Med Grand Rounds Final Study

Comprehensive vocabulary flashcards covering Rancho Los Amigos (RLA) levels, dysarthria and aphasia types, cognitive and linguistic assessments, and neurological foundations of speech and swallowing.

RLA Level $1$: No Response

Deep coma characterized by no observable response to internal or external stimuli (sound, touch, pain), complete unresponsiveness, and no purposeful movement, though reflexive posturing may be present.

RLA Level $2$: Generalized Response

A state where the patient responds to stimuli in a non-specific, inconsistent, and delayed manner, often with the same reactions regardless of stimulus (e.g., groaning, physiological changes) while still largely unconscious.

RLA Level $3$: Localized Response

Responses become more specific and purposeful but remain inconsistent; includes turning toward sound, withdrawing from pain, following simple commands inconsistently, and brief visual tracking.

RLA Level $4$: Confused/agitated

Heightened state of confusion with non-purposeful, aggressive, or restless behavior; severe attention/memory impairments, potential hallucinations/confabulations, and inability to cooperate with treatment.

RLA Level $5$: confused, inappropriate, non-agitated

Patient is less agitated but highly confused, easily overwhelmed, and distracted; can follow simple commands more consistently, but exhibits severely impaired memory and inappropriate speech.

RLA LEVEL $6$: confused, appropriate

Shows goal-directed behavior with external cueing; features improved attention, consistent following of simple directions, emerging insight into deficits, and beginning carryover of relearned skills like basic ADLs.

RLA LEVEL $7$: automatic, appropriate

Consistently oriented to person and place in familiar environments; performs routines automatically with minimal confusion but shows poor judgment, limited insight, and difficulty with abstract thinking.

RLA LEVEL $8$: purposeful, appropriate

Alert and oriented patient able to recall and integrate events; functions independently in familiar environments but has residual deficits in stress tolerance and complex problem-solving.

RLA LEVEL $9$: purposeful and appropriate (stand-by-assistance)

Independently shifts between tasks and completes activities, requiring assistance only in unfamiliar or complex situations; shows improved self-awareness but maintains slower processing.

RLA LEVEL $10$: purposeful and appropriate (modified ind.)

Functions independently in all settings using compensatory strategies; comparable to baseline though high-level cognitive demands may still be challenging.

axatic dysarthria

SOL: cerebellum. Primary symptoms include incoordination, disordered timing/force/ROM, and a 'drunken' quality; features scanning speech and irregular AMR's.

flaccid dysarthria

SOL: LMN (final common pathway). Characterized by weakness, hypotonia, atrophy, fasciculations, reduced reflexes, hypernasality, and breathy voice.

hyperkinetic dysarthria

SOL: basal ganglia control circuit (indirect loop). Characterized by abnormal involuntary movements (chorea, dystonia, tics) that vary in rate and regularity, causing irregular articulatory breakdowns.

hypokinetic dysarthria

SOL: basal ganglia control circuit (substantia nigra). Symptoms include rigidity, reduced range/speed of motion, 'masked' face, reduced loudness, and rapid nonspeech AMR's.

mixed dysarthria

SOL: multiple areas of the motor system. Reflects damage to more than one motor control circuit, combining features of two or more dysarthria types (e.g., spasticity combined with ataxia).

spastic dysarthria

SOL: bilateral upper motor neuron lesions. Characterized by spasticity, hyperactive reflexes, strained-strangled vocal quality, and slow rate of speech.

unilateral upper motor neuron dysarthria

SOL: unilateral UMN pathways (frontal lobe, internal capsule). Features weakness and spasticity on the contralateral lower face and tongue, typically resulting in a mild, transient speech disorder.

broca's aphasia

Lesion: broca's area (posterior inferior frontal gyrus). Profile: auditory comp (+), oral expression (-), repetition (-), naming (-).

Transcortical Motor Aphasia

Lesion: left prefrontal cortex near Broca's. Profile: auditory comprehension (+), oral expression (-), repetition (+), naming (-).

wernicke's aphasia

Lesion: wernicke's area (posterior superior temporal gyrus). Profile: auditory comprehension (-), oral expression (+) but not meaningful, repetition (-), naming (-).

conduction aphasia

Lesion: arcuate fasciculus. Profile: auditory comprehension (+), oral expression (+), repetition (-), naming (-).

anomic aphasia

Lesion: angular gyrus, left temporoparietal surroundings. Profile: auditory comprehension (+), oral expression (+), repetition (+), naming (-).

glasgow coma scale

A scale that assesses eye opening, verbal response, and motor response; primarily used in acute care/ICU to measure levels of consciousness.

coma recovery scale

An assessment more sensitive than the GCS used to differentiate between coma, vegetative state, and minimally conscious state by assessing auditory, visual, motor, and verbal systems.

MoCA

Assessment used for mild-moderate cognitive impairment that evaluates attention, memory, visuospatial skills, and executive function (EF).

FAVRES

Assessment designed to evaluate higher level cognitive functioning.

western aphasia battery

A comprehensive aphasia battery that classifies the specific type of aphasia and provides a severity rating.

boston diagnostic aphasia examination

An in-depth linguistic analysis tool that profiles patient strengths and weaknesses across various language domains.

boston naming

A specific skill measure for aphasia that assesses word retrieval and anomia.

communication activities of daily living

A standardized measure of functional communication ability.

right hemisphere language battery

The best overall battery for right hemisphere disorder, assessing inferencing, humor, metaphor, and prosody.

mini inventory of right brain injury

A quick screening tool for right hemisphere disorder that evaluates attention, visual neglect, and affect.

Dysarthria: Articulation (Swallow Implications)

Signs like imprecise consonants and reduced lingual control lead to poor bolus formation, reduced bolus control (anterior spillage), and oral residue.

Dysarthria: Respiration (Swallow Implications)

Signs like short phrases and reduced support lead to poor coordination of breathing/swallowing, increased aspiration risk, and difficulty maintaining airway protection.

Dysarthria: Phonation (Swallow Implications)

Signs like breathy/weak voice lead to poor vocal fold closure, reduced airway protection, and a weak cough that cannot clear aspirated material.

Dysarthria: Resonance (Swallow Implications)

Signs like hypernasality and nasal emissions lead to nasal regurgitation and poor pressure generation in the pharynx.

aphonic

Voice sign indicating an inability to produce sound; implies severe vocal fold dysfunction and high risk for aspiration due to poor airway closure.

L frontal lobe

Area responsible for speech production (motor planning), grammar, syntax, word retrieval, and EFs like sequencing. Contains Broca's area.

L temporal lobe

Area responsible for auditory comprehension, word meaning, language-based memory, and naming storage. Contains Wernicke's area.

R frontal lobe

Area responsible for social communication, emotional regulation of speech, inference, reasoning, discourse, and self-monitoring.

R temporal lobe

Area responsible for prosody, interpretation of tone/sarcasm, facial/emotional recognition, and understanding jokes or metaphors.

left inferior parietal lobe

Responsible for multimodal language integration (auditory and visual), reading, writing, and word retrieval; damage leads to anomic aphasia, alexia, and agraphia.

bilateral prefrontal cortices

Responsible for executive functions (planning, organizing, problem-solving); damage leads to poor inhibition, impulsivity, and reduced working memory.

functional independence measure (FIM) areas

Includes self-care, sphincter control, transfers, locomotion, communication, and social cognition (social interaction, problem-solving, memory).

UMN damage

Damage from the brain to the brainstem; results in spasticity, hyperactive reflexes, and muscle stiffness on the contralateral side.

LMN damage

Damage originating in the spinal cord and affecting cranial nerves; results in 'flaccid' paralysis, muscle atrophy, fasciculations, and ipsilateral damage.