Miami University Speech and Hearing Clinic Speech and Language Evaluation Name: Mary Smith Address: 123 Bachelor Ln Oxford, OH 45056 Phone Number: (765)623-7654

Date of Evaluation: 10/2/2013 Diagnosis: Global Aphasia DOB: 01/01/1951

Referred by: Dr. Guarneros on 9/30/2013 for "Speech-language Evaluation and Treatment" Background Information Mrs. Smith, a 62 year old female, was seen at Miami University Speech and Hearing Clinic on 10/2/2013. She was accompanied to the evaluation by her husband, Mr. Smith, who provided all of the information regarding Mrs. Smith's current status and medical history. The purpose of the evaluation was to determine Mrs. Smith's communication strengths and weaknesses, assess her needs, and provide recommendations for speech therapy, if warranted. Medical History Mrs. Smith was admitted to Good Sam Hospital in Cincinnati, OH, with a CVA on 07/01/2005. Mrs. Smith's MRI scan results show a blockage in the territory of both divisions of the MCA, extending from Broca's area to Wernicke's area to the angular gyrus region and deep into the subjacent white matter. She received OT, PT, and ST services at Good Sam hospital from 08/03/2005 to 8/24/2005. Mrs. Smith cheerfully participated in all rehabilitation sessions. Prior to her CVA, Mrs. Smith worked part-time as a classroom teacher aide but mainly stayed home taking care of her eight children. Post-CVA, Mrs. Smith has progressed from immobility of her right arm and leg to limited mobility of her right arm and full mobility of right leg. Her hearing is within normal limits for her age and gender. Prior to CVA, she wore glasses for reading. Past medical history includes HTN. Mrs. Smith currently takes diuretics and Tylenol as needed. History of Communication Problem Mrs. Smith has severe aphasia, exhibiting major impairments in all language modalities. After three weeks of inpatient rehabilitation at Good Sam, her discharge diagnosis indicated static severe impairments in both expressive and receptive language skills. She had no response to treatment other than regaining full mobility of her right leg. Her right arm is not fully mobile, but is used when necessary. Mrs. Smith expresses herself in repetitive neologisms. Her speech is 100% jargon and has not improved since the CVA. Mr. Smith reports that his wife is unaware of her expressive and receptive deficits. He is mostly concerned about her safety when he isn't around. He stated, "I know she's not going to get better, but my biggest concern is that if I'm not there she will be able to take care of herself and dial 911 in case of an emergency."

Social/Vocational and Educational History Mrs. Smith has been married for 37 years and lives with her husband in Oxford, OH. She worked as a teacher aide for Walnut Hills Middle School for 12 years and spent her time at home with

her eight children. Prior to her CVA, Mrs. Smith was very outgoing and friendly. She was an keen reader and singer. Mr. Smith spends all day at home with Mrs. Smith and takes her to run errands with him a couple times a week. He retired from P&G right after the CVA. Three of their children live in Arizona and the rest in Cincinnati and Columbus. They visit a couple times a month and have expressed willingness to help with Mrs. Smith's care. Evaluation Results The evaluation consisted of formal and informal assessments of Mrs. Smith's expressive and receptive language, speech production, and reading and writing abilities. Oroperipheral Examination Upon examination, Mrs. Smith presented with a mild unilateral facial weakness on the right side. Lingual coordination appeared within functional limits, as well as lingual and labial strength and range of motion. Voice Mrs. Smith's resonance, pitch range, volume, and voicing all appeared within normal limits for age and gender.

Expressive Language Both formal and informal assessments were used to evaluate Mrs. Tyner's expressive language skills. Subtests of the Western Aphasia Battery were administered. The following chart reports her scores: Verbal Expression Subtests Spontaneous Speech Information Content Fluency, Grammatical Competence, and Paraphasias Repetition Repetition Total Naming and Word Fluency Object Naming Word Fluency Sentence Completion Responsive Speech Reading Commands Reading Commands

Verbal Expression:

Score 0 0 0 0 0 0 0 0

Mrs. Smith presents with severe impairment of verbal expression, characterized by severe and repetitive neologisms, anomia, non-fluent speech, and an average best phrase length of 3 words. Her conversational speech consists mainly of neologisms (I oh growthamarrow, I love you grandpa). There are no other paraphrasias produced in her speech other than the repetitive statements above. Her responses on all spontaneous speech, repetition, naming, and reading commands out loud consisted of the same neologisms. Mrs. Smith's greatest difficulties are in all areas of verbal expression. None of her utterances are meaningful. Her longest phrases consist of 3-4 words, but also consist of the same neologisms. Mrs. Smith does not produce any functor or substantive words, other than the meaningless utterances. "I love you, grandpa," is the only syntax phrase produced sporadically in conversation, but not in a meaningful form. Mrs. Smith also produces parts of her usual neologistic phrase in conversation such as "romo, rumba, I oh gromo, and grandpa." Mrs. Smith ponders a lot when asked questions and sometimes does not respond. A mild right neglect was also observed on Mrs. Smith; all objects and stimulus book had to be placed on her left visual field to elicit a verbal response or gesture. Mrs. Smith's strengths in expressive language are intonation and comprehension of facial and tactile gestures. Her repetitive neologisms are made up of different intonation. She can clearly convey when she is confused, happy, or frustrated. Mrs. Smith is also good at detecting other people's emotions and reacts to them appropriately. Maximum cues such as repetition and segmentation were given to Mrs. Smith, but no meaningful utterance was elicited. At times, Mrs. Smith said, "thank you," when praised on an effortful response, which is the only meaningful utterance observed in her speech. The oral reading subtest also shows a severe impairment. Mrs. Smith was not able to read monosyllabic high frequency words or individual letters.

Written Expression Subtests Writing Upon Request Writing Output Writing to Dictation Writing Dictated Words Alphabet and Numbers Dictated Letters and Numbers Copying a Sentence Writing Irregular Words to Dictation Writing Non-Words to Dictation Writing Total

Score 0 0 0 0 0 0 0 0 0 0

Written Expression Mrs. Smith presents with a severe impairment in written expression, characterized by no writing and only hand-over-hand tracing and copying on a few letters and numbers. She uses her non dominant hand to write. Testing shows she is unable to self-correct, and behavior suggests she is unaware of her deficits. The pencil was put on her hand but Mrs. Smith did not know what to do with it.

Mrs. Smith could not write anything dictated to her, nor could she copy anything written for her. She was first provided a hand-over-hand direct model on a letter and independently traced it several times. She was then asked to copy the same letter in the space below and independently wrote it. Mrs. Smith correctly traced 5 out of 5 letters and copied 3 out of 5 (D, M, J, B, and F were traced; D, M, and B were copied). All numbers (5, 61, 32, 700, and 1867) were slowly traced multiple times; only the number 5 was copied correctly.

Receptive Language Both formal and informal assessments were used to evaluate Mrs. Smith's receptive language skills. Subtests of the Western Aphasia Battery were administered. The following chart presents her scores. Auditory Verbal Comprehension Yes/No Questions Auditory Word Recognition Sequential Commands Auditory Verbal Comprehension Total Auditory Verbal Comprehension Score

Score 27 14 0 41 0.205

Auditory Comprehension: Mrs. Smith's scores represent a severe impairment in auditory comprehension, characterized by an inability to answer high-frequency, one-unit yes/no questions ("Is your name Brown?"), high frequency words in response to objects and picture stimuli ("point to the cup"), and follow simple one-unit commands ("raise your hand"). Repeating the instructions slowly did not improve Mrs. Smith's performance. To elicit responses, Mrs. Smith's field of choices was narrowed (given three objects to choose from instead of six), and was gestured to point to objects in certain tasks. On the Western Aphasia Battery, Mrs. Smith correctly pointed to the object in 14 out of 60 trials with a narrowed field of choices. She was instructed to point with gestures, but sometimes did not respond. For yes/no questions, Mrs. Smith was given two pieces of paper that said "yes" and "no" and was instructed to point to her answer. The gestural cues and two choices increased correct responses from 0% to 45%, but this resulted in a 50/50 chance of her producing an accurate response. She pondered on her answers for quite a while and did not respond at times. For sequential commands, Mrs. Smith did not follow the clinician's modeling and produced verbal neologisms. In terms of general comprehension, Mrs. Smith mildly understood the clinician's nonverbal language enough to respond appropriately to the Western Aphasia Battery subtests. She is maximally dependent on hand-over-hand tracing and gestures. This suggests that gestural communication may be an alternative to verbal communication with Mrs. Smith in the future. However, when clinician said the assessment was almost done, Mrs. Smith responded "Wooooo!" which shows some indication of auditory comprehension.

Reading Comprehension

Score

Comprehension of Sentences Reading Commands Written-Word Object Choice Matching Written Word-Picture Choice Matching Picture-Written Word Choice Matching Spoken Word-Written Word Choice Matching Letter Discrimination Spelled Word Recognition Spelling Reading Irregular Words Reading Non-Words

0 0 0 0 0 1 0 0 0 0 0

Reading Comprehension Mrs. Smith's scores indicate a severe impairment in reading comprehension in all levels. All tasks were repeated several times, with the clinician demonstrating an example before each one. Mrs. Smith's score still did not improve. Mrs. Smith could not identify monosyllabic, high frequency words, and individual letters when instructed and gestured ("point to the word flower"), even with a narrowed field of choices. When given multiple choices, she perseverated on choice D. She verbalized neologisms when asked to read words and sometimes did not respond. Mrs. Smith is unaware of her reading deficits and did not show frustration during the tasks.

Apraxia Formal assessment was used to evaluate presence of apraxia for Mrs. Smith. Apraxia subtests of the Western Aphasia Battery were administered. The following charts report her scores. Apraxia Subtests Upper Limb Facial Instrumental Complex

Score 2 1 2 0

Mrs. Smith's scores are not an accurate representation of her motor planning abilities. This is proven by the fact that some gestural movements were correctly produced once the clinician provided visual and tactile models. The clinician used hand-over-hand model to get Mrs. Smith to create a fist and wave good-bye. She also imitated the clinician in three facial and instrumental commands (close your eyes, pretend to use a comb, and pretend to use a hammer), with the help of tactile cues. Mrs. Smith's scores may be reflective of severely impaired auditory comprehension. Her performance did not suggest or demonstrate apraxia of speech.

Constructional, Visuospatial, and Calculation Drawing Block Design Calculation

Score 2 0 2

Raven's Colored Progressive Matrices Constructional, Visuospatial, and Calculation Score

0 0

Construction, Visuospatial, and Calculation Mrs. Smith's scores indicate a severe impairment in constructional, visuospatial, and calculation abilities. A severe impairment in auditory comprehension indicate her inability to draw shapes, but responses increased for simple shapes (circle and square) when traced hand-over-hand and then copied. Mrs. Smith did not touch the blocks presented to her and verbalized neologisms when asked to copy the picture. Clinician modeled the activity but Mrs. Smith continued to talk. Mrs. Smith was not able to calculate any of the given math questions. She randomly chose answers from the field of choices. This suggests that maximal tactile and gestural cueing is an alternative for Mrs. Smith's communication abilities.

Quotients Aphasia Quotient Language Quotient Cortical Quotient

Score 0 0.205 1.23

Aphasia, language, and cortical quotients are indicators of Global Aphasia.

Behavioral Observation/Cognition Mrs. Smith was polite and cooperative throughout the evaluation. She did not show any sort of frustration during the assessment and was very warm towards the clinician. She remained attentive despite the length of the Western Aphasia Battery and was overjoyed when the assessment was done. Mrs. Smith's cognitive skills seem to be moderately-severely impaired. It is recommended that cognitive ability be further assessed since she sometimes seems to respond accurately when she is praised and to facial gestures. Mrs. Smith demonstrates a severe level of awareness of her deficits. She was happy throughout the assessment and was not aware of any errors she produced throughout it. She seems to think that she is having a normal conversation with others and seems to understand what is being said to her. She is unaware of her neologisms and her reading and writing inabilities.

Clinical Impressions Mrs. Smith presents with a severe expressive and receptive aphasia characteristic of Global Aphasia, secondary to unilateral CVA. Her expressive language abilities consist of short and consistent neologistic phrases. Written expression is more severely impaired than verbal expression, characterized by writing limited to tracing and seldom copying. Mrs. Smith's auditory comprehension ability is characterized by severe comprehension of language but understands some gestural cues. Reading comprehension is severe in all levels, and mirrors her auditory comprehension. She perseverated on an answer when given visual choices, but did not comprehend the tasks. No apraxia of speech was noted. Mrs. Smith's strengths include: moderate tracing of shapes, letters, and numbers with mild copying abilities, intact intonation in expressive neologistic language, occasional meaningful response (thank you) when praised and excitement when told that test was almost done, and seldom accurate responses when given gestural and

facial cues. Her percentile rankings on the Western Aphasia Battery do not reflect other aspects of her expressive and receptive communication observed clinically. Prognosis Prognosis for improvement of Mrs. Smith's expressive and receptive language abilities is mild. Mrs. Smith has shown improvement in gestural communication over the course of three weeks of inpatient rehabilitation and seems motivated to continue improving. Mrs. Smith will need a lot of support and willingness from her spouse and family to aid in treatment. Recommendations Based on this evaluation, it is recommended that Mrs. Smith participate in speech therapy three times per week for a minimum of 8 weeks to focus on improving expressive and receptive communication through hand gestures and facial expressions. Therapy will focus on the following goals: Long Term Goals (3 months) 1. Pt will follow a series of three-step directions given moderate cues with 80% accuracy. 2. Pt will gesture 3-5 high frequency words given moderate cues with 80% accuracy. 3. Pt will choose an object from a narrowed field of cues in response to a question with 80% accuracy Short Term Goals (1 month) 1. Pt will follow a series of single-step activities given moderate cues with 70% accuracy. 2. Pt will gesture 3 high frequency words with 70% accuracy. 3. Pt will 1 out of 2 objects in response to a question with 70% accuracy.

Goals and recommendations were reviewed with Mr. and Mrs. Smith. Both were in agreement with plan and recommendations. Mr. Smith voiced willingness to carryover treatment recommendations at home.

______________________________________ Cassandra Guarneros, BA