The following is a proposed WIN medical evaluation that is conducted in our first patient appointment. The physician and /or Nurse practitioner will complete a thorough examination that can be broken down into three categories: medical, neurological, and therapeutic.
|Cause of symptoms||What is affected?
|How to fix it|
|Review medical history and review of systems||Cognitive skills
Memory, Processing of information
|Explanation of findings, diagnosis and initial plan of treatment|
|Development History||Sensory||Order objective evaluations for the findings and determine severity.|
|Academic / Socioemotional History||Motor (fine, gross, balance & coordination, viso-motor)||Referrals to other health professional, if necessary|
|Previous and current treatments||Speech (Receptive, Expressive, Language)||Order laboratory test|
|Complete physical evaluation||Socioemotional (Depression, low self-esteem)||Orders for medications and treatments as necessary|
|Middle Ear Function test (Tympanogram / Acoustic Reflex test||Extensive explanation of orders and schedule in house tests|
Medical: this is an evaluation that goes over the patient’s previous medical records and treatments. The doctor reviews developmental, school, and socioemotional history. There will also be a physical evaluation. The doctor reviews all the parent, caregiver and patient’s concerns. The doctor will fully analyze these findings and discuss them with the parent/caregiver or patient.
-Estimated Time: 45 mins
Neurological: the doctor investigates what neurological aspect may be affecting the patient cognition. In this exam the doctor evaluates the cognitive, sensory, motor (fine, gross, balance and coordination, viso-motor), speech and language skills, and their academic socioemotional state.
-Estimated Time: 20 mins
Therapeutic: once the complete evaluation is done, the doctor goes over the findings with the family and patient. She explains the evaluations /referrals that are needed to provide the objective evaluation of the findings and the initial plan to improve the patient’s condition.
After the doctor finishes, the family and/ or patient meets with the administrative personnel who will review the doctor’s instructions and schedule the in-house evaluations and laboratory studies. In addition, she will orient them in the pharmacy, medications and other orders.
Estimated Time: 30-45 min.
- The estimated times can vary depending on the condition.