Case history/report writing

Question 0

What is involved in the interview process?

Answer 0

Establishes therapist-client relationship
Explore nature and history or client’s presenting problem
Attentive and sensitive listening

Client may have:
heightened anxiety
personal problems
culture
personal needs

Question 1

What does the voice evaluation enable to SLP to do?

Answer 1

Diagnose voice disorder
Determine efficacy of various treatment approaches
Formulate prognosis

Question 2

What are the responsibilities of the clinician?

Answer 2

Conduct interview.
Avoid intimidating client.
Remain sensitive to client's feelings.
Do not express personal feelings.
Remain open and accepting.
Speak in language tailored to individual

Question 3

What are some of the questions involved in a case history?

Answer 3

Client’s description (discrepancies between client’s description and ENT report, client’s aware of problem and level of concern).

Client’s opinion of cause (compare with ENT hypothesis, client may be reluctant to express own ideas)

Effect of voice disorder on client’s life (profound effect on some eg. depression or anxiety, effect on work)

Other people’s reactions (what are they? How does client feel?)

Onset of problem (sudden or slow, related to an event or illness)

Duration

Associated symptoms and stresses (swallowing problems, slurred speech, coughing, fatigue, sensations, emotional/stress factors)

Question 4

What are some of the questions involved in a case history? 2

Answer 4

Variability vs consistency (RLN palsy - no variability, functional - lots of variability, what factors make it worse or better)

Voice use (how often, where, type of usage)

Health (physical and mental)

Vocational history (type of work, environment, requirements etc)

Social history (lifestyle, family, vocal abusive environments)

Recreational history (participation in sports, exercise)

Question 5

What areas do you discuss in a report?

Answer 5

• Onset and progression.
• Degree of effort required to talk.
• How interferes with voice function.
• Medical conditions, previous surgery, medications, previous voice therapy.
• ENT findings.
• Environmental and behavioural factors.
• Typical patterns of voice use.
• Symptoms and degree of fluctuations.
• Results of voice evaluation (perceptual evaluation, instrumental assessment results, degree of functional impairment).
• Clinical impressions (based on knowledge and experience, overall description of type of disorder and factors involved, summarise physiological reasons, prognostic statement)
• Recommendations (voice therapy, referrals to other specialists)