Case history

It is important to collect a comprehensive and holistic case history when initially assessing a patient with bilateral hemispheric stroke. Reviewing the client’s medical records and talking to the client and significant others are both parts of the case history process (Daniels and Huckabee, 2008). Often nurses, whanau and carers can provide important and useful information. Ideally, the medical history would be obtained from the patient’s medical records prior to the clinical assessment (Daniels and Huckabee, 2008).
As this client has had a previous stroke, we would expect there to be information about the first stroke lesion and its effect on the patient’s swallowing. The medical file may also give an insight into the communicative abilities of the patient. However, even if this information is available, a patient interview and assessment will provide additional insights into any changes or developments since the last hospital discharge (Daniels and Huckabee, 2008). Other information in the medical file that will be particularly useful are any notes that refer to the client’s previous experiences of dysphagia, including records of the evaluations and treatments undertaken during their hospitalization and ensuing rehabilitation (Daniels and Huckabee, 2008).
The clinician should also familiarize him or herself with the physical report from the neurologist. Of particular importance to the SLT will be information concerning the stroke onset, its characteristics and any complications, as will any medical notes made since admission that may relate to the suspected dysphagia (Daniels and Huckabee, 2008). The SLT should also be aware of when the stroke occurred and the period of time since their admission to the hospital, as the client may have been nil-by-mouth since that time.
As mentioned in the previous section, an awareness of the medications that the patient is being given is important, as some medications can negatively affect the swallowing process. For more information on medication which can affect swallowing, please view the file below.

Medical Chart Review

The following list from Daniels and Huckabee (2008, p. 55) highlights the areas of the medical chart that the SLT should review:
  • Disease associated with dysphagia
  • Prior history of stroke (note residual deficits)
  • Surgeries associated with dysphagia
  • Pulmonary status
  • Current nutritional intake
  • Medications that may affect swallowing
  • Functional status prior to hospitalization

Patient and Family interview

Following this, the SLT should hold an interview with the patient or their family in order to gather more information pertaining to the patient’s swallowing. The amount of information and insight garnered from the interview depends greatly on three key issues: the acuteness of the infarct, the patient’s state and responsiveness, and awareness of any swallowing abnormalities (Daniels and Huckabee, 2008).
Daniels and Huckabee (2008) recommend that when interacting with patients in the acute setting, the clinician should begin by asking “Are you having any problems with your swallowing?” and “Do you cough or choke when eating or drinking?”. If the patient’s response is “No” to both questions, the SLT should continue with the rest of the clinical assessment (Daniels and Huckabee, 2008). If the patient does acknowledge a swallowing deficit, then the clinician should invite the patient to tell him or her about the problem(s) before moving further (Daniels and Huckabee, 2008). If the patient’s communication skills are sufficient, the SLT should avoid influencing the patient’s responses by asking open-ended questions. However, if the patient’s communication skills have been compromised or their responses are too vague, more direct questioning and yes/no questions should be incorporated into the interview (Daniels and Huckabee, 2008).
For examples of questions concerning swallowing ability, please see page 57 of Daniels and Huckabee, 2008.

As the patient in this case has had a prior stroke, the SLT should attempt to establish, through speaking with the patient and his or her family, if there is any history of dysphagia and if swallowing has again changed. As mentioned previously, information concerning prior assessment and intervention of dysphagia will be invaluable to the current SLT (Daniels and Huckabee, 2008). If records of these were not found immediately in the clinical file, then the SLT should try to ascertain from the patient and family interview the type of evaluation, assessment results, the type of intervention, and progress that came as a result of treatment, as well as the reason for discharge from treatment (Daniels and Huckabee, 2008). It is particularly important to gauge whether the patient feels their swallowing has changed since their prior intervention was discontinued, especially since a significant amount of time may have passed since then (Daniels and Huckabee, 2008). At this point, it may be beneficial for the SLT to obtain written consent from the patient in order to acquire access to any previous swallowing assessment and intervention reports that are not already accessible (Daniels and Huckabee, 2008).
The information obtained from the history and patient interview should identify certain areas on which to focus during the subsequent clinical and instrumental swallowing assessments. Information concerning the culture and religion of the patient and family will also contribute to best practice and appropriate intervention.