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Medical Chart Components for SLPs

Sep 12, 2025

Overview

This lecture provides a concise overview of essential medical chart components—imaging, laboratory values, and vital signs—that medical speech-language pathologists (SLPs) should understand to inform assessment and treatment.

Imaging in the Medical Chart

  • Chest x-rays are the most common chest imaging; look for terms like opacity, infiltrate, or density for potential aspiration clues.
  • Chest x-rays cannot confirm aspiration or dysphagia-related pneumonia alone; use findings as supporting data.
  • Chest CT produces 3D images and is more detailed than x-ray but used less frequently due to higher radiation.
  • Head CT is best for detecting brain bleeds; brain MRI is better for occlusions and ischemic strokes.
  • Esophagram (barium swallow) assesses esophageal or upper GI tract structure and function.
  • EGD uses a scope to examine the esophagus, stomach, and duodenum lining.
  • Neck CT detects disorders or injuries in the neck, including tumors, infections, or thyroid nodules.
  • Laryngoscopic exams visually assess vocal folds and pharynx for paresis, nodules, polyps, or abnormal secretions.

Laboratory Values to Monitor

  • White blood cell count (leukocytes) above 10,000 often indicates infection.
  • Neutrophils are a type of white blood cell that rise with bacterial infection; elevated levels with normal total count is neutrophilia.
  • Low neutrophil count suggests immunosuppression and is common in chemotherapy patients (neutropenia).
  • Low red blood cell count may indicate anemia and cause weakness, fatigue, or dysphagia with exertion.
  • Hemoglobin measures oxygen-carrying capacity; therapy may be deferred if hemoglobin <8.
  • Abnormal lab results may not always point to a clear diagnosis; unexplained symptoms may warrant instrumental swallowing studies.

Vital Signs

  • Oxygen saturation (O2 stats) for healthy adults is 95–100%; 88–92% may be normal in COPD patients.
  • O2 saturation below 88% may require additional respiratory support.
  • Respiration rate for healthy adults is 12–20 breaths/minute; monitor during exertion for endurance.
  • Heart (pulse) rate is 60–100 beats/minute; tachycardia is high, bradycardia is low.
  • Track heart and respiration rates during therapy to assess patient tolerance.

Key Terms & Definitions

  • Aspiration — Entry of material (food, liquid) into the airway below the vocal folds.
  • Dysphagia — Difficulty or discomfort in swallowing.
  • Chest X-ray (CXR) — Radiographic image of chest structures.
  • CT (Computed Tomography) — Detailed cross-sectional imaging; used for chest, brain, and neck.
  • MRI (Magnetic Resonance Imaging) — Imaging technique for soft tissues, especially brain.
  • Neutrophilia — Elevated neutrophil count.
  • Neutropenia — Abnormally low neutrophil count.
  • Hemoglobin — Molecule in red blood cells carrying oxygen.
  • O2 Saturation (O2 Stats) — Percentage of hemoglobin saturated with oxygen.

Action Items / Next Steps

  • Review patient charts for imaging and lab results relevant to swallowing and respiratory status.
  • Monitor vital signs during therapy and meals for signs of decreased endurance or distress.
  • Suggest instrumental swallowing studies when diagnosis remains unclear.