Donnie_Prog_Draft1_Feedback



Marshall University Speech and Hearing CenterProgress ReportPeriod Covered: May 22, 2018 – July 26, 2018Name: DFile No:Birthdate:Address:Telephone: Frequency/Duration: 2 60-minute sessions per week Attended 19 out of 20 sessionsMedical Diagnosis: History of Traumatic Brain InjuryCommunication Diagnosis: Dysarthria (Mixed Spastic-Ataxic); Cognitive-Communication DeficitICD-10: Z97.820 / R47.1 / R41.841CPT: 92507Statement of the ProblemD, a 41-year old male, suffered a traumatic brain injury (TBI) in 1994 from a motor vehicle accident. Initially, D received therapy services at Professional Therapy Services due to notable deficits in the following areas: motor ability, speech intelligibility, swallowing, and cognition. Services were discontinued at Professional Therapy Services and reconvened at Marshall University Speech and Hearing Center (MUSHC) on June 20, 2017 due to continued deficits in short-term memory and speech production. Evaluation at MUSHC on the aforementioned date revealed a moderate cognitive impairment characterized by deficits in short-term memory, orientation, attention, and problem solving with moderate-severe mixed spastic-ataxic dysarthria characterized by reduced intelligibility at the word, phrase, sentence, and conversation level.Therapy Goals and ProgressLong Term Goals:D will increase intelligibility to 75% intelligible in conversation with familiar and unfamiliar listeners in non-clinical settings.D will self-monitor when communication breakdowns occur and alter utterances (e.g. phrasing, decrease rate, increase loudness, over-articulate, provide context information) to increase intelligibility in 80% of opportunities.D will independently utilize compensatory strategies to improve memory and orientation during everyday life.Short Term GoalsBaseline MeasureCurrent Status1a) D will use speech strategies (e.g. decrease rate, increase loudness, over-articulate) in one-word responses independently in 90% of opportunities.70%, with mod-max verbal and visual cues.80% with mod-max verbal and visual cues.Increase in performance1b) D will rephrase lengthy unintelligible utterances during structured speech tasks with minimal cues in 80% of opportunities provided.Minimal cues at 70%.Minimal cues at 70%.Consistent performance2a) D will identify intelligible versus unintelligible speech as demonstrated by use of self-repair strategies in the presence of gestural cues 80% of the time.70% with gestural cues.90% with gestural cues.Increase in performance.3a) D will use appropriate memory strategies to recall weekly activities, personal information, and speech strategies in 80% of opportunities provided.Minimal-moderate support at 80%.Minimal support at 80%.Increase in performance.3b) D will navigate the iPAD independently to provide information regarding calendar events with 90% accuracy.Max assist at 100% accuracy.Mod assist at 70%.Increase in performance.4a) D will implement safe swallow compensatory strategy of small bolus volume with less than three verbal cues required in order to optimize nutrition/hydration and reduce risk of aspiration.Max verbal cues with 5 sips of water.One verbal cue with 3 sips of water.Increase in performance.5a) D will maintain appropriate behavior and require less than 3 redirections during a therapy session across four consecutive sessions.Max verbal, visual, and gestural cues approximately 10x during the session.Max verbal and visual cues 5x during the session.Increase in ments on Progress:Speech: Over the course of the term, the clinician instructed D to utilize compensatory strategies to improve speech intelligibility, including increasing inspiration for adequate breath support, pacing, slowing speech rate, increasing volume, and over-articulating. In the beginning of the term, D required consistent moderate-maximal verbal and visual cues to utilize his strategies. The clinician integrated self-monitoring strategies to improve D’s awareness of deficits and independence of using strategies. This included stopping after targeted phrases and requiring D to self-evaluate the intelligibility of his utterance, which, at times, required him to repeat using compensatory strategies. Toward the end of the semester, D more independently used strategies, including self-correcting unintelligible utterances.Cognition: Due to D’s memory and orientation deficits, a memory book page was utilized every session to promote recall of important biographical information about D. The memory book required D to complete a form including the date, his age, his high school and year of graduation, upcoming events, and the location and purpose of speech therapy. D’s performance on memory and orientation tasks were inconsistent, ranging from completing the task independently to requiring moderate verbal support, including phonemic cues such as “m” for Marshall and memory. D utilized an iPad to create and review upcoming events. During the beginning of the summer session, the clinician noted D took several consecutive gulps of water, followed by coughing. Due to decreased attention and increased risk of aspiration, the clinician required D to take small sips. D required consistent verbal prompts to remember to take small sips, but progressed to requiring only one verbal prompt at the beginning of the session. When taking small sips, no signs or symptoms of aspiration were noted.Behavior: D was alert and cooperative for the majority of therapy sessions. However, D displayed inappropriate behaviors including wanting to hold the clinician’s hand and making comments about the clinician. Therefore, the clinician implemented a behavior contract with rules for behavior during a therapy session. The clinician noted improved behavior after utilizing the contract. The clinician subjectively noted that intelligibility, cognition, and behavior were greatly impacted by fatigue. For example, when D attended physical therapy prior to speech therapy and also had to park farther away than normal, he used speech strategies less consistently and required more cues, required greater support to complete tasks, and needed consistent redirection for inappropriate behaviors.Patient/Family Education:The clinician provided education throughout the term to both D and his father regarding set up and navigation of the iPad. D appeared motivated to learn more about his iPad as well as integrate it outside of therapy. D required consistent help to unlock and navigate his iPad. As the semester progressed, D became more independent and required fewer cues to utilize the calendar application. Additionally, the clinician and clinical supervisor provided education regarding appropriate behavior during therapy. D often made inappropriate comments about the clinician, and when told such comments were not appropriate, D seemed surprised or stated that what he said was “the truth.” The clinician utilized verbal and visual cues to redirect and correct inappropriate comments.Recommendations:Continued speech-therapy 2x per week for 60 minutes, includingContinued aphasia group attendance beginning in the FallLong Term Goals:D will increase intelligibility to 75% intelligible in conversation with familiar and unfamiliar listeners in non-clincal settings.D will self-monitor when communication breakdowns occur and alter utterances (e.g. phrasing, decrease rate, increase loudness, over-articulate, provide context information) to increase intelligibility in 80% of opportunities.D will independently utilize compensatory strategies to improve memory and orientation during everyday life.Short Term Goals:1a) D will use speech strategies (e.g. decrease rate, increase loudness, over-articulate) in one-word responses independently in 90% of opportunities.1b) D will rephrase lengthy unintelligible utterances during structured speech tasks with minimal cues in 80% of opportunities provided.2a) D will identify intelligible versus unintelligible speech as demonstrated by use of self-repair strategies in the presence of gestural cues 80% of the time.3a) D will use appropriate memory strategies to recall weekly activities, personal information, and speech strategies in 80% of opportunities provided.3b) D will navigate the iPAD independently to provide information regarding calendar events with 90% accuracy.4a) D will implement safe swallow compensatory strategy of small bolus volume with less than three verbal cues required in order to optimize nutrition/hydration and reduce risk of aspiration.5a) D will maintain appropriate behavior and require less than 3 redirections during a therapy session across four consecutive sessions.Prognosis:Prognosis for increasing intelligibility, self-monitoring, and independent implementation of compensatory strategies across various settings and communication partners is fair-good due to familial support, consistent attendance, and desire to communicate.Alyssa BaileyAlyssa BaileyGraduate ClinicianRebecca Ernay Adams, M.S. CCC-SLPClinical Supervisor ................
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