Question

A 77-year-old male with vascular dementia and a history of smoking presents with an improving R middle lobe pneumonia. The wife reports a slight increase in chronic cough after meals, rhonchi over the R midlung field, poor diaphragm excursion, mildly dysarthric speech, and a MMSE score of 20/30. What is the most appropriate next step in management?

A. Initiate antibiotic therapy
B. Order a chest X-ray
C. Perform a videofluoroscopic swallow study
D. Refer to a neurologist for further evaluation

Answer 1

The next step in management should be a videofluoroscopic swallow study to evaluate for a potential swallowing disorder that could cause aspiration, contributing to the patient's respiratory symptoms.

Step-by-step explanation:

The most appropriate next step in management for a 77-year-old male with vascular dementia and a history of smoking, who presents with an improving R middle lobe pneumonia and a slight increase in chronic cough after meals, would be to perform a videofluoroscopic swallow study (option C).

The clinical signs, including increased cough after meals and poor diaphragm excursion, suggest the possibility of aspiration due to a swallowing disorder, which is common in patients with neurological conditions such as dementia. This assessment will help to identify if aspiration is occurring during meals, potentially exacerbating the patient's respiratory condition.