Medical+Records

 i.   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  · <span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">Is the client currently taking a (modified) oral diet? Are they tube-fed? <span style="font-family: 'Tahoma','sans-serif'; font-size: 14pt;">iii. Current Medical Status <span style="display: block; line-height: normal; margin: 0cm 0cm 5pt 36pt; mso-add-space: auto; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-indent: -18pt;"> · <span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">Includes exasperation of the disease. What medications are involved. <span style="display: block; line-height: normal; margin: 0cm 0cm 5pt 36pt; mso-add-space: auto; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-indent: -18pt;"> · <span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">Respiratory status (i.e., bradypnea or hyperpnea). <span style="display: block; line-height: normal; margin: 0cm 0cm 5pt 36pt; mso-add-space: auto; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-indent: -18pt;"> · <span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">fatigue of respiratory muscles

<span style="font-family: 'Tahoma','sans-serif'; font-size: 14pt;">iv. Previous Speech-Language Therapy Involvement <span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">**v**. <span style="font-family: 'Tahoma','sans-serif'; font-size: 13.5pt;">Client-Specific Information Related to the ICF Next Page
 * <span style="display: block; line-height: normal; margin: 0cm 0cm 10pt; mso-list: l4 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"> Personal factors, participation, environment, activities etc. (WHO, 2010)

<span style="display: block; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">References <span style="display: block; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">Balzer, A (2000). //Medication and Dysphagia Swallowing Risks.// Retrieved Oct.1, 2010 from: []

<span style="display: block; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-family: 'Times New Roman','serif'; font-size: 12pt;">World Health Organization. International Classification of Functioning, Disability and Health (ICF) Retrieved Sept 10, 2010, from http://www.who.int/classifications/icf/en/