Case Study Treatment Plan Project

Background History Information

Jacob Kennedy is an African American 35 year old male, who was seen today for
a speech-language evaluation and a hearing screening. He is a war veteran who has been
seen for hearing loss due to trauma received due to his occupation and how it is
impacting his speech and language. He was present during an explosion that resulted in
acoustic trauma and a perforated eardrum. He is the Presidents son and previously lived
at home with his wife and family. Currently, he is at an acute-rehab facility after having
his left leg amputated, which was damaged as well during the explosion. He first noticed
the hearing trauma after waking up from surgery for his leg amputation. He complains
that he cannot hear very well, requires people to speak to him very loudly to be able to
hear, and has difficulty understanding others. He reports that he is experiencing hearing
loss in both ears, but the left ear is more affected. He does not have any dizziness or
balance issues, but his hearing loss is a constant issue and does not tend to fluctuate. He
also does not have any history of hearing loss in his family. He has been previously
exposed to noise for long periods during his time in the military. He currently does not
wear a hearing aid. He is not taking any medications nor has any allergies. Additionally,
he does not have any difficulties with eating or swallowing. Self implementing strategies
that he uses with his family to compensate consist of having people write things down to
him versus saying them as he struggles hearing and understanding them.
Diagnosis
Patient is a 35 year old male with a primary diagnosis of bilateral hearing loss.
His diagnosis is characterized by profound, mixed hearing loss in the left ear and
moderate-severe sensorineural hearing loss in his right ear. His hearing loss is due to

sociocusis as he suffered a trauma in war while deployed. He has a perforated ear drum in
his left ear resulting from an explosion. Both the right and left cochlea have been
drastically affected from the trauma. This has impacted his ability to understand and
discriminate speech.
Description of Impairment
See attached audiogram, speech audiometry, otoacoustic emissions, and
tympanometry results.
The patient has a bilateral hearing loss. He has a moderate to severe sensorineural
hearing loss in the right ear and a profound mixed hearing loss in the left ear. With
regards to speech audiometry for the right ear, the patient has a pure-tone average and
speech reception threshold of 55 dB, a speech detection threshold of 50 dB, and word
discrimination testing would be possible at 90 dB. For the left ear, the patient has a puretone average and speech recognition threshold of 90 dB, a speech detection threshold of
80 dB, and word discrimination testing would not be possible because it would need to be
done at a sound level that is too high for an audiometer. The speech reception thresholds
are in agreement with each ears pure-tone average. Additionally, the speech detection
thresholds for each ear agree with the speech reception threshold within 5 to 10 dB.
These results corroborate a moderate to severe hearing loss in the right ear and a
profound hearing loss in the left ear.
Concerning tympanometry, the right ear would give results of a Type A
tympanogram, consistent with a sensorineural hearing loss as there is no outer and/or
middle ear pathology present. For the left ear, the results would indicate a Type B
tympanogram, indicating that there is no tympanic membrane movement as displayed by
a flat curve with no pressure peak and minimal compliance. These results are consistent
with the cause of the hearing loss, a perforated tympanic membrane.

For the otoacoustic emissions results, no transient-evoked otoacoustic emissions

(TEOAE) results would be possible as the patient would need to have hearing of 30 dB or
better. A distortion product otoacoustic emission result may be possible for the right ear,
as his hearing begins at 50 dB, but it would not be possible for the left ear because
hearing is severely impacted and sounds cannot be detected unless presented at 75 dB
HL. These OAE results are consistent with a moderate to severe hearing loss in the right
ear and a profound hearing loss in the left as these results are possible when normal to
mild moderate hearing loss is present. Therefore, an auditory brainstem response study
(ABR) may be warranted to further evaluate the left ear.
Due to the bilateral hearing loss, the patient may have speech-language
impairments that are consistent with speech sound discrimination difficulty due to the
loss of hearing of high frequency sounds, where speech occurs, and a moderate-severe
hearing loss. His hearing loss will result in him missing 100% of conversational speech;
therefore, making it necessary for speech to be very loud in order to be detected so he can
discriminate and comprehend the content of the conversation. These results suggest that
Jacob would benefit from a hearing aid, particularly for the right ear.
Impact of Hearing Loss on Communication Ability
Jacob was given two patient questionnaires to complete in order to assess the
functional impact of his hearing loss and communication. Jacobs spouse was given a
similar questionnaire to assess her feelings and on Jacobs current hearing and
communication abilities. A common theme throughout these questionnaires is the fact
that Jacob is misunderstanding majority of conversational speech and has major difficulty
participating in everyday communicative tasks. An important finding from the patient
questionnaire is that Jacob is most concerned that he is unable to understand what the

doctors are telling him. With further questioning Jacob revealed that he gets frustrated
because he wants to know his medical status and with the hearing loss the doctors have to
inform his wife and his wife relays the message back to Jacob. He has also expressed that
during group or one on one conversation he easily gets frustrated and will give up. He has
started to write things down to communicate but he feels that his communicative
partners shouldnt have to write to communicate with him. Based on his patient
questionnaire Jacob has difficulty communicating and hearing in most environments
practically always. He has scored an 87.5% severity indicating major hearing loss and
major functional impacts on communication. Jacob and his spouse both expressed
concern and both find his hearing loss hard to cope with. Prior to the accident Jacob was
a healthy, outgoing individual who loved to talk and participate in events and social
outings. However, with his condition, they feel he is more withdrawn and now dislikes
being in settings with a large group of people. Jacob stated that he can hear loud
environmental noises both in and outside of the hospital, but has trouble hearing the
important noises such as the telephone ringing for mealtime or professionals talking to
him. The significant other questionnaire revealed similar findings with an 82.5% severity
rating. This showed that the severity of Jacobs hearing and communication condition is
consistent among individuals. Jacob and his wife want him to get better and no longer
feel withdrawn and unable to communicate. This has been a drastic change for the both of
them and it is important for them that Jacob is assisted so that he can hear and
communicate in everyday situations.

Since Jacob is a healthy 35 year-old male who acquired a hearing loss due to a
traumatic event he continues to use oral communication. At this point, there is no interest
or recommendation to implement manual modes of communication. However, due to his
significant hearing loss he will experience major impacts on his communication. Severe

hearing loss results in the inability to hear conversational speech without any addition of
a hearing assistive device. Above is a chart of common sounds that Jacob will have
trouble hearing based on his hearing status. With a severe to profound hearing loss in one
ear Jacob will not hear sounds such as, a baby crying, dog barking, or a telephone
ringing. Jacobs language and cognition are seemingly intact making his situation less
complicated to remediate. If Jacob were to have suffered a brain injury that impaired his
expressive and receptive language speech-language treatment would be more
comprehensive and complex. A traumatic brain injury, alone, will impact an individuals
ability to communicate effectively as well as perform executive function and reasoning
tasks. Therefore, the individual would be able to hear language but processing and
understanding it will be affected. This individual may have difficulty expressing himself
through verbal communication. For instance a traumatic brain injury can cause apraxia of
speech that inhibits an individual to produce and sequence speech movements. The
presence of a hearing impairment paired with a language disorder will have a greater
impact on the individuals communication abilities. Trouble understanding language will
be exacerbated if the individual has a sensorineural hearing loss because not only will
they not understand what is being said they will now have issues with discriminating
speech sounds. For example, the occurrence of a fluent aphasia will cause trouble
understanding and comprehending spoken language but with a hearing impairment the
signal will be altered thus exacerbating the speech and language impairment. Treatment
would consist of treating the hearing impairment in order to ensure the individual is
hearing the information correctly before addressing the receptive understanding of the
language. Jacob has not suffered any brain injury, therefore he continues to have the same

cognitive status that he had prior to the accident. However, with his sensorineural hearing
loss Jacob will have difficulty discriminating what others are saying affecting his
receptive language.
Recommended Audiological Treatments/Remediations/Interventions
It is recommended that Jacob be referred for a tympanoplasty (type 1; with
normal middle ear function) to repair the ruptured tympanic membrane in his left ear.
According to the Ear Surgery Information Center, a tympanoplasty procedure involves
tissue being taken from the back of the ear or from the small cartilaginous lobe of skin in
front of the ear (i.e. the tragus). Jacob should undergo this surgery because the ruptured
tympanic membrane directly results in conductive hearing loss and potential for
subsequent infection/injury to the middle ear. After this surgical intervention, Jacob
should continue to visit a physician and audiologist to ensure that he is recovering
properly (i.e. no presence of invasive cholesteatoma which may prevent ear drum from
recovering). After full recovery of the tympanic membrane, Jacobs audiologist will be
able to re-test his hearing and recommend the next course of action to increase hearing
ability of the left ear (i.e. fitting him with a hearing aid if necessary).
In regards to his right ear, Jacob should be fitted for a behind the ear hearing aid.
Behind the ear hearing aids are recommended because they can supply more power than
alternate styles (i.e. fully in-the-ear style). An audiologist may recommend the Audicus
Dia which has two directional microphones, twelve channels and advanced signal
processing (information here: http://shop.audicus.com/products/dia-digital-hearing-aid?
gclid=CMjpoIOg0MkCFZEXHwodoXUCXw). Through this additional power, we can
optimize Jacobs hearing ability and attempt to overcome the detrimental impact of a

moderate-severe sensorineural hearing loss. Although hearing aids will not entirely
restore Jacobs hearing and discrimination ability to pre-injury status, they will be of
some assistance in increasing the amount he can hear. Sensorineural hearing loss is not
typically treated via medical or surgical means, therefore the hearing aid is the best option
for augmenting Jacobs hearing loss. After hearing aid placement, another audiometry test
should be completed to assess Jacobs ability to hear out of his right ear while aided. With
amplification from the hearing aid, Jacobs moderate-severe hearing loss may reduced to
a mild hearing loss. Hypothetical aided audiogram results are displayed on alternate page.
In regards to continuing care, routine audiologic management should be in place.
Jacob should visit the audiologist on a regular basis (i.e. every few months or so) to have
his right hearing aid re-checked and have frequency settings adjusted as necessary.
Initially, Jacob will need to be educated on signs that may alert him to see his audiologist
(i.e. presence of feedback due to faulty fit/improper volume/fluid in ear, presence of
cerumen in ear canal secondary to faulty fitting earmold). Self-monitoring and
assessment will be necessary during the months following surgical intervention and
hearing aid placement. It is important that the audiologist suggest that Jacob sign medical
clearance secondary to his sensorineural hearing loss. A local outpatient audiologist in the
Washington D.C. area has been identified whom which Jacob and his family can contact
and begin the evaluative process: Hillary Erickson within the GW Medical Faculty
Associates (www.gwdocs.com/audiology/find-a-physician).
Ultimately, the placement of the right hearing aid and the surgical repair of the left
tympanic membrane will augment Jacobs ability to follow directions while in the
subacute rehabilitation setting. Physical, occupational and speech therapy each require

the patient to be engaged and cooperative during sessions, and Jacob will be able to fully
participate in rehab tasks if he is able to hear the task instructions. Jacob will also be able
to better understand family and friends when they come to visit him in the subacute
rehabilitation center as well as once he is home. Re-adjusting to activities of daily living
in the community will be easier for Jacob if he is able to have somewhat of an
understanding of what is being said and what is going on in the environment around him.
Physical/Other Considerations for the Patients Condition
Jacob has suffered extensive physical injuries as a result of the explosion. After
the explosion Jacob was rushed to the hospital where he had his left leg amputated. He
currently uses a wheelchair to move around. Therefore it is important to address his
limited mobility and ensure that he has proper posture for all speech tasks. This will be
done by sitting him in his wheelchair or raising the bed to the proper degree to get the
most successful speech output. The presence of the physical condition and the hearing
impairment will impact his ability to complete tasks at a normal rate. More time should
be allotted to Jacob to give him the opportunity to complete tasks independently. His
vision and brain function remained intact and currently is functioning typically. This
makes it easier for Jacob to cope and learn how to function with his hearing loss and in
turn, speech-language deficits. Once Jacob arrived home from deployment, after the
accident, he was diagnosed with post-traumatic stress disorder (PTSD). He distances
himself from participation in social situations. The combination of PTSD and the
profound hearing loss needs to be monitored closely to ensure that Jacob doesnt become
depressed. It was recommended to Jacob and his family to attend weekly support groups
to help cope with the PTSD and another for the hearing loss and amputation both
individually and together. This is important for them in order to deal with these changes.

These support groups are held at the hospital and are held multiple times a week so Jacob
and his family can attend as often as needed.
Speech-Language Pathologist Involvement
Initially, the speech-language pathologist in the subacute setting can conduct a
cognitive screener (such as the short form of the BCAT) depending on reports from other
staff members or the results of a neurology report that are indicative of potential
neurological insult. If Jacob scores below normal limits on the cognitive screener, it is
recommended that the speech-language pathologist conduct a full evaluation to determine
Jacobs cognitive status and its potential impact on communication ability. When
evaluating Jacob, the speech-language pathologist must speak slowly, loudly and
precisely in order to ensure that Jacob understands what they are saying. It may be
necessary for the speech-language pathologist to sit in close proximity to Jacob and to
inform him that he must ask for instructions to be repeated if necessary. It is important for
the speech-language pathologist to inform the other working rehab staff (i.e. physical and
occupational therapists, rehab technicians) to communicate with Jacob in a similar
manner so that they can ensure that he understands directions and rationale for exercises.
Because Jacob does not currently have overt speech intelligibility issues, the
speech-language pathologist has the responsibility to conduct preventative measures and
educate both Jacob and his spouse on the potential impacts that hearing loss can have on
receptive and expressive language abilities. For example, Jacob should be informed that
loss of hearing can directly impact intelligibility of speech production secondary to the
decreased ability to hear self-produced speech. In regards to receptive language abilities,
the speech-language pathologist should work on discrimination of speech sounds with

Jacob once his hearing aid is placed and the tympanoplasty is conducted. An initial task
that may be worked on in therapy may involve the discrimination of minimal pair speech
sounds (i.e. math and bath). According to ASHAs Scope of Practice in SpeechLanguage Pathology document, the speech-language pathologist is also responsible for
troubleshooting and conducting listening checks of Jacobs hearing aid during his subacute rehab stay (ASHA 2007).
ASHA (2007) also specifies that the speech-language pathologist also holds the
responsibility of providing counseling to the patient and his spouse. Jacobs hearing loss
and subsequent inability to communicate as effectively as before may lead to depressive
symptoms. It is up to the speech-language pathologist to counsel Jacob and ensure him
that together they will work to get him to understand others and communicate to his
fullest potential. While in rehab, the speech-language pathologist can work with Jacob to
set up a schedule he can follow that includes audiologist appointments to ensure proper
functioning of his hearing aid. The speech-language pathologist will also make sure that
Jacob and his wife have the contact information of his hearing aid dispenser in case they
need to troubleshoot the device at home. The company who manufactures Jacobs BTE
hearing aid (Audicus) can be contacted at 888-979-6918 or online at www.audicus.com.
The speech-language pathologist must collaborate with these rehab staff members
as well as with Jacobs audiologist, neurologist and physician to create a well-rounded
treatment plan that can target a variety of Jacobs needs. For example, the speechlanguage pathologist should sit with the OT and PT and come up with overarching goals
that can be achieved in each of the three types of rehab sessions. The speech-language
pathologist should remain in constant communication with Jacobs audiologist in regards

to the surgery and hearing aid placement as well as course of treatment post-subacute
rehab.
Towards the end of Jacobs stay in rehab, the speech-language pathologist can
work with Jacob on creating a list of assistive devices that he may purchase for his home
environment. These may include telephone and doorbell alerts that flash (visual input to
help in case Jacob does not hear these stimuli) and closed captioning on the television.
Additionally, the speech-language pathologist can assist in formulating a list of
modifications to Jacobs physical environments both at home and later, at work, that will
assist him in hearing others better. For example, the speech-language pathologist may
instruct Jacob to tell conversational partners to stand on his right side (the aided ear),
until his left ear fully recovers from surgery.
Patients Demographics and Other Accommodations
Jacob is an affluent, African American 35 year old male and is the presidents son.
He is college educated and comes from an educated and well to do family as well. He is
currently in an inpatient rehabilitation facility, recovering from trauma he as suffered
during war as he was in the military. Currently he requires the use of a wheelchair due to
his left leg being amputated. His family is very supportive of him and comes to visit
often. When he transitions to outpatient care and returns home, his family will make
accommodations, such as having wheel-chair access for the house. They are also very
concerned and informed about his medical treatment plans and speak to doctors and other
medical professionals involved in his care plan. They will be able to transport him to all
treatment sessions upon returning to home and collaborate with doctors for all aspects of
treatment. Both Jacob and his family are very compliant with all medical

recommendations and treatments made. Jacob and his family are monolingual and do not
have any language concerns when speaking with involved medical providers.
Applicable Laws and Regulations
Now that Jacob is considered disabled due to his hearing and physical impairment
he is, by law, permitted to have accommodations made for him that allow him to function
in society like a typical individual. Laws that pertain specifically to Jacobs case consist
of:
1. Section 501, 502, and 504 (under Title V) of the Rehabilitation Act
2. The Americans with Disabilities Act (ADA) of 1990
3. Occupational Safety and Health Act (OSHA)
4. Health Insurance Portability and Accountability Act (HIPAA)
Title V of the Rehabilitation Act of 1973 encompasses Sections 501, 502, 503 and
504 that all consist of rights for individuals with disabilities in the community. Since
Jacob plans to go back to work when he is capable of doing so this act legally states that
he will be given equal opportunities in the work force. Section 501 states that the
government must hire and give equal training and promotions to those with disabilities.
Section 502 applies to Jacob because of his physical disability (his leg) as well as his
hearing loss. This section states that federally funded building and modes of
transportation must accommodate for any individual with disabilities in order to provide
equal access. Section 504 ensures that Jacob will not be discriminated based on his
disability in a work setting. The Occupational Safety and Health Act protects individuals
in the working environment from conditions that may impact their health. Any position
that required loud noise exposure or hazardous working environments is obligated to
protect their staff. When Jacob goes back to work, and depending on his job, he will be
covered by OSHA to ensure that he stays protected. This means he will get visual aids to
alert him in an emergency and any will be protected from any prolonged noise exposure.

This is important because Jacob is susceptible for hearing loss and it is necessary to make
sure his hearing loss does not worsen.
The Americans with Disability Act of 1990 mandates that individuals will not be
discriminated at work or in the community and will provide equal opportunity. Under this
act Jacob will be able to partake and benefit from government services, programs,
activities, employment, recreation and other social services. Therefore, Jacob will receive
visual assistance to accommodate for his hearing loss at work, such as a blinking light on
the telephone. These laws will pertain to Jacob both in the hospital and out in the real
world. The purpose of these laws is to make sure Jacob has the ability to be independent
during activities of daily living.
During Jacobs stay at the hospital he is guaranteed privacy of all medical records
and history under HIPPA. This Act maintains privacy and security of all identifiable
health records of the individual. This means, under no circumstances can Jacobs records
be revealed to any entity without his permission. This ensures that all health information
regarding Jacob remains confidential. Since Jacob is a high profile client this law is
especially important.
Recommendations
It is recommended that Jacob received speech-language pathology services 5x a
week for 3 weeks (remainder of his subacute rehab stay) in order to enhance his ability to
communicate with others.

References
ADA.gov. (n.d.). Retrieved from http://www.ada.gov/ada_intro.htm
George Washington University Speech and Hearing Center Adult Case History Form Audiology.
https://speechhearing.columbian.gwu.edu/sites/speechhearing.columbian.gwu.edu/files/d
ownloads/Adult%20Intake%20Form%20-%20Website%202015.pdf
Lamar University Case History Form: Adults Speech and Language Disorders.
https://fineartscomm.lamar.edu/_files/documents/speech-hearing/adult_intake.pdf
Tympanoplasty Surgery. Ear Surgery Information Center. Retrieved from
http://www.earsurgery.org/surgery/tympanoplasty-surgery/
Reproduced from American Speech-Language Hearing Association. (2007). Scope of
Practice in Speech-Language Pathology. http://www.asha.org/policy/SP2007-00283
Rehabilitation Act of 1973. National Association of the Deaf. Retrieve from
https://nad.org/issues/civil-rights/rehabilitation-act-1973
Schow and Nerbonne (1982). Self-Assessment of Communication.
Schow and Nerbonne (1982). Significant Other Assessment of Communication.
Self-Test for Hearing Loss. (n.d.). Retrieved from
http://www.asha.org/public/hearing/Self-Test-for-Hearing-Loss/
The Speech & Hearing Center. Hearing Case History Adult Form. Speech Case History
Adult Form.
http://www.speechhearing.com/patient-forms
Welling, D., & Ukstins, C. (2015). Fundamentals of audiology for the speech-language
pathologist.

LEFT EAR:
profound mixed hearing
loss

RIGHT EAR:
moderate-severe sensorineural hearing
loss

PTA

90 dB

55 dB

SDT

80 dB

50 dB

SRT

90 dB

55 dB

125 dB

90 dB

WDS
@ dB
LEVEL
OAE

DOAE: 50 dB