S | C.C: dysphagia - 수개월 전 - M/80. 내원 3개월 전 치매, 폐렴, 전신쇠약 등으로 호흡기내과 입원 후 퇴원하여 현재까지 요양병원 입원중인 분으로, 2개월 전 L-tube removal 이후 현재 일반죽 식이 중임. 사레걸림 간혹 있고, 딸꾹질이 지속되어 연하검사 위해 보호자 내원
- Gait disturbance d/t medical deconditioining
과거력 - DM/HTN/Tb/hepatitis(-/-)
- h/o Pneumonia ; Alzheimer's dementia
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O | - Mental: Alert
- Obey : 1 step obey (+)
- Gag reflex (+/+) Voluntary cough (+) Drooling (+)
- Tongue deviation (-/-) facial palsy (-/-) Uvula deviation (-/-) dysarthria (+) wet voice (+) laryngeal elevation (decreased)
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A | |
P | - VFSS 시행: 액체류는 straw를 이용함.
- Chest PA
- Swallowing Difficulty Test(VFSS,MBS)
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▼ |
S/O | - VFSS: OTT delay (+) initiation delay (+) penetration (-) aspiration (-) residue in vallecular (+) moderate / pyriformis (-)
oral phase | Pharyngeal phase | Esophageal phase | - lip sealing (+)
- mastication: slightly decreased
- tongue movement: slightly decreased
- oral phase delay (+)
- Bolus formation: slightly decreased
- early spillage (+)
| - initiation delay (+)
- laryngeal elevation: decreased
- pharyngeal contraction: decreased
- Nasopharyngeal reflux (-)
- epiglottic closure: slightly decreased
- penetration / aspiration (-/-)
- vallecular/ pyriform sinus retention (+; moderate / -)
| - cricopharyngeus opening / relaxation: decreased
- peristalsis: intact
- stricture ( - )
| Tongue movement, Bolus formation 및 mastication 다소 저하되어 있고 심한 oral phase delay 소견 보임. early spillage 소견 보임. | initiation delay, laryngeal elevation, pharyngeal contraction, epiglottic closure의 저하 소견 보이며, 전 성상에서 moderate degree의 vallecular residue 확인됨. multiple swallowing시, residue에 대해 partial clearing 가능함. 전 성상에서 penetration, aspiration 관찰되지 않음. | cricopharyngeus opening / relaxation 저하 소견 관찰됨. |
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A | - PAS 1 on Barium, puree, semisolid, solid, liquid (spoon, cup)
- vallecular/ pyriform sinus retention ( +; moderate / - )
Penetration-Aspiration Scale - Material does not enter the airway
- Material enters the airway, remains above the vocal folds, and is ejected from the airway
- Material enters the airway, remains above the vocal folds, and is not ejected from the airway
- Material enters the airway, contacts the vocal folds, and is ejected from the airway
- Material enters the airway, contacts the vocal folds, and is not ejected from the airway
- Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway
- Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort
- Material enters the airway, passes below the vocal folds, and no effort is made to eject
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P | - 현재 식이(SD) 유지 가능함. 수분 섭취시, 컵으로도 섭취 가능
vallecular sinus에 moderate residue 관찰되므로, multiple swallowing, effortful swallowing, chin-tuck maneuver과 같은 compensation 반드시 필요함. oral phase delay 있어 verbal cue 필요함. - Dysphagia Tx.
- direct dysphagia Tx.
- oromotor stimulant exercise
- Swallowing exercise : oromotor control exercise, oral relaxation and range of motion, oral resistance exercise, mastication exercise, oropharyngeal thermotactile stimulation, tongue base retraction, Shaker's exercise
- Compensation : double swallowing, effortful swallowing, chin-tuck maneuver
- VFSS f/u after 3 months
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▼ 3mo |
S/O | - Video-Fluoroscopic Swallowing Study (VFSS)
- 검사 진행순서 : barium - puree - semisolid - solid - liquid (spoon, straw)
oral phase | Pharyngeal phase | Esophageal phase | - lip sealing (+)
- mastication: slightly decreased
- tongue movement : slightly decreased
- oral phase delay (+)
- Bolus formation: slightly decreased
- early spillage (+)
| - initiation delay (+)
- laryngeal elevation: decreased
- pharyngeal contraction: decreased
- Nasopharyngeal reflux (-)
- epiglottic closure: relatively intact
- penetration / aspiration ( + / - )
- PAS 2 on liquid (straw)
- vallecular/ pyriform sinus retention (+; mild to moderate / +; wall coating)
| cricopharyngeus opening / relaxation: relatively intact peristalsis: intact stricture (-) | Tongue movement, Bolus formation 및 mastication 다소 저하되어 있고, semisolid, solid intake시, mastication 오랫동안 하여 심한 oral phase delay 소견 보임. early spillage 소견 보임. | initiation delay, laryngeal elevation, pharyngeal contraction의 저하 소견 보이며, 전 성상에서 mild to moderate degree의 vallecular residue 확인됨. epiglottic closure 비교적 양호함. multiple swallowing 시, residue에 대해 partial clearing 가능함. liquid straw에서 PAS 2 penetration 소견 관찰됨. | 이상 소견 없음. |
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A | - OTT delay (+) initiation delay (+)
- PAS 2 on liquid (straw)
- vallecular/ pyriform sinus retention (+; mild to moderate / +; wall coating)
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P | - 현재 식이(SD) 유지 가능함. 액체류 섭취시, straw 이용하여 가능한 상태
- vallecular sinus에 mild to moderate residue 관찰되므로, multiple swallowing, effortful swallowing, chin-tuck maneuver과 같은 compensation 반드시 필요함. oral phase delay 있어 verbal cue 필요함.
- Dysphagia Tx.
- direct dysphagia Tx.
- oromotor stimulant exercise
- Swallowing exercise : oromotor control exercise, oral relaxation and range of motion, oral resistance exercise, mastication exercise, oropharyngeal thermotactile stimulation, tongue base retraction, Shaker's exercise
- Compensation : double swallowing, effortful swallowing, chin-tuck maneuver
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▼ |
S/O | - Video-Fluoroscopic Swallowing Study (VFSS)
- 검사 진행순서: barium - puree - semisolid - solid - liquid (spoon, straw, cup)
oral phase | Pharyngeal phase | Esophageal phase | - lip sealing (+)
- mastication: relatively intact
- tongue movement : relatively intact
- oral phase delay (+)
- Bolus formation : relatively intact
- early spillage (+)
| - initiation delay (+)
- laryngeal elevation: slightly decreased
- pharyngeal contraction: slightly decreased
- Nasopharyngeal reflux (-)
- epiglottic closure : relatively intact
- penetration / aspiration (+/-)
- PAS 2 on liquid straw, liquid cup
- PAS 1 on barium, puree, semisolid, solid, liquid spoon
- vallecular fossa/ pyriform sinus retention (+; min / +; wall coating)
| UES opening /cricopharyngeus m. relaxation: relatively intact | Tongue movement, Bolus formation 및 mastication relatively intact하였고 semisolid, solid intake시, mastication 오랫동안 하여 심한 oral phase delay 소견 보임. early spillage 소견 보임. 이는 지난 검사와 유사한 소견임. | initiation delay, laryngeal elevation, pharyngeal contraction의 다소 저하된 소견 보이며, minimal amount의 vallecular residue 확인됨. epiglottic closure 비교적 양호함. multiple swallowing시, residue에 대해 partial clearing 가능함. 이는 모두 지난 검사와 유사한 소견임. 지난 검사 시와 마찬가지로 liquid straw에서 PAS 2 penetration 소견 관찰됨. Liquid cup에서도 PAS 2 소견 보임. | 지난 검사 시와 유사한 양상으로, 이상 소견 없음. |
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A | - OTT delay (+) initiation delay (+)
- PAS 2 on liquid straw, liquid cup
- PAS 1 on barium, puree, semisolid, solid, liquid spoon
- vallecular fossa/pyriform sinus retention (+; min/+; wall coating)
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P | - 일반죽으로 상향 가능합니다. 액체류 섭취 시, cup drinking 시도해볼 수 있으나, Liquid straw, Liquid cup에서 PAS 2 mild penetration 소견 관찰되므로, 사레 걸림 등의 증상 없는지 주의 깊게 살펴보도록 보호자 교육 시행. 또한, vallecular fossa에 minimal amount of residue 관찰되므로, multiple swallowing, effortful swallowing, chin-tuck maneuver과 같은 compensation 반드시 필요합니다. oral phase delay 있으므로 식사 시 지속적 verbal cue 요구됨
- Dysphagia Tx.
- Oromotor fascilitation, Thermotactile stimulation
- Compensation: Multiple swallowing
- Swallowing exercise: Shaker’s exercise
- cough, fever, chilling 등의 aspiration pneumonia 증상 발생 여부에 대해 주의 깊게 관찰해야하며 증상 발생할 경우 즉시 병원 내원할 것에 대해 보호자 교육 시행
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