Pitch: how to address/target?

-pitch apps
-keyboard app + Stemple VFE’s

Emily: strengthen muscles

What is meant by language?

Client’s name: AV Age: 26

Marital status: Single Occupation: Currently, a
gymnastics teacher but wants to be an actress
Educational level: B.S., B.A. from Wheelock College
(dual degree in Education and Theatre)
Date of injury/onset: May 1, 2018
Medical diagnosis: Stroke due to multiple emboli in right
frontal, parietal, and occipital lobes (all emboli during
mitral valve surgery—heart surgery)
Mitral valve prolapse may be rarely associated with
strokes occurring in young patients. These patients appear
to have increased blood clotting tendencies due to
abnormally sticky blood clotting elements, called platelets.
Neuroradiological results: Occlusions in right MCA and
its branches due to blood clots from her heart resulting in
right frontal, parietal, and occipital infarctions.
Associated medical history: mitral valve replacement in
2017, mitral valve repair in 2015. Otherwise healthy; no
additional medical issues.
Acute care: Admitted to hospital to have heart surgery.
Sustained strokes during surgery on May 1, 2018.
Remained in acute care at Brigham and Women’s Hospital
for one month (May 1-June 1, 2018). Lengthy medical stay
due to severity of initial status. While hospitalized at
Brigham and Women’s, she was intubated and on a
ventilator for two weeks. Subsequently, she was extubated
and then a tracheostomy was placed and was weaned off
of the trach by the time of discharge from Brigham and
Women’s (1 month post onset by June 1, 2018). She was
NPO with a G-tube inserted for her entire inpatient acute
care stay.
ACUTE CARE QUESTIONS/ANSWERS:
- What are the details of the complications that lead to her extended length of stay and
why was she intubated for so long?
Altered state of consciousness and 3 different infarctions
- What treatment was provided during her acute care? SLP? OT? PT?
• -getting means of communication due to ventilation and trach- primary
responsibility AAC means then working on speaking valve toleration till trach
weaned and removed
• Bedside eval occurred- agreement to work on swallowing due to NPO status→
G-tube inserted for primary needs of nutrition due to altered mental status
Received PT, OT, Speech. Speech was about 30 minutes a day
- What was her rehabilitation progress during that month?
She made progress, trach weaned and could communicate verbally, but no
improvement with swallowing
- Has her cognition been tested?
- Is she presenting with any other RHD symptoms?
Evidence of Left Neglect
Difficulty sustaining attention
Anosognosia
- Any other paralysis or paresis other than her focal folds?
• Presented with left hemiplegia of arm & leg
• Never in coma
- How compliant is she during treatment

Was AV ever in a coma state? (level of consciousness?)

• No
How was AV getting nutrients when she was discharged?
• Discharged NPO w/ G-tube dependence to Spaulding
Who assisted with these decisions? Does AV have any family/support in the US?
• Mom was present during her stay in acute rehab.

Type of Progress?
No improvement with swallowing
Did not address cognition
Acute rehab: Once medically stable and ready for rehab,
she transferred to Spaulding Rehabilitation Hospital where
her length of stay was 3 months (June 1 – September 1,
2018).
- What services was she receiving? (PT, OT, Speech/language)
Speech, OT, PT one hour each total of three hours a day.
- What goals was she working toward?
PT- left sided weakness
OT- ADLs (activities of daily living)
Speech- swallowing (1st priority, 5-7 days/week for an hour each day), cognition (2nd
priority)
- What progress did she make on her goals? Does make progress
Placed on trial of pureed food and thickened liquids to get use to feeding PO progressed
up to full meals on puree thick, no signs or symptoms of aspiration, when she left
Spaulding she was eating regular thin
- What strategies worked well during treatment?
- Was the FIM administered? How’d she perform on the FIM at discharge?
Yes did pre and post, results given later

Questions for Acute Rehab:

1. What tests were administered? Results? Goals?
Not giving us the results of tests yet--that will be part 2
Not telling us goals yet--part 2
Participated in cognitive-linguistic evaluation
2. In state for MBS now (or other objective swallow test)? Prognosis for return
to feeding orally (PO/baseline diet)?
Performed beside swallow, Did send her for MBS--placed on trial of pureed food
and thickened liquids, not for primary nutrition, but to get her used to eating PO
again. And progressed to puree thick no signs or symptoms of aspiration,
advanced diet. When left spaulding, eating regular thin (all food consistencies
and liquids)
3. Response to various levels of prompting?
Saving this for later
Participated in tx and made progress
4. Vocal quality post-extubation? (Is it at baseline from prior to
intubation?)
• Voice disorder as a result of intubation (will be discussed further)

Biographical Questions
1. What is AV’s learning style?
a. Visual challenging because of left neglect
 b. Better learning when things were realistic and focused on what she
wanted to work on (functional, meaningful, related to her life)
2. Behavioral observations
. Cooperative
a. Denial of deficits--anosognosia

***** Request ENT report

Home health/therapy: AV has been home for 2 months

(all of September and October) receiving home speech
therapy while awaiting outpatient therapy at your facility.
• How frequently is AV receiving services?
PT/OT/SLP at home for 60 min sessions 1X a week
• What goals has she been working on? Progress?
See in Interview
• How is she functionally communicating in her environment now? What are some
things you want to continue to work on?
• Functional communicator, she does not have any language impairments
as one would imagine with RHD. She describes her communication skills
and the voice disorder impacts her ability to communicate in the home and
• in the community.
• What other services is she receiving (other than SLP)?What is her feeding and
swallowing status? Still NPO?
o Fully resolved, full diet, regular thin, no aspiration
• How is her left neglect impacting therapy/daily life?
Impacting daily life- see in interview
• Once her mom leaves, is there any other support that AV will receive or will she
be expected to be independent at home?
o Goal at this point- mom has to leave, she will live alone at home and
manage by herself in 2 months
• What are AV’s personal goals for herself in therapy?

Will have to navigate doctors appointments for the ongoing monitoring of her heart
condition

Lives in Watertown, does not drive, takes public transportation

Has quad cane, small based, to help get around, she is not safe to be alone in the
community as of right now

Meds: heart condition meds, blood thinner (important because of multiple strokes)
Coumadin (have to go in multiple times for blood draws, weekly or biweekly) (how will
she navigate those appointments once mom leaves)
Close circle of friends- but they have jobs and families so they can’t take on full role of
their care
No previous history of learning/psych history

Outpatient: It is now November 5, 2018 and you are the

SLP who will interview her and complete an evaluation.
Your task is to determine the following:
a.) Does AV present with a disorder
(speech/language/cognitive/swallowing)?
b.) If yes, what is the hypothetical diagnosis based upon
the background information given and then gathered
during the interview?
c.) What would be your next step?
Test results: will be distributed in class at a later date
Voice: Please note that she has paralysis of one vocal
cord. Describe how you think her voice sounds
-Rough? Breathy? strained?
Hearing: No known hearing impairment
Vision: Wears glasses for acuity
Visual perceptual: has left neglect
Language: AV’s native language is Serbian but she
is also fluent in English. Came to the US when she was 19
years old to attend college. She has resided alone in the
US since then. Mom’s native language is also Serbian
and she and AV speak in Serbian at home while AV
speaks English in all other settings. Mom arrived in US on
an emergency Visa in order to care for AV. But her Visa
will expire in 2 months.
Video Observations:

Voice: strained
Able to orient to mom (on her right side) --> left neglect resolving?
Followed model of clinician speaking louder (stimulability)
No overt language impairments (verbal and nonverbal)
Was able to turn left, not “seeing” on the left

Self Report:
Difficulties with organizing, planning tasks, daily activities (EF)
Voice is low-pitched and soft since the stroke, previously able to project as an actress
No reported difficulty taking deep breath or running out of breath
Reportedly wants to work on memory and concentration (attention)
“I have left neglect, that’s what they told me”

Interview Q’s:
Goal: “to go back to the old Alex” (indicating awareness of deficits)
Wants to work on “concentration and initiation-starting a task or conversation, maintaining a
conversation” (right frontal)
“forget to put my left hand down, it always creeps up (tone)” --> right hand keeps left in place
Instructed by PT to use right hand to keep left in place, and to remember to use left hand more
often
Mom helps prepare breakfast/meals, helps get dressed/chooses close (I’m getting there) -->
used to have a harder time sequencing, but getting better
“watch” for alarm clock?

Assignment:

Single spaced, no more than ~2 pages (DUE in 2 weeks)

Upload to Canvas

Writing a clinic summary report (like for Robbins)

-header
-background information (2 parts)
-medically related info (1st paragraph): “AV is a 26-year-old female who sustained
multiple strokes in the right hemisphere, occipital lobes during m… valve surgery,” then
in chronological order, summarize acute care, to acute rehab, to home health what has
happened to her. Include neuroradiological results. Add vision and hearing at bottom,
“PMH including hearing status and vision and visuoperceptual and physical status
(hemiplegia) and VF paralysis.
-social/biographical/personal information (2nd paragraph): previous and current
occupation, bilingual, how she communicates with others, living situation/status, family
 support, MUST include mom’s role and the fact that she is leaving and will have no
other support, education level.
-Behavioral Observations (3rd paragraph): summarize interview observations, and additional
relevant information gleaned
-Hypothetical Diagnosis (4th section):
RHD --> based on pt … It is suspected that AV presents with RHD based on or as a result of
location of strokes and damage… based on neuroradiological results
Presenting with the following symptoms left neglect, reduced attention, impaired EF,
aprosodia, anosognosia, left hemiplegia

It is suspected that AV presents with a voice disorder as a result of … CN damage OR intubation

presenting with the following symptoms strained, breathy, low volume … It is recommended
that she seek a referral to ENT to confirm VD and recommendations for Tx.

Oral-pharyngeal dysphagia was resolved --> using strategies?