Name: Kayla Bullock
Date: 10/23/13
Case Study: Mark
Age: 58
Practice Setting: In-Patient Rehabilitation
Reason for referral: Mark was on vacation with his wife when he fell on the side of his bed. The next morning, he felt his legs buckle and knew to
sit down. He waited for someone to come home to take him to the hospital. Once he was at the hospital, it was discovered by an MRI that Mark had
a small infarction on the left side of his brain. He is currently reciveing treatment at Northeast Rehab Hospital in Portsmouth, New Hampshire
Client Name: Mark
Diagnosis: Mark had a left MCA (middle cerebral artery) stroke.
PMH: Mark had Medastatic Melanoma (brain tumor) in his right occipital and parietal lobes. In 2006 and 2007 he had radiation and a total of three
surgeries to remove the tumor. He has been cancer free since 2008 but it caused chronic left side weakness. Mark also has a history of parital
complex seizures, ataxia, high blood pressure, GERD (acid reflex), dyslipidemia (abnormal amounts of lipids), and a visual field cut.
Social History: Mark is a retired podiatrist and owns his own practice. He retired after he was diagnosed with a brain tumor but still volunteers at his
practice, which his wife manages. Mark lives with his wife in New York and usually handles the laundry, cooking, and dishes. He has three children
and two grandchildren. Some of his family lives nearby. He enjoys doing outdoor activities which include biking and hiking with his wife. He also
owns an RV which he and his wife used to travel.
Level of function PTA: Mark had partial complex seizures and left side weakness due to his previous diagnosed brain tumor. Although he had left
side weakness, Mark stated that he was still independent and was able to function with the weakness.
Medications: Lacosamide Vimpat (seizures), Atorvastatin calcium (lowers LDL or bad cholesterol in blood), Pantoprazole sodium (treats
gastroesophageal reflux disease or GERD and damage to the esophagus), Asprin (heart attack prevention), Albuterol Ventolin (inhaler), Fluticasone
Propionate (asthma and allergies), Finasteride Proscar (treats prostate gland enlargement), Tamsulosin HCL (benign prostatic hyperplasia or BPH)
Allergies: Mark is allergic to inhalants and sulfur.
Home Environment: Mark has a split level, raised ranch style home. It has two steps to get into the home, and once inside, you either go upstairs or
downstairs.
Leisure Interests: Mark enjoys traveling in his RV and outdoor activities such as biking, hiking, and walking trails with his wife.
Strengths: Mark has a good sense of humor and is motivated to become independent again. He also has a great support system. He lives with his
wife and has other family members close by.
Weaknesses: Mark’s wife is currently in New York taking care of his practice. Mark was admitted to a New Hampshire hospital for treatment and is
staying in New Hampshire until his discharge. He also already had left side weakness, and now because of his left CVA, he has right side weakness.
Right Upper extremity range of motion scores include: 90° flexion and 80° abduction. Right manual muscle testing scores include: 3- abduction, 3external and internal rotation, and a 3+ elbow flexion and extension.
Summary of OT Focus in relation to other team members: In the OT treatment sessions, Mark will work feeding, dressing, and doing laundry. He
will also be educated on the use of adaptive equipment and one-handed techniques.
Insurance Considerations: Mark has Capital District Physicians insurance which is an HMO. It is commercial insurance.
What are the occupational performance areas affected based on the case study information: The occupational performance areas affected are ADLs
and IADLs.
What will you need to assess: I will need to assess pain, range of motion, strength, endurance, cognition, ADLs, and IADLs,
How will you assess what you have listed above? To assess pain, I would have the patient rate their pain level with a rating 1-10. To test for range
of motion, I will use a goniometer. To test for strength, I will use manual muscle testing. To test for cognition I could use the MOCA or the
Contextual Memory Test. To assess for ADLs, I would use the Functional Independence Measure or the Barthel Index. To assess for IADLs, I
would use the KELS (Kohlman Evaluation of Living Skills).
Discuss environmental/contextual factors that would be important to consider as part of your evaluation: Mark will have a support system at home.
He lives with his wife that is able to help him with his daily routine. He also has children and grandchildren that live nearby. It is also important to
consider the home environment and how Mark’s home is set up. It is important to look at the way his bedroom and kitchen/dining room are set up
for his ADL goals of dressing and feeding. It is also important to look at the structure of his laundry room for his discharge goal of completing a load
of laundry.
Recommended service frequency and duration: 2X daily, five days a week for three weeks, treatment sessions 45 minutes long.
Treatment plan includes: ADL training (dressing himself using one handed techniques, and feeding himself using adaptive equipment), adaptive
equipment training, and patient education on one handed techniques.
Anticipated discharge setting: home with continued OT services in outpatient rehab.
_Kayla Bullock OTS_____________
Date: 11/4/2013
Targeted
Occupational
Performance
Problem Area &
Specific Problem to
Address
ADL: Mark
has a
decreased
ability to
engage in
the ADL task
of dress
himself.
Outcome of OT
Long Term Goal
&
3 short-term
goals
Cause(s) of Problem
LTG: By
discharge, Mark
will dress
himself while
seated using
both his right
and left arm,
with
supervision
Client Factors:
Mark has limited
range of motion
(ROM) and strength
in his right upper
and lower
extremity. He has
decreased endurance
and decreased
cognitive skills
(especially
memory). He also
has a left visual
field cut.
STG: Within 4
treatment
sessions, Mark
will button his
shirt using a
button hook
with minimal
assistance.
STG: Within 7
treatment
sessions, Mark
will donn a tshirt both
upper
extremities
with moderate
assistance
STG: Within 13
treatment
sessions, Mark
will donn his
pants using
both upper
extremities
with minimal
assistance.
Performance
Patterns: Mark’s
daily dressing
routine will change
because his right
upper extremity is
weaker than the is
used to. He will
have to move at a
slower rate until
he regains his
strength and ROM
Context: Mark is
not in his natural
environment and the
therapist may have
him do his dressing
at a time he is not
use to.
Performance Skills:
Mark’s right UE is
very weak and so he
will have to learn
Intervention
Approach &
Frame of Reference
Intervention
Approach: adapt
and restore
Frame of
Reference:
Rehabilitative
because I want to
maximize
performance in
occupations
through
adaptation of the
environment or
activity.
Biomechanical:
With Mark, the OT
will want to work
on regaining
strength and
range of motion,
which is needed
for one to dress
themselves.
Intervention Activities
(at least two activities)
& rationale for each using FOR
(& any grading anticipated)
Service Delivery
(who, where, when,
& frequency)
Activity: Mark will work on
dressing his upper and lower
body using his right UE
which is weak and has
limited range of motion. To
grade down this activity,
the OT can assist Mark with
the dressing task, or allow
him to complete task
sitting. To grade this task
up, the OT can have Mark
dress himself while
standing. This activity
would be part of the
Rehabilitative FOR because
it works on maximizing his
overall performance in
dressing by using new
techniques that will allow
him to be successful.
Who: Occupational
Therapist or COTA
Activity: Mark will work on
gathering clothing, using
only his weak right arm.
This will help Mark increase
strength and range of motion
in the right upper
extremity. To grade this
activity, the OT can
increase or decrease the
weight of the clothing item.
For example, to grade up,
the OT can have Mark gather
jeans rather than cotton
sweatpants. To grade down,
the OT would have Mark
gather the cotton sweatpants
over the jeans. This
activity uses the
Biomechanical FOR because it
Where: Inpatient
Rehab Hospital
within patients
room.
When: AM
Frequency:
3weeks, 2X a day
for 45 minutes, 5
days a week.
to move slower
until he regains
strength
works on increasing strength
and ROM in the weak right
upper extremity.
Targeted
Occupational
Performance
Problem Area &
Specific Problem to
Address
IADL: Mark
has a
decreased
ability to
engage in
the home
management
occupation
of doing
laundry.
Outcome of OT
Long Term Goal &
3 short-term goals
Cause(s) of Problem
LTG: By
discharge, Mark
will complete one
full load of
laundry using
both his right
and left upper
extremity, with
two verbal cues.
Client Factors:
Mark has limited
range of motion
(ROM) and strength
in his right upper
and lower
extremity. He has
decreased
endurance and
decreased
cognitive skills
(especially
memory). He also
has a left visual
field cut.
STG: Within 3
treatment
sessions, Mark
will collect
clothing spread
throughout the
room, while
seated in a
wheelchair, with
moderate
assistance
STG: Within 9
treatment
sessions, Mark
will separate
clothing items
using only his
right upper
extremity with
moderate
assistance.
STG: Within 2
weeks, Mark will
carry a small
load of laundry
in a laundry
basket over to
the washer, with
Performance
Patterns: One of
Mark’s roles is to
do the laundry.
This routine will
change because he
will have to start
doing a lot of the
task with his nondominant hand.
Context: Mark is
not in his natural
environment and
the washer may be
different than one
that he is use to.
Performance
Skills: Mark will
have to learn how
to use his nondominant hand to
help him complete
Intervention
Approach &
Frame of
Reference
Intervention
approach: adapt
and restore
FOR:
Rehabilitative
because I want
to maximize
performance in
this occupation
through
adaptation of
the environment
or activity
FOR:
Biomechanical
because it is
important to
have Mark work
on regaining
strength and
ROM, which is
needed to
complete this
occupation
Intervention Activities
(at least two activities)
& rationale for each using FOR (& any
grading anticipated)
Activity: Mark will work on
collecting clothing that
the therapist has spread
throughout therapy room.
Throughout this activity,
the therapist can indicate
which arm she wants Mark to
use. First, he should
start with his right arm,
which will also work on
range of motion and
strength, and as he gets
tired allow him to switch
to his left arm
(biomechanical FOR). This
activity can be graded up
by spreading the clothing
items really far apart
requiring more endurance.
It can be graded down by
placing the clothing in
close proximity to Mark.
Activity: Mark will
separate laundry items into
two piles: whites and
darks, using only his right
arm. This will work on
building strength and ROM
while also doing an
activity that is meaningful
to him (both rehabilitative
and biomechanical FOR). To
grade this activity, the
therapist can increase or
decrease the weight of the
clothing. To grade up, use
jeans and sweatshirts, and
to grade down, use tshirts.
Service Delivery
(who, where, when,
& frequency)
Who: Occupational
Therapist or COTA
Where: In-patient
laundry room
When: AM
Frequency: 3weeks,
2X a day for 45
minutes, 5 days a
week.
minimal
assistance.
this task
Targeted
Occupational
Performance
Problem Area &
Specific Problem
to Address
ADL: Mark
has a
decreased
ability to
engage in
the ADL task
of feeding
himself.
Outcome of OT
Long Term Goal &
3 short-term goals
LTG: By
discharge, Mark
will eat a bowl
of pasta
independently
with only his
right hand,
using adaptive
equipment.
STG: Within 3
treatment
sessions, Mark
will eat a meal
using a long
handled spoon
with moderate
assistance.
STG: Within 9
treatment
sessions, Mark
will drink a
glass of water
with his right
hand, using a
covered cup with
minimal
assistance.
STG: Within 2
weeks, Mark will
eat a sandwich
using both his
right and left
upper extremity
with minimal
assistance.
Cause(s) of
Problem
Client Factors:
Mark has limited
range of motion
and strength in
his right upper
extremity. He
has decreased
endurance and
decreased
cognitive skills.
He also has a
left visual field
cut.
Performance
Patterns: Mark
was independent
in feeding prior
to his CVA. He
must now adapt
his feeding
process until he
regains the
strength and ROM.
Context: Mark is
not in his
natural
environment and
may have to eat
in front of other
patients (if
eating in
cafeteria).
Performance
Skills: Mark will
have to learn how
to use the
adaptive
Intervention Approach
&
Frame of Reference
Intervention
Approach: adapt and
restore
FOR: Rehabilitative:
mainly because we
will be adapting the
process of feeding
to help maximize his
performance in the
occupation
FOR: Biomechanical:
the process of
feeding (with or
without adaptive
equipment) requires
strength and ROM in
the upper extremity.
Working on feeding
activities
simultaneously works
on strength and ROM.
Intervention Activities
(at least two activities)
& rationale for each
using FOR (& any
grading anticipated)
Activity: Mark will
eat meals using a long
handled spoon or fork.
This will adapt the
occupation so that
Mark does not need to
elevate his scapula or
flex his elbow to eat.
To grade this activity
the therapist would
need to use an
adjustable long
handled utensil. To
grade the activity up,
make the utensil
shorter. To grade the
activity down,
increase the length of
the utensil.
Activity: Mark will
drink a cup of water
using an adapted cup.
This cup will be
covered to prevent
spilling. To grade
this activity up, the
therapist can increase
the amount of water in
the cup, which will
increase the weight.
To grade this activity
down, the therapist
can decrease the
amount of water in the
cup.
Service Delivery
(who, where, when,
& frequency)
Who: Occupational
Therapist or COTA
Where: patient’s
bedroom or cafeteria.
When: AM and PM
Frequency: 3 weeks, 2X
a day for 45 minutes,
5 days a week.
equipment to help
with the process
of feeding.