Videofluoroscopic swallowing assessment report Template

Videofluoroscopic Swallow Study Report:
Patient Information:
- John Doe
- Date of Birth: 05/12/1950
- Medical Record Number: 123456789
- Date of Study: 10/15/2023
Indication for Study:
- Recurrent aspiration pneumonia, difficulty swallowing, and history of stroke.
Procedure:
- The procedure was conducted using 20 ml of barium sulfate contrast material. The patient was seated upright and instructed to swallow various consistencies of barium.
Findings:
- Oral Phase: Mild delay in oral transit time with reduced tongue control.
- Pharyngeal Phase: Delayed swallow initiation with mild residue in the valleculae.
- Esophageal Phase: Normal esophageal clearance.
- Presence of aspiration or penetration: Trace penetration observed with thin liquids.
- Compensatory strategies attempted and their effectiveness: Chin tuck maneuver was attempted and found to be effective in reducing penetration.
Impression:
- The study indicates mild dysphagia with risk of aspiration on thin liquids. Compensatory strategies were effective in managing symptoms.
Recommendations:
- Dietary modifications: Recommend thickened liquids to nectar consistency.
- Swallowing strategies or exercises: Encourage chin tuck during swallowing.
- Further evaluations or referrals: Follow-up with a speech and language therapist in 4 weeks.
Signature:
- Dr. Emily Smith, SLP
- Date of Report: 10/16/2023