Internship Case Study

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Case Study: Speech and Swallow Therapy for Ischemic Stroke
Elizabeth Cox
Clemson University
Grand Strand Regional Medical Center
Supervisor: Eileen McLaughlin
Objective: To describe the recovery process of an ischemic stroke patient focusing on speech
and swallowing therapy treatment at Grand Strand Regional Medical Center.
Background: Majority of patients who suffer from an ischemic stroke experience decreased
swallow function and speech and language impairments. With intensive speech and swallowing
therapy these patients have the potential to restore lost function through beginning in the
acute care setting and continuing with rehabilitation services.
Treatment: Following initial evaluation, the patient was administered swallowing and speech
therapy for the duration of the time in Grand Strand Regional Medical Center to improve
function.
Conclusion: The patient made significant progress until discharged and admitted to an
intensive rehabilitation facility to further recovery through aggressive therapy.
The following is a case study of a Grand Strand Regional Medical Center patient observed between
May 10 and May 16 of 2016 in the acute care setting. The purpose of this case study is to
acknowledge the importance of speech and swallowing therapy for stroke patients in the hospital
setting. This therapy begins the patient’s process of regaining their ability to swallow safely and
use understandable language and speech to communicate at the level they were prior to the
stroke occurrence. Therapy in the acute setting is the first step in the recovery process and often
requires patients to enter an intensive rehab program following discharge from this setting.
INTRODUCTION
Every year roughly 795,000 Americans
suffer from a stroke. Of these 795,000
individuals, 130,000 end with death. 87% of the
strokes that occur are considered ischemic
strokes1. An ischemic stroke occurs when blood
vessels connected to the brain are clogged or
blocked, often with deposits of plaque. A clot
forms and blocks the flow of blood to certain
areas of the brain causing the stroke to occur2.
The brain is divided into two
hemispheres, the right and left, both functioning
and specializing in different body controls and
responses. The right side of the brain controls
the left side of the body and vice versa. Due to
this method of control, a stroke affecting the
right side of the brain will impair the left side of
the body and vice versa. Common effects
resulting from a stroke affecting the right side of
the brain include paralysis or weakness on the
left side of the body specifically upper and lower
limbs as well as facial muscles, impairment of the
left visual field, impulsive behavior, poor insight,
memory deficits, and lack of spatial
understanding.
Effects of a stroke also depend on the
specific location in which the stroke occurred.
Therefore, an important part of determining the
prognosis of a stroke patient is determining the
exact location3.
This study focuses on an ischemic stroke
affecting the Middle Cerebral Artery (MCA).
The MCA supplies blood to several important
functioning lobes of the brain; frontal, temporal,
and parietal. More importantly the MCA supplies
the Broca’s area and the Wernicke’s area of the
brain responsible for language expression and
language comprehension respectively. This
explains why patients suffering from an ischemic
stroke in the MCA experience extreme

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communication problems and decreased
language comprehension and expression. These
deficits combined with the lack of muscle
strength and coordination on the left side of the
face greatly impair the patient’s speech. The
weakness of half of the body’s muscles that
follow a stroke also impact an individual’s
swallow function putting them at risk for unsafe
swallow capabilities. These problems patient’s
experience with swallowing are referred to as
dysphagia. Dysphagia is difficulty chewing or
swallowing food or liquids. There are two main
types of dysphagia; oropharyngeal and
esophageal. Oropharyngeal dysphagia is
difficulty with the initial stage of the swallowing
process. With this type of dysphagia, the patient
has difficulty moving the food to the back of the
mouth. Common signs of oropharyngeal
dysphagia are drooling, choking, coughing
during meals, pocketing food between the teeth
and cheeks due to unsuccessful movement, a
gurgly voice quality, and inability to suck from a
straw. This dysphagia is most often caused by a
nerve or brain disorder such as stroke, cerebral
palsy, multiple sclerosis, Parkinson’s,
Alzheimer’s, or neck and throat cancer. In
comparison, esophageal dysphagia occurs
when foods and liquids stop in the esophagus
and do not reach the stomach properly. The most
common cause of this type of dysphagia is the
backing up of stomach acid into the esophagus
due to reflux problems. This eventually narrows
the passageway making it harder for the
esophagus to pass foods to the stomach.
Oropharyngeal dysphagia is a major concern and
risk for stroke patients and once diagnosed, a
treatment plan needs to be put into place to
ensure patients are getting adequate nutrition in
the safest manner possible. An SLP’s
responsibility is to diagnose the severity of
dysphagia the patient is experiencing and to
prevent the patient from unsuccessful swallow
functioning that can potentially lead to future
problem food/liquid reaching the lungs
(pneumonia). There are standard diet levels that
include foods/liquids with a variety of
consistency levels. After evaluating a patient’s
swallow function, the SLP chooses the diet level
that is safest for the patient to consume their
nutrients4. The diet levels will be explained
further in this case study.
The ultimate goal of the recovery process
for stroke victims is to restore lost function and
for the individual to return to their abilities prior
to the stroke. Due to the loss of coordination and
muscle weakness, these patients struggle with
daily activities that were second nature prior to
the stroke. Therapy plays a huge role in the
process of treating the deficits experienced by
these patients. Speech Language Pathologists
(SLP’s) work with stroke victims to address
swallowing function, speech and language
expression and comprehension, cognitive and
memory ability. SLP’s work closely with patients
initially in the acute care setting to evaluate the
patient’s status and develop a treatment plan.
Following therapy in the acute setting, patients
often are admitted to an inpatient rehabilitation
center to receive intensive and aggressive
therapy to tackle their weaknesses and regain
strength and maximum function. Depending on
the severity of the stroke and intensity of
therapy as well as length of stay in the acute
settings, patients can receive therapy in
outpatient settings or in the comfort of their own
home. However, these individuals tend to leave
acute care with higher function and level of
independency than those referred to inpatient
rehab. With therapy and perseverance, many
stroke patients fully return to their function level
prior to the incident.
DIAGNOSIS & PATIENT HISTORY
The patient was a 66 year old female
initially admitted to Novant Brunswick County
Medical Center on 5/10/16 due to reported
weakness in left upper extremities (LUE) and left
lower extremities (LLE) as well as aphasia.
Aphasia is difficulty with speech and language
functioning due to damage to the brain, very
common in stroke patients. Symptoms of aphasia
often include non-fluent speech, difficulty
producing or understanding language, and
difficulty reading or writing. The severity of
aphasia varies by patient and level and location
of damage to the brain5. A head CT was done at
Novant at 8:07 am on 5/10/16 and revealed
subacute densities in both the right (R) frontal
and parietal areas of the brain.

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The patient was diagnosed with an
ischemic stroke and transferred via helicopter to
Grand Strand Regional Medical Center on
5/10/16 due to the severity of the stroke.
Further testing was done and an MRI revealed
complete occlusion of the right side thrombosis
of the internal carotid artery. The internal
carotid artery is located on the side of the head
and neck on both sides of the body. This artery
directs blood flow to the brain, which it needs to
properly function. An occlusion of the internal
carotid artery is a complete blockage of blood
flow therefore the brain stops receiving blood in
the anterior areas the internal carotid supplies6.
Thrombosis refers to a localized clot therefore
the clot most likely formed inside of the blood
vessel. In contrast, an embolus is a clot that has
formed somewhere else in the body and traveled
through circulation to that particular blood
vessel6. This occlusion can lead to several typical
stroke symptoms such as a decrease in motor
function and ability, impaired speech and
language, a change in personality, a decrease in
memory function, a loss of vision and sensation,
and essentially a loss of function and
independence the individual had prior6.
Past medical history of the patient
revealed hypertension, diabetes, glaucoma,
osteoporosis, breast cancer, and hyperlipidemia.
The patient was a current and long-term smoker
as well. Hypertension, diabetes, and
hyperlipidemia all increase an individual’s risk
for stroke1.
The neurologist assigned to this patient
officially diagnosed her with a right MCA
ischemic stroke and right carotid occlusion with
expressive aphasia and left hemiparesis.
Hemiparesis is weakness on one side of the
body. Individuals normally have the potential to
move the weaker side but the lack of muscular
strength makes it difficult to initiate movement.
This one sided weakness is extremely common
following a stroke and can affect the legs, arms,
face, hands, mouth, and feet. This makes it more
difficult to perform daily activities including day-
to-day communication making it necessary for
therapy following a stroke2. Tissue
plasminogen activator or tPA is a protein that
works to breakdown blood clots and is often
administered to stroke victims. However, tPA
must be administered within roughly the first 3
hours of onset of stroke like symptoms to be
effective, therefore this method of intervention
was not applicable of this patient. It was noted to
monitor the patient for cerebral swelling and
neurological decline and speech therapy
consultation/evaluation and treatment was
ordered2.
INITIAL EVALUTION: 5/11
The purpose of the initial evaluation
conducted by the speech pathologist on 5/11
was to determine the patient’s safety swallowing
and masticating or chewing food by mouth (PO).
It was noted that the patient had a decline in
labial and lingual strength, of the lip and tongue
respectively. Facial asymmetry was apparent
due to a significant left facial droop as a result of
the stroke. It was noted that the patient suffered
from significant left sided neglect including
upper and lower extremities and vision. These
symptoms proved the patient suffered from
significant left hemiparesis or weakness of the
left side of the body.
To determine the patient’s swallow function,
a bedside swallow evaluation was performed.
This evaluation measures the patient’s ability to
trigger the swallow response and initiate the
reflex. The most important concern with
swallowing among stroke patients is aspiration.
Aspiration is the entry of food or liquid into the
airway. This is common in stroke patients due to
loss of coordination and strength of oral and
facial muscles used in the swallowing reflex.
Deficiencies in the oral, pharyngeal, or laryngeal
phases of swallowing all pose risks for
aspiration. Aspiration can lead to pneumonia or
a lung infection if these contents are released
into the lungs instead of the stomach or in
extreme scenarios it can lead to death.
Symptoms of aspiration include coughing after
swallowing, difficulty breathing when eating or
drinking, a change in voice, and fever8. The
ultimate goal of a swallow evaluation conducted
by an SLP is to find the consistency of food and
liquid that will prevent aspiration from
occurring and ensure a safe swallow response is
triggered in the appropriate amount of time. The
liquid levels for patients with dysphagia from
least restricted to most restricted are as follows:

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 Liquids (Non-Reduced): Thin
 Reduced Level 1: Nectar Thick
(mildly thick)
 Reduced Level 2: Honey Thick
(moderately thick)
 Reduced Level 3: Pudding Thick
(extra thick)4
To test thin liquids such as water, tea, soda,
the patient was given an ice chip however,
showed immediate signs of aspiration after
letting the chip melt and eventually attempting
to swallow.
The next trial performed tested consumption
of nectar thick liquids. Nectar thick liquids have
a thicker consistency such as tomato juice. A
nectar thickening packet was added to water or
juice to test the patient’s response to this
viscosity. The patient was given two tablespoons
and responded with an immediate cough and
throat clear, again suspecting signs of aspiration.
The next level of honey thick liquids was
conducted using a honey thickening packet
mixed with water. The patient responded with a
delayed cough and throat clear as well as a spoke
with a wet vocal quality. Due to these responses
and clear signs of aspiration at each level of
viscosity, the SLP recommended continuing a
short term nothing by mouth (NPO) diet
meaning non-oral means of nutrition, hydration,
and medication. It was recommended for
continued follow up by an SLP to determine
readiness to obtain nutrition by mouth. The
patient was diagnosed with oropharyngeal
dysphagia, swallowing difficulty related
specifically to the mouth and throat4.
The overall behavior status of the patient
on 5/11 during the initial evaluation showed
behavior directly related to an ischemic stroke of
the MCA. The patient was alert but inattentive,
followed basic commands, but showed a great
amount of impulsivity. The patient showed
moderate dysarthria or unclear speech6. The
patient also suffered from apraxic like speech an
was only able to use 3 word sentences. Apraxia
of speech is common following a stroke and
includes difficulty producing sounds, a slower
speech rate, and is apparent when individuals
know what they want to say but cannot
coordinate their body and brain to say the word
properly6.
Initial short and long term goals were set
on 5/11 and are shown below.
 Short Term Goal 1: Patient will
participate in dysphagia therapy to
improve swallow function. Complete by
5/23
 Long Term Goal 1: Patient will tolerate
PO (by mouth) trials with SLP without
signs and symptoms of aspiration.
Complete by 5/25
The SLP recommended speech/language (SL)
therapy 3 times per week for 2 weeks or until
discharged.
SWALLOW TREATMENT: 5/12
On 5/12, the SLP conducted a swallowing
therapy session with the patient due to orders
for skilled dysphagia treatment. The patient was
alert, awake, and cooperative for the session
however, slurred and abnormal speech was
palpable with minute change. The left facial
droop and left hemiparesis were still significant
with no improvement. A left tongue deviation
was noted and is common in stroke patients due
to lack of strength on the affected side to keep
the tongue midline. The patient aspirated when
given thin liquids, but showed no aspiration or
difficulty with nectar thick liquids. The patient
was also given teaspoons of pudding and
applesauce and did not show signs or symptoms
of aspiration following these trails as well.
Overall, there was an improvement in swallow
function and alertness. This led the SLP to
recommend a PO diet or food by mouth. The
levels of PO diets for dysphagia patients are as
follows from most restrictive to least:
1. Solids- Regular: No restrictions
2. Reduced Level 1- Mechanical Soft:
Moist, soft textured foods that require
little chewing
3. Reduced Level 2- Pureed: Pudding like;
requires very little chewing4
The SLP recommended a pureed diet including
foods that are blended and of creamy
consistency. This thicker creamy consistency
increases the amount of time before the patient
has to initiate the swallow reflux allowing them
to do so more safely and effectively. Moving up
to this diet assisted the patient in reaching one of
the goals set by the SLP at initial evaluation. The

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SLP recommended nectar thick liquids until
further notice and medications to be crushed
and taken in a spoonful of applesauce or
pudding. To avoid aspiration, the SLP
recommended full 1:1 assistance when eating or
drinking, small sips/bites, sitting in an upright
position when eating or drinking, and full
alertness and lack of distraction during meal
time.
SWALLOW TREATMENT: 5/13
On 5/13, an SLP revisited the patient to
practice another swallow therapy. The patient
tried 4 bites of pureed food with success and 1
bite of mechanical soft food. A mechanical soft
diet is one step closer to a regular diet and
includes foods of smooth consistency that
require very little amount of chewing for
example, soft chopped meats. The patient
showed a decreased ability to masticate the
mechanical soft food and took roughly 5 minutes
for a single bite. The SLP had to remove the
bolus due to failure to swallow. The patient still
showed signs of aspiration with thin liquids
therefore it was recommended to continue with
a pureed diet and nectar thick liquids.
Throughout the weekend the patient
continued on the recommended diet until seen
on 5/16 for swallowing therapy and a speech
and language cognitive evaluation. The patient
passed the thin liquid swallowing trial sipping
both water and soda with no signs of aspiration.
Elevation of the larynx assists in the covering of
the epiglottis during the swallowing reflex to
prevent materials from passing through the
airway. This was palpated by the SLP when the
patient took a sip of water and a teaspoon of
pudding suggesting a successful swallow. With
failure to fully chew a bite of peach, the SLP
recommended maintaining a pureed diet but
upgrading to thin liquids.
SL EVALUATION: 5/13
Following the swallowing treatment, the
SL evaluation was performed and lasted 22
minutes. This was conducted to gather an
understanding of the patient’s current level of
speech and cognitive ability before entering a
rehabilitation setting. The patient showed a
decrease in attention and insight compared to
previous days. Before performing the evaluation,
the SLP took into consideration the patient’s
previous cognitive functioning and abilities.
Prior to the stroke the patient was independent,
able to drive, no speech difficulty, and able to
consume a regular diet with thin liquids. Post-
stroke the patient displayed poor self-regulation
and insight, a lack of sustained attention, a
decrease in memory functioning, and poor
problem solving skills. To conduct the SL
evaluation the SLP used portions of the Boston
Diagnosis Aphasia Evaluation and the Ross
Information Processing Assessment. Informal
observations and interview responses were also
taken into account. An overview of the results in
each skill area is shown below.
Speech Language Evaluation Results
Skill Level of Severity
Problem Solving Moderate-Severe
Auditory Comprehension
Impairment
Mild-Moderate
Oral Expression
Impairment
Mild-Moderate
Phonation Impairment None
Articulation Impairment Moderate
Orientation Moderate
Memory Impairment Moderate-Severe
Swallowing Impairment Mild-Moderate
Auditory Comprehension
The patient’s auditory comprehension was
tested through several exercises and the results
are as follows.
 Simple yes/no reliability and processing:
80%
 Receptive identification of objects: 100%
 Direction following of 1 step simple
commands: 100%
 Direction following of 2 step simple
commands: 50%
The patient demonstrated poor sustained
attention and was very easily distracted. The
patient’s lack of topic maintenance and attention
span decrease both heavily interfere with her
actions and level of performance.
Automatic Speech:

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The patient’s automatic speech was tested
through several exercises and the results are as
follows.
 Counting from 1-10: 70% accuracy; Patient
started counting but stopped at 7 due to
inability to maintain attention long enough to
complete counting.
 Stating the days of the week: Patient stated
the first 3 days then stopped due to lack of
attention
 Stating the months of the year: Patient
started stating the months of the year but
was unable to complete all 12 months.
 Object Naming: 100%
 Divergent Naming: This task focuses on the
ability to name items in a particular category.
The patient was asked to name 3 states and
was able to do so. However, the patient was
unable to name 3 vegetables and 3 animals.
This shows a lack of flexibility in her
cognitive ability.
 Convergent Naming: In comparison to
divergent naming, convergent naming
focuses on the ability to name the concept
that is being described. For example, the SLP
describes coffee as brown, hot, liquid,
caffeine, Starbucks and the patient should
answer coffee. This patient could not
understand the task enough to complete it.
 Conversation Skills: Due to distraction and
lack of attention the patient could not sustain
a conversation for longer than 30 seconds.
Memory
 Immediate Recall: The SLP stated 3 digits
and the patient was able to recite them. The
patient was also able to recite a 4 digit
pattern, but not a 5 digit pattern. The SLP
presented a 6 word sentence and the patient
failed to recite the sentence.
 Delayed Memory: The SLP stated 3 objects
(hamburger, sweater, rose) and instructed
the patient to memorize the words as they
would be asked in a few minutes. After 5
minutes the patient was asked to state the
original 3 words however she failed to do so.
 Long Term Memory: The patient was able
to state her age, hometown, street address,
and previous work experience. However,
details were not intact and the patient had
difficulty explaining further.
It is evident that the patient’s short term
memory is impaired due to inability to recall
immediate information as well as inability to
recall doctor names and visits from earlier that
morning.
Orientation: The patient was aware of her
surroundings as she knew her name, the place,
city and state, and building. However, the patient
was unaware of the details of the situation as to
why she was in the hospital and what occurred
thus far.
Problem Solving: When proposed a problem
the patient did not provide a reasonable answer
showing she has poor insight of the situation and
lack of executive functioning or the ability to
plan/organizing, remember details, pay
attention, act on previous experience, and avoid
doing the wrong thing. This puts the patient at
risk for managing day to day problems and living
independently.
Verbal Math Computations: The SLP asked
several basic questions regarding money such as
the value of different coins and the sum of 2 and
3 coins. The patient was able to interpret the
value of a coin but was unable to perform simple
addition or subtraction.
The patient was unwilling to continue the
exam further to measure cognitive skills. The
SLP concluded overall the patient was still
suffering from moderate dysarthria,
oropharyngeal dysphagia with deficits in
memory, attention, regulation, executive
functioning, and problem solving. Speech and
language strengths of the patient that were
determined from the evaluation were ability to
follow 1 step directions. The SLP suggested
intense inpatient rehab for a minimum of 2
weeks. The patient’s plan of care included
intensive speech and language therapy,
patient/family education, and dysphagia
therapy. The SLP suggested speech treatment at
least 15 minutes 3 times a week for 4 weeks or
until maximum potential is reached. The patient

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was discharged for inpatient rehab on 5/17 with
an intensive therapy plan.
CONCLUSION
Although the patient needs further
recover due and is not safe to return home and
live independently, she demonstrated overall
advancement during her time in acute care. The
patient improved from a nothing by mouth diet
(NPO) to a pureed consistency diet (PO). She left
the acute setting being able to consume pureed
foods with goals to reach a regular diet in the
future. The patient advanced to thin liquids
during her stay in the acute setting, another
important accomplishment achieved through
dysphagia therapy. The patient left the facility
with a positive prognosis of having the capability
of gaining back complete function. The patient
will now strive to achieve goals in the rehab
settings such as improving attention, improving
communication and cognitive skills such as being
able to solve simple problems, holding a longer
conversation, and controlling topic maintenance.
The occupational therapist (OT) noted
the patient suffered from severe decline in self
care meaning the patient needed full assistance
in activities such as bathing, dressing, and eating,
all things the patient was capable of doing
independently before the stroke. The physical
therapist (PT) who worked closely with the
patient reported poor standing balance, a decline
in left side strength both arms and legs, and gait
or walking impairment.
Both the OT and PT recommended acute
rehab as the patient was not currently able to
function independently and needed therapy to
regain strength and mobility. This is a prime
example of how speech, occupational, and
physical therapy all play an important role in
recovery of patients particularly stroke patients
who are trying to return to their functional
status prior to the incidence. The patient will
have to undergo intensive therapy to restore lost
function but with her current prognosis this will
be achievable.
REFERENCES
1. Stroke Statistics and Maps. Centers for
Disease Control and Prevention 2015.
Available at:
http://www.cdc.gov/stroke/statistics_m
aps.htm.
2. Let's Talk About Stroke . American Stroke
Association 2015. Available at:
http://www.strokeassociation.org/idc/g
roups/stroke-
public/@wcm/@hcm/documents/downl
oadable/ucm_309725.pdf.
3. About Stroke. American Stroke
Association 2016. Available at:
http://www.strokeassociation.org/strok
eorg/aboutstroke/about-
stroke_ucm_308529_subhomepage.jsp.
Accessed 5ADAD.
4. Dysphagia Diet. GI Care.
http://gicare.com/diets/dysphagia-diet/.
Accessed May 25, 2016.
5. Speech and Language Disorders and
Diseases. American Speech Language
Hearing Association 2016. Available at:
http://www.asha.org/public/speech/dis
orders/.
6. King AB. Neurologic Symptoms Following
Extensive Occlusion Of The Common Or
Internal Carotid Artery. Archives of
Neurology And Psychiatry Arch NeurPsych
1941;46(5):835.
7. Thrombus or Embolus. StrokeSTOP 2014.
Available at:
http://umassmed.edu/strokestop/modul
e_one/thrombus_embolus.html
8. Swallowing Disorders (Dysphagia) in
Adults. Speech Language and Swallowing .
Available at:
http://www.asha.org/public/speech/sw
allowing/swallowing-disorders-in-
adults/.