Mr. Simmons is a 70 y.o. man who was referred to your clinic because of
reports of progressively worsening speech. The patient’s wife reported that
she was having increased difficulty understanding him, so he went to his
doctor who referred him for a comprehensive Speech-Language
evaluation.
Medical History Hypertension. No prior history of neurological disease.
Social history: The patient was an editor for the Washington Post.
MRI: unremarkable. No lesions were noted.
Neurology Report
Mental Status: The patient was alert and oriented to person, place, and
time. He was able to follow one and second-order commands without
difficulty. Although it was noted that the initiation of movement was slow. He
was able to recall 6/6 digits forward and 3/5 digits backward. The patient
was able to recall three (3) items immediately and after a 5-minute
delay. His language was fluent. He was able to name common and
uncommon objects without difficulty; repetition was intact; writing was
moderately illegible. The patient was noted to have resting tremors in the
hands and face. The patient denied any visual hallucinations, delusional
thoughts, or a history of psychiatric disorders.
Cranial Nerves: On cranial nerve examination, the patient’s pupils were
equal, round, and reactive to light. Extraocular movements were intact with
no noted nystagmus or abnormal eye deviation. At rest, the patient’s face
was masked with little facial expression. The patient had some difficulty
wrinkling the forehead bilaterally but was thought to be as a result of
hypokinesia and not facial weakness. The retraction of his lips was a
minimal asymmetric on the left side (left facial droop). Mandibular strength
was normal with a reduced range of motion. The tongue protruded with
some marked limited range of motion. The uvula presented with adequate
elevation on repetitions of “ah”. The patient also presented with a normal
gag reflex. Sternocleidomastoid and shoulder shrug was intact.
Motor Exam: The patient presented with resting tremors in the lower and
upper extremities. Muscle strength was 5/5 on upper and lower extremities
bilaterally. Deep Tendon reflexes testing (resistance to stretch) revealed
increased rigidity in all extremities, in all directions and through the full
range of motion. Muscle strength was at 3+ bilaterally. Hyporeflexia noted
Reflexes: Extensor plantar responses (Babinski sign) were present
bilaterally.
Coordination and Gait:
Appendicular Coordination:
Rapid Alternating movements such as finger tapping were slow and
imprecise. Finger-nose-finger testing was also slow and imprecise with
marked paucity and hesitation of movement bilaterally.
Bradykinesia was present on repetitions of finger tapping.
Arm swing during walking was deemed to be reduced. The patient was
slow to initiate sit to stand and during walking his gait was characterized as
short with festination.
Motor Speech Performance
Oral Mechanism Exam:
The oral mechanism examination was unremarkable and without deficit
with the exception of lingual tremulousness on protrusion and during lateral
movements. Conversational speech, reading, and repetition displayed a
remarkable degree of Speech AMRs was rapid or accelerated.
Cough and glottal coup were weak. Gag reflex was normal.
AMRs and SMRs: rapid, imprecise AMRs with variable rate and
inappropriate silences.
Vowel prolongation: 12 seconds, 12 sec and 9 seconds.
Vocal Quality: Judged to be Breathy, hoarse, monopitch, monoloud
Conversational Speech/Reading passage: slow, imprecise articulation
(especially noted on consonants), reduced stress, weak pressure on
consonants, reduced rate, shortened phrases, and short rushes of speech
and inappropriate silences. There was a notable deterioration of speech
and dysfluency, characterized by rapid repetition of initial sounds, syllables,
and occasionally words and phrases. Sound and syllable repetitions
occurred up to 30 to 40 repetitions per dysfluent moment.
There was no evidence of associated struggle behavior during
dysfluencies, but he was frustrated by them. Articulation was moderately
imprecise, and overall pitch and loudness variability were reduced.
Words of Increasing Length: Intact but slow. At times the patient had
difficulty initiating some responses.
Speech intelligibility: Mild-moderately impaired in conversational speech
and a reading passage.
Swallowing
The patient reports that it has been taking longer to complete a meal. It
typically takes anywhere from 45 mins to an hour. He currently eats regular
textures and reports softer foods are easier to eat. During the observation
of the first meal, the nursing staff noted that the patient became fatigued
when chewing the regular textures and started coughing on the prescribed
regular liquids and solid textures.
Case Video
Case Conversational Speech Sample
Assignment Questions:
Interpret all sections of the neurological examination.
1. Identify at least 5 questions you would ask this patient during your
Patient Interview. Provide a rationale for your question (what
information does it provide you?). Remember that your questions
MUST lead you to develop a Clinical Hypothesis for differentially
diagnosing this patient.
2. Where is the site of the lesion? Provide justification with your answer
from the neurological report provided.
3. What neurons are involved UMN and/or LMN? Provide justification
with your answer. Provide justification with your answer from the
neurological report provided.
4. What motor pathway is involved?
5. What type of dysarthria do you suspect? Provide a justification for
your answer.
6. Outline a therapy approach you might use with this patient.
7. Provide at least one (1) long-term goal and two short-term objectives
to address in therapy
