Clinical Evolution Report: Speech & Language Assessment
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ScribdTranslationsClinical Evolution Report: Speech & Language Assessment
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ScribdTranslationsCLINICAL EVOLUTION REPORT
1) IDENTIFICATION:
Name: Date of birth
Current age:
Name of the responsible person:
Intern:
Supervisor:
2) PHONOAUDIOLOGICAL DIAGNOSTIC HYPOTHESIS OF MANIFESTATION:
Changes in speech
3) SYNDROMIC PHONOAUDIOLOGICAL DIAGNOSTIC HYPOTHESIS:
Language delay, DMO and ADHD
4) AUDIOLOGICAL DIAGNOSTIC HYPOTHESIS ETIOLOGICAL:
Organic
5)RELACIONAR OS OBJETIVOS (GERAL E OS PRINCIPAIS ESPECÍFICOS):
To promote the development of speech and language and to adjust orofacial functions.
6) TO REPORT, SUMMARILY, HOW THE EVOLUTION OF THE BEGINNING OF TREATMENT WAS
UP TO THE YEAR 2017 (PREVIOUS PERIOD)
The patient has significant spatial, temporal, and balance psychomotor difficulties.
besides language aspects such as unintelligible speech, disorganization of discourse, delay in
receptive and expressive language and learning difficulties. Still does not know how to read or
writing and does not recognize most letters and numbers. It also has issues with
attention and concentration and deficits in working memory and long-term memory.
A goal was set to work on psychomotricity through circuits and
games that stimulate motor coordination, proprioception, and balance and for the
language aspects were outlined activities that worked on cognitive skills
superior: memory, attention, and concentration that are the foundation for later skills of
reading, writing and language.
During the activities carried out to stimulate higher cognitive skills, it was
it is possible to notice an improvement in attention, concentration, and organization of speech
patient and currently he manages to complete the proposed tasks with difficulty. The speech
it is more intelligible, but it still needs adjustments.
7) RECOUNT THE EVOLUTION
The patient showed good interaction with the therapist from the first session.
showing interest in the proposed activities.
During the initial sessions, the patient had a lot of difficulty maintaining attention,
concentration and especially memory in the execution of the activities developed. It was necessary to
intervention of the therapist to be able to direct him to maintain focus, as he was getting distracted
easily and tried to bypass the established rules of the games. The therapist talked with the
patient on how to behave, not to shout and sit properly and also reinforced with her
mother about the importance of carrying out activities both in therapy and at home and during
in the following sessions the patient has already shown significant improvement, changing his/her
behavior.
8) CURRENT STRATEGIES USED
Use of chronological sequence games from UTFONO, in which the patient should
put the scenes in order and then tell what the assembled story is. Accomplished with
ease.
Activity for spatial organization, which is the ability of the individual to locate-
and to orient oneself, in relation to objects, people, and one's own body in a certain
Space. It is knowing how to locate what is to the right or to the left; in front or behind; above or below.
of yes, or again, an object in relation to another. (ASSUNÇÃO; COELHO, 1996, p.91-96). And still
today/yesterday/tomorrow (the days of the week). Cardboard and everyday figures were used
for the creation of a framework in which the patient should choose the main activities of
week. It was an activity in which the patient had good participation organizing the
sequence of the figures represented as daily activities, the collage, and then made the summary
about how your day was using your own figures.
Strengthening exercises for the orofacial structures (lips and
language) and adequacy of the lingual position.
A therapeutic resource called 'The Rabbit's Gift' was used.
the patient should maintain attention, concentration to memorize the items
found along the way and adding to an invented story. The patient
managed to add some items to the story, however the strategy remained at a high level
for the patient, as there were many figures to remember.
As a therapeutic resource, the reading of a children's book was used so that the patient
pay attention and then give an example of five objects that were in the illustrations and make the
recounting while recovering memory.
Games with rhymes where the child had to recognize the sounds of words,
identifying the rhymes; The game 'Who am I' was used in which the patient should guess the
figure through the characteristics mentioned by the therapist. In this strategy, the patient had
quite a difficulty in understanding the rules of the game and did not do well; in a second
At the moment, various figures were used where the patient had to separate them and stick them on.
different leaves according to their respective rhymes.
9) CONDUCT / REFERRAL
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