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Modified Mondays: Even clear signs can point you in the wrong direction

I have written a lot lately about how important clinical information is when setting a plan of care (and it really is important!!) But this patient is a good example of how relying solely on clinical information can lead us to the wrong conclusions-even when the clinical evidence seems especially compelling.

This patient from our Chicago team had a known history of a cervical esophageal web-it had been noted on a prior MBS, and the patient reported having it “stretched”, but was uncertain of the date. The patient had recently had some choking episodes and complained of food being stuck. The clinical history, previous findings, plus patient complaint easily lends itself to a complication from the web. The physician at the facility referred the patient back to the GI, all assumed the patient needed either repeated dilation or some other treatment of the web. However, given COVID, the patient was not able to be seen by the GI for several weeks. The facility decided to order an MBS study in the meantime.

You can see that, in fact, everything clears through the web pretty cleanly. Our SLP did notice very little actual mastication of the solids, however (despite outwardly appearing to do so). She then talked to the patient a little more, finally discovering that the patient had lost her dentures during a recent hospitalization, and that prior to this, she always wore them for eating. We recommended the patient be changed to minced and moist foods until she was able to have her dentures remade (which the patient agreed with)-a follow up phone call a couple weeks later showed the patient had no further choking episodes and was prioritized for the dental consult. (They also decided to keep the GI appointment for further eval, in case you were wondering.)

It’s also worth mentioning here that this patient is also a lovely example of how an SLP conducting a good MBS study with a thorough understanding of the physiology needed can use clinical skills to assess even if we don’t “see” something happen-this patient clearly did not choke during the study, but by looking at the physiology, not the food, the SLP was able to make a comprehensive assessment and a good plan of care. We don’t need to have a smorgasbord of food in the Radiology suite, but a good protocol and a focus on the physiology is essential.

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