Case Study 1, Sample Patient 4

Sample Patient Four (audio: sample 2)

DOB: 4/28/33
Sex: F
Post-onset: 3 years?
Referral: self

Pertinent Medical History (PMH): T1N0Mx SCCa floor of mouth resected 1981, s/p XRT

Social history: Tobacco: none
Alcohol: none
Married, retired professional singer

Family history: father died age 65 MI
mother died age 37 cervical Ca

Surgical history: see above

Current complaints: voice is wavery

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? My voice has a lot of tremolo

2. When did the speech problem begin?
Did it begin suddenly or gradually?
Who noticed it first, you or someone else? I was still singing with an orchestra until last year. About 3 years ago, or maybe longer than that, I noticed that I had more tremolo on sustained notes. I didn’t really notice it in my speech until last year.

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 sppech problem began? no

4. Has the speech problem changed?
Better, worse, stable, better-than-stable, fluctuating? It’s becoming more noticeable in my everyday speech. People ask me if I’m upset.

5. Has your speech ever returned to normal?
If so, when and for how long? Well, some days I don’t notice it as much so maybe it does.

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 yournose 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 wheen completing a swallow?
Have you had to modify your diet because of these problems?
Have you lost weight? no

6. Have you had any cahnge 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? Like I had more tremolo, but not on purpose

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? My voice seems shaky. It sounds like tremolo but since I’m not doing it on purpose it feels shaky. I don’t really go slower or faster. No, it’s not more difficult, just strange

3. Have you noticed any change in the appearance or feeling in your face or mouth? I look like I’m using tremolo a lot

CONSEQUENCES OF THE DISORDER:

1. Do people ever have trouble understanding you?
When? What do you do if that happens? No

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? I can still sing, although I don’t sing professionally anymore. My voice sounds older now, but I can still hold the notes. Sometimes I sing at weddings and funerals.

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? Nothing until now

2. Do you think you need help with your speech now? I want to know if there’s something wrong, if I should be worried. I wouldn’t mind seeing if I could change back to my real voice.

AWARENESS OF DIAGNOSIS AND PROGNOSIS:

1. What have you been told is the cause of this problem? I don’t know

2. In view of this diagnosis, what is going to happen? That’s what I hope you’ll tell me

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

Pertinent Medical History (PMH):	T1N0Mx SCCa floor of mouth resected 1981, s/p XRT
Social history:	Tobacco: none Alcohol: none Married, retired professional singer
Family history:	father died age 65 MI mother died age 37 cervical Ca
Surgical history:	see above
Current complaints:	voice is wavery

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?	My voice has a lot of tremolo
2. When did the speech problem begin? Did it begin suddenly or gradually? Who noticed it first, you or someone else?	I was still singing with an orchestra until last year. About 3 years ago, or maybe longer than that, I noticed that I had more tremolo on sustained notes. I didn’t really notice it in my speech until last year.
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 sppech problem began?	no
4. Has the speech problem changed? Better, worse, stable, better-than-stable, fluctuating?	It’s becoming more noticeable in my everyday speech. People ask me if I’m upset.
5. Has your speech ever returned to normal? If so, when and for how long?	Well, some days I don’t notice it as much so maybe it does.
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 yournose 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 wheen completing a swallow? Have you had to modify your diet because of these problems? Have you lost weight?	no
6. Have you had any cahnge 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?	Like I had more tremolo, but not on purpose
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?	My voice seems shaky. It sounds like tremolo but since I’m not doing it on purpose it feels shaky. I don’t really go slower or faster. No, it’s not more difficult, just strange
3. Have you noticed any change in the appearance or feeling in your face or mouth?	I look like I’m using tremolo a lot
CONSEQUENCES OF THE DISORDER:
1. Do people ever have trouble understanding you? When? What do you do if that happens?	No
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?	I can still sing, although I don’t sing professionally anymore. My voice sounds older now, but I can still hold the notes. Sometimes I sing at weddings and funerals.
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?	Nothing until now
2. Do you think you need help with your speech now?	I want to know if there’s something wrong, if I should be worried. I wouldn’t mind seeing if I could change back to my real voice.
AWARENESS OF DIAGNOSIS AND PROGNOSIS:
1. What have you been told is the cause of this problem?	I don’t know
2. In view of this diagnosis, what is going to happen?	That’s what I hope you’ll tell me

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