What is the approach to taking a speech history in a patient?

How to Take a Speech History

A comprehensive speech history should systematically assess symptom onset, temporal patterns, voice characteristics across multiple dimensions (pitch, loudness, quality), functional impact, and psychosocial context, while actively listening to the patient's voice during the interview itself.

Core Components of Speech History Taking

1. Patient Self-Report and Symptom Characterization

Begin by documenting the patient's subjective experience of their speech changes across three primary dimensions 1:

Pitch Changes:

• Has the voice become higher or lower than typical during conversation? 1
• Has singing range been affected? 1
• Document changes in pitch range overall 1

Loudness Alterations:

• Is conversational volume affected? 1
• Has the ability to speak over background noise decreased (reduced endurance)? 1
• Assess overall loudness range 1

Quality Disturbances:

• How does voice quality change during conversation versus singing? 1
• Does quality vary at different times of day? 1
• Does prolonged talking worsen voice quality? 1

2. Temporal Pattern and Onset

Critical timeline questions include 1:

• How and when did symptoms begin? What does the patient understand caused the onset? 1
• Are symptoms constant or intermittent? Do they come and go? 1
• What factors exacerbate or relieve symptoms? 1
• Have there been periods of complete symptom resolution? 1

This temporal characterization helps differentiate acute self-limited conditions (typically resolving in 7-10 days with upper respiratory infections) from chronic dysphonia requiring more extensive evaluation 1.

3. Previous Medical Encounters and Treatments

Document what the patient has been told by other healthcare professionals about their symptoms 1. Inquire about outcomes of any previous treatments for the same symptoms 1. This prevents redundant workups and identifies failed therapeutic approaches.

4. Functional Impact Assessment

Systematically assess impact on 1:

• Daily life activities
• Work performance (particularly critical for professional voice users) 1
• Interpersonal relationships 1

Consider using standardized tools like the Voice Handicap Index for quantifiable assessment 1.

5. Psychosocial Context

Explore relevant psychosocial factors with sensitivity 1:

• Recent life stresses or significant events
• Predisposing factors: personality traits, previous functional symptoms, adverse life events 1
• Precipitating mechanisms: physical injury, surgery, medical illness, psychological trauma 1

Critical caveat: While gentle inquiry about stresses is appropriate, avoid injudicious probing if trauma history is not forthcoming 1. Repeated uninvited questioning about trauma can undermine the therapeutic relationship 1. Not all speech disorders have psychological triggers.

6. Red Flag Identification for Expedited Evaluation

Immediately identify factors requiring urgent laryngeal assessment 1:

• Recent head, neck, or chest surgery
• Recent endotracheal intubation
• Concomitant neck mass
• Respiratory distress or stridor
• History of tobacco abuse
• Professional voice user status

7. Medication and Medical History

Document medications that may cause dysphonia 1:

• Inhaled steroids (mucosal irritation, fungal laryngitis)
• Anticoagulants (vocal fold hematoma risk)
• ACE inhibitors (chronic cough)
• Antihistamines/diuretics (mucosal drying)

8. Occupational and Voice Use Patterns

Elicit detailed occupational history 1:

Professional voice users (teachers, singers, public speakers) require early evaluation as voice symptoms significantly impact livelihood 1. Over 50% of teachers experience dysphonia from voice overuse, with 20% missing work as a result 1.

Auditory-Perceptual Assessment During History

While taking the history, actively listen and document 1:

Use structured rating systems:

• GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain) with 4-point ordinal rating 1
• CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice) for Overall Severity, Strain, Breathiness, Roughness, Pitch, and Loudness 1

Or use simplified clinical rating 1:

• Normal: Voice sounds clear with expected pitch and loudness
• Mild abnormality: Minimal but noticeable quality change
• Moderately abnormal: Noticeable and sometimes distracting
• Severely abnormal: Obviously abnormal and distracting

Documentation Strategy

Record observations of 1:

• Features observable during history-taking itself
• Social utterances and conversational speech patterns
• Any inconsistencies between reported symptoms and observed speech during the interview

Consider audio recording (with appropriate consent and HIPAA compliance) for objective documentation, particularly for professional voice users or preoperative assessment 1.

Common Pitfalls to Avoid

• Don't assume psychological causation: Functional neurological disorders should be diagnosed based on positive clinical features, not exclusion 1
• Don't delay evaluation in high-risk patients: Smokers, professional voice users, and those with red flag symptoms need prompt laryngeal examination 1
• Don't overlook comorbidity: Structural pathology and functional disorders can coexist 1
• Don't probe excessively about trauma: Balance psychosocial exploration with maintaining therapeutic rapport 1