A 5-year-old boy is brought to the office by his parents due to concerns about his speech. The patient is talkative, speaks in full sentences, and has a large vocabulary. However, he frequently mispronounces words, and over 30% of his speech is unintelligible. The patient was born at 30 weeks gestation, and his newborn course was complicated by pneumonia requiring several days of mechanical ventilation. He has no chronic medical conditions. Height and weight have been consistent at the 25th percentile. His older sibling has autism spectrum disorder and participates in special education classes. When given a crayon and paper, the patient runs and climbs onto the examination table and writes his first name. Tympanic membranes are clear bilaterally. Mucous membranes are moist. The rest of the physical examination is normal. Which of the following is the best next step in evaluation of this patient?

Question

A 5-year-old boy is brought to the office by his parents due to concerns about his speech.  The patient is talkative, speaks in full sentences, and has a large vocabulary.  However, he frequently mispronounces words, and over 30% of his speech is unintelligible.  The patient was born at 30 weeks gestation, and his newborn course was complicated by pneumonia requiring several days of mechanical ventilation.  He has no chronic medical conditions.  Height and weight have been consistent at the 25th percentile.  His older sibling has autism spectrum disorder and participates in special education classes.  When given a crayon and paper, the patient runs and climbs onto the examination table and writes his first name.  Tympanic membranes are clear bilaterally.  Mucous membranes are moist.  The rest of the physical examination is normal.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d68e_759e_bc81_f56abec41f1a_MD0003_00 Speech delay and language disorders are the most common developmental disabilities in children. Patients with language disorders have difficulty understanding others (eg, receptive language) and/or communicating thoughts (eg, expressive language). In contrast, isolated speech delay is characterized by problems with: articulation (eg, mispronunciation) fluency (eg, stuttering) vocal quality (eg, abnormal volume or pitch) Because speech should be 100% intelligible by age 4, this patient has speech delay consistent with an articulation disorder. Hearing impairment, either hereditary or acquired, can hinder speech and language development and may go unnoticed by family members if mild. The most common cause of hearing impairment in young children is conductive hearing loss from recurrent acute otitis media. The first step in evaluation of all patients with a speech or language disorder, even without a history of frequent ear infections or abnormalities on otoscopy (as in this patient), is a hearing test. (Choice A) Lead toxicity can cause neurobehavioral deficits (eg, decreased IQ, poor attention) but not isolated speech delay. In addition, other manifestations of lead toxicity, such as fatigue, irritability, and abdominal pain, are not present. (Choice B) Electroencephalogram (EEG) is indicated in patients with an epilepsy syndrome (eg, Lennox-Gastaut) associated with global developmental delay. However, this patient has isolated speech delay and no history of abnormal movements, making EEG unnecessary. (Choice D) MRI of the brain may be performed for dysarthria, a speech disorder characterized by slurred speech, which can be indicative of a stroke or brain tumor. Trouble swallowing is common with dysarthria (not seen here), and this patient has difficulty with articulation, not slurring of words. (Choice E) Reassurance and routine follow-up is provided for normal development, which includes intelligible 5-word sentences at age 5. Although this patient has an age-appropriate vocabulary, >30% of his speech is unintelligible, warranting further evaluation. Educational objective: Disorders of speech (eg, delayed articulation) and language (eg, receptive language delay) are often associated with hearing loss. The first step in management is a hearing test. References: Speech and language delay in children. (http://www.ncbi.nlm.nih.gov/pubmed/21568252)

A 5-Year-Old Boy Is Brought to the Office by His