22.History taking: from a review of past medical history and person's chief complaint, through medical interview

Explanation

In this module, we first cover chief concerns that suggest dysphagia and then the methods for medical history-taking and conducting a medical interview.

Explanation

If dysphagia is suspected based on the patient's chief concerns, previously overlooked dysphagia can be detected by taking a detailed medical history and conducting a medical interview. Dysphagia can occur anywhere along the lengthy route from the mouth to the stomach, and from a wide variety of causes ranging from psychosomatic manifestations to cancer. Conducting a medical interview is the first step in narrowing down the possibilities in diagnosing dysphagia, and it also functions as a screening procedure.

Explanation

Examining patients for dysphagia starts with asking them and their caregivers about chief concerns. Here is a list of chief concerns typically seen with impairment from the anticipatory stage to the oral stage. When patients have problems with sensory recognition of food due to a condition like dementia, their caregivers may share concerns that the patients don't eat spontaneously (they refuse food), that there is residual food in their mouth, and that food spills out of their mouth.

A dry mouth also makes it difficult to initiate swallowing. Other chief concerns in patients with neuromuscular diseases are difficulty chewing and swallowing food. These difficulties result in lengthy mealtimes and weight loss.

Explanation

The chief concerns seen with impairment during the pharyngeal and esophageal stages include (1) not eating spontaneously, (2) weight loss, (3) lengthy mealtimes, (4) food residue in the mouth, (5) recurring fever, (6) increased sputum, (7) feeling of residue in the pharynx, (8) choking or coughing during or after meals, (9) hoarseness during or after meals, and (10) nighttime coughing.

Concerns (1) through (4) are also seen with impairment from the anticipatory stage to the oral stage. Concerns (8) through (10) suggest aspiration.

Explanation

If we suspect dysphagia based on the chief concerns, we need to ask detailed questions about underlying diseases, past medical history, and family history (history-taking).

Explanation

The important points of history-taking for cerebrovascular disease are to obtain information about the time since onset, affected areas, and number of events (single or multiple). For head injuries, we must be careful to note not only the severity and location of the injury, but also whether the patient is intubated, has a tracheotomy, or has higher brain dysfunction.

Explanation

For patients with head and neck cancer, we need to obtain information not only about tumor size and location but also about history of surgery, radiotherapy, and chemotherapy. For patients with neuromuscular diseases such as Parkinson's disease, we should also confirm the progression of the disease and motor impairment, medications, and dementia status.

Explanation

At the same time as history-taking, we should conduct a medical interview about symptoms that suggest dysphagia, nutrition intake status, medication use, and cognitive abilities.

Explanation

The main symptoms that suggest dysphagia are as follows: impairment of consciousness, choking during swallowing, coughing, food residue mixed with sputum, pharyngeal discomfort, sensation of food residue retention, difficulty swallowing, loss of appetite, lengthy mealtimes, change in dietary content, change in way of eating, fatigue during eating, salivation, dysarthria, wet hoarseness, buccofacial apraxia, repeated respiratory infection and fever, weight loss not related to an underlying disease, reduced urine output, and dehydration.¹

We can also use a questionnaire form in a medical interview about dysphagia symptoms.

Explanation

Commonly used questionnaire forms include the Seirei Swallowing Questionnaire and the EAT-10. Here we see the Seirei Swallowing Questionnaire.² Questionnaires have the advantage of enabling us to systematically understand the situation in a short period of time, and they can be used as screening tools.

Explanation

Questions on nutrition intake status should cover whether the patient is getting all nutrition through oral feeding, is exclusively being tube fed, or is being supplemented with tube feeding.³ It is easiest to understand by looking at the percentages of nutrition obtained through oral feeding and tube feeding using an outcome evaluation measure for dysphagia patients.⁴ Regardless of the percentages, we should also confirm the course that led the patient to their current nutrition intake status.

Explanation

Here we see an outcome evaluation measure for dysphagia patients. It evaluates nutrition intake status and medical stability.

Explanation

Medications can worsen pre-existing dysphagia or even directly cause dysphagia, so we need to collect information on medication use. It is particularly important to know if the patient is using any psychotropic drugs that affect the central nervous system.

Explanation

Conditions such as dementia and buccofacial apraxia cause problems during the anticipatory stage, oral preparation stage, and oral stage. So, in the medical interview we should confirm whether patients have any conditions that could cause dementia or any central nervous system disorders that could cause higher brain dysfunction such as buccofacial apraxia.

References

1. Hiraoka T: Dysphagia Rehabilitation, Evaluation of Dysphagia - Points of medical history, physical findings (in Japanese), Modern Physician, 26: 19-21, 2006
2. Ohkuma R et al:Development of a questionnaire to screen dysphagia. The Japanese Journal of Dysphagia Rehabilitation, 6:3-8, 2002
3. Tohara H: Team approach in dysphagia home care rehabilitation (in Japanese), ZEN・NIHONBYOIN・SHUPPANKAI, 2007
4. Onogi K et al: Videoflouroscopic evaluation (in Japanese). Journal of Clinical Rehabilitation, 11:973-803, 2002