This document outlines a short case approach to analyzing speech through a series of tests of receptive and expressive language abilities, speech characteristics, repetition of sentences, and testing of other cognitive functions localized to different areas of the brain such as the frontal, temporal, parietal and occipital lobes. Tests include commands, writing, naming objects, line bisection, calculations, and motor skills to evaluate for conditions such as aphasia, dysarthria, apraxia, neglect and Gerstmann's syndrome resulting from lesions in specific brain regions. Physical exam of cardiovascular system is also recommended to investigate potential causes of stroke.

1. Short Case Approach to Speech Analysis
1) Ask for name, age, occupation, handedness. MMSE
2) Receptive aphasia (superior temporal lobe / Wernicke’s area):
a. One step commands – Shut eyes, stick tongue out, touch nose
b. Two step commands – touch your left ear with your right hand
c. Three step command – eg close eyes, stick out your tongue and raise your right hand.
3) Expressive aphasia (posterior inferior part of dominant frontal lobe / Broca’s area):
a. Write something
4) Assess speech for volume – dysphonia
5) Assess speech for dysarthria (slurred speech)
a. Ask PT to say ‘Raffles Institution / British constitution/ La la la’ – loud jerky explosive speech in
cerebellar lesion.--> test for other cerebellar signs
b. Ask Pt to say ‘Ka ka ka’ – CN IX and X lesion assess CN IX, X, XII for bulbar/pseudobulbar
palsy
c. Ask Pt to say ‘Ba ba ba’ – CN VII Facial nerve palsy
d. Nasal speech: bulbar palsy
e. Hot potato: pseudobulbar palsy
6) Repeat sentence (conductive dysphasia - lesion of connection between Wernicke’s &
Broca’s area)
7) Transcortical dysphasia
a. Name objects
b. Name parts of objects (eg watch strap, sleeves of shirt)
Continue to test for Parietal lobe function
8) Visual neglect:
a. Check for neglect with finger movement on both sides of visual field. Test visual field first to
exclude visual field defect.
b. Line bisection:
i. Control: Place string vertically & ask PT to point to center. Should be normal.
ii. Hold string horizontally & ask PT to point to center. When string is displaced towards
side of neglect, the PT will identify the center of the string wrongly.
9) Test for sensory neglect (superior temporal lobe / Wernicke’s area)
10) Test for Parietal dysfunction with Optokinetic nystagmus – OKN is lost when moving
tape towards side of lesion.
11) Test other dominant hemisphere functions
a. Right-left dissociation (use R hand to touch L shoulder)
b. Finger identification (finger agnosia)
c. Calculation
d. Dysgraphia
e. Dysphasia
♦ Isolated loss of dominant hemisphere function = Gerstmann’s syndrome)
12) Test for non-dominant hemisphere functions
a. Awareness of body and space – Visual, sensory and auditory neglect
b. Drawing ability
c. Construction apraxia – copy double pentagon
d. Dressing apraxia
e. Facial recognition
f. Motor persistence
g. Topographic ability
13) Test UL & LL for signs of Middle Cerebral Artery infarction.
14) Exam CVS looking for cause of stroke – AF, murmurs, carotid bruits
Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI
University, School of Medicine, KT-Campus,
Terengganu, ou=Internal Medicine Group,
email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4
students.
Date: 2009.02.24 14:15:04 +08'00'