The Clinical Swallowing Evaluation
One of the most crucial components, at least for me, of the Clinical Swallow Evaluation (CSE), is the interview.
I haven’t found a lot of published research regarding the interview portion of the CSE, so if you’ve found any, please let me know in the comments!
There is a nice example of some interview questions in The Source for Dysphagia by Nancy Swigert.
I probably spend the better half of my evaluation time digging in the chart for information and then interviewing anyone I can find that can answer to questions about the patient.
The chart review gives me an idea of the patient. You are looking for diagnoses, medications, lab values, history, etc. (Not to fear, there will be a post on chart reviews!)
As I said before, the interview is where I can get an abundance of information! I typically will try to find the nurse or even the doctor after reading the chart to get more information. What is the patient doing? How are they eating their meals, taking their pills? How alert is the patient? What is the plan for the patient?
Now, unless you want the person to get all defensive on you, don’t just run into the room and start firing questions at the patient! You don’t want them to feel ambushed. Introduce yourself and tell them why you are there. Maybe ask a couple of questions not swallowing related. You can comment on who is in the room. “Oh, you have a lot of visitors today.” That will usually prompt some introductions as well.
I try to keep it as light as possible. Don’t go in with the “I think you’re aspirating and you will probably get pneumonia and die” line up and ready to fire. You have no idea what is going on with this person and they probably had no clue that a Speech Language Pathologist worked with swallowing.
We all know the famous line. You: “Hi, I’m Susie/Stan and I’m the Speech Language Pathologist.” Patient/family: “There is nothing wrong with my/their speech. Just listen to me/them talk.”
Make that person comfortable. Sometimes, they know that we work with swallowing. Maybe they have had some experience or someone they love has had some experience with dysphagia and they don’t want that thick crap to drink. Let them know you’re not the thickened liquid police and you just need to see what’s going on so that you know if you can help them with any problem they may be having related to swallowing.
What do I ask?
In a perfect world, the family is present in the room for an evaluation. Don’t look at the family as judging you and what you’re doing. Chances are, they have no idea what to expect from you.
If the patient is able to answer questions and the family is available, I interview them all at the same time. I really have tried to develop a list of interview questions, but have found the interview much more effective if it is patient-driven.
I do ask about the current or most recent hospitalization. What happened that you had to come to the hospital? What is your current problem? Are you having trouble with swallowing your food? How about those pills? How do you do when you are at home? Do you have any trouble swallowing pills at home?
I also like to find out if there are any foods that are avoided or if there is a specific method they use to take pills. Bonus if the nurse comes in to pass meds so that you can actually observe the patient taking their pills!!
Speaking of pills, I almost always have patients say, well, I do ok with my pills except for one. It’s huge. When I ask if it’s the potassium pill, the answer is almost always yes. I would say nearly every patient I evaluate that takes a potassium pill has trouble with it.
I always ask the patient/family about neurologic diagnoses or even previous surgeries or cancer treatment. The thing is, the chart can be great as well as the history and physical section of the chart, BUT there can be information missing or inaccurate.
Take for example, the patient I had several years ago that was in the hospital for weakness. The chart had nothing in it about previous tonsil cancer with 37 sessions of radiation or the fact that the person had a large portion of their stomach removed due to cancer.
I really want my patient to feel like they were interrogated by the FBI. Now, don’t shine a bright light in their face or slam the table trying to intimidate them, but you need to get down to the heart of the problem, or the lack of a problem with swallowing.
If the person is having trouble with any consistency, how long has this been happening? Have they ever had an instrumental assessment? Have they ever had therapy for swallowing? If so, when, where and for how long? It’s also nice if they or the family can remember what they did for therapy.
Has the person already had their meal today? If so, how did they do? Was there a consistency more difficult than the others? What happens with that consistency, does it get stuck? Does it make them cough? Have them define difficulty as much as possible.
Is it Dysphagia or is it GERD?
Many times, the patient complains that the food gets stuck “right here”. If I were a betting person, I would bet nearly every time they point to the same spot on their throat. Which is often associated with GERD.
How do you know which is which?
Well, you don’t without instrumental assessment, but you can do something to find out the probability of GERD or reflux. Do you use the Reflux Symptom Index? This is a great way to have the patient answer questions related to GERD. You can download a free copy right here.
Remember to let the interview guide you. You may have a million more questions based on a particular answer or comment by a patient. The more comfortable you make the patient, the more they will likely share with you.
If they complain of difficulty with some foods, what foods are they. Sometimes that patient may be taking pills that cause xerostomia (dry mouth) or they may have had radiation treatment causing xerostomia making it more difficult to swallow foods such as meat, bread or rice. Maybe they need to include water with their meal. Sometimes dipping the food in an oil, such as olive oil or adding gravy will help to eliminate the difficulty chewing or swallowing.
The interview process should answer so many questions for you and lead you into the actual hands-on part of the evaluation, maybe giving the patient some trial consistencies, recommending an instrumental assessment, the cranial nerve assessment, etc.
What do YOU ask?
Do you have a list of go-to questions or a questionnaire that you find helpful? Post it in the comments below! You can also go to the Internet Resources page and find some downloadable outcome measures to use in your evaluation during the interview.