Case Study 1- Sample Patient 1

Example Patient (audio: none)

DOB:     5/6/71
Sex:     M
Post onset:     10 years
Referral:     self

Pertinent Medical History (PMH): MVA 5/3/89
initial GCS 7
Coma 6 weeks
positive MRI findings for L frontotemporal lesion

Social history: Tobacco: none
Alcohol: none in last several years
Single, unemployed

Family history: unknown

Surgical history: evacuation of hematoma s/p MVA

Current complaints: speech is hard to understand

Interview: (Questions quoted from Duffy (1995) Motor Speech Disorders)

ONSET & COURSE

1. Do you have any difficulty with your speech? If not, has anyone else commented on a change or problem with your speech? People don't always understand me. I have to repeat myself.

2. When did the speech problem begin?
Did it begin suddenly or gradually?
Who noticed it first, you or someone else? I've had this problem since my accident

3. Did you develop any other difficulties when your speech problem began?
Were other problems present before your speech problem began?
Did other problems develop after the speech problem began? I was in a coma because of the accident. I had trouble with my memory. I still have some weakness in my right leg.

4. Has the speech problem changed?
Better, worse, stable, better-than-stable, fluctuating? It was better when I had therapy but now it's bad again

5. Has your speech ever returned to normal?
If so, when and for how long? WEll, not normal, but it's been better when I'm working on it.

ASSOCIATED DEFICITS

1. Have you had any difficulty with chewing? drooling? no

2. Is it difficult to move food around in your mouth? Why? no

3. Does food get stuck in your cheeks or in the roof of your mouth?
Do you have to remove it with your finger or a fork? no

4. Do you have trouble moving food back in your mouth to get a swallow started? no

5. Do you have trouble with swallowing?
Food or liquid?
Do you have trouble getting a swallow started?
Do you lose food or liquid out of your mouth?
Does food or liquid ever get into or out of your nose when you swallow?
Does food or liquid go down before you swallow and cause coughing or choking?
Do you gag or choke when swallowing?
Do you cough or choke when completing a swallow?
Have you had to modify your diet because of these problems?
Have you lost weight? no

6. Have you had any change in your emotional expression?
Do you cry or laugh more easily or less easily than in the past? no

7. Are you taking any medications that seem to affect your speech? no

PATIENTS PERCEPTION OF THE PROBLEM:

1. What did your speech sound like when the problem began?
Did anything feel different when you spoke? It's mumbly, I maybe talk a little too fast.

2. Describe your current speech difficulty. How does it sound to you?
How does it feel to speak?
Is it faster or slower?
Louder or slower?
Less precise?
Is speaking effortful? I feel like people should be able to understand me, cuz I know what I'm saying, but I guess I mumble or go too fast. I feel like I'm speaking normally.

3. Have you noticed any change in the appearance or feeling in your face or mouth? no

CONSEQUENCES OF THE DISORDER:

1. Do people ever have trouble understanding you?
When? What do you do if that happens? I usually repeat myself and try to speaker slower

2. Do you ever have to write to make yourself understood?
Has your speech problem affected your work?
Does it prevent you from doing anything? no. no. no.

MANAGEMENT

1. What have you done to compensate for your speech difficulty?
Have you had any help for your speech?
When?
For how long?
What was done?
Did it help? I had therapy after the accident for about 4 years, and I think it got pretty good. But since then I haven't kept up with what I should do and I think it's worse again now.

2. Do you think you need help with your speech now? Yeah, that's why I'm here

AWARENESS OF DIAGNOSIS AND PROGNOSIS:

1. What have you been told is the cause of this problem? Yes, it's because of the brain damage

2. In view of this diagnosis, what is going to happen? I don't know

Report of Handicap
(Adapted from Verdonlini (1994) "Voice Disorders" in Tomblin et al. (Eds) Diagnosis in Speech-language Pathology

Area No Impact Very little impact Some impact Significant Impact Profound (can't perform in this area)

Professional x

Social x

Communicative x

Physical x

Emotional x

Example Report

S: Mr. Example was seen today for a speech evaluation. PMH includes MVA 10 years ago with subsequent TBI. MRI findings were positive for left frontotemporal infarct, and the patient was in a coma for 8 weeks. He reportedly received speech therapy for several years after the accident which he felt was beneficial, but now reports that his speech has worsened. He reports that people have difficulty understanding him. He feels he "mumbles" or speaks "too fast." He reports he is eager to resume therapy to improve his speech. He is currently unemployed but his speech difficulties impact his ability to communicate and interact socially.

O: Mr. Example's speech was assessed utilizing the Darley, Aronson, & Brown perceptual scale. During conversational speech and oral reading, the patient's speech was characterized by increased speaking rate and imprecise articulation. Vocal quality and resonance were wnl. Respiratory support for speech was judged to be adequate. Range of motion of the articulators was reduced during AMR tasks. The patient was able to reduce rate when provided with a model, and increased articulatory precision when asked to attempt to "overarticulate." He reported that slowing down and overarticulating were strategies he had learned during his earlier therapy experiences.

A: Mr. Example exhibits characteristics of hypokinetic dysarthria, however his speech disturbance might also be characterized as "neurogenic dysfluency" resulting from TBI. He is highly motivated and demonstrates the ability to apply strategies for improving speech intelligibility. Prognosis for improvement with therapy is good.

P: It is recommended that Mr. Example attend speech therapy 2 times per week for 6 weeks. Treatment goals will include: decrease speaking rate to 100 wpm during conversation with familiar and unfamiliar partners, increase use of overarticulation strategy to improve articulatory ROM during conversational speech, increase self-monitoring of speaking rate and intelligibility during conversational speech.

Heather M. Clark, Ph.D. 8/31/99
Speech Pathologist Extraordinaire

Pertinent Medical History (PMH):	MVA 5/3/89 initial GCS 7 Coma 6 weeks positive MRI findings for L frontotemporal lesion
Social history:	Tobacco: none Alcohol: none in last several years Single, unemployed
Family history:	unknown
Surgical history:	evacuation of hematoma s/p MVA
Current complaints:	speech is hard to understand

ONSET & COURSE
1. Do you have any difficulty with your speech? If not, has anyone else commented on a change or problem with your speech?	People don't always understand me. I have to repeat myself.
2. When did the speech problem begin? Did it begin suddenly or gradually? Who noticed it first, you or someone else?	I've had this problem since my accident
3. Did you develop any other difficulties when your speech problem began? Were other problems present before your speech problem began? Did other problems develop after the speech problem began?	I was in a coma because of the accident. I had trouble with my memory. I still have some weakness in my right leg.
4. Has the speech problem changed? Better, worse, stable, better-than-stable, fluctuating?	It was better when I had therapy but now it's bad again
5. Has your speech ever returned to normal? If so, when and for how long?	WEll, not normal, but it's been better when I'm working on it.
ASSOCIATED DEFICITS
1. Have you had any difficulty with chewing? drooling?	no
2. Is it difficult to move food around in your mouth? Why?	no
3. Does food get stuck in your cheeks or in the roof of your mouth? Do you have to remove it with your finger or a fork?	no
4. Do you have trouble moving food back in your mouth to get a swallow started?	no
5. Do you have trouble with swallowing? Food or liquid? Do you have trouble getting a swallow started? Do you lose food or liquid out of your mouth? Does food or liquid ever get into or out of your nose when you swallow? Does food or liquid go down before you swallow and cause coughing or choking? Do you gag or choke when swallowing? Do you cough or choke when completing a swallow? Have you had to modify your diet because of these problems? Have you lost weight?	no
6. Have you had any change in your emotional expression? Do you cry or laugh more easily or less easily than in the past?	no
7. Are you taking any medications that seem to affect your speech?	no
PATIENTS PERCEPTION OF THE PROBLEM:
1. What did your speech sound like when the problem began? Did anything feel different when you spoke?	It's mumbly, I maybe talk a little too fast.
2. Describe your current speech difficulty. How does it sound to you? How does it feel to speak? Is it faster or slower? Louder or slower? Less precise? Is speaking effortful?	I feel like people should be able to understand me, cuz I know what I'm saying, but I guess I mumble or go too fast. I feel like I'm speaking normally.
3. Have you noticed any change in the appearance or feeling in your face or mouth?	no
CONSEQUENCES OF THE DISORDER:
1. Do people ever have trouble understanding you? When? What do you do if that happens?	I usually repeat myself and try to speaker slower
2. Do you ever have to write to make yourself understood? Has your speech problem affected your work? Does it prevent you from doing anything?	no. no. no.
MANAGEMENT
1. What have you done to compensate for your speech difficulty? Have you had any help for your speech? When? For how long? What was done? Did it help?	I had therapy after the accident for about 4 years, and I think it got pretty good. But since then I haven't kept up with what I should do and I think it's worse again now.
2. Do you think you need help with your speech now?	Yeah, that's why I'm here
AWARENESS OF DIAGNOSIS AND PROGNOSIS:
1. What have you been told is the cause of this problem?	Yes, it's because of the brain damage
2. In view of this diagnosis, what is going to happen?	I don't know

Area	No Impact	Very little impact	Some impact	Significant Impact	Profound (can't perform in this area)
Professional		x
Social			x
Communicative				x
Physical	x
Emotional			x