I had been working as a nurse practitioner in stroke/neurology for three years when I encountered Mr. B, a 67-year-old patient who came to our hospital with acute onset of right-sided weakness and aphasia following a moderately-sized left-middle cerebral artery stroke.

Mr. B’s course was typical of an acute stroke patient, and we proceeded through our work up and evaluation as usual. Since Mr. B’s language center was in the left side of his brain, he was suffering from language deficiencies that included profound expressive aphasia. During his stay in our hospital, he worked with our skilled therapy team. It was evident to all of his healthcare providers that he was extremely frustrated with his inability to communicate.

The day before we had scheduled to send him to acute rehab, I entered the room for daily rounds with another nurse practitioner on our team. Mr. B again seemed agitated and frustrated as he tried to communicate his wishes to us. I grabbed my notebook and a dry erase marker, which he was able to grip in his right hand.

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To our surprise Mr. B was able to write, but the letters were jumbled, and we set the notebook page aside feeling unsuccessful in our attempt to communicate.

An hour later we were called back to Mr. B’s room by his daughter. It turns out that when she was a child, her father had used mirror image writing to communicate with her as a special code. She saw the notebook page from earlier that morning lying on his bedside table and recognized the pattern immediately. We grabbed a mirror and were able to decode the message.

Unfortunately, Mr. B had written that he wanted to die. My feeling of elation at having uncoded this strange mirror writing from his younger years was immediately overwhelmed by the realization that my patient was very depressed. Mr. B had been a very active person before the stroke, and now that he was unable to communicate and unable to walk, he was dreadfully depressed. He wanted to die.

We immediately got neuropsychology in to see Mr. B, and he was treated for his depression. He did well in rehab, regained most of his motor function and his ability to communicate through speech. 

Mr. B’s clinical course in the hospital was unremarkable until the moment we discovered the backwards writing. His depression would likely have gone undetected for weeks longer, if we had not been able to decode his cryptic message. I will never forget how strange, exciting and then profoundly sad the experience was for me as a healthcare provider. I am now much more aggressive in screening patients with stroke for signs of depression through all means possible.

Adrienne Clements, APRN, ACNP-BC, practices in Hartford, Conn.