History Taking Format for Dysarthria

1. Patient Details

• Name, Age, Sex, Occupation, Address

2. Presenting Complaint

• Difficulty in speaking or slurred speech (dysarthria)

• Duration and progression

3. History of Presenting Illness

• Onset:

  • Sudden, gradual, or fluctuating?

  • Exact time and circumstances of onset (e.g., after stroke, trauma, infection)

• Course and Progression:

  • Static, progressive, or intermittent?

  • Any periods of improvement or worsening?

• Nature of Speech Difficulty:

  • Slurred, slow, rapid, nasal, monotonous, or scanning speech?

  • Difficulty with articulation, volume, pitch, or rhythm?

• Associated Symptoms:

  • Difficulty swallowing (dysphagia)

  • Hoarseness or change in voice

  • Weakness or numbness in face, tongue, or limbs

  • Double vision, facial droop, or drooling

  • Headache, dizziness, or altered mental status

• Triggers/Relieving Factors:

  • Fatigue, emotional stress, medications, or time of day

• Impact on Daily Life:

  • Difficulty being understood by others

  • Social or occupational impact

• Previous Episodes:

  • Any similar episodes in the past?

  • Recovery pattern and duration

4. Past Medical History

• Stroke, head injury, brain tumor, multiple sclerosis, Parkinson’s disease, myasthenia gravis, or other neurological disorders

• Recent infections (e.g., encephalitis, meningitis)

• History of surgery or radiation to head/neck

5. Drug History

• All current and recent medications (including sedatives, antiepileptics, muscle relaxants)

• Recent changes in medication or missed doses

• Alcohol or illicit drug use

6. Family History

• Similar neurological disorders in family members

• Hereditary neuromuscular diseases

7. Personal and Social History

• Alcohol, tobacco, or illicit drug use

• Occupational exposures (toxins, chemicals)

• Diet and nutritional status

8. Systemic Enquiry

• Fever, weight loss, night sweats (infection, malignancy)

• Visual, hearing, or swallowing disturbances

• Limb weakness, gait disturbance, or incoordination

9. Special Notes

• Source and reliability of history (often from relatives or caregivers)

• Baseline speech and language abilities (compare to current state)

• Recent travel, exposure to toxins, or sick contacts

Case History

Personal Details:
Mr. Arvind Mehta, 55-year-old male, schoolteacher

Presenting Complaint:

• Progressive slurred speech for 3 months

History of Presenting Illness:
Mr. Mehta reports a gradual onset of slurred speech over the past 3 months. He first noticed difficulty pronouncing certain words, particularly with "t" and "d" sounds, and his speech has become increasingly slow and effortful. His family mentions his voice now sounds "muffled" and occasionally nasal. The slurring worsens toward the end of the day or when he is fatigued.

Associated Symptoms:

• Mild difficulty swallowing solids (no choking or coughing)

• Occasional twitching in his tongue

• No headache, dizziness, or visual changes

• No limb weakness, numbness, or coordination issues

Precipitating Factors:

• Fatigue exacerbates symptoms

• No recent infections, trauma, or emotional stress

Previous Episodes:

• No prior speech difficulties

Past Medical History:

• Hypertension (controlled with telmisartan)

• No diabetes, stroke, or neurological disorders

Drug History:

• Telmisartan 40 mg once daily (no recent changes)

• No sedatives, muscle relaxants, or alcohol abuse

Family History:

• No family history of neurological diseases

Personal/Social History:

• Non-smoker, occasional social alcohol use

• No occupational toxin exposure

Systemic Enquiry:

• No weight loss, fever, or night sweats

• No joint pain, rashes, or sensory deficits

Case Summary

A 55-year-old hypertensive male presents with progressive slurred speech, mild dysphagia, and tongue fasciculations over 3 months, worsening with fatigue. No limb weakness, sensory deficits, or systemic symptoms.

Differential Diagnosis

1. Amyotrophic Lateral Sclerosis (ALS)

   • Most likely: Progressive bulbar involvement (slurred speech, tongue fasciculations) without sensory deficits.

2. Myasthenia Gravis

   • Possible due to fatigue-related worsening, but less likely without ptosis or diplopia.

3. Multiple Sclerosis (MS)

   • Less likely without relapsing-remitting history or other neurological symptoms.

4. Parkinson’s Disease

   • Hypophonic/monotonous speech is typical, but no rigidity or tremor reported.

5. Brainstem Stroke or Tumor

   • Requires neuroimaging to rule out, though gradual progression favors neurodegenerative causes.

6. Hypothyroidism

   • Can cause slow speech but unlikely without other systemic features (e.g., weight gain, cold intolerance).

1. What is dysarthria?
Dysarthria is a motor speech disorder resulting from impaired movement of the muscles used for speech production, leading to slurred, slow, or difficult-to-understand speech.

2. How does dysarthria differ from aphasia?
Dysarthria is a problem with the physical production of speech due to motor impairment, while aphasia is a language disorder affecting comprehension or expression, usually due to cortical brain lesions.

3. What are the main types of dysarthria?

• Spastic (upper motor neuron lesions)

• Flaccid (lower motor neuron lesions)

• Ataxic (cerebellar involvement)

• Hypokinetic (basal ganglia, e.g., Parkinson’s disease)

• Hyperkinetic (basal ganglia, e.g., Huntington’s disease)

• Mixed (e.g., ALS)

4. What are common causes of dysarthria?

• Stroke (brainstem or cortical)

• Motor neuron disease (ALS)

• Myasthenia gravis

• Multiple sclerosis

• Parkinson’s disease

• Cerebellar disorders

• Brain tumors

• Trauma or infections affecting cranial nerves

5. What features in the history suggest bulbar involvement?
Slurred speech, nasal voice, difficulty swallowing (dysphagia), tongue fasciculations, and choking indicate bulbar muscle involvement.

6. Why does myasthenia gravis cause dysarthria?
In myasthenia gravis, fatigable weakness of bulbar muscles leads to slurred speech that worsens with prolonged talking or at the end of the day.

7. What is the significance of tongue fasciculations in dysarthria?
Tongue fasciculations suggest lower motor neuron involvement, commonly seen in motor neuron diseases like ALS.

8. How does dysarthria in Parkinson’s disease typically present?
Speech is often hypophonic (soft), monotonous, and may be slow or rapid, with imprecise articulation.

9. What investigations are useful in evaluating dysarthria?

• MRI brain and brainstem

• Electromyography (EMG)

• Nerve conduction studies

• Blood tests for metabolic and autoimmune causes

• Thyroid function tests

10. What is mixed dysarthria and where is it seen?
Mixed dysarthria involves features of more than one type (e.g., spastic and flaccid) and is characteristic of ALS.

11. What is the role of speech therapy in dysarthria?
Speech therapy helps improve articulation, volume, and communication strategies, enhancing quality of life.

12. What is the difference between spastic and flaccid dysarthria?
Spastic dysarthria (UMN lesions) causes slow, strained, and effortful speech; flaccid dysarthria (LMN lesions) causes breathy, nasal, and imprecise speech.

13. How can hypothyroidism cause dysarthria?
Myxedematous infiltration of tongue and laryngeal muscles can cause slow, thick speech in hypothyroidism.

14. What is the importance of progression in the history of dysarthria?
Gradual progression suggests neurodegenerative causes (e.g., ALS), while sudden onset suggests vascular or traumatic causes.

15. What are the red flag features in a patient with dysarthria?
Rapid progression, associated dysphagia, respiratory difficulty, limb weakness, or cognitive changes require urgent evaluation.

16. Can cerebellar lesions cause dysarthria?
Yes, cerebellar lesions cause ataxic dysarthria, characterized by irregular, scanning speech with variable pitch and volume.

17. How does multiple sclerosis cause dysarthria?
Demyelination in the brainstem or cerebellum can disrupt coordination of speech muscles, leading to spastic or ataxic dysarthria.

18. What is bulbar palsy?
Bulbar palsy is a lower motor neuron lesion affecting cranial nerves IX, X, XI, and XII, leading to dysarthria, dysphagia, and tongue atrophy.

19. What is pseudobulbar palsy?
Pseudobulbar palsy is an upper motor neuron lesion affecting the same cranial nerves, causing spastic dysarthria, emotional lability, and brisk jaw jerk.

20. Why is it important to assess swallowing in a patient with dysarthria?
Swallowing difficulty increases the risk of aspiration and pneumonia, and may require dietary modifications or feeding support.