Nursing Assignment needed ASAP

Read the following case and answer the questions. (answers needs to have rationale and be detailed.)

Mr. Simmons is a 70 y.o. man who was referred to your clinic because of reports of progressively worsening speech. The patient’s wife reported that she was having increased difficulty understanding him, so he went to his doctor who referred him for a comprehensive Speech-Language evaluation.   

Medical History Hypertension. No prior history of neurological disease. 

Social history: The patient was an editor for the Washington Post.

MRI: unremarkable. No lesions were noted.

 Neurology Report

Mental Status:  The patient was alert and oriented to person, place, and time.   He was able to follow one and second-order commands without difficulty. Although it was noted that the initiation of movement was slow. He was able to recall 6/6 digits forward and 3/5 digits backward. The patient was able to recall three (3) items immediately and after a 5-minute delay.  His language was fluent.  He was able to name common and uncommon objects without difficulty; repetition was intact; writing was moderately illegible. The patient was noted to have resting tremors in the hands and face. The patient denied any visual hallucinations, delusional thoughts, or a history of psychiatric disorders. 

Cranial Nerves: On cranial nerve examination, the patient’s pupils were equal, round, and reactive to light. Extraocular movements were intact with no noted nystagmus or abnormal eye deviation. At rest, the patient’s face was masked with little facial expression.  The patient had some difficulty wrinkling the forehead bilaterally but was thought to be as a result of hypokinesia and not facial weakness.  The retraction of his lips was a minimal asymmetric on the left side (left facial droop). Mandibular strength was normal with a reduced range of motion.   The tongue protruded with some marked limited range of motion. The uvula presented with adequate

elevation on repetitions of “ah”. The patient also presented with a normal gag reflex. Sternocleidomastoid and shoulder shrug was intact.

Motor Exam:  The patient presented with resting tremors in the lower and upper extremities. Muscle strength was 5/5 on upper and lower extremities bilaterally. Deep Tendon reflexes testing (resistance to stretch) revealed increased rigidity in all extremities, in all directions and through the full range of motion. Muscle strength was at 3+ bilaterally. Hyporeflexia noted

Reflexes: Extensor plantar responses (Babinski sign) were present bilaterally.

Coordination and Gait: 

 Appendicular Coordination:

Rapid Alternating movements such as finger tapping were slow and imprecise. Finger-nose-finger testing was also slow and imprecise with marked paucity and hesitation of movement bilaterally. 

Bradykinesia was present on repetitions of finger tapping.

Arm swing during walking was deemed to be reduced. The patient was slow to initiate sit to stand and during walking his gait was characterized as short with festination. 

Motor Speech Performance

Oral Mechanism Exam:

The oral mechanism examination was unremarkable and without deficit with the exception of lingual tremulousness on protrusion and during lateral movements. Conversational speech, reading, and repetition displayed a remarkable degree of Speech AMRs was rapid or accelerated.

Cough and glottal coup were weak. Gag reflex was normal.

AMRs and SMRs: rapid, imprecise AMRs with variable rate and inappropriate silences.

Vowel prolongation: 12 seconds, 12 sec and 9 seconds.

Vocal Quality: Judged to be Breathy, hoarse, monopitch, monoloud 

Conversational Speech/Reading passage: slow, imprecise articulation (especially noted on consonants), reduced stress, weak pressure on consonants, reduced rate, shortened phrases, and short rushes of speech and inappropriate silences. There was a notable deterioration of speech and dysfluency, characterized by rapid repetition of initial sounds, syllables, and occasionally words and phrases. Sound and syllable repetitions occurred up to 30 to 40 repetitions per dysfluent moment.

There was no evidence of associated struggle behavior during dysfluencies, but he was frustrated by them. Articulation was moderately imprecise, and overall pitch and loudness variability were reduced.

Words of Increasing Length: Intact but slow. At times the patient had difficulty initiating some responses.

Speech intelligibility: Mild-moderately impaired in conversational speech and a reading passage.

Swallowing

The patient reports that it has been taking longer to complete a meal. It typically takes anywhere from 45 mins to an hour. He currently eats regular textures and reports softer foods are easier to eat. During the observation of the first meal, the nursing staff noted that the patient became fatigued when chewing the regular textures and started coughing on the prescribed regular liquids and solid textures.  

Case Video Case Conversational Speech Sample

Assignment Questions:

Interpret all sections of the neurological examination.

1. Identify at least 5 questions you would ask this patient during your Patient Interview. Provide a rationale for your question (what information does it provide you?). Remember that your questions MUST lead you to develop a Clinical Hypothesis for differentially diagnosing this patient.

2. Where is the site of the lesion? Provide justification with your answer from the neurological report provided.

3. What neurons are involved UMN and/or LMN? Provide justification with your answer. Provide justification with your answer from the neurological report provided.

4. What motor pathway is involved? 5. What type of dysarthria do you suspect? Provide a justification for

your answer. 6. Outline a therapy approach you might use with this patient. 7. Provide at least one (1) long-term goal and two short-term objectives

to address in therapy.