Ask Patient’s name, DOB and what they like to be called
Explain examination and obtain consent
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
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 nerves9, 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
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’)
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
‘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?
Which tests may be used to assess muscle fatiguability in patients with myasthenia gravis?
How would a patient present if they had complete damage to cranial nerve X (Vagus nerve)?
How would you differentiate between and bulbar and pseudobulbar palsy?