Clinical Communication – Evaluation Report
Patient Evaluation- SOAP notes.
S Difficulty in reading. Patient sees words as ‘floating off the page’. Patient’s mother suspects dyslexia as the cause of the symptoms. Although developmental milestones were achieved at right ages, the patient’s father has a history of dyslexia and his younger brother exhibits similar symptoms. Patient wears spectacles.
O Informal narrative analysis- appropriate level.
Auditory comprehension / verbal expression – difficulty in receptive language comprehension. Difficulty in understanding spoken narrative. Auditory process screening- ok. No physiological auditory problems. Verbal skills- appropriate for age. Written expression – trouble with fluency i.e. grammar, spelling, punctuation and sentence structure Informal spelling inventory-difficulty with multisyllabic words. Visual comprehension –extreme difficulty in reading and comprehension of what has been read.
A-Characteristics of the condition are consistent with those present in dyslexic individuals.
P- Patient presented with several characteristics of dyslexia. However due to inconsistency of instruction an absolute dyslexia diagnosis may not be confirmed.
It is recommended that he receive the services of a qualified professional, possibly a dyslexia specialist, who should provide consistent and adequate instruction for his education needs. Multi-sensory approaches should be used to maximize learning and improve on areas of difficulty. A list of specialists to be given to his parents. A reevaluation of his condition to be done after a year. Special accommodation should be made for him in school such as more time, multi-sensory learning aids, and a reduction of his reading load. Parents should be assisted to clearly understand the condition and instructed on how they may offer support.
His level of academic achievement is below where it should be at his age as a result of his difficulties. His performance is below what is expected at his age academically.
His condition does not directly impact his ability to relate socially as he can express himself verbally. However, the condition might affect him emotionally and psychologically leading to withdrawal and reduced confidence.
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