Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Speech Therapy Evaluation - 1
Description: Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.
(Medical Transcription Sample Report)
DIAGNOSIS: Status post brain tumor with removal.
SUBJECTIVE: The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time.
OBJECTIVE: Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed.
The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.
The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. In the storytelling task, she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design, memory, and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.
ORAL MECHANISM EXAMINATION: The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline, and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient's speech is judged to be 100% intelligible without background noise.
DIAGNOSTIC IMPRESSION: The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.
PLAN OF CARE: Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.
SHORT-TERM GOALS (THREE WEEKS):
1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.
2. The patient will complete perspective memory test with 100% accuracy using compensatory strategy.
3. The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.
4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.
PATIENT'S GOAL: To improve functional independence and cognitive abilities.
LONG-TERM GOAL (FOUR WEEKS): Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.
Keywords: consult - history and phy., linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive,