Assessment Case Presentation

By: Jamie Davis, Amanda Fowler, Robin Carter, and Crystal Brown

Historical Information: 74 year old male with ten year history of Parkinson's disease, now admitted with worsening speech and aspiration pneumonia

History obtained: Medical Chart, Client interview, and Caregiver interview

Medical Chart

Pertinent medical history, reason for referral, current diagnosis, evaluation and therapy through other services (such as PT, OT, RT, ST, etc.). In these services how well the patient follows commands, visual-perceptual problems, and family support were all noted.

Recent scans/tests completed were noted, change in arousal/alertness levels, restrictions such as positioning, ambulation, and hearing/visual were all noted.

Current feeding status, current weight, and/or recent weight loss.

Information Obtained: Medications, Diet, ADL, Mobility Status, Dentition

Significant Doctor/Nurse/Therapy notes were noted.

Interview

Questions for patients:

(Overview questions) 1. What have you done to compensate for/improve your problem?

(Speech questions) 2. Describe your speech.

3. Do you feel that people understand you when you speak?

4. Have you seen any other doctors/specialists for the difficulties with your speech?

5. How has the problem changed since it first began?

6. Are there times when your speech is better than others?

7. How well does your family/friends understand you?

(Swallowing questions) 8. Do you cough or choke while eating?

9. Which foods are easier to swallow? (i.e., problems with liquids or solids)

10. Does your mouth get dry easier/often?

11. Do you experience pain when eating?

12. Have you experienced any recent appetite change?

13. Do you perfer certain foods?

Questions for families/caregivers:

1. Do you have any difficulty understanding him?

2. Is he able to communicate his basic needs?

3. Does he seem to understand you well?

4. Does he use gestures or other means besides speech?

5. What kind of communication situations will he be involved in?

6. Have you noticed any difficulty with attention, memory, or judgement?

7. Have you noticed any personality changes?

8. Does he have or need much help/support at home?

9. Do you feel like he will want to participate in therapy?

Formal Observations

1. Oral Motor exam: Assess structure and degree of functionality

2. Speech Production: Admitted with worsening speech, reading passage or elicitation of spontaneous speech- dependent upon patient alertness and cognitive status, simultaneously assess speech subsystems and include elicitation tasks as necessary.

3. Dysphagia: Obtain as much information as possible from interview, conduct clinical swallowing assessment to determine what and why he is aspirating, administer Modified Barium Swallow.

Expectations

1. Oral Motor exam: tongue tremor, reduced initiation of lingual movement, repetitive tongue pumping action, lingual festination, and reduced ROM.

2. Speech Production: Hypokinetic Dysarthria- monopitch/monoloudness, loudness decay, overall reduced loudness, increased rate of segments, increased overall rate, reduced stress, inappropriate silences, short rushes of speech, and repeated phonemes. Speech Subsystems- respiration (muscular rigidity resulting in decreased loudness, loudness decay, and tremor), phonation (breathiness often resulting from vocal cord bowing and monopitch as a result of muscular rigidity), resonation (often spared), articulation (imprecise articulation). Some patients with Parkinson's Disease ultimately become nonverbal.

3. Dysphagia: Oral Phase- drooling, slowed oral transit time, piecemeal deglutititon, premature delivery, reflux from base of tongue into mouth (half way down and comes back up). Pharyngeal Phase- moderate delay in swallow, reduced pharyngeal peristalsis, pharyngeal residue, incomplete laryngeal closure, decreased laryngeal elevation, cricopharyngeal spasm. Esophageal Phase- reduced peristalsis.

Informal Observations

1. Orientation- getting idea of mental status (who are you, where are you, what day is it).

2. Observe positioning, alertness and responsiveness (eye contact and visual/auditory tracking), facial expression, ability to follow conversation, social appropriateness, stamina, and hearing screening.

3. Screening Receptive and Expressive Language- Go and talk with patient. Have client do activites to assess Auditory Comprehension (Is your name George, have you had breakfast yet?), Auditory Word Comprehension- (Name the following objects), Commands- (touch your nose, raise your hand), Repetition- (read each phrase and ask client to repeat it), Naming- (Look at diagram and name each item), Writing- (have patient write words or sentences), Automatic Speech- (have patient count form 1 to 20, say the names of the week), Reading- (grandfather passage), and screen for anomia, paraphasia, effortful speech, etc.

Expectations

1. Deficits associated with demetia: reduced initiation, impaired problem solving and reasoning, impaired verbal memory and slowed processing

2. Additional deficits: auditory comprehension, sentence processing, reduced syntactic complexity, naming, reduced spontaneous verbalization, poor word generation, reduced self correction, and flat affect.

Estimated Length of Assessment Session and Number of sessions required:

2 15-30 minutes sessions within 36 hours

 

Mock Report

Client: George Smith

DOB: 06/02/28

Referral: Admitted with worsening speech and aspiration pneumonia

History:

Mr. Smith was admitted with worsening speech and aspiration pneumonia. His medical history is significant for Parkinson's Disease that has progressed over 10 years. Mr Smith reports and increased difficulty that has progressed dramtically in the last 3 years. He described moderate to severe oral phase swallowing difficulties related to bolus manipulation.

Evaluation:

A brief protocol of speech production was adminstered. Performance on the following subtests were rated as follows: respiration, phonation, resonation, and articulation. Significant deficits were noted for tongue movements for speech and nonspeech movements, impacting articulation accuracy, and reducing overall intelligibility. A Clinical Swallowing Evaluation was conducted in the following deficits were noted in the oral phase: drooling and slowed oral transit time; in the pharyngeal phase: pharyngeal residue and decreased pharyngeal elevation; and in the esophageal phase: reduced peristalsis.

Impressions:

Mr. Smith exhibits moderate-severe hypokinetic dysarthria and moderate-severe dysphagia with aspiration of liquids and solids.

Recommendations:

1. Mr. Smith should be restricted to soft solids/puree consistencies with supervision.

2. If Mr. Smith wishes to address his speech deficits, treatment could be provided here, twice per week for four weeks with the following goals:

a. Effectively communicate basic needs and wants

b. Increase ROM of articulators for speech and nonspeech movements

Amanda Fowler, Graduate Clinician

Jamie Davis, Graduate Clinician

Crystal Brown, Graduate Clinician

Robin Carter, Graduate Clinician