Follow-Up Consultation Notes for Marco

Follow-Up Consultation Overview

  • Patient: Marco

  • Condition: Follow-up after a stroke, 3 months post-event

Key Observations

  • Marco has experienced significant weight loss (15 pounds) within 3 months since his stroke.

  • Current Body Mass Index (BMI): 17.9, indicating underweight status.

  • Weight loss exceeding 5% in one month is concerning.

Health Concerns Raised

  • Weight Loss: Major complaint, the patient feels it's the biggest issue.

Dietary Assessment

  • Appetite:

    • No sense of smell; food lacks appeal.

    • Minimal intake: difficult to eat much.

  • Food Preferences:

    • Vegetarian, prefers soft and cooked fruits and vegetables due to mouth pain while chewing.

  • Recent Dietary Intake (Last 24 hours):

    • No breakfast.

    • Lunch: apple sauce and mashed potatoes.

    • Supper: canned peaches and cottage cheese with chocolate milk before bed.

  • Eating Difficulties:

    • Fatigue post-eating.

    • Difficulty holding utensils.

  • Shopping:

    • Daughter assists with grocery shopping weekly; budgeting for food is challenging due to high costs.

Physical Exam Findings

  • Hair: Dry, brittle, and thin.

  • Mouth Examination:

    • Presence of sores in the mouth; expected to improve with better nutrition.

  • Gag Reflex: Positive, but with deviation of the tongue to the left.

Swallowing Assessment

  • Swallowing Test: Conducted to evaluate effectiveness using pudding.

  • Instructions for Safe Swallowing:

    1. Push tongue against the roof of the mouth.

    2. Move food around in the mouth before swallowing.

    3. Swallow twice with each bite.

    4. Extend head back before swallowing.

  • Patient's Response: Expresses difficulty with instructions but attempts to repeat them.

Indicators of Impaired Swallowing

  • Sign: Coughing during swallowing attempt.

  • Action Taken: Assess for sensations of obstruction in throat; patient reported relief after coughing.

Next Steps

  • Discuss findings with the healthcare provider about Marco’s nutrition and swallowing concerns.

  • Consider modifications to diet based on swallowing capability and nutritional needs.