neuro eval lecture 5b

control of speech

Broca's aphasia

• some weakness or dyscoordination, spasticity, or hypotonia affection production of speech
• it's a control problem, a motor problem, not a proplem of lang or comprehension 

lisp, stutter, bit or burnt tongue causing blurry speech, missing teeth, cerebellar impact on breath control, etc

the big thing to remember here is it's the motor mechanism that's impaired, nothing about language or comprehension - that's aphasia

• difficulty w swallowing
• (don't confuse this with dysarthria - a motor problem w speech)

• often sounds intoxicated (overshooting)
• due to cerebellar problems

phonaon, respiratio, resonance, prosity of speech, intonation, articulation

hoarseness or low quality of boice production

• inabilty to speak
• often w bilateral damage to recurrent laryngeal nerves

• aphasia: always CNS
• dysphasia: either

melodic intonation therapy: patients are taught to sing their conversations

• expressive aphasia: bc can't get words out
• non-fluent aphasia: bc broken both w spoken and written language

comprehension intact but pt can't communicate - ranges from missing pronouns and connecting words (sounds "telegraphic) to total inability to make coherent sounds

• common in stroke and TBI pts, rarely MS
• not in SCI because it's
• a cortical issue

• stroke, TBI, occasionally MS
• not SCI bc this, like Broca's is a cortical issue

• receptive aphasia: bc pt doesn't understand others's speech
• fluent aphasia: bc can get words out, though the words are meaningless

• impaired comprehension of speech and writing
• "word salad" or gobble-dee-gook speech and writing

• a communication issue
• difficulty using lang to communicate
• always CNS issue
• cortical issue
• aphasia says nothing about the motor production, just about the way the pt is using the tools in the mouth... see, it's a communication, not a motor problem (dysarthria is a motor problem, dysphagia is difficulty swallowing)q

• level of consciousness
• orientation ot time, place, person
• attention
• concentration (able to attend to a task for a particular amouint of time)
• judgement (common sense about veering into danger)
• memory (number sequence, PT's name....)
• ability to calculate (count in 3s...)
• language

• alert
• lethargy
• oabtunded
• stupor
• coma (semi or deep)
• irreversible coma

• drowsiness o inattention
• will wake up on command and participate for short interval of time
• somnolence

slow, but can encourage/motivate self

• difficult to arouse
• when aroused is confused and disoriented
• wavers btwn lethargy and stupor

• great effort to arouse
• has minimal physical and mental activity

needs outside source to encourage self to wake up

• semi - may respond to noxious pain (reflexes)
• deep and irreversible - no visual tracking or reactive pupils

unable to arouse

• no response to verbal stim
• responds to pain (pressure on nailbed)
• no movement except decorticate or decerebrate posturing
• wandering or disconjugate eye movement
• decreased reflex activity (such as Babinski)
• may make sounds

decorticate: lesion in premotor cortex or higher corticospinal tract

withdrawal/flexion in UEs, ext in LEs

lesion in high brainstem at intercollicular area, midbrain, and pons

ext of all extremities, hyperpronation of forearm, flex wrists

decerebrate damage hits the high brainstem and affects breathing and basic life functions, so a pt wounded here is more likely to die than go into coma

• no consistent response to verbal or painful stim
• no movement
• decreased or sporadic reflexes
• decreased respiration
• pupillary abnormalities
• eyes may be open, but no tracking

• brain death
• loss of cerebral autoregulation
• intracranial circulatory arrest --> necrosis --> cesation of meaningful cerebral activity (ie, stop the flow of cerebrospinal fluied and you'll get brain necrosis)
• flat EEG

• a special case
• it's btwn irreversible and deep coma
• increased DTRs + Babinski
• no pupillary light reflex, but might visually track (tracking is somatically controlled)
• appears awake by day and asleep at night, but no higher mental function

• akinetic mutism
• wakeful unresponsiveness

• inerrption of corticobulbar and crticospinal fxn causing parlysis of lower cranial nerves and quadriplegia
• basilar-pontine destruction or infarct
• end stages of ALS (this purely affects motor nerves)

• call pt name in normal or loud voice
• light touch on arm
• vigorous shake n shoulder
• painful stim into nailbed finger or toe
• noxious stim using sternal rub

ordinal scale that describes pt's repose following vebal commands or painful stim

• eye opening
• best verbal response
• best motor response

• max 15 points
• coma </= 8 pts

• decorticate: bilat withdrawal, body flexes inappropriately much to the pain
• decerebrate: body becmes rigid in ext

ability to concentrate on a specific stim w/o being distracted by extraneous stim

ability to concentrate on a stim fr > 30 sec

• looks at something but doesn't see it
• can be clinical or specific

inability to pass a formal attention test, such as digit repetition or connect the dots (trail making) in an appropriate amount of time

• inbility to notice two stim presented at thesame time
• (like hearing the water boil while you're reading)
• auditory: 1 sound/ear
• visual: 1 stim / each field of vision (L/R)
• tactile: 1stim/location on body (like the double simultaneous extinction test)

• polymodal: all sensory modalities are affected
• unimodal: just one

• anxiety and depression
• difuse brain dysfunction
• metabolic disturbances
• post-surgical state of confusion
• systmic infection
• frontal lobe or limbic system (emotions) lesions
• parietal lobe lesions (this lobe deals w sensory info)
• right hemsphere lesions

reentin of learned info and experiences

• attention to info,
• encoding info,
• storage of info,
• retrieval of info

• hippocampus in food shape
• cortical and subcrtical function
• (bc mem is partly sensory, need healthy basal ganglia)
• norml sensatons, motion, and lang

• input: register the specific sensory modality
• hold it temporarily: short term mem - limbic system
• store it: long term mem - limbic
• recall it: limbic (this is why slep is important for memory - helps encode memories)

• immediate: short term (seconds)
• recent:day to day events, held a few hours
• remote: long term memory - past events

can't learn new info

can't remember evens prior to CNS insult (TBI)

• block out a period of time
• this is a dissociative state

recall a short string of numbers or a poem

tell pt 4 unrelated words and ask pt to recall them in 10 and 30 min

• last 4 presidents
• details from childhood

new learning and recent mem are impaired

thiamine deficiency assoc w ETOH abuse and malnutrition --> organic amnesiac state

functional memory disturbances

ask hypothetical q's about what pt would do in X situation (fire in the wastebasket....)

ask pt to explain a phrase "a rolling stone gathers no moss"

reasoning: ability to draw conclusions and problem solve when dealing w abstract thoughts

• 30 pt questionnaire
• assesses congnition - orientation, registration, attention, calculation, lang, basic motor skills, memory

• out of 30
• norm: 28-30
• mild dementia: 20-26
• mod dementia: 10-19
• severe dementia: <10