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Modified Monday: Putting it all together

Sometimes, the diagnoses are already there, the history is there, the symptoms are there, and it just needs someone to put it all together. Our case from Pittsburgh this week is just a perfect example of this.

The patient was an 80+ year old male who was originally admitted to the hospital after two falls at home in two days. He complained of "feeling weak". Imaging showed a possible epidural abscess and vertebral osteomyelitis and possibly an esophageal perforation. No swallow imaging was completed while in acute care-the hospital did attempt an upper GI, but the patient was unable to tolerate laying down for the study, complaining of back pain. The patient was then scoped, and no evidence of a perforation or leaking of anything into or from the cervical spine area was noted, and - per the patient's POA - looked "good enough".

Our patient was subsequently discharged to skilled nursing, the SLP there received eval orders, the patient at that time had a PEG tube (the exact reasons for the PEG tube placement were uncertain, only limited records had been received at admission) and the patient and POA both confirmed a history of swallowing problems and some pain with swallowing. After the clinical swallow evaluation was completed, the facility SLP determined that imaging was needed, and given the questionable esophageal perforation/epidural abscess, etc. that the modified barium swallow study would be a good fit. Our SLP immediately saw the barium leak through the posterior wall of the esophagus, our Radiologist was consulted, and agreed with our SLP's call on an esophageal fistula and the recommendation to go back to the GI for a contrast study to further assess.

Our team SLP and I looked back over the whole history of the patient-an epidural abscess (an infection in the epidural space of the brain or spinal column) can present with symptoms like back pain-which the patient complained about when trying to complete the upper GI, weakness due to spinal compression-two falls in two days, and complaints with localized pain-in this case, the patient with some complaints of pain with swallowing.

To add more to the story-the esophageal fistula, which we don't know the cause of, is very likely the source of the infection, and if left unseen/untreated could have led to recurrent infections. The patient was also difficult to position and the barium popping through the esophageal fistula is very quick and could easily have been missed if his shoulder was positioned just a little higher. The swallow physiology itself (if you didn't see the fistula) looks pretty intact and this would have been an easy one to think "ehh, I don't really need to review this guy". However, by NOT reviewing we could have missed this critical referral-even though the swallow itself is not that remarkable for an 80+ year old.

Looking at the whole patient story-even if a lot of it doesn't seem relevant to swallowing (like when they complain about their back pain)-is how we can pull it all together and results in better decision making for our patients.

Side note: this patient also has some calcification of the epiglottis, which can be normal, but is a little uncommon-and can sometimes be mistaken for penetration and/or aspiration. Just a little bonus content for you.

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