practice exam Flashcards
Mrs Jones, aged 35, 5-days post TBI.
Mrs Jones is a waitress who is 5-days post-TBI. Cranial nerve assessment revealed a significant left sided facial droop and unilateral tongue weakness. You are planning to conduct food and fluid trials. a) What is your clinical hypothesis regarding the presentation of Mrs Jones’ 3- phases of swallowing function on regular food consistencies and thin liquids? (5 marks)
Provide a rationale for your hypothesis. (5 marks) In your response booklet, write your answer as:
• Oral preparatory outcomes and rationale
Oral phase outcomes and rationale
• Pharyngeal phase outcomes and rationale
Mrs Jones is likely to experience dysphagia, including difficulties with bolus preparation, swallow initiation and potentially airway protection.
b) Provide a rationale for your hypothesis. (5 marks) In your response booklet, write your answer as:
• Oral preparatory outcomes and rationale
Facial droop and tongue weakness mean Mrs Jones will have difficulty preparing the bolus through mastication and moving the bolus around in the mouth. There is likely to be spillage from the mouth due to poor lip closure. These observations suggest the TBI has impacted CNV, CNVII and CNXI which are the CNs involved in the oral preparatory phase. Impairment at this level, means there may residue left in the mouth as there is inadequate preparation of the bolus.
• Oral phase outcomes and rationale
Damage of CNV, CNVII, CNIX, CNX and CNXII impairs the oral phase of the swallowing. Unilateral tongue weakness will impact Mrs Jones’ ability to initiate the swallow. The tongue moves posteriorly to move the food or liquid to the oropharynx, causing the soft palate to elevate and provide airway protection. Reduced sensation may inhibit the appropriate sensory signals, which then initiate motor movements to perform a swallow. Lips are sealed in this phase and it is likely Mrs Jones will be unable to achieve this due to the facial droop. As such, food or liquids may move into the oropharynx undetected, limiting airway protection and risking aspiration.
• Pharyngeal phase outcomes and rationale
Sensory receptors receive the input the bolus has moved into the pharynx. If this does not happen, the actions to protect the airway from aspiration will be unlikely to occur. In this phase, the larynx is elevated and the epiglottis moves anteriorly to provide airway protection. Respiration ceases momentarily and the pharyngeal constrictor muscles engage to move the bolus down into the esophagus. Mrs Jones may have difficulty with this phase if there is damage to CNX and CNIX. Failure to elevate the larynx and move the epiglottis over the trachea will result in aspiration of the bolus.
Case study: Patrick Vine is a 20-year-old man who stutters. He has referred himself to your clinic for
management of his stuttering. As part of the assessment, you will gather case history
information. Write a plan for the case history interview, specifying the questions you will
ask and why (10 marks).
would want to ask questions from all aspects of the ICF
Introduction: Say hello and introduce yourself:
This will build rapport with Patrick
Personal & Environmental factors
What has brought you here today:
We can find out about Patrick’s stutter, especially his opinion of the stutter. This lets Patrick know that we are not making any assumptions and will build rapport.
Culture/linguistic history:
Assessment and intervention will need to be culturally appropriate and either in Patrick’s first language or with an interpreter.
Tell me about your living situation, your friends and family? Do your family live close by?:
This will let us know what kind of support Patrick has around him. Support can be a barrier or a facilitator to outcomes.
How long have you had the stutter? Do you notice it gets better or worse in particular situations? Could you describe what happens?:
These questions will help us to understand the stuttering behaviours and what impacts on Patrick’s stuttering. We can also take notes of Patrick’s stutter as he is answering the questions. It would be helpful to video record (with Patrick’s Consent) a speech sample during the case history interview.
Activities & Participation
What is your current occupation? What are some of your interests and hobbies?:
These questions are rapport building but also help us to understand Patrick’s activities.
How is the stutter affecting your job/school, social life, hobbies:
Asking Patrick how the stutter affects his participation. This may help us to build some functional goals.
Ask him if the stutter makes him feel anxious.
What are your goals/ what would you like to get out of SP?:
This is important to gather Patrick’s view on which parts of his life the stutter affects the most and what he would like to get out of speech therapy, this will help us to build functional goals.
Bodily structure & function
Medical history and medications list:
Important to gather as medications and other medical conditions can impact on Patrick’s alertness, fatigue levels and may be barriers to treatment.
Have you ever seen a SP and/or had other communication difficulties?:
Check in on Patrick’s communication history, any other speech impairments might affect therapy. We could also gather information on Patrick’s views of Speech Pathology.
Hearing and visual status:
Check if Patrick has had his hearing and vision checked recently.
Mr Smith is a retired teacher referred for speech assessment two weeks after discharge for a mild left sided hemispheric ischaemic stroke. Mr Smith complains of sounding like he’s drunk all the time. Specifically, he feels like “words are slurred” and his tongue and lips “won’t do what they are meant to”. In conversation on the phone, Mr Smith does not appear to have any language issues.
a) In order to make a differential diagnosis of this type of speech disorder, list the types of speech assessment tasks you might focus on and explain each of your suggestions.
- Speech sample - this can be taken while doing a case history interview. A speech sample gives a general overview of how the client is presenting and from this, the clinician can rate various aspects of pitch, loudness, voice quality, resonance, respiration, prosody, and articulation.
- Alternating motion rates (AMRs) - asking the client to repeat “puh-puh-puh” for as long and as fast as they can while maintaining accuracy, followed by the same for “tuh-tuh-tuh” and “kuh-kuh-kuh”. The speed and accuracy can be rated for this. An inability to sustain AMRs reflects inadequacies at the respiratory-phonatory or velopharyngeal levels. These are good for judging speed and regularity of rapid, repetitive articulatory movements.
- Sequential motion rates - repeating “puh-tuh-kuh” as fast and accurately as possible. This measures the clients ability to move quickly and in proper sequence from one articulatory position to another and can be particularly useful for diagnosing apraxia of speech.
This collection of data should provide enough information to point to a specific speech disorder.
OR:
Take a detailed case history of Mr Smith’s, including relevant medical conditions and communication concerns. Use this as an opportunity to collect a spontaneous speech sample, which can be used to provide analysis. Mr Smith has described his speech as “slurred’ and “his tongue and lips won’t do what he wants them to do”, which are generally indications of motor planning, motor execution and articulation impairments. It is important to assess speech in different levels (eg. Conversational, single word level, automatic speech) to contribute to a differential diagnosis, as different impairments will have varying features.
Perform an Oromotor assessment. By examining the physical features and functions of the face and oral cavity, it will be possible to determine any obvious structural impairments that may contribute to communication impairments. The Cranial Nerve assessment will indicate generally functionality of the structures innervated by CNV, CNVII, CNIX, CNX, CNXI and CNXII, which are the nerves involved in respiration, phonation and articulation. Understanding the level of cranial nerve impairment will provide further information about the structures and functions which are likely to have been impacted by the TBI Mr Jones experienced. Such information will be useful for differential diagnosis of any impairment.
Complete SMRs and AMRs. This will provide information about Mr Jones’s motor speech planning abilities, respiratory and phonatory abilities. He has indicated he is having difficulty with articulation and motor execution, which should be evident in this task. SMRs are helpful for assessing Apraxia of Speech which is an impairment of motor planning.
Have Mr Smith read the Rainbow passage, complete automatic sentences (eg. Bacon and ?) and repeat single words of increasing complexity. These language tasks place different demands on the person’s capacity to plan and execute speech tasks, which will allow the assessor to understand the particular impairments Mr Smith is experiencing
Use the Mayo Clinic form to assess the perceptual features of impairment to the subsystems of speech in the samples taken. This will allow the assessor to determine a severity rating for any distinguishing impairment and further contribute to differential diagnosis.
If the assessor determines Mr Jones has features of dysarthria, the Frenchay Dysarthria Assessment (2nd edition) can be used to determine the particular type of Dysarthria Mr Jones is experiencing. Generally particular disorders are related to a particular type of dysarthria, although some individuals may experience a “mixed” dysarthria.
melody 3.5 . preschool. concerns about inteliigibiity. sounds diffrent to other kids. mum has easte european accent and latral lisp. what tasks for assessment and why. in what order? priority?
Pre assessment :
Medical history from GP including any medications
Case history form to gather : demographics, hearing status, main concern, culture/linguistic history, birth and development, health, feeding, family history, cultural background due to the accent of mum. medical family history due to mums lisp?
Why: Personal and environmental factors including medical history can impact on assessment planning and invention (Howe, 2008). Culture and linguistic background will impact on what assessments are appropriate (SPA, 2016).
Assessment:
Case history interview: family life, environment, language use and participation, goals for therapy
Why: Gather information that will impact on assessment planning and intervention, gather Kim’s view of Melodys speech and the impact it has on Melodys participation. Build rapport with Kim and Melody. Determine Kim’s view of Speech therapy and possible motivation levels. Establish goals with Kim to build rapport and increase motivation.
Intelligibility testing : Intelligibility in context scale (ICS, McLeod, Harrison & McCormack, 2012)
Why: The ICS provides information on Melodys Intelligibility in everyday life from ratings from Kim. Can be used along side Percent Consonants Correct (and Vowels and total phonemes). Takes only 5 minutes and is free.
Language sample of Melody: Including Single word and connected speech assessment
Why: check other areas of language, voice, fluency. Check perception, to see if further testing needed, also eyeball potential Childhood Apraxia of Speech and motor speech problems. We can check pattens or errors and determine if errors seem to be consistent or inconsistent. From the language sample we will get a feel if we want to do formal testing. Allow Speech Pathologist to get a broad overview of Melodys speech and other areas to determine where to head with assessment. to analyse with SODA or CHIRPA.
OroMotor Assessment (OMA): including oral structure, function and cranial nerve involvement Why: Check Melodys Oral structure to check for any abnormalities, check the function and cranial nerve involvement to get a feel if any nerves may be impaired, and if so what is likely to be affected.
Diagnostic Evaluation of Articulation & Phonology (DEAP, Dodd et al, 2002),
Why:to identify the type and severity of speech disorder. 5 minutes to screen, specific assessments if deemed appropriate, minimum age is 3 and has Australian norms.
Q5b)
Case history first: to establish contextual factors and build rapport
Intelligibly testing: this is the reason for referral and is quick to administer.
Language sample: Video record to analyse later, but will allow Speech Pathologist to get a broad overview to decide what to do next.
OMA :Check oral structure and function to ermine cranial nerve impairment and abnormalities
Formal testing: ie DEAP. Last, usually the most time consuming. May need to be done in the next session as Melody may be fatigued.
38 year old PE teacher. has ENT booked in 4 weeks time. case history alr4eady taken. voice sounded different since knee operation. cant project voice anymore. A preceptual evaluation shows that her voice sounds rough, hoarse. using her voice make her feel tight in her throat. lots of tests came back negative.
describe two key voice evaluations tasks that will give you diagnostic information. , desribe them and justify your choice. also explain what you are looking for in the results based on the4 functionign of her vocal cords.
Ask Bronwyn to produce Voluntary cough(Model)
To produce a voluntary cough the vocal folds must be able to adduct together with sub-glottic pressure building up, forcing the VF’s apart and the air to be expelled. It is important that the vocal folds can adduct together (evenly) to effectively close off the airway at this level (in conjunction with the epiglottis and false vocal folds) to prevent food or liquid entering the lungs that can cause choking or aspiration; and enable an effective cough to expel foreign matter.
Listening for a sudden outburst of air would indicate the vocal folds have adducted completely and no air has been escaping. This would indicate vocal folds are working together with no indication of vocal paresis, nodules etc.
Task 2:
Ask Bronwyn to produce‘Uh Oh’ (Model)
Producing uh-oh (which starts with vowels) can be indicative of vocal functioning. It evaluates use of vocal onsets (glottal stroke) which should be sudden, clear and without constriction. This would indicate both VF’s are working together to produce a clear and not constricted voice.
We would be checking for clarity of the glottal stroke at voice onset and whether both vowels are produced in the same way with glottal stroke - without excessive effort or constriction.
