Patient Information: 64 yr old male with sudden onset right-sided weakness, apparent expressive aphasia with halting effortful speech.

Process of Obtaining the History (Acute Care Setting)

Obtain the medical history.

Information found within the medical chart

i. Doctor information

ii. Neurologic information

1. Etiology

Informational conversation with the nurse

i. More personal information

1. Glasses, hearing aides, etc.

ii. Alertness and Responsiveness

Family/Primary Caregiver History

Home communication needs
Interview (Patient and Family)

Interview Questions

(Questions my need to be answered by a family member/ caregiver)

1. Please describe the problem.

2. When did the problem begin?

3. Do you know the cause of your speech problems?

4. Has the problem changed since it was first noticed? Gotten better or worse?

5. Are there certain circumstances that create fluctuations or variations?

6. What medications is the patient currently taking?

7. (If different from above) are there any eating or swallowing difficulties? If so, please describe.

8. How do you react or respond to the problem? Does it bother you? What do you do when the situation arises?

9. How have you tried to help the problem? How have others tried to help?

10. What other specialists (i.e. Doctors, PTs, OTs, etc) have you seen?

11. What do you hope will result from our services?

Formal Observations

For Acute Care Setting

Complete Oral Mechanism Exam to assess oral motor function (5-10 minutes)

Burns Brief Inventory of Communication and Cognition to assess expressive and receptive language (15-20 minutes)

§ Auditory Comprehension

§ Naming

§ Repetition

§ Reading

§ Writing

Bedside (clinical) Assessment (10 minutes)

Four Point Test

Write order for a Modified Barium Swallow to further assess swallowing function.

Informal Observations

Patient was observed to be lying in bed in an upright position at a 45 degree angle. Patient was alert and responsive to the clinician by exhibiting sufficient eye contact during entire formal assessment session. Patient responded to auditory stimuli (e.g. running water, knocking on door upon entry.) Patient exhibited right sided weakness during writing assessment and when expressing facial gestures. Patient was unable to verbally respond to the following orientation questions however he responded nonverbally by nodding his head: 1. Who are you? 2. Are you in a hospital? 3. Is she your wife? 4. Are you sitting in a chair? Conversational interaction with the

clinician was disrupted by the patient’s inability to verbally express himself. No hearing loss was indicated by family members. It was reported by his wife that he coughs and drools slightly during eating.

Estimated Length of Assessment Session

2-3 sessions depending on alertness and fatigue of patient. MBS estimated time 10-15 minutes. Total estimated time of assessment process 40-45 minutes within 36 hours.

Mandy Crow, soon-to-be-CCC-SLP

Kellan Williams,soon-to-be-CCC-SLP

Corinne Kelsey, soon-to-be-CCC-SLP

Heather Browing, soon-to-be-CCC-SLP

Erin Ward, soon-to-be-CCC-SLP

Shaun Key, soon-to-be-CCC, SLP

(Assessment report located on next page)

Assessment Report:

Patient: P. Diddy DOB: 05/29/35 Referral: Dr. Dre

History:

Mr. Diddy was referred by Dr. Dre, his family doctor, because of concerns about his communication and swallowing abilities. Medical history is significant for left hemisphere stroke, effortful speech, and sudden onset of right sided weakness. Mrs. Rap Video Girl reports that difficulty with Mr. Diddy’s speech and swallowing was evident after the stroke. She described his inability to communicate as “He can’t get the words out.” She also described his swallowing difficulty as “Food comes out of his mouth, and he coughs a lot when he eats.”

Evaluation: A complete oral mechanism exam indicated poor lip seal and tongue weakness on the right side. The Burns Brief Inventory of Communication and Cognition indicated good auditory comprehension, moderate to severe deficits in naming, repetition, reading, and writing impacting intelligibility. The Four Point Test indicated a delayed swallow reflex.

Impressions: Mr. Diddy exhibits Broca’s aphasia affecting his expressive communication. The presence of decreased pharyngeal peristalsis and poor bolus control due to right sided weakness indicates dysphagia.

Recommendations:

1. Family was informed to continue compensatory strategies outside of therapy sessions with Mr. Diddy.

2. Following medical work-up, Mr. Diddy should receive swallowing and speech therapy twice per week until improvement is noted, with the following compensatory techniques: