Speech

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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48 Speech

Instruction

Ask this patient some questions.

Salient features

Examination

• Proceed by asking the patient simple questions regarding personal details such as name, age, occupation, address and handedness (remember that over 90% of left-handed people have a dominant left hemisphere).

Test the following:

• Comprehension:

• Put your tongue out
• Shut your eyes
• Touch your nose
• Smile
• Two-step commands, such as touch your left ear with your right hand.

• Orientation:

• Time–date
• Place.

• Name familiar objects:

• Pen
• Coin
• Watch.

• Articulation, ask the patient to repeat the following:

• British constitution
• West Register Street
• Baby hippopotamus
• Biblical criticism
• Artillery.

• Abbreviated mental test:

• Address to recall: 42 West Street.
• Age
• Date of birth
• Time
• Year
• Recognition of two persons such as doctor and nurse
• Name of this place
• Name of the monarch or prime minister
• Year of World War I or World War II
• Count backwards from 20 to 1
• Serially subtract 7 from 200.

• Tell the examiner that you would like to check the ‘primitive’ reflexes:

• Snout reflex: brought about by tapping the upper lip slightly; there is puckering or protrusion of the lips with percussion and the muscles around the mouth and the base of the nose contract.
• Palmomental reflex: occurs when a disagreeable stimulus is drawn from the thenar eminence at the wrist to the base of the thumb (Arch Neurol 1988;45:425–7); there is ipsilateral contraction of the orbicularis oris and mentalis muscles, the corner of the mouth elevates slightly and the skin over the chin wrinkles.
• Sucking reflex: elicited by tapping or lightly touching the lips with a tongue blade or the examiner’s finger; sucking movements of the lips occur when they are stroked or touched.

Note: The above three reflexes are normal in infants, may be present in normal individuals and are said to be present in a larger number of patients with neurological disease. They are most often seen in those with diffuse cerebral conditions that affect the frontal lobes and pyramidal tracts. The occurrence of more than one reflex is more suggestive of disease than normality.

• Grasp reflex: obtained when the examiner’s hand is gently inserted into the palm of the patient’s hand (when the patient is distracted, usually by engaging him in conversation). With a positive response, the patient grasps the examiner’s hand and continues to grasp it as it is moved. The presence of the grasp reflex indicates disease of the supplementary motor area of the frontal cortex.
• Jaw jerk (p. 156).

Diagnosis

This patient has expressive dysphasia (lesion) caused by a stroke (aetiology) and is unable to express himself (functional status).

Questions

What do you understand by the term dysphasia?

Dysphasia is a disorder of the content of speech, which usually follows a lesion of the dominant cortex. The type of dysphasia indicates the site of the lesion in the cortex:

• Expressive, nominal or motor dysphasia: site is the posterior inferior part of the dominant frontal lobe of the cortex (i.e. Broca’s area)

• Sensory or receptive dysphasia: site is the superior temporal lobe or Wernicke’s area.

Note: Sites associated with speech function are variably located along the cortex and can go well beyond the classic anatomical boundaries of Broca’s area. These sites typically involve an area contiguous with the face–motor cortex; however, they can be located several centimeters from the sylvian fissure (N Engl J Med 2008;358:18).

What do you understand by the term dysarthria?

Dysarthria is an inability to articulate properly caused by local lesions in the mouth or disorders of speech muscles or their connections. There is no disorder of the content of speech. The causes of dysarthria are:

• stutter

• paralysis of cranial nerves: Bell’s palsy, ninth, tenth and eleventh nerves

• cerebellar disease: staccato, scanning speech

• Parkinson’s speech: slow, quiet, slurred, monotonous

• pseudobulbar palsy: monotonous, high-pitched ‘hot potato’ speech

• progressive bulbar palsy: nasal.

Advanced-level questions

What are the components of speech?

• Phonation: abnormality is called dysphonia

• Articulation: abnormality is called dysarthria

• Language: abnormality is called dysphasia.

What are the other dominant hemisphere functions?

• Right–left orientation

• Finger identification

• Calculation.

What are the non-dominant hemisphere functions?

• Drawing ability

• Topographic ability

• Construction

• Dressing

• Facial recognition

• Awareness of body and space

• Motor persistence.

What are the parietal lobe signs?

• Loss of accurate localization of touch, position, joint sense and temperature appreciation

• Loss of two-point discrimination

• Astereognosis

• Dysgraphaesthesia

• Sensory inattention

• Attention hemianopia, homonymous hemianopia, or lower quadrantic hemianopia.

What do you understand by the term agnosia?

Agnosia is a failure to recognize objects despite the fact that the sensory pathways for sight, sound or touch are intact. This is tested by asking the patient to feel, name and describe the use of certain objects.

What are the different types of agnosia?

• Tactile agnosia and astereognosis: the patient is unable to recognize objects placed in his or her hands despite the fact that the sensory system of the hands and fingers is intact and there is adequate motor function to allow examination of the object. The lesion is in the parietal lobe.

• Prosopagnosia: the inability to recognize a familiar face. The lesion is in the parieto-occipital lobe.

• Visual agnosia: the inability to recognize objects despite the fact that the main visual pathways to the occipital cortex are preserved. The lesion is in the parieto-occipital lobe.

• Anosognosia: the lack of awareness or realization that the limbs are paralysed, weak or have impaired sensation. The lesion is usually in the non-dominant parietal lobe.

What do you understand by the term apraxia?

Apraxia is the inability to perform purposeful volitional movements in the absence of motor weakness, sensory deficits or severe incoordination. Usually the defect is in the dominant parietal lobe, with disruption of connections to the motor cortex and to the opposite hemisphere.

What are the different types of apraxia?

• Dressing apraxias: patient is unable to put on his clothes correctly.

• Gait apraxia: difficulty in walking, although patients may show intact leg movements when examined in bed.

• Ideomotor apraxia: patients are unable to perform movements on command, although they may do this automatically, e.g. lick their lips.

• Ideational apraxias: difficulty in carrying out a complex series of movements, e.g. to take a match from a box to light a cigarette.

• Constructional apraxia: patient has difficulty in arranging patterns on blocks or copying designs.

What do you know about dyslexia?

Reading difficulties, including dyslexia, occur as a part of a continuum that also includes normal reading ability. It is not an all-or-none phenomenon but, like hypertension, occurs in degrees. It has been defined as a disorder that is manifested by difficulty in learning to read despite conventional instruction, adequate intelligence and sociocultural opportunity.

Sir Charles Sherrington (1857–1952), Oxford University, and Lord Edgar Douglas Adrian (1889–1977), Cambridge University, were awarded the Nobel Prize in 1932 for their discoveries regarding the functions of neurons.

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