Case Description -North American 22 years
old patient is suffering from persisting pain
making it hard to stand up straight and decreasing in
quality of life.
Subjective:
The patient reports a severe pain in the low
back when prolongued sitting or standing, even
when she lies on the bed. She expresses
frustration and concern over this, which has
been progressively worsening over the past few
weeks despite the pain killers taken.
She reports thar she spends many hours sitting
studying for her university exams.
The patient denies any previous history of
neurological conditions or surgeries that could
potentially contribute to his current pain.
The severe pain is worsering to very severe one
and is significantly impacting his daily living
activities and his quality of life. She is eager to
participate in therapy to relieve pain and
restore her quality of live.
Objective:
- Observations of Performance:
- The patient sitting demonstrated a wrong
possture leading to a rounded upper back which
can cause the pain.
- No visible signs of trauma or injury to the hand
were observed.
- Assessment Data:
- Signs of pain were observed during the
assessment.
- Therapeutic Interventions Used:
- The patient was guided through a series
mussles strengthening and extension
exercises: core, back and chest streches, neck
posture drills and planks are recomended to
help correct her hunched low back.
- The patient was also educated on improving
her sitting posture.
- Patient Response to Intervention:
- The patient was able to complete the hand
strengthening exercises with moderate
difficulty.
- The patient responded positively to the
adaptive strategies .
- Duration and Intensity of Treatment:
- The session lasted for 50 minutes, with the
patient engaged in therapeutic activities for
approximately 15 minutes of the session.
- The intensity of the treatment was moderate,
with the patient demonstrating effort and
engagement in all activities.
- Assistive Devices or Modifications:
- The patient was shown how to modify her
posture when sitting and how to perfomance
exercices at home
- Physical Condition:
- The patient appeared in good health, with
stable vital signs.
Assessment:
The patient presents with decreased fine motor
skills and grip strength in his right hand, which
is impacting his ability to perform daily living
activities such as buttoning his shirt and holding
his toothbrush. The patient's grip strength is
significantly below the normal range for men,
and he struggles with tasks requiring precision.
Despite these challenges, the patient is
motivated to improve his hand function and
regain his independence.
The patient responded positively to the
therapeutic interventions used during the
session, including hand strengthening exercises
and the introduction of adaptive strategies and
devices. He was able to complete the exercises
with moderate difficulty and demonstrated a
slight improvement in grip strength by the end
of the session. The patient was also able to use
a buttonhook with minimal assistance,
improving his ability to button his shirt.
The patient's medical conditions, hypertension
and type 2 diabetes, are well-managed and did
not appear to impact the session. The patient's
right hand exhibited weakness but no signs of
injury or trauma.
Given the patient's motivation and positive
response to the interventions, there is potential
for improvement with continued occupational
therapy. The patient will benefit from a
continued focus on hand strengthening
exercises and the use of adaptive strategies
and devices to assist with daily tasks.
Plan:
Short Term Goal: Within 2 weeks, the patient
will demonstrate a 25% improvement in right
hand grip strength as measured by a
dynamometer. This will be achieved through
regular hand strengthening exercises and the
use of adaptive devices during occupational
therapy sessions.
Long Term Goal: Within 8 weeks, the patient will
independently perform fine motor tasks such as
buttoning his shirt and holding his toothbrush
with 80% success rate. This will be achieved
through continued occupational therapy
focusing on hand strengthening exercises, fine
motor skills training, and the use of adaptive
devices.
Specific Interventions and Modalities: Continue
with hand strengthening exercises, fine motor
skills training, and the use of adaptive devices
such as a buttonhook and modified toothbrush.
Frequency and Duration: Occupational therapy
sessions will be held twice a week for 60
minutes each for the next 8 weeks.
Modifications to Treatment Plan: The treatment
plan will be reviewed and adjusted as necessary
based on the patient's progress and feedback.
Patient Education or Home Program: The patient
will be encouraged to practice the exercises and
use the adaptive devices at home to reinforce
the skills learned during therapy sessions.
Potential Barriers or Considerations: The
patient's motivation and adherence to the home
program will be crucial for the success of the
treatment plan. Any changes in the patient's
medical conditions (hypertension and type 2
diabetes) may also impact the treatment plan
and will need to be monitored closely.
Based on the entire SOAP note, the most
appropriate ICD-10 code would be G56.9 -
Mononeuropathy of unspecified upper limb,
which covers conditions related to weakness
and decreased function in the hand.
SLP
Case Description - "8 year old male, previous
evaluation indicated difficulties with articulation
of specific phonemes."
Subjective:
The patient is an 8-year-old male who has been
previously evaluated for difficulties with
articulation of specific phonemes. The patient's
parents report that he continues to struggle
with the correct pronunciation of certain
sounds, particularly /s/, /r/, and /l/. They express
concern that this is affecting his ability to
communicate effectively and is leading to
frustration and decreased self-confidence,
especially in school and social settings.
The patient himself has expressed frustration
with his speech difficulties, particularly when
trying to communicate with his peers. He has
reported feeling embarrassed when he is unable
to pronounce words correctly. He has also
expressed a strong desire to improve his speech
and articulation skills.
The parents also report that the patient's
teacher has noticed his speech difficulties and
has expressed concern about his ability to
participate fully in class discussions. The
teacher has reported that the patient often
avoids speaking in class, possibly due to fear of
embarrassment.
The patient's medical history is unremarkable,
with no known hearing loss, neurological
disorders, or other medical conditions that could
contribute to his speech difficulties. The patient
has no history of speech therapy. The parents
report that the patient's speech difficulties have
been present since he started talking, but have
become more noticeable as he has gotten older
and the demands on his speech and language
skills have increased.
The parents are eager for the patient to receive
speech therapy and are committed to
supporting him in his therapy sessions. They are
hopeful that with therapy, the patient will be
able to improve his articulation skills and
increase his confidence in his ability to
communicate effectively.
Objective:
- Observations of Speech and Language:
- Articulation: The patient exhibits difficulty in
pronouncing /s/, /r/, and /l/ phonemes. This was
observed during conversational speech as well
as during structured tasks.
- Fluency: The patient's speech fluency appears
within normal limits [normal fluency: smooth,
rapid, effortless speech].
- Voice: The patient's voice quality, pitch, and
volume are within normal limits [normal voice:
clear, no strain or breathiness, appropriate pitch
and volume].
- Language: The patient's receptive and
expressive language skills appear age-
appropriate, with difficulties primarily in
articulation.
- Swallowing Assessment: Not applicable, as the
patient's reported concerns are related to
articulation, not swallowing.
- Results of Standardized Tests:
- Goldman-Fristoe Test of Articulation 2 (GFTA-
2): The patient scored below average for his age
group, particularly struggling with /s/, /r/, and /l/
sounds [average score: 85-115].
- Nonverbal Communication: The patient uses
appropriate eye contact, facial expressions, and
body language during interactions.
- Functional Communication Skills: The patient
is able to communicate his needs and ideas
effectively, but his articulation difficulties often
lead to misunderstandings, particularly in noisy
environments or with unfamiliar listeners.
- Therapeutic Interventions Used: The patient
participated in a variety of articulation exercises
targeting /s/, /r/, and /l/ sounds. He also
practiced these sounds in words, sentences,
and conversation.
- Assistive Devices or Technology: Not currently
applicable, as the patient's primary need is for
articulation therapy, not augmentative or
alternative communication.
Assessment:
Interpretation of Findings: The patient is an 8-
year-old male presenting with articulation
difficulties, specifically with the /s/, /r/, and /l/
phonemes. These difficulties have been
observed in both structured tasks and
conversational speech. Despite these
challenges, the patient demonstrates age-
appropriate receptive and expressive language
skills, normal speech fluency, and appropriate
nonverbal communication skills. His voice
quality, pitch, and volume are also within
normal limits. The patient's articulation
difficulties have been present since he started
speaking and have become more noticeable as
he has aged. The Goldman-Fristoe Test of
Articulation 2 (GFTA-2) results confirm these
observations, with the patient scoring below
average for his age group.
Challenges or Barriers: The patient's articulation
difficulties are causing him significant distress,
particularly in social and academic settings. He
often avoids speaking in class and struggles
with misunderstandings when communicating,
especially in noisy environments or with
unfamiliar listeners. These issues are impacting
his self-confidence and overall quality of life.
Clinical Judgement: Based on the patient's
history, subjective reports, and objective
findings, the patient would benefit from
targeted speech therapy focusing on the /s/, /r/,
and /l/ phonemes. The patient's strong desire to
improve, along with the support from his
parents, suggests a good prognosis for
improvement with therapy.
Plan: The plan is to provide the patient with
individualized speech therapy sessions
targeting his specific articulation difficulties.
Therapy will include a variety of articulation
exercises and practice in different contexts
(words, sentences, conversation) to help
generalize the skills. The patient's progress will
be monitored closely and adjustments to the
therapy plan will be made as needed. The
parents will be provided with strategies and
exercises to support the patient's therapy at
home. Regular communication with the
patient's teacher will also be beneficial to
ensure that the therapy strategies are being
implemented in the school setting as well.
Plan:
Short Term Goals:
1. The patient will accurately produce the /s/
sound in isolation with 80% accuracy in 4 out of
5 trials over 3 consecutive therapy sessions.
2. The patient will accurately produce the /r/
sound in isolation with 80% accuracy in 4 out of
5 trials over 3 consecutive therapy sessions.
3. The patient will accurately produce the /l/
sound in isolation with 80% accuracy in 4 out of
5 trials over 3 consecutive therapy sessions.
Long Term Goals:
1. The patient will accurately produce the /s/,
/r/, and /l/ sounds in conversational speech with
90% accuracy in 4 out of 5 trials over 3
consecutive therapy sessions.
2. The patient will demonstrate increased
confidence in speaking in various settings
(classroom, social situations) as reported by
himself, his parents, and his teacher.
Specific Therapeutic Interventions:
1. Articulation therapy: This will include a
variety of exercises targeting the /s/, /r/, and /l/
sounds. The exercises will be practiced in
different contexts (isolation, words, sentences,
conversation) to help generalize the skills.
2. Home program: The parents will be provided
with strategies and exercises to support the
patient's therapy at home. This will include daily
practice of articulation exercises.
3. School program: Regular communication with
the patient's teacher will be established to
ensure that the therapy strategies are being
implemented in the school setting as well.
Frequency and Duration:
The patient will attend speech therapy sessions
twice a week for 45 minutes each session. This
plan will be reassessed and adjusted as needed
based on the patient's progress.
Modifications to Treatment Plan:
The treatment plan will be modified as needed
based on the patient's progress. If the patient is
not making expected progress, additional
therapy sessions may be added, or different
therapeutic interventions may be tried.
Patient Education or Home Program:
The parents will be provided with strategies and
exercises to support the patient's therapy at
home. This will include daily practice of
articulation exercises.
Potential Barriers or Considerations:
Potential barriers to progress may include the
patient's frustration or embarrassment related
to his speech difficulties. Strategies to address
these issues will be included in the therapy
plan, such as positive reinforcement and
building self-confidence skills.
Based on the entire SOAP note, the
recommended billable ICD10 code is F80.0,
which refers to Phonological Disorder.
