Speech-Language Pathologist: A Case Study

II. Background Information

This client was seen for the purpose of fulfilling a requirement for the following course: Assessment and Intervention for Speech-Language Pathologists. The following information was extracted from the interview that took place in Mrs. Lara's household on February 04, 2017.

III. History (Communication)

a. Medical History

Mrs. Lara indicated she was ecstatic when she found out she was pregnant, but soon that emotion turn into guiltiness. Her drastic emotional change was caused because Mrs. Lara was born with cleft and lip palate, and there was a high probability that her daughter would be born with the same complications as her. In her second trimester, Mrs. Lara found out Angelica had developed a cleft lip through an ultrasound. Mrs. Lara had a great support system (I.e, husband, mother-in-law, and her mother) which helped her enjoy her pregnancy. No other complications

were observed during her pregnancy.
Angelina was born on July 11, 2009 in Northwestern Women Prentice Hospital with no complications. Angelina was diagnosed with cleft and lip palate. Mrs. Lara explained that she did not received the adequate support from medical professionals teaching her feeding techniques. She believes the medical professionals did not take the time to demonstrate feeding techniques, because Angelina was born with the same complications as her and believed she knew how to manage feeding her. Immediately, Mrs. Lara was faced with multiple obstacles when trying to feed Angelina. Mrs. Lara was not able to breastfeed Angelina because she would not latch and suck. Therefore, Angelina was not gaining weight and was slowly losing weight. Mrs. Lara became frustrated and started researching the different types of bottles, and nipples to use for feeding. Throughout the different error and trials, she finally constructed the perfect feeding bottle for her daughter. Additionally, Angelica was faced with breathing complications. Mrs. Lara explained that she at times would not sleep to make sure Angelina would be breathing. There was incident were Angelina was rush to Ann and Robert H. Lurie's Hospital emergency department because she had breathing complications. The staff cleared Angelina's nose using a bulb syringe and was in observance for a few hours before getting discharge. Therefore, Mrs. Lara learned to clear Angelina’s airway before taking a nap.
The first set of surgeries Angelina encountered were to close the fissure on her lip at 3 months-old and palate at 9- months-old allowing her to breath and swallow her food properly. At age 4 and 7, Angelica had a myringotomy where ear tubes where implanted to help regulate air pressure between the middle and outside ear. She has a pending surgery to happen in the following months (appointment needs to be schedule) with an Orthodontist to widen her palate and prepare her for braces.
Angelina has no known allergies and is not taking any medications.
b. Developmental
Developmental milestones were reported within the anticipated time frames. Angelina did obtain early intervention and speech therapy. After re-evaluating her it was concluded the need for speech therapy was not needed. Mrs. Lara is concerned with Angelina's nasal rustle production when speaking at times.
According to last year testing done at school, Angelina’s reading and writing skills are demonstrated to be of a second grader. She enjoys reading every day before going to sleep and likes learning new words. With only seven years of age, Angelina now understands sarcasm.
c. Social/Family
Angelina currently resides in Chicago with her mother and father in a predominantly English household. However, when visiting her grandmother she only speaks Spanish because her grandmother only speaks Spanish. Angelina has no siblings, but does have a dog name, Sully. Sully is currently living with her uncle because Angelina's parents are thinking of moving soon to a bigger house. Mrs. Lara is a Case Manager Supervisor at UCP Seguin of Greater Chicago and Mr. Lara a Insurance Specialists at Blue Cross Blue Shield.
Angelina loves spending quality time with her mother.

On a weekday day, Mrs. Lara dedicates her time to cook for breakfast, wakes and prepares Angelina for school, drops Angelina at school, and then she heads to work. In the afternoon, she picks-up her from after-school program and then heads home to cook dinner. After eating dinner, Mrs. Lara helps Angelina with her homework and listens to her while she practices her violin. On the weekends, Mr. and Mrs. Lara takes Angelina to her violin lessons, go out for lunch and dinner, and goes to visit her grandmother. All of them enjoy spending quality together watching movies, playing apps on the iPad, playing with her dolls and playing board games (I.e. monopoly, UNO).

Angelina's peers consist of her parents, grandmother, teacher, and friends. Angelina doesn't demonstrate having an obstacle communicating with others, or others not understanding her. She love interacting with others and learning new things. Angelina can be describe as playful, thoughtful, energetic, adventurous, and independent little girl.

d.

Education
Angelina is currently attending 2nd grade at Academy for Global Citizenship. Academy for Global Citizenship is a Chicago Charter Public school and an International Baccalaureate school. This program embraces the philosophy of changeling each student in each subject by incorporating innovative curriculum and examining how their choices impact their community and the world. Additionally, she is enrolled in a dual program where she gets exposed to both English and Spanish languages through the various activities of the day. She is currently enrolled in the following classes: art, math, science, reading/writing, and wellness. Moreover, she attends an after-school program from Monday through Thursday. Each day there is a different activity, such as, Sewing, Cool Tools, Meditation, Heart Class, and Leap Class. According to Angelina, her favorite after-school activity is Cool tools because she gets to build bird houses. She admits at times school could get boring and hard, because managing both languages can be difficult and the amount of homework given to her. Although school might be boring, she does enjoy reading about animals