Modified Mondays: An Obvious (?) Problem

Spoiler alert: Figuring out what is happening with a patient during a Modified Barium Swallow study is not always completely obvious, even when you’ve been doing them FOREVER. It can take quite a bit of problem solving, and putting the data you gather during the MBS together with what you know clinically about the patient. For some patients, when you put it all together-it seems obvious. This case is a great example.

Patient with a history of schizophrenia, non-verbal, with violent episodes. Sudden onset of clinical signs and symptoms, including coughing with all PO, spitting out solids, refusing to eat, with gagging and throat clearing throughout the day. This persisted for a couple days before we were called in to complete an MBS. With the patient’s behaviors throughout, including agitation and refusing several consistencies, it was (to this day) one of the most exhausting studies I’ve ever done. The patient did take several liquid presentations for me, and the presentation was really confusing-I wasn’t sure what on earth I was seeing. I gave the patient a break for a minute to settle down, thinking hard about the clinical information. Finally, I kept going back to “sudden onset”, and realized that there was a real possibility that the patient had swallowed a foreign body. We turned the patient A-P, and sure enough, we could then see the faint outline of a perfect circle. It turned out that the patient had somehow gotten hold of the rubber topper of a blood draw vial-and swallowed it. It became perfectly lodged and remained there… patient was immediately sent out to the ER for removal. 

Now when I watch this study, I honestly cringe a little bit, because once you know what’s happening, it appears to be so obvious! However, it’s actually such a great learning tool of why it’s so very important to know the patient’s clinical information and medical history… and not just rely on the MBS blindly. Had I not done a pretty thorough chart review, I am certain that I would have recommended a GI consult, and this patient might have gone several more days in this condition. 

PS Keep an eye out for an upcoming MM with a foreign body that was a little easier to figure out… 

PPS See the picture for a snapshot of the foreign object outlined...

PPPS See the links below for more information!

https://www.researchgate.net/publication/272928461_Clinical_Swallow_Examination_CSE_Can_We_Talk

https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/pica