Diagnosis of Apraxia
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APHASIA, APRAXIA, AND AGNOSIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it intermittent? Episodic aphasia, apraxia, or agnosia would suggest epilepsy, transient ischemic attacks, migraine, or hypertensive encephalopathy.
- Is it acute or gradual in onset? Acute onset of aphasia, apraxia, or agnosia would suggest a cerebral vascular accident, or if there is fever, the onset of a cerebral abscess. It may also mark the onset of acute encephalitis. The gradual onset of aphasia, apraxia, and agnosia would suggest a tumor or other type of space-occupying lesion.
- Is there associated headache or papilledema? Headaches with aphasia, apraxia, and agnosia might suggest migraine, but one should not forget a brain tumor. Obviously, papilledema is a sign of a space-occupying lesion.
- Is there significant dementia? The development of dementia along with the aphasia, apraxia, and agnosia suggest Alzheimer's disease, Pick's disease, herpes encephalitis, multiple sclerosis, or Korsakoff's psychosis.
DIAGNOSTIC WORKUP
All patients should have a CBC, sedimentation rate, chemistry panel, a VDRL test, and a CT scan of the brain. The CT scan may demonstrate an infarct, a space-occupying lesion, a degenerative disease, or multiple sclerosis. If this is negative, a neurologist should be consulted before ordering MRI or a spinal tap.
If the patient presents with intermittent aphasia, apraxia, or agnosia, an EEG should be done to rule out epilepsy, and a carotid scan should be done to rule out carotid stenosis or carotid plaques with ulceration. Four-vessel angiography may need to be considered, but a neurologist should be consulted before this is done.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Apraxia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect apraxia, ask about previous neurologic disease. If the patient fails to report such disease, begin a neurologic assessment. First, take the patient’s vital signs and assess his level of consciousness. Be alert for any evidence of aphasia or dysarthria. Ask the patient if he has recently experienced headaches or dizziness. Then test the patient’s motor function, observing for weakness and tremors. Next, use a small pin or another pointed object to test sensory function. Check deep tendon reflexes for quality and symmetry. Finally, test the patient for visual field deficits.
Be alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If you detect these, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Help him to a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. If the patient’s teeth are clenched, don’t force anything into his mouth. If his mouth is open, protect the tongue by placing a soft object, such as a washcloth, between his teeth. Turn the patient’s head to provide an open airway.
After completing the examination and ensuring the patient’s safety, take a history. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type. (See Apraxia: Causes and associated findings, page 72.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Apraxia:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain the patient’s history. Ask whether he has a previous history of neurologic disease. Does he have a history of headaches or dizziness?
Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease.
Physical examination
First, obtain the patient’s vital signs and assess his level of consciousness. Perform a neurologic assessment, staying alert for evidence of aphasia or dysarthria. Assess motor function, observing for weakness and tremors. Assist with testing sensory function, deep tendon reflexes, and visual field deficits.
Stay alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If present, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema after inserting a urinary catheter to avoid bladder rupture.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Assist him into a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. Don’t place anything into his mouth. Turn the patient’s head to the side to provide an open airway.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Apraxia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you detect apraxia, ask about previous neurologic disease. Ask the patient if he has recently experienced headaches or dizziness. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Verbal Communication Difficulty:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Receptive and Expressive Language Disorders
Languageis the understanding and use of meaningful speech. Receptive languageis the ability to understand the language of others, whereas expressivelanguage is the ability to choose and combine words into meaningfulspeech.Children with receptive language disorderhave difficulty understanding speech of others and answering questionsappropriately.Those with expressive language disorderhave limited vocabulary and experience difficulty in forming sentencestructures and using words appropriately.Causes of receptive and expressivelanguage disorders include maturational delay, hearing loss, neurologicdisorders, and psychologic disorders, including psychosocial deprivation. Maturational Delay
Although maturational language delay is common,the cause remains unknown. The language is normal, but its developmentis unusually slow. There is no evidence of hearing, cognitive, orpsychologic problems.
Hearing Loss
Normal hearingis necessary for normal language development.Hearing loss, especially sensorineural,can affect perception and learning of speech sounds. Even mild hearingloss may contribute to delayed language development.Children with delayed or impaired languagedevelopment should have their hearing tested.Causes of hearing loss and types ofage-appropriate hearing tests are discussed in Chap. 26, Hearing Loss and Deafness. Neurologic Disorders
Mental retardationis common cause of impaired language acquisition. Affected childrenhave delayed and impaired language at any age. See Chap. 13, Developmental Delay.Cerebral malformations may affect languagedevelopment if they involve the language area in dominant hemisphere.Acquired language disorders also mayoccur from focal cerebral lesions in the dominant hemisphere. Theselesions may be due to head trauma, infection, neoplasm, vasculardisease, and degenerative diseases of the nervous system. Psychologic Disorders
Severe psychologicproblems can cause disturbed or bizarre communication patterns inwhich affected children do not behave or relate to other peoplein normal ways.Autism, most extreme form of disturbedcommunication, involves severe disturbances in attention, cognition,and behavior.Psychosocial deprivation is anothercause of delayed or impaired language development.Intellectual and language stimulationis critical during early language development, which occurs duringfirst 3 yrs of life. If such stimulation is absent or inadequate,delayed and impaired language development may occur. Speech Disorders
Speech is the physical production of soundsin sequence to form spoken words. A speech disorder is characterizedby defective production of individual speech sounds in comparisonwith one's peers. Speech may be difficult to understandor even unintelligible.
Articulation Disorders
Causes of articulation problems include anatomicconditions (cleft palate, dental malocclusion, macroglossia) andneurologic insult or dysfunction (cerebral palsy).
Phonology Disorders
Phonologyconcerns rules that govern the production of speech sounds.A phonology disorder is characterizedby speech sound errors due to difficulty in applying a rule forthe production of a class of speech sounds (e.g., child may substitute /t/ for /s/, /t/ for /sh/,and /d/ for /z/). In this case,child is using the process of "stopping" to producethese sounds.Therapy involves teaching the childthe common feature of production, so that this feature can be generalizedto the entire class of sounds. Fluency Disorders
Fluency disorder, commonly known as stuttering,is a type of speech disorder with abnormal number of repetitions,hesitations, blocks, and prolongations in normal flow or rhythmof speech. Stuttering seems to be learned behavior and often beginsat 2–4 yrs.
Voice Disorders
Voice maybe defined as sound produced by vocal cords (phonation), which isaltered when it vibrates in oral and nasal cavities (resonance).Voice disorders can be classified into2 major types: phonation disorders and resonance disorders. Phonation Disorders
Hoarseness,abnormal pitch, inappropriate loudness, severe pitch breaks, andaphonia characterize phonation disorders, which are usually causedby laryngeal pathology.Common causes include laryngitis, vocalnodules, papillomas, and vocal cord paralysis. Most common causeof persistent hoarseness in children is vocal nodules, which maydevelop on vocal cords due to overuse, misuse, or abuse of voice.See further discussion of these disorders in Chap. 31, Hoarseness, and Chap. 63, Stertor, Stridor, and Airway Obstruction. Resonance Disorders
Abnormalvibration of sound in oral, nasal, and pharyngeal spaces of respiratorytract produces hyponasal or hypernasal voice that characterizesresonance disorders.Lack of adequate nasal resonance produceshyponasal voice, which is due to obstruction in posterior nasalpassages or nasopharynx. Most common cause is enlargement of adenoidglands, which is usually due to recurrent viral URI or allergicrhinitis.Escape of too much sound from nasalcavity and nasopharynx produces hypernasal voice, which is oftenaccompanied by nasal air emission during consonant production. Thisis due to incomplete closure of velum against posterior pharyngealwall (velopharyngeal insufficiency). Cleft palate, submucous cleftpalate, short palate, wide nasopharynx, adenoidectomy, and poorvelar mobility can produce velopharyngeal insufficiency. Diagnostic Approach
Problemin verbal communication often presents as delay in language development orinadequate use of speech. Table72.1 describes normal sequence of receptive and expressivelanguage development.Children at high risk for problemswith verbal communication include those with cleft palate, mentalretardation, cerebral palsy, hearing loss or deafness, deprivation,or psychologic disturbance.Complete history, physical exam, anddevelopmental assessment should be performed when a child exhibitsverbal communication difficulties. Physician can listen to childrentalking in natural conversation and have them repeat specific wordsor sentences to assess use of consonants, vowels, pronouns, vocabulary,syntax, and intelligibility of speech. Communication disorder shouldbe suspected if any indications listed in Table 72.2 are observed.Children with delayed language or inadequatespeech should have their hearing tested and language and speechskills evaluated by speech-language pathologist. Children with voicedisorders should be referred to otolaryngologist or speech pathologistif voice is chronically hoarse or of poor quality, pitch is inappropriatefor age or sex, pitch brakes occur often, or voice is hypernasalor hyponasal.Child with stuttering should be referredto speech-language pathologist if parents have expressed concernabout the condition; if child has abnormal number of repetitions,hesitations, prolongations, blocks, or disruptions in natural courseof speech; or if child is concerned and becomes anxious or tenseduring speech, or avoids speaking due to fear of stuttering.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
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