Speech and Higher Mental Function Examination — Clinical Case

DCE Short Case — "Please examine this patient's speech and higher mental function"

Instruction

"Please examine this patient's speech and higher mental function. Her family say her speech changed suddenly an hour ago. You have 7 minutes for examination and 8 minutes for discussion." ^[1]

Patient brief (provided to examiner / simulated patient)

Patient: Mrs Harpreet Kaur, 72 years old, retired schoolteacher, hypertensive, type 2 diabetes. ^[1]

Findings the trainee elicits: She is alert and afebrile, blood pressure 156/92, glucose 6.8. Spontaneous speech is fluent — long phrases, normal melody, effortless — but empty, with phonemic and verbal paraphasias and several neologisms; she is not frustrated by this. She manages an occasional one-step command but cannot follow a two-step command. She cannot repeat "no ifs, ands, or buts." She cannot name a watch or a pen. Hearing is intact to a whispered number in each ear. Attention, tested by digit span (six forward, four backward) and months backwards, is preserved. There are no focal limb signs. The cranial nerves, including the facial nerve and the tongue, are normal. ^[1]

Systematic examination routine (model)

1. Set the stage: introduce, consent, seat the patient upright at eye level, ensure her hearing aids are in and working, exclude pain, fever and hypoxia, and state the plan to examine speech first then higher mental function.
2. Listen to spontaneous speech: ask her to describe why she came in. Note fluent but empty speech with paraphasias and neologisms, and the lack of frustration.
3. Assess fluency: confirm the speech is fluent — full phrase length, normal melody, effortless.
4. Test comprehension: yes/no questions, then one-step commands (she manages), then two-step commands (she fails).
5. Test repetition: "no ifs, ands, or buts" — she fails, with phonemic paraphasias on the attempt.
6. Test naming: a watch, a pen, the fingers — she fails (anomia is present in all aphasias).
7. Test reading and writing: she cannot read a simple command or write a meaningful sentence.
8. Confirm hearing is intact to exclude a peripheral auditory cause.
9. Assess attention (digit span, months backwards) to exclude delirium and confirm this is a focal aphasia.
10. Screen the other cognitive domains noting they are limited by the aphasia, and state this at presentation. ^[1]

Presentation template (model)

"I examined Mrs Kaur, a 72-year-old woman with hypertension and diabetes, brought in forty minutes after the sudden onset of strange speech. She is alert and afebrile. On examination of the speech, spontaneous speech is fluent but empty, with phonemic and verbal paraphasias and several neologisms, and she is not frustrated by it. Comprehension is impaired — she manages an occasional one-step command but cannot follow a two-step command. Repetition is impaired — she cannot repeat 'no ifs, ands, or buts.' Naming is impaired for objects and fingers. Hearing is intact. Attention, tested by digit span and months backwards, is preserved. ^[1]

'In summary, this patient has a fluent aphasia with impaired comprehension and impaired repetition — a Wernicke aphasia. The sudden onset in a vasculopathic patient localises to the dominant superior temporal gyrus in the inferior division of the left middle cerebral artery, and this is an acute stroke. Her preserved alertness and attention confirm this is a focal aphasia, not delirium. My immediate priority is to activate the acute stroke pathway for urgent CT to exclude haemorrhage, then assess for thrombolysis and thrombectomy.'" ^[1]

Discussion questions

Q: "How do you know this is aphasia and not delirium?" ^[1]

"Because the core features of delirium are absent. Delirium is an acute, fluctuating impairment of attention with altered consciousness. This patient is fully alert, her digit span is preserved at six forward, and she manages one-step commands — her attention is intact. In delirium the speech is globally disorganised — rambling and tangential — whereas here the fluency and melody are normal and only the content is disordered, with specific language errors: paraphasias and neologisms. The onset is sudden and discrete, consistent with a vascular event, not the fluctuating, precipitant-driven course of delirium. The danger of the confusion label is that a patient with an acute dominant-hemisphere stroke is worked up for sepsis while the thrombolysis clock runs out. I confirm attention formally, then activate the stroke pathway." ^[1]

Q: "Why does she not have limb weakness if it is an MCA stroke?" ^[1]

"Because Wernicke area lies in the superior temporal gyrus, which is supplied by the inferior division of the middle cerebral artery and sits outside the primary motor cortex. The superior division of the MCA supplies the frontal motor cortex and the face and arm area, so a superior-division or complete-MCA occlusion produces a contralateral hemiparesis, but an isolated inferior-division occlusion can produce a Wernicke aphasia with no limb weakness. The absence of limb signs therefore does not exclude the stroke — it localises it to the inferior division of the MCA. I would still image urgently, because the clinical story of a sudden focal language deficit is an acute stroke until proven otherwise." ^[1]

Q: "What does her clock-drawing test tell you, and what are its limits?" ^[1]

"In the acute phase, a clock-drawing test would be confounded by her aphasia — she may not understand the instruction, and even if she does, the language of the task (numbers, the concept of ten past eleven) is precisely what she cannot access. So I would not over-interpret a clock drawing in an acute aphasic patient; the speech examination is the primary tool here. In a non-aphasic patient, clock drawing is a high-yield visuospatial and executive screen whose error patterns localise: neglect of one side to a non-dominant parietal lesion, perseveration to a frontal executive deficit, and a conceptual breakdown to a generalised dementia. A systematic review reports a pooled sensitivity of about 80 per cent and specificity of about 75 per cent under the Shulman system, though it is less sensitive for very mild impairment ^[5]."