Monday, March 15, 2010

Case review

Case Review

Patient details: Female, 56

Event leading to admission: Prolonged hypoglycemia - unconcious episode, lowered GCS

Pre-admission occupational performance
- Independent with grooming, and personal care tasks
- Independent mobility

Social Situ
- Lives with Husband - primary carer

OT input - Assessments:

Basic cognitive assessments - orientation, attention, object naming/use, working memory
Basic tasks - writing, reading,
Joint session with SLT - ruled out language problem - more cognitive problems
AMPS observation of grooming - combing hair and brushing teeth
Observations from AMPS
  • Prompt to start task
  • Indep with manipulating toothpaste - fine motor
  • Chose appropriate tools and used them appropriately
  • Assistance gathering and organising task environment - therapist intitated
  • Sitting in chair, stabilising body on table
  • Assistance to position table appropriately to perform task
  • Coordinating bilateral hand tasks effectively
  • Reduced grip strength ? due to arm positioning akwardly
  • Obtaining and holding task objects effectively
  • Poor endurance throughout task
  • Pace slow, however ? due to difficulty with terminating task
  • Attends to task, however distracted by others talking, however contiunes with tasks indep
  • Handles task objects appropraitely
  • Sequencing task appropriately
  • Repeats steps ? difficulty terminating task
  • Searches and locates objects
Overall minimal assistance with task and safe performing task with environment set up

Next step:
Further assessment of ADL's - showering and dressing
Determining a good understanding of prior level of cognition - mixed reports
Goal setting with rehab team - realistic goals


1 comment:

dog said...