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Mr. Les Nessman is a 78-year old right-hand dominant male. He lives at home with his wife and a Labrador Retriever. He has a history hypertension, cardiovascular disease, and transient ischemic attacks. Prior to this event, his wife reports that Mr. Nessman loved to garden, golf and belonged to a ham radio club. He was very active in the community and with the local VFW. He was independent and required no assistance for ADLs. Mr. Nessman was on a walk when he experienced a sudden onset of dizziness and right-side weakness. He sat down to rest and called his wife. Mr. Nessman’s wife noticed his disorientation and slurred speech and called 911. He was taken to the ER by ambulance. When he arrived at the ER his ability to communicate verbally was limited. He was hospitalized and diagnosed with an ischemic infarct of the left insular cortex.

OBJECTIVE

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The following test(s) was/were administered: The Boston Diagnostic Aphasia Examination 3rd Edition (BDAE-3), The Revised Token Test (RTT), orofacial examination, motor examination and bedside swallow evaluation were also performed.

ASSESSMENT

The Boston Diagnostic Aphasia Examination 3rd Edition (BDAE-3) was performed to evaluate the patient’s overall communication. The Revised Token Test (RTT), Motor examination, orofacial examination and a bedside swallow assessment were also performed.

Results of above tests are as follows:

Receptive: Mr. Nessman’s results regarding word comprehension, understanding complex information, syntactic processing and following commands of increasing complexity were all within normal limits. Mr. Nessman was able to comprehend nouns and verbs in a sentence, however, had difficulty understanding grammatical morphemes such as prepositions and conjunctions. Results of the BDAE-3 also indicated that Mr. Nessman’s reading comprehension was well preserved. A high score (30/ 36) on the Revised Token Test (RTT), supported language comprehension.

Expressive: The patient was cooperative, well-oriented, with slow spontaneous speech which was relatively fluent. There were literal paraphasias (two in every 15 words) and sporadic anomia. He used sentences of a normal length and no agrammatism was observed. Severe repetition defects were evident in words with more than two syllables. Mr. Nessman’s reading was slow, with literal paralexias equivalent to the paraphasias in oral language. Mr. Nessmen showed a good capacity for verbal memory in sentence repetition. He was able to repeat sentences in lengths of 8 words; however, these sentences usually contained literal paraphasias. Other errors observed included changes in phoneme order and omission of phonemes. Mr. Nessman exhibited difficulties in writing with slow and disautomated, uneven graphemes. He also presented errors in letter choice and sequencing. Errors were consistent to those observed in oral language during repetition. Mr. Nessman’s writing was full of literal paragraphias which were often unintelligible.

Informally Mr. Nessman was cooperative and well-oriented. He was able to list the days of the week and the months in the year. When asked to identify the month and year on the calendar, he was able to verbally or gesturally respond correctly. During production of the alphabet, minimal omissions of letters were present. Automated sequences and the ability to produce melodies (Twinkle Twinkle Little Star) were preserved. During the evaluation, Mr. Nessman was aware of his paraphasic errors and produced recurrent perseveration of the intended word. He often performed numerous self-corrections while trying to repeat or produce a word.

Orofacial Examination:
An orofacial examination was performed. Testing of reflexes (cough/swallow), respiration, lips (at rest, spread, seal, alternate), palate, laryngeal, tongue, etc. were evaluated. The following are the results from the orofacial examination.

Oral motor structure/function is normal in all aspects: No
Facial Appearance: mild right sided weakness
Strutural Abnomality: none
Strenght Reduced in: lips (right side); mandible (right side); tongue (right side)
Range of Motion Reduced for: lips (right side); mandible (right side); lingual lateralization (right side)
Rate of Movement Reduced for: lips and tongue
Tremor/Involuntary Movement Noted in: none
Sustained phonation reveals: within normal limits
Vocal Cord Adduction appears weak on: none
Is Drooling Present: Yes
Diadochokinetic Testing Reveals: Sequential Motion Rates: Slow Alternate Motion Rates: Slow

Motor Examination:
To evaluate the presence of Apraxia, Mr. Nessman was asked to perform five sets of movements for each of the following groups: (1) movements of the tongue and mouth and face with a score of 2/5 for verbal instruction and 1/5 for imitation; (2) meaningless movements with imitation using each hand (i.e. finger identification and tactile perception) scoring 1/5 with the right hand, 3/5 with the left hand; (3) intransitive movements (i.e. waving goodbye) with scores for both the right and left hands of 2/5 for verbal instruction and 3/5 for imitation; (4) transitive movements involving use of both hands (e.g. drinking out of a glass) – the movements were performed following an appropriate sequence, however underutilization of the right hand was noted.

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