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SPEECH AND LANGUAGE ASSESSMENT REPORT
SECTION 1 — PATIENT AND REFERRAL INFORMATION
| Field | Details |
|---|---|
| Patient Name | Mr. Arjun Sharma (fictional) |
| Date of Birth | 14 March 1975 (Age: 51 years) |
| Gender | Male |
| Laterality | Right-handed |
| Education | Graduate (B.Com), primary language: Hindi; bilingual (English) |
| Occupation (pre-morbid) | Accounts Manager |
| Date of Assessment | 30 April 2026 |
| Referred by | Dr. P. Mehta, Consultant Neurologist, Dept. of Neurology |
| Assessed by | [Speech-Language Pathologist Name], M.Sc. SLP, RCI Certified |
| Setting | Inpatient Rehabilitation Unit, Neurology Ward |
| Report Date | 30 April 2026 |
SECTION 2 — REASON FOR REFERRAL
Mr. Arjun Sharma was referred for a comprehensive speech and language assessment following a diagnosis of Tubercular Meningitis (TBM) with subsequent neurological complications, specifically for evaluation of reported difficulties with language comprehension, functional communication, and cognitive-communication skills. The referring neurologist documented clinical features consistent with Transcortical Sensory Aphasia (TSA) and a superimposed Cognitive Communication Disorder (CCD), as identified during bedside neurological examination.
SECTION 3 — MEDICAL AND SOCIAL HISTORY
3.1 History of Present Illness
Mr. Sharma presented to the emergency department approximately 8 weeks prior to this assessment with a 3-week history of low-grade fever, progressive headache, photophobia, and altered sensorium. Cerebrospinal fluid (CSF) analysis confirmed Tubercular Meningitis: CSF protein elevated at 180 mg/dL, glucose 28 mg/dL (corresponding blood glucose 90 mg/dL), lymphocytic pleocytosis (78 cells/mm³), and positive Adenosine Deaminase (ADA). Ziehl-Neelsen staining revealed acid-fast bacilli.
Neuroimaging (MRI Brain with gadolinium): Meningeal enhancement predominating in the basal cisterns; communicating hydrocephalus; areas of ischemic infarction in the distribution of the middle cerebral artery territory (left posterior parieto-temporal region, angular gyrus area 39, posterior middle temporal gyrus area 37) and watershed zone changes in the posterior peri-ventricular white matter, consistent with TBM-associated vasculitis.
Treatment initiated: Four-drug anti-tubercular therapy (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol), adjunct corticosteroids (Dexamethasone), and ventriculoperitoneal shunt placement for hydrocephalus management.
Neurological sequelae documented at discharge from acute care:
- Right hemiplegia (MRC Grade 3/5 upper limb, 2/5 lower limb)
- Language disturbance consistent with Transcortical Sensory Aphasia
- Impaired memory and attention
- Mild dysphagia (resolved prior to this assessment)
3.2 Past Medical History
- Pulmonary tuberculosis (2019) — treated, declared cured
- Hypertension — on Amlodipine 5 mg
- No prior history of neurological or speech-language disorders
3.3 Family and Social History
- Married, two children (ages 18 and 22)
- Lives in joint family; wife is primary caregiver
- No family history of neurological disease
3.4 Pre-morbid Communication Status
- Fluent bilingual communicator (Hindi and English)
- No prior history of speech, language, hearing, or cognitive difficulties
- Literacy: functionally literate in both Hindi and English; used written communication routinely for work
SECTION 4 — ASSESSMENT FRAMEWORK
4.1 Assessment Rationale
The clinical presentation of Transcortical Sensory Aphasia following TBM-related posterior peri-temporal/angular gyrus infarction requires systematic evaluation across all language modalities — comprehension, expression, repetition, naming, reading, and writing — as well as an assessment of cognitive-communication skills that mediate functional communication in real-world contexts.
As established in the Boston anatomoclinical classification of aphasias (Goodglass and Kaplan), Transcortical Sensory Aphasia is characterised by:
- Fluent spontaneous speech (with semantic paraphasia and anomia)
- Severely impaired auditory and visual word comprehension
- Preserved repetition (often echolalic)
- Impaired reading and writing
- Naming usually impaired
(Localization in Clinical Neurology, 8e; Adams and Victor's Principles of Neurology, 12th Ed.)
The superimposed Cognitive Communication Disorder — arising from diffuse cortical and subcortical disruption caused by meningeal inflammation, vasculitis, and hydrocephalus — may further affect attention, memory, executive function, pragmatics, and discourse, independent of the focal aphasia profile.
4.2 Assessment Tools Used
| Instrument | Domain |
|---|---|
| Western Aphasia Battery – Revised (WAB-R) | Aphasia type, Aphasia Quotient (AQ), Language Quotient (LQ), Cortical Quotient (CQ) |
| Boston Diagnostic Aphasia Examination – 3rd Ed. (BDAE-3) | Comprehensive language modalities; severity rating |
| Boston Naming Test – Revised (BNT-R) | Confrontation naming / word retrieval |
| Token Test (De Renzi and Faglioni) | Auditory comprehension of commands (syntax/length) |
| Revised Token Test (RTT) | Graded auditory processing load |
| Functional Communication Profile – Revised (FCP-R) | Real-life communicative functioning |
| Communicative Effectiveness Index (CETI) | Caregiver-rated communicative competence |
| Montreal Cognitive Assessment (MoCA) | Global cognitive screening |
| Clinical Evaluation of Language Fundamentals (CELF-5) | Language processing and formulation |
| Informal Discourse Sampling | Narrative, procedural, and conversational discourse |
| Reading comprehension (informal) | Word, sentence, and paragraph level |
| Writing sample (informal) | Spontaneous and copied writing |
| Oral Motor Examination | Articulatory mechanism, praxis |
| Informal Hearing Screen | Peripheral hearing adequacy |
SECTION 5 — BEHAVIOURAL OBSERVATIONS
Mr. Sharma was transported to the assessment room in a wheelchair. He was alert and appeared interested in the interaction, maintaining appropriate eye contact throughout. He was cooperative and appeared to understand the general context and social demands of the assessment situation (e.g., smiling at the examiner, turning toward the speaker), suggesting preserved pragmatic social awareness at a gross level.
He demonstrated marked comprehension difficulty: when spoken to at normal pace, he frequently nodded inappropriately or produced echolalic repetitions of the examiner's utterances without demonstrating comprehension. On several occasions, he echoed multi-word commands verbatim with good phonemic accuracy yet proceeded to perform the incorrect or no action.
Spontaneous speech was fluent in rate and prosody, with phrase length of 5–8 words; however, speech content was characterised by:
- Semantic paraphasias (e.g., "pen" → "book," "chair" → "table")
- Circumlocutions and empty phrases ("the thing that you do for … you know … the one")
- Occasional neologisms
- No significant articulatory errors or motor speech disturbance
He demonstrated visible frustration during naming tasks when unable to retrieve target words, occasionally abandoning attempts with a head shake.
Attention: Easily distracted by ambient ward noise; required frequent redirections (approximately 4–5 times per 30 minutes).
Fatigue: Noted after approximately 40 minutes; all formal testing was completed across two sessions (Day 1 and Day 3).
SECTION 6 — RESULTS OF FORMAL ASSESSMENT
6.1 Western Aphasia Battery – Revised (WAB-R)
| Subtest | Score | Max | % |
|---|---|---|---|
| Spontaneous Speech – Information Content | 6 | 10 | 60% |
| Spontaneous Speech – Fluency, Grammatical Competence & Paraphasia | 7 | 10 | 70% |
| Auditory Verbal Comprehension – Yes/No Questions | 44 | 60 | 73% |
| Auditory Verbal Comprehension – Auditory Word Recognition | 36 | 60 | 60% |
| Auditory Verbal Comprehension – Sequential Commands | 44 | 80 | 55% |
| Repetition | 78 | 100 | 78% |
| Naming – Object Naming | 34 | 60 | 57% |
| Naming – Word Fluency | 8 | 20 | 40% |
| Naming – Sentence Completion | 8 | 10 | 80% |
| Naming – Responsive Speech | 7 | 10 | 70% |
Aphasia Quotient (AQ): 52.4 / 100
(AQ < 93.8 = aphasia present; 51–75 = moderate aphasia)
Aphasia Type (WAB-R Classification): Transcortical Sensory Aphasia — Fluency preserved, Comprehension impaired, Repetition relatively preserved (with echolalia), Naming impaired.
Language Quotient (LQ): 58.1 (reading and writing deficits contributing)
Cortical Quotient (CQ): 54.7 (reflecting additional cognitive-communication deficits)
6.2 Boston Diagnostic Aphasia Examination – 3rd Ed. (BDAE-3)
Severity Rating: 2 / 5 (Moderate aphasia; conversational speech possible in limited areas but listener must make frequent inferences, questions, and restatements)
6.2.1 Auditory Comprehension
| Task | Performance |
|---|---|
| Word Discrimination | 42/72 (58%) — significantly impaired across all semantic categories |
| Body Part Identification | 10/18 (56%) — below cut-off |
| Commands (1-step) | 4/5 (80%) — adequate for simple single-step |
| Commands (2-step) | 2/5 (40%) — significantly impaired |
| Commands (3-step) | 0/5 (0%) — severely impaired |
| Complex Ideational Material (yes/no passages) | 6/12 (50%) — chance level performance |
Interpretation: Comprehension impairment is present across word-level, syntactic, and discourse levels. Single-step commands are partially accessible; multi-step and complex auditory comprehension is severely compromised.
6.2.2 Oral Expression
| Task | Performance |
|---|---|
| Conversational / Expository Speech | Fluent; phrase length 5–8 words; melodic line normal |
| Paraphasia Rating | Semantic paraphasia: frequent (score 3); Literal/Phonemic: infrequent (score 1); Neologistic: occasional (score 2) |
| Articulation Rating | Normal articulatory agility (score 5) |
| Phrase Length | Normal range |
| Responsive Naming | 7/10 (70%) |
| Confrontation Naming (Object) | 30/60 (50%) |
| Animal Fluency (1 min) | 6 items |
| Body Part Naming | 8/16 (50%) |
| Action Naming | 12/24 (50%) |
Interpretation: Expressive output is fluent in form but severely impaired in semantic content. Naming is consistently deficient across modalities; word fluency is below expected range (normative: ≥15 items/min for age-matched controls).
6.2.3 Repetition
| Task | Performance |
|---|---|
| Words (High Frequency) | 8/10 (80%) |
| Words (Low Frequency) | 6/10 (60%) |
| Sentences | 6/8 (75%) — echolalic quality noted on longer sentences |
| Nonwords | 5/8 (63%) |
Interpretation: Repetition is disproportionately preserved relative to comprehension, confirming the hallmark profile of TSA. Echolalia was observed: Mr. Sharma repeated the examiner's sentence "Put the pencil on the book" accurately but then stared blankly, unable to execute the command. This dissociation between phonological accuracy of repetition and semantic processing is diagnostic of transcortical sensory aphasia.
(Adams and Victor's Principles of Neurology, 12th Ed.: "...the ability to repeat the spoken word is preserved. This facility in repetition may be of extreme degree, taking the form of echoing, parrot-like, words, phrases, and songs that are heard.")
6.2.4 Reading
| Task | Performance |
|---|---|
| Symbol and Word Discrimination | 4/10 (40%) |
| Word Recognition (Matching) | 12/30 (40%) |
| Oral Reading (Single Words) | 10/20 (50%) — reads aloud with normal phonation; no comprehension |
| Oral Sentence Reading | Fluent oral reading of text; unable to demonstrate comprehension on verification tasks |
| Reading Comprehension (Sentences) | 2/10 (20%) |
| Reading Comprehension (Paragraphs) | Unable to answer questions about read text |
Interpretation: Mr. Sharma demonstrates surface alexia with preserved oral decoding — he reads text aloud fluently but comprehension of written material is severely impaired, consistent with TSA involvement of angular gyrus and posterior temporal associative cortex.
6.2.5 Writing
| Task | Performance |
|---|---|
| Mechanics / Motor Quality | Laboured; right hemiplegia necessitates left-hand writing |
| Dictated Spelling (letters, numbers) | 60% accuracy |
| Written Picture Naming | 2/10 (20%) |
| Dictated Words | 4/10 (40%) |
| Dictated Sentences | Unable (no intelligible written output beyond isolated letters) |
| Narrative Writing | Could not produce coherent written narrative |
Interpretation: Writing is severely impaired across all tasks. Motor writing is constrained by right hemiplegia; however, even with left-hand transcription, linguistic writing content is severely compromised, indicating agraphia secondary to aphasia rather than purely motor limitation.
6.3 Boston Naming Test – Revised (BNT-R)
- Raw Score: 28 / 60 (47th percentile adjusted for age and education → severely impaired)
- Semantic paraphasias: 12 items (e.g., "stethoscope" → "doctor's thing," "comb" → "hair brush")
- Phonemic cues accepted: 6/10 successful
- Semantic cues accepted: 7/10 successful
- Self-corrected: 3 items
- Unrelated errors / perseverations: 4 items
Interpretation: Confrontation naming is severely impaired. The relative benefit from both phonemic and semantic cues indicates partial lexical access difficulty rather than complete lexical loss — prognosis for naming with cueing strategies is cautiously positive.
6.4 Token Test
| Part | Commands | Score | Interpretation |
|---|---|---|---|
| Part I (single attribute, simple) | Single-step with large shapes | 9/10 | Near normal |
| Part II (single attribute, size) | Small shapes added | 7/10 | Mild impairment |
| Part III (two attributes) | Colour + size | 5/10 | Moderate impairment |
| Part IV (two shapes, two attributes) | Multiple attributes | 3/10 | Severe impairment |
| Part V (complex relational commands) | Relational/sequential | 0/10 | Severely impaired |
Total Token Test Score: 24/50 (Normative cut-off ≥ 44; score < 29 = severe receptive language impairment)
Interpretation: Demonstrates a gradient of comprehension breakdown inversely proportional to syntactic complexity and linguistic load, consistent with disrupted semantic processing. Simple object recognition with one attribute is partially preserved; multi-attribute and relational commands are severely compromised.
6.5 Montreal Cognitive Assessment (MoCA)
| Domain | Score | Max |
|---|---|---|
| Visuospatial / Executive | 2 | 5 |
| Naming | 1 | 3 |
| Memory (registration) | 3 | 5 (deferred recall score: 0/5) |
| Attention | 3 | 6 |
| Language (repetition + fluency) | 1 | 3 |
| Abstraction | 1 | 2 |
| Orientation | 5 | 6 |
Total MoCA Score: 16 / 30 (< 26 = cognitive impairment; < 18 = moderate-severe cognitive impairment)
Key cognitive findings:
- Attention / Working Memory: Digit span forward: 5/7 (adequate); backward: 2/5 (impaired). Serial subtraction severely impaired. Sustained attention fluctuates; lapses observed every 8–12 minutes.
- Memory: Immediate recall 3/5 items; delayed recall 0/5 items at 5 minutes. Recognition with semantic cues: 3/5. Consistent with anterograde memory impairment likely attributable to hippocampal involvement secondary to meningeal inflammation and hydrocephalus.
- Executive Function: Trails-B equivalent: Unable to complete. Clock drawing: distorted; numbers placed on right side only (hemi-inattention). Category fluency reduced (animals: 6; vegetables: 4). Abstraction (proverb interpretation): concrete responses only.
- Orientation: Day, month, year, and place correctly identified (5/6); day of week error only.
6.6 Informal Discourse Analysis
Picture description (Cookie Theft, BDAE-3):
Mr. Sharma produced approximately 78 words in 3 minutes. Transcription sample:
"The boy is… the… the… thing there… taking the biscuit box… no, the… up, the thing with the… water is going out, running… she is… the woman… she is something… washing…"
Discourse Analysis Findings:
| Measure | Finding |
|---|---|
| Utterance length | Mean length of utterance (MLU): 4.2 morphemes |
| Information units | 4 out of expected 15 units conveyed |
| Semantic content | Sparse; circumlocutions, semantic substitutions dominant |
| Syntactic completeness | Simple sentence structure; few complex sentences |
| Cohesion | Poor — multiple incomplete utterances; few cohesive ties |
| Topic maintenance | Inconsistent; veered off stimulus content without apparent awareness |
| Narrative macrostructure | Absent — no sequential logical structure identified |
Procedural Discourse (describe how to make tea):
Unable to produce a sequential procedural account. Output consisted of isolated nouns and semantic approximations without procedural links.
6.7 Functional Communication Profile – Revised (FCP-R)
| Domain | Score (0–4 scale; 4 = normal) |
|---|---|
| Movement / Motor | 2.0 |
| Speaking | 1.8 |
| Understanding | 1.5 |
| Reading | 1.2 |
| Writing | 0.9 |
| Overall FCP-R Score | 1.5 / 4.0 (38%) |
Interpretation: Functional communication is severely limited. Mr. Sharma is currently dependent on gesture, context, and caregiver interpretation for basic communication needs. He is unable to communicate complex messages, make informed decisions, or participate in health-care conversations independently.
6.8 Communicative Effectiveness Index (CETI) — Caregiver Report (Wife)
Wife reported:
- He can make basic needs known (e.g., thirst, pain location) using gesture + single words: sometimes
- Ability to start a conversation: rarely
- Understanding TV news: never
- Following group conversation: never
- Understanding written instructions: never
- Using telephone: never
- Discussing daily events: rarely
- Making decisions about daily activities: rarely
CETI Score: 22 / 100 (severe communicative disability from caregiver perspective)
6.9 Oral Peripheral and Motor Speech Examination
| Structure/Function | Findings |
|---|---|
| Lips | Symmetry adequate; rounding/retraction intact bilaterally |
| Tongue | Strength and range of motion within normal limits |
| Soft palate | Adequate elevation bilaterally; no hypernasality |
| Diadochokinesis (AMR) | /pa/ = 5.8/sec, /ta/ = 5.4/sec, /ka/ = 5.0/sec — all within normal limits |
| Sequential motion rates | /pataka/ = 4.8/sec — within low-normal range |
| Voice | Normal quality, pitch, loudness; no dysphonia |
| Fluency | No stuttering or cluttering observed |
| Prosody | Normal rate and intonation; appropriate for conversational context |
| Resonance | Normal |
Interpretation: No dysarthria or apraxia of speech is identified. The motor speech mechanism is intact, consistent with the supramodal nature of TSA where articulatory execution is spared. All speech disturbance is of linguistic-semantic origin.
6.10 Hearing Screen
Informal pure-tone audiometric screening (500, 1000, 2000, 4000 Hz at 25 dBHL, bilateral):
- Pass bilaterally. No peripheral hearing loss identified.
Audiological referral recommended for formal pure-tone audiometry given patient age (51 years) and protracted course of Ethambutol (potential ototoxicity monitoring).
SECTION 7 — SYNTHESIS AND CLINICAL INTERPRETATION
7.1 Aphasia Profile: Transcortical Sensory Aphasia
The assessment findings confirm the presence of Transcortical Sensory Aphasia (TSA), characterised by the following clinical profile:
| Feature | Findings in Mr. Sharma |
|---|---|
| Fluency | Preserved (fluent, melodic speech) |
| Auditory comprehension | Severely impaired (WAB-R 55–73%; Token Test 24/50) |
| Repetition | Relatively preserved (WAB-R 78%); echolalia present |
| Naming | Significantly impaired (BNT 47%; WAB-R object naming 57%) |
| Reading comprehension | Severely impaired |
| Writing | Severely impaired |
| Motor speech | Normal |
This profile is anatomically consistent with the neuroimaging findings of ischemic infarction in the posterior middle temporal gyrus (area 37), angular gyrus (area 39), and posterior periventricular white matter — regions disrupted in TBM-associated vasculitis of the middle and posterior cerebral artery territories. Preserved repetition indicates integrity of the direct arcuate fasciculus connecting Broca's and Wernicke's areas, while the isolation of Wernicke's area from surrounding semantic associative cortex results in the failure of word meaning extraction.
(Localization in Clinical Neurology, 8e: "...information cannot be transferred to the Wernicke area for conversion into word meaning... preservation of this direct connection [arcuate fasciculus] is said to account for the ability to repeat.")
The presence of echolalia — automatic, parroting repetition of the examiner's utterances without demonstrated comprehension — is a recognized hallmark of severe TSA and must be distinguished from intact comprehension during clinical communication.
7.2 Cognitive Communication Disorder
Beyond the focal language disturbance of TSA, Mr. Sharma demonstrates a Cognitive Communication Disorder (CCD) arising from diffuse cerebral dysfunction secondary to:
- Meningeal inflammation affecting frontal-subcortical networks
- Communicating hydrocephalus (VP shunt in situ)
- Bilateral temporal and watershed zone ischemia
- Raised intracranial pressure sequelae
CCD Domains Affected:
| Cognitive Domain | Severity | Clinical Impact on Communication |
|---|---|---|
| Sustained attention | Moderate | Cannot maintain communicative exchange >10 minutes without fatigue/distraction |
| Working memory | Moderate-severe | Impaired tracking of multi-step instructions; loses conversational thread |
| Episodic memory | Severe | Cannot retain information from session to session; impairs therapy carryover |
| Executive function | Moderate-severe | Cannot plan, organise, or sequence communicative messages; poor self-monitoring |
| Discourse | Severe | Absent narrative and procedural macrostructure; poor topic maintenance |
| Pragmatics | Mild-moderate | Social conventions partially preserved; inappropriate responses due to comprehension failure rather than pragmatic unawareness |
| Self-monitoring | Moderate | Partial awareness of errors; frustration responses present but self-correction inconsistent |
The interaction between TSA and CCD is clinically important: TSA disrupts language processing at the semantic-lexical level, while CCD disrupts the broader cognitive scaffolding that supports communication in real-world contexts. Effective management must address both dimensions.
SECTION 8 — SUMMARY OF COMMUNICATION PROFILE
Strengths:
- Intact motor speech mechanism (no dysarthria/apraxia)
- Preserved prosody and fluency of output
- Relatively preserved repetition (useful as a therapeutic starting point)
- Adequate gross orientation (time/place)
- Partial self-monitoring awareness (frustration responses signal residual metacognitive insight)
- Cooperative, socially engaged demeanour
- Supportive and engaged caregiver (wife)
- High pre-morbid literacy and bilingual language foundation
- Simple one-step auditory commands partially accessible
Difficulties:
- Severely impaired auditory and visual word comprehension across all complexity levels
- Severely impaired reading comprehension (surface decoding preserved; meaning extraction severely impaired)
- Severely impaired writing — both linguistic content and motor execution (right hemiplegia)
- Significant anomia — impaired confrontation naming, category fluency, and word retrieval
- Absent functional discourse — narrative and procedural organisation absent
- Severe anterograde memory impairment — impacts carryover and therapy learning
- Significantly impaired attention and executive function
- Echolalia masking true comprehension, creating risk of misunderstanding in clinical care
SECTION 9 — DIAGNOSIS
- Transcortical Sensory Aphasia (TSA) — Moderate severity (WAB-R AQ: 52.4), secondary to TBM-associated posterior parieto-temporal and angular gyrus infarction (left hemisphere dominant)
- Cognitive Communication Disorder (CCD) — Moderate-to-severe, secondary to diffuse cortical and subcortical involvement from Tubercular Meningitis with communicating hydrocephalus
- Agraphia — Secondary to aphasia and right hemiplegia
- Alexia with Preserved Oral Decoding — consistent with TSA profile
- Echolalia — Automatic, without comprehension; clinical safety risk in consent/decision-making contexts
ICD-10-CM Codes:
- R47.01 Aphasia (primary language disturbance)
- F98.5 Stuttering / Communication Disorder (CCD category, as applicable)
- A17.0 Tubercular Meningitis (primary aetiology)
- G94.2 Communicating hydrocephalus in diseases classified elsewhere
- R48.0 Dyslexia / Acquired alexia
SECTION 10 — PROGNOSIS
Prognosis for functional language recovery in TSA is guarded to fair based on:
- Favourable factors: Young age (51 years), high pre-morbid literacy, bilingualism, early initiation of rehabilitation, cooperative engagement, active caregiver support, and partial preservation of repetition.
- Unfavourable factors: Severe comprehension deficit (word-level failure on Token Test), severity of MCA territory ischemic infarction, concurrent hydrocephalus, significant memory impairment limiting therapy learning, active anti-tubercular therapy with potential fatigue burden, and complexity of dual diagnosis (TSA + CCD).
As noted in neurology literature, TSA has a "good prognosis" as a class relative to global aphasia, with many patients recovering toward anomic aphasia over months, particularly when Wernicke-type aphasia evolves through a TSA phase toward anomia. However, the magnitude of cognitive impairment in this case indicates a longer rehabilitation trajectory and a need for functional compensatory approaches alongside restorative language therapy.
(Adams and Victor's Principles of Neurology, 12th Ed.: "In general, this disorder has a good prognosis.")
(Neuroanatomy through Clinical Cases, 3rd Ed.: "Wernicke's aphasia may recover to a transcortical sensory aphasia... and eventually to a subtle dysnomia.")
SECTION 11 — RECOMMENDATIONS
11.1 Speech-Language Therapy Goals
Short-Term Goals (4–6 weeks)
- Comprehension Enhancement: Improve auditory word-level comprehension from current ~60% to ≥75% accuracy using semantic feature analysis and contextual cues (objects, pictures, gesture) via modified Total Communication approach.
- Echolalia Management: Train patient and caregiver to distinguish echolalic from intentional responses; implement comprehension verification strategies (e.g., "show me," gesture-matching) in daily interactions.
- Naming / Word Retrieval: Implement Semantic Feature Analysis (SFA) for high-frequency functional vocabulary (personal care, food, family members) — target 20 core functional words with cueing hierarchy.
- Functional Communication: Establish a low-tech Augmentative and Alternative Communication (AAC) system — personalised communication board with picture symbols, gesture codes, and written keywords accessible via left hand.
- Attention Training: Integrate cognitive attention tasks (sustained + selective attention) within communication therapy sessions; limit session duration to 30–40 minutes with breaks.
- Caregiver Training: Educate wife and family on: communication strategies (simple language, one message at a time, visual supports, verification prompts), recognition of echolalia, emotional support, and avoiding communication breakdown.
Long-Term Goals (3–6 months)
- Achieve functional auditory comprehension of simple-to-moderate complexity sentences (2-step commands) in structured contexts.
- Expand functional expressive vocabulary (AAC + verbal combined) to support communication of daily needs, medical information, and preferences independently.
- Develop reading comprehension at single-word level for functional literacy (signage, medication labels, basic written instructions).
- Improve narrative discourse — production of at least 5 information units in structured picture description.
- Transition from total communication board to use of tablet-based AAC application for expanded vocabulary.
- Facilitate community re-integration communication skills — ordering, transacting, social greetings.
11.2 Cognitive Communication Recommendations
- Memory compensation strategies: External memory aids — diary, visual schedule, whiteboard in room; consistent routine and environment to reduce cognitive load.
- Attention management: Minimise distraction during therapy and caregiving; structure environment; reduce competing stimuli.
- Executive function support: Provide structured checklists for ADL sequences; visual task prompts.
- Dual-task training avoidance in early rehabilitation; introduce gradually as capacity improves.
11.3 Ototoxicity Monitoring
Referral to Audiology for formal pure-tone audiometry and speech audiometry at baseline and at 6-month interval, given ongoing Ethambutol therapy (potential optic and auditory nerve toxicity).
11.4 Multidisciplinary Team Coordination
- Neurology: Ongoing monitoring of VP shunt function, cerebrovascular status, and ATT progression; SLP to receive updates on imaging changes.
- Physiotherapy/Occupational Therapy: Coordinate AAC integration with upper limb rehabilitation for right hand recovery; support left-hand writing strategies.
- Neuropsychology: Formal neuropsychological testing (Halstead-Reitan Battery equivalent or NIMHANS battery) recommended at 3 months to profile cognitive domains for targeted rehabilitation.
- Social Work: Support caregiver; explore vocational counselling at 6–12 months.
- Psychiatry liaison: Monitor for post-TBM depression or adjustment disorder; depression is common in aphasia and can limit rehabilitation engagement.
11.5 Communication Access and Safety Alerts
- Informed consent: Mr. Sharma's echolalia and comprehension impairment render him currently unable to give reliable verbal informed consent for medical procedures. All consent decisions must be validated through structured yes/no questioning with verification; family/legal surrogate involvement as per hospital policy.
- Pain and symptom communication: Ensure nursing staff use visual pain scale (Faces Pain Scale or visual analogue scale) and body diagram charts.
- Medication instructions: Written instructions alone are insufficient; all medication guidance must be provided through caregiver with verbal reinforcement and visual supports.
11.6 Reassessment
Formal reassessment with WAB-R and MoCA is recommended at 8 weeks from this assessment date to monitor recovery trajectory, revise goals, and update AAC prescription.
SECTION 12 — CLINICIAN SIGNATURE
Assessed and reported by:
Name: ___________________________________
Designation: Speech-Language Pathologist, M.Sc. SLP
RCI Registration No.: ___________________
Department: Speech-Language Pathology / Neurorehabilitation Unit
Contact: ___________________________________
Date of Report: 30 April 2026
Signature: ___________________________________
Countersigned by (Supervising Clinician / HOD):
Name: ___________________________________
Designation: ___________________________________
Date: ___________________________________
Signature: ___________________________________
APPENDIX A — SUMMARY SCORE TABLE
| Test | Score | Interpretation |
|---|---|---|
| WAB-R Aphasia Quotient | 52.4 / 100 | Moderate aphasia — TSA profile |
| WAB-R Language Quotient | 58.1 | Moderate language impairment |
| WAB-R Cortical Quotient | 54.7 | Moderate cognitive-communication impairment |
| BDAE-3 Severity | 2 / 5 | Moderate aphasia |
| Boston Naming Test-R | 28 / 60 | Severely impaired |
| Token Test Total | 24 / 50 | Severe receptive language impairment |
| MoCA | 16 / 30 | Moderate-severe cognitive impairment |
| FCP-R Overall | 38% | Severely impaired functional communication |
| CETI (caregiver) | 22 / 100 | Severe communicative disability |
APPENDIX B — CLASSIFICATION OF APHASIAS (Reference)
| Type | Fluency | Comprehension | Repetition | Naming | Lesion |
|---|---|---|---|---|---|
| Broca | ↓ | Good | ↓ | ↓ | Frontoparietal operculum |
| Wernicke | Good | ↓ | ↓ | ↓ | Inferoposterior temporal |
| Conduction | Good | Good | ↓ | ↓ | Posterior perisylvian |
| Transcortical Motor | ↓ | Good | Good | May be normal | Frontal / striatum |
| Transcortical Sensory | Good | ↓ | Good | Usually impaired | Parietal / temporal / thalamus |
| Anomic | Good | Good | Good | ↓ | Variable posterior |
| Global | ↓ | ↓ | ↓ | ↓ | Large perisylvian |
Adapted from Boston anatomoclinical classification — Localization in Clinical Neurology, 8e (Table 20-3)
APPENDIX C — REFERENCES
- Ropper AH, Samuels MA, Klein JP, Prasad S. Adams and Victor's Principles of Neurology, 12th Edition. McGraw-Hill, 2023. [Transcortical Aphasias, pp. 510–511]
- Goetz CG (Ed.). Bradley and Daroff's Neurology in Clinical Practice, 8th Edition. Elsevier, 2022. [Transcortical Aphasias; Outcome Measures for Aphasia]
- Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology, 8th Edition. Wolters Kluwer, 2022. [Transcortical Sensory Aphasia, p. 1251; Classification of the Aphasias, Table 20-3]
- Blumenfeld H. Neuroanatomy through Clinical Cases, 3rd Edition. Sinauer/OUP, 2022. [Recovery from Aphasia]
- Kandel ER et al. Principles of Neural Science, 6th Edition. McGraw-Hill. [Transcortical Aphasias]
- Kertesz A. Western Aphasia Battery – Revised (WAB-R). PsychCorp/Pearson, 2007.
- Goodglass H, Kaplan E, Barresi B. Boston Diagnostic Aphasia Examination, 3rd Edition (BDAE-3). PsychCorp, 2001.
- De Renzi E, Faglioni P. Normative data and screening power of a shortened version of the Token Test. Cortex, 1978.
- Nasreddine ZS et al. The Montreal Cognitive Assessment (MoCA): a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society. 2005;53(4):695–699.
- Frattali CM et al. Functional Communication Profile-Revised (FCP-R). Pro-Ed, 2003.
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