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

• 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

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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’)
  • Example objects: 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