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Examination of speech

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent

General

  • Listen to their speech, for example ask questions such as:
    • What’s your name?
    • How old are you?
    • Describe how you got here today
    • Describe the room
  • Determine if the pathology is dysarthria or dysphasia, then proceed to the appropriate examination
    • Dysarthria (difficulty with mechanics of speech)
      • Bulbar palsy = flaccid
      • Pseudobulbar palsy = spastic
      • Cerebellar = slurred, staccato (broken up into syllables, i.e. jerky), scanning (variability in pitch/volume) 
      • Myasthenic = weak, quiet, fatigable
    • Dysphasia (difficulty with processing of speech)
      • Expressive (Broca’s) = patient knows what they want to say but cannot say it, resulting in non-fluent speech – they still understand speech and have awareness of their speech difficulty
      • Receptive (Wernicke’s) = fluent, effortless speech that is disorganised and lacks meaning (talk Rubbish) + cannot understand language (written or spoken) – they lack awareness of their speech difficulty

Dysarthria

  • Repeat difficult phrases
    • ‘Yellow lorry’ (tests tongue)
    • ‘Baby hippopotamus’ (lips)
    • ‘We see three grey geese’ (palate)
  • Repeat sounds: ‘pa’ (facial and mouth), ‘ta’ (tongue), ‘ka’ (palate)
  • Count to 30 (fatigability in myasthenia gravis)
  • Test cranial nerves 9, 10 and 12
    • Look in mouth and say ‘ahhh’ to observe palatal movement
    • Look at uvula (deviates away from the side of lesion)
    • Look at tongue (fasciculations = lower motor neuron, e.g. bulbar palsy)
    • Assess cough and swallow
    • Stick tongue out (deviates to side of lesion)
    • Say you would also test gag reflex

Dysphasia

  • Commands (unable to follow = receptive)
    • Single stage: ‘open your mouth’
    • Two stage: ‘with your right hand, touch your nose’
    • Three stage: ‘with your right hand, touch your nose then your ear’
  • Naming objects (difficulty saying name = expressive; incorrect names = receptive; difficulty naming objects when other aspects of speech are normal = ‘nominal dysphasia’)
    • Watch
    • Watch hands
    • Pen
    • Tie
    • Belt
  • Repetition (poor flow and articulation = expressive; lacking meaning = receptive)
    • ‘No ifs ands or buts’
  • Read a sentence (poor flow and articulation = expressive; lacking meaning = receptive)
  • Write a sentence (effortful with poor flow and mostly content words = expressive; effortless but lack of meaning = receptive)

To complete exam

  • Thank patient
  • ‘To complete my examination, I would perform a full neurological examination.’
  • Summarise and suggest further investigations you would consider after a full history

Here’s some viva questions

Please describe the difference between Broca’s and Wernicke’s aphasia. Damage to which areas of the cerebral cortex cause each of these aphasias?

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Which tests may be used to assess muscle fatiguability in patients with myasthenia gravis?

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How would a patient present if they had complete damage to cranial nerve X (Vagus nerve)?

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How would you differentiate between and bulbar and pseudobulbar palsy?

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