swallow tx indicated at this time
Goal N/A
HPI 66yoM admitted w/ cough, sore throat, dyspnea, dysphagia. Pt describes he feels his “vocal fords are being
cut.” XR & US neck unremarkable. Pending CT Head & CT Soft Tissue Neck.
PMHx Hyperthyroidism s/p surgical intervention (per pt report, not confirmed)
S Pt alert, pleasant for exam in ED. Severe dysphonia noted, yielding reduced intelligibility. Persistent throat
clearing noted. Wet reads of CT Soft Tissue Neck & CT Head phoned in during clinical exam, which were both
unremarkable. Of clinical relevance, pt endorses high vocal demand at work & endorses progressive
dysphagia/dysphonia.
O Predisposing dysphagia risk Hyperthyroidism s/p surgical intervention (per pt report, not confirmed)
factors
Pt endorses progressive dysphagia symptoms x1 month w/ 20 lb unintentional
Clinical signs of possible weight loss; pt reports presenting to OSH & undergoing “Barium Swallow”
chronic dysphagia (likely Barium Esophagram, per pt description) & states results were
unremarkable
factors
Vitals/labs
RR 14 WBCs Low
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Impaired; persistent S/Z ratio 1.5
throat clearing
IDDSI 0 Throat clear, cough, IDDSI 6 N/A
multiple swallows/bolus,
globus
IDDSI 2 N/A IDDSI 7 Solid trials deferred for
instrumentation
PO trials
IDDSI 4 Multiple swallows/bolus, Standardized N/A
globus
Notes Pt endorsed near choking event last night; stated he felt a solid
food felt “stuck in [his] throat” & that he was unable to breathe or
voice until he belched, which relieved sensation; of relevance,
significant belching approx. 2 mins after p.o. trials during exam
today

A Clinical signs of pharyngoesophageal dysphagia of unknown etiology. Signs of likely laryngeal
dysfunction/pathology, given comorbid dysphonia. Pt endorses progressive dysphagia x1 month. Instrumental
swallow study is indicated to evaluate swallow physiology; FEES is preferred exam to evaluate laryngeal
function, w/ VFSS to follow for further diagnostic information & to screen esophageal function. In the context of
clear chest radiography & stable ventilation, pt does appear safe to continue modified oral diet until
instrumental swallow study results.
P Instrumentation FEES ASAP. VFSS to follow FEES.

Diet recommendation Full liquid diet until swallow study results. Discontinue diet if SOB/distress.
Risk management Utilize behavioral reflux precautions, including upright positioning during + 1 hr after
meals & HOB elevation for sleeping.
Specialist referrals Possible ENT &/or GI consults, pending FEES & VFSS results
Ancillary tests Possible ENT laryngosocpy & GI EGD, pending FEES & VFSS results
Therapy Pending FEES/VFSS results.

HPI 68yoF admitted w/ L facial numbness & generalized weakness.
PMHx CAD
S Pt alert, pleasant for exam. Pt endorses L facial numbness & generalized weakness.

factors
chronic dysphagia
Precipitating dysphagia risk Possible acute CVA (pending brain imaging)
factors
Vitals/labs
RR 14 WBCs WNL
CN V Signs of L CN V involvement of V1-3 distribution; ophthalmic
branch – pt endorses L eye tearing >1 year; maxillary branch –
numbness throughout maxillary distribution; mandibular branch –
pt endorses difficulty chewing on L for several months; pt denies
TMJ symptoms or facial/jaw pain
Cranial nerve exam
CN VII Signs of possible L CN VII involvement; subtle L facial droop of L
lower quadrant, unable to exclude subtle involvement of L upper
quadrant (unable to discriminate LMN vs. UMN)
CN IX/X Intact b/l
CN XII Intact b/l
Laryngeal function exam VQ Clear Pitch range Perceptually WNL
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Notes N/A
A No clinical signs of oropharyngeal dysphagia. However, cranial nerve exam reveals focal abnormality of the left
trigeminal nerve (CN V1-3) & left facial nerve (CN VII); pt endorses chronic/progressive involvement of cranial
nerves warranting Neurologist evaluation.
Risk management N/A
Specialist referrals Neurologist consult to evaluate possible CN V/VII pathology.
Ancillary tests N/A
Therapy No SLP swallow tx indicated at this time; SLP will sign off.
Goal N/A

HPI 16yoF admitted s/p GSW to face/neck s/p emergent trach & ORIF mandible.
PMHx None
S Pt received asleep, roused to verbal stim. Very pleasant/cooperative for exam. Eager to eat/drink & speak.
Received w/ tracheostomy tube, cuff deflated, on trach mask.

factors
chronic dysphagia
Penetrating injury through oral cavity/hypopharynx s/p emergent tracheostomy
(Shiley #8 cuffed; POD #10) & ORIF mandible/maxillomandibular fixation, 10
factors
day NPO status (likely muscle disuse atrophy)
Vitals/labs mask
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to assess 2/2 absent upper airway patency w/ current
tracheostomy tube + maxillomandibular fixation
CN XII Unable to assess 2/2 maxillomandibular fixation
Secretions Adequate S/Z ratio Aphonic
VQ Aphonic 2/2 absent Pitch range Aphonic
Laryngeal function exam upper airway patency
w/ current trach
MPT Aphonic Cough Aphonic
Ice N/A IDDSI 5 N/A
IDDSI 0 Elicited swallow trigger IDDSI 6 N/A
to palpation without
distress
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A Presumable oropharyngeal dysphagia, likely multifactorial r/t penetrating oropharyngeal injury +/- peripheral
nerve injury, tracheostomy w/ absent upper airway patency (likely r/t trach size), maxillomandibular fixation, &
likely muscle disuse atrophy (r/t 10 day NPO status). Instrumental swallow study is required prior to initiation of
oral diet. Swallow prognosis to be determined after further diagnostic information on extent of
pharyngeal/laryngeal trauma.
P Instrumentation VFSS to define oropharyngeal structural integrity + swallow physiology

Diet recommendation Strict NPO, pending VFSS results
Risk management N/A
Specialist referrals ENT f/u for tracheostomy tube downsize to Shiley #6 cuffless to improve airway patency
for cough/airway protection & phonation
Ancillary tests N/A

HPI 63yoM admitted w/ BHT/TBI, found down. B/l SAH/SDH. Endotracheal intubation x1 day; extubated to
HFNC at 40 L/min.
PMHx None known
S Pt alert, pleasant for exam but confused. Overt left visual inattention. Oriented x2. Received breathing
comfortably on HFNC at 40 L/min.

factors
chronic dysphagia
Precipitating dysphagia risk TBI w/ bifrontal SDH/SAH, endotracheal intubation x1.5 days, iatrogenic high
factors peak pharyngeal pressure 2/2 HFNC at 40 L/min
Temp WNL SpO2 94% on 40L via HFNC
Vitals/labs
RR 20 WBCs Elevated
CN VII Intact b/l
CN IX/X Unable to exclude CN IX/X involvement; grossly symmetrical
Cranial nerve exam
palatal elevation, however, diminished gag reflex bilaterally & mild
dysphonia
CN XII Signs of UMN involvement of L CN XII
Laryngeal function exam VQ G1R1B0A1S0 Pitch range Unable to assess
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Notes Additional trials deferred for instrumentation
A Clinical signs of oropharyngeal dysphagia 2/2 TBI w/ signs of UMN involvement of L CN XII; unable to exclude
CN IX/X involvement. In the context of pt’s critical illness, reduced physical mobility, impaired pulmonary
function & iatrogenic high pharyngeal pressures, risk for dysphagia-related pulmonary complication appears
high. Instrumental swallow study is indicated prior to initiation of p.o. diet.

Ancillary tests N/A
Therapy Therapy recs pending FEES results
HPI 57yoM admitted for cough, fever, dyspnea, hypoxia, leukopenia & dysphagia; acute dxs: CAP, influenza, &
sepsis. Pt endorses subjective weight loss (not quantified); endorses recent onset dysphonia. Smoking hx (1
pack/week x10 years).
PMHx Smoking
S Pt alert, sitting upright on HFNC at 40 L/min. Pt appears mildly SOB w/ exertion from speaking & swallowing. Pt
endorses progressive dysphagia symptoms for several weeks to both solid & liquid.
O Predisposing dysphagia risk Smoking

factors
Pt endorses progressive dysphagia symptoms for several weeks, including
Clinical signs of possible globus sensation to solids, more effortful swallowing in general, coughing w/
chronic dysphagia p.o. intake, & sensation of food/liquid “coming back up”; pt endorses subjective
weight loss; admission w/ PNA
factors
Vitals/labs
RR 25-30 WBCs Low
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Laryngeal function exam VQ G1R1B0A1S0 Pitch range Perceptually reduced
throat clearing
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Notes Further trials deferred for instrumentation; of relevance, exam
conducted w/ pt on HFNC at 40 L/min
A Clinical signs of pharyngeal and/or esophageal dysphagia of unknown etiology. In the content of hospitalization
w/ PNA/sepsis w/ critically low WBCs & impaired pulmonary function (on HFNC at 40 L/min), risk for aspiration-
related complication appears increased. Instrumental swallow study is indicated. In the context of dysphonia,
endoscopic evaluation of swallowing is preferred initial exam; however, videofluoroscopic swallow study w/
esophageal screening and/or barium esophagram may also be required to answer all clinical questions
regarding pt’s swallow function.

Ancillary tests N/A
Therapy Further recs pending FEES results.

HPI 62yoM admitted w/ SOB/hypoxia, respiratory distress, & vomiting event; presumable “aspiration PNA” per
physician.
PMHx CVA, epilepsy, mild oral phase dysphagia
S Pt received awake but lethargic w/ eyes open; limited visual tracking. Nonverbal, not following commands
(which represents significant change from prior admission last month, when pt was verbal & communicating at
sentence level). Physician reports plan for PEG due to recurrent “aspiration PNA.”
O Chronic R insular CVA; CT Head revealed generalized cerebral atrophy w/

Predisposing dysphagia risk extensive white matter disease may be due to chronic small vessel ischemia but
factors mitochondrial encephalopathy w/ lactic acidosis & stroke-like episodes (MELAS)
is differential diagnosis; epilepsy
Known mild oral phase dysphagia & functional pharyngeal swallow, per Video
Swallow Study last month (revealed no aspiration of any consistency &
chronic dysphagia
recommended IDDSI Level 5/Level 0 diet)
Precipitating dysphagia risk Vomiting episode w/ acute “aspiration PNA” & respiratory failure
factors
Vitals/labs
RR 20 WBCs Elevated
Cranial nerve exam
Laryngeal function exam VQ No vocalization elicited Pitch range Unable to assess
Ice N/A IDDSI 5 N/A
IDDSI 0 Poor bolus IDDSI 6 N/A
awareness/acceptance,
no active acceptance of
bolus; severe anterior
loss of likely 100% of
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bolus
Notes Further trials deferred for instrumentation, when mental status
improved
A Pt w/ known history of mild oral phase dysphagia but functional pharyngeal swallow, per VFSS last month. This is
pt’s second admission in 2 months w/ reported “aspiration PNA”, however, there is no current evidence that
etiology of aspiration PNA is related to oropharyngeal dysphagia. In the content of epilepsy + vomiting event
prior to admission, query potential aspiration of gastric content as source of recurrent PNA; long-term enteral
feeding route (e.g., PEG) is unlikely to be successful in preventing aspiration PNA r/t aspiration of gastric
content. Pt’s current mental status is significantly altered compared to known baseline, likely r/t current

PNA/sepsis, though interval neurological change is not excluded. Pt will require repeat instrumental swallow
study, when mental status improved.
P Instrumentation VFSS w/ esophageal screening tomorrow, or once mental status improved

Diet recommendation Strict NPO pending VFSS results. Defer enteral feeding (e.g., NGT) until VFSS if
medically feasible. PEG tube does not appear indicated at this time, given suspicion for
possible aspiration of gastric content.
Specialist referrals GI consult for suspected aspiration of gastric content
Ancillary tests N/A

HPI 31yoM admitted w/ GSW through mandible w/ mandibular fracture, massive lingual edema/bleeding s/p
emergent trach.
PMHx None
S Pt alert, pleasant & cooperative for exam. Endorsed 10/10 facial pain, receiving pain meds w/ RN. NGT & trach
in place.

factors
chronic dysphagia
GSW though mandible/tongue w/ upper airway obstruction & submandibular
hematoma s/p emergent trach (Shiley #8 cuffed, non-fenestrated; POD #4), 4
factors
day ventilator dependency
Vitals/labs mask
RR 18 WBCs WNL
CN V Unable to assess 2/2 extensive facial edema
CN VII Unable to assess 2/2 extensive facial edema
Cranial nerve exam CN IX/X Unable to assess 2/2 extensive lingual edema obstructing view of
palate
CN XII Unable to assess 2/2 extensive lingual edema
Secretions Impaired; severe S/Z ratio Aphonic
drooling
VQ Aphonia to digital trach Pitch range Aphonic
Laryngeal function exam occlusion, likely r/t
upper airway
obstruction
MPT Aphonic Cough Aphonic
Ice N/A IDDSI 5 N/A
IDDSI 0 100% anterior bolus loss IDDSI 6 N/A
w/ trials of thin liquid via
syringe to lateral sulcus
2/2 massive lingual
edema
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Notes Pt NPO except water, per OMFS surgeon, x10 days post-op due to
intraoral injuries & risk for infection; massive submandibular
hematoma visible

A Clinical signs of oropharyngeal dysphagia r/t GSW mandible/tongue w/ submandibular hematoma & massive
lingual edema resulting in upper airway obstruction, s/p emergent trach (POD #4). Pt medically cleared only for
p.o. water, per OMFS, if swallow function is safe x6 additional days. Pt will require instrumental swallow study,
once lingual edema improved & pt medically cleared for oral intake.
P Instrumentation VFSS in 6 days (when medically cleared by OMFS for oral intake), pending clinical
progress & improvement in lingual edema
Diet recommendation Strict NPO. Continue short-term enteral feeding via NGT.
Ancillary tests N/A
Therapy SLP following x5/week for voice/swallow tx; further recs to follow VFSS results

HPI 32yoF admitted w/R throat/ear pain x9 days 2/2 peritonsillar cellulitis/abscess/phlegmon w/ severe
narrowing of oropharynx/larynx. Currently protecting airway & responding well to steroid/antibiotic
intervention.
PMHx None
S Pt alert & cooperative for exam. Breathing comfortably on room air w/out stridor; states her breathing improved
significantly once steroids/antibiotics started. Denies pain. States it is difficult for her to swallow solid food.

factors
chronic dysphagia
Precipitating dysphagia risk R peritonsillar cellulitis/abscess/phlegmon w/ narrowing of oropharynx/larynx
factors
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
CN IX/X + dysphonia, increased clinical suspicion for possible right
superior/recurrent laryngeal nerve (SLN/RLN) involvement
Cranial nerve exam
(possibly via extrinsic compression), given associated
visible/palpable enlargement of R neck; of clinical relevance,
severe hyponasality noted
CN XII Intact b/l
Laryngeal function exam VQ Mod hoarse Pitch range Perceptually reduced
MPT 2.5 secs Cough Perceptually WNL
IDDSI 2 N/A IDDSI 7 Deferred per pt
preference
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IDDSI 4 Deferred per pt Standardized N/A
preference
Notes N/A
A Clinical signs of pharyngeal phase dysphagia r/t right peritonsillar cellulitis/abscess/phlegmon w/ associated
narrowing of the pharynx/larynx. In the context of significant dysphonia, there is risk for involvement of the right
superior/recurrent laryngeal nerves (e.g., via extrinsic compression). Prognosis appears good for rapid
improvement in voice/swallow function w/ continued medical interventions (e.g., antibiotics, steroids). Risk for
aspiration-related complication appears low, given pt’s immunocompetence, good physical mobility, &
preserved cough strength. Pt may require instrumental swallow study if no resolution of dysphonia/dysphagia in
next 1-3 days.
P Instrumentation VFSS vs. FEES if dysphagia symptoms not resolved in 1-3 days
Diet recommendation Full liquid diet. Meds crushed/dissolved in liquid.
Risk management Oral hygiene q4h. Close airway monitoring.
Specialist referrals F/u w/ ENT
Ancillary tests N/A
Therapy SLP will f/u x5/week for diagnostic swallow tx & to monitor for changes in swallow
function or complications r/t oral diet

HPI 53yoM admitted s/p MVA w/ ALOC, found down w/ CHI/TBI (SAH/SDH), pulmonary contusion, rib
fractures. Hospital course involved L frontoparietotemporal craniectomy w/ decompression of L
hemisphere & evacuation of L SDH. Endotracheal intubation x15 days s/p trach. S/p PEG.
PMHx None
S Pt received alert w/ spontaneous eye opening, no visual tracking. Manipulating objects in environment &
localizing to sounds. Received w/ trach on vent w/ family at bedside.

factors
chronic dysphagia
TBI s/p L frontoparietotemproal craniectomy w/ decompression of L
hemisphere & evacuation of L SDH; endotracheal intubation x15 days s/p trach
factors
(POD #3)
Temp WNL SpO2 98% on vent in AC
RR 19 WBCs WNL
Cranial nerve exam
CN IX/X Pt did not follow commands to assess; aphonia 2/2 trach/vent
Secretions Impaired S/Z ratio N/A
VQ Aphonic (including w/ Pitch range N/A
Laryngeal function exam cuff deflation & PMV
trial in-line on vent)
Ice Elicited reflexive oral- IDDSI 5 N/A
motor movements in
response to ice chip; as
trials progressed,
elicited increased
spontaneous jaw
closure; elicited
spontaneous swallows
PO trials
Notes Further trials deferred for pt’s airway protection, given severely
reduced LOC & ventilator-dependency; of clinical relevance, exam
conducted w/ Shiley #8 cuffed trach, cuff deflated, on vent in AC
mode, FiO2 40%, RR 19-30, Vt 600 mL (partial upper airway
patency w/ cuff deflated, PMV tolerance 3 secs); see voice/PMV
eval

A Clinical signs of oropharyngeal dysphagia, likely multifactorial 2/2 TBI, prolonged endotracheal intubation, &
tracheostomy/ventilator-dependency (trach POD #3). Pt is not safe for any oral intake at this time, largely r/t
reduced level of consciousness (Rancho Los Amigos Level of Cognitive Functioning 3 – Localized Response).
Risk for aspiration-related pulmonary complication appears high, given pt’s critical illness, ventilator-
dependency, & acutely reduced physical mobility. Swallow prognosis appears excellent, given acuity of illness +
excellent family support.

Diet recommendation Strict NPO. Continue nutrition/hydration via PEG.
Ancillary tests N/A
Therapy SLP following for daily swallow/cognitive-communication/voice tx

HPI 55yoF admitted w/ dyspnea (progressive x1 month) & > 20 lb weight loss. Required BiPAP on hospital
admission, now weaned to RA. CXR clear.
PMHx Smoking, recent hospital admission for dyspnea, R vocal fold lesion identified on laryngoscopy 2 months
ago (possible malignancy, pending biopsy; pt lost to outpatient follow-up), weight loss
S Pt alert, very pleasant for exam. Received s/p breakfast; denied dysphagia symptoms. Breathing w/ normal
RR/effort on room air, though mild inspiratory stridor & profoundly breathy, largely aphonic vocal quality.
O Predisposing dysphagia risk R vocal fold lesion identified 2 months ago on laryngoscopy (possible
factors malignancy, pending biopsy; pt lost to outpatient follow-up)
Clinical signs of possible >20 lb unintentional weight loss in the past 1 year; malnutrition
chronic dysphagia
factors
Temp WNL SpO2 95% on RA; BiPAP
dependent on
Vitals/labs
admission
RR 18 WBCs Low
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to exclude CN X branch involvement 2/2 dysphonia; +
known R vocal fold lesion
CN XII Intact b/l
VQ G3R3B3A3S2; mild Pitch range Perceptually reduced
inspiratory stridor
MPT 1.5 secs Cough Perceptually WNL
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Notes N/A
A Clinical signs of chronic pharyngeal dysphagia (i.e., overt signs of aspiration, > 20 lb weight loss), likely r/t
laryngeal dysfunction/right TVC lesion (possibly malignancy, pending biopsy). Instrumental swallow study is
indicated to define swallow physiology for baseline pre-tx measure & for tx planning. Given presumed chronicity
of dysphagia & currently clear lungs, pt does appear safe to continue oral diet prior to instrumental swallow
study.
Diet recommendation IDDSI 7/0 diet prior to FEES results.

Risk management Control risk factors for aspiration pneumonia via: oral hygiene x4/day, increasing
Specialist referrals ENT for f/u regarding known vocal fold lesion. Dietitian consult 2/2 weight loss & poor
appetite.
Ancillary tests Pending FEES results

HPI 50yoM admitted with R facial droop & b/l UE numbness; progressive generalized weakness x2 yrs
PMHx Myopathy (type unknown) per muscle biopsy 2 months ago; progressive generalized weakness x2 yrs
S Pt alert, very pleasant for exam. Pt w/ overtly reduced R cervical strength, unable to sustain head in
upright/midline position. Pt denies dysphagia.
O Predisposing dysphagia risk Myopathy (type unknown) per muscle biopsy 2 months ago
factors
chronic dysphagia
Precipitating dysphagia risk Pt endorses acute worsening of R sided weakness (r/o acute CVA)
factors
Vitals/labs
RR 14 WBCs WNL
CN V Sensation intact b/l but impaired contraction of R temporalis &
masseter
CN VII Signs of LMN vs. neuromuscular involvement of R CN VII
Cranial nerve exam distribution; complete R facial paralysis
CN IX/X Intact b/l; CN XI (Accessory) impaired on R; poor R cervical
strength
CN XII Intact b/l
VQ Clear Pitch range Perceptually WNL
MPT 8 secs; suspect reduced Cough Perceptually WNL
breath support
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Notes Impaired mastication on R due to impaired contraction of R
temporalis/masseter; functional mastication in L oral cavity; pt
states he prefers soft/chopped solids
A Clinical signs of oral phase dysphagia isolated to mastication 2/2 impaired contraction of R
masseter/temporalis; R facial paralysis; R cervical weakness. Deficits are c/w LMN vs. neuromuscular disease;
however, in the context of pt’s known myopathy, suspect r/t neuromuscular disease. No evidence of current
pharyngeal phase dysphagia, however, anticipate future pharyngeal dysphagia r/t progressive myopathy. Pt will
benefit from outpatient skilled swallow therapy to increase functional reserve to prevent/reduce dysphagia r/t
oropharyngeal myopathy.
P Instrumentation Outpatient Video Swallow Study & exercise-based swallow therapy with SLP within the
next 6 weeks
Diet recommendation Soft & bite-sized solid (IDDSI Level 6)/Thin Liquid (IDDSI Level 0) diet. Meds whole w/
thin liquid. (Solid diet modification per pt preference; safe to advance/downgrade at
pt’s request)

Risk management Oral hygiene QID. Increase physical mobility as tolerated.
Specialist referrals Outpatient SLP for outpatient swallow rehabilitation.
Ancillary tests N/A
Therapy No acute care SLP service indicated; f/u w/ outpatient SLP
Goal N/A

HPI 71yoM admitted w/ fever & AMS; + COVID-19
PMHx Parkinson’s disease w/ known hx of oropharyngeal dysphagia (w/ silent aspiration of thin liquids) per VFSS
2 yrs ago w/ diet rec for chopped solid/mildly-thick liquid diet; seizure history; DM; HTN
S Pt on isolation for COVID-19; precautions observed. Pt received awake, moaning perseveratively w/ gross
involuntary movement of b/l UEs & Les, L>R; significant intermittent R facial/eye twitching. Discussed w/ RN that
in the context of pt’s seizure hx, these movements may also be concerning for active seizure; movements did not
appear c/w tremor in Parkinson’s disease.
O Parkinson’s disease w/ known hx of oropharyngeal dysphagia (w/ silent

aspiration of thin liquids) per VFSS 2 yrs ago w/ diet rec for chopped
factors
solid/mildly-thick liquid diet; seizure history
Clinical signs of possible Known hx of oropharyngeal dysphagia; admission w/ PNA (though + COVID-
chronic dysphagia 19)
Precipitating dysphagia risk AMS, severe sepsis, PNA/COVID-19, questionable seizures
factors
Vitals/labs
RR 25 WBCs Elevated
CN VII Pt did not follow commands for assessment; involuntary
Cranial nerve exam “twitching” movements of R face/eye
Secretions Severely impaired; S/Z ratio Unable to assess
wet/gurgly VQ w/
productive coughing;
required extensive
Yankauer suctioning
VQ Wet gurgly, severely Pitch range Unable to assess
asthenic
MPT 1 sec Cough Perceptually weak
Ice N/A IDDSI 5 N/A
Notes All p.o. trials deferred for pt’s airway protection; provided
extensive Yankauer suctioning

A Pt w/ confirmed oropharyngeal dysphagia hx (per VFSS) 2/2 Parkinson’s disease w/ acutely exacerbated
dysphagia signs. Suspect aspiration of sections r/t severity of dysphagia; pt does not appear to be protecting his
airway well at this time. Gross involuntary movements of extremities + R face/eye during exam concerning for
possible seizure. Pt is not safe for any oral intake at this time & appears to require close airway monitoring; there
is high risk for imminent dysphagia-related pulmonary complication.

Risk management Oral hygiene q4h. HOB upright as tolerated. Suction PRN for secretion management.
Close airway monitoring.
Ancillary tests N/A
Goal Pt will manage secretions without acute dysphagia-related aspiration PNA.

HPI 66yoM found down w/ blood in oropharynx, aphasic, w/ L gaze preference/R visual neglect, flaccid
paralysis of RUE, critically high fever, sepsis, possible meningitis vs. pyelonephritis vs. COVID-19; suspect
CVA, not tPA candidate
PMHx DM, HTN, BPH
S Pt on isolation for COVID-19; precautions observed. Pt received asleep, roused to tactile stim. Demonstrated
overt L gaze preference & R visual neglect. Communicative intent limited to gesture & vocalization of vowel.
Unable to follow commands.

factors
chronic dysphagia
Precipitating dysphagia risk Suspected acute CVA, possible blunt head/neck trauma
factors
Temp Critically high SpO2 98% on 3L via NC
Vitals/labs
RR 18 WBCs WNL
CN VII Pt did not follow commands for assessment; overt R lower
Cranial nerve exam quadrant facial droop
VQ Clear during Pitch range Unable to assess
Laryngeal function exam spontaneous
vocalization x1
MPT Unable to assess Cough: Absent volitional
IDDSI 0 No s/s of aspiration; IDDSI 6 N/A
reduced awareness of
bolus in oral cavity
(bolus visualized in
anterior oral cavity w/
partial open mouth
posture intermittently
>1 min); required
PO trials
repeated tactile
stimulation to elicit
swallow response
IDDSI 4 Absent oral transit, Standardized N/A
requiring Yankauer
suctioning of bolus from
oral cavity

Notes Further trials deferred for airway protection, given severity of
dysfunction
A Clinical signs of oropharyngeal dysphagia, suspect r/t acute neurologic injury. Instrumental swallow study will be
indicated prior to initiation of oral diet, however, pt not yet appropriate for swallow study 2/2 poor awareness of
bolus in oral cavity & intermittently absent swallow. Long-term swallow prognosis appears fair, given likely
etiology of dysphagia & some anticipated spontaneous recovery.

Diet recommendation NPO except ice chips (1 at a time) w/ RN assist for swallow stim. Short-term enteral
feeding route (e.g., NGT).
Ancillary tests N/A

HPI 81yoF admitted w/ fever, cough, sepsis 2/2 PNA
PMHx Hx of CVA w/ residual L weakness, dementia
S Pt received awake, non-verbal. Opened mouth reflexively to p.o. presentations. Discussed case w/ daughter via
phone, who states she has been providing pt chopped solid & thin liquid diet at home (despite prior SLP
recommendation for puree/mildly-thick liquid last hospitalization 2 months ago due to oropharyngeal
dysphagia & silent aspiration of thin liquids)
O Predisposing dysphagia risk Hx of CVA w/ residual L weakness; dementia

factors
Known hx of oropharyngeal dysphagia (per VFSS 2 months ago) w/ silent
aspiration of thin liquids & recommendation for oral diet of puree/mildly-thick
chronic dysphagia
liquids
Precipitating dysphagia risk Sepsis 2/2 PNA
factors
Vitals/labs
RR 22 WBCs Elevated
Cranial nerve exam
VQ Unable to elicit Pitch range N/A
phonation
MPT N/A Cough Absent volitional
Ice N/A IDDSI 5 N/A
Notes Thickened liquid trials provided above, per prior VFSS results (w/
no known interval change in neurologic status)
A Pt w/ hx of moderate oropharyngeal dysphagia r/t CVA and/or dementia hx resulting in silent aspiration of thin
liquid, w/ prior recommendation for puree/mildly-thick liquid diet. Daughter reports pt has not adhered to SLP’s
recommendation for diet modification since prior hospital discharge. In the context of admission w/ sepsis +
cough + lower lobe PNA, there is a high level of suspicion for dysphagia-related aspiration PNA. Pt is at
increased risk for further pulmonary complications, given poor physical mobility & oral hygiene. Pt appears to
be a poor candidate for swallow rehabilitation, given cognitive deficit. Diet modification, per prior VFSS results,
appears indicated; pt’s daughter verbalized understanding & agreement w/ POC.

Diet recommendation Puree (IDDSI Level 4)/Mildly-thick liquid (IDDSI Level 2) diet. Meds crushed in puree.
Risk management Aspiration precautions: 1:1 feeding assist, feed only when fully alert/upright. Control
risk for aspiration PNA via increasing oral hygiene to QID.
Ancillary tests N/A
Therapy SLP will f/u x1 for caregiver education
Goal Caregiver will perform verbal teachback of diet modification recommendations and
demonstrate thickening of liquid to IDDSI Level 2.

HPI 58yoM admitted w/ SOB, cough, & chest pain; CXR reveals likely R-sided PNA
PMHx Hx of L oropharyngeal/base of tongue SCC (diagnosed 2019); pt states he initiated chemotherapy but
developed “leukemia” & “an issue with my white blood cells” in early 2020, so discontinued chemotherapy;
pt states “that’s gone now” & he is planning to resume chemotherapy & initiate XRT in the upcoming weeks
S Pt alert, very pleasant for exam. Pt appears to be an excellent historian & informed about his medical conditions.
Pt denies dysphagia to liquids but endorses dysphagia to hard/dry solids w/ associated 50+ lb weight loss.
Visible fullness of L superior neck.
O Hx of L oropharyngeal/base of tongue SCC (diagnosed 2019); pt states he

initiated chemotherapy but developed “leukemia” & “an issue with my white
blood cells” in early 2020, so discontinued chemotherapy; pt states “that’s gone
factors
now” & he is planning to resume chemotherapy & initiate XRT in the upcoming
weeks
Clinical signs of possible Pt endorses 50+ lb weight loss since 2019, which he attributes to dysphagia to
chronic dysphagia solids
Precipitating dysphagia risk PNA w/ SOB
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Adequate S/Z ratio 1.86 (norm <1.4)
PO trials IDDSI 4 N/A Standardized N/A
Notes Further trials deferred for instrumentation; pt states he has never
received a swallow study (videofluoroscopy or endoscopy) for
baseline swallow diagnostics or swallow tx planning; pt states he
has never received any SLP interventions
A Clinical signs of pharyngeal dysphagia (including 50+ lb weight loss, suspected laryngeal dysfunction, & solid
food dysphagia symptoms), presumably related to known pharyngeal SCC. Unknown if current right-sided PNA
represents sequelae of dysphagia (e.g., aspiration PNA). Instrumental swallow study is indicated to define
baseline swallow physiology prior to XRT, to guide swallow treatment planning, & to recommend
compensations to maximize swallow safety & efficiency. Endoscopic swallow study is preferred exam over
fluoroscopy at this time, given suspicion for laryngeal dysfunction.

Diet recommendation Continue full liquid diet, per MD order, until FEES results
Risk management Oral hygiene QID. Encourage physical mobility as tolerated.
Ancillary tests N/A

HPI 67yoM admitted w/ dysphagia & abdominal pain x3 days, generalized weakness
PMHx CHF
S Pt alert, very pleasant for exam. Pt endorses dysphagia symptoms w/ associated odynophagia to both solids &
liquids x3 days preceding hospitalization; states his odynophagia is now resolved & his swallowing feels “fine.”
Pt also endorses generalized weakness, which he attributes to poor oral intake x3 days.
O Predisposing dysphagia risk CHF

factors
Clinical signs of possible Pt endorses dysphagia symptoms x3 days preceding hospitalization
chronic dysphagia
Precipitating dysphagia risk None known; brain imaging unremarkable
factors
Vitals/labs
RR 14 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Adequate S/Z ratio Unable to elicit
IDDSI 2 N/A IDDSI 7 Pt declined regular
solids; states he prefers
PO trials pureed foods 2/2
dentition
Notes Pt states his dysphagia/odynophagia are now resolved
A Pt endorses dysphagia (pharyngeal and/or esophageal) x3 days of unknown etiology. Cranial nerve & laryngeal
function appear normal. Instrumental swallow study is indicated to obtain objective data regarding swallow
physiology, though pt does appear safe for oral diet prior to study results. Videofluoroscopy is preferred initial
exam for nonspecific dysphagia symptoms, given ability for simultaneous esophageal screening.
Diet recommendation Puree (IDDSI Level 4)/Thin Liquid (IDDSI Level 0) diet prior to VFSS results.
Risk management N/A
Ancillary tests N/A

HPI 25yoF admitted for AMS, LLE pain, nausea/vomiting, SOB. + encephalopathy (uremic vs. hypertensive vs.
lupus cerebritis). Systolic CHF/cardiomyopathy.
PMHx SLE, PRES, lupus cerebritis, seizure disorder, CHF
S Pt received awake, sitting upright w/ eyes open, w/ repetitive/stereotypical movements of all extremities (LEs >
UEs). No eye contact/visual tracking elicited. Open mouth posture. + intermittent spontaneous vocalizations of
vowels only. Pt did not follow any commands.
O Predisposing dysphagia risk SLE, PRES, lupus cerebritis, seizure disorder, CHF
factors
chronic dysphagia
Precipitating dysphagia risk Encephalopathy (uremic vs. hypertensive vs. lupus cerebritis); MRI Brain
factors unremarkable, pending lumbar puncture
Vitals/labs
RR 18 WBCs WNL
Cranial nerve exam
Secretions Impaired; drooling S/Z ratio Unable to assess
VQ Clear in spontaneous Pitch range Unable to assess
vocalizations
Ice Pt did not demonstrate IDDSI 5 N/A
bolus awareness to
accept bolus from tsp
IDDSI 0 Pt did not demonstrate IDDSI 6 N/A
bolus awareness to
PO trials accept bolus from tsp
Notes Open mouth posture w/ drooling; absent bolus awareness or
intent to accept bolus presentations
A Clinical signs of oropharyngeal dysphagia, likely r/t pt’s profoundly altered mental status. Pt is not safe for any
p.o. intake at this time & is not appropriate for instrumental swallow study at this time. Swallow prognosis is
unknown, as underlying etiology of AMS remains unknown.
P Instrumentation Instrumental swallow study pending improved mental status

Ancillary tests N/A


HPI 79yoM admitted w/ SOB, fever, respiratory failure on HFNC. R/o COVID-19. RN reports signs of
aspiration/dysphagia. PMHx: dementia, COPD.
PMHx COPD, dementia, DM, HTN
S Pt alert, very pleasant for exam. Seen in isolation for COVID-19. RN reports pt is coughing in response to p.o.
liquids/solids. Pt received on HFNC at 40 L/min.
O Predisposing dysphagia risk COPD, dementia

factors
Clinical signs of possible Admission w/ SOB/fever & R lower lung opacity on CXR c/w possible PNA
chronic dysphagia
Precipitating dysphagia risk Acute respiratory failure on HFNC at 40 L/min
factors
Vitals/labs
CN V Motor intact bl/; unable to assess sensory
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Laryngeal function exam VQ Clear Pitch range Unable to assess
IDDSI 0 Cough IDDSI 6 N/A
PO trials
IDDSI 4 Cough Standardized N/A
A Clinical signs of oropharyngeal dysphagia in pt with multiple chronic (dementia, COPD) + acute (HFNC)
dysphagia risk factors, admitted w/ potential dysphagia sequalae (fever, dyspnea, RLL PNA). Unable to exclude
dysphagia at bedside; pneumonia may represent a dysphagia-related pulmonary complication (e.g., aspiration
PNA). Instrumental swallow study (e.g., VFSS) is indicated.
Diet recommendation NPO except ice chips, pending VFSS results
Ancillary tests N/A

HPI 69yoM admitted w/ shock, respiratory failure, AMS, PNA. Endotracheal intubation x1 day.
PMHx Chronic L frontal SDH
S Pt alert but appeared confused. Followed commands inconsistently. Breathing comfortably on NC.
O Predisposing dysphagia risk Chronic L frontal SDH

factors
Clinical signs of possible Admission w/ possible PNA (though unknown source)
chronic dysphagia
Precipitating dysphagia risk Acute respiratory failure s/p endotracheal intubation x1 day, septic shock
factors
Vitals/labs
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
VQ G1R1B0A1S0 Pitch range N/A
MPT 4 secs, likely r/t reduced Cough Perceptually weak
breath support
IDDSI 0 Wet VQ IDDSI 6 N/A
Notes Further trials deferred for pt’s airway protection, given critical
illness
A Clinical signs of acute oropharyngeal dysphagia, likely multifactorial r/t recent endotracheal intubation + septic
encephalopathy. Risk for aspiration-related pulmonary complication appears high for this patient, given critical
illness + poor oral hygiene + dystussia. Pt does not appear safe for oral diet at this time, though prognosis for
spontaneous swallow recovery is good.
P Instrumentation Possible instrumental swallow study pending clinical progress.

Diet recommendation NPO except ice chips & p.o. meds crushed in puree.
Ancillary tests N/A
HPI 54yoM admitted w/ intermittent substernal chest pain, SOB
PMHx COPD, CHF, PE
S Pt alert, very pleasant for exam. Received consuming breakfast. + coughing, although pt endorses chronic
cough. Pt endorses 10 yr hx of dysphagia symptoms but reports his baseline diet is regular solid/thin liquid.
O Predisposing dysphagia risk COPD, CHF, PE

factors
Clinical signs of possible Pt endorses dysphagia symptoms x10 yrs
chronic dysphagia
Precipitating dysphagia risk Endotracheal intubation x2 days
factors
Temp WNL SpO2 86-94% on 2L via NC
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Secretions Coughing S/Z ratio 1.4
IDDSI 0 Delayed cough IDDSI 6 N/A
IDDSI 2 N/A IDDSI 7 Delayed cough
PO trials
IDDSI 4 Delayed cough Standardized N/A
Notes N/A
A Unable to exclude pharyngeal phase dysphagia at bedside in pt w/ chronic cough, multiple chronic dysphagia
risk factors (COPD, CHF) + acute dysphagia risk factor (2-day endotracheal intubation). Signs of laryngeal
dysfunction warranting endoscopic view of the larynx/vocal folds.
Diet recommendation Continue Regular Solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet, pending FEES
results.
Risk management N/A
Ancillary tests N/A
HPI 47yoF admitted w/ nausea/vomiting, “throat hardness”, dysphagia x1 week to both liquid/solid (solid worse
than liquid), weight loss. Hx of metastatic ovarian adenocarcinoma s/p surgical intervention +
chemotherapy.
PMHx Hx of malignancy (ovarian adenocarcinoma)
S Pt alert, very pleasant for exam. Endorsing progressive dysphagia symptoms x1 week, although weight loss x1
month. Pt endorses associated vocal quality change (mildly hoarse, “weak”). Pt also endorses cervical weakness
& weakness of proximal LLE (onset over past 1 week).
O Predisposing dysphagia risk Hx of malignancy (ovarian adenocarcinoma)

factors
Clinical signs of possible Pt endorses dysphagia symptoms x1 week, weight loss x1 month
chronic dysphagia
factors
Vitals/labs
RR 16-20 WBCs Low
CN Intact b/l
CN VII Signs of subtle (nearly subclinical) b/l involvement; given such
mild b/l deficit, localize to level of muscle or NMJ
CN IX/X Signs of b/l involvement; + mild hypernasality & reduced bilateral
Cranial nerve exam
palatal elevation; + mild dysphonia; given such mild b/l deficit,
localize to level of muscle or NMJ
CN XII + mild hypernasality & reduced bilateral palatal elevation; + mild
dysphonia
PO trials
A Clinical signs of oropharyngeal dysphagia of currently undiagnosed etiology. Pt’s symptoms are chronic (x1
month) & progressive in nature. Cranial nerve exam reveals very subtle (nearly subclinical) bilateral
facial/oropharyngeal weakness, c/w likely disease localization to the muscular level or neuromuscular junction.
Instrumental swallow study is indicated, in addition to medical workup for dysphagia etiology.

Diet recommendation Full liquid diet, per pt preference, pending FEES results

Risk management N/A
Specialist referrals Neurologist and/or rheumatology consult, given unknown dysphagia etiology in the
context of possible neuromuscular/rheumatic disease symptoms
Ancillary tests N/A
Therapy Further recommendations pending FEES results

HPI 76yoM admitted w/ toe infection + progressive speech changes; brain imaging revealed L frontal brain
mass.
PMHx Brain mass (newly identified), DM, PAD
S Pt alert. Limited participation in tx. Family states pt is “grumpy” & does not want to answer questions.
O Predisposing dysphagia risk Brain mass (newly identified)

factors
Clinical signs of possible Family endorses some chronic dysphagia symptoms
chronic dysphagia
factors
Vitals/labs
RR 16 WBCs Elevated
CN V Intact b/l
CN VII Signs of UMN involvement of R CN VII
Cranial nerve exam
CN IX/X Signs of R CN IX/X involvement
CN XII Signs of UMN involvement of R CN XII
Secretions Adequate S/Z ratio Pt declined task
Laryngeal function exam VQ G2R2B0A1S2 Pitch range Pt declined task
MPT Pt declined task Cough Perceptually weak
PO trials
Notes N/A
A Clinical signs of oropharyngeal dysphagia, likely chronic r/t L frontal brain mass. Instrumental swallow study is
indicated, however, pt does appear safe to continue oral diet until swallow study results. Risk for immediate
dysphagia-related aspiration PNA appears low, given pt’s good oral hygiene, immunocompetence, & preserved
physical mobility.
Diet recommendation Regular Solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet, pending FEES results.
Ancillary tests N/A
Therapy Further recommendations pending FEES results.

HPI 42yoF admitted w/ LUE weakness, chest pain, SOB, & “hot flashes.” Brain imaging unremarkable.
PMHx None
S Pt alert, cooperative for exam. Reported 2 weeks of episodic dysphagia to both liquids & solids; states she feels
she is “choking” & cannot breathe during episodes.

factors
Clinical signs of possible Pt endorses 2 weeks of dysphagia symptoms
chronic dysphagia
Precipitating dysphagia risk Acute neurological symptoms, though brain imaging unremarkable
factors
Vitals/labs
RR 14 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
cough, globus,
gestured to sternal
notch & appeared
PO trials
distressed
A Clinical signs of pharyngeal vs. esophageal dysphagia, unable to differentiate at bedside. + coughing & globus
sensation, despite intact cranial nerves & normal perceptual laryngeal/voice measures. Given pt’s reports of
dysphagia of unknown etiology, instrumental swallow study is indicated. Videofluoroscopy is preferred
methodology, given its ability for esophageal screening.
P Instrumentation VFSS immediately to follow

Diet recommendation NPO pending VFSS results
Risk management N/A
Ancillary tests N/A

HPI 45yoM admitted w/ AMS, coffee ground emesis, & acute respiratory failure 2/2 acute UGIB s/p massive
blood transfusion, septic shock 2/2 aspiration PNA. Hospital course involved endotracheal intubation x5
days. EGD revealed distal esophageal varices s/p band ligation.
PMHx ETOH abuse
S Pt alert, very pleasant for exam. States he is hungry & wishes to eat.

factors
chronic dysphagia
Endotracheal intubation x5 days, PNA w/ high O2 flow rate demand (i.e.,
iatrogenic high peak pharyngeal pressure), acute toxic-metabolic/hepatic
factors
encephalopathy
Temp WNL SpO2 95% on 40L via HFNC
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Laryngeal function exam MPT 3 secs; 2-3 syllable Cough Perceptually WNL
dyspnea r/t reduced
breath support
Notes Further trials deferred at this time, given recency of extubation &
signs of aspiration
A Clinical signs of pharyngeal dysphagia, likely acute/transient r/t laryngeal dysfunction s/p 5-day endotracheal
intubation + iatrogenic high peak pharyngeal pressures 2/2 HFNC. Swallow prognosis appears excellent for
spontaneous recovery in the next several days, assuming no significant laryngeal trauma.
P Instrumentation Pending clinical progress

Diet recommendation NPO except ice chips for swallow stim. Short-term enteral feeding (e.g., NGT).
Risk management Oral hygiene q4h. HOB upright as tolerated for reflux precaution.
Ancillary tests N/A
Therapy SLP following x5/week for diagnostic swallow tx. Will re-assess tomorrow am.

HPI Approx 80yo unidentified male brought by EMS, found down/unconscious for uncertain amount of time.
CT Head reveals acute R MCA CVA. Acute respiratory failure, AKI, + 2nd degree burns on abdomen & UEs,
& rhabdomyolysis. Intubated x4 days.
PMHx Unknown
S Pt alert, very pleasant & smiling; conversant but confused & oriented x2.
O Predisposing dysphagia risk Unknown

factors
chronic dysphagia
Precipitating dysphagia risk Acute R MCA CVA, 4-day endotracheal intubation
factors
Vitals/labs
RR 16 WBCs Elevated
CN V Intact b/l
CN VII Signs of UMN involvement of L CN VII
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
PO trials
Notes Further trials deferred for instrumentation, given large R MCA CVA
A Unable to exclude oropharyngeal dysphagia in pt w/ large acute R MCA CVA + 4-day endotracheal intubation.
No overt s/s of aspiration, though R MCA CVA + intubation are both risk factors for impaired sensation to
aspiration. Given pt’s acuity of illness, risk for dysphagia-related aspiration PNA is increased. Instrumental
swallow study is indicated prior to oral diet initiation.
P Instrumentation VFSS ASAP

Diet recommendation NPO except ice chips & critical p.o. meds crushed in puree, pending VFSS results
Specialist referrals PT & OT consults 2/2 acute CVA.
Ancillary tests N/A

HPI 64yoM admitted w/ chest pain, SOB, cough, abdominal pain x1 week w/ vomiting. + SBO, non-operative. +
AKI.
PMHx Hx of CVA w/ bifrontal SDH s/p crani, tobacco use (1.5 packs/day x40 years)
S Pt alert, cooperative for exam. Requesting water. Notably dysphonic w/ persistent hiccups throughout exam. Pt
was cleared for swallow evaluation by surgeon, who states bowel function appears to be returning s/p SBO; per
surgeon, pt is medically cleared for a full liquid diet, if pt’s swallow function is safe to support it.
O Predisposing dysphagia risk Hx of CVA w/ bifrontal SDH s/p crani, tobacco use (1.5 packs/day x40 years)
factors
Clinical signs of possible Admission w/ possible PNA, cachexia/weight loss, chronic dysphonia
chronic dysphagia
Precipitating dysphagia risk Encephalopathy
factors
Temp WNL SpO2 96% ON RA
Vitals/labs
RR 16 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
IDDSI 0 Wet VQ IDDSI 6 N/A
Notes + persistent hiccups throughout exam c/w possible phrenic nerve
involvement; further trials deferred for instrumentation
A Unable to exclude pharyngoesophageal dysphagia in pt w/ multiple chronic dysphagia risk factors (CVA,
craniotomy, tobacco use) + possible chronic dysphagia sequelae (cachexia/weight loss, PNA). In the context of
pt’s dysphonia (concerning for laryngeal dysfunction/pathology) + possible phrenic nerve irritation, instrumental
swallow study is indicated. Pt would benefit from FEES to evaluate laryngeal function as it relates to swallowing;
pt may also benefit from VFSS, if clinical questions regarding pt’s swallow physiology are not sufficiently
answered via FEES.
P Instrumentation FEES today; possible VFSS, pending FEES results

Diet recommendation NPO except ice chips, small sips of water, & p.o. meds crushed in puree until FEES
results.
Ancillary tests N/A
Therapy Further recommendations to follow FEES results.
Goal Pt will participate in FEES/VFSS to define swallow physiology & therapy need.
HPI 70yoM admitted w/ angioedema s/p endotracheal intubation x1.5 days.
PMHx HTN, a-fib
S Pt alert, very pleasant for exam. Pt seen approx. 1 hour s/p extubation; vocal quality hoarse/harsh but loud.

factors
chronic dysphagia
Precipitating dysphagia risk Angioedema, endotracheal intubation x1.5 days
factors
Vitals/labs
RR 18-20 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X: Unable to exclude CN X branch involvement 2/2 dysphonia
CN XII Intact b/l
Laryngeal function exam VQ G2R2B0A1S2 Pitch range Perceptually WNL
PO trials IDDSI 3 N/A 3 oz water Pass
Note Unable to exclude silent aspiration at bedside, particularly in post-
extubation population
A Unable to exclude silent aspiration/subclinical dysphagia in pt post-extubation. However, total duration of

intubation was short (1.5 days/) & pt has no hx of predisposing dysphagia risk factors. Pt is immunocompetent
w/ good oral hygiene & physical mobility; thus, pt is at low risk for aspiration-related complication. Should pt
have an acute subclinical dysphagia, anticipate rapid spontaneous resolution prior to aspiration-related
complication.
P Instrumentation FEES if dysphonia persists >1 week or if pt endorses dysphagia symptoms

Diet recommendation Regular solid (IDDSI Level 7)/thin liquid (IDDSI Level 0) diet. Meds whole w/ puree.
Risk management Control risk factors for aspiration PNA via (a) oral hygiene QID, & (b) encouraging
Ancillary tests N/A
Therapy SLP will f/u x2-3 to monitor for potential dysphagia-related complication
complication.

HPI 21yoM admitted s/p bicycle vs. automobile accident. C5 SCI w/ quadriplegia s/p ACDF (C4-C6 anterior
instrumentation w/ cage placement) + C3-C7 posterior instrumentation.
PMHx None
S Pt received alert. MD & PA suctioning pt’s oropharynx; pt reports “something is stuck in my throat”; pt producing
large volume of secretions. + epistaxis from nasopharyngeal suctioning. Pt appeared anxious throughout exam,
repeatedly requesting repositioning & stating he “feels heavy.” Pt requested supine position for p.o. water;
demonstrates evidence of hemodynamic instability w/ HOB elevation. Pt required counseling for coping w/
acute injury, “I keep asking myself why, why did I ride my bike?”

factors
chronic dysphagia
C5 SCI w/ quadriplegia s/p ACDF (C4-C6 anterior instrumentation) & PCDF (C3-
Precipitating dysphagia risk C7 fusion), now POD #4; pt developed fever + cough + PNA (COVID-19
factors negative) concerning for possible post-operative dysphagia-related aspiration
PNA
Vitals/labs
RR 25 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Impaired; required S/Z ratio Unable to assess; pt
extensive suctioning, self reported “anxiety”
Trendelenburg as reason to decline
positioning, & directed task
coughs for secretion
clearance
Laryngeal function exam VQ Clear Pitch range Unable to assess; pt
self reported “anxiety”
as reason to decline
task
MPT Unable to assess; pt self Cough Perceptually weak
reported “anxiety” as
reason to decline task
Ice N/A IDDSI 5 N/A
Notes Trials provided in near supine position (HOB elevated 15 degrees)
2/2 evidence of hemodynamic instability w/ HOB elevation & very
poor sitting tolerance 2/2 cervical SCI; pt states he prefers to
consume p.o. intake in near supine position; pt also endorses
post-operative dysphagia symptoms; pt states that while his diet
order is currently regular solid/thin liquid, he only accepted small
amounts of applesauce & water yesterday; pt reports that
swallowing is difficult & he is fearful of choking
A Clinical signs of iatrogenic pharyngeal dysphagia 2/2 C4-C6 anterior cervical instrumentation/fusion (now POD
#4) for C5 SCI. Clinical evidence of dysphagia-related aspiration PNA, marked by post-operative development
of fever/cough & perihilar/basilar opacity on chest radiography, in the context of acute dysphagia symptoms. Pt
is at high-risk for further aspiration-related pulmonary complication, given acute quadriplegia & dystussia.
Instrumental swallow study is indicated ASAP.
P Instrumentation VFSS ASAP today

Diet recommendation NPO except small sips (<5 mL) of water via pipette, pending VFSS results
Risk management Control risk for aspiration PNA via oral hygiene QID
Ancillary tests N/A
Therapy Dysphagia treatment recommendations pending VFSS results

HPI 59yoF admitted w/ SOB, cough, fever 2/2 COVID-19 w/ associated PNA & sepsis + respiratory failure, s/p
endotracheal intubation/dislodgement/re-intubation/failed extubation/re-intubation s/p tracheotomy.
PMHx DM, HTN, hyperlipidemia, asthma, obesity
S Pt alert but w/ reduced participation in exam, suspect partially r/t emotional/motivational component. Oriented
x1.

factors
chronic dysphagia
COVID-19 PNA + ARDS s/p prolonged endotracheal intubation (x30 total days),
Precipitating dysphagia risk including multiple intubations (x3 total due to 1 ETT dislodgement & 1 failed
factors extubation) now s/p tracheotomy (POD #5); COVID encephalopathy, severe
deconditioning & critical illness myopathy 2/2 prolonged sedation/paralytics
Temp Febrile SpO2 94% on 6L via trach
Vitals/labs mask
RR 20 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to exclude CN X branch involvement; pt aphonic w/ trach
& poor upper airway patency
CN XII Intact b/l
VQ Aphonic (likely Pitch range N/A
multifactorial, but at
least partially related to
poor upper airway
patency w/ current
tracheostomy tube)
MPT N/A Cough N/A
Ice No overt s/s of IDDSI 5 N/A
aspiration, though very
high probability of silent
aspiration in this pt
population
Notes Further trials deferred for instrumentation; pt w/ cuff deflated on
trach mask for exam (unable to tolerate PMV)

A Presumable pharyngeal dysphagia r/t prolonged (x30 days) endotracheal intubation (total intubations x3) s/p
tracheotomy (POD #5) w/ high probability of severe laryngeal trauma. Poor upper airway patency for
PMV/phonation at this time, which is likely multifactorial r/t trach diameter (Shiley #8) + likely comorbid
laryngeal and/or tracheal pathology. Long-term swallow prognosis is likely fair. Patient requires instrumental
swallow study once optimized for exam.
P Instrumentation FEES s/p trach downsize

Diet recommendation NPO except ice chips w/ RN assist for swallow stim. Continue short-term enteral
feeding via NGT.
Risk management Control risk for aspiration PNA via (a) oral hygiene QID, & (b) Physical Therapy consult
to improve physical mobility
Specialist referrals ENT f/u for tracheostomy tube downsize to Shiley #6 cuffless to improve upper airway
patency for phonation/swallowing
Ancillary tests N/A
Therapy SLP following x5/week for voice/swallow rehabilitation

HPI 50yoF admitted w/ SOB & cough x3 weeks, found to be COVID-19 +, s/p respiratory failure w/ intubation
x3 days
PMHx HTN, DM, obesity
S Pt alert but confused; oriented x2. Pt demonstrates very poor insight into her deficits & poor retention of
education on disease process, including her dysphagia & aspiration risk. Perseveratively pointing to applesauce
after education on dysphagia symptoms; unable to demonstrate comprehension of current medical conditions
or aspiration risk.

factors
chronic dysphagia
Precipitating dysphagia risk Respiratory failure (2/2 COVID-19 PNA) s/p endotracheal intubation x3 days
factors
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
Ice Cough IDDSI 5 N/A
IDDSI 0 Cough, wet VQ, IDDSI 6 N/A
expectorating
secretions
PO trials
A Clinical signs of pharyngeal dysphagia, likely temporary post-extubation dysphagia r/t laryngeal dysfunction. Pt
has multiple risk factors for dysphagia/aspiration-related pulmonary complication, including pulmonary
comorbidities, reduced physical mobility, & critical illness. Pt does not appear safe for an oral diet at this time.

Diet recommendation NPO except ice chips w/ RN assist for swallow stim. Continue short-term enteral
feeding via NGT.

Risk management Control risk for aspiration PNA via (a) oral hygiene QID, & (b) Physical Therapy consult
to improve physical mobility.
Ancillary tests N/A
Therapy SLP will f/u for diagnostic swallow tx & assessment for instrumental exam

HPI 84yoF admitted w/ ALOC, refusing to eat. Hx of dementia on home hospice.
PMHx Dementia
S Pt awake but lethargic & confused; responds to name, vocal but non-verbal. Notably leaning to left & yells when
repositioned. Family at bedside expressing concern regarding recently poor oral intake.
O Predisposing dysphagia risk Dementia

factors
Malnutrition/dehydration, food refusal; family states baseline diet is puree/thin
liquid; family stated patient has been demonstrating signs of oral dysphagia
(i.e., oral holding, anterior loss, poor oral acceptance) for “a long time” but
chronic dysphagia
states symptoms have been “progressing to where she hardly eats.” Family
expressing concern regarding malnutrition.
Precipitating dysphagia risk R/o acute CVA (brain imaging unremarkable for acute process)
factors
Vitals/labs
RR 14 WBCs Elevated
CN V Pt did not follow commands
CN VII Pt did not follow commands
Cranial nerve exam
CN IX/X Pt did not follow commands
CN XII Pt did not follow commands
Ice N/A IDDSI 5 N/A
PO trials
Notes + anterior bolus loss w/ thin liquid; suspect oral holding w/ liquid;
perseverative expectoration of thin liquid & puree boluses c/w
cognitive deficits
A Clinical signs of oral phase dysphagia c/w dementia, though no overt signs of pharyngeal phase involvement.
Risk for malnutrition/dehydration & potential intermittent aspiration events appears high & cannot be
eliminated. Use of behavioral feeding strategies may facilitate oral intake & reduce complications of oral stage
dysphagia. Further swallow intervention (including instrumental swallow study) unlikely to alter POC at this time,
given current hospice care.
Pt’s oral intake improved with use of the following feeding strategies: hand-under-hand assist, distraction during
oral intake, alternating texture/temperature/flavor. Extensive education provided to pt’s family on
pathophysiology of dysphagia in dementia. Family required extensive education on dysphagia in dementia &

poor swallow prognosis; benefitted from education on feeding strategies. Family receptive to education &
stated, “I didn’t know that.” Family advised against “force feeding” methods via syringe & to appreciate pt’s non-
verbal cues regarding readiness/willingness to eat/drink. Family advised to discuss reduced oral intake w/
physician, as this may be c/w end-stage of pt’s disease process.
Diet recommendation Puree (IDDSI Level 4)/Thin Liquid (IDDSI Level 0) diet. Meds crushed in puree.
Risk management Feeding strategies to promote oral intake: careful hand feeding w/ hand-under-hand
assist; alternate flavor/texture/temperature; offer distractions during meals;
small/frequent snacks
Specialist referrals Dietitian consultation to discuss options for potential p.o. supplementation and/or
family education on disease process
Ancillary tests N/A
Therapy Family to implement feeding strategies. Pt is unlikely to benefit from skilled SLP tx at
this time. SLP will sign off.
Goal N/A

HPI 48yoF transferred from OSH for “throat pain” radiating to chest, nausea & vomiting. To SLP, pt endorses hx
of dysphagia >1.5 years, which acutely worsened approx. 1 week ago.
PMHx HTN, ETOH, reflux, hemorrhagic gastritis. Questionable hx of CVA; pt endorses, “I think I had a stroke in
2016” but no documentation of this in medical records, other than GI note in 2018 that also stated pt
reported she “believed” she had a stroke. No brain imaging from prior admissions.
S Pt alert, very pleasant for exam. Endorsing significant acute-on-chronic dysphagia symptoms; “I haven’t eaten in
3 days.” Notably dysarthric & dysphonic.
O Questionable hx of CVAs; pt endorses “I think I had a stroke in 2016” & reports

chronic dysphagia symptoms >1.5 years, however, this dx not confirmed by
medical records and no brain imaging available. Pt states her PCP attributes her
multiple symptoms (dysphagia & LE weakness) to likely “old strokes.” Hx of
factors
hemorrhagic gastritis (dx by EGD in 2018). Pt reports she attends “speech
therapy” x5 visits/week for her “speech” not swallowing. Records from Barium
Swallow at OSH in 2017 reveal tertiary esophageal contractions.
Clinical signs of possible Pt endorses chronic dysphagia symptoms >1.5 years; no known weight loss or
chronic dysphagia PNA
Precipitating dysphagia risk Questionable acute neuro symptoms; approx. 1 week of increased “throat
factors pain”, dysphagia symptoms, & reportedly worsened dysarthria
Vitals/labs
RR 12 WBCs WNL
CN V Signs of R CN involvement
CN VII Signs of UMN R CN involvement; pt endorses R facial droop as
chronic (> 1.5 years)
CN IX/X Signs of R CN involvement
Cranial nerve exam
CN XII Signs of LMN R CN involvement; ipsilateral lingual deviation &
atrophy/fasciculations; pt endorses dysarthria is acute-on-chronic
(>1.5 years, but worse within the past week); pt overtly dysarthric
w/ moderately impaired articulatory precision & mild hypernasality
PO trials Notes Further trials deferred for instrumentation; pt endorsed
acute/subacute neuro symptoms (including worsening dysphagia
& dysarthria) to SLP, although Code Neuro not called as pt’s last
known well time >1 week ago, per her report. SLP immediately
informed MD of neuro findings & requested Neurology consult.

A Clinical signs of significant oropharyngeal dysphagia in the setting of mixed UMN & LMN CN involvement. Pt
endorses acute/subacute (approx. 1 week) on chronic (>1.5 years) dysphagia symptoms, which pt attributes to
multiple possible CVAs, though not verified via brain imaging. Presentation is concerning for possible
progressive neurological process, warranting Neurologist evaluation. Pt reports she has never received
VFSS/FEES; instrumental swallow study is indicated.

Diet recommendation NPO until FEES results
Specialist referrals Neurologist consult 2/2 mixed UMN/LMN findings w/ suspected progressive
dysarthria/dysphagia
Ancillary tests N/A

HPI 72yoM admitted from SNF w/ fever, hypoxia, sepsis, PNA. Recent hospitalization (approx. 1 month ago) at
OSH x8-10 days for PNA; discharged to SNF.
PMHx CVA w/ residual L weakness, PNA requiring recent hospitalization & intubation
S Pt alert, very pleasant for exam; on HFNC at 50 L/min w/ tachypnea. Son at bedside, providing PLOF info.
O CVA approx. 3 months ago, PNA approx. 1 month ago, recent endotracheal
intubation x4-6 days (per son’s report) at OSH (where patient was hospitalized
factors
an estimated 8-10 days for PNA)
Recurrent PNA in gravity-dependent lung zones s/p recent CVA; son endorses
Clinical signs of possible signs of aspiration with regular solid/thin liquid diet s/p extubation at OSH and
chronic dysphagia at SNF; pt/son deny that pt received swallow assessment by SLP at OSH
Precipitating dysphagia risk PNA & acute respiratory failure on HFNC at 50 L/min w/ tachypnea (RR 25-35),
factors sepsis/critical illness
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Dysphonic but adequate bilateral palatal elevation; unable to
exclude vocal fold/RLN injury
CN XII Intact b/l
Notes Further trials deferred for instrumental exam; high risk for silent
aspiration
A Patient presents with multiple risk factors for oropharyngeal dysphagia (CVA hx, recent PNA s/p endotracheal
intubation, HFNC, tachypnea) in the setting of possible dysphagia-related sequalae (recurrent basilar PNA,
sepsis) & in the context of overt signs of aspiration. Given current respiratory failure & sepsis, pt is at high risk for
aspiration-related complication. Instrumental swallow exam is indicated.

Risk management Oral hygiene QID
Ancillary tests N/A

HPI 86yoM admitted w/ SOB, + influenza A. Hospital course involved BiPAP dependency x1 day + HFNC
dependency x1 day, now weaned to NC. PMHx of COPD & tobacco use.
PMHx COPD, DM, HTN, PAD, BPH
S Pt alert & oriented x4. Participated well in exam. Breathing comfortably on 2L/min O2 via NC.

factors
Admission w/ PNA (CT Chest reveals right lower lung peribronchial ground-
glass & mild nodular opacities) & hypercapnic respiratory failure (though
chronic dysphagia
unknown if dysphagia-related)
Precipitating dysphagia risk PNA, acute respiratory failure
factors
Vitals/labs
RR 20-24 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Laryngeal function exam VQ Clear Pitch range Perceptually reduced
PO trials
Notes Further trials deferred for instrumental exam
A Clinical signs of pharyngeal and/or esophageal dysphagia in the setting of PNA & acute respiratory failure in pt
w/ + historical dysphagia risk factor (COPD). Instrumental swallow exam is warranted to define swallow
physiology. It is unclear if the pt’s PNA is possibly r/t chronic undiagnosed dysphagia, or if the patient presents
w/ temporary dysphagia r/t acute CAP.
P Instrumentation VFSS to define swallow physiology

Diet recommendation NPO except ice chips & critical meds crushed in puree until VFSS results
Ancillary tests N/A

HPI 93yoF admitted w/ SOB & edema 2/2 acute CHF exacerbation; + orthopnea. PAD in b/l legs.
PMHx COPD, CHF, dementia, HTN, DM, a-fib, CAD, NSTEMI, PAD
S Pt alert, very pleasant but confused for exam. Daughter at bedside. Pt appeared SOB w/ + rib cage flaring & use
of accessory muscles.
O Predisposing dysphagia risk COPD, CHF, dementia

factors
Clinical signs of possible Acute respiratory failure (though likely attributable to CHF exacerbation)
chronic dysphagia
Precipitating dysphagia risk Acute respiratory failure/tachypnea (RR 25-35)
factors
Vitals/labs
RR 25-35 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Impaired; + S/Z ratio Unable to assess
wet/congested upper
airway sounds
Laryngeal function exam VQ G2R2B0A1S2 (which Pitch range Unable to assess
daughter reports is
acute)
IDDSI 0 Throat clear, wet VQ, IDDSI 6 N/A
cough
PO trials
Notes Further trials deferred 2/2 aspiration risk w/ pt’s tachypnea & work
of breathing
A Clinical signs of oropharyngeal dysphagia in pt w/ acute CHF exacerbation. Suspect dysphagia is temporary or
acutely exacerbated related to pt’s current tachypnea, although unable to exclude chronic dysphagia in pt w/ hx
of dementia & COPD. Pt does not appear safe for oral intake at this time, given tachypnea & overt s/s of
aspiration. However, swallow prognosis is likely good, pending medical tx of acute CHF exacerbation.

P Instrumentation Pending clinical progress, if dysphagia symptoms not resolved w/ medical tx of CHF
exacerbation
Diet recommendation NPO except ice chips & critical meds crushed in puree
Ancillary tests N/A

HPI 58yoF admitted w/ leg edema + dyspnea/orthopnea. Hospital course involved BiPAP dependency x1 day
+ endotracheal intubation x6 days, now extubated to NC.
PMHx HTN, COPD, seizure, heroine abuse on methadone.
S Pt somnolent, poorly responsive except to max multimodal stim. Appeared SOB w/ use of accessory muscles &
rib cage flaring; tachypneic on NC at 2L/min.

factors
Clinical signs of possible Acute respiratory failure (though unknown/unlikely r/t dysphagia)
chronic dysphagia
Precipitating dysphagia risk Acute respiratory failure s/p prolonged endotracheal intubation x6 days; septic
factors shock; VAP; seizures; encephalopathy; tachypnea (RR 30-35)
Vitals/labs
CN V Pt unable to participate in assessment tasks
CN VII Intact b/l
Cranial nerve exam
CN IX/X Pt unable to participate in assessment tasks
CN XII Pt unable to participate in assessment tasks
Secretions Impaired; S/Z ratio N/A
wet/congested upper
airway sounds & vocal
Laryngeal function exam quality c/w possible
aspiration of secretions
VQ G3R3B3A3S2, wet Pitch range N/A
MPT 1 sec Cough Absent
Ice N/A IDDSI 5 N/A
Notes All p.o. trials deferred 2/2 high aspiration risk w/ current
respiratory status & secretion management
A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t encephalopathy + prolonged endotracheal
intubation. Given current critical illness & pulmonary comorbidities, risk for aspiration-related complication
appears high. Pt does not appear safe for oral intake at this time. However, swallow prognosis appears fair-
good, pending improved mental status.

Diet recommendation Strict NPO. Short-term enteral feeding route (e.g., NGT) per MD.
Risk management Monitor respiratory status closely, given concern for impaired airway protection.
Yankauer suction PRN for secretion management. Oral hygiene QID. HOB elevation as
tolerated.
Ancillary tests N/A
Therapy SLP following x5/week for diagnostic swallow tx. Further recs pending clinical progress.

HPI 58yoF admitted w/ leg edema + dyspnea/orthopnea. Hospital course involved BiPAP dependency x1 day
+ endotracheal intubation x6 days, extubated to NC; complicated by post-extubation dysphagia w/
suspected aspiration PNA requiring re-intubation x6 days, now s/p tracheotomy (POD #5).
PMHx HTN, COPD, seizure, heroine abuse on methadone.
S Pt alert, attempting to communicate via mouthing words. Received w/ trach on vent in AC mode. Participated
well w/ SLP but required encouragement & frequent re-direction to task. Once voice achieved, pt requested
methadone.

factors
Clinical signs of possible Acute respiratory failure (though unknown/unlikely r/t dysphagia)
chronic dysphagia
Acute respiratory failure s/p prolonged endotracheal intubation x6 days; septic
Precipitating dysphagia risk shock; VAP; seizures; encephalopathy; post-extubation dysphagia w/ suspected
factors aspiration PNA requiring repeat endotracheal intubation x6 days s/p
tracheotomy (POD #5; Shiley #7 cuffed proximal XLT) & ventilator-dependency
Temp Febrile SpO2 93% on vent in AC
RR 20 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to assess; poor upper airway patency w/ current trach
(Shiley #7 cuffed proximal XLT) w/ cuff deflation trial on vent
CN XII Intact b/l
w/ cuff deflation on vent
MPT 1-2 secs Cough Perceptually weak
Ice Impaired IDDSI 5 N/A
Notes Elicited volitional swallows to palpation; all p.o. trials deferred for
instrumental exam
A Clinical signs of oropharyngeal dysphagia 2/2 multiple prolonged endotracheal intubations s/p tracheotomy
(POD #5), complicated by pt’s encephalopathy + aspiration PNA/VAP + ventilator-dependency. Pt is at high risk
for dysphagia-related complications. Instrumental swallow study is indicated, once optimized for exam, prior to
oral diet initiation.

P Instrumentation FEES in 1-3 days to assess swallow physiology; ideally, once upper airway patent for
PMV use
Diet recommendation Strict NPO. Short-term enteral feeding route (e.g., NGT) per MD.
Risk management Oral hygiene QID. HOB elevation as tolerated. Cuff deflation during waking hours as
tolerated on vent to facilitate laryngeal sensation & reflexive airway protection; see
Pulmonologist orders for vent adjustments to compensate for leak on vent.
Ancillary tests N/A

HPI 56yoM admitted w/ abdominal pain x2 weeks, silent hypoxia to 70s 2/2 COVID-19 PNA/ARDS. HFNC
dependent x1 day. Intubated x5 days.
PMHx None
S Pt alert but confused. Pt refuses to wear nasal cannula, repeatedly removes it saying, “It will kill me.” Refuses
education on his medical conditions. Oral hygiene poor.

factors
chronic dysphagia
Precipitating dysphagia risk COVID-19 PNA/ARDS s/p 5-day endotracheal intubation
factors
Vitals/labs
RR 25-30 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/ Unable to exclude CN X branch involvement 2/2 dysphonia
CN XII: Intact b/l
Notes Further trials deferred 2/2 high risk for silent aspiration in post-
extubation population
A Clinical signs of oropharyngeal dysphagia & laryngeal dysfunction, presumably post-extubation in etiology.
Given pt’s acuity of illness, poor oral hygiene, & poor physical mobility, pt is at high risk for aspiration-related
complication. Pt is not safe for oral diet initiation today, though swallow prognosis is good.
P Instrumentation FEES in 1-3 days, pending clinical progress

Diet recommendation NPO except ice chips w/ RN assist for swallow stim. P.O. meds crushed in puree.
Risk management Oral hygiene q4h. HOB upright as tolerated. Increase physical mobility as medically
feasible.
Specialist referrals PT consult to improve physical mobility.
Ancillary tests N/A

HPI 63yoM admitted w/ acute encephalopathy. Approx 1 month ago, pt developed progressive weakness; was
evaluated OSH & found w/ “encephalitis” & Miller Fisher Guillain-Barre Syndrome (GBS), required
mechanical ventilation s/p tracheotomy & PEG. Transferred from OSH for insurance purposes.
PMHx DM
S Pt alert, very pleasant for exam. Pt appeared highly motivated to communicate & eat. Pt w/ Shiley #8 cuffed
PERC trach on trach mask w/ cuff inflated; pt achieved phonation w/ PMV s/p cuff deflation & repeatedly
expressed gratitude for care (see trach/PMV/voice evaluation). + severe flaccid dysarthria (see motor speech
evaluation).

factors
chronic dysphagia
Miller Fisher variant of Guillain-Barre Syndrome (GBS) w/ respiratory failure s/p
Precipitating dysphagia risk prolonged endotracheal intubation (# of days unknown), s/p tracheotomy (POD
factors #28); s/p 5-day tx w/ IVIG; presumable muscle disuse atrophy r/t >1.5 month
NPO status
Vitals/labs mask
RR 16 WBCs WNL
CN V Intact b/l
CN VII Impaired b/l
Cranial nerve exam
CN IX/X Suspect impaired b/l
CN XII Impaired b/l; minimal lingual movement observed
Ice Absent oral transit; IDDSI 5 N/A
bolus observed in
anterior oral cavity
IDDSI 0 Absent oral transit; + IDDSI 6 N/A
severe anterior bolus
loss; absent swallow to
PO trials palpation
Notes Suspect absent oral transit & swallow trigger; further trials
deferred for instrumentation to assess secretion management &
pharyngeal function

A Clinical signs of oropharyngeal dysphagia. In the setting of Miller Fisher GBS, instrumental swallow exam is
required to assess secretion management, vocal fold mobility/airway protection, & oropharyngeal swallow
function for tx planning. Potential for immediate aspiration-related complication is high, given pt’s acuity of
illness; instrumental swallow study is indicated prior to any oral diet initiation.
Diet recommendation Strict NPO, pending FEES results. Continue use of PEG for nutrition/hydration.
Risk management HOB upright as tolerated. Suction PRN. Oral hygiene QID.
Ancillary tests N/A
Therapy SLP following x7/week for swallow tx.

HPI 73yoF admitted from SNF w/ dyspnea, + COVID-19 PNA/ARDS requiring endotracheal intubation x24
days, s/p tracheotomy (POD #14).
PMHx dementia, CVA (L frontal/parietal), HTN.
S Pt alert, participated in exam w/ encouragement but became agitated & repeatedly stated, “Oh my god” in
response to requests for participation. Pt received w/ Shiley #8 cuffed trach, cuff inflated; weaned from vent in
SBT to t-piece blowby immediately prior to SLP exam.
O Predisposing dysphagia risk Dementia, CVA

factors
Pt w/ confirmed mild-moderate dysphagia hx 2/2 dementia and/or CVA (L
frontal/parietal); prior VFSS at this facility in 2019 rec’d puree/mildly-thick liquid
chronic dysphagia
diet
COVID-19 PNA/ARDS s/p 24-day endotracheal intubation s/p tracheotomy
(POD #14); presumed muscle disuse atrophy due to nearly 1.5 month NPO
factors
status
Temp Elevated SpO2 98% on 8L via t-piece
Vitals/labs
RR 20 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN XII Intact b/l
VQ G2R2B0A0S2 w/ cuff Pitch range N/A
deflated & PMV in place
MPT Pt refused Cough Absent
PO trials
Notes Pt accepted ice chip trials x2 prior to refusing all further trials
A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t multiple chronic (dementia, CVA) & acute (24-
day intubation, tracheotomy, muscle disuse atrophy) dysphagia risk factors. Pt is at high risk for aspiration-
related pulmonary complication, given poor oral hygiene (fungal sputum infection), poor physical mobility, &
overall acuity of illness. Instrumental swallow study is indicated, once pt participation improves.
P Instrumentation Instrumental swallow study (i.e., VFSS vs. FEES) in 1-3 days, pending improved pt
participation.

Diet recommendation NPO except ice chips w/ RN for swallow stim. Short-term enteral feeding route (e.g.,
NGT).
Risk management Oral hygiene q4h. Suction PRN.
Ancillary tests N/A
Therapy SLP following for diagnostic swallow tx x7/week.

HPI 63yoF admitted w/ cough, dyspnea, hypoxia (SpO2 55% on RA) 2/2 COVID-19 PNA & ARDS. H/c involved
HFNC dependency x6 days; pt developed b/l pneumothoraces s/p b/l chest tubes; worsening respiratory
failure requiring endotracheal intubation x18 days s/p tracheotomy & persistent ventilator-dependency. +
COVID encephalopathy, encephalitis, & b/l watershed CVAs in b/l frontotemporal & posterior R parieto-
occipital regions.
PMHx DM, HTN, obesity
S Pt received alert, very pleasant for exam. Smiling & following all verbal-only commands. Mouthing words to
communicate in Spanish. Pt highly interactive, expressing gratitude by mouthing words. Received w/ trach
(Shiley #8 cuffed) on vent w/ cuff inflated in SIMV mode. RT assisted for vent management throughout PMV &
swallow evals.

factors
chronic dysphagia
COVID-19 PNA/ARDS s/p 18-day endotracheal intubation s/p tracheotomy
Precipitating dysphagia risk (POD #19); presumed muscle disuse atrophy due to prolonged NPO status >1
factors month & ventilator-dependency; COVID encephalopathy; COVID encephalitis;
COVID-associated b/l watershed CVAs in b/l frontotemporal lobes
Temp WNL SpO2 98% on vent in SIMV
Vitals/labs mode, 40% FiO2
RR 25-30 WBCs WNL
CN V Intact b/l
CN VII Impaired b/l
Cranial nerve exam CN IX/X Unable to exclude CN X branch involvement 2/2 aphonia, though
presumably iatrogenic 2/2 large trach diameter
CN XII Intact b/l
VQ Aphonic (though Pitch range N/A
presumably iatrogenic
2/2 large trach diameter
Laryngeal function exam w/ poor upper airway
patency); not a
candidate for PMV use
at this time
Ice Pt accepted oral trials & IDDSI 5 N/A
demonstrated swallow
response to palpation
PO trials

A Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t 18-day endotracheal intubation, exacerbated
by additional 19-day NPO status w/ presumable muscle disuse atrophy, bilateral watershed CVAs, & COVID
encephalopathy/encephalitis. Pt is at high risk for aspiration-related complication, given poor physical mobility
& ventilator-dependency. Instrumental swallow exam is indicated; ideally, pt will receive trach downsize +
tolerate PMV to optimize swallow potential for exam.
P Instrumentation FEES after trach downsize, & ideally PMV tolerance, within 1-3 days.
Diet recommendation NPO except ice chips w/ RN for swallow stim. Short-term enteral feeding route (e.g.,
NGT).
Risk management Oral hygiene QID. Suction PRN.
Specialist referrals F/u w/ ENT for trach downsize to Shiley #6 cuffed to optimize swallow function for
further diagnostics (see PMV/voice evaluation)
Ancillary tests N/A

HPI 24yoF admitted w/ generalized weakness & dysphagia.
PMHx None
S Pt received alert, very pleasant for exam. Endorses some mild dysphagia symptoms for 4-6 months, which she
sates worsened acutely approx. 1 week ago.
O Predisposing dysphagia risk None known/diagnosed

factors
Clinical signs of possible Pt endorses 4-6 months of dysphagia symptoms, though no weight loss
chronic dysphagia
Precipitating dysphagia risk 1 week of generalized weakness (though still ambulatory)
factors
Vitals/labs
RR 16 WBCs WNL
CN V Intact b/l
CN VII Impaired b/l; mildly reduced facial movement b/l of both upper &
lower quadrants; of clinic]al relevance, + b/l ptosis
Cranial nerve exam
CN IX/X Mildly reduced b/l palatal elevation; no notable hypernasality;
mildly hoarse vocal quality
CN XII Intact b/l
Laryngeal function exam VQ G1R1B0A0S1 Pitch range Perceptually WNL
IDDSI 2 N/A IDDSI 7 Multiple
PO trials swallows/bolus
IDDSI 4 Multiple swallows/bolus Standardized N/A
Notes N/A
A Clinical signs of chronic/progressive pharyngeal dysphagia of unknown etiology warranting thorough

dysphagia diagnostic battery. Cranial nerve exam findings are concerning for possible pathology the level of
peripheral cranial nerves, neuromuscular junction, or muscle; Neurologist evaluation is indicated. Pt is at low risk
for aspiration-related pulmonary complication, given good oral hygiene, good physical mobility, & presumed
immunocompetence.
P Instrumentation FEES & VFSS today

Diet recommendation Regular solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet, pending FEES/VFSS
results.
Risk management Control risk factors for aspiration PNA via (a) oral hygiene QID, & (b) increasing physical
mobility as feasible.
Specialist referrals Neurologist consult for dysphagia etiology
Ancillary tests Pending VFSS/FEES results

HPI 62yoM admitted w/ SOB. Hospital course complicated by reported “choking” event on solid food w/
subsequent dysphagia symptoms.
PMHx COPD, HIV
S Pt received alert, agitated. Sitting EOB and reporting SOB on nasal cannula.
O Predisposing dysphagia risk COPD, HIV

factors
chronic dysphagia
Precipitating dysphagia risk Acute “choking” event during hospital course w/ subsequent worsening
factors dysphagia symptoms
Vitals/lab
RR 24 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions Impaired; expectorating S/Z ratio N/A
secretions & suctioning
Laryngeal function exam via Yankauer
VQ Wet Pitch range N/A
MPT Declined 2/2 SOB Cough Perceptually WNL
Ice Effortful swallowing w/ IDDSI 5 N/A
grimacing & reported
odynophagia;
immediate coughing &
worsening in wet vocal
quality
PO trials
Notes Further trials deferred for instrumentation 2/2 severity of
dysphagia symptoms; pt agreeable to FEES
A Clinical signs of acute onset dysphagia of unknown etiology; cranial nerves intact & no neurological symptoms.
Secretion management is impaired. Given severity of clinical symptoms, pt does not appear safe for oral intake
at this time & requires immediate instrumental swallow study. Endoscopic exam is preferred to evaluate
secretion management.

Diet recommendation Strict NPO, pending FEES results
Risk management N/A
Ancillary tests N/A
Therapy Pending FEES Results

HPI 48yoM admitted w/ generalized weakness & hypotension
PMHx ESRD on HD, rejected kidney transplant
S Pt received alert, very pleasant for exam. Pt endorses 2 years of progressive dysphagia symptoms, including
difficulty “passing solid food”, coughing w/ foods & liquids, nasal regurgitation, & effortful/difficult swallowing.
Pt denies receiving any dysphagia workup.
O Predisposing dysphagia risk None known/diagnosed

factors
Clinical signs of possible Weight loss, PNA this year, progressive dysphagia symptoms x2 years
chronic dysphagia
Precipitating dysphagia risk Generalized weakness
factors
Vitals/labs
RR 14 WBCs Low
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Ice Multiple swallows/bolus, IDDSI 5 N/A
odynophagia
odynophagia
IDDSI 2 N/A IDDSI 7 Multiple
PO trials swallows/bolus,
odynophagia, globus
IDDSI 4 Multiple swallows/bolus, Standardized N/A
odynophagia, globus
Notes N/A
A Clinical signs of progressive pharyngoesophageal dysphagia (weight loss, PNA, progressive dysphagia
symptoms) of unknown etiology. Instrumental swallow study is indicated. As symptoms appear
chronic/progressive & respiratory status is stable, pt does appear safe to continue oral diet until swallow study
results.

Diet recommendation Continue Regular Solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet, per physician
order, until VFSS results
Ancillary tests N/A

HPI 69yoF admitted w/ left foot dog bite w/ cellulitis, on IV antibiotic. Developed acute dysphagia, hoarseness,
& stridor; developed aspiration PNA & required HFNC.
PMHx DM, obesity
S Pt received alert, cooperative for exam. Following commands well. Voice is severely hoarse & whispered.
Reports dysphagia/dysphonia began acutely yesterday.

factors
chronic dysphagia
Precipitating dysphagia risk Acute onset dysphagia/dysphonia/stridor after L foot dog bite; HFNC; PNA
factors
Vitals/labs
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to exclude CN X branch involvement due to dysphonia;
palatal elevation intact b/l
CN XII Intact b/l
VQ G3R3B3A3S3; phonation Pitch range N/A
breaks
PO trials
A Clinical signs of acute pharyngeal dysphagia & laryngeal dysfunction of unknown etiology; symptoms began
days after dog bite to foot w/ MRSA infection. In the context of pneumonia (suspected dysphagia-related
aspiration pneumonia) + HFNC requirement, pt appears at increased risk for further aspiration-associated
pulmonary complication. Endoscopic evaluation of swallowing is indicated prior to oral diet.
Diet recommendation NPO until FEES
Ancillary tests N/A

HPI 82yoF admitted w/ cough & congestion x2 weeks.
PMHx HTN, osteoarthritis, aortic regurgitation.
S Pt received alert, cooperative for exam. Pt appeared in mild distress (use of accessory muscles/increased WOB)
w/ severe expiratory wheezing/stridor, though vitals WNL. Pt endorses self-restricting her diet to purees for 1-2
years due to dysphagia symptoms.
O Predisposing dysphagia risk None known; however, EMR reports history of “dysphagia” on pureed diet
factors
Clinical signs of possible Weight loss/cachexia; EMR reports chronic “dysphagia” on pureed diet
chronic dysphagia (unknown etiology)
Precipitating dysphagia risk Tachypnea/increasing WOB
factors
Vitals/labs
RR 30-35 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam CN IX/X Unable to exclude CN X branch involvement due to dysphonia;
palatal elevation intact b/l
CN XII Intact b/l
Secretions Impaired; coughing S/Z ratio N/A
VQ G3R3B3A3S3, nearly Pitch range N/A
aphonic
PO trials
A Clinical signs of chronic/progressive pharyngeal dysphagia in pt presenting w/ severe expiratory

stridor/wheezing. Etiology of dysphagia is unknown. Endoscopic swallow study is indicated to observe
laryngeal/pharyngeal function related to swallowing. In the context of respiratory distress, pt does not appear
safe for an oral diet until FEES results.
Specialist referrals Pending FEES results
Ancillary tests N/A

HPI 59yoM admitted s/p blunt neck trauma (bus stopped suddenly & pt fell forward into seat in front of him);
neck imaging reveals hematoma at L aryepiglottic fold, tracheal deviation to right, mildly displaced fx of L
ala of thyroid cartilage, s/p emergent tracheotomy.
PMHx Asthma
S Pt received alert, cooperative, & oriented x4. Received w/ Shiley #8 cuffed tracheostomy tube (POD #2), cuff
inflated, on trach mask.
O Predisposing dysphagia risk N/A

factors
Clinical signs of possible N/A
chronic dysphagia
Precipitating dysphagia risk Blunt neck trauma w/ displaced fx of L thyroid cartilage + hematoma of L
factors aryeptiglottic fold, emergent tracheotomy
Temp WNL SpO2 97% on trach mask 6 L
Vitals/labs
RR 18 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
CN IX/X Unable to exclude CN X branch involvement; unable to assess
Cranial nerve exam vocal quality 2/2 trach (aphonia to digital occlusion, though
unknown if this represents large trach diameter, tracheal
pathology, or VCD).
CN XII Intact b/l
Secretions Impaired; copious S/Z ratio N/A
thick/bloody secretions
VQ Aphonic Pitch range N/A
MPT N/A Cough N/A
Ice + swallow response IDDSI 5 N/A
PO trials
A Likely pharyngeal dysphagia s/p blunt neck trauma w/ thyroid fracture & laryngeal hematoma, s/p emergent
tracheotomy. Instrumental swallow study is indicated to define swallow physiology; endoscopic exam preferred
to evaluate laryngeal anatomy/function. Given acuity of illness, pt does not appear safe for oral diet until FEES
results.
Diet recommendation NPO except ice chips
Specialist referrals ENT for flexible laryngoscopy
Ancillary tests N/A

HPI 57yoM admitted for total thyroidectomy & microlaryngoscopy by ENT for thyroid papillary metastatic
cancer. Pt endorses worsened post-operative dysphagia.
PMHx Thyroid papillary metastatic cancer, osteolytic R L1-L2 lumbar mass s/p laminectomy w/ resection and
spinal fusion with chronic wound, small anterior cervical osteophytes, mild pharyngoesophageal dysphagia
S Pt alert at time of exam, communicating verbally w/ notable dysphonia. Pt denies significant vocal quality
change post-operatively but does endorse worsened dysphagia symptoms, “I was choking on my saliva.”
Breathing comfortably on room air.
O Predisposing dysphagia risk Anterior cervical osteophytes, hx of likely esophageal dysmotility (identified on
factors Video Swallow last month) with secondary pharyngeal swallow changes
Confirmed hx of mild pharyngeal dysphagia (marked by reduced swallow
efficiency but spared swallow safety) that is presumably secondary in response
chronic dysphagia
to a suspected primary esophageal motility disorder, per Video Swallow
Precipitating dysphagia risk Total thyroidectomy yesterday
factors
Temp WNL SpO2 98% on room air
Vitals/lab
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam:
CN XII Intact b/l
Secretions Impaired; expectoration S/Z ratio 1.2
of copious secretions,
Laryngeal function exam suctioning, wet VQ
VQ G1R1B0A0S1; wet Pitch range Perceptually reduced
PO trials
A Clinical signs of acute-on-chronic pharyngoesophageal dysphagia, likely multifactorial r/t thyroidectomy +

chronic suspected esophageal dysmotility. Immediate endoscopic evaluation of swallowing is indicated to
evaluate vocal fold mobility & laryngeal vestibule closure for airway protection s/p thyroidectomy. Pt may be at
increased risk for dysphagia-related aspiration pneumonia, given his active malignancy, number of medical
morbidities, & decayed dentition.

Diet recommendation NPO except ice chips/small sips of water until FEES results
Risk management Oral hygiene q4h. Increase physical mobility as feasible.
Specialist referrals Outpatient Gastroenterologist for suspected chronic esophageal motility disorder
Ancillary tests Consider outpatient High Resolution Esophageal Manometry and/or Barium
Esophagram


HPI 55yoF admitted s/p ingestion of multiple unknown substances (presumed suicide attempt), found down w/
seizures. Currently encephalopathic & post-ictal.
PMHx HTN, depression
S Pt awake but drowsy for exam. Sustained alertness/attention briefly (x2-3 min intervals). Oriented x1. Delayed &
inconsistent verbal responses. Breathing comfortably on nasal cannula.

factors
chronic dysphagia
Precipitating dysphagia risk Encephalopathy, seizures
factors
Temp WNL SpO2 94% on nasal cannula
Vitals/labs
RR 18 WBCs WNL
CN V Intact b/l
CN VII Intact b/l
Cranial nerve exam
CN IX/X Intact b/l
CN XII Intact b/l
Secretions WNL S/Z ratio Unable to assess
Ice No s/s of aspiration IDDSI 5 No s/s of aspiration
PO trials
Notes Pt notably drowsy w/ solids in oral cavity & required intermittent
tactile stimulation to sustain alertness during mastication of solid
bolus
A Clinical signs of acute oral phase dysphagia r/t encephalopathy & post-ictal state. No evidence of
pharyngeal/laryngeal dysfunction at bedside. Temporary solid diet modification appears indicated while pt’s
mental status remains altered; pt also requires feeding assistance to prevent dysphagia-related complication.
Swallow prognosis is excellent for spontaneous resolution of dysphagia symptoms, pending improved LOA.
Diet recommendation IDDSI 5/0 diet.
Risk management 1:1 feeding assistance. Feed only when alert/upright. Check oral cavity for pocketed
food after meals. Discontinue diet if signs of aspiration or if decline in mental status.
Ancillary tests N/A
Therapy SLP will f/u x1-2 to advance solid diet as pt’s mental status improves
Goal Pt will tolerate least-restrictive PO diet without acute dysphagia-related aspiration PNA.

HPI 34yoM admitted s/p GSW to L neck (Zone 1) w/ subcutaneous emphysema & C7 transverse process
fracture (non-operative). Endotracheal intubation x4 days.
PMHx ESRD on HD
S Pt alert, pleasant for exam in Fowler’s position. Endorses significant L neck/shoulder pain; repositioned pt &
informed RN for medication management.

factors
chronic dysphagia
Precipitating dysphagia risk GSW to L neck, endotracheal intubation x4 days
factors
Temp Febrile SpO2 96% on nasal cannula
Vitals/labs
RR 18 WBCs Elevated
CN V Intact b/l
CN VII Intact b/l
CN IX/X Unable to exclude CN X branch involvement 2/2 significant
Cranial nerve exam
dysphonia; of relevance, significant fullness of L neck, inferolateral
to L cricoid cartilage, at area of GSW entry
CN XII Intact b/l
Secretions Impaired; suctioning & S/Z ratio 1.5
coughing; copious
Laryngeal function exam secretion production
VQ G2R2B0A1S2 Pitch range Perceptually reduced
Ice Cough IDDSI 5 N/A
PO trials
A Clinical signs of pharyngeal dysphagia & laryngeal dysfunction in pt w/ penetrating neck injury & 4-day
endotracheal intubation. High risk for vocal fold dysfunction r/t direct trauma from ETT and/or possible L
RLN/SLN injury from L penetrating neck injury. Both videofluoroscopic & endoscopic swallow studies are
indicated to fully evaluate the integrity/physiology of the pharynx/cervical esophagus (including exclusion of
extravasation) & to evaluate vocal fold mobility. Given pt’s acuity of illness, pt does not appear safe for oral
intake until instrumental study results.
P Instrumentation VFSS & FEES today

Diet recommendation NPO except ice chips, pending VFSS & FEES results
Specialist referrals Pending VFSS & FEES results
Ancillary tests Pending VFSS & FEES results
Therapy SLP will f/u x5/week for swallow rehabilitation
Goal Pt will participate in VFSS/FEES to define swallow physiology & therapy plan.
Videofluoroscopic Swallow Studies

Videofluoroscopic Swallow Study 1
PMHx Mediastinal tumor & possible vocal fold paralysis
S Pt alert, very pleasant for exam. Following commands with ease. Breathing comfortably, however, 1 instance of
stridor (<2 secs) noted.
swallow function.
Anatomic view under WNL
fluoroscopy
Lip closure WNL
Tongue control WNL
Oral phase findings Bolus preparation WNL
Bolus transport WNL
Oral residue None
Initiation of swallow WNL
Velar elevation WNL
Laryngeal elevation WNL
Anterior hyoid excursion WNL
Epiglottic movement WNL
Pharyngeal phase
Laryngeal vestibule closure WNL
findings
Pharyngeal stripping wave WNL
Pharyngeal contraction WNL
PES opening Mildly impaired
BOT retraction WNL
Pharyngeal residue None
Esophageal clearance Abnormal esophageal screening in the AP view; the
cervical esophagus deviated significantly to the left
(presumably r/t known R-sided
Esophageal findings thyroid/neck/mediastinal mass), however, there was
no overt mechanical obstruction; there was some
mild retained contrast in the cervical-thoracic
esophagus
Thin liquid 1
Mildly-thick liquid N/A
Moderately-thick liquid N/A
Pudding 1
Solid 1
Compensatory Swallow N/A
Strategies

Dysphagia Outcome and 5
A Mild pharyngoesophageal dysphagia 2/2 mechanical deviation of the upper esophageal sphincter/cervical
esophagus (presumably by known neck/mediastinal mass). No significant obstruction to the upper esophageal
lumen. No airway invasion. Both swallow safety & efficiency appear sufficient to support for full oral diet. Pt is
unlikely to benefit from swallow rehabilitation at this time, however, may benefit from post-surgical swallow
rehabilitation.
P Diet recommendation No diet restrictions from SLP standpoint. Solid diet modification per pt preference. Pt
requests Soft & Bite-Sized (IDDSI 6)/Thin Liquid (IDDSI Level 0) diet at this time.
Risk management Aspiration/reflux precautions: small bites of solid food, upright position for meals
Specialist referrals Cardiothoracic surgery evaluation for dysphagia r/t mediastinal/neck mass
Ancillary tests ENT laryngoscopy to evaluate vocal fold mobility & upper airway patency
Therapy SLP will f/u for patient education. If pt is a surgical candidate, may benefit from post-
surgical swallow rehabilitation.
Goal Patient will perform verbal teachback of recommendations for aspiration/reflux
precautions. Direct swallow rehabilitation program pending results of surgical
evaluation.
Follow-up exam N/A

HPI 55yoF seen for outpatient VFSS under order from ENT. Pt endorses globus sensation to solids & sensation
of regurgitation of food/liquid, which is reportedly progressive x2 years.
PMHx Tinnitus (progressive x5 years)
S Pt alert, very pleasant for exam. Endorsed globus sensation at sternal notch during exam.
swallow function.
fluoroscopy
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
Pharyngeal phase Pharyngeal stripping wave WNL
findings Pharyngeal contraction WNL
PES opening Adequate extent of PES relaxation, however, reduced
duration of relaxation (i.e., premature closure of PES
w/ trace bolus remaining)
BOT retraction WNL
Pharyngeal residue Trace PES residue; pt endorsed globus sensation at
sternal notch while trace PES residue observed
Esophageal clearance Abnormal esophageal screening w/ + retained
Esophageal findings contrast in mid-distal esophagus w/ some retrograde
bolus flow within the esophageal lumen
Thin liquid 1
Pudding 1
Solid 1
Strategies

A Functional oropharyngeal swallow but abnormal esophageal screening. Suspect primary esophageal dysphagia
warranting gastroenterology evaluation. Oropharyngeal swallow safety & efficiency are preserved. No diet
modification or behavioral swallow therapy is indicated.
P Diet recommendation Regular Solid (IDDSI 7)/Thin Liquid (IDDSI Level 0) diet.
Risk management Behavioral reflux precautions
Specialist referrals Gastroenterology evaluation for suspected gastroesophageal reflux and/or esophageal
dysmotility.
Ancillary tests Consider Barium Esophagram, High Resolution Esophageal Manometry, and/or 24-
hour pH monitoring.
Therapy No SLP behavioral swallow tx indicated at this time.
Goal N/A
Follow-up exam N/A

HPI 16yoF admitted s/p GSW to face/neck s/p emergent trach & closed reduction of mandible
PMHx None
S Pt alert & cooperative for evaluation. Tracheostomy tube (Shiley #8 cuffed, cuff deflated) in situ POD #7 (not a
candidate for speaking valve use 2/2 absent upper airway patency); on tracheostomy mask for exam.
swallow function.
Anatomic view under Post-surgical changes w/ jaw wiring noted; radiopaque foreign body c/w shrapnel
fluoroscopy at level of the mandible w/ significant submental fullness; tracheostomy tube in situ.
Isovue-270 diluted (thin liquid), Varibar thin liquid, Varibar nectar (mildly-thick)
liquid, Varibar thin honey (moderately-thick) liquid, Varibar pudding; boluses were
P.O. contrast trials administered via tsp & syringe to lateral sulcus 2/2 mandibular fixation; all boluses
were 1-5 mL volumes; larger volumes not administered for pt’s safety, given absent
airway patency for cough
Lip closure WNL
Tongue control Moderately impaired
Oral phase findings Bolus preparation N/A; mandibular fixation
Bolus transport Severely impaired
Oral residue Mild-moderate
Initiation of swallow Mildly delayed
Velar elevation WNL
Epiglottic movement Moderately impaired
Pharyngeal phase Laryngeal vestibule closure WNL
findings Pharyngeal stripping wave Mildly impaired
Pharyngeal contraction Mildly impaired b/l
PES opening WNL
BOT retraction Moderately impaired
Pharyngeal residue Moderate vallecular residue relative to bolus volume
administered, most significant w/ pudding
Esophageal findings Esophageal clearance Not completed due to limited contrast volume
Thin liquid 8; inconsistent aspiration before the swallow (due to
delayed swallow trigger) & after the swallow (from
8-point Penetration- vallecular residue/impaired BOTR)
Aspiration Scale (PAS) Mildly-thick liquid 8; inconsistent aspiration before the swallow (due to
vallecular residue/impaired BOTR)

Moderately-thick liquid 8; inconsistent aspiration before the swallow (due to
vallecular residue/impaired BOTR)
Pudding 1
Solid N/A
Compensatory Swallow Unable to perform volitional coughs due to absent upper airway patency; chin tuck
Strategies posture limited by presence of tracheostomy tube; cued dry swallows were
successful in reducing pharyngeal residue but not eliminating aspiration of residue
post-swallow
A Severe oropharyngeal dysphagia of traumatic (penetrating oropharyngeal injury) & iatrogenic (tracheostomy
tube size precludes upper airway patency, mandibular fixation) etiology. Safety & efficiency of swallow are not
adequate to support oral nutrition/hydration at this time. Swallow prognosis is excellent, pending improved
upper airway patency for laryngotracheal sensation & cough. Pt’s swallow function will likely improve s/p
tracheostomy tube downsize and/or decannulation, when medically feasible.
P Diet recommendation NPO with short-term enteral feeding route (e.g., Dobhoff tube).
Risk management Control risk factors for aspiration PNA via (a) oral hygiene QID, (b) increasing physical
mobility as medically feasible
Specialist referrals F/u w/ ENT for tracheostomy tube downsize to Shiley #6 cuffless/fenestrated, when
medically feasible
Ancillary tests N/A
Therapy Continue swallow/voice rehabilitation with SLP x5/week.
Goal Pt will improve BOT retraction & pharyngeal wall contraction via Effortful Swallows x50
per tx
Follow-up exam Repeat instrumental swallow study (VFSS vs. FEES) after tracheostomy tube downsize

HPI 16yoF admitted s/p GSW to face/neck s/p emergent trach & closed reduction of mandible, s/p trach
downsize
PMHx None
S Pt alert & cooperative for repeat evaluation. Tracheostomy tube (Shiley #6 cuffless/fenestrated) in situ POD #9
w/ Passy-Muir valve (PMV) in place; on tracheostomy mask for exam.
swallow function.
Anatomic view under Post-surgical changes w/ jaw wiring noted; radiopaque foreign body c/w shrapnel
fluoroscopy at level of the mandible w/ significant submental fullness; tracheostomy tube in situ
Varibar thin liquid, Varibar nectar (mildly-thick) liquid, Varibar thin honey
P.O. barium contrast trials (moderately-thick) liquid, Varibar pudding; trials via tsp, syringe, & straw 2/2
mandibular fixation
Lip closure WNL
Tongue control Mildly impaired
Bolus preparation N/A; mandibular fixation
Oral phase findings
Bolus transport Mildly impaired, which worsened w/ increased
viscosity
Oral residue Mild
Velar elevation WNL
Epiglottic movement Mildly impaired
findings Pharyngeal stripping wave WNL
PES opening WNL
BOT retraction Mildly reduced
Pharyngeal residue Mild vallecular residue, cleared by reflexive dry
swallows
Esophageal findings Esophageal clearance WNL
Thin liquid 1
Mildly-thick liquid 1
Moderately-thick liquid 1
Pudding 1
Solid N/A; mandibular fixation
Compensatory Swallow Reflexive dry swallows were effective in clearing oropharyngeal residue
Strategies

A Mild oropharyngeal dysphagia of traumatic (penetrating oropharyngeal injury) & iatrogenic (tracheostomy tube,
mandibular fixation) etiology, which represents significant improvement in swallow physiology since
comparison exam 2 days prior. Improved swallow function is attributable to upper airway patency s/p
tracheostomy tube downsize, now w/ PMV in place. Safety & efficiency of swallow are adequate for oral
nutrition/hydration, though pt is at increased risk for malnutrition due to mandibular fixation.
P Diet recommendation Puree (IDDSI Level 4) vs. Liquidized (IDDSI Level 3) solid diet, per pt preference. Thin
Liquid (IDDSI 0) liquid diet. ADAT once mandibular fixation removed, under guidance
from physician.
Risk management Aspiration precautions: Puree or liquidized food items via tsp and/or syringe to lateral
sulcus. Don PMV for all p.o. intake. Oral hygiene after meals.
Specialist referrals Dietitian evaluation to ensure adequate oral nutrition, given restricted solid diet
Ancillary tests N/A
Therapy Continue swallow/voice rehabilitation with SLP
Goal Pt will improve BOT retraction via Effortful Swallows x50 per tx
Follow-up exam N/A

HPI 69yoM admitted w/ shock, respiratory failure, AMS, PNA. Endotracheal intubation x1 day.
PMHx CHF, CAD, HTN, BPH, MI, MVA w/ chronic L frontal SDH
S Pt alert, confused but following commands during exam.
swallow function.
fluoroscopy
P.O. barium contrast trials Varibar thin liquid, Varibar nectar (mildly-thick) liquid, Varibar pudding
Lip closure Mildly impaired
Bolus preparation N/A; solids deferred 2/2 pt’s lethargy & WOB
Oral phase findings
combined w/ absent dentition
Bolus transport Mildly impaired
Oral residue Mild
Velar elevation WNL
Laryngeal elevation Moderately impaired
Anterior hyoid excursion Moderately impaired
Laryngeal vestibule closure Moderately impaired
Pharyngeal phase Pharyngeal stripping wave Mildly impaired
findings Pharyngeal contraction Mildly impaired b/l
Pharyngeal residue Mild-moderate vallecular/pharyngeal wall/pyriform
residue, which increased w/ increased viscosity; pt
demonstrated spontaneous swallows in response to
pharyngeal residue
Thin liquid 8; consistent aspiration of thin liquid during the
swallow 2/2 impaired LVC
Mildly-thick liquid 7; 1 instance of small-volume aspiration of mildly-
thick liquid during the swallow 2/2 impaired LVC only
during very large/uncontrolled cup drinking of
mildly-thick liquid
Pudding 1
Solid N/A

Compensatory Swallow Small/controlled boluses of mildly-thick liquids were successful in eliminating
Strategies airway invasion; unable to execute complex commands for chin tuck posture or
breath hold maneuvers at this time; reflexive dry swallows were effective at clearing
oropharyngeal residue

A Moderate oropharyngeal dysphagia resulting in reduced airway protection & swallow efficiency. Dysphagia is
likely acute r/t endotracheal intubation + septic encephalopathy, though unable to exclude
chronic/undiagnosed dysphagia (r/t chronic L frontal SDH) as precipitating factor for admission w/ PNA. Given
pt’s critical illness, poor oral hygiene, reduced physical mobility, & dystussia, pt is at increased risk for
dysphagia-related aspiration PNA; temporary diet modification is indicated.
P Diet recommendation Puree (IDDSI Level 4)/Mildly-Thick Liquid (IDDSI Level 2) diet. Meds crushed w/ puree.
Risk management Aspiration precautions: 1:1 feeding assist, upright position, small/controlled cup sips of
mildly-thick liquid, avoid thin liquids. Control risk factors for aspiration PNA via (a)
increasing oral hygiene to QID & (b) increasing physical mobility as medically feasible
Specialist referrals Dietitian evaluation to ensure adequate oral nutrition, given restricted diet.
Ancillary tests N/A
Therapy SLP following x5/week for swallow rehabilitation
Goal Pt will improve BOT retraction & pharyngeal wall contraction via Effortful Swallows x50
per tx. Pt will improve LVC via Effortful Pitch Glide x50 per tx. Pt will improve PES
relaxation via CTAR x50 per tx. Pt will improve cough strength for airway protection via
EMST w/ MEP 30 cm H2O.
Follow-up exam Repeat instrumental swallow study in approximately 3-7 days, pending clinical
progress.

HPI 42yoF admitted w/ LUE weakness, chest pain, SOB, & “hot flashes.” Brain imaging unremarkable.
PMHx None
S Pt alert, cooperative for exam. Coughing significantly throughout exam, holding her chest & appearing in
distress (despite absent aspiration events; see below).
swallow function.
fluoroscopy
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
findings Pharyngeal stripping wave WNL
PES opening WNL
BOT retraction WNL
Pharyngeal residue None; multiple swallows per bolus, despite no
significant oropharyngeal residue
Esophageal clearance Abnormal; mild retained contrast in distal esophagus
Esophageal findings
w/ notable retrograde flow
Thin liquid 1
Pudding 1
Solid 1
Strategies

A Normal oropharyngeal swallow, despite overt dysphagia symptoms throughout exam. Abnormal esophageal
screening marked by retained contrast and retrograde bolus flow concerning for possible esophageal
dysmotility, warranting Gastroenterology evaluation.
P Diet recommendation Regular solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet.
Risk management Behavioral reflux precautions, including upright position during + 90 mins after meals.
Specialist referrals Gastroenterology evaluation for suspected gastroesophageal reflux and/or esophageal
dysmotility.
Ancillary tests Consider Barium Esophagram, high resolution esophageal manometry, and/or 24-hour
pH monitoring.
Therapy SLP will sign off, as oropharyngeal swallow WNL.
Goal N/A
Follow-up exam N/A

HPI 66yoM admitted w/ cough, sore throat, dyspnea, dysphagia x1 month. XR & US Neck unremarkable.
Pending CT Head & CT Soft Tissue Neck.
PMHx Hyperthyroidism s/p “ablation” (not confirmed)
S Pt alert, cooperative for exam. Continues to report “choking” sensation with eating & coughing with drinking. Pt
also endorses reflux symptoms.
swallow function.
Anatomic view under Small bony protrusion at C3-C4 c/w anterior cervical osteophyte
fluoroscopy
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
Pharyngeal phase
findings
Pharyngeal stripping wave Mildly impaired
PES opening WNL
BOT retraction WNL
Pharyngeal residue Mild pharyngeal wall/pyriform residue
Esophageal clearance Abnormal; large amount of retained contrast in distal
Esophageal findings esophagus w/ semisolid bolus, which cleared only
with liquid wash
Thin liquid 1
Pudding 1
Solid 1
Strategies

A Functional oropharyngeal swallow but abnormal esophageal screening, c/w suspected esophageal dysphagia
warranting GI workup.
Risk management Behavioral reflux precautions, including upright position during + 90 mins after meals.
Specialist referrals Gastroenterology evaluation for suspected esophageal dysphagia. ENT & outpatient
SLP due to chronic hoarseness.
Ancillary tests Consider Barium Esophagram and/or High Resolution Esophageal Manometry.
Consider flexible laryngoscopy w/ ENT. Consider videostroboscopy w/ SLP.
Therapy Outpatient voice evaluation/therapy w/ SLP, pending flexible laryngoscopy and/or
videostroboscopy results.
Goal N/A
Follow-up exam N/A

HPI 67yoM admitted w/ LBP, BLE/BUE weakness, falls. Cervical & lumbar central canal stenosis s/p C3-C6 ACDF
& C2-C6 PCDF
PMHx DM, peripheral neuropathy, CVA
S Pt alert, cooperative for exam. Soft cervical collar in place for exam.
O Videofluoroscopic Swallow Study was conducted in the lateral projection by Speech-Language Pathologist
Kelsey Day, in collaboration with Radiologist Dr. Fluoro, to evaluate oropharyngeal swallow function. Unable to
obtain AP view due to positioning limitations with pt’s body habitus & reduced physical mobility.
Anatomic view under Hardware at C3-C6 anterior spine & C2-C6 posterior spine; + thickening of the
fluoroscopy prevertebral soft tissue, anterior to the cervical hardware
Varibar thin liquid, Varibar nectar (mildly-thick) liquid, Varibar pudding, solid
P.O. barium contrast trials
coated in Varibar pudding
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
Laryngeal vestibule closure Functional vs. mildly impaired
Pharyngeal phase
Pharyngeal stripping wave Moderately impaired
findings
Pharyngeal contraction Unable to assess in AP view
PES opening Moderately impaired
BOT retraction Mildly impaired
Pharyngeal residue Moderate vallecular, pharyngeal wall, & pyriform
sinus residue, which increased w/ increased viscosity;
+ spontaneous swallows of pharyngeal residue
Esophageal clearance Unable to complete 2/2 poor positioning, pt’s body
Esophageal findings
habitus, + reduced physical mobility
Thin liquid 4; consistent transient penetration of thin liquids to
the vocal folds during the swallow 2/2 reduced LVC
8-point Penetration- Mildly-thick liquid 1
Aspiration Scale (PAS) Moderately-thick liquid N/A
Pudding 1
Solid 1
Compensatory Swallow Pt independently demonstrated multiple swallows per bolus (i.e., spontaneous
Strategies swallows) to reduce pharyngeal residue; alternating pudding/solid with thin liquid
wash was successful in reducing but not eliminating pharyngeal residue

A Moderate pharyngeal dysphagia 2/2 ACDF marked by reduced swallow efficiency but preserved swallow safety.
Temporary diet modification appears indicated to reduce risk for dysphagia-related complication. Pt appears to
be at increased risk for malnutrition/dehydration, but low risk for aspiration pneumonia. Pt appears to be a good
candidate for exercise-based swallow rehabilitation as adjunct to medical management of prevertebral soft
tissue edema. Swallow prognosis is good, pending time for spontaneous improvement + swallow rehabilitation.
P Diet recommendation Puree (IDDSI Level 4)/Thin Liquid (IDDSI Level 0) diet. Meds crushed in puree.
Risk management Aspiration precautions: upright position, small sips/bites, alternate liquid/solid, slow
rate to allow for spontaneous swallows. Control risk factors for aspiration pneumonia
via (a) oral hygiene QID, & (b) Physical Therapy evaluation to improve physical mobility
Specialist referrals Dietitian evaluation due to risk for malnutrition/dehydration
Ancillary tests N/A
Therapy Exercise-based swallow rehabilitation w/ SLP x3/week
Goal Pt will improve BOT retraction & pharyngeal wall contraction via Effortful Swallow
x50/tx; Pt will improve pharyngeal wall contraction via Effortful Pitch Glide x50/tx
Follow-up exam Follow-up instrumental swallow study in 2-4 weeks, pending improved clinical
symptoms, to evaluate progress in tx and ongoing need for diet modification.

HPI 62yoM admitted w/ SOB, hypoxia, respiratory distress, sepsis, & vomiting event; presumable “aspiration
pneumonia.” Physician reports current consideration for PEG placement 2/2 aspiration PNA. Pt w/ hx of
mild oropharyngeal dysphagia per VFSS last month (s/p CVA), which revealed no airway invasion &
recommended minced & moist solid/thin liquid diet. SNF records state pt on puree/mildly-thick liquid diet
s/p hospital d/c, though no evidence of repeat instrumental swallow study; phoned SNF for clarification,
awaiting callback.
PMHx CVA w/ residual aphasia, dementia, DM, aspiration PNA, epilepsy
S Pt awake, slightly lethargic, following some commands w/ limited verbal output during exam. Pt’s posturing
yielded technically difficult exam w/ limited view of the larynx/trachea; view improved during laryngeal
elevation. View slightly oblique 2/2 pt motion.
obtain AP view due to positioning limitations with pt’s body habitus & reduced physical mobility.
Anatomic view under Partially obstructed view of the inferior hypopharynx, larynx, & trachea 2/2 pt’s
fluoroscopy posture; view was improved during laryngeal elevation
P.O. barium contrast trials Varibar thin liquid, Varibar pudding
Oral phase findings Bolus preparation N/A due to oral stage deficits & AMS
Oral residue Mild
Velar elevation WNL
Pharyngeal phase
findings
PES opening WNL
Esophageal clearance Grossly unremarkable in the lateral view; very trace
Esophageal findings
retrograde flow of contrast in the distal esophagus
Thin liquid 1
Pudding 1
Solid N/A
Compensatory Swallow Unable to trial 2/2 AMS
Strategies
A Mild oropharyngeal dysphagia marked by mildly impaired efficiency of swallowing but preserved swallow
safety. No airway invasion w/ any trial. Temporary solid diet modification is indicated 2/2 pt’s AMS, likely
transient r/t sepsis. Aspiration pneumonia appears unlikely r/t oropharyngeal dysphagia, given 2 VFSS this year
with absent aspiration. In the context of epilepsy & witnessed vomiting event, consider aspiration of gastric
content. Long-term enteral feeding route (e.g., PEG) may exacerbate aspiration of gastric content.
Risk management Aspiration/reflux precautions: upright position during + 1 hour after meals, slow rate of
intake. Control risk factors for aspiration pneumonia via (a) oral hygiene QID, & (b)
increasing physical mobility as tolerated
Specialist referrals GI consult for management of suspected aspiration of gastric content
Ancillary tests N/A
Therapy SLP will f/u x1-2 in acute care setting to advance solid diet texture to baseline as
mentation improves
complication.
Follow-up exam N/A

HPI 95yoF admitted w/ AMS 2/2 + acute R posterior frontal/parietal/temporal CVA + UTI/sepsis + colitis.
PMHx CVAs, b/l blindness, dementia
S Pt awake but lethargic; alertness improved to multimodal stim. Participated w/ eyes closed 2/2 chronic
blindness. Pt did not follow any commands.
swallow function.
fluoroscopy
(moderately-thick liquid), Varibar pudding
Lip closure Profoundly impaired
Tongue control Profoundly impaired
Bolus preparation N/A due to severity of oral stage deficits
Bolus transport Profoundly impaired; required manual posterior head
Oral phase findings
tilt positioning to facilitate passive AP transit w/ thin
liquid & mildly-thick liquid; unable to achieve AP
transit of moderately-thick liquid or pudding
Oral residue Severe
Initiation of swallow Severely delayed
Velar elevation WNL
Anterior hyoid excursion Moderately impaired
Epiglottic movement Severely impaired
Pharyngeal phase
Laryngeal vestibule closure Severely impaired
findings
Pharyngeal stripping wave Moderately impaired
Pharyngeal contraction Moderately impaired, L worse than R
Pharyngeal residue Moderate
Esophageal findings Esophageal clearance N/A
Thin liquid 7; aspiration of thin liquid during & after the swallow
2/2 impaired LVC + significant pharyngeal residue
from the aforementioned deficits
Mildly-thick liquid 8; aspiration of mildly-thick liquid during & after the
swallow 2/2 impaired LVC + significant pharyngeal
residue from the aforementioned deficits
Moderately-thick liquid Contrast did not reach pharynx for assessment
Pudding Contrast did not reach pharynx for assessment
Solid N/A

Compensatory Swallow Pt unable to follow any commands; trialed posterior head tilt (w/ manual assist) to
Strategies facilitate AP transit of moderately-thick liquid & pudding, which was unsuccessful
A Severe oropharyngeal dysphagia, multifactorial r/t acute + chronic bilateral CVAs + dementia + sepsis 2/2
UTI/colitis. Both safety and efficiency of swallowing are severely impaired. Pt is unsafe for any oral intake at this
time. Swallow prognosis appears guarded, given pt’s profound cognitive-communication disorder, medical
comorbidities, and age. Pt is unlikely to participate in direct swallow therapy, however, there is potential for
some spontaneous swallow progress (in the context of acute CVA + sepsis) over the next several days/weeks.
P Diet recommendation NPO except ice chips or ½ tsps water for swallow stimulation. Short-term enteral
feeding route (e.g., NGT) x3-7 days. If pt unsafe for oral diet after repeat VFSS, consider
palliative care or hospice evaluation (given pt’s advanced age & guarded swallow
prognosis). Long-term enteral feeding route (E.g., PEG) is likely contraindicated in 95-
year-old pt w/ advanced & multiple medical morbidities.
Risk management Control risk factors for aspiration pneumonia via increasing oral hygiene to QID
Ancillary tests N/A
Therapy SLP following x3/week to monitor spontaneous progress in swallow function as mental
status & acuity of illness improve
Goal Pt will participate in repeat VFSS in 3-7 days to evaluate spontaneous swallow progress
& determine long-term nutrition/hydration POC.
Follow-up exam Repeat VSS in 3-7 days to evaluate potential spontaneous swallow progress.

HPI 53yoM admitted s/p MVA w/ ALOC, found down w/ closed head injury/TBI (SAH/SDH), pulmonary
contusion, rib fractures. Hospital course involved L frontoparietotemporal craniectomy w/ decompression
of L hemisphere & evacuation of L EDH. Endotracheal intubation x15 days s/p trach.
PMHx Drug abuse
S Pt alert, confused but cooperative w/ encouragement. Significantly restless, which limited view of the oral cavity
due to patient motion. Pt w/ trach & PMV in place, breathing comfortably on trach mask.
swallow function.
Anatomic view under Tracheostomy tube (Shiley #6 cuffless/fenestrated) in place; of clinical relevance,
fluoroscopy PMV in place for exam; pt on trach mask for O2 delivery
P.O. barium contrast trials Varibar thin liquid, Varibar pudding
Lip closure Moderately impaired
Tongue control Severely impaired
Bolus preparation N/A due to severity of oral stage deficits
Bolus transport Severely impaired; pt required thin liquid wash to
Oral phase findings
intermittently elicit AP transit of pudding
Oral residue Moderate-severe, which increased w/ pudding
compared to thin liquid; pt required thin liquid wash
to clear residue from oral cavity
Velar elevation WNL
Pharyngeal phase Laryngeal vestibule closure Mildly impaired
Pharyngeal contraction Mildly impaired, R worse than L
PES opening WNL
Pharyngeal residue Mild-moderate w/ pudding, which was largely
cleared w/ thin liquid
Thin liquid 4; consistent penetration of thin liquid during & after
the swallow to the level of the vocal folds, however,
no aspiration was elicited
Pudding 1
Solid N/A
Compensatory Swallow Alternating thin liquid & pudding was successful in eliciting AP transit of pudding &
Strategies reducing oropharyngeal residue from pudding

A Moderate oropharyngeal dysphagia 2/2 TBI and endotracheal intubation, resulting in markedly impaired
swallow efficiency but preserved swallow safety. There appears to be increased risk for malnutrition/dehydration
w/ oral intake alone, however, no significant risk for aspiration-related pulmonary complication. Of clinical
relevance, these results are valid only w/ use of PMV in place on tracheostomy. Pt will benefit from
compensation (via diet modification, feeding assistance, & use of compensatory strategies) as adjunct to
exercise-based swallow rehabilitation.
Risk management Aspiration precautions/compensatory swallow strategies: 1:1 feeding assistance, don
PMV for all oral intake, alternate liquid/puree, check oral cavity for pocketed food after
meals. Control risk factors for aspiration pneumonia via (a) increasing oral hygiene to
QID, & (b) increasing physical mobility as medically feasible.
Specialist referrals Dietitian evaluation 2/2 risk for malnutrition/dehydration
Ancillary tests N/A
Therapy SLP following x5/week for exercise-based swallow rehabilitation
Goal Pt will improve BOT retraction & pharyngeal wall contraction via Effortful Swallows
x50/tx. Pt will improve pharyngeal wall contraction & laryngeal vestibule closure via
Effortful Pitch Glide x50/tx.
Follow-up exam Plan for repeat VFSS in 2-4 weeks, pending clinical progress.

HPI 30yoM admitted w/ oropharyngeal abscess, epiglottitis, dysphagia, dysphonia, & airway compromise s/p
emergent trach
PMHx None
S Pt alert, very pleasant for exam. Expressed gratitude for care. Study conducted w/ tracheostomy tube in place,
breathing comfortably on trach mask, no PMV 2/2 poor upper airway patency.
swallow function.
Anatomic view under Tracheostomy tube (Shiley #8 cuffed, cuff deflated) in place; of clinical relevance,
fluoroscopy PMV not utilized for exam 2/2 poor upper airway patency; NGT in place for exam
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
Pharyngeal phase
findings
PES opening WNL
BOT retraction WNL
Thin liquid 2; transient penetration of thin liquid during the
swallow, which is normal
8-point Penetration- Mildly-thick liquid N/A
Pudding 1
Solid 1
Strategies

A Normal oropharyngeal swallow, despite oropharyngeal abscess s/p emergent tracheotomy.
P Diet recommendation Regular (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet. Advise NGT removal.
Risk management N/A
Specialist referrals F/u w/ ENT for tracheostomy tube downsize to Shiley #6 cuffless, when medically
feasible, to improve upper airway patency for both swallowing & phonation
Ancillary tests N/A
Therapy SLP will d/c swallow goal, as swallow goal met. Will continue voice tx.
Goal N/A
Follow-up exam N/A

HPI 80yoM admitted w/ respiratory failure, PNA s/p endotracheal intubation x5 days.
PMHx COPD (home O2 dependent), CHF, HTN, pacemaker
S Pt alert, very pleasant for exam. Eager to eat/drink by mouth today. Accompanied to radiology by ICU RN for
monitoring.
swallow function.
Massive bony projections of the entire anterior cervical spine, which were confluent
Anatomic view under & most prominent at C2-C3 & C3-C4, c/w presumable confluent anterior cervical
fluoroscopy osteophytes; anterior bony projections nearly contacted the base of tongue at rest;
see Radiologist’s report for details
Lip closure WNL
Tongue control WNL
Bolus preparation N/A; solids deferred due to absent dentition
Oral phase findings
combined w/ severity of pharyngeal phase deficits
Bolus transport WNL
Oral residue None
Velar elevation WNL
Pharyngeal phase Pharyngeal stripping wave Moderately impaired
findings Pharyngeal contraction Moderately impaired b/l
Pharyngeal residue Moderate-severe vallecular residue, which increased
w/ increased viscosity; poor sensation of pharyngeal
residue requiring cued dry swallows, which were
effective in reducing pharyngeal residue
Thin liquid 7; gross aspiration of thin liquid during the swallow
2/2 impaired LVC
Mildly-thick liquid 6; inconsistent penetration of mildly-thick liquid
during the swallow 2/2 impaired LVC w/ 2 small-
volume aspiration events that were transient/cleared
spontaneously w/ cough & swallow

Pudding 1
Solid N/A
Compensatory Swallow Chin tuck posture was effective in reducing vallecular residue w/ pudding & mildly-
Strategies thick liquid; alternating pudding & mildly-thick liquid was successful in reducing
pharyngeal residue; cued dry swallows were effective in reducing pharyngeal
residue; cued coughs were effective in ejecting some penetrated contrast from the
larynx
A Moderate pharyngeal dysphagia resulting in both impaired safety & efficiency of swallow physiology; however,
pt appears safe for p.o. intake w/ total use of diet modification & compensatory strategies. Risk for dysphagia-
related pulmonary complication & malnutrition/dehydration appear increased 2/2 pt’s age & deconditioning.
Suspect dysphagia is chronic r/t massive/confluent anterior cervical osteophytes + COPD, although acutely
exacerbated by recent endotracheal intubation. It is probable that pt’s multiple recent respiratory
failures/pneumonias are related, at least in part, to pt’s dysphagia. Swallow prognosis is fair for some
improvement w/ swallow rehabilitation.
P Diet recommendation Puree (IDDSI Level 4)/Mildly-Thick Liquid (IDDSI Level 2) diet. Meds crushed in puree.
Risk management Aspiration precautions/compensatory swallow strategies: 1:1 feeding assist, chin tuck
posture, alternate puree & mildly-thick liquid, encourage double swallows, encourage
intermittent coughing during meals. Control risk factors for aspiration pneumonia via
(a) oral hygiene QID, (b) increasing physical mobility as tolerated, including after meals,
& (c) encourage cough strength training after meals for pulmonary hygiene.
Specialist referrals Dietitian evaluation 2/2 risk for malnutrition/dehydration
Ancillary tests N/A
Therapy Exercise-based swallow rehabilitation x5/week to target cough strength, LVC, &
pharyngeal contraction; plan for family training tomorrow at 15:00
x50/tx. Pt will improve LVC & pharyngeal wall contraction via Effortful Pitch Glides
x50/tx. Pt will improve PES relaxation via CTAR x50/tx. Pt will improve functional reserve
for cough strength/airway protection against aspiration via EMT w/ MEP 100 cm H2O.
Follow-up exam Repeat VFSS in 4 weeks to evaluate progress in swallow tx & safety to advance
solid/liquid diet textures

HPI 97yoM admitted w/ SOB & respiratory failure 2/2 bibasilar PNA s/p endotracheal intubation ~12 hrs. Pt is
full code.
PMHx PNA x3 this year; family endorses chronic dysphagia symptoms for several months without medical
attention
S Pt alert, very pleasant for exam. Participated well.
swallow function.
fluoroscopy
Varibar thin liquid, Varibar pudding; further trials were discontinued for pt’s airway
P.O. barium contrast trials protection, given severity of dysfunction, inefficacy of compensatory strategies, &
critical illness
Oral phase findings Bolus preparation N/A; solids deferred 2/2 severity of dysphagia
Bolus transport WNL
Oral residue None
Velar elevation WNL
findings Pharyngeal stripping wave Severely impaired
Pharyngeal contraction Severely impaired b/l
PES opening Severely impaired; <5-10% of all bolus trials passed
via UES
BOT retraction WNL
Pharyngeal residue Severe pyriform sinus/pharyngeal wall residue
Esophageal clearance Contrast did not sufficiently enter the UES to assess
Esophageal findings
esophageal function
Thin liquid 7; recurrent gross aspiration of thin liquid after the
swallow 2/2 severe pyriform sinus/pharyngeal wall
residue 2/2 severely impaired pharyngeal wall
contraction & UES relaxation; inlet to UES appeared
obstructed, unclear if functional or mechanical
Pudding 7; recurrent gross aspiration of pudding after the
swallow 2/2 severe pyriform sinus/pharyngeal wall

residue 2/2 severely impaired pharyngeal wall
contraction & UES relaxation; inlet to UES appeared
obstructed, unclear if functional or mechanical
Solid N/A
Compensatory Swallow Attempted bilateral head rotations & cued dry swallows in attempt to improve
Strategies bolus passage via UES, which were not successful; recurrent gross aspiration could
not be prevented & cough was weak/non-protective
A Severe oropharyngeal dysphagia resulting in aspiration of all trialed textures. Dysphagia is likely chronic from an
undiagnosed underlying medical condition, given admission w/ bibasilar PNA & family report of recurrent PNA
& chronic cough + dysphagia symptoms. Pt’s ~12 hour endotracheal intubation does not sufficiently explain
severity of swallow dysfunction & specific physiologic deficits visualized on fluoroscopy, though likely has
exacerbated his underlying dysphagia. Swallow safety is not sufficient to support oral diet & this patient is at
high risk for serious aspiration-related pulmonary complication, given critical illness, age, severe dystussia, &
reduced physical mobility. Swallow prognosis is also guarded, given age & unknown etiology of dysphagia.
There is no evidence to support improved pt survival or QOL after PEG placement in pts w/ advanced age +
severe dysphagia. Burdens of NPO status + PEG placement in this pt likely include poor QOL, continued
aspiration of secretions, aspiration of tube feedings, persistent malnutrition/dehydration, & increased risk of
mortality.* In this clinician’s opinion, the risks of long-term enteral feeding (e.g., PEG) outweigh the risks of p.o.
comfort feedings despite known dysphagia/aspiration. This complex bioethical decision is deferred to the pt &
physician.
*Sources: (while pt does not have medical dx of dementia, nor does he present w/ signs of dementia to this
clinician, data from these studies may be generalized to pts w/ advanced age & probable chronic/progressive
medical conditions)
Ayman AR, Khoury T, Cohen J, et al. PEG insertion in patients with dementia does not improve nutritional status
and has worse outcomes as compared with PEG insertion for other indications. Journal of Gastroenterology.
2017;51(5):417-420.
Hallenbeck J. Reevaluating PEG tube placement in advanced illness. Gastrointestinal Endoscopy.

2005;62(6):960-962.
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. The American
Journal of Gastroenterology. 2000;95(6):1472-1475.
Ticinesi A, Nouvenne A, Lauretani F, et al. Survival in older adults with dementia and eating problems: to PEG or
not to PEG? Clinical Nutrition. 2016;35(6);1512-1516.
P Diet recommendation Pt/physician discussion regarding goals of care. Consider:

(a) NPO w/ long-term enteral feeding route (e.g., PEG) – this option does not
reduce probability of aspiration of secretions & will likely reduce QOL
(b) PO comfort feedings, despite known aspiration/malnutrition/dehydration risk.
Advise full liquid diet, w/ liquids by ½ tsp, in upright position.
Risk management Control risk factors for aspiration pneumonia via (a) oral hygiene QID, (b) increasing
physical mobility as tolerated

Specialist referrals Palliative care/hospice evaluation; Should pt/physician seek to determine underlying
dysphagia etiology, consider (a) neurological evaluation, including brain imaging, & (b)
otolaryngology evaluation, including laryngoscopy & soft tissue neck imaging
Ancillary tests See above
Therapy Pt is unlikely to benefit from direct swallow rehabilitation, given age & likely
chronic/progressive dysphagia. SLP will f/u for POC discussion.
Goal Pt will perform verbal teachback of strategies to control risk factors for aspiration PNA
Follow-up exam N/A

HPI 75yoF admitted from SNF w/ acute respiratory failure 2/2 PNA; BiPAP x3 days. Pt severely malnourished &
dehydrated. CXR reveals bibasilar PNA. Brain imaging unremarkable for acute process.
PMHx COPD, CVA, HTN, dementia
S Pt alert but confused & not following any commands. Breathing comfortably on nasal cannula. Accepted p.o.
trials of barium contrast.
position pt for AP view.
fluoroscopy
(moderately-thick) liquid, Varibar pudding
Tongue control Severely impaired
Bolus preparation N/A; solids deferred 2/2 severity of dysphagia +
Oral phase findings
cognitive deficits
Bolus transport Severely impaired
Oral residue Severe
Initiation of swallow Severely delayed w/ thin liquid, mildly-thick liquid, &
moderately-thick liquid; absent swallow trigger w/
pudding on this exam; unable to elicit swallow trigger
for pudding trial >3 mins despite max multimodal
cues, including empty tsp presentations
Velar elevation WNL
Pharyngeal phase Anterior hyoid excursion Moderately impaired
findings Epiglottic movement Severely impaired
Pharyngeal stripping wave Severely impaired
Pharyngeal contraction Unable to position pt for AP view
Pharyngeal residue Severe pyriform sinus & vallecular residue; significant
laryngeal & tracheal residue
Esophageal clearance Contrast did not sufficiently enter the UES to assess
Esophageal findings
esophageal function
Thin liquid 8; silent aspiration occurred before, during, & after
the swallow r/t global timing & strength deficits
8-point Penetration- Mildly-thick liquid 8; silent aspiration occurred before, during, & after
Aspiration Scale (PAS) the swallow r/t global timing & strength deficits
Moderately-thick liquid 8; silent aspiration occurred before, during, & after

Pudding 8; silent aspiration occurred before, during, & after
Solid N/A
Compensatory Swallow Pt unable to follow commands to execute compensatory strategies; sensory
Strategies techniques to elicit swallow trigger (e.g., empty teaspoon presentations) were
unsuccessful
A Severe oropharyngeal dysphagia resulting in aspiration of all textures. Dysphagia is likely chronic r/t hx of
CVA/COPD/dementia, given admission w/ dysphagia-related complications (i.e., PNA, respiratory failure,
malnutrition, dehydration) in the absence of acute neurological event. Swallow safety is not sufficient to support
oral diet. However, pt’s swallow prognosis is poor due to severity of cognitive-communication disorder &
suspected chronicity of dysphagia.
There is no evidence to support improved pt survival or QOL after PEG placement in pts w/ advanced age +
dementia + severe dysphagia. Burdens of NPO status + PEG placement in this pt w/advanced illness likely
include poor QOL, physical restraint, continued aspiration of secretions, aspiration of tube feedings, persistent
malnutrition/dehydration, & increased risk of mortality.* In this clinician’s opinion, the risks of long-term enteral
feeding (e.g., PEG) outweigh the risks of p.o. comfort feedings despite known dysphagia/aspiration. This
complex bioethical decision is deferred to the pt’s POA & physician.
*Sources:
Ayman, A. R., Khoury, T., Cohen, J., Chen, S., Yaari, S., Daher, S., Benson, A. A., & Mizrahi, M. (2017). PEG
Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as
Compared With PEG Insertion for Other Indications. Journal of clinical gastroenterology, 51(5), 417–420.
Hallenbeck J. (2005). Reevaluating PEG tube placement in advanced illness. Gastrointestinal endoscopy, 62(6),
960–962.
Sampson, E. L., Candy, B., & Jones, L. (2009). Enteral tube feeding for older people with advanced
dementia. The Cochrane database of systematic reviews, 2009(2), CD007209.
Ticinesi, A., Nouvenne, A., Lauretani, F., Prati, B., Cerundolo, N., Maggio, M., & Meschi, T. (2016). Survival in
older adults with dementia and eating problems: To PEG or not to PEG?. Clinical nutrition (Edinburgh,
Scotland), 35(6), 1512–1516.
P Diet recommendation Pt/physician discussion regarding goals of care. Consider:

(a) NPO w/ long-term enteral feeding route (e.g., PEG) – this option does not
reduce probability of aspiration of secretions or mortality & will likely reduce
QOL
(b) PO comfort feedings, despite known aspiration/malnutrition/dehydration risk.
Advise full liquid diet, w/ liquids by ½ tsp, in upright position.
Risk management Control risk factors for aspiration pneumonia via oral hygiene QID. Careful hand
feeding, should POA opt for PO diet.
Specialist referrals Palliative care/hospice evaluation. Bioethics consult.
Ancillary tests N/A
Therapy Pt is unlikely to benefit from direct swallow rehabilitation. SLP will f/u for POC
discussion.
Goal Pt’s family/POA will perform verbal teachback of recommendations to reduce risk for
aspiration PNA.
Follow-up exam N/A

HPI 47yoF admitted w/ nausea/vomiting, “throat hardness”, dysphagia x1 week to both liquids & solids, weight
loss
PMHx Metastatic ovarian adenocarcinoma s/p surgical tx & chemotherapy
S Pt alert & pleasant for exam. Communication skills intact. Exam was conducted 1.75 hours s/p administration of
Pyridostigmine; pt denies any change/improvement in her symptoms since medication administration.
swallow function.
fluoroscopy
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue Trace
Velar elevation WNL
Laryngeal elevation Mildly impaired
Anterior hyoid excursion Mildy impaired
Pharyngeal phase
findings
Pharyngeal contraction Severely impaired b/l in AP view
Pharyngeal residue Mild-moderate vallecular & pyriform sinus residue w/
thin liquid, which increased to a moderate volume w/
puree & solid trials
Esophageal clearance Abnormal screening warranting further workup of
esophageal motility; retention of contrast within the
Esophageal findings
entire proximal-distal esophagus; suspect impaired
peristalsis
Thin liquid 2; penetration of thin liquids after the swallow from
pharyngeal residue, which was spontaneously
ejected from the larynx
Pudding 1
Solid 1

Compensatory Swallow Chin tuck: no significant change in volume of pharyngeal residue w/ comparison to
Strategies head neutral
Liquid wash: somewhat effective in reducing pharyngeal residue of pudding/solid
Dry swallows: effective in reducing pharyngeal residue following multiple (2-6)
swallows per bolus
A Mild-moderate pharyngoesophageal dysphagia of unknown etiology marked by diffuse/bilateral pharyngeal

weakness & suspected impaired esophageal motility. Swallow efficiency is significantly impaired, though
swallow safety is preserved. Study was conducted 1.75 hrs s/p Pyridostigmine dose; w/ comparison to FEES
yesterday (prior to Pyridostigmine), there is no change in swallow physiology. Further physician workup of
potential dysphagia etiology is indicated; swallow prognosis is unknown until medical dx obtained. Pt may
benefit from exercise-based swallow rehabilitation, pending further medical diagnostics.
P Diet recommendation Regular easy-to-chew (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet. Solid diet
modification is per pt’s preference; adjust solid diet at pt’s discretion.
Risk management Aspiration precautions/compensatory strategies: upright position, small bites/sips,
alternate solid/liquid, multiple swallows per bolus. Control risk factors for aspiration
pneumonia via (a) oral hygiene QID, & (b) increasing physical mobility as tolerated
Specialist referrals F/u w/ Neurologist for further workup of potential dysphagia etiology. Consider
hematology/rheumatology consultation for potential systemic/rheumatic dysphagia
etiologies. Dietitian consult 2/2 high risk for malnutrition/dehydration.
Ancillary tests N/A
Therapy Trial of low-intensity exercise-based swallow rehabilitation x3/week w/ SLP
Goal Pt will improve pharyngeal wall contraction & BOT retraction via Effortful Swallows
x10/tx. Pt will improve pharyngeal wall contraction via Effortful Pitch Glide x10/tx. Pt will
improve PES relaxation via CTAR x10/tx.
Follow-up exam Pending medical dxs/txs

HPI 21yoM admitted s/p bicycle vs. automobile accident. C5 SCI w/ quadriplegia s/p ACDF (C4-C6 anterior
instrumentation w/ cage placement) + C3-C7 posterolateral instrumentation.
PMHx None
S Pt alert, pleasant for exam. However, pt self-reports anxiety & requested repeated repositioning. Exam
conducted w/ pt in near-supine position (HOB elevation approx. 10-15 degrees) 2/2 poor hemodynamic
stability & sitting tolerance (2/2 C5 SCI).
Anatomic view under Extensive post-surgical changes/hardware in anterior & posterior cervical spine w/
fluoroscopy associated prevertebral soft tissue edema
Varibar thin liquid via syringe (1-5 mL boluses) to lateral sulcus w/ cues for oral
P.O. barium contrast trials closure around syringe; unable to provide tsp/cup/straw drinking in near supine
position; Varibar pudding; Solids deferred 2/2 severity of dysphagia + positioning
Lip closure WNL
Tongue control Mildly impaired r/t positioning
Oral phase findings Bolus preparation N/A; solids deferred 2/2 positioning
Bolus transport Mildly impaired r/t positioning
Oral residue None
Velar elevation WNL
Pharyngeal phase Pharyngeal contraction Unable to position for AP view
findings PES opening Severely impaired
BOT retraction WNL
Pharyngeal residue Severe (relative to bolus volumes administered);
residue significantly increased w/ increased viscosity;
profound pyriform residue w/ pudding; pt
demonstrated sensation to pharyngeal residue, but
was unable to clear pudding residue despite 10+
cued dry swallows & multiple liquid washes
Esophageal findings Esophageal clearance Unremarkable w/ consideration of supine position
Thin liquid 1
Pudding 1
Solid N/A

Compensatory Swallow Cued dry swallows/multiple swallows per bolus, which reduced but did not clear
Strategies pharyngeal residue
Liquid wash after pudding, which reduced but did not clear pharyngeal residue
Cued effortful swallows, which reduced but did not clear pharyngeal residue
A Moderate-severe oropharyngeal dysphagia POD #4 s/p C4-C6 ACDF, largely r/t prevertebral soft tissue edema.
Oral phase of swallowing impacted by pt’s supine positioning 2/2 poor hemodynamic stability. No aspiration
was elicited on this exam, though swallow efficiency was moderate-severely impaired. Pt requires diet
modification & strict aspiration precautions; pt is also at increased risk for malnutrition/dehydration r/t
dysphagia if no rapid improvement in pharyngeal edema/physiology.
P Diet recommendation Full liquid diet of IDDSI Level 0 (thin liquids) only. Meds crushed/dissolved in thin
liquids.
Risk management Aspiration precautions/compensatory strategies: 1:1 feeding assist, okay to feed w/
HOB elevated 10-15 degrees via 5 mL boluses via syringe to lateral sulcus. Control risk
factors for aspiration pneumonia via oral hygiene QID.
Specialist referrals Dietitian consult 2/2 risk for malnutrition/dehydration
Ancillary tests N/A
Therapy SLP following x5/week for swallow tx
Goal Pt will improve pharyngeal wall contraction via Effortful Swallow & Effortful Pitch Glide
x50 each per tx.
Follow-up exam Plan for repeat swallow study w/ goal to advance oral diet in 3-5 days.

HPI 80yoF admitted w/ AMS, lethargy, weakness, SOB, & dark stools. + GI bleed + acute respiratory failure +
acute bilateral deep white matter ischemic infarcts in centrum semiovale and corona radiata. Pt intubated
x3 days.
PMHx HTN, CAD, CHF, a-fib, MI
S Pt alert, very pleasant but confused for exam. Followed simple commands, though inconsistently w/ delayed
response times.
Anatomic view under Multiple external lines visualized at level of the larynx/trachea; NGT in situ
fluoroscopy
Oral phase findings Bolus preparation N/a; solids deferred 2/2 missing dentition + AMS
Bolus transport Moderately impaired
Oral residue Mild
Velar elevation WNL
Pharyngeal phase
Laryngeal vestibule closure Mildly impaired
findings
Pharyngeal contraction Unable to position in AP view
PES opening WNL
BOT retraction WNL
Pharyngeal residue Trace pharyngeal wall residue, suspect r/t NGT
Thin liquid 8; inconsistent laryngeal penetration of thin liquids
during the swallow 2/2 incomplete LVC with
significant laryngeal residue, resulting in 2 instances
of trace aspiration after the swallow (from laryngeal
residue that was not cleared during swallowing)
Pudding 1
Solid N/A
Compensatory Swallow Pt’s mental status not sufficient for reliance on compensatory strategies at this time
Strategies
Dysphagia Outcome and Level 5

A Mild oropharyngeal dysphagia resulting in inconsistent aspiration of thin liquids. Dysphagia is likely
multifactorial r/t acute CVAs + endotracheal intubation. Given the pt’s severity of illness & medical
comorbidities, combined w/ poor oral hygiene & physical mobility, pt is at increased risk for aspiration-related
pulmonary complication at this time. Temporary diet modification appears indicated. Prognosis for swallow
improvement is good.
Risk management Aspiration precautions/compensatory strategies: 1:1 feeding assist, upright position,
small/single cup sips of mildly-thick liquids, avoid thin liquids. Control risk factors for
aspiration pneumonia via (a) oral hygiene QID, & (b) increasing physical mobility as
medically feasible. Once pt’s risk factors for aspiration pneumonia improve (i.e., oral
hygiene improves, physical mobility improves, & severity of illness improves), pt is
unlikely to require further liquid diet modification.
Ancillary tests N/A
Therapy Exercise-based swallow rehabilitation w/ SLP x5/week to improve laryngeal vestibule
closure & cough strength
Goal Pt will improve LVC via Effortful Pitch Glides x50/tx; Pt will improve cough strength for
airway protection via EMST w/ MEP of 50 cm H2O
Follow-up exam N/A

HPI 73yoF admitted w/ respiratory failure/ARDS 2/2 COVID-19, endotracheal intubation x30 days s/p trach
PMHx Dementia, HTN
S Pt alert, pleasant & cooperative for exam. Exam conducted w/ Shiley #8 cuffed trach, cuff deflated, on trach
mask w/ PMV in place. COVID-19 precautions observed.
Anatomic view under Tracheostomy tube & NGT in situ
fluoroscopy
(moderately-thick) liquid, Varibar pudding, solid coated in Varibar pudding
Bolus preparation Severely impaired; pt unable to masticate solid &
Oral phase findings
required expectoration & manual bolus extraction
Oral residue Mild w/ all consistencies, except severe w/ solid
Velar elevation WNL
Pharyngeal phase
Laryngeal vestibule closure Mild-moderately impaired
findings
Pharyngeal contraction Unable to position for AP view
PES opening WNL
BOT retraction WNL
Pharyngeal residue Trace; not clinically significant
Thin liquid 8; consistent penetration of thin liquid via tsp &
aspiration of thin liquid via cup during the swallow
2/2 impaired LVC
Mildly-thick liquid 2; transient shallow penetration of mildly-thick liquid
8-point Penetration- via cup during the swallow 2/2 impaired LVC
Aspiration Scale (PAS) Moderately-thick liquid 2; transient shallow penetration of moderately-thick &
moderately-thick liquid via cup during the swallow
2/2 impaired LVC
Pudding 1
Solid Solid bolus did not reach pharynx for assessment

Compensatory Swallow Pt unable to follow/execute complex commands for use of compensatory strategies
Strategies
A Mild-moderate oropharyngeal dysphagia resulting in reduced swallow safety & efficiency. + silent aspiration of
thin liquids. Exam was conducted w/ Shiley #8 cuffed trach, cuff deflated, w/ PMV in place on trach mask; results
are valid only in this condition. Pt is at increased risk for aspiration pneumonia, given poor oral hygiene &
reduced physical mobility; temporary diet modification is indicated to mitigate risk of aspiration pneumonia.
Risk management Aspiration precautions/compensatory strategies: 1:1 feeding assist, PMV required for
meals, upright position, small/single sips of mildly-thick liquids, avoid thin liquids.
Control risk factors for aspiration pneumonia via (a) oral hygiene QID, & (b) increasing
physical mobility as medically feasible.
Specialist referrals F/u w/ ENT for trach tube downsize to Shiley #6 cuffless to facilitate airway patency for
phonation/swallowing & long-term goal for decannulation
Ancillary tests N/A
Goal Pt will improve LVC via Effortful Pitch Glides x50/tx; Pt will improve cough strength for
airway protection via EMST w/ MEP of 30 cm H2O
Follow-up exam Repeat VFSS vs. FEES in approx. 1 week, pending progress in swallow tx

HPI 63yoM admitted w/ acute encephalopathy. Approx 1 month prior to hospitalization, pt developed
progressive weakness; was evaluated OSH & found w/ “encephalitis” & Miller Fisher Guillain-Barre
Syndrome (GBS), required mechanical ventilation s/p tracheotomy & PEG. Transferred from OSH for
insurance purposes. Now s/p hospital d/c to subacute care facility; seen as outpatient.
PMHx Miller Fisher GBS s/p trach & PEG, oropharyngeal dysphagia 2/2 GBS
S Pt alert & followed commands for outpatient VFSS. Spouse present to observe. Brought by EMS from subacute
care facility. Pt/spouse indicate pt’s primary goal is to eat by mouth; currently NPO & G-tube dependent. Study
conducted w/ Shiley #6 cuffless trach w/ PMV in place, on trach mask.
swallow function.
Anatomic view under Tracheostomy tube in situ
fluoroscopy
Varibar thin liquid, Varibar pudding; trials were presented via tsp & syringe; pt
consented to syringe feeding as method to bypass profound oral stage deficits
(due to b/l labial/lingual paralysis) & verbally indicated readiness to accept each
syringe trial
Lip closure Profoundly impaired; profound anterior bolus loss w/
thin liquid & pudding
Tongue control Profoundly impaired
Bolus preparation N/A; solids deferred 2/2 severity of dysphagia
Bolus transport Profoundly impaired; oral transit slightly aided by
posterior head tilt posture, but ultimately required
Oral phase findings
syringe feeding to pass thin liquid contrast to
pharynx; pudding via syringe reached the pharynx x1,
however, left profound oral residue & did not reach
the pharynx in additional trials; cup/straw drinking
was not attempted 2/2 severity of deficits
Oral residue Profound
Velar elevation Mildly impaired
Anterior hyoid excursion Mildly impaired
Pharyngeal phase Laryngeal vestibule closure Moderately impaired
Pharyngeal residue Moderate vallecular residue & mild pyriform sinus
residue
Esophageal findings Esophageal clearance Abnormal; retained contrast

Thin liquid 2; penetration of thin liquid during & recurrently after
the swallow 2/2 impaired LVC & reduced BOTR; the
patient demonstrated a consistent throat clear
response to all penetration events, which was
successful in clearing the larynx of contrast &
preventing aspiration
Pudding 2; penetration of pudding during & recurrently after
the swallow 2/2 impaired LVC & reduced BOTR; the
patient demonstrated a consistent throat clear
response to all penetration events, which was
successful in clearing the larynx of contrast &
Solid N/A
Compensatory Swallow Posterior head tilt to facilitate oral transit, which was successful w/ thin liquids but
Strategies not w/ puree
Syringe feeding (w/ pt’s consent) to facilitate oral transit, which was successful w/
thin liquids but not w/ puree
A Profound oral stage + moderate pharyngeal stage dysphagia 2/2 Miller Fisher GBS. Pt benefitted from both
posterior head tilt & syringe feeding to facilitate bolus transfer to pharynx 2/2 b/l lingual paralysis. Pt likely
requires g-tube to meet nutrition/hydration needs, but appears safe to trial partial p.o. intake w/ strict use of
strategies/precautions for oral gratification & swallow stimulation. Study results are valid only w/ PMV in place.
Pharyngeal function appears improved w/ comparison to inpatient FEES approx. 2 months ago.
P Diet recommendation Continue use of G-tube as primary nutrition/hydration source 2/2 severity of
oropharyngeal dysphagia
Risk management Provide p.o. full liquid diet (IDDSI Level 0) for oral gratification/swallow exercise.
Position pt upright but w/ posterior head tilt. Pt to self-administer <5 mL boluses via
syringe to facilitate oral transit. PMV recommended for all oral intake. Allow extra time
for spontaneous dry swallows. Do not discontinue trials if + coughing/throat clearing,
as this is pt’s protective sensory response to airway invasion. Yankauer suctioning & oral
hygiene after all p.o. intake.
Specialist referrals F/u w/ dietitian for management of g-tube feeding w/ addition of oral intake
Ancillary tests N/A
Therapy Continue outpatient exercise-based swallow tx w/ SLP
Goal Per primary/treating SLP
Follow-up exam Repeat outpatient VFSS in 4-8 weeks, pending continued swallow progress

HPI 63yoM admitted w/ acute encephalopathy. Approx 1 month prior to hospitalization, pt developed
progressive weakness; was evaluated OSH & found w/ “encephalitis” & Miller Fisher Guillain-Barre
Syndrome (GBS), required mechanical ventilation s/p tracheotomy & PEG. Transferred from OSH for
insurance purposes. Now s/p hospital d/c to subacute care facility; seen as outpatient.
PMHx Miller Fisher GBS s/p trach & PEG, oropharyngeal dysphagia 2/2 GBS
S Pt alert & very pleasant for repeat outpatient VFSS. Pt notably s/p trach decannulation since prior outpatient
VFSS last month. Pt w/ notably clear vocal quality but persistent moderate dysarthria. Accompanied to exam by
pt’s son & transport team. Pt w/ improved physical mobility since prior exam; independently stood & transferred
to chair. Pt states he has been consuming primarily thin liquids but some purees; pt states he is able to drink via
cup & no longer requires syringe feeding. Pt states his goal is to return to regular diet.
swallow function.
fluoroscopy
Tongue control Moderate-severely impaired
Bolus preparation Moderately impaired
Oral phase findings
Oral residue Moderate; oral residue largely cleared w/
spontaneous dry swallows
Velar elevation WNL
Pharyngeal phase
findings
Pharyngeal contraction WNL; symmetrical in AP view
PES opening WNL
Thin liquid 6; 1 instance of aspiration of thin liquid before the
swallow 2/2 impaired oral containment (this was
notably during large volume cup drinking of thin
liquids); intermittent penetration of thin liquids
during the swallow, which is normal; immediate
sensory cough response to aspiration w/ eventual
clearance of contrast from the trachea
Pudding 1
Solid 1
Compensatory Swallow Spontaneous use of posterior head tilt for all textures, which was effective in
Strategies facilitating AP transit
A Moderate oral stage dysphagia; functional pharyngeal swallow. 1 instance of aspiration of thin liquids 2/2 oral
stage deficits, although pt ejected aspirated contrast from the airway. Pt benefited from use of posterior head
tilt strategy to facilitate oral transit. Overall, significant progress in swallow physiology w/ comparison to
outpatient VFSS last month.
P Diet recommendation IDDSI Level 5 vs. 6 solid diet, per pt preference; pt appears to demonstrate good
awareness of his deficits & can likely self-restrict/make appropriate solid diet selections.
Safe for all liquid consistencies. Consider meds whole or crushed in puree.
Risk management Aspiration precautions: upright position, avoid mixed consistencies, small bolus
volumes. Compensatory strategies: continue use of posterior head tilt to facilitate oral
transit. Continue oral hygiene x3-4/day & encourage physical mobility/ambulation to
reduce risk for aspiration pneumonia.
Ancillary tests N/A
Therapy Continue outpatient swallow tx w/ SLP
Goal Per primary/treating SLP
Follow-up exam N/A

HPI 26yoM admitted w/ generalized weakness, cough, fever, PNA, sepsis. PMHx: malnutrition/cachexia, PNA x2
this year
PMHx None
S Pt alert, pleasant, & participatory in exam.
swallow function.
fluoroscopy
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue Mild
Velar elevation WNL
findings Pharyngeal stripping wave Severely impaired
Pharyngeal contraction Severely impaired b/l in AP view
BOT retraction Severely impaired
Pharyngeal residue Moderate-severe; inconsistent sensory response (i.e.,
dry swallows) to pharyngeal residue
Thin liquid 2; trace penetration of thin liquid after the swallow x1
due to diffuse pharyngeal residue
Pudding 1
Solid 1
Compensatory Swallow Cued dry swallows reduced but did not eliminate pharyngeal residue
Strategies Alternating liquid/solid reduced but did not eliminate pharyngeal residue
Dysphagia Outcome and Level 3-4

A Mild oral stage & moderate pharyngeal stage dysphagia of unknown etiology. Primary deficit is diffuse bilateral
pharyngeal weakness resulting in moderate-severe pharyngeal residue w/ all consistencies. No aspiration
directly observed, however, potential for microaspiration events post-swallow was evident.
Given pt’s hx of cachexia/malnutrition + recurrent PNA + unexplained neurological symptoms (i.e., dysphagia,
dysphonia, impaired oral-nasal resonance), medical workup of dysphagia etiology is indicated.
Risk management Compensatory strategies/aspiration precautions: Encourage volitional dry swallows &
coughs throughout meals. Oral hygiene QID. Increase physical mobility as tolerated.
Specialist referrals F/u w/ Neurologist for further workup of dysphagia etiology. Dietitian consult 2/2 risk
for malnutrition/dehydration.
Ancillary tests N/A
Therapy SLP following x5/week for exercise-based swallow tx.
Goal Pt will improve pharyngeal wall contraction & BOT retraction via Effortful Swallows
x25/tx; Pt will improve functional reserve for cough/airway protection against aspiration
via EMST w/ MEP of 100 cm H2O
Follow-up exam Pending medical dx/tx; consider repeat exam in 3-6 months, if dysphagia etiology
remains undiagnosed, to assess dysphagia progression

HPI 48yoF transferred from OSH for “throat pain” radiating to chest, nausea & vomiting. To SLP, pt endorses hx
of dysphagia >1.5 years, which acutely worsened approx. 1 week ago. PMHx of HTN, ETOH, reflux,
hemorrhagic gastritis. Questionable hx of CVA; pt endorses, “I think I had a stroke in 2016” but no
documentation of this in medical records, other than GI note in 2018 that also stated pt reported she
“believed” she had a stroke. No brain imaging from prior admissions.
PMHx Questionable hx of CVA(s)
S Pt alert, pleasant, & participatory in exam. Notably dysarthric.
swallow function.
fluoroscopy
Oral phase findings Bolus preparation Mildly impaired
Oral residue Mild
Velar elevation WNL
Pharyngeal stripping wave Mildly impaired
Pharyngeal phase Pharyngeal contraction Mildly impaired b/l; asymmetry of the pharynx could
findings not be appreciated in the AP view, despite clear
evidence of asymmetry on FEES yesterday
Pharyngeal residue Mild; pt appeared in mild distress w/ significant
discomfort during swallowing tasks; repeated dry
swallowing x2-3 per bolus, + gagging, & report of
globus sensation
Esophageal clearance Abnormal; significant retained contrast in esophagus,
Esophageal findings w/ sporadic, spastic-appearing movements of the
distal esophagus
Thin liquid 1
Pudding 1

Solid 1
Strategies Alternating liquid/solid reduced but did not eliminate pharyngeal residue
A Mild-moderate oropharyngeal dysphagia w/ suspected comorbid esophageal dysmotility. Dysphagia etiology is

currently unknown. Dysphagia is marked by bilateral pharyngeal weakness & swallow inefficiency, though
swallow safety/airway protection is preserved. Further medical workup of dysphagia etiology is indicated.
P Diet recommendation Initiate full liquid diet, per pt’s preference. Advance solid diet slowly as tolerated at pt’s
discretion.
Risk management Aspiration/reflux precautions: upright position during + 60 mins after meals, small
boluses, slow rate. Control risk factors for aspiration PNA via oral hygiene QID &
increasing physical mobility as tolerated.
Specialist referrals F/u w/ Neurologist for further workup of dysphagia etiology
Ancillary tests N/A
Therapy SLP following x5/week for swallow tx
Goal Pt will improve pharyngeal wall contraction & BOT retraction via Effortful Swallow
x30/tx; Pt will improve PES relaxation via CTAR x30/tx
Follow-up exam Pending medical dx/tx

HPI 64yoM found down with coffee-ground emesis from GI bleed. CT Head unremarkable for acute pathology.
PMHx CVA & R frontal craniotomy, ETOH cirrhosis, seizures
S Pt alert, pleasant, & cooperative for exam. Followed commands, though pt remains confused/confabulatory.
swallow function.
Anatomic view under Calcification at the level of the thyroid cartilage
fluoroscopy
Varibar thin liquid, Varibar nectar (mildly-thick) liquid, Varibar pudding, solid
coated in Varibar pudding
Lip closure WNL
Oral residue Mild
Velar elevation WNL
Pharyngeal phase Pharyngeal stripping wave Mildly impaired
findings Pharyngeal contraction In the AP view, there was significantly reduced left-
sided pharyngeal wall contraction (resulting in
unilateral “bulging” appearance of the left pharynx)
PES opening WNL
Pharyngeal residue Mild-moderate pharyngeal residue 2/2 reduced
BOTR & left pharyngeal wall contraction
Esophageal clearance Unremarkable w/ near complete esophageal
Esophageal findings clearance (trace residue likely within the range of
normal)
Thin liquid 7; inconsistent penetration of thin liquids via tsp to
the vocal folds during the swallow 2/2 reduced LVC;
1 instance of aspiration of thin liquid during the
swallow 2/2 impaired LVC; additional penetration of
thin liquid after the swallow from mild pharyngeal
residue; + cough response to aspiration event,
though this was weak & nor protective; immediately

after aspiration event, pt stated, “That felt great. Felt
really good.”
Pudding 1
Solid 1
Strategies Pt unable to execute complex commands (e.g., breath hold, head rotation) to
improve airway protection during the swallow
A Mild oropharyngeal dysphagia, likely chronic as deficits (e.g., left pharyngeal weakness) correlate clinically w/
old R frontal craniotomy; no acute neuro pathology to cause change in swallow physiology. + aspiration of thin
liquids, however, chest radiography on admission is clear & pt’s respiratory status is stable on room air. There is
no indication for diet modification in pt w/ chronic dysphagia/aspiration who is tolerating w/out pulmonary
complication. Pt is ambulatory, immunocompetent, & oral hygiene is fair; risk factors for dysphagia-related
pulmonary complication are low. However, pt may benefit from exercise-based swallow rehabilitation in next
level of care.
P Diet recommendation Regular Solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet, from SLP standpoint.
Ordered IDDSI Level 5 diet, per GI recommendation s/p EGD.
Risk management Aspiration/reflux precautions: upright position during + 60 mins after meals,
small/single sips of liquid, medications crushed or whole in puree. Control risk factors
for aspiration PNA via (a) oral hygiene QID, & (b) increasing physical mobility as
medically feasible.
Ancillary tests N/A
Therapy SLP will f/u x1 for patient education in acute care setting. Recommend outpatient SLP
swallow therapy to improve chronic dysphagia.
Goal N/A
Follow-up exam N/A

HPI 48yoM admitted w/ generalized weakness & hypotension.
PMHx ESRD on HD, rejected kidney transplant
S Pt alert & very pleasant for exam. Followed commands well.
swallow function.
Anatomic view under Significant thickening of the prevertebral soft tissue throughout the entire pharynx
fluoroscopy w/ extension to the esophagus; accentuated cervical lordosis
Lip closure WNL
Tongue control WNL
Bolus transport WNL
Oral residue None
Velar elevation WNL
Pharyngeal phase Pharyngeal stripping wave Severely impaired
findings Pharyngeal contraction Severely impaired b/l in AP view
Pharyngeal residue Severe vallecular, pharyngeal wall, & pyriform sinus
residue, which increased with viscosity; spontaneous
3-7 swallows per bolus, which were successful in
reducing pharyngeal residue
Esophageal findings Esophageal clearance Abnormal; retained contrast
Thin liquid 4; penetration of thin liquids to the vocal folds after
the swallow from severe pharyngeal residue, which
cleared w/ spontaneous swallows
Pudding 1
Solid 1
Compensatory Swallow Chin tuck posture appeared to improve BOTR w/ all consistencies & resulted in
Strategies fewer spontaneous dry swallows to reduce vallecular residue

Bilateral head rotations were not successful in improving UES relaxation; pt also
endorsed pain w/ head rotation
A Moderate pharyngoesophageal dysphagia, which appeared related to abnormal thickening of the prevertebral
soft tissue w/ near absent posterior pharyngeal wall contraction & reduced UES relaxation. Etiology of
prevertebral soft tissue thickening is unknown. Swallow efficiency is moderate-severely impaired, while swallow
safety is preserved. Pt is at increased risk for malnutrition/dehydration, but does appear safe for a full oral diet.
Further medical workup of dysphagia etiology is indicated.
P Diet recommendation Regular Solid (IDDSI Level 7)/Thin Liquid (IDDSI Level 0) diet.
Risk management Compensatory swallow strategies: chin tuck posture for all p.o. intake, slow rate of
intake (allow time for spontaneous dry swallows). Control risk factors for aspiration PNA
via (a) oral hygiene QID, & (b) increasing physical mobility as medically feasible.
Specialist referrals Infectious Disease and/or Rheumatology consultations for medical workup of
dysphagia etiology
Ancillary tests Consider CT Soft Tissue Neck to evaluate thickening of prevertebral soft tissue, which
appears to be contributing to pt’s dysphagia
Therapy SLP will f/u x5/week for exercise-based swallow rehabilitation
x50/tx. Pt will improve pharyngeal wall contraction via Effortful Pitch Glides x50/tx. Pt
will improve PES relaxation via CTAR x50/tx.
Follow-up exam Pending medical dx/tx

Flexible Endoscopic Evaluations of Swallowing

Flexible Endoscopic Evaluation of Swallowing 1
HPI 57yoM admitted w/ dyspnea x3 days, fever, chills, silent hypoxia (SpO2 50%) 2/2 COVID-19 PNA/ARDS &
sepsis s/p endotracheal intubation x18 days.
PMHx None
S Pt alert, participated well in exam. Pt expressing his desire to recover & discharge the hospital & eagerness for
NGT removal. During exam, large bore NGT was partially obstructive to view of the larynx & appeared to
interfere w/ pt’s swallow function; physician gave phone order for RN removal of NGT during exam. Remainder
of exam completed s/p NGT removal.
swallowing.
Velopharyngeal function WNL
Nasopharyngoscopic
Anatomic findings NGT in situ at initiation of exam; removed during the
findings
exam
Secretions WNL
Vocal fold motion Near absent vocal fold movement b/l c/w likely b/l
severe vocal fold paresis; very subtle/tremulous
movement of the right vocal fold; vocal folds were in
Pharyngoscopic & an abducted position throughout the exam; severe
laryngoscopic findings hyperfunction of the ventricular folds/supraglottic
larynx
Sensory integrity Inconsistent sensation to aspiration
Anatomic findings Moderate-severe edema of the arytenoids b/l;
abducted vocal fold position
Posterior containment WNL
Oral phase findings Mastication WNL
Clearance WNL
Initiation of swallow Timely
BOT retraction WNL
Epiglottic movement Initially impaired, which appeared r/t NGT
Pharyngeal phase
findings
Laryngeal vestibule closure Impaired
PES opening WNL
Other findings N/A
Thin liquid 7; gross aspiration of thin liquids during the swallow
2/2 impaired LVC
Mildly-thick liquid 8; small-volume aspiration of mildly-thick liquids
during the swallow 2/2 impaired LVC
Pudding 1
Solid 1
Valleculae 1
Yale Pharyngeal Residue Pyriform sinuses 1
Severity Rating Scale
Compensatory Swallow B/l head rotations not effective in improving LVC/vocal fold adduction; unable to
Strategies achieve adduction w/ attempted breath holds; coughs effective in reducing but not
clearing aspirate from the trachea

A Moderate pharyngeal dysphagia marked by impaired laryngeal vestibule closure/vocal fold adduction, resulting
in aspiration of thin & mildly-thick liquid. Laryngoscopic exam revealed near absent mobility of the b/l vocal
folds (in abducted position) c/w likely severe b/l vocal fold paresis; significant hyperfunction of the supraglottic
larynx, which was effective in protecting the airway against moderately-thick liquid, puree, & solid. Pt appears
safe for modified oral diet w/ strict use of aspiration precautions. Risk for aspiration pneumonia is likely
moderate, given good oral hygiene, impaired but rapidly improving physical mobility, & recent critical illness.
Swallow prognosis is fair, pending intensive swallow rehabilitation & potential medical/surgical interventions by
Laryngologist.
P Diet recommendation IDDSI 7/3 diet. Meds crushed in puree.

Risk management Aspiration precautions: upright position, small/single sips of moderately-thick liquids,
avoid thin & mildly-thick liquids. Control risk factors for aspiration PNA via (a) oral
hygiene QID, & (b) increasing physical mobility as feasible.
Specialist referrals Laryngologist evaluation for possible medical/surgical interventions to address vocal
fold dysfunction
Ancillary tests Laryngoscopy
Therapy High-intensity/high-frequency swallow rehabilitation w/ SLP
Goal Pt will improve laryngeal vestibule closure/vocal fold adduction via R pharyngeal wall
contraction via Effortful Pitch Glide x50/tx. Pt will increase functional reserve for cough
strength/airway protection via EMST w/ MEP 20 cm H2O.
Follow-up exam Repeat FEES in approximately 2-4 weeks, pending clinical progress

HPI 41yoF admitted w/ right-sided weakness, drooling, dysphagia, dysphonia, headache.
PMHx Chiari malformation s/p VP shunt & midline low occipital craniotomy with cervical fusion, CVA w/ residual R
weakness, mild pharyngeal dysphagia (per VFSS 2016)
S Pt alert, very pleasant/cooperative for exam. Tolerated procedure without adverse event.
swallowing.
P.O. trials Ice chips, thin liquid, puree, & solid
Nasopharyngoscopic Velopharyngeal function Reduced R palatal elevation
findings Anatomic findings WNL
Secretions Mild-moderate secretions in pyriforms, valleculae,
pharyngeal walls, & post-cricoid area
Vocal fold motion Complete left vocal fold abduction/adduction;
severely reduced abduction/adduction of the right
Pharyngoscopic &
true vocal fold, which was in the paramedian position
laryngoscopic findings
at rest
Sensory integrity Impaired
Anatomic findings Significant asymmetry of the larynx (as described
above)
Posterior containment Impaired
Clearance Moderate R oral residue
BOT retraction Mild-moderately reduced (R worse than L)
Epiglottic movement Impaired
Pharyngeal phase
Pharyngeal contraction Severely reduced R pharyngeal wall contraction
findings
PES opening Impaired; retrograde bolus flow of thin liquid
Other findings N/A
Thin liquid 4; penetration of thin liquid to the true vocal folds
during & after the swallow 2/2 impaired LVC +
reduced right pharyngeal strength; however,
spontaneous coughs & swallows were effective in
Pudding 1
Solid 4; 1 instance of trace/transient penetration of solid to
the vocal folds during the swallow, which cleared w/
spontaneous cough & swallow

Yale Pharyngeal Residue Valleculae 4; R worse than L; spontaneous swallows of residue
Severity Rating Scale Pyriform sinuses 4; R worse than L; spontaneous swallows of residue
Compensatory Swallow Very limited cervical ROM; unable to perform right head rotation (absent rotation
Strategies right of midline)
Pt performed spontaneous dry swallows& coughs, which were effective in
preventing aspiration & reducing pharyngeal residue
A Moderate oropharyngeal dysphagia marked by atrophic right tongue (c/w LMN involvement of R CN XII) &
severely impaired right pharyngeal/laryngeal movement (c/w possible LMN involvement of CN X). + transient
airway invasion of multiple consistencies, however, preserved protective sensory response. Risk for dysphagia-
related aspiration pneumonia appears mildly increased in the context of acutely reduced physical mobility. Risk
for malnutrition/dehydration appears significant, given reduced swallow efficiency. Pt appears to be a good
candidate for exercise-based swallow rehabilitation.

Risk management Aspiration precautions: small sips of liquid, multiple swallows per bolus, alternate
liquid/solid, allow extra time for meals. Do not discontinue diet for coughing during
meals, as this is pt’s protective sensory response against aspiration. Control risk factors
for aspiration PNA via (a) oral hygiene QID, & (b) increasing physical mobility as feasible
Specialist referrals Neurosurgery evaluation, given acute onset right CN X dysfunction in the context of
Chiari malformation. Dietitian consult 22/ reduced swallow efficiency.
Ancillary tests N/A
Therapy High-intensity/high-frequency swallow rehabilitation w/ SLP
Goal Pt will improve R pharyngeal wall contraction via Effortful Swallow x50/tx. Pt will
improve R laryngeal/vocal fold mobility & R pharyngeal wall contraction via Effortful
Pitch Glide x50/tx. Pt will increase functional reserve for cough strength/airway
protection via EMST w/ MEP 100 cm H2O.
Follow-up exam Repeat instrumental swallow study in approx. 3 months, or sooner if medical/surgical
intervention

HPI 69yoF admitted w/ left foot dog bite w/ cellulitis, on IV antibiotic. Developed acute dysphagia, hoarseness,
& stridor; developed aspiration PNA & required HFNC.
PMHx HTN
S Pt alert, very pleasant/cooperative for exam. Tolerated procedure without adverse event. Exam conducted w/ pt
on HFNC at 60 L/min.
swallowing.
P.O. trials Ice chips, thin liquid, mildly-thick liquid, puree, & solid
Nasopharyngoscopic Velopharyngeal function WNL
Secretions Mild secretions in the pyriforms
Vocal fold motion Absent movement of L vocal fold/larynx; L vocal fold
in paramedian position; complete
abduction/adduction of R vocal fold/arytenoid;
Pharyngoscopic &
unable to achieve complete vocal fold adduction
throughout exam
Anatomic findings Significant asymmetry of the larynx (as described
above)
Clearance WNL
BOT retraction WNL
Pharyngeal phase
findings
Other findings N/A
Thin liquid 8; aspiration of thin liquid during the swallow due to
impaired laryngeal vestibule closure
Mildly-thick liquid 4; penetration of mildly-thick liquid during the
swallow due to impaired laryngeal vestibule closure
Pudding 1
Solid 1
Yale Pharyngeal Residue Valleculae 1
Severity Rating Scale Pyriform sinuses 3

Compensatory Swallow Unable to achieve laryngeal vestibule closure with use of supraglottic swallow
Strategies Left head rotation not successful in eliminating aspiration of thin liquids
A Mild-moderate pharyngeal dysphagia due to absent mobility of the left larynx/vocal fold resulting in silent
aspiration of thin liquids. Etiology of dysphagia/laryngeal dysfunction is unknown at this time; query possible left
recurrent laryngeal nerve involvement. Swallow safety & efficiency are impaired. In the context of pt’s active
MRSA infection + pneumonia w/ HFNC dependency, diet modification appears indicated at this time. Further
medical workup for dysphagia etiology is indicated for swallow treatment/prognostic information.
P Diet recommendation IDDSI 7/2 diet. Meds whole in puree or with mildly-thick liquid.
Risk management Control risk factors for aspiration pneumonia via (a) oral hygiene QID & (b) increasing
Specialist referrals ENT consult to evaluate potential dysphagia etiologies; concern for possible extrinsic
compression of left recurrent laryngeal nerve
Ancillary tests Consider CT Soft Tissue Neck
Therapy Exercise-based swallow rehabilitation w/ SLP x5/week in the acute care setting.
Goal Pt will improve L laryngeal/vocal fold mobility via Effortful Pitch Glides & Hard Glottal
Attacks x50/tx
Follow-up exam Repeat FEES in approx. 4 weeks, or sooner pending medical dx/intervention

HPI 82yoF admitted w/ cough & congestion x2 weeks.
PMHx HTN, osteoarthritis, aortic regurgitation.
S Pt alert, participated well in exam. Tolerated procedure without adverse event. Pt wheezing/stridorous during
exam; SpO2 99%.
swallowing.
P.O. trials Ice chips, thin liquid via tsp, & puree
Secretions Mild secretions in pyriforms, along pharyngeal walls,
& in post-cricoid area
Vocal fold motion Absent movement of the right true vocal fold w/
significant bowing; severely reduced vocal fold
adduction; intact abduction/adduction of the left
Pharyngoscopic &
vocal fold
Anatomic findings The right oropharyngeal wall appeared to have a
convex appearance, which could possibly represent
flaccidity of the right pharyngeal wall OR a possible
soft tissue fullness of the right pharyngeal wall
Clearance WNL
BOT retraction Impaired
Pharyngeal phase Pharyngeal contraction Impaired right pharyngeal wall contraction
findings Laryngeal vestibule closure Severely impaired
PES opening Suspect impaired
Other findings Study terminated prior to further trials 2/2 severity of
aspiration events & stridor/wheezing
Thin liquid 8; aspiration of thin liquid during & after the swallow
2/2 impaired laryngeal vestibule closure & reduced
8-point Penetration- right pharyngeal wall contraction + reduced UES
Aspiration Scale (PAS) relaxation

Pudding 7; aspiration of puree during & after the swallow 2/2
impaired laryngeal vestibule closure & reduced right
pharyngeal wall contraction + reduced UES relaxation
Solid N/A
Yale Pharyngeal Residue Valleculae 4; right worse than left
Severity Rating Scale Pyriform sinuses 4; right worse than left
Compensatory Swallow Volitional cough & re-swallow were not effective in clearing the airway of aspirated
Strategies material or significantly reducing pharyngeal residue
A Severe pharyngeal dysphagia marked by impaired right laryngeal function, pharyngeal wall contraction, & PES
relaxation. Dysphagia is of unknown but likely chronic/progressive etiology; further medical workup is indicated.
Given concomitant expiratory wheezing/stridor, consider possible extrinsic compression of upper aerodigestive
tract/CN X. Pt does not appear safe for oral diet at this time. Swallow prognosis TBD pending etiology of
dysphagia.
P Diet recommendation NPO except ice chips for swallow stimulation & patient comfort.
Specialist referrals ENT consult to evaluate potential dysphagia etiologies; concern for possible extrinsic
compression of upper aerodigestive tract
Ancillary tests Consider CT Soft Tissue Neck and/or Chest
Goal Pt will improve R laryngeal adduction/pharyngeal contraction via Effortful Pitch Glides
x50/tx; Pt will improve cough strength for airway protection against aspiration via EMST
w/ MEP of 30 cm H2O
Follow-up exam Repeat FEES in approx. 4-6 weeks, pending medical dx/interventions

HPI 59yoM admitted s/p blunt neck trauma (bus stopped suddenly & pt fell forward into seat in front of him);
neck imaging reveals hematoma at L aryepiglottic fold, tracheal deviation to right, mildly displaced fracture
of left ala of the thyroid cartilage, s/p emergent tracheotomy.
PMHx Asthma
S Pt alert, participated well in exam. “I’m hungry” & reports his goal is to eat.
swallowing.
P.O. trials Ice chips, thin liquid via tsp, & puree
Secretions Copious amounts of thin/clear secretions in the
pyriforms, valleculae, pharyngeal walls, post-cricoid
area, & larynx
Vocal fold motion the vocal folds appeared adducted at rest (possibly
related to severity of bilateral vocal fold edema);
minimal vocal fold abduction was observed during
cued inhalation
Pharyngoscopic & Anatomic findings Severe edema & ecchymosis of the epiglottis,
laryngoscopic findings arytenoid cartilages (L > R), post-cricoid space,
aryepiglottic folds, false vocal folds (L > R), & true
vocal folds (L > R); the left true vocal fold appeared
dark red in color, concerning for possible
hemorrhage; the vocal folds were severely
edematous and erythematic b/ (L > R); view of the
vocal folds was difficult 2/2 pooling secretions in the
larynx, supraglottic edema, & severe edema of the
epiglottis
Oral phase findings Mastication N/A
Clearance WNL
BOT retraction WNL
Pharyngeal phase Pharyngeal contraction Impaired b/l
findings Laryngeal vestibule closure Impaired
PES opening Impaired
Other findings Study terminated prior to further trials 2/2 severity of
aspiration events & stridor/wheezing

Thin liquid 5 (suspect 8); recurrent gross penetration of thin
liquid after the swallow 2/2 reduced PES relaxation
(likely related to significant post-cricoid edema)
resulting in severe post-cricoid/pyriform residue;
cued coughs were not successful in clearing material
from the larynx; assume aspiration of thin liquid from
laryngeal residue, although difficult visualization 2/2
severe supraglottic/vocal fold edema w/ largely
adducted vocal fold position
Pudding 5 (suspect 8); recurrent gross penetration of puree
after the swallow 2/2 reduced UES relaxation (likely
related to significant post-cricoid edema) resulting in
severe post-cricoid/pyriform residue; cued coughs
were not successful in clearing contrast from the
larynx; assume aspiration of puree from laryngeal
residue, although difficult visualization 2/2 severe
supraglottic/vocal fold edema w/ largely adducted
vocal fold position
Solid N/A
Compensatory Swallow Volitional cough & re-swallow were not effective in clearing the airway of material
Strategies or significantly reducing pharyngeal residue
A Severe pharyngeal dysphagia due to gross laryngeal/pharyngeal edema s/p blunt neck trauma. Endoscopic
examination revealed severe edema of the bilateral vocal folds w/ bilateral vocal fold adduction, which
appeared to obstruct the patient’s airway. Recurrent gross penetration (& suspected aspiration) of thin liquid &
puree. Pt does not appear safe for oral diet at this time, given acuity of illness & critical condition. Anticipate
spontaneous recovery as laryngeal/pharyngeal edema improves.
P Diet recommendation NPO except ice chips for swallow maintenance & patient comfort. Short-term
nutrition/hydration route per MD discretion. Caution bedside NGT placement due to
severity of pharyngeal edema & poor UES relaxation to reduce risk for further
pharyngeal/laryngeal trauma.
Specialist referrals Management of laryngeal/pharyngeal edema per ENT
Ancillary tests N/A
Goal Pt will improve pharyngeal wall contraction via Effortful Swallows x50/tx; Pt will improve
PES relaxation via CTAR x50/tx; Pt will improve cough strength for airway protection
against aspiration via EMTS w/ MEP of 50 cm H2O
Follow-up exam Repeat FEES approx. q1 week until safe for oral diet

HPI 47yoF admitted w/ nausea/vomiting, “throat hardness,” dysphagia x1 week to both liquids & solids, weight
loss
PMHx Metastatic ovarian adenocarcinoma s/p surgical tx & chemotherapy
S Pt alert, very pleasant/cooperative for exam. Excellent tolerance of endoscopic exam; no adverse event. Dr.
Scope present at bedside for exam.
swallowing.
P.O. trials Ice chips, thin liquid via tsp/straw, puree, & solid
Velopharyngeal function Reduced b/l palatal elevation; unable to achieve
Nasopharyngoscopic
complete velopharyngeal closure
findings
Anatomic findings WNL
Secretions Moderate secretions throughout the oropharynx
Vocal fold motion Mildly reduced vocal fold adduction b/l; unable to
Pharyngoscopic &
achieve full vocal fold adduction
Sensory integrity WNL
Clearance WNL
Pharyngeal phase
Pharyngeal contraction Severely impaired pharyngeal contraction b/l
findings
Other findings 3-6 spontaneous swallows per bolus
Thin liquid 3
Pudding 1
Solid 1
Compensatory Swallow Pt spontaneously utilized multiple swallows per bolus (3-6), which was successful in
Strategies reducing pharyngeal residue

A Moderate pharyngeal dysphagia of unknown etiology, marked by b/l pharyngeal weakness. Dysphagia is
characterized by severely impaired swallow efficiency, but grossly preserved airway protection & swallow safety.
Deficits are concerning for possible disease process at muscular level or neuromuscular junction & warrant
immediate physician evaluation. Swallow prognosis is unknown until dysphagia etiology is diagnosed; however,
pt may benefit from low-intensity exercise-based swallow rehabilitation in combination w/ compensation &
supportive care.
P Diet recommendation Solid diet level per pt’s discretion; pt currently requests IDDSI 7 (easy-to-chew). IDDDSI
0 liquids. Meds crushed in puree.
mobility as tolerated.
Specialist referrals Neurology & Rheumatology consults for undiagnosed dysphagia etiology. Dietitian
consult 2/2 high risk for malnutrition/dehydration.
Ancillary tests Per Neurology & Rhematology
Goal Pt will improve pharyngeal wall contraction & laryngeal vestibule closure via Effortful
Pitch Glides x20/tx; Pt will improve functional reserve for cough strength/airway
protection via EMST at 40% of pt’s MEP x20/tx
Follow-up exam Repeat FEES vs. VFSS in 4-6 weeks, or sooner pending medical dx & interventions

HPI 75yoF admitted from SNF with acute respiratory failure, hypoxia (SpO2 85%), AMS 2/2 PNA. Intubated x1
day. + dehydration & malnutrition.
PMHx COPD, CVA, HTN, renal failure
S Pt alert, pleasant but confused for exam. Tolerated endoscopy well w/out adverse event. Did not follow
commands during exam.
swallowing.
P.O. trials Ice chips, thin liquid, mildly-thick liquid, moderately-thick liquid, & puree
Secretions Copious thick white secretions in the post-cricoid
space & larynx; significant secretion production from
trachea & PES observed
Vocal fold motion Complete right vocal fold abduction/adduction;
mildly reduced abduction/adduction of the left vocal
Pharyngoscopic &
fold/arytenoid, however, the right larynx
compensated to achieve full adduction
Anatomic findings Focal erythema on the anterior tracheal wall in the
immediate subglottic space, c/w likely trauma r/t
recent endotracheal intubation
Posterior containment Impaired; entire ice chip bolus noted to escape to
pyriforms x2
Oral phase findings
Mastication N/A
Clearance Impaired
Initiation of swallow Moderate-severely delayed w/ all consistencies
BOT retraction Impaired
Pharyngeal phase
Pharyngeal contraction Impaired b/l
findings
PES opening Impaired
Other findings N/A
Thin liquid 7; aspiration before the swallow 2/2 delayed swallow
trigger
Mildly-thick liquid 8; aspiration before the swallow 2/2 delayed swallow
8-point Penetration- trigger
Aspiration Scale (PAS) Moderately-thick liquid 8; aspiration before the swallow 2/2 delayed swallow
trigger
Pudding 2; deep laryngeal penetration x1 before the swallow,
which spontaneously cleared the airway

Solid N/A
Compensatory Swallow Pt unable to follow commands
Strategies
A Moderate-severe oropharyngeal dysphagia resulting in airway invasion of all trialed consistencies. In the context
of historical dysphagia risk factors (i.e., CVA, COPD). + admission w/ likely dysphagia-related complications (i.e.,
PNA, respiratory failure, malnutrition, dehydration), pt does not appear safe for oral intake at this time. Suspect
dysphagia is chronic, however, unable to exclude acute dysphagia exacerbation r/t 1-day endotracheal
intubation. Repeat assessment in 2-3 days appears indicated, prior to long-term nutrition/hydration POC.
P Diet recommendation NPO except ice chips. Short-term enteral feeding route (e.g., NGT)
Ancillary tests N/A
Goal Pt’s POA/caregiver will perform verbal teachback of recommendations to control pt’s
risk factors for dysphagia-related aspiration PNA
Follow-up exam Repeat FEES in 2-3 days to evaluate potential spontaneous recovery s/p extubation;
long-term nutrition/hydration POC pending repeat FEES results

HPI 55yoF admitted w/ dyspnea (progressive x1 month), >20 lb weight loss
PMHx COPD, anxiety, polysubstance abuse, MRSA, R vocal fold lesion (possible malignancy, pending biopsy),
smoking hx
S Pt alert, very pleasant & cooperative for exam. Excellent tolerance of endoscopy w/out adverse event, though
stridorous at rest & throughout exam. Sister at bedside. Pt highly receptive to all education.
swallowing.
P.O. trials Ice chips, thin liquid via tsp/straw, puree, & solid
Secretions Mild secretions in larynx, pyriforms, & valleculae
Vocal fold motion Reduced b/l vocal fold motion (R worse than L); right
vocal fold in paramedian position w/ very limited
abduction/adduction; complete adduction of the left
vocal fold & mildly reduced abduction (however,
vocal fold motion was difficult to assess 2/2
obstructive soft tissue mass)
Pharyngoscopic &
Anatomic findings Very large, irregular pink soft tissue fullness of the
inter-arytenoid space, which obliterated the posterior
½-2/3 of the glottis; severe edema of the b/l vocal
folds w/ severely irregular phonating margins w/
multiple irregular white lesions on the b/l vocal folds
(R>L), which were also partially obstructive of the
anterior ½ of the glottis
Clearance WNL
BOT retraction WNL
Pharyngeal phase
findings
PES opening WNL
Other findings N/A
Thin liquid 8; large volume penetration & small volume
aspiration of thin liquid during the swallow 2/2
impaired LVC

Pudding 1
Solid 1
Compensatory Swallow Volitional cough, which was successful in reducing volume of airway invasion; b/l
Strategies head rotations were not effective in eliminating aspiration of thin liquids during the
swallow
A Mild pharyngeal dysphagia 2/2 reduced laryngeal vestibule closure/vocal fold mobility r/t large posterior glottic
soft tissue mass w/ b/l true vocal fold involvement, which obstructed the posterior ½-2/3 of the glottis. There is
significant concern regarding this patient’s airway patency; mildly stridorous at rest. Pt is at mildly increased risk
for dysphagia-related aspiration PNA 2/2 poor oral hygiene (i.e., obvious dental carries), which may transit
pathogens to the lungs with aspirated content. However, pt is immunocompetent & ambulatory, which decrease
her risk for aspiration PNA. In the context of clear CXR, diet modification does not appear indicated at this time.
Pt will benefit from immediate initiation of swallow rehabilitation, oral hygiene/dental interventions, & medical
management of partial upper airway obstruction.
P Diet recommendation IDDSI 7/0 diet. Meds whole w/ puree.

Risk management Compensatory swallow strategy: volitional cough every 3-5 sips of liquid. Control risk
for aspiration PNA via (a) oral hygiene QID, (b) dental intervention ASAP, (c) increasing
physical mobility after meals, & (d) EMST after meals for pulmonary hygiene
Specialist referrals ENT consult for airway assessment & previously recommended laryngeal biopsy.
Dietitian evaluation for possible nutrition supplementation, given weight loss.
Ancillary tests ENT laryngoscopy & biopsy (per prior ENT recommendation)
Goal Pt will increase cough strength for airway protection against aspiration via EMST at 80%
of pt’s MEP x30/tx
Follow-up exam Repeat FEES and/or VFSS q2-3 months to monitor changes in swallow function w/
anticipated medical interventions for laryngeal pathology

HPI 62yoM admitted w/ SOB. Hospital course complicated by “choking” event on solid w/ subsequent
worsening dysphagia symptoms.
PMHx COPD, HIV, CAD, MI, BPH
S Pt alert, cooperative for exam. Appeared in extreme discomfort prior to exam r/t dysphagia symptoms;
coughing & expectorating secretions. Tolerated exam without adverse event. SpO2 >98% throughout exam.
swallowing.
P.O. trials N/A
Secretions Copious frothy secretions in the pyriforms, valleculae,
pharyngeal walls, post-cricoid area, & larynx; +
aspiration of secretions
Pharyngoscopic &
Vocal fold motion Unable to assess 2/2 reduced visualization r/t copious
secretions
Posterior containment N/A
Clearance N/A
Initiation of swallow Elicited swallows of secretions
BOT retraction WNL
PES opening Suspect severely impaired vs. mechanically
obstructed; absent passage of secretions into PES
despite repeated swallows
Other findings Study was terminated prior to p.o. trials 2/2 severity
Pharyngeal phase
of dysphagia w/ secretions; after withdrawal of
findings
endoscope, SLP again questioned pt regarding his
symptoms; pt continues to endorse severe globus
sensation after consuming meat at dinner last night.
Pt now clarifies he was able to breath/voice during
reported “choking” event. Upon further questioning,
pt endorses hx of esophageal impaction of chicken
x1 s/p endoscopic removal at OSH. These results
were communicated to RN & physician was phoned
immediately after exam.
Thin liquid N/A

Pudding N/A
Solid N/A
Yale Pharyngeal Residue Valleculae 4 w/ secretions
Severity Rating Scale Pyriform sinuses 5 w/ secretions
Compensatory Swallow Dry swallows & b/l head rotations were not effective in improving passage of
Strategies secretions into PES
Dysphagia Outcome and 7; suspect severe esophageal dysphagia/mechanical obstruction
A Copious frothy secretions throughout the pharynx/larynx, despite grossly normal pharyngeal & laryngeal
physiology. + aspiration of secretions w/ intact sensory response. Pt unable to pass saliva via PES & endorses
severe globus sensation after consuming meat last night. Study was terminated 2/2 concern for possible
esophageal food impaction; critical result phoned to physician.
P Diet recommendation Strict NPO, pending GI evaluation

Risk management HOB upright. Suction PRN. Close airway monitoring.
Specialist referrals STAT GI consult to r/o possible esophageal obstruction/food impaction
Ancillary tests Consider EGD
Therapy Pending results of GI consult
Follow-up exam Pending results of GI consult

HPI 48yoF transferred from OSH for “throat pain” radiating to chest, nausea, & vomiting. To SLP, pt endorses hx
of progressive dysphagia >1.5 years, which acutely worsened approx. 1 week ago.
PMHx HTN, ETOH, reflux, hemorrhagic gastritis. Questionable hx of CVA; pt states, “I think I had a stroke in 2016,
but no documentation of this in medical records other than GI note in 2018 that also stated pt reported
she believed she had a stroke; no brain imaging in medical records. Barium Esophagram in 2017 revealed
possible tertiary contractions.
S Pt alert for exam. Tolerated endoscopy without adverse event. Exam terminated w/ pt in stable condition, & pt
then transported to MRI Brain.
swallowing.
P.O. trials Ice chips, thin liquid via tsp, & puree via ¼ tsp
Nasopharyngoscopic Velopharyngeal function Reduced R palatal elevation
Secretions Moderate-severe secretions pooling in the pyriforms,
valleculae, along pharyngeal walls, & post-cricoid
area; mild secretions within the larynx
Vocal fold motion Reduced mobility of the R vocal fold/larynx, although
Pharyngoscopic &
compensation/complete adduction achieved
Anatomic findings Convexity of the R pharyngeal wall, c/w possible R
pharyngeal weakness vs. fullness; asymmetry of
larynx as described above
Clearance Impaired (R oral residue)
Pharyngeal contraction Severely impaired R pharyngeal contraction
Pharyngeal phase
PES opening Severely impaired
findings
Other findings Estimated <10% passage of all boluses into PES 2/2
severity of pharyngeal dysphagia; study terminated
prior to larger bolus volumes for pt’s airway
protection, given objective dystussia (PEFR <60
L/min) & severity of pharyngeal weakness
Thin liquid 1
Pudding 1
Solid N/A

Yale Pharyngeal Residue Valleculae 5; severe b/l residue w/ thin liquid & pudding, which
Severity Rating Scale did not clear desite repeated dry swallows
Pyriform sinuses 5; severe b/l residue w/ thin liquid & pudding, which
did not clear desite repeated dry swallows
Compensatory Swallow Cued dry swallows, which were not successful in improving bolus passage into PES;
Strategies b/l head rotations were not successful in improving bolus passage into PES
A Severe oropharyngeal dysphagia of unknown etiology marked by R lingual, pharyngeal, & laryngeal weakness
c/w likely R CN X & XII involvement. Swallow efficiency is severely impaired, w/ estimated <10% bolus passage
into PES; airway invasion was not directly observed on this exam, though study was terminated for pt’s airway
protection 2/2 severity of pharyngeal weakness, inefficacy of compensatory strategies, & pt’s severe dystussia. Pt
will benefit from further dysphagia diagnostics to assess oropharyngeal & cervical esophageal swallow function.
High clinical concern for neurogenic dysphagia warranting Neurology workup. Swallow prognosis is unknown
until medical dx of pt’s dysphagia etiology, however, pt may benefit from low-intensity swallow rehabilitation.
P Diet recommendation NPO except ice chips & tsps of water for pt comfort & swallow exercise. Consider short-
term enteral feeding route (e.g., NGT) while pt undergoes medical workup for
dysphagia etiology.
Specialist referrals Neurologist consult 2/2 dysphagia of unknown etiology.
Ancillary tests Per Neurologist
Therapy Swallow rehabilitation w/ SLP x5/week
Goal Pt will improve pharyngeal contraction & laryngeal vestibule closure via Effortful Pitch
Glides x20/tx; Pt will improve cough strength for airway protection via EMST at 40% of
pt’s MEP x20/tx; Pt will improve PES relaxation via CTAR x20/tx
Follow-up exam VFSS tomorrow for additional swallow diagnostic information

HPI 44yoF transferred from OSH after being found down w/ quadriplegia 2/2 C6-C7 subluxation & severe
occlusion of spinal canal w/ cutoff of R vertebral artery. S/p emergent posterior decompression & fusion of
c-spine & tracheotomy.
PMHx Polysubstance abuse, questionable psychiatric hx
S Pt alert & participated in exam, however, confused & mouthing that she’d “like to ger [her] car.” Study
conducted w/ Shiley #8 cuffed tracheostomy tube, cuff inflated, on vent in Spontaneous mode w/ 30% FiO2 &
RR 25-39. Pt tolerated brief trach mask trial earlier, however, quickly fatigued & required pressure support. Not a
candidate for PMV use in-line on vent at this time 2/2 poor upper airway patency w/ current trach size. Pt
requiring cuff inflation for pressure support at this time.
swallowing.
P.O. trials Ice chips, thin liquid via tsp/straw, & puree
findings Anatomic findings NGT in situ
Secretions Mild secretions in the valleculae & pyriforms
Vocal fold motion Significantly reduced right vocal fold mobility (both
abduction & adduction), highly concerning for
Pharyngoscopic & possible right vocal fold paresis; normal left vocal
laryngoscopic findings fold mobility
Anatomic findings Laryngeal asymmetry as described above;
tracheostomy tube & NGT in situ
Clearance WNL
Pharyngeal phase
Pharyngeal contraction Mildly impaired
findings
Other findings N/A
Thin liquid 1
Pudding 5; penetration of puree to the vocal folds after the
swallow from pharyngeal residue; pt unable to cough
to clear penetrated material from the larynx 2/2
impaired upper airway patency w/ current trach size +
cuff inflation
Solid N/A
Valleculae 3
Compensatory Swallow Cued dry swallows were effective in clearing pharyngeal residue; pt unable to
Strategies cough 2/2 absent upper airway patency w/ cuff inflation & current trach diameter
A Moderate-severe pharyngeal dysphagia resulting in both impaired safety & efficiency of swallowing, which
appears largely r/t absent upper airway patency w/ current trach diameter + cuff inflation; pt unable to protect
airway via cough response due to absent upper airway patency. Significantly reduced mobility of the right vocal
fold concerning for possible paresis. Swallow prognosis is good for oral diet, pending trach downsize, cuff
deflation, & PMV use. Strongly advise deferring consideration of PEG tube, as this pt’s dysphagia is likely to
improve s/p trach change.
P Diet recommendation NPO except ice chips & tsps of water for oral gratification/swallow stimulation.
Continue use of NGT for nutrition/hydration.
Specialist referrals F/u w/ ENT for trach tube downsize to Shiley #6 cuffed tracheostomy tube
Ancillary tests N/A
Therapy Swallow tx w/ SLP x5/week
Goal Pt will perform Effortful Swallows w/ 1-3 mL water boluses x50/tx to combat effects of
muscle disuse atrophy during temporary NPO status
Follow-up exam Repeat FEES s/p trach downsize & cuff deflation/PMV use (goal for 1-3 days)

HPI 44yoF transferred from OSH after being found down w/ quadriplegia 2/2 C6-C7 subluxation & severe
occlusion of spinal canal w/ cutoff of R vertebral artery. S/p emergent posterior decompression & fusion of
c-spine & tracheotomy.
PMHx Polysubstance abuse, questionable psychiatric hx
S Pt alert & requesting NGT removal; states she is eager to eat by mouth. Agreeable to exam. Shiley #6 cuffed
trach in place, cuff fully deflated, on trach mask w/ PMV in place. NGT removed during exam for improved
pharyngeal/laryngeal visualization, under order from Intensivist.
swallowing.
P.O. trials Ice chips, thin liquid via tsp/straw, mildly-thick liquid via straw, puree, & solid
Secretions WNL
Vocal fold motion Significantly reduced right vocal fold mobility (both
abduction & adduction), highly concerning for
Pharyngoscopic & possible right vocal fold paresis (unchanged from
laryngoscopic findings prior exam); normal left vocal fold mobility
Anatomic findings Laryngeal asymmetry as described above;
tracheostomy tube & NGT in situ
Clearance WNL
Pharyngeal phase
Pharyngeal contraction Mildly impaired
findings
Other findings N/A
Thin liquid 3; recurrent penetration of thin liquids during the
swallow 2/2 impaired LVC & after the swallow from
mild post-cricoid/pyriform residue; no sensation of
8-point Penetration- laryngeal residue
Aspiration Scale (PAS) Mildly-thick liquid 1
Pudding 1
Solid 1

Compensatory Swallow Cued dry swallows were effective in clearing pharyngeal residue; cued coughs &
Strategies dry swallows after thin liquids were not effective in clearing material from the
larynx; pt’s waxing/waning mental status & level of acuity not appropriate for more
complex compensatory maneuvers
A Mild pharyngeal dysphagia 2/2 impaired right laryngeal/vocal fold mobility, mild pharyngeal weakness, &
dystussia. Both swallow efficiency & safety appear mildly impaired. Exam conducted w/ Shiley #6 trach w/ cuff
deflated & PMV in place on trach mask. Given pt’s acuity of illness, pulmonary comorbidities/dystussia, & limited
physical mobility, risk for dysphagia-related aspiration PNA is increased; temporary diet modification appears
indicated.
P Diet recommendation IDDSI 7 (easy-to-chew)/2 diet. Meds crushed or whole in puree.

Risk management Aspiration precautions: feed only when on trach mask w/ cuff fully deflated & PMv in
place, avoid thin liquids. Control risk for aspiration PNA via (a) oral hygiene q4h, & (b)
Ancillary tests N/A
Goal Pt will improve pharyngeal strength & laryngeal vestibule closure via Effortful Pitch
Glides x50/tx; Pt will improve cough strength for airway protection against aspiration
via EMST at 70% of pt’s MEP x30/tx
Follow-up exam Repeat FEES in 1-2 weeks to evaluate progress in swallow tx & safety to liberalize liquid
diet

HPI 72yoM admitted from SNF w/ fever & hypoxia 2/2 PNA; h/c involved endotracheal intubation x3 days.
PMHx DM, HTN, CVA in 2018, PNA w/ 10 day hospitalization, liver transplant on immunosuppression tx
S Pt alert, participated well in exam; study conducted on HFNC at 40L/min. Son at bedside, who endorses pt has
demonstrated symptoms of dysphagia since CVA in 2018.
swallowing.
Ice chips, thin liquid, mildly-thick liquid, moderately-thick liquid, & puree; solid not
P.O. trials
trialed 2/2 pt’s WOB on HFNC
Secretions Significant dried secretions in the pyriforms,
valleculae, pharyngeal walls, base of tongue, & post-
cricoid area
Vocal fold motion Significantly reduced mobility of the L arytenoid/truve
Pharyngoscopic & vocal fold (reduced abduction/adduction); complete
laryngoscopic findings R laryngeal mobility; severely impaired vocal fold
adduction 2/2 severe b/l vocal fold bowing
Anatomic findings Asymmetry of the larynx, as described above; severe
bowing of b/l true vocal folds
Posterior containment Impaired w/ thin liquids
Clearance WNL
Pharyngeal phase
findings
PES opening WNL
Other findings
Thin liquid 8; silent aspiration of thin liquid during the swallow
2/2 impaired LVC
Mildly-thick liquid 3; penetration of mildly-thick liquid during the
8-point Penetration- swallow 2/2 impaired LVC; material could not be
Aspiration Scale (PAS) cleared from the larynx
Pudding 1
Solid N/A
Valleculae 3

Compensatory Swallow Cued cough ineffective in clearing material from the airway; complex
Strategies compensatory maneuvers (e.g., head rotations, supraglottic swallow) not utilized,
given pt’s critical illness & poor likelihood for consistent implementation
A Moderate oropharyngeal dysphagia marked by impaired swallow safety & efficiency, likely r/t reduced L
laryngeal mobility + b/l vocal fold bowing. Suspect dysphagia is multifactorial, likely acute (r/t recent
endotracheal intubation) on chronic (r/t hx of CVA), given PNA x2 + dysphagia symptoms s/p CVA. In the
context of pt’s critical illness & immunosuppression, diet modification appears indicated. Swallow prognosis
appears fair, pending participation in exercise-based swallow rehabilitation.

Risk management Aspiration precautions: 1:1 feeding assist, small/single sips of moderately-thick liquid,
feed only when RR <25. Control risk factors for aspiration PNA via (a) oral hygiene QID,
& (b) increasing physical mobility as tolerated.
Specialist referrals PT consult to improve physical mobility during critical illness. Dietitian consult 2/2 risk
for malnutrition/dehydration. Consider ENT consult if vocal fold/laryngeal function not
improved w/ behavioral tx within 2 weeks.
Ancillary tests N/A
Goal Pt will improve laryngeal vestibule closure via Effortful Pitch Glide x50/tx; Pt will
improve cough strength for airway protection against aspiration via EMST at 70% of
MEP x30/tx
Follow-up exam Repeat FEES in 1-2 weeks, pending clinical progress in swallow tx

HPI 25yoM admitted for cough, dyspnea, hypoxia, fever, & generalized weakness 2/2 PNA.
PMHx PNA x3 this year, cachexia/malnutrition
S Pt alert, agreeable to exam but reported, “I’m feeling anxious.” Pt states he is agreeable to participate in exam.
Excellent tolerance of endoscopy w/overt adverse event.
swallowing.
Nasopharyngoscopic Velopharyngeal function Reduced b/l velopharyngeal closure
Secretions Moderate-severe frothy secretions in the b/l pyriform
sinuses & mild frothy secretions within the larynx at
rest
Pharyngoscopic & Vocal fold motion Significantly reduced b/l vocal fold abduction;
laryngoscopic findings minimally/inconsistently impaired b/l vocal fold
adduction
Clearance WNL
Pharyngeal phase Pharyngeal contraction Moderate-severely impaired pharyngeal wall
findings contraction b/l; no “white out” period during swallow
Other findings
Thin liquid 2; penetration of thin liquid post-swallows 2/2 diffuse
pharyngeal weakness/residue
Pudding 1
Solid 2; penetration of thin liquid post-swallows 2/2 diffuse
pharyngeal weakness/residue

Compensatory Swallow Cued dry swallows, which were effective in reducing but not eliminating
A Moderate pharyngeal dysphagia of unknown etiology marked by diffuse bilateral pharyngeal weakness,
resulting in significantly impaired swallow efficiency. Mildly impaired b/l laryngeal function, most notably
impaired b/l vocal fold abduction. No aspiration directly observed, however, potential for microaspiration
events post-swallow is evident (given severity of pharyngeal residue). In the context of recurrent PNA, aspiration
precautions (described below) are advised. Immediate medical workup of dysphagia etiology is indicated.
P Diet recommendation IDDSI 7/0 diet.

Risk management Aspiration precautions: small bolus volumes, multiple swallows per bolus, encourage
volitional dry swallows & coughs throughout meals. Control risk for aspiration PNA via
(a) oral hygiene QID, (b) increasing physical mobility, particularly after meals, & (c)
EMST for pulmonary hygiene after meals
Specialist referrals Neurology & Rheumatology consults for unknown dysphagia etiology
Ancillary tests Per Neurology & Rheumatology
Goal Pt will improve pharyngeal wall contraction via Effortful Swallows x50/tx; Pt will improve
PES relaxation via CTAR xs50/tx; Pt will improve functional reserve for cough strength
for airway protection against aspiration via EMST at 60% of pt’s MEP x30/tx
Follow-up exam VFSS today for further swallow diagnostics, given unknown dysphagia etiology

HPI 63yoM admitted w/ acute encephalopathy. Approx 1 month ago, pt developed progressive weakness; was
evaluated OSH & found w/ “encephalitis” & Miller Fisher Guillain-Barre Syndrome (GBS) (s/p 5-day IVIG tx),
required mechanical ventilation s/p tracheotomy & PEG. Transferred from OSH for insurance purposes. H/c
involved 1.5 month NPO status for dysphagia.
PMHx DM
S Pt alert, cooperative, & highly motivated for exam. Excellent tolerance of endoscopy w/out adverse event. Shiley
#6 cuffed trach, cuff deflated, w/ PMV for exam; pt on trach mask for O2 delivery.
swallowing.
P.O. trials Thin liquid, mildly-thick liquid, & puree
Nasopharyngoscopic Velopharyngeal function Reduced b/l palatal elevation
Secretions Copious thick/yellow secretions in the post-cricoid
space & pyriform sinuses; yellow secretions visible
Pharyngoscopic & within the trachea on the tracheostomy tube
laryngoscopic findings Vocal fold motion WNL
Anatomic findings Tracheostomy tube in situ
Posterior containment Severely impaired w/ all consistencies; absent oral
transit, requiring posterior head tilt & reclined
positioning via lowering HOB to near supine position
to elicit AP transit, which resulted in immediate
aspiration event (see below)
Clearance Severely impaired w/ all consistencies; absent oral
transit, requiring posterior head tilt & reclined
positioning via lowering HOB to near supine position
to elicit AP transit, which resulted in immediate
aspiration event (see below)
Initiation of swallow Absent
BOT retraction Absent
Epiglottic movement Absent
Pharyngeal contraction Absent
Laryngeal vestibule closure Absent
Pharyngeal phase PES opening Absent
findings Other findings Multiple trials of thin liquid, mildly-thick liquid, &
puree were administered in attempt to facilitate AP
transfer; due to severity of oral stage deficits,
required near supine position to transit material to
the pharynx; study was terminated & tracheal
suctioning completed

Thin liquid 7; gross aspiration event 2/2 absent swallow trigger;
aspiration event was of mixture of thin liquid, mildly-
thick liquid, & puree oral residue
Mildly-thick liquid 7; gross aspiration event 2/2 absent swallow trigger;
Pudding 7; gross aspiration event 2/2 absent swallow trigger;
Solid N/A
Compensatory Swallow Utilized posterior head tilt posture + HOB lowering to near supine position to
Strategies facilitate oral bolus transfer; unable to trial additional compensatory techniques 2/2
absent pharyngeal swallow response
A Profound oropharyngeal dysphagia marked by absent oral transit & swallow trigger. Dysphagia likely r/t b/l CN
X involvement & diffuse oropharyngeal weakness 2/2 Miller Fisher variant of GBS. Pt is at high risk for
dysphagia-related aspiration PNA, given severity of dysphagia/dystussia & impaired physical mobility. Pt is not
safe for any oral intake at this time. Swallow prognosis is fair for long-term improvement, pending intensive
swallow rehabilitation.
P Diet recommendation Strict NPO. Continue use of PEG for nutrition/hydration.

Risk management Oral hygiene QID. Continue w/ PT & OT to improve physical mobility.
Ancillary tests N/A
Goal Pt will elicit swallow trigger to palpation x5/tx w/ max multimodal sensory stimulation;
pt will improve cough strength for airway protection against aspiration via EMST at 50%
of pt’s MEP x20/tx
Follow-up exam Repeat FEES vs. VFSS in approx. 4 weeks, pending clinical progress

HPI 63yoF admitted w/ cough, SOB, hypoxia (SpO2 55%) 2/2 COVID-19 PNA/ARDS. H/c involved HFNC
dependency x6 days; pt developed b/l pneumothoraces s/p b/l chest tubes. Worsening respiratory failure
requiring endotracheal intubation x18 days s/p tracheotomy. + COVID encephalopathy, encephalitis, & b/l
watershed CVAs (per MRI Brain) in b/l frontotemporal & posterior R parieto-occipital regions.
PMHx RA, hypothyroidism, remote lacunar infarcts in b/l cerebellar hemispheres
S Pt alert, very pleasant for exam. Followed all commands & mouthed words during exam. Shiley #6 cuffed trach
w/ cuff inflated on vent in SIMV mode for exam; unable to complete exam w/ cuff deflation & PMV use 2/2 SpO2
desaturation.
swallowing.
Secretions WNL
Pharyngoscopic & Vocal fold motion WNL
laryngoscopic findings Sensory integrity Impaired
Anatomic findings Tracheostomy tube & NGT in situ
Posterior containment Impaired w/ thin liquids; oral containment improved
w/ increased viscosity
Oral phase findings
Mastication Impaired; pt appeared to fatigue during mastication
Clearance WNL
Initiation of swallow Mildly delayed, which improved w/ increased
viscosity
BOT retraction WNL
Pharyngeal phase Epiglottic movement WNL
findings Pharyngeal contraction WNL
PES opening WNL
Other findings N/A
Thin liquid 8; penetration of thin liquid via tsp & silent aspiration
of thin liquid via cup before the swallow 2/2 impaired
oral containment + delayed swallow trigger
Pudding 1
Solid 1
Compensatory Swallow Pt unable to perform chin tuck posture w/ cueing (repeatedly demonstrated neck
Strategies extension) 2/2 cognitive deficits; unable to communicate instructions for 3-esc prep
set 2/2 noise from PAPR & HEPA filter (COVID-19 isolation precautions)
A Mild oropharyngeal dysphagia, multifactorial r/t prolonged endotracheal intubation + impaired upper airway
patency w/ trach cuff inflated + ventilator dependency + acute b/l CVAs. Exam was conducted w/ Shiley #6
cuffed trach, cuff inflated, on vent in SIMV mode. Swallow safety is mildly impaired & swallow efficiency is grossly
preserved. Pt appears safe for full oral diet.
P Diet recommendation IDDSI 5/2 diet. Meds crushed in puree. Safe to eat/drink while on vent w/ cuff inflated in
SIMV mode. SLP will advance solid diet at bedside as pt’s endurance improves, given
deconditioning.
Risk management Aspiration precautions: 1:1 feeding assist, upright position, small/single sips of mildly-
thick liquids, avoid thin liquids. Control risk factors for aspiration PNA via (a) oral
hygiene q4h, & (b) PT/OT consults to improve physical mobility.
Specialist referrals PT & OT consults to improve physical mobility 2/2 acute CVAs + critical
illness/deconditioning
Ancillary tests N/A
Therapy Swallow/voice rehabilitation w/ SLP x5/week
Goal Pt will tolerate cuff deflation w/ PMV in-line on ventilator x1 hour to improve upper
airway patency for cough/airway protection
Follow-up exam Repeat FEES after tolerance of cuff deflation & PMV use

PMHx Mediastinal tumor, possible vocal fold paralysis
S Pt alert, very cooperative for exam. Highly receptive to education regarding swallow function. Expressing
concern regarding his dyspnea & w/ questions regarding overall POC (e.g., “Do I need surgery?”); referred pt to
discuss w/ physician. Pt tolerated endoscopy well w/out adverse event.
swallowing.
Secretions Mild secretions throughout the pharynx/larynx
Vocal fold motion Significant dysfunction of the /bl larynx/vocal folds;
the right true vocal fold was in the median position at
rest (elicited minimal/inconsistent R vocal fold
abduction only w/ cues for deep inspiration); the left
true vocal fold was in the paramedian position at rest
w/ incomplete L arytenoid abduction & complete
Pharyngoscopic & adduction; the patient was observed to breathe via a
laryngoscopic findings small posterior glottic gap for the majority of the
exam (the anterior 2/3 of the vocal folds were in an
adducted position for the majority of the exam); there
was significant hyperfunction of the b/l ventricular
folds
Anatomic findings Abnormal laryngeal configuration as described
above
Clearance WNL
BOT retraction WNL
Pharyngeal phase Laryngeal vestibule closure WNL for swallowing tasks
findings PES opening Moderately impaired; inconsistent retrograde bolus
from PES/cervical esophagus into post-cricoid space
(query possible extrinsic compression by known
mediastinal mass?)
Other findings
Thin liquid 1
Pudding 1
Solid 1
Compensatory Swallow Pt demonstrated spontaneous dry swallows, which were successful in clearing
A Mild pharyngoesophageal dysphagia marked by PES dysfunction & possible partial cervical esophageal
obstruction. Laryngoscopic findings revealed b/l vocal fold dysfunction w/ poor b/l abduction, resulting in
functional partial upper airway obstruction. In the context of known R neck/mediastinal mass, findings are
concerning for possible extrinsic compression of the b/l RLNs. Solid diet modification appears indicated until
further diagnostic information on patency of cervical esophagus. Swallow prognosis is likely guarded without
medical/surgical intervention for mediastinal mass & should focus on compensation; however, pt may be an
excellent candidate for exercise-based swallow rehabilitation after medical/surgical intervention.
P Diet recommendation IDDSI 4/0 diet until VFSS results. Meds crushed in puree.
Risk management Aspiration/reflux precautions: small bites of solids, upright position during + 60 mins
after meals. Control risk factors for aspiration PNA via (a) oral hygiene QID, & (b)
Specialist referrals Cardiothoracic surgery and/or ENT consults 2/2 suspected RLN compression by
mediastinal mass.
Ancillary tests N/A
Therapy SLP following x2/week for pt education on compensatory strategies & supportive care;
increase tx to x5/week s/p medical/surgical interventions
Goal Pt will perform verbal teachback of strategies to reduce risk for aspiration PNA.
Follow-up exam VFSS to better evaluate PES function & cervical esophageal patency

HPI 26yoM admitted for GSW to L face w/ bullet ricochet inferiorly through L lateral neck & chest w/ L mandible
fx s/p ORIF & tracheotomy, R clavicle fx (non-op), & pneumothorax s/p chest tube.
PMHx None
S Pt alert, very pleasant & cooperative for exam. States he is hopeful to eat by mouth. Tolerated endoscopy well
w/out adverse event. Study conducted w/ Shiley #6 cuffed trach, cuff deflated, on trach mask; unable to utilize
PMV 2/2 absent upper airway patency.
swallowing.
Ice chips, thin liquid, mildly-thick liquid, moderately-thick liquid, puree; solids not
P.O. trials
administered 2/2 maxillo-mandibular fixation (MMF)
Secretions Mild-moderate secretions in the pyriforms, valleculae,
Vocal fold motion Complete R vocal fold adduction but mildly reduced
abduction; severely reduced L vocal fold mobility, w/
near absent adduction/abduction (slight tremulous
movement)
Anatomic findings Severe ecchymosis of the left arytenoid cartilage &
left pyriform sinus w/ associated moderate edema of
the left arytenoid; moderate ecchymosis & edema of
Pharyngoscopic &
the left ventricular fold; bright red & yellow coloring
of the entire left true vocal fold, c/w likely vocal fold
hemorrhage; severe fullness/edema of the inter-
arytenoid space/posterior commissure; profound soft
tissue fullness of the immediate subglottic space
(which appeared to emerge from he inferior surface
of the L true vocal fold + L tracheal wall), which
entirely obstructed the trachea/immediate subglottic
space; there was absent visualization of any tracheal
rings & absent airspace/patency in the subglottic
space
Oral phase findings Mastication Unable to assess 2/2 MMF
Clearance Unable to assess 2/2 MMF
Pharyngeal phase
findings
Other findings Pt endorsed significant difficulty w/ oral transit of
puree & requested liquidized/moderately-thick
consistency
Thin liquid 8; trace silent aspiration during the swallow 2/2
impaired LVC/vocal fold adduction
Mildly-thick liquid 8; trace silent aspiration during the swallow 2/2
impaired LVC/vocal fold adduction
Pudding 1
Solid N/A
Compensatory Swallow Attempted L head rotation, however, very poor cervical ROM (presumably r/t
Strategies massive L facial/cervical edema); unable to achieve full glottic closure w/ attempted
breath hold
A Mild-moderate oropharyngeal dysphagia 2/2 maxillo-mandibular fixation (which impairs pt’s bolus preparation,
oral transit, & mastication) + significant laryngeal dysfunction/pathology (which impairs laryngeal vestibule
closure/airway protection) 2/2 penetrating head/neck injury. Pt will benefit from ENT evaluation/intervention of
laryngeal/tracheal pathology. Given pt’s independence for oral hygiene, age, immunocompetence, & physical
mobility, risk for dysphagia-related aspiration PNA appears low & pt appears safe for modified oral diet. Pt
appears to be a good candidate for exercise based swallow rehabilitation.
P Diet recommendation IDDSI 3/0 diet. Meds dissolved in liquids.

Risk management Control risk for aspiration PNA via (a) oral hygiene QID, including before & after meals,
& (b) increasing ambulation, especially after meals, for pulmonary toilet.
Specialist referrals ENT f/u for medical interventions to address laryngeal/tracheal pathology.
Ancillary tests Per ENT
Therapy SLP following x5/week for swallow/voice rehabilitation
Goal Pt will improve laryngeal vestibule closure via Effortful Pitch Glide x50/tx
Follow-up exam Repeat FEES, pending medical interventions by ENT

HPI 58yoF admitted for cough & dyspnea/hypoxia 2/2 COVID-19 PNA/ARDS s/p endotracheal intubation x11
days.
PMHx HTN, DM, obesity
S Pt alert, confused but cooperative for exam. Tolerated endoscopy well w/out adverse event. Did not follow
commands for compensatory strategies. Study conducted on nasal cannula at 5 L/min.
swallowing.
P.O. trials Ice chips, thin liquid, mildly-thick liquid, moderately-thick liquid, & puree
Secretions Mild-moderate secretions in the pyriforms & larynx
Vocal fold motion Complete arytenoid movement b/l; bowing of the b/l
true vocal folds, resulting in severely impaired glottic
closure
Anatomic findings Areas of erythema & blood product in the b/l true
Pharyngoscopic & vocal folds c/w possible vocal fold hemorrhage;
laryngoscopic findings large/rounded white lesions on the b/l posterior true
vocal folds/vocal processes of the arytenoids (R>L)
c/w possible granulomas; 2 large yellow masses in
the immediate subglottic space (questionably arising
from the inferior aspects of the vocal
folds/arytenoids) c/w possible granulomas; bowing of
the b/l true vocal folds
Clearance WNL
Pharyngeal phase
findings
PES opening WNL
Other findings N/A
Thin liquid 7; aspiration before the swallow 2/2 impaired
posterior oral containment + delayed swallow trigger
8-point Penetration- Mildly-thick liquid 7; aspiration during the swallow 2/2 impaired LVC
Aspiration Scale (PAS) Moderately-thick liquid 7; aspiration during the swallow 2/2 impaired LVC
Pudding 1
Solid N/A

Compensatory Swallow Pt unable to follow commands
Strategies
A Moderate-severe oropharyngeal dysphagia & significant laryngeal pathology 2/2 11-day endotracheal
intubation. Swallow safety & airway protection are severely impaired. Pt is at high risk for dysphagia-related
aspiration PNA, given critical illness, poor physical mobility, & poor oral hygiene. However, prognosis for
spontaneous swallow recovery is good.
P Diet recommendation NPO except ice chips & p.o. meds crushed in puree. Short-term enteral feeding (e.g.,
NGT).
Risk management Control risk for aspiration PNA via (a) oral hygiene q4h, & (b) increasing physical
Specialist referrals PT & OT consults to improve pt’s physical mobility.
Ancillary tests N/A
Therapy SLP will f/u x3/week to monitor for signs of spontaneous swallow improvement & to trial
exercise-based swallow rehabilitation
Goal Pt will tolerate least-restrictive p.o. diet, per FEES recs, w/out acute dysphagia-related
pulmonary complication.
Follow-up exam Repeat FEES in 4-5 days, pending clinical progress

HPI 50yoM admitted from SNF w/ abdominal pain, dysuria, elevated BUN. H/c involved dislodgement of
tracheostomy tube w/ Code Blue, s/p tracheostomy revision to Shiley #8 distal XLT. Pt reports to physicians
that his goal is to eat by mouth & pt declines g-tube feeding; pt states he has not received any swallow
study or SLP swallow rehabilitation s/p trach/PEG at OSH approx. 6 months ago s/p cardiac arrests.
PMHx DM, HTN, HLD, ESRD, R BKA, sepsis, multiple cardiac arrests approx. 6 months ago s/p trach & PEG,
dysphagia.
S Pt alert, very pleasant for exam. Pt states he is eager to eat/drink by mouth & that he wishes to decline g-tube
feeding until swallow study. Shiley #8 distal XLT in place; not a candidate for PMV 2/2 absent upper airway
patency.
swallowing.
findings Anatomic findings Enlarged inferior turbinate in L nare
Secretions WNL
Vocal fold motion WNL
Pharyngoscopic &
Anatomic findings Tracheostomy tube hardly visible within the trachea
2/2 significant circumferential narrowing of the
trachea/subglottic space c/w possible subglottic
stenosis
Clearance WNL
BOT retraction WNL
Pharyngeal phase
findings
PES opening Mildly reduced
Other findings WNL
Thin liquid 2; transient penetration of thin liquids during the
swallow, which is normal
Pudding 1
Solid 1
Strategies

A Functional oropharyngeal swallow. Transient penetration of thin liquids, which is normal; no aspiration elicited.
Both swallow safety & efficiency are functional. Laryngoscopic exam revealed narrowing of the trachea above
the tracheostomy tube c/w possible subglottic stenosis, for which pt may benefit from ENT medical/surgical
intervention. Pt appears safe for full oral diet.

Risk management N/A
Specialist referrals ENT for treatment of suspected subglottic stenosis. Dietitian assessment to transition pt
from g-tube feeding to full oral diet.
Ancillary tests ENT laryngoscopy
Therapy SLP will sign off, as swallow goal met
Goal N/A
Follow-up exam N/A

HPI 59yoM admitted w/ dyspnea & hypoxia (SpO2 50%) 2/2 COVID-19 w/ viral PNA/ARDS s/p endotracheal
intubation x29 days s/p tracheotomy & g-tube. H/c involved barotrauma/pneumomediastinum 2/2
prolonged intubation s/p b/l chest tubes.
PMHx None
S Pt alert, highly motivated for exam. Excellent tolerance of endoscopy. Shiley #8 cuffed trach, cuff deflated, w/
PMV in place on t-piece blowby for O2 delivery; RR 25-35.
swallowing.
Secretions Mild-moderate secretions in the pyriforms, valleculae,
Vocal fold motion Incomplete left vocal fold mobility w/ significantly
impaired adduction; complete right vocal fold
Pharyngoscopic & abduction/adduction; right vocal fold appeared to
laryngoscopic findings cross midline to compensate for suspected left vocal
fold paresis
Anatomic findings Abnormal laryngeal configuration, as described
above; tracheostomy tube in situ
Mastication Impaired; pt fatigued quickly & required puree bolus
Oral phase findings
to facilitate mastication/AP transit
Clearance WNL w/ liquids/puree; impaired w/ solid
Pharyngeal phase
Pharyngeal contraction Mildly impaired bilaterally
findings
Other findings N/A
Thin liquid 3; recurrent penetration of thin liquid during the
swallow 2/2 impaired LVC + after the swallow from
pharyngeal residue; unable to clear thin liquid from
larynx w/ cued cough
Mildly-thick liquid 3; no airway invasion w/ mildly-thick liquid via tsp,
cup sip, or single straw sip; 1 instance of shallow
penetration of mildly-thick liquid during consecutive
straw drinking

Pudding 1
Solid 1
Compensatory Swallow Pt spontaneously demonstrated dry swallows, which were effective in clearing
Strategies pharyngeal residue; cued cough was ineffective in clearing material from the larynx
A Mild-moderate oropharyngeal dysphagia resulting in impaired swallow safety & efficiency 2/2 prolonged
endotracheal intubation. In the context of pt’s acuity of illness, pulmonary comorbidities, dependence for oral
hygiene, & poor physical mobility, pt is at increased risk for dysphagia-related aspiration PNA. Temporary diet
modification appears indicated, while pt participates in intensive exercise-based swallow rehabilitation.
P Diet recommendation IDDSI 4/2 diet. Meds crushed or whole in puree.

Risk management Aspiration precautions: upright position, don PMV for meals, single sips of mildly-thick
liquid. Control risk factors for aspiration PNA via (a) oral hygiene QID, & (b) increasing
physical mobility as tolerated.
Specialist referrals PT & OT consults to improve physical mobility. Dietitian consult to assist in weaning pt
from g-tube nutrition to modified oral diet.
Ancillary tests F/u w/ ENT for trach downsize to Shiley #6 cuffless to improve upper airway patency for
voice/swallowing
x50/tx; Pt will improve LVC & pharyngeal wall contraction via Effortful Pitch Glides
x50/tx; Pt will improve PES relaxation via modified CTAR x20/tx; Pt will improve cough
strength for airway protection via EMST at 60% of MEP x20/tx
Follow-up exam Repeat FEES in 2-4 weeks, pending clinical progress

HPI 67yoM admitted w/ MGSW to L anterior chest, face, & neck. Open fx of mandible. Hemorrhagic shock. S/p
tracheotomy.
PMHx Unknown
S Pt alert, very pleasant & cooperative for exam. Requesting to eat. Pt denies jaw pain & requests solid foods.
Shiley #8 cuffed trach, cuff fully deflated, on trach mask for exam; unable to tolerate PMV 2/2 poor upper airway
patency.
swallowing.
Secretions WNL
Vocal fold motion Absent movement of the right true vocal
fold/arytenoid, which may be c/w R RLN/SLN injury (in
the context of R neck GSW); complete left vocal fold
Pharyngoscopic &
abduction/adduction
Anatomic findings Asymmetry of the larynx, as detailed above;
significant subglottic edema, which largely obscured
view of the patient’s tracheostomy tube
Clearance WNL
BOT retraction WNL
Pharyngeal phase
findings
Laryngeal vestibule closure WNL during swallow tasks
Other findings N/A
Thin liquid 1
Pudding 1
Solid 1
Compensatory Swallow Spontaneous dry swallows effective in clearing trace pyriform residue
Strategies

A Functional oropharyngeal swallow. Pt appears safe for full oral diet. Laryngoscopic exam revealed absent
movement of the right true vocal fold/larynx c/w likely R RLN/SLN injury r/t R neck GSW. Significant subglottic
edema that appeared to obstruct pt’s airway.
P Diet recommendation No diet restrictions from SLP standpoint. Defer diet order to OMFS, given mandibular
fx.
Risk management N/A
Specialist referrals F/u w/ OMFS for diet order. F/u w/ ENT for subglottic edema.
Ancillary tests N/A
Therapy No swallow tx indicated; SLP will f/u for voice tx
Goal N/A
Follow-up exam N/A

HPI 31yoM admitted w/ GSW though mandible w/ mandibular fracture, massive lingual edema/bleeding s/p
tracheotomy.
PMHx None
S Pt alert w/ excellent tolerance of transnasal endoscope. Scope passed easily under NGT with no bleeding or
adverse event. Shiley #8 cuffed trach in place, cuff deflated, on trach mask for O2 delivery; PMV not utilized 2/2
absent upper airway patency.
swallowing.
P.O. trials Evaluated swallowing of secretions only
Secretions Copious clear secretions throughout the entire
nasopharynx/oropharynx/hypopharynx & larynx
Vocal fold motion Unable to visualize vocal folds
Anatomic findings Massive smooth/round soft tissue structure (c/w
possible massive cyst obliterating view of the L
arytenoid, versus massive focal edema of the L
Pharyngoscopic &
arytenoid cartilage) that entirely obliterated view of
the post-cricoid space, L pyriform sinus, & entire
supraglottic larynx/true vocal folds; this structure is
slightly left of midline, however, obliterates the entire
larynx b/l; mild edema of the base of tongue &
epiglottis b/l; NGT in situ, presumably coursing into
PES (although unable to visualize post-cricoid space
beyond pathologic structure)
Posterior containment N/A
Clearance N/A
Initiation of swallow Elicited swallows of secretions
BOT retraction WNL
Pharyngeal phase
Laryngeal vestibule closure Difficult to assess 2/2 obstructive mass/edema
findings
PES opening Inlet to UES mechanically obstructed by massive soft
tissue structure
Other findings Gross penetration & presumable aspiration of
secretions
Thin liquid N/A
Pudding N/A
Solid N/A
Yale Pharyngeal Residue Valleculae 4 w/ secretions
Severity Rating Scale Pyriform sinuses 5 w/ secretions
Compensatory Swallow Unable to trial 2/2 massive soft tissue structure
Strategies
A Severe oropharyngeal dysphagia r/t penetrating lingual injury + massive laryngeal pathology (i.e., cyst vs
massive focal edema of arytenoid) that is obliterating the larynx & inlet to the PES. Prompt ENT intervention is
required for medical management of laryngeal pathology. Pt does not appear safe for oral intake at this time.
P Diet recommendation NPO w/ short-term alternate means of nutrition/hydration (e.g., NGT)

mobility as feasible
Specialist referrals F/u w/ ENT ASAP
Ancillary tests ENT laryngoscopy and/or CT Soft Tissue Neck
Therapy SLP following x5/week for voice/swallow rehabilitation
Goal Pt will perform Effortful Swallows of saliva x50/tx to reduce effects of muscle disuse
atrophy 2/2 NPO status
Follow-up exam Repeat FEES, pending intervention by ENT

HPI 54yoM admitted w/ intermittent substernal chest pain, SOB, & dysphagia.
PMHx CHF, COPD, asthma, PE s/p IVC filter, CAD, DM, HTN. Pt endorses hx of dysphagia symptoms >10 years.
S Pt alert, very pleasant for exam. Excellent tolerance of endoscopy w/out adverse event.
swallowing.
Secretions WNL
Vocal fold motion Complete & frequently hyperfunctional vocal fold &
arytenoid adduction b/l w/ the phonating margins of
the true vocal folds & vocal processes of the
arytenoids intermittently crossing midline (left over
right) due to suspected alteration in vertical plane of
vocal folds; there appeared to be paradoxical vocal
fold motion w/ paramedian or partially adducted
vocal fold configuration during most inspiration
(anterior 2/3 of vocal folds adducted; posterior 1/3
abducted); intermittent spindle-shaped vocal fold
Pharyngoscopic &
configuration; severe hyperfunction of the b/l
ventricular folds, w/ ventricular fold adduction for
many inspiration/expiration tasks
Sensory integrity Suspect hypersensitivity 2/2 significant coughing in
the absence of laryngeal stimulation
Anatomic findings Significant convex appearance of the b/l pharyngeal
walls, which significantly narrowed the diameter of
the naso-/oro-/hypopharynx; generalized moderate
edema of the entire larynx (including the arytenoid
cartilages, aryepiglottic folds, & ventricular folds);
very prominent vascularization throughout the entire
larynx
Clearance WNL
BOT retraction WNL
Pharyngeal phase
findings
Pharyngeal contraction Appeared hyperfunctional b/l
Laryngeal vestibule closure Intermittently impaired
PES opening WNL
Other findings Of clinical relevance, abnormal adduction of the vocal
folds during inspiration was noted to correlate w/
small SpO2 desaturations (87-90%)
Thin liquid 5; intermittent penetration of thin liquid to the vocal
folds, which occurred before & during the swallow
2/2 incoordination of swallow apneic period
Pudding 1
Solid 1
Compensatory Swallow Attempted coaching to slow pt’s RR & verbal cues to coordinate swallow apenic
Strategies period, however, not successful in eliminating airway invasion of thin liquid
A Mild pharyngeal phase dysphagia r/t irregular ventilation pattern & poor coordination of swallow apneic period
2/2 suspected paradoxical vocal fold motion disorder (PVFMD). Highly abnormal laryngoscopic examination
marked by paramedian or partially adducted vocal fold configuration during inspiration, despite full b/l vocal
fold ROM; highly variable vocal fold abduction/adduction pattern, significant laryngeal & pharyngeal
hyperfunction, & laryngeal hypersensitivity. + intermittent penetration of thin liquids to the vocal folds; no
aspiration directly observed, although abnormal vocal fold configuration yielded this difficult to exclude. Pt
appears to be a good candidate for voice/swallow rehabilitation w/ use of endoscopic biofeedback. Diet
modification does not appear indicated at this time.

Specialist referrals Outpatient Laryngologist evaluation for suspected PVFMD. Outpatient voice/swallow tx
w/ SLP w/ specialization in voice & upper airway disorders.
Ancillary tests Outpatient videostroboscopy w/ SLP. Outpatient laryngoscopy w/ Laryngologist.
Goal Pt will coordinate swallow apneic period w/ inhale-exhale-swallow-exhale swallow
pattern w/ use of endoscopic biofeedback w/ 50% accuracy.
Follow-up exam Outpatient FEES after 4-6 weeks of outpatient voice/swallow tx w/ SLP

HPI 63yoM admitted w/ BHT, found down; b/l SDH/SAH. Endotracheal intubation x1 day; extubated to HFNC at
40 L/min.
PMHx Unknown
S Pt alert & cooperative for exam. However, confused, perseverative, & impulsive; attempting to self-feed boluses
at rapid rate during exam. Significantly restless w/ right gaze preference/right gaze rotation. Pt did not follow
commands for positioning or compensatory strategies.
swallowing.
Velopharyngeal function WNL
Nasopharyngoscopic
Anatomic findings Enlarged right inferior turbinate; scope passed via L
findings
nare
Secretions Mild secretions in the pyriforms & valleculae
Vocal fold motion Complete right vocal fold abduction/adduction;
Pharyngoscopic &
mildly reduced left vocal fold mobility
Anatomic findings Asymmetric laryngeal configuration
Posterior containment Impaired w/ thin liquid
Oral phase findings Mastication Impaired
Clearance Impaired
Initiation of swallow WNL w/ thin liquid, mildly-thick liquid, & puree;
absent swallow response >10 secs w/ solid bolus in
valleculae post-mastication; pt did not elicit swallow
trigger of solid until mildly-thick liquid bolus
administered
Pharyngeal phase
findings
Pharyngeal contraction Mildly impaired left pharyngeal contraction
PES opening WNL
Other findings
Thin liquid 8; silent aspiration of thin liquid during the swallow
2/2 impaired LVC; significant laryngeal residue post-
swallow w/ absent sensory response; cued cough not
8-point Penetration- effective in clearing material from the larynx/trachea
Aspiration Scale (PAS) Mildly-thick liquid 1
Pudding 1
Solid 1
Compensatory Swallow Pt did not follow complex commands for these maneuvers
Strategies
A Mild-moderate oropharyngeal dysphagia marked by both impaired swallow safety & efficiency.
Pharyngoscopic/laryngoscopic exam revealed reduced L vocal fold movement & L pharyngeal contraction, c/w
likely UMN lesion of L CN X r/t TBI. Reduced L lingual strength 2/2 likely UMN lesion of L CN XII r/t TBI. Pt’s risk
for dysphagia-related aspiration PNA is increased, given pt’s acuity of illness & reduced physical mobility.
Temporary diet modification appears indicated while pt participates in exercise-based swallow rehabilitation.
P Diet recommendation IDDSI 4/2 diet. Meds whole or crushed in puree.

Risk management Aspiration precautions: 1:1 feeding assist, upright position, slow rate of intake. Control
risk factors for aspiration PNA via (a) oral hygiene QID, & (b) increasing physical
Specialist referrals PT & OT consults to improve pt’s physical mobility.
Ancillary tests N/A
Goal Pt will improve cough strength for airway protection via EMST at 70% of pt’s MEP
x30/tx; Pt will improve pharyngeal contraction & LVC via Effortful Pitch Glides x30/tx
Follow-up exam Repeat FEES vs. VFSS, pending participation in 2-3 weeks of swallow rehabilitation

Bonus Documents

Abbreviation Glossary
# CABG coronary artery bypass graft

2/2 secondary to CAD coronary artery disease
CAP community-acquired pneumonia
A CAPE-V Consensus Auditory Perceptual
AAA abdominal aortic aneurysm Evaluation of Voice
ABG arterial blood gas CBC complete blood count
a.c. before meals CC chief complaint
AC assist control CCU critical care unit
ACA anterior cerebral artery CPA cardiopulmonary arrest
ACDF anterior cervical decompression and CHF congestive heart failure
fusion CHI closed head injury
ACE angiotensin-converting enzyme CKD chronic kidney disease
Ach acetylcholine CN cranial nerve
ADAT advance diet as tolerated CAN certified nursing assistant
ADL activities of daily living CNE cranial nerve exam
a-fib atrial fibrillation CNS central nervous system
AIDS acquired immunodeficiency c/o complaints of, complains of
syndrome CO carbon monoxide
AKA above knee amputation CO2 carbon dioxide
ALOC altered level of consciousness COPD chronic obstructive pulmonary
ALS amyotrophic lateral sclerosis disease
AMA against medical advice CPA cardiopulmonary arrest
AMS altered mental status CPAP continuous positive airway pressure
ANA antinuclear antibody CPR cardiopulmonary resuscitation
AP anterior-to-posterior CSF cerebrospinal fluid
A&O alert & oriented CT computerized tomography
ARDS acute respiratory distress syndrome c/w consistent with
AROM active range of motion CVA cerebrovascular accident
AVM arteriovenous malformation CXR chest x-ray
B D
BHT blunt head trauma d/c discharge
b.i.d. twice a day ddx differential diagnosis
BiPAP bilevel positive airway pressure DKA diabetic ketoacidosis
BKA below knee amputation DM diabetes mellitus
b/l bilateral, bilaterally DNH do not hospitalize
BLBS bilateral breath sounds DNI do not intubate
BM bowel movement DNR do not resuscitate
BP blood pressure d/o disorder
BPH benign prostatic hypertrophy d/t due to
bpm beats per minute DTs delirium tremens
BUN blood urea nitrogen DTR deep tendon reflexes
Bx biopsy DVT deep vein thrombosis
d/w discussed with
C dx diagnosis
C1, C2, etc. cervical vertebra #1, #2, etc
CA carcinoma
E HFNC high flow nasal cannula
ECG electrocardiogram h/o history of
ECHO echocardiography HOB head of bed
ECMO extracorpeal membrane oxygenation H&P history & physical
EEG electroencephalogram HPI history of present illness
EF ejection fraction HPV human papilloma virus
EGD esophagogastro-duodenoscopy HR heart rate
EKG electrocardiogram HTN hypertension
EMG electromyogram, electromyography
EMR electronic medical record I
ENT ear/nose/throat, otolaryngology ICH intracranial hemorrhage
EOB edge of bed ICP intracranial pressure
ESRD end-stage renal disease ICU intensive care unit
ETOH ethanol (alcohol) ID infectious disease
ETT endotracheal tube I&D incision & drainage
IDDSI international dysphagia diet
F standardization initiative
F frequency INR international normalized ratio
FB foreign body I&O intake & output
FEES Flexible Endoscopic Evaluation of IV intravenous
Swallowing IVC inferior vena cava
FFP fresh frozen plasma IVH intraventricular hemorrhage
FiO2 fraction of inspired oxygen IVIG intravenous immunoglobin
FTT failure to thrive
f/u follow-up J
fx fracture J-tube jejunostomy tube
FWB full weight bearing
K
G K potassium
GCS Glasgow Coma Scale
GERD gastroesophageal reflux disease L
GI gastrointestinal/gastroenterology L liter
G-J tube gastrostomy-jejunostomy tube L2, L3, etc. second lumbar vertebrae, etc
GLF ground-level fall LE lower extremity
GRBAS grade, roughness, breathiness, LKW last known well (in reference to
asthenia, strain stroke symptoms)
GSW gunshot wound LKWT last known well time (in reference to
G-tube gastrostomy tube stroke symptoms)
LLE left lower extremity
H LMN lower motor neuron
H hour LOC level of consciousness, loss of
HA headache consciousness
HAP hospital acquired pneumonia LOS length of stay
h/c hospital course LP lumbar puncture
HCAP healthcare associated pneumonia LUE left upper extremity
HD hemodialysis
HF heart failure M
HIV human immunodeficiency virus MAP mean arterial pressure
H&N head & neck MBSS Modified Barium Swallow Study
MCA middle cerebral artery p.c. after meals
MD muscular dystrophy PCT percussive chest therapy
MEP maximum expiratory pressure PE pulmonary embolism
MG myasthenia gravis PEA pulseless electrical activity
MGSW multiple gunshot wounds PEEP positive end expiratory pressure
MI myocardial infarction PEFR peak expiratory flow rate
MIP maximum inspiratory pressure PEG percutaneous endoscopic
MPT maximum phonation time gastrostomy
MRI magnetic resonance imaging PEJ percutaneous endoscopic
MRSA methicillin-resistant Staphylococcus jejunostomy
aureus PERRLA pupils equal, round, reactive to light
MS multiple sclerosis & accommodate
MVA motor vehicle accident PET positron emission tomography
PFT pulmonary function test
N PIP peak inspiratory pressure
NAD no apparent/acute distress PLOF prior level of function
NC nasal cannula PMH past medical history
NGT nasogastric tube PO by mouth
NICU neonatal intensive care unit POC plan of care
NIPPV noninvasive positive pressure POD post-operative day
ventilation POLST physician orders for life-sustaining
NKA no known allergies therapy
NMJ neuromuscular junction PNA pneumonia
NOS not otherwise specified PPN peripheral parenteral nutrition
NPO nil per os (nothing by mouth) PRES posterior reversible encephalopathy
NRB non-rebreather syndrome
NSAID nonsteroidal anti-inflammatory drug PRN as needed
NSTEMI non-ST elevation myocardial PROM passive range of motion
infarction PSH past surgical history
N/V nausea & vomiting PT physical therapy
NWB non-weight bearing PTA prior to arrival
PUD peptic ulcer disease
O PVD peripheral vascular disease
O2 oxygen PVFM paradoxical vocal fold motion
OD overdose
OGT orogastric tube Q
OMFS oromaxillofacial surgery q every
OOB out of bed q2h every 2 hours
OPMD oculopharyngeal muscular dystrophy q4h every 4 hours
ORIF open reduction with/and internal qh every hour
fixation qid four times a day
OSH outside hospital
OT occupational therapy R
OR operating room RA rheumatoid arthritis
OSA obstructive sleep apnea RA room air
RLA Rancho Los Amigos (level of
P cognitive functioning)
PA physician assistant RLE right lower extremity
PACU post-anesthesia care unit RLL right lower lobe
RLN recurrent laryngeal nerve t.i.d. three times a day
RML right middle lobe TMJ temporomandibular joint
r/o rule out TNE transnasal esophagoscopy
ROM range of motion tPA tissue plasminogen activator
ROSC return of spontaneous circulation TPN total parenteral nutrition
RND radical neck dissection TVC true vocal cord
RR respiratory rate Tx treatment
r/t related to
RUE right upper extremity U
Rx prescription UA urinalysis
UE upper extremity
S UGIB upper gastrointestinal bleed
SAH subarachnoid hemorrhage UMN upper motor neuron
SBO small bowel obstruction US ultrasound
SDH subdural hemorrhage UTI urinary tract infection
SCI spinal cord injury
SICU surgical intensive care unit V
SIMV synchronized intermittent mandatory VAP ventilator-associated pneumonia
ventilation VC vital capacity
SLE systemic lupus erythematosus VCD vocal cord dysfunction
SLN superior laryngeal nerve v-fib ventricular fibrillation
SLP speech-language pathologist VFSS Videofluoroscopic Swallow Study
SNF skilled nursing facility VP shunt ventriculoperitoneal shunt
SOAP subjective, objective, assessment, V/Q ventilation/perfusion
plan Vt tidal volume
SOB shortness of breath Vte exhaled tidal volume
s/p status post
SpO2 saturation of peripheral oxygen W
s/s signs and symptoms WBAT weight bearing as tolerated
STAT immediately WBC white blood cell
WFL within functional limits
T WNL within normal limits
T&A tonsillectomy & adenoidectomy WOB work of breathing
TB tuberculosis w/u workup
TBI traumatic brain injury
TEF tracheoesophageal fistula X
TIA transient ischemic attack XRT radiation therapy

Phraseology
Alertness
• Agitated
• Alert
• Combative
• Lethargic
• Obtunded
• Responsive to…
• Roused to…
• Somnolent
• Sustained alertness to…
Aspiration Pneumonia
• Clinical evidence of dysphagia-related aspiration PNA, marked by post-operative development of

fever/cough & perihilar/basilar opacity on chest radiography, in the context of acute dysphagia
symptoms.
• Control risk factors for dysphagia-related aspiration pneumonia via (a) oral hygiene QID, & (b) increasing
physical mobility as tolerated
• Increased risk for dysphagia-related aspiration PNA, given…
• In the context of ______, query potential aspiration of gastric content as source of recurrent aspiration
PNA
• It is unclear if the patient’s PNA is possibly r/t chronic undiagnosed dysphagia, or if the patient presents
w/ temporary dysphagia symptoms r/t acute PNA.
• It is unlikely that the patient’s current aspiration pneumonia is dysphagia-related, given absence of
chronic dysphagia risk factors
• Long-term enteral feeding route (e.g., PEG) is unlikely to be successful in preventing aspiration PNA r/t
aspiration of gastric content
• Patient is at high/low risk for dysphagia-related aspiration PNA
• Patient is at high-risk for further aspiration-related pulmonary complication, given acute quadriplegia &
dystussia.
• Patient’s personal risk factors for development of dysphagia-related aspiration PNA are low (i.e., good
oral hygiene, good physical mobility, immunocompetence)
• Patient’s pneumonia likely represents dysphagia-related sequela
• Risk for aspiration-related pulmonary complication
• Suspect patient’s aspiration pneumonia is sequela of an isolated or non-dysphagia related aspiration
event
• There is no current evidence that etiology of aspiration PNA is r/t oropharyngeal dysphagia
• Unknown if current PNA represents potential dysphagia-related sequela
Clinical Swallow Evaluation
• Acuity of illness
• Acute dysphagia risk factor(s)

• Based upon patient’s symptomatology…
• Both endoscopic and videofluoroscopic swallow studies are indicated to thoroughly evaluate oral,
pharyngeal, laryngeal, & esophageal function
• Clinical signs of chronic/progressive pharyngeal dysphagia of unknown etiology, warranting thorough
dysphagia diagnostic battery
• Clinical signs of oropharyngeal dysphagia
• Clinical signs of oropharyngeal dysphagia in pt w/ acute/subacute/chronic dysphagia risk factors
• Clinical signs of pharyngeal dysphagia, likely acute/transient r/t laryngeal dysfunction s/p ___-day
endotracheal intubation
• Clinical signs of oropharyngeal dysphagia, likely multifactorial r/t ______, _________, and _________
• Clinical signs of oropharyngeal dysphagia w/ associated odynophagia r/t…
• Clinical signs of pharyngoesophageal dysphagia…
• Encourage physical mobility as tolerated
• Endoscopic swallow study is preferred exam over fluoroscopy at this time, given suspicion for laryngeal
dysfunction
• Fluoroscopic swallow study is preferred exam over endoscopy at this time, given suspicion for comorbid
esophageal dysphagia
• Fluoroscopic swallow study is preferred exam over endoscopy at this time, given suspicion for primary
oral phase deficits
• Further trials deferred for instrumentation
• Given acuity of illness, instrumental swallow study is recommended prior to initiation of oral diet
• Given patient’s acuity of illness…
• Given patient’s current mental status, anticipate several days prior to sufficient LOA for instrumental
swallow study
• High probability of pharyngeal phase dysphagia in patient with…
• Historical dysphagia risk factor(s)
• …in patient with known chronic and acute dysphagia risk factors
• Instrumental swallow study in ___-___ days, pending clinical progress
• Instrumental swallow study is indicated to define baseline swallow physiology prior to XRT, to guide
swallow treatment planning, & to recommend compensations to maximize swallow safety & efficiency
• Instrumental swallow study is indicated to evaluate swallow physiology prior to oral diet initiation
• Instrumental swallow study pending improved LOA
• In the context of concomitant dysphonia…
• In the setting of multiple acute dysphagia risk factors…
• Laryngeal dysfunction
• …likely muscle disuse atrophy
• Likely reflects an isolated/non-dysphagia related aspiration event
• No clinical signs of oropharyngeal dysphagia
• No known historical dysphagia risk factors
• Odynophagia in the absence of oropharyngeal dysphagia symptoms in patient with…
• Oral hygiene q4h/QID
• Patient endorses chronic/progressive dysphagia symptoms
• Patient presents with chronic dysphagia risk factors (____, _____) & possible chronic dysphagia sequelae
(recurrent lower lobe PNA, cachexia/malnutrition, dehydration, weight loss)
• Patient requires endoscopic swallow study
• Patient requires videofluoroscopic swallow study
• Patient will benefit from FEES to evaluate laryngeal function as it relates to swallow; patient may also
benefit from VFSS, if clinical questions regarding swallow physiology are not sufficiently answered via
FEES
• Patient will benefit from instrumental swallow study, once optimized for exam via…
• Patient will require instrumental swallow study to define swallow physiology, once LOA improves
• Patient will require instrumental swallow study via VFSS and/or FEES, once respiratory status stable
• Patient with confirmed oropharyngeal dysphagia hx (per prior VFSS/FEES) 2/2…
• Pending VFSS/FEES results
• Possible chronic dysphagia of undiagnosed etiology
• Possible subclinical dysphagia…
• Precipitating dysphagia risk factor(s)
• Predisposing dysphagia risk factor(s)
• Presumable pathology is severe post-op edema of the prevertebral soft tissue, +/- comorbid laryngeal
dysfunction
• Presumable pharyngeal phase dysphagia related to…
• Presumably related to history of…
• Recommend medical evaluation for undiagnosed dysphagia etiology
• Reduced physical mobility
• Unable to exclude chronic pharyngeal dysphagia r/t…
• Unable to exclude subclinical dysphagia and/or silent aspiration at bedside in post-extubation
population
• Unable to exclude oropharyngeal dysphagia in patient with acute-on-chronic dysphagia risk factors
• Unable to exclude oropharyngeal dysphagia at bedside in patient with multiple dysphagia risk factors
• Unable to exclude oropharyngeal dysphagia in patient with multiple chronic dysphagia risk factors (____,
____, _____) + possible chronic dysphagia sequalae (cachexia, weight loss, PNA)
• Unable to exclude potential chronic dysphagia sequalae
• Videofluoroscopy is preferred initial exam for nonspecific dysphagia symptoms, given ability for
simultaneous esophageal screening
• …warranting instrumental swallow study
• Will defer instrumentation until clinical improvement in…
Cough
• Atussia
• Bovine
• Chest physiotherapy
• Dystussia
• Huffing
• Hypertussia
• Hypotussia
• Maximum Expiratory Pressure
• Maximum Inspiratory Pressure
• Non-productive
• Peak Expiratory Flow Rate
• Percussive chest therapy
• Postural drainage
• Productive
• Spirometry
Cranial Nerve Exam

• …concerning for possible lower motor neuron (LMN) involvement of CN ___
• …concerning for possible upper motor neuron (UMN) involvement of CN ___
• Cranial nerve exam findings are concerning for possible pathology the level of peripheral cranial nerves,
neuromuscular junction, or muscle; Neurologist evaluation is indicated.
• Cranial nerve exam revealed…
Diet
• Consider short-term enteral feeding route (e.g., NGT)

• Early consideration of long-term enteral feeding route (e.g., PEG) may be indicated for this patient
• Given patient’s currently stable respiratory status & clear lungs (in the context of the aforementioned
chronic conditions), patient does appear safe to continue oral diet until instrumental swallow study
• Given presumed chronicity of dysphagia & currently clear lungs, pt does appear safe to continue oral diet
prior to instrumental swallow study.
• In the context of clear chest radiography & stable ventilation, patient does appear safe to continue oral
diet until instrumental swallow study
• Medications alternate route
• NPO except ______ with short-term enteral feeding route (e.g., NGT) for nutrition/hydration
• Once risks/benefits of diet options explained (i.e., NPO versus oral diet with known aspiration risk),
patient/family made informed decision to proceed with oral diet despite likely aspiration risk and its
sequalae.
• Short-term enteral feeding route per physician discretion
• Strict NPO
• Strict NPO with short-term enteral feeding route (e.g., NGT)
• Temporary solid diet modification appears indicated 2/2 reduced LOA
Dysphagia Symptoms
• Acute
• Emesis
• Epigastric pain
• Episodic
• Exacerbated by…
• Expectoration
• Globus pharyngeus
• Intermittent
• Odynophagia
• Post-prandial
• Prandial
• Progressive
• Recurrent
• Regurgitation
• Relieved by…
• Subacute
• Substernal chest pain

End-of-Life
• Burdens of NPO status + PEG placement in this patient with advanced age + illness/dementia likely
include poor QOL, physical restraint, continued aspiration of secretions, aspiration of tube feedings,
persistent malnutrition/dehydration, & increased risk of mortality
• Careful hand-under-hand feeding via…
• Dietitian consultation to discuss options for potential p.o. supplementation and/or family education on
disease process
• Discontinue feeding if nonverbal signs of refusal
• Family advised to discuss reduced oral intake w/ physician, as this may be c/w end-stage of pt’s disease
process.
• Family benefitted from education on pathophysiology of dysphagia in dementia & overall poor swallow
prognosis.
• Feeding strategies to promote oral intake: careful hand feeding w/ hand-under-hand assist; alternate
flavor/texture/temperature; offer distractions during meals; small/frequent snacks
• Further swallow intervention (including instrumental swallow study) unlikely to alter POC at this time,
given current hospice care.
• Instrumental swallow study unlikely to alter POC, given patient/family goal for comfort
• In this clinician’s opinion, the risks of long-term enteral feeding (e.g., PEG) for this patient outweigh the
risks of PO comfort feedings despite known dysphagia/aspiration
• Patient’s oral intake improved with use of the following feeding strategies: hand-under-hand assist,
distraction during oral intake, alternating texture/temperature/flavor.
• Patient’s swallow physiology appears sufficient to meet patient’s goal for oral intake without distress
Family advised against “force feeding” methods via syringe & to appreciate pt’s non-verbal cues
regarding readiness/willingness to eat/drink.
• Recommend patient/POA/physician discussion regarding goals of care. Consider:
o (a) NPO with long-term enteral feeding route (e.g., PEG), which does not reduce probability of
aspiration of secretions or mortality & will likely reduce QOL
o (b) PO comfort feedings, despite known aspiration/malnutrition/dehydration risk. Advise full
liquid diet, with liquids by ½ tsp, in upright position
• Risk for malnutrition/dehydration & potential intermittent aspiration events appears high & cannot be
eliminated.
• Swallow prognosis is poor due to underlying disease characteristics and patient is unable to participate in
direct swallow rehabilitation due to severity of cognitive-communication disorder
• There is no evidence to support improved patient survival or QOL after PEG placement in patients with
advanced age/dementia + severe dysphagia
• This complex bioethical decision is deferred to the pt’s POA & physician
• Use of behavioral feeding strategies may facilitate oral intake & reduce complications of oral stage
dysphagia.
Flexible Endoscopic Evaluation of Swallowing (FEES)
• Abduction
• Absent vocal fold movement c/w likely paralysis
• Adduction
• Anterior commissure
• Broad-based mass/lesion
• Circumferential contraction of supraglottic larynx
• Circumscribed
• Cobblestoning
• Depressed
• Ecchymosis
• Edema
• Endophytic growth
• Erythema
• Exophytic growth
• Flexible endoscope was passed transnasally to evaluate the anatomy and physiology of swallowing
• Fullness of…
• Glottic
• Hourglass glottic configuration
• Hyperfunction of the ventricular folds
• Hypertrophy of the inter-arytenoid space
• Incomplete abduction
• Incomplete adduction
• Inter-arytenoid edema
• Inter-arytenoid space
• Irregular
• Laryngoscopic findings
• Narrowing of…
• Nasopharyngoscopic findings
• Normal glottic configuration
• …of unknown etiology
• Omega-shaped epiglottis
• Papular
• Paradoxical vocal fold motion
• Paramedian vocal fold position at rest
• Pedunculated mass/lesion
• Pharyngoscopic findings
• Phonating margins of the true vocal folds
• Post-cricoid space
• Posterior commissure hypertrophy
• Posterior glottic chink
• Reduced vocal fold movement c/w likely paresis
• Sessile mass/lesion
• Spindle-shaped glottic configuration
• Subglottic
• Submucosal
• Supraglottic
• Ulcerated
• Vascular lesion
• Varix/varices
• Velopharyngeal function
• Vocal fold bowing
• Vocal fold motion
• Vocal processes of the arytenoid cartilages
• …with associated edema and erythem
• …with associated hyperemia
Gastrointestinal
• Achalasia
• Apical
• Behavioral reflux precautions
• Esophageal dilatation
• Esophagogastroduodenoscopy
• Gastroenterology consult for suspected aspiration of gastric content
• Gastroenterology consult for suspected esophageal dysmotility
• High Resolution Esophageal Manometry
General Terms/Phrases
• Appreciate…
• As probable component of…
• Complicated by…
• Compounded by…
• Concerning for…
• Consider…
• Consistent with…
• Given…
• High clinical concern for…
• History and exam favor…
• In the context of…
• In the setting of…
• …is indicated
• Likely…
• Marked by…
• No clinical concern for…
• Pending clinical progress
• Unable to exclude…
• Will benefit from…
• With consideration of…
Goals
• Caregiver will perform verbal/demonstration teachback of recommended feeding strategies to facilitate

oral intake & reduce aspiration risk
• Patient will improve laryngeal vestibule closure & vocal fold adduction via Effortful Pitch Glide x50/tx.
• Patient will improve pharyngeal wall contraction via Effortful Swallow x50/tx.
• Patient will improve UES relaxation via CTAR x50/tx.
• Patient will increase cough strength for airway protection against aspiration via Expiratory Muscle
Strength Training (EMST) with Maximum Expiratory Pressure (MEP) of 20 cm H2O.
• Patient will increase cough strength for airway protection against aspiration via Expiratory Muscle
Strength Training (EMST) at 75% of Maximum Expiratory Pressure (MEP) x25/tx.
• Patient will participate in VFSS/FEES to define swallow physiology & therapy need.
• Patient will tolerate least-restrictive PO diet without acute dysphagia-related aspiration PNA.
Interventions
• …given dysphagia severity & poor prognosis

• Given pt’s goals of care (comfort measures/DNR), instrumental swallow study is unlikely to alter POC
• No skilled SLP swallow intervention indicated at this time
• Patient likely requires medical/surgical intervention prior to behavioral swallow rehabilitation
• Patient unlikely to benefit from behavioral swallow rehabilitation
• program
• SLP will f/u for caregiver training
• SLP will f/u to advance solid diet as mental status and subsequent oral dysphagia symptoms improve
• SLP will sign off, as patient’s swallow is functional for current needs (comfortable oral intake)
• SLP will sign off, per patient’s request; please re-consult if change in patient motivation for services
Medical
• Apneic
• As medically feasible
• Bradycardia/bradycardic
• Bradypnea/bradypneic
• Diaphoresis/diaphoretic
• Hypoxic
• Hypercapnic
• Iatrogenic
• Ileus
• Infectious
• Neurologic
• Respiratory
• Rheumatic
• Sarcopenia
• Systemic
• Tachycardia/tachycardic
• Tachypnea/tachypneic
• Traumatic
Nutrition
• Cachexia/cachectic
• Dehydration
• Dietitian consult for malnutrition/dehydration
• Dietitian consult 2/2 risk for malnutrition/dehydration r/t swallow inefficiency
• Malnutrition
• Temporal wasting

Operation/Procedure
• Extubation/post-extubation
• Intra-operative
• Intubation
• Pre-operative
• Post-operative
Position
• High Fowler’s
• Fowler’s
• Left lateral recumbent
• Prone
• Reverse Trendelenburg
• Right lateral recumbent
• Semi Fowler’s
• Supine
• Trendelenburg
• Unable to position patient for AP view due to body habitus
Prognosis
• Anticipate spontaneous swallow improvement with medical management of…

• Prognosis appears good for rapid improvement in voice/swallow function w/ continued medical
interventions (e.g., antibiotics, steroids)
• Prognosis for spontaneous swallow recovery is ________ in the next ___-___ days/weeks
• Swallow prognosis is ________, pending intensive swallow rehabilitation
Respiration/Ventilation
• Abdominal paradox
• Accessory muscles
• Asynchronous
• Atelectasis
• Basilar
• Coarse
• Consolidation
• Copious secretion production
• Diaphoresis
• Dyspnea
• Given severity of tachypnea, pt unlikely to coordinate necessary swallow apneic period
• Gravity-dependent lung zones
• High peak pharyngeal pressure
• Hypercapnic
• Hyperventilation/hypoventilation
• Hypoxic
• Impaired secretion management
• Infrahilar
• Intercostal retractions
• In mild respiratory distress, marked by…
• Opacification
• Orthopnea
• Retractions
• Rhonchi
• Rib cage flaring
• Stridor/stridorous
• Subcostal retractions
• Substernal retractions
• Suprasternal retractions
• Tachypneic
• Use of accessory muscles
• Wheezing
• …with associated tachypnea
Tubes/Lines
• In situ
Videofluoroscopic Swallow Study (VFSS)
• Prevertebral soft tissue (thickness/fullness of)

• Soft tissue density
• Abnormal soft tissue fullness
• Filling defect
• Radiolucent/radiolucency
• Radiopaque
• Retained contrast within…
• Retrograde flow of contrast
• Reversal of the normal cervical lordosis
• Sarcopenia
• Symmetrical pharyngeal contraction in the AP view
Vocal quality
• Asthenic
• Harsh
• Hoarse
• Rough
• Strained
8-Point Penetration-Aspiration Scale (PAS)
PAS Description
1 No material enters the airway.
2 Material enters the airway, remains above the vocal folds, and is ejected
from the airway.
3 Material enters the airway, remains above the vocal folds, and is not
ejected from the airway.
4 Material enters the airway, contacts the vocal folds, and is ejected from the
airway.
5 Material enters the airway, contacts the vocal folds, and is not ejected from
the airway.
6 Material enters the airway, passes below the vocal folds, and is ejected into
the larynx or out of the airway.
7 Material enters the airway, passes below the vocal folds, and is not ejected
from the trachea despite effort.
8 Material enters the airway, passes below the vocal folds, and no effort is
made to eject.
Reference:
Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A
penetration-aspiration scale. Dysphagia, 11, 93-98.

Yale Pharyngeal Residue Severity Rating Scale
Definitions for severity of vallecula residue

I None 0% No residue
II Trace 1-5% Trace coating of the mucosa
III Mild 5-25% Epiglottic ligament visible
IV Moderate 25-50% Epiglottic ligament covered
V Severe >50% Filled to epiglottic rim
Definitions for severity of pyriform sinus residue

I None 0% No residue
II Trace 1-5% Trace coating of the mucosa
III Mild 5-25% Up wall to quarter full
IV Moderate 25-50% Up wall to half full
V Severe >50% Filled to aryepiglottic fold
Reference:
Neubauer, P. D., Rademaker, A. W., & Leder, S. B. (2015). The Yale Pharyngeal
Residue Severity Rating Scale: An Anatomically Defined and Image-Based
Tool. Dysphagia, 30(5), 521–528.

Murray Secretion Scale
MSS Description
0 Most normal rating. No visible secretions anywhere in the hypopharynx or
some transient bubbles visible in the valleculae and pyriform sinuses.
1 Deeply pooled bilateral secretions in the valleculae and pyriform sinuses
and ending the observation segment with no visible secretions
2 Any secretions that changed from a “1” rating to a “3” rating during the
observation period
3 Most severe rating. Any secretions in laryngeal vestibule. Pulmonary
secretions were included if not cleared by swallowing or coughing
Reference:
Murray J, Langmore SE, Ginsberg S, Dostie A. (1996). The significance of

accumulated oropharyngeal secretions and swallowing frequency in predicting
aspiration. Dysphagia 11:99–103.

Dysphagia Outcome and Severity Scale (DOSS)
Full PO: normal diet LEVEL 7 Normal diet
Normal in all situations No strategies or extra time needed
LEVEL 6 Normal diet, functional swallow
Within functional limits/modified Patient may have mild oral or pharyngeal delay, retention or trace epiglottal
independence undercoating but independently and spontaneously compensates/clears
May need extra time for meal
Have no aspiration or penetration across consistencies
Full PO: modified LEVEL 5 Aspiration of thin liquids only but with strong reflexive cough to clear completely
diet and/or Mild dysphagia Airway penetration midway to cords with 1 or more consistencies or to cords with 1
independence Distant supervision, may need 1 diet consistency but clears spontaneously
consistency restricted Retention in pharynx that is cleared spontaneously
Mild oral dysphagia with reduced mastication and/or oral retention that is cleared
spontaneously
LEVEL 4 Retention in pharynx cleared with cue
Mild-moderate dysphagia Retention in oral cavity cleared with cue
Intermittent supervision/cueing, 1 or 2 Aspiration with 1 consistency, with weak or no reflexive cough
consistencies restricted
LEVEL 3 Moderate retention in pharynx, cleared with cue
Moderate dysphagia Moderate retention in oral cavity, cleared with cue
Total assist, supervision, or strategies Airway penetration to the level of the vocal cords without cough with 2 or more
2 or more diet consistencies restricted consistencies; or aspiration with 2 consistencies with weak or no reflexive cough; or
aspiration with 1 consistency with no cough and airway penetration to cords with 1
with no cough
Nonoral nutrition LEVEL 2 Severe retention in pharynx, unable to clear or needs multiple cues
necessary Moderate-severe dysphagia Severe oral stage bolus loss or retention, unable to clear or needs multiple cues
Maximum assistance or use of strategies Aspiration with 2 or more consistencies, no reflexive cough, weak volitional cough;
with partial PO only (tolerates at least 1 or aspiration with 1 or more consistency with no cough and airway penetration to
consistency safely with total use of cords with one or more consistency with no cough
strategies)
LEVEL 1 Severe retention in pharynx, unable to clear
Severe dysphagia Severe oral stage bolus loss or retention, unable to clear
NPO, unable to tolerate any PO safely Silent aspiration with 2 or more consistencies, nonfunctional volitional cough
Or unable to achieve swallow
Reference:
O'Neil, K., Purdy, M., Falk, J., & Gallo, L. (1999). The Dysphagia Outcome and Severity Scale. Dysphagia, 14, 139
Disclaimer: Documentation examples provided are inspired by real cases, however, all potentially identifying
patient information has been modified for patient privacy. Modifications include, but are not limited to, patient
age, sex, medical diagnoses, and procedures performed.

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Table of Contents

Clinical Swallow Evaluations 4-9

Videofluoroscopic Swallow Studies 10-12

Flexible Endoscopic Evaluations of Swallowing 13-14

Clinical Swallow Evaluations 16

Videofluoroscopic Swallow Studies 17-18

Flexible Endoscopic Evaluations of Swallowing 19-20

Clinical Swallow Evaluations 22-165

Videofluoroscopic Swallow Studies 166-218

Flexible Endoscopic Evaluations of Swallowing 219-269

Abbreviation Glossary 271-274

8-Point Penetration-Aspiration Scale 285

Yale Pharyngeal Residue Severity Rating Scale 286

Murray Secretion Scale 287

Dysphagia Outcome and Severity Scale 288

Kelsey Day, MS, CCC-SLP 2

Kelsey Day, MS, CCC-SLP 3

FILE PREDISPOSING RISK CHRONIC DYSPHAGIA PRECIPITATING RISK ADDITIONAL

Kelsey Day, MS, CCC-SLP 4

Kelsey Day, MS, CCC-SLP 5

Kelsey Day, MS, CCC-SLP 6

Kelsey Day, MS, CCC-SLP 7

Kelsey Day, MS, CCC-SLP 8

Kelsey Day, MS, CCC-SLP 9

Kelsey Day, MS, CCC-SLP 11

Kelsey Day, MS, CCC-SLP 12

Kelsey Day, MS, CCC-SLP 14

O Predisposing dysphagia risk

Kelsey Day, MS, CCC-SLP 16

Kelsey Day, MS, CCC-SLP 17

Kelsey Day, MS, CCC-SLP 18

Kelsey Day, MS, CCC-SLP 19

Kelsey Day, MS, CCC-SLP 20

Kelsey Day, MS, CCC-SLP 21

Kelsey Day, MS, CCC-SLP 22

PMHx COPD, tobacco use

S Pt alert, oriented x4. Participated well in exam.

O Predisposing dysphagia risk COPD

P Instrumentation VFSS today

Kelsey Day, MS, CCC-SLP 23

Kelsey Day, MS, CCC-SLP 24

PMHx CHF, cervical spinal stenosis

O Predisposing dysphagia risk CHF, cervical spinal stenosis

P Instrumentation FEES tomorrow

PMHx Tobacco abuse

O Predisposing dysphagia risk Tobacco abuse

P Instrumentation FEES ASAP

Kelsey Day, MS, CCC-SLP 26

PMHx Unknown medical hx; patient currently unidentified

O Predisposing dysphagia risk Unknown

P Instrumentation VFSS vs. FEES, pending clinical improvement

Kelsey Day, MS, CCC-SLP 27

O Predisposing dysphagia risk COPD, undiagnosed R lung malignancy

O Predisposing dysphagia risk COPD

Kelsey Day, MS, CCC-SLP 29

O Predisposing dysphagia risk None

P Instrumentation FEES in 1-2 days, pending clinical progress

PMHx Tobacco use, ETOH use, HTN

S Pt alert, very pleasant for exam. Received eating breakfast EOB.

Kelsey Day, MS, CCC-SLP 31

PMHx PNA x3 this year, cachexia/malnutrition

O Predisposing dysphagia risk None

P Instrumentation FEES + VFSS today