Dick- Intervention (SLP)
DIAGNOSTIC REPORT
Client Name: Dick (Preferred Name); Richard (Legal Name)
Client Age: 69
Diagnosis: Moderate RHD; aprosodia; apragmatism; executive functioning impairment, left
neglect, neglect dyslexia, cognitive-communication impairment, and optic atrophy-related vision
loss (right eye)
Date: July 13, 2025
Setting: Outpatient Center
Reason for Referral:
Dick, a 69-year-old male, was referred by his Home Health Speech-Language Pathologist for a
speech-language evaluation at an outpatient clinic to address concerns related to communication
and cognitive skills following a right hemisphere stroke that occurred 18 months ago. Other
concerns include left neglect, neglect dyslexia, excessive pausing, acquired attention deficits,
executive functions, difficulties with topic maintenance and turn-taking, flat affect, and
apragmatism, including aprosodia.
Background Information:
Dick experienced a right hemisphere stroke 18 months ago, where he was initially treated in a
local hospital, transferred to an acute rehabilitation unit, and then to a rehabilitation facility
before being discharged four months post-stroke. Medical history is significant for moderate
bilateral sensorineural hearing loss, managed with hearing aids, and tinnitus, which Dick had
before the stroke. Dick has no vision in his right eye due to optic atrophy, with limited vision in
the right half of his left eye. He reports no recent changes in medical status. Current medications
include Eliquis and aspirin. Dick resides with his wife, Cindy, who provides significant support
with ADLs. Dick enjoys outdoor activities like hunting, though these are now limited due to
mobility and vision impairments. Dick reports challenges with slowed processing, reduced
speech rate, and difficulty with reading and writing, particularly due to left-sided neglect since
the stroke. Cindy reports flat affect, frequent pauses in speech, and difficulty with topic
maintenance, which impact social interactions. Dick has a history of physical, occupational, and
speech therapy, with notable progress in physical strength and speech intelligibility. However,
deficits persist in pragmatics, attention, and executive functioning. Despite these challenges,
because of his motivation to continue therapy, Dick has made significant progress since his
stroke, particularly in speech intelligibility, physical mobility, pragmatics, left-sided attention
and executive function as reported by his wife and previous therapists.
,Assessment Results:
Cognitive and Executive Functions:
• Apple's Test: Dick displayed both viewer-centered and object-centered left neglect,
correctly crossing out only 29/50 apples, mostly on the right side and middle of the page.
Dick neglected the left side of the page, indicating significant visuospatial attention
deficits consistent with right hemisphere damage (RHD).
• Clock Drawing Task: When instructed to draw a clock set to "ten minutes after eleven",
Dick omitted the numbers 7, 8, and 10 on the left side, further confirming left neglect. He
referenced a clock in the room to assist with the task, relying on external cues to
compensate for cognitive deficits.
• Indented Paragraph Task: Dick read 120/138 words correctly, omitting one complete line
(9 words) and 11 words on the left side of other lines, indicative of neglect dyslexia. He
used his finger to track text and used cues from the clinician to look left, which improved
performance but did not eliminate errors.
Discourse, Language, and Pragmatics:
• Discourse Protocol from RHDBank: Dick exhibited frequent long pauses across various
tasks (e.g., free speech, conversational, descriptive, narrative, and procedural discourse),
with challenges in topic maintenance and turn-taking. His main concept score was 10/18
for narrative discourse (indicating reduced informativeness), 24/30 for procedural
discourse (relatively stronger), and only four utterances in the Cat Picture Description
task, reflecting limited descriptive ability. He asked minimal questions during
conversational and question-asking tasks, failing to engage fully with his conversation
partner. Left neglect was evident when describing pictures, as he focused on the right
side.
• Global Coherence Rating: Dick's utterances were mostly on-topic, as his rating was high.
• Montreal Protocol for the Evaluation of Communication (MEC): Dick scored below the
alert point in Conversational Discourse, Linguistic Prosody - Comprehension, and
Emotional Prosody - Repetition, indicating deficits in understanding and producing
prosodic cues and maintaining conversational flow. His scores were above the alert point
for Metaphor Interpretation and Emotional Prosody - Comprehension. Observed
behaviors included monotone voice, lack of facial expression, inconsistent eye contact,
and failure to respond to light-hearted comments, consistent with apragmatism and
aprosodia.
• Descriptive Writing Task: Dick produced a writing sample to describe his kitchen and
read it aloud. Dick's errors concerning letter formation included not crossing any of his
Ts, but he adds dots to most of his Is. In addition, he misspelled the words "refrigerator"
and "with," and the spacing on the paper was uneven and more focused on the right side.
Oral Peripheral Exam:
The exam revealed left-sided facial droop and weakness in the tongue and lips, with occasional
anterior saliva loss from the left side, resulting in brain deficits that are affecting motor control.
, Psychosocial:
Communicative Item Participation Bank (CPIB): Dick scored 19/30, and his wife scored 22/30.
Dick perceives his communication as more impaired than his wife does, reflecting self-
awareness of his deficits.
Discussion:
Dick presents with a cognitive-communication impairment secondary to a right hemisphere
stroke. His primary challenges include left neglect (both viewer- and object-centered), neglect
dyslexia, apragmatism, aprosodia, and executive functioning deficits, which significantly impact
his ability to engage in social interactions and perform daily tasks. The Apples Test and Clock
Drawing Task resulted in left neglect, as Dick consistently ignored stimuli on the left side of
space and objects. The Indented Paragraph Task highlighted neglect dyslexia, including
omissions of left-sided text. Compensatory strategies including finger tracking and using a red
line as a visual cue to look left improved Dick's performance.
Discourse analysis revealed strengths in global coherence but significant weaknesses in
pragmatic skills, including flat affect, monotonous voice, and difficulty with topic maintenance
and turn-taking, as seen on the MEC's Conversational Discourse and Prosody subtests. These
deficits, including aprosodia, limit Dick's ability to convey emotion and appropriately engage in
conversations, which his wife notes as a significant change post-stroke. Dick's cognitive profile
shows strengths in memory and receptive and expressive language but weaknesses in executive
functioning, such as planning and organizing information. The CPIB results indicate that both
Dick and his wife perceive moderate communicative limitations, particularly in time-sensitive
situations, impacting his social participation. Despite these challenges, Dick has made significant
progress since his stroke, particularly in speech intelligibility and physical mobility, as reported
by his wife and previous therapists. His motivation to continue therapy and strong family support
suggest a good prognosis for further progress, though his vision is unlikely to improve.
Recommendations:
Treatment Frequency/Duration: Skilled intervention is recommended for 2x a week (30 minutes
each) to address current deficit areas for 12 weeks, with re-evaluation to determine the need for
continued intervention and to assess progress and adjust goals.
Treatment Approaches:
DIAGNOSTIC REPORT
Client Name: Dick (Preferred Name); Richard (Legal Name)
Client Age: 69
Diagnosis: Moderate RHD; aprosodia; apragmatism; executive functioning impairment, left
neglect, neglect dyslexia, cognitive-communication impairment, and optic atrophy-related vision
loss (right eye)
Date: July 13, 2025
Setting: Outpatient Center
Reason for Referral:
Dick, a 69-year-old male, was referred by his Home Health Speech-Language Pathologist for a
speech-language evaluation at an outpatient clinic to address concerns related to communication
and cognitive skills following a right hemisphere stroke that occurred 18 months ago. Other
concerns include left neglect, neglect dyslexia, excessive pausing, acquired attention deficits,
executive functions, difficulties with topic maintenance and turn-taking, flat affect, and
apragmatism, including aprosodia.
Background Information:
Dick experienced a right hemisphere stroke 18 months ago, where he was initially treated in a
local hospital, transferred to an acute rehabilitation unit, and then to a rehabilitation facility
before being discharged four months post-stroke. Medical history is significant for moderate
bilateral sensorineural hearing loss, managed with hearing aids, and tinnitus, which Dick had
before the stroke. Dick has no vision in his right eye due to optic atrophy, with limited vision in
the right half of his left eye. He reports no recent changes in medical status. Current medications
include Eliquis and aspirin. Dick resides with his wife, Cindy, who provides significant support
with ADLs. Dick enjoys outdoor activities like hunting, though these are now limited due to
mobility and vision impairments. Dick reports challenges with slowed processing, reduced
speech rate, and difficulty with reading and writing, particularly due to left-sided neglect since
the stroke. Cindy reports flat affect, frequent pauses in speech, and difficulty with topic
maintenance, which impact social interactions. Dick has a history of physical, occupational, and
speech therapy, with notable progress in physical strength and speech intelligibility. However,
deficits persist in pragmatics, attention, and executive functioning. Despite these challenges,
because of his motivation to continue therapy, Dick has made significant progress since his
stroke, particularly in speech intelligibility, physical mobility, pragmatics, left-sided attention
and executive function as reported by his wife and previous therapists.
,Assessment Results:
Cognitive and Executive Functions:
• Apple's Test: Dick displayed both viewer-centered and object-centered left neglect,
correctly crossing out only 29/50 apples, mostly on the right side and middle of the page.
Dick neglected the left side of the page, indicating significant visuospatial attention
deficits consistent with right hemisphere damage (RHD).
• Clock Drawing Task: When instructed to draw a clock set to "ten minutes after eleven",
Dick omitted the numbers 7, 8, and 10 on the left side, further confirming left neglect. He
referenced a clock in the room to assist with the task, relying on external cues to
compensate for cognitive deficits.
• Indented Paragraph Task: Dick read 120/138 words correctly, omitting one complete line
(9 words) and 11 words on the left side of other lines, indicative of neglect dyslexia. He
used his finger to track text and used cues from the clinician to look left, which improved
performance but did not eliminate errors.
Discourse, Language, and Pragmatics:
• Discourse Protocol from RHDBank: Dick exhibited frequent long pauses across various
tasks (e.g., free speech, conversational, descriptive, narrative, and procedural discourse),
with challenges in topic maintenance and turn-taking. His main concept score was 10/18
for narrative discourse (indicating reduced informativeness), 24/30 for procedural
discourse (relatively stronger), and only four utterances in the Cat Picture Description
task, reflecting limited descriptive ability. He asked minimal questions during
conversational and question-asking tasks, failing to engage fully with his conversation
partner. Left neglect was evident when describing pictures, as he focused on the right
side.
• Global Coherence Rating: Dick's utterances were mostly on-topic, as his rating was high.
• Montreal Protocol for the Evaluation of Communication (MEC): Dick scored below the
alert point in Conversational Discourse, Linguistic Prosody - Comprehension, and
Emotional Prosody - Repetition, indicating deficits in understanding and producing
prosodic cues and maintaining conversational flow. His scores were above the alert point
for Metaphor Interpretation and Emotional Prosody - Comprehension. Observed
behaviors included monotone voice, lack of facial expression, inconsistent eye contact,
and failure to respond to light-hearted comments, consistent with apragmatism and
aprosodia.
• Descriptive Writing Task: Dick produced a writing sample to describe his kitchen and
read it aloud. Dick's errors concerning letter formation included not crossing any of his
Ts, but he adds dots to most of his Is. In addition, he misspelled the words "refrigerator"
and "with," and the spacing on the paper was uneven and more focused on the right side.
Oral Peripheral Exam:
The exam revealed left-sided facial droop and weakness in the tongue and lips, with occasional
anterior saliva loss from the left side, resulting in brain deficits that are affecting motor control.
, Psychosocial:
Communicative Item Participation Bank (CPIB): Dick scored 19/30, and his wife scored 22/30.
Dick perceives his communication as more impaired than his wife does, reflecting self-
awareness of his deficits.
Discussion:
Dick presents with a cognitive-communication impairment secondary to a right hemisphere
stroke. His primary challenges include left neglect (both viewer- and object-centered), neglect
dyslexia, apragmatism, aprosodia, and executive functioning deficits, which significantly impact
his ability to engage in social interactions and perform daily tasks. The Apples Test and Clock
Drawing Task resulted in left neglect, as Dick consistently ignored stimuli on the left side of
space and objects. The Indented Paragraph Task highlighted neglect dyslexia, including
omissions of left-sided text. Compensatory strategies including finger tracking and using a red
line as a visual cue to look left improved Dick's performance.
Discourse analysis revealed strengths in global coherence but significant weaknesses in
pragmatic skills, including flat affect, monotonous voice, and difficulty with topic maintenance
and turn-taking, as seen on the MEC's Conversational Discourse and Prosody subtests. These
deficits, including aprosodia, limit Dick's ability to convey emotion and appropriately engage in
conversations, which his wife notes as a significant change post-stroke. Dick's cognitive profile
shows strengths in memory and receptive and expressive language but weaknesses in executive
functioning, such as planning and organizing information. The CPIB results indicate that both
Dick and his wife perceive moderate communicative limitations, particularly in time-sensitive
situations, impacting his social participation. Despite these challenges, Dick has made significant
progress since his stroke, particularly in speech intelligibility and physical mobility, as reported
by his wife and previous therapists. His motivation to continue therapy and strong family support
suggest a good prognosis for further progress, though his vision is unlikely to improve.
Recommendations:
Treatment Frequency/Duration: Skilled intervention is recommended for 2x a week (30 minutes
each) to address current deficit areas for 12 weeks, with re-evaluation to determine the need for
continued intervention and to assess progress and adjust goals.
Treatment Approaches:
