AIChatLog

ENT Referral & Symptom Management Summary

Patient: Robert Trower
Date: June 12, 2025
Location: Kingston General Hospital (KGH)
Prepared by: Patient + AI Clinical Support System ("Vous et Moi")

🧠 Clinical Context

• Post-CABG + valve replacement (June 1, 2025)
• Post-op stroke with current speech impairment
• SLP-cleared for pureed diet; aspiration risk resolved
• Primary complaints:
  • Persistent dry cough (feels like it should be productive)
  • Pain during swallowing (odynophagia)
  • Speech-limiting throat irritation

🔍 Key Concerns

• Laryngeal inflammation (post-intubation or reflux-related)
• Residual vocal cord paresis or edema
• Laryngopharyngeal reflux (LPR)

🎯 Consult Request

ENT Evaluation Requested to visualize vocal cords and supraglottic region:

• Rule out laryngeal trauma, edema, or ulceration
• Check for cord immobility or post-stroke effects
• Evaluate for signs of chronic irritation or reflux (LPR)

💊 Suggested Adjunct Measures

• Consider trial of PPI (e.g., pantoprazole) or H2 blocker
• Use of saline nebulizer or humidified air
• Ongoing SLP monitoring for speech and voice
• Pain management for swallowing discomfort

Note: Patient is alert, cooperative, and participating actively in care. ENT input is timely and appropriate for ongoing symptom resolution.