Case+History

Case history for Patients presenting with COPD and (possible) Dyspahgia // **feel free to print and keep for you personal records*** // (Adapted from the questionnaire used in the John Hopkins Swallowing Centre, found in, Castell D.O., and Donner M.W., 1987) //1. ////Basic Information:// Name: Age: //2. ////Work/Personal History // Profession Exposure to dust, chemicals Smoker For how long When/have they quit //3. ////Previous Medical examinations // <span style="font-family: 'Times New Roman','serif';">Neurological <span style="font-family: 'Times New Roman','serif';">ENT/GI <span style="font-family: 'Times New Roman','serif';">Radiology <span style="font-family: 'Times New Roman','serif';">Swallowing examination, including VFS <span style="font-family: 'Times New Roman','serif';">Most recent hospital stay <span style="font-family: 'Times New Roman','serif';">For how long <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">4. ////<span style="font-family: 'Times New Roman','serif';">Family history // <span style="font-family: 'Times New Roman','serif';">General <span style="font-family: 'Times New Roman','serif';">Developmental <span style="font-family: 'Times New Roman','serif';">Swallowing <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">5. ////<span style="font-family: 'Times New Roman','serif';">Food History // <span style="font-family: 'Times New Roman','serif';">Cultural identity (could include: religion and/or ethnicity): <span style="font-family: 'Times New Roman','serif';">Foods avoided pre-morbidity <span style="font-family: 'Times New Roman','serif';">Post-morbidity <span style="font-family: 'Times New Roman','serif';">Preferred pre-morbidity <span style="font-family: 'Times New Roman','serif';">Post-morbidity <span style="font-family: 'Times New Roman','serif';">Depend on others for: <span style="font-family: 'Times New Roman','serif';">food preparation <span style="font-family: 'Times New Roman','serif';">feeding <span style="font-family: 'Times New Roman','serif';">Are preferred foods given <span style="font-family: 'Times New Roman','serif';">Who is the primary food provider <span style="font-family: 'Times New Roman','serif';">Gauge feelings towards this person <span style="font-family: 'Times New Roman','serif';">What utensils are used (i.e., eat with hands or adapted devices) <span style="font-family: 'Times New Roman','serif';">What do you eat for: <span style="font-family: 'Times New Roman','serif';">Breakfast <span style="font-family: 'Times New Roman','serif';">Lunch <span style="font-family: 'Times New Roman','serif';">Dinner <span style="font-family: 'Times New Roman','serif';">Snacks/treats <span style="font-family: 'Times New Roman','serif';">Taking any supplements (i.e., Ensure) <span style="font-family: 'Times New Roman','serif';">Preferred textures: <span style="font-family: 'Times New Roman','serif';">Food <span style="font-family: 'Times New Roman','serif';">Liquids <span style="font-family: 'Times New Roman','serif';">Meal time environement <span style="font-family: 'Times New Roman','serif';">Where do you generally eat <span style="font-family: 'Times New Roman','serif';">With whom <span style="font-family: 'Times New Roman','serif';">If at a restaurant/noisier environment, are symptoms more severe? <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">6. ////<span style="font-family: 'Times New Roman','serif';">Eating habits: // <span style="font-family: 'Times New Roman','serif';">Slow-average-fast (pre and post swallowing difficulty) <span style="font-family: 'Times New Roman','serif';">What state (i.e, sleepy, angry, sad, agitated) does Pt. Often feel at mealtimes? <span style="font-family: 'Times New Roman','serif';">(note this in mealtime observation also. Could also inquire with caregivers) <span style="font-family: 'Times New Roman','serif';">Manoeuvres (posture, head/neck position) <span style="font-family: 'Times New Roman','serif';">Tastes <span style="font-family: 'Times New Roman','serif';">Food temperatures <span style="font-family: 'Times New Roman','serif';">Carbonated beverages <span style="font-family: 'Times New Roman','serif';">Loss of food from front of mouth <span style="font-family: 'Times New Roman','serif';">Fatigue during meals <span style="font-family: 'Times New Roman','serif';">More fatigue after swallows <span style="font-family: 'Times New Roman','serif';">General duration of meals <span style="font-family: 'Times New Roman','serif';">Cough during meals <span style="font-family: 'Times New Roman','serif';">Choking during meals <span style="font-family: 'Times New Roman','serif';">How many episodes <span style="font-family: 'Times New Roman','serif';">Where: at home? When out? <span style="font-family: 'Times New Roman','serif';">Loss of appetite/food refusal <span style="font-family: 'Times New Roman','serif';">Afraid to initiate swallow <span style="font-family: 'Times New Roman','serif';">Pain during swallow <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">7. ////<span style="font-family: 'Times New Roman','serif';">Swallowing History: // <span style="font-family: 'Times New Roman','serif';">Duration of swallowing trouble <span style="font-family: 'Times New Roman','serif';">When did it begin? <span style="font-family: 'Times New Roman','serif';">Progressive or intermittent <span style="font-family: 'Times New Roman','serif';">Are solids or liquids harder to swallow <span style="font-family: 'Times New Roman','serif';">Foods causing symptoms <span style="font-family: 'Times New Roman','serif';">Liquids: i.e., water, milk, orange juice <span style="font-family: 'Times New Roman','serif';">Pureed Food: i.e., mashed potatoes, milk shakes, ground beef <span style="font-family: 'Times New Roman','serif';">Solid Foods: met, chicken, fish and nuts <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">8. ////<span style="font-family: 'Times New Roman','serif';">Voice Changes // <span style="font-family: 'Times New Roman','serif';">When began <span style="font-family: 'Times New Roman','serif';">Comprehensible <span style="font-family: 'Times New Roman','serif';">Nasality <span style="font-family: 'Times New Roman','serif';">Hoarseness/breathiness/gurgly <span style="font-family: 'Times New Roman','serif';">Was it first symptom prior to swallowing difficulties <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">9. ////<span style="font-family: 'Times New Roman','serif';">Sleep // <span style="font-family: 'Times New Roman','serif';">Sudden onset of snoring <span style="font-family: 'Times New Roman','serif';">Sleep apnea <span style="font-family: 'Times New Roman','serif';">Change in sleeping position

<span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">10. ////<span style="font-family: 'Times New Roman','serif';">Oesophageal symptoms (including reflux) // <span style="font-family: 'Times New Roman','serif';">Heart burn <span style="font-family: 'Times New Roman','serif';">Sour taste in mouth <span style="font-family: 'Times New Roman','serif';">Sore throat <span style="font-family: 'Times New Roman','serif';">Lump in throat <span style="font-family: 'Times New Roman','serif';">Wet pillow in morning <span style="font-family: 'Times New Roman','serif';">Food sticking in throat (neck, chest); try to pinpoint site of most difficulty <span style="font-family: 'Times New Roman','serif';">Does heart rhythm change during swallow <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">11. //<span style="font-family: 'Times New Roman','serif';">//Chest pain// <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">12. ////<span style="font-family: 'Times New Roman','serif';">Respiratory Symptoms // <span style="font-family: 'Times New Roman','serif';">Chronic cough <span style="font-family: 'Times New Roman','serif';">Pneumonia in past (how many episodes) <span style="font-family: 'Times New Roman','serif';">Medications for this <span style="font-family: 'Times New Roman','serif';">Exasperations of COPD <span style="font-family: 'Times New Roman','serif';">How often <span style="font-family: 'Times New Roman','serif';">Most recent episode (and previous) <span style="font-family: 'Times New Roman','serif';">Postnasal drip

<span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">13. ////<span style="font-family: 'Times New Roman','serif';">Current medical conditions // <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">14. ////<span style="font-family: 'Times New Roman','serif';">Medications/Supplements taken (including addition Oxygen) // <span style="display: block; margin: 0cm 0cm 0pt 25.1pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -18pt;">//<span style="font-family: 'Times New Roman','serif';">15. ////<span style="font-family: 'Times New Roman','serif';">General medical history // <span style="font-family: 'Times New Roman','serif';">Childhood diseases/developmental disorder/foreign body ingestion <span style="font-family: 'Times New Roman','serif';">Major illnesses <span style="font-family: 'Times New Roman','serif';">Previous surgery <span style="font-family: 'Times New Roman','serif';">Trauma <span style="font-family: 'Times New Roman','serif';">Has Pt. Ever had NG or PEG feeding <span style="font-family: 'Times New Roman','serif';">Weigh loss <span style="font-family: 'Times New Roman','serif';">How much <span style="font-family: 'Times New Roman','serif';">Since when <span style="font-family: 'Times New Roman','serif';">Neurological history <span style="font-family: 'Times New Roman','serif';">Gait <span style="font-family: 'Times New Roman','serif';">Weakness Reference

Castell, D. and M. Donner (1987). "Evaluation of dysphagia: A careful history is crucial." //Dysphagia// 2 (2): 65-71.