PORTFOLIO PART 2: DIFFERENTIAL DIAGNOSIS WRITING COMDIS 711

KIM CARON

Objective: Familiarize yourself with specific MSD clinical manifestation and related neurology through
collaborative learning.
A. Submit your ten written samples from the Duffy book. Include the case numbers.
Dysarthria Subtype:
Rewrite Case Number:

New Case Number:

Dysarthria Subtype:
Rewrite Case Number:

New Case Number:

Unilateral Upper Motor Neuron Dysarthria

Case 9-6:
Original: The patient is a 66-year-old man who exhibits mild flaccid unilateral upper
motor neuron dysarthria. Dysarthria is characterized by imprecise articulation,
repetition of the first phoneme of words, mild hesitations, and increased rate.
Vocal quality is harsh and breathy. Additionally, a lower right facial droop was
noted.
Rewrite: Patient is a 66-year-old man who exhibits mild flaccid unilateral upper
motor neuron dysarthria. Speech is characterized by imprecise articulation,
repetition of the first phoneme of words, and increased rate. Difficulty initiating
utterances was noted. Vocal quality is harsh and breathy. The physical exam
revealed a lower right facial droop (i.e., Central VII). Lateral lingual movements
were mildly slow. Despite speech characteristics, speech is intelligible and
functional.
Case 9-4:
Patient is a 57-year-old man who exhibits mild unilateral upper motor neuron
dysarthria secondary to a stroke 3 years prior. Speech is characterized by mildly
imprecise articulation. Speech AMRs were imprecise. A moderate slowing of rate
improved articulatory accuracy. The physical exam revealed a mild lower left facial
weakness and tongue weakness. Despite articulatory imprecision, speech
intelligibility is functional.
Flaccid
Case 4-7:
Original: Patient is a 62-year-old female who exhibits mild flaccid dysarthria.
Speech is characterized by imprecise articulation (i.e., fricatives, liquids, and bilabial
sounds), and slow rate. Speech AMRs and SMRs were normal. Additionally, mildmoderate lingual and facial weakness was noted.
Rewrite: Patient is a 62-year-old woman who exhibits mild flaccid dysarthria
following a reported 8-10-year history of mild swallowing problems and a 2-3-year
history of speech problems. Speech is characterized by imprecise articulation of
lingual fricatives, liquids, and bilabials, and a reduced rate. Diadochokinetic rates
were normal. The physical exam revealed bilateral facial and lingual weakness.
Lateral lingual nonspeech AMRs were slow, and there was noted fluttering of the
cheeks during production of bilabials. Despite the presence of weakness and
associated reduced tongue movement, she demonstrates the ability to compensate
and produce intelligible speech. She did not report any difficulty with swallowing
at this time.
Case 4-2:
Patient is a 37-year-old man who exhibits mild-moderate dysphagia and mild
flaccid dysarthria. Dysphagia is characterized by poor posterior transit of the bolus
by the tongue and excess saliva accumulation. Drooling results from reduced oral
transit and reduced frequency of swallows. Speech is characterized by distorted
lingual sounds. Speech AMRs were normal except for productions of kuh, which
were slow and imprecise. Tongue mobility and strength against resistance were

PORTFOLIO PART 2: DIFFERENTIAL DIAGNOSIS WRITING COMDIS 711

KIM CARON

severely reduced. Exaggeration of jaw and facial movements were noted. Despite
the presence of reduced lingual movement and strength, patient continues to use
effective compensatory strategies to maintain intelligible speech.
Dysarthria Subtype:
Rewrite Case Number:

Ataxic
Case 6-3:
Original: Patient is a 56-year-old woman who presented with an 8-month history of
progressive speech difficulty. She currently exhibits with a moderate ataxic
dysarthria. Speech is characterized by irregular articulatory breakdowns which
contributes to mild-moderately reduced speech intelligibility. Vowel prolongation
was unsteady and speech AMRs were irregular. Physical examination revealed no
abnormalities.
Rewrite: Patient is a 56-year-old woman who exhibits moderate ataxic dysarthria
following a reported 8-month history of progressive speech difficulty. Speech is
characterized by irregular articulatory breakdowns. Vowel prolongation was
unsteady and speech AMRs were irregular. Physical examination revealed no
abnormalities. Due to irregular articulatory breakdowns, speech intelligibility is
mild-moderately reduced.

New Case Number:

Dysarthria Subtype:
Rewrite Case Number:

An 18-month follow-up revealed a mild dysphagia and that speech symptoms had
progressed.
Case 6-6:
Patient is s a 48-year-old woman who exhibits moderate ataxic dysarthria following
a reported 2-year progression of speech difficulty and cognitive decline. Speech is
characterized by irregular articulatory breakdowns, a mildly reduced rate, pitch
variations, and a hoarse-rough vocal quality. Vowel prolongation was unsteady and
speech AMRs were moderately irregular. During examination, patient reported
occasional word retrieval difficulties, yet there was no evidence of aphasia. Due to
deviant speech characteristics, speech intelligibility is mild-moderately reduced.
Hypokinetic
Case 7-2:
Original: Patient is a 68-year-old man who exhibits mild-moderate hypokinetic
dysarthria following a reported 5-year history of having difficulty getting into and
out of chairs, stiffness during walking, difficulty turning in bed, problems with
voice, and deterioration of his handwriting. During the speech exam, he also
reported a 1 year-history of problems with initiating speech productions. Speech is
characterized by reduced loudness, accelerated rate, breathiness, hoarseness, and
repetitions and prolongations of initial phonemes. Nasal emission was noted
during production of pressure-sound filled sentences. Hoarseness and breathiness
were noted on vowel prolongation. Speech AMRs were normal. Speech did not
deteriorate on stress testing. Physical exam revealed mild mandibular, labial, and
lingual tremors during sustained postures.
Rewrite: Patient is a 68-year-old man who exhibits mild-moderate hypokinetic
dysarthria following a reported a 5 year-history of voice difficulties. Patient
reported experiencing hesitancies initiating speech within the past year, along with
reduced rate and loudness after prolonged speaking. Upon examination, speech is
characterized by reduced loudness, accelerated rate, and inconsistent repetitions
and prolongations of initial phonemes. Speech AMRs were normal. Nasal emission
was noted during production of pressure-sound filled sentences. Vocal quality was

PORTFOLIO PART 2: DIFFERENTIAL DIAGNOSIS WRITING COMDIS 711

New Case Number:

Dysarthria Subtype:
Rewrite Case Number:

New Case Number:

KIM CARON

hoarse and breathy during vowel prolongation. Speech did not deteriorate on
stress testing, despite his complaint of speech changes with extended speaking;
therefore, myasthenia gravis was ruled out. Physical exam revealed a masked face,
and mild mandibular, labial, and lingual tremors during sustained postures.
Case 7-3:
Patient is a 72-year-old woman who exhibits mild-moderate hypokinetic dysarthria
following a reported history of speech complaints. Upon examination, speech is
characterized by mildly imprecise articulation, prolonged silent intervals, mildly
accelerated rate, and a harsh vocal quality. Episodes of whole word and syllable
repetitions (e.g., I took dic-ta-ta-ta-ta-tion from him) during spontaneous speech
were noted, synonymous with palilalia. Speech did not deteriorate during stress
testing, despite suspicion of myasthenia gravis; therefore, myasthenia gravis was
ruled out. Due to deviant speech characteristics, speech intelligibility is mildly
reduced.
Hyperkinetic
Case 8-3:
Original: Patient is a 49-year-old woman who exhibits moderate hyperkinetic
dysarthria secondary to myoclonic epilepsy. Patient reported a 1-year history of
speech difficulties, along with an intermittent feeling of tightness in her face and
neck when speaking. Upon examination, conversational speech is characterized by
reduced rate, excess and equal stress (scanning), and imprecise articulation. Vocal
quality is characterized by strain-hoarseness with monopitch and monoloudness.
Nasal emission was noted during pressure-sound productions. Vowel prolongation
was unsteady and speech AMRs were regular when produced at a reduced rate (1
per second). The physical exam revealed lingual and mandibular myoclonic
movements. Patient presented with dystonic lip contractions which led to difficulty
achieving bilabial closure during connected speech. Speech intelligibility is mildmoderately reduced. Although speech rate is slow, the reduced rate and scanning
characteristics appear to be an effective compensation for increasing speech
intelligibility.
Rewrite:
Patient is a 49-year-old woman who exhibits moderate hyperkinetic dysarthria
secondary to myoclonic epilepsy. Patient reported a 1-year history of speech
difficulties. Upon examination, conversational speech is characterized by reduced
rate, excess and equal stress (scanning), and imprecise articulation. Vocal quality is
characterized by strain-hoarseness with monopitch and monoloudness. Nasal
emission was noted during pressure-sound productions. Vowel prolongation was
unsteady. Speech AMRs were regular when produced at a reduced rate (1 per
second), but became irregular with increased rate. The physical exam revealed
lingual and mandibular myoclonic movements. Patient presented with dystonic lip
contractions which led to difficulty achieving bilabial closure during connected
speech. Speech intelligibility is mild-moderately reduced. Although speech rate is
slow, the reduced rate and scanning characteristics appear to be an effective
compensation for increasing speech intelligibility.
Case 8-5:
Patient is a 70-year-old woman who exhibits moderate hyperkinetic dysarthria of
organic voice tremor following a reported 1-year history of voice difficulty. Speech
is characterized by a vocal tremor with occasional voice interruptions. Voice
tremor was apparent during vowel prolongation. Physical exam revealed a lowamplitude labial tremor at rest. Mandibular, lingual, palatal, and pharyngeal

PORTFOLIO PART 2: DIFFERENTIAL DIAGNOSIS WRITING COMDIS 711

KIM CARON

tremor were noted during vowel prolongation. While voice tremor is evident,
speech intelligibility is functional.
B. Identify and recognize areas for improvement in your writing and as observed in peer samples.
Over the course of the semester, my writing style has changed. At the beginning of the semester, I would
only include the diagnoses and speech characteristics in my impressions statement. I did not elaborate much on
each case. Throughout the semester, I believe my writing has improved. I am now able to pick out the most
salient information and use my clinical judgement to make conclusions. It has helped to organize my impression
statements into four main parts: the diagnoses, the speech characteristics (including vowel prolongation and
diadochokinetic performance), the physical examination, and speech intelligibility. Although I do believe my
writing has improved, I still have much room for improvement. At times, I still feel like I write a laundry list of all
of the speech characteristics. I have also struggled making my impression statements flow from one thought to the
next. I will continue to improve my clinical writing for my future practice.