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Initial Diagnostic Report Client Name

February 20, 2019 0 Comment

Initial Diagnostic Report
Client Name: Roman DiCaprio File Number: 123456 Date of Birth: 9-26-13 Age: 4;9 Phone: (555) 555-5555 Address: 1234 Happy St. Redwood Forest CA, 94061Medical Diagnosis: N/ASpeech-Language Diagnosis: Phonological DisorderHearing Status: Within normal limitsReferral Source: PhysicianDate of report: 11-29-18Clinician: Allison Wheeler M.A., CCC-SLP
Referral Information
Roman DiCaprio, a 4-year-nine-month male, was referred by his physician Dr. FunGuy to the Yosemite Center of Clinical Care and Education for a speech and language screening in November of 2018. Roman is currently attending Redwood Forest Preschool. Romans father, Leonardo DiCaprio expressed concern to Romans physician, Dr. FunGuy about Romans speech intelligibility reporting “He does not sound like his peers”. Dr. FunGuy performed a physical and reviewed Romans history of developmental milestones to rule out medical problems. Romans parents, Leonardo and Allison DiCaprio were mailed a questionnaire to be filled out before Romans initial appointment at Yosemite Center for Clinical Care and Education. Romans father, Leonardo DiCaprio completed the child case history questionnaire and accompanied Roman to the initial appointment. Upon completion of the initial speech and language screening, the clinician suggested further evaluation and treatment due to pertinent evidence of Romans compromised speech intelligibility.

Background and Medical History Information
A child case history form was mailed to Mr. and Mrs. DiCaprio in order to gain information about Romans family and developmental history. Mr. DiCaprio completed and returned the case history form for Romans initial appointment. Mr. DiCaprio indicated that Romans mother’s health during pregnancy was good. Her pregnancy was full term and Roman was born naturally weighing 7 pounds, 5 ounces. Mr. DiCaprio indicated that Roman is one of three children, with a twin brother, Atticus and a younger brother, Cillian who do not display speech difficulties. Mr. DiCaprio reported Romans developmental milestones being within normal limits. He noticed Romans compromised speech intelligibility as Roman began to talk more but thought he would grow out of it. In the case history questionnaire, Mr. DiCaprio stated that Roman is an overall healthy child with semi-frequent sinus infections, approximately three per year resulting in a tonsillectomy at age 2. Roman also experienced reoccurring ear infections specifically, ten ear infections per year from the time Roman was six weeks of age until six months ago, when he received pressure equalizing (PE) tubes in each ear. AUDIOLOGIST INFO HERE? Romans mother, Allison DiCaprio is a wildlife photographer, and his father, Leonardo DiCaprio is an environmentalist who works from home the majority of the time. Mr. DiCaprio is Romans primary communication partner. Mr. DiCaprio indicated in the case history form that “Roman is hard to understand. He says many sounds wrong”. Mr. DiCaprio also stated that immediate family understands most of Romans speech, but family friends and preschool teachers have a hard time understanding him unless there is context. In the case history questionnaire, Mr. DiCaprio reported that Roman enjoys going to school and socializing with friends but uses gestures to help his communication partners understand him. Mr. DiCaprio indicated that Roman does not seem to be aware of his speech problem but can get frustrated when he is not understood, resulting in temper tantrums. Mr. DiCaprio expressed concern for Romans compromised speech intelligibility and is willing to work with Roman and implement recommendations of the clinician.

Assessment Information
Formal and informal assessments were used to evaluate Romans speech and language skills. Roman was shy but compliant and friendly throughout the assessment period. He put forth appropriate effort and was engaged for each activity. The results of the assessments were judged to be a valid estimate of Romans current communication skills.

Oral-facial Examination
An examination of Romans oral structures and speech motor function was completed during the evaluation. Roman was shy at first but complied by taking turns “playing doctor” with the clinician. Per parent report, Roman has no difficulties chewing or swallowing. Initial observation of Romans facial structures revealed symmetry at rest with no abnormal movements. Roman is not characterized as a mouth breather per parent report and clinician observation throughout the evaluation. To assess Romans jaw and dentition he was prompted by clinician using verbal and visual cues to open and close his mouth multiple times. Adequate range of motion and normal jaw movement with normal symmetry of lips and jaw in open and closed positions was observed. Dentition arrangement was normal and proper dental hygiene was reported by Mr. DiCaprio. Roman was prompted by clinician to stick out his tongue. Romans tongue color, size and symmetry appeared normal. Tongue range of motion and frenum appeared normal and unrestricted. To examine Romans lips, a variety of activities were offered and Roman chose to blow bubbles. While blowing bubbles, Roman naturally smiled, puckered his lips and puffed his cheeks which showed lip symmetry in open and closed positions and adequate range of motion. During the oral-facial exam, Romans hard and soft palate were not visible; but voice quality and resonance appeared typical for his age. Various components of the oral structures and speech motor functions were assessed through prompted tasks by the clinician. The strength of Romans oral structures; lips tongue and jaw and speech motor function appear to be adequate to support speech.
Hearing Screening
Prior to Romans initial appointment at Yosemite Center for Clinical Care and Education, Roman was referred to Joshua Tree Audiology Clinic for a hearing screening and tympanogram due to Roman having pressure equalizing tubes. Tympanometry was conducted to measure ear canal volume, tympanic membrane compliance and middle ear pressure. Romans tympanometry resulted in a Type A tympanogram for both ears. A type A tympanogram indicates a normal ear canal volume, tympanic membrane compliance and a normal middle ear system, free of fluid. A bilateral hearing screening was conducted across all frequencies (250Hz, 500Hz, 1000Hz, 2000Hz, 3000Hz, 4000Hz and 8000Hz) at 20dB HL. Roman passed the bilateral hearing screening by accurately responding to each frequency.
Language Assessment
The Goldman-Fristoe Test of Articulation: Second Edition provides information about a child’s