History of Present Condition:

Pt is 82 y.o. male with PD, dementia, diabetes, HTN, Hx of stroke, and pacemaker who was referred by
Dr. Visvalingam for potential aspiration. Pt arrived moderately alert with a perceived moderate cognitive
impairment with his son and daughter-in-law present. Pt’s daughter is the primary family medical
contact who was not present. Pt was diagnosed with PD 3 years ago and was in the hospital in October
2021 for stroke symptoms (slurred speech, weakness). Pt reports having COVID-19 in early 2020, but is
now vaccinated. Pt is currently on a mechanical soft diet with thin liquids at LifeCare in New Market. Pt
reports avoiding hamburgers, but no other consistencies and reports taking approx. 30 mins to complete
a meal. Pt has lost 5-10 lbs. over the last year. Patient has partial dentures on top and bottom. Pt is
right-handed and reports some left sided weakness in his arm with some slurred speech. Pt has
defibrillator in his pacemaker and does not wear an insulin pack for his diabetes. Pt reports no instances
of pneumonia or any other respiratory diseases besides COVID-19. Pt reports that his Sinemet dosage
was recently modified.

Clinical Swallowing Evaluation:

The clinical swallow evaluation was completed to look at voice production, oral motor and cranial
nerves. Pt has upper and lower dentures mixed with natural dentition. Vocal quality was WNL, however
respiratory effort was diminished as demonstrated by a maximum phonation time of 4 secs in vowel
prolongation task. Facial symmetry was observed to be WNL at rest. CN V demonstrated WNL sensation
for all three branches and sufficient jaw strength. CN VII demonstrated labial ROM and strength to be
reduced with reduced coordination in alternating labial positions task (smile-pucker). CN IX
demonstrated adequate velum elevation and swallow initiated, but delayed initiation when asked for a
special swallow. Gag reflex was not tested. CN XII demonstrated reduced lingual strength with increased
weakness of the left tongue and reduced ROM. Trials of thin liquid (water), puree (applesauce), semi-
soft (peaches), and mechanical soft (Rice Krispies) were administered. Palpation was completed and
observed on a dry swallow with complete laryngeal elevation, but reduced elevation on the second
swallow. A trace amount of residue remained within the oral cavity after peach and Rice Krispies trials.
And vocal quality remained the same through all trials with coughing present during liquid rinse (after
Rice Krispies). Volitional cough was observed to sufficient and WNL. Given concerns for possible silent
aspiration a modified barium swallow is recommended for objective assessment of the pharyngeal
swallow mechanism/function and to rule out possible aspiration.

MBSS: In conjunction with Radiology, the patient participated in a modified barium swallow study. Pt
self-fed for liquid trials and was clinician fed for peach, Rice krispies, and solid trials. Trials included: thin
barium (10mL x2, cup sip x2, cup sip straw x1, sequential x1), nectar-thick barium (10mL, cup x2), puree
(applesauce), semi-soft x1 (peaches), mechanical-soft with thin (rice krispies), solid (graham cracker) and
tablet with puree. Results follow:

Oral Phase: Pt demonstrated labial escape on thin trials possibly related to cup oral transfer. Tongue
control was disorganized on puree, peach, mech + thin, and solid with slow prolonged chewing. Escape
to the buccal cavity was observed in cup sip thin, puree, and peach trials. Bolus preparation was
complete and the bolus transfer was timely once the swallow was initiated. A collection of residues
remained in the floor of mouth, palate, tongue, and lateral sulci after thin and nectar trials.

Pharyngeal Phase: . Complete soft palate elevation, complete hyoid, and laryngeal elevation, and
complete epiglottic inversion. Pt had complete PES opening and no obstruction no flow. Pt
demonstrated WFL bolus initiation at the vallecula or higher for all consistencies except sequential thin.
Incidents of penetration were observed on three trials of cup sip thin and straw sip then (PAS-2) with
aspiration observed on sequential thin only Laryngeal vestibular closure showed a narrow column of
contrast on cup sip thin and straw thin. Pharyngeal stripping wave was reduced likely due to presence
of a PES stint. Pt demonstrated reduced tongue base retraction on all trials. Pt had complete PES
opening and no obstruction no flow. A collection of residues was observed between sequential swallows
in the vallecula likely contributing to bolus size of second swallow within the pharyngeal cavity. A-P view
was not observed.

Penetration/Aspiration: Patient demonstrated 4 incidents of penetration (PAS 2) on all three-cup sip

thin trials and one straw sip trial. Pt has one incident of aspiration on sequential thin trial. Pt is a risk for
penetration/aspiration during large swallows.

Esophageal Phase: The patient’s esophageal phase cannot be substantiated on the MBS exam given the
limited esophageal views.

Summary: On today’s evaluation Pt presents with mild oropharyngeal dysphagia with 4 incidents of
penetration on cup sip thin and straw thin trials (PAS 2) and 1 incident of aspiration on sequential thin
trial. Today’s exam does fully capture the cause of Pt symptoms, which may be attributed to age and
PD resulting in reduced tongue base retraction, prolonged mastication, and reduced laryngeal
vestibular closure in instances of large boluses. Pt is to continue mechanical soft diet with thin liquids
with or without a straw with the following recommendations: single small sips, multiple swallows,
and increased oral hygiene to reduce potential of aspiration pneumonia. Swallowing therapy is
recommended to address tongue base retraction weakness.

Recommendations:
Diet: Mechanical soft with thin liquids, medications with puree
Supervision: may feed self independently
Therapy: Therapy is recommended for tongue base retraction (Masako, Effortful)
Strategies: 1. Single small sips (no large sequential sips to reduce penetration), 2. double swallow, 3.
increase oral hygiene to reduce potential of aspiration pneumonia
Follow-up: referring physician

Education: The patient was educated on the results of today’s exam with verbal understanding and
agreement. Pt was provided with written recommendations and strategies.

Patient will tolerate diet baseline diet of mechanical soft (IDDSI level 5/6) and thin liquids (IDDSI
0) with no overt signs/symptoms of aspiration in order to meet adequate hydration and
nutritional needs