i. medical_records.jpg
Medical Records 

The first step in clinical evaluation is to check the client's medical records. The following is a list of items to consider whilst reviewing the client's records:
i. Medical Diagnosis
· The client likely already has a diagnosis of COPD. Clinician should note if the client is experiencing an exasperation
· Is the client currently taking any medication that may cause dysphagia?
· For a review of medications that may cause dysphagia as a side effect, please refer to this external link (Balzer, 2000):
ii. Nutritional Status and Current Nutritional Needs
· Is the client currently taking a (modified) oral diet? Are they tube-fed?
iii. Current Medical Status
· Includes exasperation of the disease. What medications are involved.
· Respiratory status (i.e., bradypnea or hyperpnea).
· fatigue of respiratory muscles

iv. Previous Speech-Language Therapy Involvement
v. Client-Specific Information Related to the ICF
  • Personal factors, participation, environment, activities etc. (WHO, 2010)
Next Page

Balzer, A (2000). Medication and Dysphagia Swallowing Risks. Retrieved Oct.1, 2010 from: http://www.ct.gov/dds/lib/dds/health/attacha_med_dsyphagia_swallowing_risks.pdf

World Health Organization. International Classification of Functioning, Disability and Health (ICF) Retrieved Sept 10, 2010, from http://www.who.int/classifications/icf/en/