Tuesday, March 3, 2009

Case review - performance components

Gender/age/primary diagnosis - Female/86/Compression # T12

Reason for referral - OT review decreased mobility

Medical Hx: Macular degeneration/Angina/AF/Bilat TJHR/Diverticulosis

Diverticulosis is a condition where pockets (pouches) form in the large intestine (colon).
Macular degeneration results in a gradual distortion of central vision, and sometimes leads to a central blind spot called a scotoma. When central vision is impaired, you may have difficulty recognizing faces and colors, driving a car, reading print, or doing close handwork, such as sewing or other handcrafts.

Social situ: Lives alone/Family supportive live close

Prior OT input: Rails installed by ACC for husband in bathroom, toilet and access

Supports before admission: HH 1/7

How managing before admission: I with ADL's ? unsafe cooking meals due to MD

Assistance on ward (mobility/self cares) - Supervision with mobility, Assist with transfers chair/bed/toilet.
Indep with upper body washing/drying/dressing
Assist with lower body washing/drying/dressing

OT input this admission/ Assessment(s): Initial assessment, transfer assessment, disussion with RN and Health care assessment

Problems identified:
-Unable to stand for long period of time
-Decrease vision ? safety at home for cooking meals (issue prior to admission)
-Assistance with lower body cares
-Assistance with transfers 1X

Goals for rehab:
-Increase independace - selfcare/transfers
-Pain management
-Increase standing tolerance
-Assess home situ re: safe for dishcharge re: visual impairment

Recommend for rehab
Handover to rehab team

Pt is happy to go to rehab for a week or two and increase her independance. She will most certainly require a home visit re: safety with cooking at home, and home environment.

Performance Components:

Sensory: age related hearing loss/macular degeneration(loss of central vision)/nociceptive - back pain, elbow and shoulder pain during shoulder flexion/extension/ mild hip pain

Physical: Good posture when supported; reduced ROM in R elbow and R shoulder; reduced strenght in arms for transfers; moderate endurance; visual motor eye hand slightly inpaired

Cognitive: now problems with attention/concetration/insight/orientation - nil others assessed

Percpetual: (Visual) recognition of faces/objects/words/colour; colour disccriminations; figure ground; pattern and shape recognition/matching

Perceptual: (Spacial) Depth percpetion; percpetion of angles and levels

Social: Little expression or gesture/emotion/

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