Case Studies for Contemporary Occupational Therapy Practice Guiding Critical Thinking for Students

Case Studies for Contemporary
Occupational Therapy Practice

Guiding Critical Thinking for Students
Edited by Donald Auriemma, Yves Roseus,

Clover Hutchinson, and Vikram Pagpatan
Case Studies for Contemporary
Occupational Therapy Practice
Edited by Donald Auriemma, MS ED, OTR/L; Yves Roseus, OTD, OTR/L;

Clover Hutchinson, OTD, MA, OTR/L; and Vikram Pagpatan, OTR/L, ATP, BCP, CLA
AOTA Vision 2025
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The American Occupational Therapy Association advances occupational therapy practice, education, and research through
standard-setting and advocacy on behalf of its members, the profession, and the public.
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Cover art by Darlyn Mora Almonte, Jamaica, NY

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Case study photo sources: Chapters 7, 8, and 10 by Unsplash.com. All others by Getty Images. Used under license.
Reference citation: Auriemma, D., Roseus, Y., Hutchinson, C., & Pagpatan, V. (Eds.). (2023). Case studies for contemporary occupa-
tional therapy practice: Guiding critical thinking for students. AOTA Press.
Dedication
This text is dedicated to Professors Wimberley Edwards, Yvonne Flowers, and Ruth Kriam, the founding
faculty of the Occupational Therapy Program at York College of the City University of New York. Their
vision, efforts, and foresight have inspired the collaboration of York alumni to create this text.
iii
In Memoriam
In memory of Dr. Yves Rosesus, co-editor, contributing author, and dear
friend. He lost his life in the service of humanity during the COVID-19 pan-
demic. His memory lives on through his many selfless acts, his contribu-
tions, the lives he touched, and this text.
iv
Contents
About the Editors..............................................................................................................................................................ix
Contributors ......................................................................................................................................................................xi
Note From the Artist .......................................................................................................................................................xv
Introduction.................................................................................................................................................................. xvii
Donald Auriemma, MS ED, OTR/L; Clover Hutchinson, OTD, MA, OTR/L; and Vikram Pagpatan,
OTR/L, ATP, BCP, CLA
Section I. Acute Care......................................................................................................................1

Chapter 1. Juan: Myocardial Infarction....................................................................................................................... 3
Donald Auriemma, MS ED, OTR/L
Chapter 2. Song: Cerebral Vascular Accident (Right) .............................................................................................11
Chapter 3. Ethan: Complete C6 Spinal Cord Injury ............................................................................................... 19
Chapter 4. Hannah: Congestive Heart Failure.........................................................................................................27
Chapter 5. Howie: Right Distal Radius and Ulna Fracture ...................................................................................35
Yves Roseus, OTD, OTR/L
Section II. Outpatient Rehabilitation ....................................................................................43

Chapter 6. Florence: Rheumatoid Arthritis..............................................................................................................45
Chapter 7. Brian: Traumatic Above-Elbow Amputation........................................................................................53
Chapter 8. Yvonne: Breast Cancer .............................................................................................................................. 61
Chapter 9. Chin: Carpal Tunnel Syndrome...............................................................................................................69
Clover Hutchinson, OTD, MA, OTR/L
Chapter 10. Patricia: Laceration of Flexor Digitorum Profundus and Superficialis Tendons ...................... 77
Section III. Rehabilitation Unit or Rehabilitation Hospital .............................................85

Chapter 11. Chapter 11. Fetu: Cerebral Vascular Accident ....................................................................................87
v
vi | CONTENTS
Chapter 12. Bianca: Spinal Cord Injury, Complete C5 ...........................................................................................95

Chapter 13. Derrick: Traumatic Brain Injury .........................................................................................................103
Chapter 14. Sharon: Peripheral Vascular Disease................................................................................................... 111
Chapter 15. Zachary: Burn .......................................................................................................................................... 119
Section IV. Subacute Rehabilitation ..................................................................................... 127

Chapter 16. Isaura: Lupus ...........................................................................................................................................129
Chapter 17. Pierre-Louis: Osteoarthritis.................................................................................................................. 137
Bebe Hanif, OTR/L
Chapter 18. Rosalind: Multiple Sclerosis................................................................................................................. 145
Eva Rodriguez, PhD, OTR
Chapter 19. Aki: Congestive Heart Failure .............................................................................................................. 153
Frederick Wolodin, MS, OTR/L
Chapter 20. Ting: Osteoporosis ..................................................................................................................................161
Section V. Skilled Nursing Facility or Long-Term Care .................................................... 169

Chapter 21. Jacob: Alzheimer’s Disease ...................................................................................................................171
Bebe Hanif, MS, OTR/L
Chapter 22. Aretha: End-Stage Renal Disease ....................................................................................................... 179
Vikram Pagpatan, OTR/L, ATP, BCP, CLA
Chapter 23. Epa: Diabetes........................................................................................................................................... 187
Chapter 24. Mohammad: Chronic Obstructive Pulmonary Disease................................................................. 195
Section VI. Home and Community Health ..........................................................................203

Chapter 25. Eileen: Amyotrophic Lateral Sclerosis ............................................................................................. 205
Chapter 26. José: Alcohol Abuse ............................................................................................................................... 213
Donald Auriemma, MS ED, OTR/L; Clover Hutchinson, OTD, MA, OTR/L; and Vikram Pagpatan,
OTR/L, ATP, BCP, CLA
vi
CONTENTS | vii
Chapter 27. Katrina: Huntington’s Disease............................................................................................................. 221

Chapter 28. Ivy: SARS-CoV-2 (COVID-19) ............................................................................................................ 229
Section VII. Inpatient Behavior Health Hospital or Unit ................................................ 237

Chapter 29. Zoran: Depression ................................................................................................................................. 239
Chapter 30. Gabriela: Bipolar Disorder ................................................................................................................. 247
Chapter 31. Samuel: Schizophrenia ..........................................................................................................................255
Mary Devadas, MS, OTR/L, DBA, and Kerron Blunte, MS, OTR/L, CLT
Chapter 32. Emmanuel: Posttraumatic Stress Disorder ..................................................................................... 263
Donald Auriemma, MS ED, OTR/L; Clover Hutchinson, OTD, MA, OTR/L;
and Vikram Pagpatan, OTR/L, ATP, BCP, CLA
Chapter 33. Andres: Alcohol and Substance Use Disorders ............................................................................... 271
Chapter 34. Brianna: Anorexia Nervosa ..................................................................................................................279
Tiffany Cordero-Velez, MS, OTR/L
Section VIII. Pediatric Services.............................................................................................. 287

Chapter 35. Victoria: Spina Bifida ............................................................................................................................ 289
Paula Stewart, MS, OTR/L
Chapter 36. Abigale: Autism Spectrum Disorder ..................................................................................................297
Chapter 37. Andrei: Dyslexia ..................................................................................................................................... 305
Tiffany Cordero-Velez, MS, OTR/L; Susan Quintin, MS, OTR/L; and Tiffany Almonte, MS, OTR/L
Chapter 38. Dara: Down Syndrome .......................................................................................................................... 313
Ivy Rentz, EdD, MSA, OTR/L
Chapter 39. Chi-Ling: Cerebral Palsy ....................................................................................................................... 321
Chapter 40. Dion: Fetal Alcohol Syndrome ........................................................................................................... 329
Carol Brown-Wassinger, MS, OTR/L
Appendix A. Educator’s Guide ..................................................................................................................................337

Appendix B. Matching ACOTE® Standards and Learning Outcomes With Text Questions
and Activities Tool ....................................................................................................................................................... 345
Appendix C. Diversity Represented Through Individuals Presented in Cases.............................................. 351
vii
About the Editors
Donald Auriemma, MS ED, OTR/L (he/him), is an Italian American occupational therapist
from Southold, New York. He is an associate professor and chair in the Department of Occupational
Therapy, at York College of the City University of New York (CUNY). He earned his bachelor of science
degree in occupational therapy in 1982 at York College of CUNY and his master of science degree in
education from Queens College of CUNY in 1985.
As a clinician, Donald’s concentration of practice was adult disabilities. During his career, he earned
board certification in both neurorehabilitation and assistive technology. As a scholar, his research has fo-
cused on the methods programs have used to admit its students and the impact of the use of those selected
tools. As an educator, he has been he has been dedicated to the development of York’s students pursuing
professional education, and their professional development beyond graduation. The three additional ed-
itors and all contributing authors but one are former students.
Yves Roseus, OTD, OTR/L (he/him), was a Haitian American occupational therapist from Queens, New
York. He was an adjunct assistant professor at several occupational therapy programs, including York
College, CUNY, his alma mater. Yves was a passionate practitioner and delegate at Brookdale Hospital &
Medical Center in Brooklyn, New York.
Yves was a board member of and instrumental in the establishment of the only occupational therapy
program at Faculté des Sciences de Réhabilitation de Léogâne (FSRL)—Léogâne, Haiti. Yves was an ar-
dent advocate for occupational therapy, a New York State Occupational Therapy Association (NYSOTA)
trustee, an Accreditation Council for Occupational Therapy Education evaluator, and a member of the
American Occupational Therapy Association (AOTA) and New York State Black Occupational Therapy
Caucus (NYSBOTC). He was a recipient of the NYSBOTC Celeste Pasely Merit Award. Yves’s service
and contribution to the profession has been memorialized by renaming the Dr. Yves Roseus Department
of Rehabilitation at Brookdale Hospital & Medical Center and the establishment of the Dr. Yves Roseus
Citizen’s Award for Service and Advocacy in Occupational Therapy at York College, CUNY, and NYSOTA,
and the Dr. Yves Roseus Memorial Lectureship and Practicum that is awarded to an occupational therapy
student and practitioner living in Haiti.
Clover Hutchinson, OTD, MA, OTR/L (she/her), is a Jamaican American occupational therapist from
Queens, New York. She is an assistant professor at and graduate of York College, CUNY. Formerly, she was
the chief of occupational therapy for over 23 years at Brookdale Hospital & Medical Center in Brooklyn,
New York, where she established occupational therapy in acute care and expanded its outpatient de-
partment. Clover is passionate about the advocacy and mentorship of students, practitioners, and the
profession.
Clover’s passion is evident in her work as president of NYSBOTC; co-founder of the Coalition of
Occupational Therapy Advocates for Diversity, York College Chapter; leadership and committee mem-
ber of NYSOTA; member of the American Occupational Therapy Association’s Accreditation Roster of
Evaluators and other local organizations. Clover is a recipient of the NYSOTA distinguished Dr. Jim
Hinojosa Memorial Lectureship award, which honors practitioners who exemplify qualities of leader-
ship, mentorship, and contributions to the practice and education in occupational therapy. Additionally,
Clover volunteers as an instructor for the Faculté des Sciences de Réhabilitation de Léogâne (FSRL)—
Léogâne, Haiti, and facilitates mentorship to occupational therapy practitioners in Kenya.
ix
x | ABOUT THE EDITORS
Vikram Pagpatan, OTR/L, ATP, BCP, CLA (he/him), is an Indian American occupational therapist from
Queens, New York. He is an assistant professor and admissions coordinator for the State University of
New York (SUNY) Downstate Health Sciences University graduate occupational therapy program and
an adjunct assistant professor for the occupational therapy program at York College, CUNY, his distin-
guished alma mater.
Vikram’s clinical specialties are assistive technology, neuromotor pediatric practice, and community
reintegration with progressive neurological populations. Vikram’s clinical focus is on the integration
of assistive technology as an integral and practical part of ADLs and IADLs for individuals throughout
the lifespan. Vikram’s research interests include investigating concepts of e-professionalism in higher
education curriculums, social media integration as a form of professional development for health care
professions, exploring holistic higher education admissions best practice to address gender diversity for
gender-exclusive professions, and highlighting marginalized populations through reformed admissions
procedures.
Vikram’s leadership roles includes his service as an AOTA Board Director and AOTA DEI commit-
tee member, continued work on statewide policy reform within multiple SUNY-wide University Faculty
Senate committees, and his passion for advocacy as the communications chair of the Association of Asian-
Americans and Pacific Islanders in Occupational Therapy.
x
Contributors
Tiffany Almonte, MS, OTR/L
Adjunct Lecturer
York College of the City University of New York
Jamaica, NY
Occupational Therapy Supervisor
Saint Dominic’s Family Services/CISS
New York, NY
York College Class of 2016

Associate Professor and Chair
Department of Occupational Therapy
Jamaica, NY
Kerron Blunte, MS, OTR/L, CLT

Adjunct Lecturer
Jamaica, NY
Northwell Health STARS Rehabilitation
Jamaica, NY
Carol Brown-Wassinger, MS, OTR/L

Senior Occupational Therapist
New York City Department of Education, District 75
New York, NY
Tiffany Cordero-Velez, MS, OTR/L

Adjunct Lecturer
Jamaica, NY
New York City Department of Education
New York, NY
xi
xii | CONTRIBUTORS
Mary Devadas, MS, OTR/L, DBA

Adjunct Assistant Professor
Jamaica, NY
Kingsbrook Jewish Medical Center
Brooklyn, NY
Bebe Haniff, MS, OTR/L

Jamaica Nursing Home
Jamaica, NY

Assistant Professor
Jamaica, NY

Jamaica, NY
Assistant Professor and Admissions Coordinator
SUNY Downstate Health Sciences University
Brooklyn, NY
Susan Quintin, MS, OTR/L

New York City Department of Education
New York, NY
Ivy Rentz, EdD, MSA, OTR/L

Assistant Professor and Doctoral Capstone Coordinator
Quinnipiac University
Hamden, CT
CONTRIBUTORS | xiii
Eva Rodriguez, PhD, OTR

Associate Professor and Program Director
Jamaica, NY

Jamaica, NY
Brookdale Hospital & Medical Center
Brooklyn, NY

Adjunct Lecturer
Jamaica, NY
Co-Executive Director
Occupational Therapy for Kidz Specializing in Sensory Integration for Kids
Cambria Heights, NY
Frederick Wolodin, MS, OTR/L

Montefiore Medical Center
Bronx, NY
Note From the Artist
For the artwork used on the cover of this text, Lives and Apples, the apples represent how diverse yet sim-
ilar we are as human beings. Just as apples are categorized by color, sweetness, or acidity, human beings
are often categorized based on physical appearances, race, ethnicity, culture, sex, gender, physical and
mental health, and so forth. Society should approach human beings in a way that promotes and practices
social equity. Regardless of individuals’ traits, each person deserves to live in an environment that ac-
cepts, understands, and respects them and facilitates their participation and engagement in occupations.
Occupational therapy is a holistic profession that treats an individual as a whole person—not just the
symptoms of their diseases, conditions, or disorders. The occupational therapy profession believes that
having a disability does not mean being disabled. Even when participation in an occupation might not be
achieved by remediation or restoration approaches, occupational therapy professionals will always work
on modifying and adapting the environment to the individual’s needs.
In the painting, the book represents education and resources, which give the yellow apple an advantage
over the rest. The book gives support and clarity to the individual, who once felt useless and incapable—
like a mannequin—to recognize their strengths, find their courage, and chase their dreams. Education,
occupational therapy, and many other resources and experiences can affect how one faces and overcomes
challenges; the individual is functional in society with or without, in this case, an extremity. The peeled
half-apple and the gray apple symbolize role and identity—despite their stage of life or appearance, they
remain apples.
No matter the labels, condition, or stage of life, participation in meaningful activities gives people dig-
nity, self-efficacy, and health.
—Darlyn Mora Almonte, OTS

York College, City University of New York, Jamaica, NY
xv
Introduction
DONALD AURIEMMA, MS ED, OTR/L; CLOVER HUTCHINSON, OTD, MA, OTR/L;
AND VIKRAM PAGPATAN, OTR/L, ATP, BCP, CLA
Case Studies for Contemporary Occupational Therapy Practice: Guiding Critical Thinking for Students was
created by the combined efforts of 16 accomplished alumni of the Occupational Therapy Program at York
College of the City University of New York. The focus of this group was to create a case-based text that
could be used across an occupational therapy curriculum, guide critical thinking, and bridge contempo-
rary practice with the Occupational Therapy Practice Framework: Domain and Process (4th ed; American
Occupational Therapy Association, 2020) and Accreditation Council on Occupational Therapy Education
(2018) standards. It is the desire of the contributors to better prepare students to enter practice in our
diverse and rapidly changing world.
This text was envisioned for occupational therapists, occupational therapy assistants, occupational
therapy students, and educators through a model of cultural humility, awareness, and competency. It ac-
knowledges the importance of incorporating the various principles and tenets of diversity, equity, jus-
tice, inclusion, and belonging through a contemporary and practice-based interpretation of occupational
therapy.
This text threads various aspects of diversity and cultural humility throughout each case and accom-
panies the reader through a journey of exploring social determinants of health; problem solving through
an array of sociocultural and socioeconomic disparities that exist within communities; and developing
analytical, pragmatic, inferential, and clinical reasoning skills through a holistic, case-based lens.
How This Text is Organized

This case text is structured through a discovery and exploration model. Each case begins by presenting
the medical and social history of each client, illustrating the individual’s past and current occupational
identities, and highlighting a potential mechanism of injury or explaining events that brought the indi-
vidual to occupational therapy.
Readers are guided through a uniformed structure for every case presented in this text, fostering a
greater awareness of process throughout a series of practice areas and domains. Readers are presented
with a detailed social history that correlates clients’ occupational identities to their current need of care
while allowing readers to explore other meaningful aspects of clients’ identities that can be used to design
treatment and services. Additionally, readers are presented with information outlining the occupational
therapy initial evaluation findings. This is done through a culturally centered occupational profile and
an occupation-centered exploration of the client’s cognitive, mental, and physical functions. In the last
section of each case study, readers are presented with thought-provoking questions that are designed to
address aspects of community reintegration, social determinants of health, and disparities.
xvii
xviii | INTRODUCTION
Students
Occupational therapy students, occupational therapy assistant students, and postprofessional occupa-
tional therapy students can use this text as a resource, tool, and guide to develop clinical reasoning and
interpersonal skills through a model of diversity, equity, and justice while fostering a greater awareness of
cultural humility and competency building. Students will be confronted with and challenged by ethical di-
lemmas and disparities within the contexts of culture and community as they develop their professional,
interpersonal, and clinical reasoning skills as entry-level practitioners. Students are encouraged to ask
questions, challenge notions, discuss their implicit biases, and integrate a holistic perspective throughout
each occupational therapy case.
Educators
This text enables students to grow and develop intricate competencies of cultural humility and a greater
understanding of diversity, equity, and inclusion at their own pace through guidance and facilitation.
Academic and clinical educators can use this comprehensive text as a part of their program curriculums
as a pathway text for each major component of the occupational therapy educational process, such as
through principles evaluation, treatment planning, and outcome assessment. Each case study also allows
educators to select a specific practice population or diagnosis while integrating principles of diversity,
equity, inclusion, and cultural humility throughout the entire case—from the occupational profile to the
critical guiding questions that directly align with the OTPF–4.
REFERENCES
Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational
Therapy Education (ACOTE®) standards and interpretive guide (effective July 31, 2020). American Journal of
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org/10.5014/ajot.2018.72S217
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process
(4th ed.). American Journal of Occupational Therapy, 74(2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
Acute Care SECTION I
1
1
Juan: Myocardial Infarction

DONALD AURIEMMA, MS ED, OTR/L
Juan (he, him, his, himself)
MEDICAL HISTORY
Juan is a 67-year-old Guatemalan American male who is 6' 1" and weighs 190 pounds. He was brought to
the emergency department (ED) via emergency medical services after experiencing uncomfortable pres-
sure in his chest, shortness of breath (SOB), and nausea while gardening at home. An electrocardiogram,
blood tests, echocardiogram, and chest X-ray were performed, and he received a diagnosis of myocardial
infarction (MI) and coronary artery disease. He was then transferred from the ED to the coronary care
unit (CCU), where an emergency coronary artery bypass graft ×3 was performed.
His past medical history included treatment for hypertension and high cholesterol. Upon admission,
he reported living a sedentary lifestyle, smoking one pack of cigarettes per week, drinking 4 to 5 cups of
coffee per day, and consuming 2 to 3 glasses of wine per day. Juan reported no known allergies.
SOCIAL HISTORY
Juan lives with his partner of 25 years, Brian, in a two-story brownstone townhouse that they both own.
There are three steps to enter the first floor, which consists of a living room, dining room, and galley
kitchen. The second floor has two bedrooms and a full bath. The home is neat and orderly. There is no ga-
rage, but there are two dedicated parking spots in front of their home. Their home is just 5 miles from the
university where they both work. Juan reported having no blood relatives in the area but having a close
group of friends. He and his partner both observe the Catholic religion.
REFERRAL OR PRESCRIPTION
At the CCU, Juan will receive occupational therapy, physical therapy, and registered nursing services for
5 days.
3
4 | CASE STUDIES FOR CONTEMPORARY OCCUPATIONAL THERAPY PRACTICE
Occupational Therapy Initial Evaluation Findings: Acute Care
OCCUPATIONAL PROFILE
Juan’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Juan has been employed as a tenured professor of fine arts for the past 27 years and
serves as the chair of his department. Juan stated, “Being department chair is extremely stressful,”
and he felt fortunate that this happened to him during summer break. His patterns of daily living
most commonly included having a quick cup of coffee in the morning, arriving on campus by 9:00
a.m., and returning home by 5:00 p.m. He and Brian enjoy dining out for dinner and seldom have
dinner at home. After dinner, Juan enjoys reading and sculpting. On the weekends, he loves to work
in his garden. When school is out, Juan and Brian love to travel. His interests include art, design,
and exploration, and he values how art can affect and shape society. Juan reported that his greatest
current need is to understand what happened to him and feel safe enough to return to the life he
loves.
ADLs
Regarding self-care, Juan was able to feed himself independently but reported SOB after eating a
large meal. While seated, Juan was able to dress both upper extremities independently in a slow
spontaneous fashion, but he required minimal assistance to dress his lower extremities. During
dressing, his respiration rate elevated to 30 breaths per minute from a baseline of 20; he also com-
plained of SOB. He was able to independently perform the grooming tasks of brushing his hair
and teeth. He reported he did not feel he had enough endurance to attempt standing in the tub
to shower but was able to sit to manage bowel and bladder care. A score of 4 was achieved on the
modified Medical Research Council (mMRC) scale (Mahler & Wells, 1988).
Regarding functional mobility, Juan was able to independently roll and transition between su-
pine and short sit and transferred without a device on and off the bed, chair, and toilet. Tub trans-
fers were not attempted. During the assessment, he required multiple rest periods and verbal cues
to maintain a slower pace, because he reported feeling lightheaded.
IADLs
Activities needed that provide day-to-day quality of life and relative independence were explored.
Juan can manage his phone and computer communications and handle his finances. Currently, he
is not able to maintain his home, prepare meals, or shop.
Regarding rest and sleep, Juan reported having a history of short sleep duration. Currently, he
becomes anxious and feels uncomfortable when sleeping in a fully reclined position.
MENTAL FUNCTIONS
Cognitive assessment found Juan to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. He is able to follow three-step commands and make his
needs known. Affect appeared appropriate, and no gross deficits in perception were observed.
JUAN: MYOCARDIAL INFARCTION | 5
SENSORY FUNCTIONS
No gross deficits were observed with visual, hearing, vestibular, taste, smell, proprioceptive, and
cutaneous functions. Juan reported pain and swelling to his right posterior hand at the site of intra-
venous. Pain was scored as a 4 using a numerical rating scale (0–10) and was described as “throb-
bing.” Edema was assessed using circumferential measurements at the distal palmar crease: 20.3
cm on the right and 17.6 cm on the left.
CARDIOVASCULAR AND RESPIRATORY SYSTEMS FUNCTION

Juan presented with a metabolic equivalent of task (MET) value of 2.5.
MOVEMENT FUNCTIONS
Passive and active range of motion is within functional limits in all extremities. Assessment of mus-
cle strength was contraindicated. Prehension was grossly intact. Juan tolerated standing for 2–3
minutes before reporting fatigue.
NEUROMUSCULAR FUNCTIONS
Static and dynamic sitting balance are both graded as good (G). Static and dynamic standing bal-
ance are both graded as fair plus (F+). Muscle tone is normal, and reflex integration is grossly intact.
PLAN FOR DISCHARGE

After 5 days in the CCU, Juan will be discharged home with home health care services, including occu-
pational therapy; physical therapy; and registered nursing, social work, and home health aide services.
Questions and Activities
SAFETY OF CLIENT AND OTHERS: PRECAUTIONS AND CONTRAINDICATIONS

1. While working with Juan, what are the signs and symptoms of cardiac distress you need to be
monitoring?
2. Which vital signs should be taken when working with Juan? What are the norms for each? Explain
when these vital signs should be taken.
3. The assessment of muscular strength was contraindicated at the time of the initial evaluation. Explain
why, and site your source.
4. Create a handout identifying precautions to be taken after a coronary bypass graft.
5. Identify the common psychological reactions associated with an MI that may affect the intervention
process.
6. To keep Juan and others safe, what other factors should be considered?
OCCUPATIONS: ADLs, IADLs, EDUCATION, WORK, PLAY, SOCIAL PARTICIPATION, REST AND SLEEP
1. Given the information provided for this case, identify the areas of occupation that will and will not be
addressed. Justify your decisions.
2. Identify the MET value for each ADL and IADL that Juan will be engaged in. How could you verify
that the values you identified are accurate?
3. Which activities have a value below, at, and above Juan’s present MET level? Explain how these values
would influence occupational therapy intervention.
4. Identify the areas of education that will be addressed and explain why.
PERFORMANCE SKILLS: MOTOR, PROCESS, AND SOCIAL INTERACTION SKILLS

1. Given the information provided, identify the motor, process, and social interaction skills that affect
Juan’s occupational performance.
2. Which of these skills would be appropriate to address within this service delivery site? Justify your
selection.
3. Which skills would be addressed through remediation, compensation, and education?
4. Which skills would be addressed through the following intervention approaches: create and promote,
establish and restore, maintain, modify, and prevent?
PERFORMANCE PATTERNS: HABITS, ROUTINES, ROLES, AND RITUALS

1. Identify Juan’s useful habits, routines, roles, and rituals that support his valued occupations. Discuss
how you can make use of this information.
2. Identify Juan’s impoverished habits, routines, roles, and rituals that do not support his valued occupa-
tions. Discuss how can you make use of this information.
3. Identify Juan’s dominating habits, routines, roles, and rituals that interfere with his valued occupa-
tions. Discuss how can you make use of this information.
CLIENT FACTORS
Values, beliefs, and spirituality
How can the identified values, beliefs, and spirituality be used in this case?
Body structures
Consider the primary and secondary diagnoses and identify the related body structures.
Body functions
1. Identify how the primary and secondary diagnoses have affected the function of the identified body
structures.
2. Explain the relationships between the structural and functional factors and Juan’s current level of
occupational performance.
MENTAL FUNCTIONS: AFFECTIVE, COGNITIVE, AND PERCEPTUAL

1. What common affective issues related to MI may Juan face?
2. How would these issues be addressed in occupational therapy?
3. To address these issues, what other disciplines could you refer Juan to?
4. Identify three tools to assess the level of stress that Juan experienced as department chair. Evaluate
them and select one. Justify your selection.
5. How would you assess Juan’s ability to cope with the stress of serving as department chair?
6. Identify three stress-reduction techniques that may benefit Juan, evaluate them, select one, and justify
your selection.
7. Given the information provided, what additional mental function considerations need to be addressed?
NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS

1. Given the information provided, which neuromusculoskeletal or movement-related functions need to
be addressed? Justify your selections.
2. If Juan has to perform a sustained activity at 90° shoulder flexion or greater, what would be the effect
on myocardial perfusion?
3. If Juan has to perform a sustained activity at 90° shoulder flexion or greater, how could the surgical
site be affected?
CARDIOVASCULAR, HEMATOLOGICAL, IMMUNOLOGICAL, AND RESPIRATORY FUNCTIONS

1. Given the information provided, which cardiovascular, hematological, immunological, or respiratory
functions need to be addressed?
2. Cardiac rehabilitation has traditionally been divided into three phases; identify and describe each.
How can this information serve as a guide to your intervention and discharge plan?
3. Did Juan’s MI affect his muscular or cardiovascular endurance? Justify your response.
4. Which type of endurance does MET assess?
5. Compare and contrast MI with chronic heart failure.
SKIN AND RELATED-STRUCTURE FUNCTIONS

1. Create an instruction sheet for Juan to address the edema in his right hand when he is not engaged in
his therapy sessions.
2. Given a surgical wound that is not fully healed, when would it be appropriate to initiate shower activity?
3. What other skin and related-structure functions should be considered?
VOICE AND SPEECH FUNCTIONS

Describe how Juan’s diagnoses may affect his voice, speech, or occupational performance.
ASSISTIVE TECHNOLOGIES AND DEVICES

1. What assistive technologies or adaptations might be used or made for Juan while he is receiving occu-
pational therapy services on the coronary care floor? Why?
2. What assistive technologies or adaptations might be recommended for when he returns home? Why?
PHARMACOLOGY
Juan is currently taking acebutolol.
1. What is the brand name?
2. Does this drug have a high alert status?
3. What is the classification of this drug?
4. What is the indication for this drug?
5. What is the action of this drug?
6. How may this drug affect client participation during a therapy session?
SOCIOCULTURAL, SOCIOECONOMIC, AND DIVERSITY FACTORS AND LIFESTYLE CHOICES

1. Given Juan’s profile, examine how your own culture and beliefs affect your interaction with him.
2. Based on this self-examination, what area of cultural knowledge do you need to pursue?
3. How can this newly acquired cultural knowledge be integrated for effective outcomes?
4. How can you foster cultural interaction and awareness among your coworkers?
5. Discuss how a lack of understanding in the areas of discrimination and stigma, implicit bias, social
identity, or racism may contribute to disparities in the delivery of occupational therapy services in this
case.
ASSESSMENT TOOLS AND INTERPRETATION OF RESULTS

1. What is the purpose of the mMRC?
2. Which population is this test designed for?
3. How much time is required to administer it?
4. Provide a brief description of this assessment.
5. What is the reliability of the mMRC?
6. What is the validity of the mMRC?
7. What functional inference can be deduced from Juan’s score of 4?
8. What additional standardized assessment can be used in this case? Why?
INTERPROFESSIONAL RELATIONSHIPS AND EFFECTIVE INTRAPROFESSIONAL COLLABORATION

1. Identify the other professions that would make up the care team. Explain the focus of each.
2. Identify the roles of the occupational therapy assistant (OTA) that could be used in the occupational
therapy process for this case.
3. Identify interventions that can be assigned to the OTA for this case. Justify your selections.
BILLING AND CODING

1. Identify the current International Classification of Diseases (ICD) codes for Juan’s diagnoses.
2. For this case, identify at least two Current Procedural Terminology (CPT®) codes that are most appropriate.
REIMBURSEMENT SYSTEMS AND DOCUMENTATION

1. Who are the authorized individuals you could share the occupational therapy findings with? Explain
why.
2. For this case, what forms and frequency of documentation will be required?
3. Which reimbursement system or systems most commonly cover occupational therapy services in this
practice setting?
ADVOCACY
1. Which of the following areas of advocacy would be beneficial in this case: patient rights, matters
of privacy, confidentiality, informed consent, awareness building, accessing education, and benefits/
resources?
2. Create a plan to advocate for this client based on the selected areas of advocacy.
ETHICAL DECISION MAKING

1. Brian is very concerned about Juan and asks you about the initial evaluation findings. Under what
conditions would you be free to share the findings of Juan’s evaluation with him?
2. You observe a bruise on Juan’s right elbow. He tells you he fell in his room last night but did not report
it to any of the staff, and then he asks you not to report it. What should you do?
3. Juan asks you whether he and his partner will be able to resume their sex life when he returns home. Is
it the role of occupational therapy to deal with sexual activity? How would you handle this situation?
TELEHEALTH
1. How can telehealth be integrated as a component of the occupational therapy process in this case?
2. Before launching telemedicine services, what questions would be essential to ask Juan to determine
whether it is appropriate for him to engage in telemedicine services?
3. What are the challenges you foresee if you attempt to integrate telehealth services with Juan?
Intervention Plan Formulation and Implementation
INTERVENTION PLAN FORMULATION

Create an intervention plan that includes the following:
1. List this individual’s strengths.
2. List this individual’s barriers in occupational performance, performance skills, and performance
patterns.
3. Based on the individual’s goals, health, performance, and service delivery site, identify the barriers
that will be addressed.
4. From the barriers identified to be addressed, formulate goals and objectives.
5. Identify the focus of each goal and objective as either create, promote, establish, restore, maintain,
modify, or prevent.
6. Identify the theoretical basis, model(s) of practice, or frame(s) of reference that will be used to
address each goal and objective.
7. For each proposed goal and objective, describe clearly and precisely the methods that will be used.
This description should include, but not be limited to, safety considerations, environmental consider-
ations, therapeutic use of self, preparatory activities, activity selection, materials, equipment, and flow.
8. Classify the activities selected in the methods description as either preparatory, enabling, purpose-
ful, or occupation based.
9. Explain how each activity can be graded up or down, creating the just-right challenge.
10. Provide at least two primary sources of evidence to support the intervention plan.
INTERVENTION PLAN IMPLEMENTATION

1. Based on your intervention plan, identify which goals and objectives require more immediate
attention.
2. Describe your proposed first treatment session.
3. As the treatment session is progressing, what is essential to be observed?
Transition and Discontinuation

Create a plan for discharge from occupational therapy services in collaboration with Juan and members
of the interprofessional team. Review the needs of Juan, caregivers, family members, and significant oth-
ers. The plan must match needs with available resources and the discharge environment.
REFERENCES
American Medical Association. (2019). CPT® 2020 professional edition.
World Health Organization. (2019). International statistical classification of diseases and related health problems
(11th ed.). https://icd.who.int/
Mahler, D. A., & Wells, C. K. (1988). Evaluation of clinical methods for rating dyspnea. Chest, 93, 580–586. https://
doi.org/10.1378/chest.93.3.580
2
Song: Cerebral Vascular Accident (Right)

Song (she, her, hers, herself)
MEDICAL HISTORY
Song is a 69-year-old North Korean refugee female who is 5' 1" and weighs 117 pounds. She was brought
to the emergency department by emergency medical services after waking in bed and discovering she
was unable to move her left arm and leg. A computed tomography scan of her head, X-rays, magnetic
resonance imaging, and blood tests were performed. She received a diagnosis of a right cerebral vascular
accident (CVA) of ischemic nature. An emergency endarterectomy was performed. After her surgery, she
was transferred to the intensive care unit.
Song reported no previous medical conditions, surgery, or use of medications. She did report the use of
a doctor of Chinese medicine for knee and back pain. She reported no substance, nicotine, or caffeine use
and an allergic reaction to dairy products.
SOCIAL HISTORY
Song lives with her granddaughter and her granddaughter’s family. Six family members share a rented
three-bedroom walk-up apartment on the third floor. Song immigrated to the United States just under
2 years ago to assist her granddaughter with child care and care of the home. Her presence allowed her
granddaughter to return to work. The children include a 6- and 7-year-old attending school, a 2-year-old,
and a newborn at home. The apartment building in which they live is located in a community with many
other recent North Korean refugees. Song reports practicing the Taoism religion.
At the acute care hospital, Song will be on the neurological floor, where she will stay for 5 days. She will
receive occupational therapy, physical therapy, and social work services.
11
Song’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. In North Korea, Song and her husband were farmers. After the death of her husband
a little more than 2 years ago, she found it impossible to farm on her own. At her daughter’s en-
couragement, she fled North Korea for the United States. Song has the equivalent of primary school
education, and her ability to speak English is very limited. Her most common pattern of daily living
includes waking up at 5:00 a.m., preparing breakfast for the family, preparing the oldest two chil-
dren for school, caring for the two younger children at home, shopping, cleaning, preparing dinner,
and supervising the two older children after school until their parents return home to assist them
with their homework. Her interests include cooking, watching American television, and on occa-
sion socializing with other refugees. She values her family and the opportunity the United States
offers her daughter and her daughter’s family. Song reported that her greatest current need is not
to be a burden to her family.
ADLs
Regarding self-care, while seated, Song was able to don and doff loose-fitting clothing for both
upper extremities and both lower extremities. She was unable to effectively manage buttons, zip-
pers, hooks, and laces. Grooming tasks required verbal cues to effectively brush her teeth, comb her
hair, and apply makeup on the left side of her body. Regarding functional mobility, Song was able
to independently roll and transition between supine and short sitting in bed. She required contact
guarding and verbal cuing to transfer with a narrow-base quad cane, on and off the bed, chair, and
toilet. Tub transfers were not attempted.
IADLs
Activities that provide day-to-day quality of life and relative independence were explored.
Song reported difficulty making voice calls, texting, searching the web, managing money, and
caring for her granddaughter’s home and her great-grandchildren. Regarding rest and sleep,
Song reported difficulty falling asleep and remained asleep for no more than 3–4 hours in the
hospital.
MENTAL FUNCTIONS
Cognitive assessment of Song revealed she was alert and oriented to person, place, time, and situ-
ation. Short- and long-term memory were intact. She presented with impulsivity and poor insight.
She has a tendency to attempt unsupervised transfers, disregarding instructions to use a call bell for
assistance. Affect appeared appropriate. A perceptual assessment was performed. The Behavioral
Inattention Test (Wilson et al., 1987) indicated mild left visual inattention.
SONG: CEREBRAL VASCULAR ACCIDENT (RIGHT) | 13
SENSORY FUNCTIONS AND PAIN

cutaneous functions. Use of the Wong-Baker FACES® Pain Rating Scale (Wong-Baker FACES
Foundation, 2018) indicated a 2 (hurts a little bit) in both knees, with pain described as “achy.”

No deficits were noted.
MOVEMENT FUNCTIONS
Full passive range of motion and active range of motion were present in all extremities. The man-
ual muscle test indicated scores of 3+ and 5 in left upper extremity (LUE) and left lower extremity
(LLE), respectively. Assessment of fine motor (prehension) abilities indicated that Song was able
to form gross grasp patterns, lateral pinch, and tripod pinch but was unable to effectively form a
palmer and tip-to-tip pinch pattern in the left hand. Additionally, in-hand manipulation skills of tip
to palm and palm to tip were slow and awkward. Gross grasp strength was 3 pounds on the left hand
and 24 pounds on the right. Standing tolerance was 10–15 minutes.
Song was able to sit unsupported without losing her balance and without upper-extremity support.
She was able to stand unsupported for 1–2 minutes without losing balance. Any attempt to move
either her upper or lower body resulted in her becoming unstable. Muscle tone in the right upper
extremity was normal, and coordination was intact. Active isolated movement in the LUE and the
LLE was present. Muscle tone appeared normal. Coordination in the LUE and LLE presented with
mildly reduced speed and accuracy.
PLAN FOR DISCHARGE

After her 4-day stay on the neurological care floor, Song will be discharged to a subacute rehabil-
itation facility and will receive occupational therapy, physical therapy, and social worker services.
SAFETY OF CLIENT AND OTHERS: PRECAUTIONS OR CONTRAINDICATIONS

1. Identify the components of “standard precautions.”
2. Song presents with impulsivity. What safety concerns do you anticipate?
3. Song presents with left-sided visual inattention. What safety concerns do you anticipate?
4. Create a handout identifying precautions to be followed by individuals placed on blood thinners.
5. Identify the common psychological reactions associated with CVA that may affect the treatment
process.
6. To keep Song and others safe, what other factors should be considered?
OCCUPATIONS: ADLs, IADLs, EDUCATION, WORK, PLAY, SOCIAL PARTICIPATION, AND REST AND SLEEP
2. What clothing choices would you recommend to Song to eliminate the need to manage fasteners to
dress?
3. What equipment and strategies do you anticipate can be used to increase Song’s safety while showering?
4. Which functional mobility skills would be appropriate to address with Song?
5. Identify the areas of education that would be appropriate to engage in with Song, and explain why.
PERFORMANCE SKILLS: MOTOR SKILLS, PROCESS SKILLS, AND SOCIAL INTERACTION SKILLS
Song’s occupational performance.
2. Which of these skills would be appropriate to address in this service delivery site? Justify your selection.
3. Which of these skills would be addressed through remediation, compensation, and education?
4. Which of these skills would be addressed through the following intervention approaches: create/pro-
mote, establish/restore, maintain, modify, and prevent?

1. Identify Song’s useful habits, routines, roles, and rituals that support valued occupations. How can you
make use of this information?
2. Identify Song’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
tions. How can you make use of this information?
3. Identify Song’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
How can you make use of this information?
CLIENT FACTORS
Body structures
Considering the primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationship between structural and functional factors and Song’s current level of occupa-
tional performance.

1. What common affective issues related to CVA may Song face?
3. To address these issues, what other disciplines could you refer Song to?
4. What strategies can be used to maximize effective communication with Song?
5. What common strategies are available to assist Song with her impulsiveness?
6. What common strategies are available to assist Song with her left-sided visual inattention?

1. Given the information provided, which neuromusculoskeletal and movement-related functions need
to be addressed? Justify your selections.
2. Based on the finding that the “patient was able to sit unsupported without losing her balance and
without upper-extremity support,” should Song’s static sitting balance be assigned a grade of fair or
fair plus? Justify your selection.
3. Based on the finding that “the patient presented with slightly less than normal speed and skill,” should
Song’s coordination be assigned a grade of 4 or 5? Provide a reference.
4. Compare and contrast neuromusculoskeletal and movement-related functions of CVA and traumatic
brain injury.

1. Given the information provided, which cardiovascular, hematological, immunological, and respiratory
functions need to be addressed? Justify your selection.
2. Which vital signs should be taken when working with Song? What are the norms for each of these vital
signs? When should Song’s vital signs be taken?
SKIN AND RELATED STRUCTURE FUNCTIONS

1. On arrival at occupational therapy, you noticed an abrasion on Song’s lateral aspect of her elbow. Would
this abrasion be a concern, and, if so, what possible action would you take?
2. What other skin and related structure functions should be considered?

Describe how a CVA may affect the voice and/or speech and their impact on occupational performance.

What assistive technologies or adaptations might be used or made for Song while she is receiving occupa-
tional therapy services on the neurological care floor? Why?

1. You have only 4 days to provide service to Song before she is transferred to the subacute rehabilitation
facility. What factors will you weigh in deciding which of Song’s areas of need will and will not be ad-
dressed at your service delivery site?
2. It is time for Song’s occupational therapy session, but the hospital interpreter has not yet arrived.
Identify options to maintain Health Insurance Portability and Accountability Act compliance. Select
the most appropriate option and support your decision.
3. You walk past Song’s room and observe her walking to the bathroom with her quad cane, but she is
unguarded. Identify options of what you should do. Select the most appropriate option and support
your decision.
4. Song has exclusively used chopsticks to eat her meals all her life. The hospital supplies only plastic
spoons, forks, and knives. Identify options of what you should do. Select the most appropriate option
and support your decision.
5. A patient in the occupational therapy gym has made a derogatory statement concerning the Chinese in
the presence of Song. Identify options of what you should do. Select the most appropriate option and
support your decision.
PHARMACOLOGY
Song is currently taking heparin.

1. Given Song’s profile, examine how your own culture and beliefs affect your interaction with her.
case.

1. What is the purpose of the Wong-Baker FACES Scale?
5. What is the reliability of this assessment?
6. What is the validity of this assessment?

7. What functional inference can be deduced from a score of 2 on this assessment?
INTERPROFESSIONAL RELATIONSHIP AND EFFECTIVE INTRAPROFESSIONAL COLLABORATION

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) code for Song’s diagnosis.
2. For this case, identify at least two Current Procedural Terminology (CPT®) codes that are most appro-
priate. Justify your selection.

1. Who are the authorized individuals you could share the occupational therapy findings with? Explain
why.
practice setting?
ADVOCACY
1. Which of the following areas of advocacy would be beneficial in this case: patient rights, matters of
privacy, confidentiality, informed consent, awareness building, accessing education, and benefits/
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Song to determine
whether it is appropriate for her to engage in telemedicine services?
3. What challenges do you foresee if you attempt to integrate telehealth services with Song?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Song and members
of the interprofessional team. Review the needs of Song, caregivers, family members, and significant oth-
REFERENCES
Wilson, B., Cockburn, J., & Halligan, P. (1987). Behavioral Inattention Test. Pearson.
Wong-Baker FACES Foundation. (2018). Wong-Baker FACES® Pain Rating Scale. Author.
3
Ethan: Complete C6 Spinal Cord Injury

Ethan (he, him, his, himself)
MEDICAL HISTORY
Ethan is a 26-year-old Black male who is 6' 3" and weighs 220 pounds. He was brought to the emergency
department by emergency medical services after falling from a roof. Immediately after his fall, Ethan
was unable to move and feel both upper extremities and both lower extremities. Medical assessments
included testing sensory function and movement, X-rays, computerized tomography scan, and magnetic
resonance imaging. Ethan received a diagnosis of a complete C6 spinal cord injury (SCI). In the operating
room, he was fitted with a halo brace. After his procedure, he was transferred to the neurological intensive
care unit. His past medical history was unremarkable. He reported no drug, alcohol, caffeine, or tobacco
use, and a penicillin allergy.
SOCIAL HISTORY
Ethan is an accounting student and part-time roofer. He lives with his wife, Shana, and their 6-month-old
daughter, Crystal. Shana is at work and Ethan is at school. They share a one-bedroom basement apart-
ment in Ethan’s parents’ home. There are 13 steps from the first floor to the basement apartment through
a narrow doorway. Ethan has two younger brothers, ages 16 and 19 years, who still live at home. Ethan
identifies as a Black Hebrew Israelite.
At the acute care hospital, Ethan will be on the neurological care floor for a 5-day stay. He was referred for
occupational therapy, physical therapy, registered nursing, and social work services.
19
Ethan’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Ethan had been employed as a roofer for the past 6 months and viewed roofing as a
temporary career until he could complete his accounting degree. His patterns of daily living most
commonly included having a quick breakfast in the morning, arriving on a job site by 7:00 a.m., and
returning home by 8:00 p.m. He frequently worked weekends when overtime was available. During
his limited free time, he liked to be home with Shana and his daughter and, when a babysitter
was available, to go to the gym or dinner with Shana. His interests include exercise, camping, and
finance. He values his family, education, and ability to support his family. Ethan reported that his
greatest current need is to do everything possible—not to be a burden on his family.
ADLs
Regarding self-care, Ethan was dependent in his ability to feed, dress, groom, bathe, and toilet him-
self. Regarding functional mobility, Ethan was dependent on his ability to roll, sit up, scoot, and
transfer. When placed in a short sitting position, he immediately complained of being lightheaded,
dizzy, and feeling as if he was going to pass out. The Canadian Occupational Performance Measure
(COPM; Law et al., 2019) was administered and a score of 73 was obtained.
IADLs
Ethan is dependent for using electronic communications, handling his finances, maintaining his
home, preparing meals, performing cleanup tasks, and the ability to shop.
Regarding rest and sleep, Ethan reported poor sleep quality and not being able to sleep more
than 1–2 hours before waking up. Before his SCI, he primarily slept in prone and had no problem
sleeping through the night.
MENTAL FUNCTIONS
Cognitive assessment found Ethan to be alert and oriented to person, place, time, and situation.
Short- and long-term memory were intact. Affect assessment revealed mixed emotions. At times,
he was soft-spoken and tearful as he verbalized optimism about his recovery, and other times he
expressed anger toward his employer for not providing safe working conditions. No gross deficits
in perception were observed.

No gross deficits were observed with visual, hearing, vestibular, taste, and olfactory functions.
There was an absence of cutaneous sensation below dermatome C6; vision, hearing, olfactory, and
vestibular senses were intact. He reported no pain.
ETHAN: COMPLETE C6 SPINAL CORD INJURY | 21
CARDIOVASCULAR AND RESPIRATORY SYSTEMS FUNCTIONS

Ethan was able to breathe without a ventilator but exhibited low stamina. He presented with a
weak cough. Assessment of cardiovascular and respiratory systems function indicated a decrease in
blood pressure from 132/75 to 82/47 when transitioned from supine to short sitting.
MOVEMENT FUNCTIONS
Ethan was within normal limits for passive range of motion in both upper and both lower extrem-
ities. Active range of motion was within normal limits for all shoulder movements, elbow flexion,
forearm supination, and radial wrist extension. Elbow extension, wrist flexion, and hand move-
ments were absent. Total paralysis of the trunk and lower extremities was present. Assessment of
muscle strength and endurance was contraindicated at the time of evaluation.
Ethan was intact for involuntary and voluntary reactions and movements at the level of C6 and
above and absent below. The assessment of sitting and standing balance was contraindicated at the
time of evaluation. Muscle tone in innervated musculature was intact, and below the level of injury,
flaccid. Deep tendon reflexes in both lower extremities were absent.
PLAN FOR DISCHARGE

After his stay on the neurological care floor, Ethan will be transferred to a rehabilitation center that
specializes in SCIs. He will receive occupational therapy, physical therapy, and social work and
registered nursing services.

1. What are the signs and symptoms of orthostatic hypotension and postural hypotension?
2. If Ethan experiences an episode of orthostatic hypotension or postural hypotension, identify the ac-
tions that need to be taken.
3. What are the signs and symptoms of autonomic dysreflexia to be aware of while working with Ethan?
4. If Ethan experiences an episode of autonomic dysreflexia, what immediate actions need to be taken?
5. Create a handout identifying the signs and symptoms of deep vein thrombosis (DVT).
6. If Ethan develops a DVT, what immediate actions need to be taken?
7. Ethan is at risk to acquire a pressure ulcer. Explain why.
8. What are the most common sites in which pressure ulcers form? How can occupational therapy play a
role in the prevention of pressure ulcers?
9. Which vital signs should be taken when working with Ethan? What are their norms? When should
they be taken?
10. Performing the manual muscle test was contraindicated at the time of the initial evaluation. Why?
11. After his SCI, Ethan presents with a weak cough. What risks does this symptom pose?
12. Identify the common psychological reactions associated with a SCI that may affect the treatment
process.
13. To keep Ethan and others safe, what other factors should be considered?
2. What activities can be introduced to Ethan for him to begin feeding himself? Which assistive devices
would be needed? Explain why.
3. Ethan wishes to be able to use a phone so he can communicate with his family while he is hospitalized.
How can his phone use be facilitated?
4. You receive orders that Ethan is cleared to begin out-of-bed-to-wheelchair activities. Which wheel-
chair choice and features would be best suited for him? Explain why.
5. What would be a reasonable schedule to increase Ethan’s sitting tolerance in a wheelchair? Provide
support for your choice of schedule.
6. Ethan wishes to have the ability to contact the floor nurse from his hospital bed; currently, he is unable
to use the call bell. What options are available?
7. Which areas of patient education should be given priority? Why?
8. Briefly describe what Ethan’s first occupational therapy treatment session would look like.
Ethan’s occupational performance.
selection.

1. Identify Ethan’s useful habits, routines, roles, and rituals that support valued occupations. How can
you make use of this information?
2. Identify Ethan’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Ethan’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering the primary diagnosis, identify the related body structures.
Body functions
1. How has the primary diagnosis affected the function of the identified body structures?
2. Explain the relationships between the structural and functional factors and Ethan’s current level of

1. What common affective issues related to SCI may Ethan face?
3. To address these issues, what other disciplines could you refer Ethan to?
4. What common affective issues related to SCI may Ethan’s family experience?
5. What support would be available to recommend to Ethan’s family to address these issues?

2. What early steps should be taken to prevent atrophy from disuse in Ethan’s innervated muscle groups?
3. What early steps should be taken to prevent the shortening of soft tissues and the development of
contracture?
4. Create an exercise program for Ethan based on occupational performance.
5. Compare and contrast paraplegia with quadriplegia.

functions need to be addressed? Justify your selections.
2. Would it be expected that the energy costs of performing a given ADL be the same for Ethan before his
injury? Explain why.
3. Identify the metabolic equivalent of task value for upper-body dressing in a person without dysfunc-
tion. How would Ethan’s value differ?

1. Which pressure relief strategies would be the best match for Ethan? Explain why.

Describe how Ethan’s diagnosis may affect his voice, speech, and occupational performance.

What assistive technologies or adaptations might be used or made for Ethan while he is receiving occupa-
tional therapy services on the neurological care unit? Why?

1. During your first session with Ethan, he asked you how long it usually takes for patients like him to
regain their ability to walk. How can his question be best addressed?
2. You arrive at Ethan’s room for his scheduled treatment session, and it becomes apparent to you that he
has had a bowel movement that has not yet been attended to. How can this situation be best addressed?
3. During a treatment session, you observe that Ethan presents with an abrasion over his left lateral mal-
leolus that was not previously observed or documented. How should this observation be addressed?
PHARMACOLOGY
Ethan is currently taking codeine.
SOCIOCULTURAL, SOCIOECONOMIC, DIVERSITY FACTORS, AND LIFESTYLE CHOICES

1. Given Ethan’s profile, examine how your own culture and beliefs affect your interaction with him.
case.
1. What is the purpose of the COPM?

5. What is the reliability of the COPM?
6. What is the validity of the COPM?
7. What functional inference can be deduced from Ethan’s score of 73?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Ethan’s diagnosis.

1. Who would be the authorized individuals you could share the occupational therapy findings with?
Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Ethan to determine
3. What are the barriers, obstacles, or challenges you foresee if attempting to integrate telehealth ser-
vices with Ethan?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Ethan and members
of the interprofessional team. Review the needs of Ethan, caregivers, family members, and significant
others. The plan must match needs with available resources and the discharge environment.
REFERENCES
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (2019). Canadian Occupational Performance
Measure (5th ed., rev.). COPM Inc.
4
Hannah: Congestive Heart Failure

Hannah (she, her, hers, herself)
MEDICAL HISTORY
Hannah is an 81-year-old Chippewa Native American who is 5' 2" and weighs 90 pounds. She was brought
to the emergency department (ED) by emergency medical services after reporting shortness of breath
and presenting with bilateral rales, jugular venous distension, bilateral lower-extremity edema, and the
following vital signs: heart rate 103 beats/minute, respiratory rate 32 breaths per minute, blood pressure
154/92 mm hg, and oxygen saturation 88%. Blood tests, urinalysis, echocardiogram, and chest radiogra-
phy were performed, and she received a diagnosis of congestive heart failure (CHF). From the ED she was
transferred to the coronary care unit (CCU) where she received nitrates to decrease preload, myocardial
oxygen consumption, systemic vascular resistance, and supplementary oxygen.
Her medical history included hypertension, myocardial infarct atrial arrhythmia, and two previous ad-
missions for CHF episodes. Upon admission, she reported living a sedentary lifestyle, drinking 3 to 4 cups
of coffee per day, and no alcohol, drug, or nicotine use. Hannah reported no known allergies.
SOCIAL HISTORY
Hannah lives alone in a one-bedroom garden apartment on the ground floor. At home, she uses a straight
cane only for outside ambulation. Her daughter, Eva, lives in the apartment above her with two adult
grandchildren. All three are dedicated to Hannah and are employed full time, working weekdays. There
are three steps to enter Hannah’s apartment, which consists of a living room, bathroom, bedroom, dinette,
and small kitchen. Hannah follows the Ojibwa religion.
At the acute care hospital, Hannah will be in the CCU for a 5-day stay. She has been referred for occupa-
tional therapy, physical therapy, social work, and registered nursing services.
27
Hannah’s preadmission occupational history and experiences included being independent in all
ADLs, although performing them in a slow and effortful manner. Regarding IADLs, her daughter
prepared meals that Hannah reheated. Additionally, she shopped and cleaned Hannah’s apartment
on weekends. Hannah has been retired for 6 years. Her patterns of daily living most commonly in-
cluded spending the day at home watching television and being taken to church on Sundays by her
granddaughter. At least three evenings per week, one of her grandchildren eats dinner with her in
her apartment. Her interests include following the local baseball team and reading her bible. She
values her family, church, and Native American heritage. Hannah reported that her current goal is
to return home and be able to attend church on Sundays.
ADLs
Regarding self-care, Hannah was able to feed herself independently, but consumption of a large
meal left her feeling short of breath. While seated, Hannah was able to dress both her upper ex-
tremities independently in a slow spontaneous fashion but required moderate assistance to dress
both lower extremities secondary to becoming noticeably short of breath. Her respiration rate el-
evated to 29 breaths per minute from a baseline of 20 breaths per minute during lower-extremity
dressing. Hannah was able to independently perform the grooming tasks of brushing her hair and
teeth while seated but reported that she did not feel she had enough endurance to attempt stand-
ing in the tub to shower. Regarding functional mobility, Hannah was able to independently roll
and move between supine and short sit with contact guarding. She required minimal assistance to
transfer with her adult rolling walker on and off the bed, chair, hospital wheelchair, and toilet in a
very slow and mindful manner. Tub transfers were not attempted.
IADLs
Hannah can manage her communications and her checkbook but is dependent on others to prepare
meals using the stove, clean up, and shop. Regarding rest and sleep, Hannah reported that she is
unable to sleep unless she is propped up by three or four pillows. She has been diagnosed with cen-
tral sleep apnea with Cheyne-Stokes breathing. The Satisfaction, Alertness, Timing, Efficiency and
Duration (SATED) questionnaire (Buysse, 2014) was administered, and a score of 5 was obtained.
MENTAL FUNCTIONS
Cognitive assessment found Hannah to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. She was able to follow three-step commands and
make her needs known. Affect appeared appropriate, and no gross deficits in perception were
observed.
HANNAH: CONGESTIVE HEART FAILURE | 29

cutaneous functions. Hannah did report using reading glasses. No pain was reported.
CARDIOVASCULAR AND RESPIRATORY SYSTEM FUNCTIONS

Edema in both ankles was 2+ using a pitting edema scale. Assessment of cardiovascular and respi-
ratory systems function indicated a metabolic equivalent of task (MET) value of 2.0. At the time of
evaluation, Hannah was receiving 2 liters of supplemental oxygen through a nasal cannula.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion in all four extremities were within normal limits.
Manual muscle testing was performed and revealed a gross muscle strength of 3+/5 in both upper
and both lower extremities. Gross grasp strength in both right and left hands was 17 pounds. No
gross deficits in prehension and coordination were observed. Standing tolerance was 3–5 minutes.
Static and dynamic sitting balance were both 5/5, static standing balance was 3+/5, and dynamic
standing balance was 3/5. Muscle tone was normal, and no gross deficits in reflex integration were
observed.
PLAN FOR DISCHARGE

After her stay on the medical floor, Hannah will be discharged home with home health care ser-
vices. She will be receiving occupational therapy; physical therapy; and social work, registered
nursing, and home health aide services.

1. What are the signs and symptoms of respiratory distress to be aware of while working with Hannah?
2. If Hannah experiences respiratory distress, what immediate actions must be taken?
3. Which vital signs should be taken when working with Hannah? What are the norms for each? When
should they be taken?
4. Create a handout identifying precautions that need to be followed when using supplemental oxygen.
5. Describe the correct guarding method to be used during transfer-training sessions.
6. Identify the common psychological reactions associated with CHF that may affect the treatment
process.
7. To keep Hannah and others safe, what other factors should be considered?
2. Identify the MET value for each ADL and IADL that Hannah will be engaged in during her interven-
tion sessions.
3. Which activities have a value below, at, and above Hannah’s present MET level? Explain how these
values would influence occupational therapy intervention.
4. Identify the areas of education that would be appropriate to engage in with Hannah and explain why.
5. Briefly describe what Hannah’s first occupational therapy treatment session would look like.
Hannah’s occupational performance.
selection.

1. Identify Hannah’s useful habits, routines, roles and rituals that support valued occupations. How can
2. Identify Hannah’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Hannah’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Hannah’s primary and secondary diagnoses, identify the related body structures.
Body functions
1. How have the primary and secondary diagnoses affected the function of the identified body structures?
2. Explain the relationships between the structural and functional factors and Hannah’s current level of

1. What common affective issues related to CHF may Hannah face?

3. To address these issues, what other disciplines could you refer Hannah to?
4. How might the social worker address these issues with Hannah?

2. What is disuse atrophy? Explain how it relates to Hannah’s current condition.
3. How can 3+/5 muscle strength in Hannah’s four extremities be best addressed?
4. Create an exercise program for Hannah based on occupational performance.

functions need to be addressed? Justify your selections.
2. Identify energy conservation principles and describe how Hannah could apply these concepts while
performing her ADLs.
3. Compare and contrast central sleep apnea with Cheyne-Stokes breathing and obstructive sleep apnea.

1. How can Hannah address the edema in her right hand when she is not actively engaged in therapy
sessions?

Describe how Hannah’s diagnoses may affect her voice, speech, and occupational performance.

1. What assistive technologies or adaptations might be used or made for Hannah while she is receiving
occupational therapy services on the coronary care floor? Why?
2. What assistive technologies or adaptations might be recommended for when she returns home? Why?

1. Hannah informs you that her dentures were accidentally thrown out by the morning hospital staff.
What should you do?
2. You observe Hannah walking to use the bathroom without the use of oxygen or a walker. What do you
do?
3. Hannah informs you she is behind in paying her utility bills and does not wish her family to know.
What should you do? Explain your decision.
PHARMACOLOGY
Hannah is currently taking acebutolol.

1. Given Hannah’s profile, examine how your own culture and beliefs affect your interaction with her.
case.

1. What is the purpose of the SATED?
5. What is the reliability of the SATED?
6. What is the validity of the SATED?
7. What functional inference can be deduced from Hannah’s score of 5?

4. What other professionals would be part of this patient’s care and what would be their primary focus?
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Hannah’s diagnoses.

Explain why.
practice setting?
ADVOCACY
privacy, confidentiality, informed consent, awareness building, accessing education, and/or benefits/
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Hannah to deter-
mine whether it is appropriate for her to engage in telemedicine services?
vices with Hannah?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Hannah and mem-
bers of the interprofessional team. Review the needs of Hannah, caregivers, family members, and signifi-
cant others. The plan must match needs with available resources and the discharge environment.
REFERENCES
Buysse, D. J. (2014). Sleep health: Can we define it? Does it matter? Sleep, 37(1), 9–17. https://doi.org/10.5665/
sleep.3298
5
Howie: Right Distal Radius

and Ulna Fracture
YVES ROSEUS, OTD, OTR/L
Howie (he, him, his, himself)
MEDICAL HISTORY
Howie is an 84-year-old Filipino male, living in the United States, who is 5' 10" and weighs 185 pounds. He
was brought to the emergency department (ED) by emergency medical services after slipping in his bath-
tub, which resulted in pain, swelling, and deformity of his distal right forearm. After X-rays were taken,
he received a diagnosis of comminuted fractures of his right distal radius and ulna bones. From the ED, he
was taken to the operating room, where an open reduction and internal fixation (ORIF) was performed
to stabilize the fracture sites. A postsurgical volar fiberglass splint was applied to protect the surgical site.
Howie was transferred to the orthopedic care unit after his surgery.
Howie’s medical history includes hypertension, high cholesterol, and insulin-dependent diabetes mel-
litus. He reported living an active lifestyle and no nicotine, drug, or caffeine use, but he consumes between
three and six cans of beer per day. He reported being allergic to shellfish.
SOCIAL HISTORY
Howie has recently been widowed after 52 years of marriage. He lives alone in a three-bedroom ranch-
style home. His suburban home is located just 15 miles from the city. There is a ramp to enter the first
floor, which consists of a living room, dining room, den, eat-in kitchen, and one-and-a-half baths. There is
a detached garage. Howie reported having one daughter who lives out of state with her husband and two
children. He reports following the Catholic religion.
At the acute care hospital, Howie is currently in the orthopedic care unit for a 3-day stay. He has been
referred for occupational therapy, registered nursing services, and social work services.
35
Howie’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Howie is a retired baggage handler from a major international airline. His former
career had allowed him and his wife to travel to every continent. His patterns of daily living most
commonly included attending his local senior citizen center Monday through Friday. He usually
drove himself to the center and stayed for both breakfast and lunch and participated in its variety of
groups. He typically returned home between 3:30 and 4:00 p.m. and prepared and ate dinner alone.
After dinner, he enjoyed watching the evening news and would be in bed by 9:00 p.m. Weekends
were usually filled with grocery shopping and working around his home. Each Christmas, he trav-
els and stays with his daughter and her family and returns home after New Year’s Day; in turn, they
spend 1 week each summer with him. His interests include spending time with his many friends at
the senior citizen center and traveling. He values independence, community, and his family. Howie
reported his greatest current need is to return home and be able to care for himself.
ADLs
Howie was evaluated in the occupational therapy gym. Regarding self-care, he was able to feed
himself using his left hand when food was presented precut. While seated, Howie was able to don
and doff all his clothing for his upper and lower body but required assistance managing fasten-
ers (buttons, zippers, and laces). Howie was able to wash at the sink but required assistance to
wash and dry his left upper extremity. He was able to independently perform the grooming tasks of
brushing his hair and teeth. Regarding functional mobility, Howie is able to independently roll and
move between supine and short sit in bed. He transfers and ambulates without a device.
IADLs
Howie can manage his communications, handle his finances, and perform simple cleanup tasks. He is
aware that he currently is not able to maintain his home, prepare meals, and shop without assistance.
Regarding rest and sleep, Howie reports waking up every 1 to 2 hours because of pain at the fracture site.
MENTAL FUNCTIONS
Cognitive assessment found Howie to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. He is able to follow three-step commands and make
his needs known. Affect appeared appropriate, and no gross deficits in perception were observed.

cutaneous functions. Pain in the right distal forearm and hand was scored as a 7 on the numerical
HOWIE: RIGHT DISTAL RADIUS AND ULNA FRACTURE | 37
rating scale (0–10). The pain was described as “continuous.” Circumferential measurements were
taken at the distal palmar crease: 21.3 cm on the right and 17.6 cm on the left.

Howie is able to perform all self-care and functional ambulation without report of or noticeable
signs of fatigue.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion are intact in all four extremities except the right
forearm, wrist, and digits (Table 5.1). Active range of motion for right forearm supination is 0–15°
and for forearm pronation is 0–65°. Wrist flexion and extension were not assessed secondary to
immobilization with a splint.
TABLE 5.1. Active Range of Motion (Degrees) of Right Digits
Joint Digit 1 Digit 2 Digit 3 Digit 4 Digit 5
Metacarpophalangeal joint 0–50 5–52 0–55 0–55 10–70

Interphalangeal joint 0–15
Proximal interphalangeal joint 5–43 0–46 0–46 0–55
Distal interphalangeal joint 0–10 0–14 0–15 0–20
Total active motion 65 95 115 116 135
Assessment of muscle strength in the left upper extremity and right shoulder groups through a
functional muscle test (FMT) indicated all tested groups to be 5/5. Muscle strength testing of the
right forearm, wrist, and digits were contraindicated. Gross grasp strength in the left hand is 37
pounds, and the right hand was not evaluated. Prehension in the left hand is grossly intact, and the
right hand was not evaluated.
Static and dynamic sitting balance are 5/5, and static and dynamic standing balance are 4/5. Muscle
tone is normal, and reflex integration is grossly intact.
PLAN FOR DISCHARGE

After his stay on the orthopedic care floor, Howie will be discharged home and receive outpatient
occupational therapy services.

1. Create a precaution sheet identifying the risks of a poorly fitted hand splint.
2. Which vital signs should be taken when working with Howie? What are the norms for each? When
should they be taken?
3. Using the FMT to assess his right forearm, wrist, and digits was contraindicated at the time of the
initial evaluation. Why?
4. What are the precautions to be followed for an ORIF?
5. Would it be contraindicated for Howie to remove his splint to bathe? Support your decision.
6. To keep Howie and others safe, what other factors should be considered?
2. Identify the areas of education that would be appropriate to engage in with Howie and explain why.
3. Briefly describe what the first treatment session with Howie would be like.
PERFORMANCE SKILLS: MOTOR SKILLS, PROCESS SKILLS, AND SOCIAL INTERACTION

Howie’s occupational performance.

1. Identify Howie’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Howie’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Howie’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Body Functions
structures.
2. Explain the relationships between the structural and functional factors and Howie’s current level of

1. What common affective issues related to fracture and surgical treatment may Howie face?
3. To address these issues, what other disciplines could you refer Howie to?

2. Identify the theory for reducing edema.
3. According to the evidence, which is the best edema reduction technique or techniques that should be
implemented to address the edema in Howie’s right hand? Justify your selection.
4. Identify the theory for remediation of shortened soft tissue.
5. According to the evidence, which intervention selection would be the best choice? Explain why.
6. Compare and contrast ORIF with closed reduction and external fixation.
7. Create an exercise program for Howie based on occupational performance.

1. Given the information provided, identify cardiovascular, hematological, immunological, or respiratory
functions that need to be addressed. Justify your selections.
2. As an 84-year-old patient, Howie is susceptible to cardiorespiratory risks associated with being in bed
for 3 days. What are these risks? What preventive measures should be considered?
3. As you evaluate Howie in his bed, you notice he is wearing a cuff around each of his lower legs attached
to a pneumatic device. What is the name and purpose of this medical device?

1. As a result of the trauma that Howie experienced, an inflammatory response was triggered resulting
in the accumulation of fluids to his right upper extremity. Explain the physiological process of an
inflammatory response.
2. List the most common types of edema.
3. Which type of edema is Howie most likely experiencing? Support your selection.
4. What are the signs and symptoms of an infected surgical wound?
5. What precautions must be followed during the treatment session to prevent an infection?

Describe how Howie’s diagnoses may affect his voice, speech, and occupational performance.

1. Which assistive technologies or adaptations can be implemented to allow Howie to manage fasteners
(buttons, zippers, and laces) independently?
2. Which assistive technologies or adaptations can be implemented to allow Howie to cut his food
independently?
3. Which assistive technologies or adaptations can be implemented to allow Howie to prepare a simple
meal independently?
4. What assistive technologies or adaptations might be recommended for use at home?

Howie revealed that he typically drinks three to six cans of beer per day. Should this habit be addressed?
Why or why not?
PHARMACOLOGY
Howie is currently taking Motrin®.
1. What is the generic name?

1. Given Howie’s profile, examine how your own culture and beliefs affect your interaction with him.
case.

1. What is the purpose of goniometric measurement?

5. What is the reliability of goniometric measurement?
6. What is the validity of goniometric measurement?
7. What functional inference can be deduced from the active range of motion in Howie’s right hand?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Howie’s diagnoses.
2. For this case, identify at least two Current Procedural Terminology (CPT) codes that are most appropri-
ate. Justify your selection.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Howie to determine
vices with Howie?

patterns.
5. Identify the focus of each goal and objective identify as either create, promote, establish, restore,
maintain, modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Howie and members
of the interprofessional team. Review the needs of Howie, caregivers, family members, and significant
REFERENCES
Outpatient Rehabilitation SECTION II
43
6
Florence: Rheumatoid Arthritis

Florence (she, her, hers, herself)
MEDICAL HISTORY
Florence is a 69-year-old Irish-American female who is 5' 0" and weighs 127 pounds. She was electively
admitted to the orthopedic service with a diagnosis of rheumatoid arthritis (RA). She underwent a left
total shoulder arthroplasty (TSA). Her medical history included RA for 35 years, pleurisy, osteoporosis,
hypertension, Sjogren’s syndrome, and gastrointestinal bleeding. Surgical history included bilateral (B/L)
total knee replacements, B/L wrist synovectomy, and B/L metacarpal phalangeal arthroplasty of Digits
2–5. She reported living a sedentary lifestyle and no alcohol, drug, or tobacco use. Florence reported
drinking 4 to 5 cups of tea per day. She has no known allergies.
SOCIAL HISTORY
Florence worked as a high school food service worker until age 52, when her condition did not allow her
to work any longer. She qualified and received Social Security disability. Florence lives alone in a city-sub-
sidized one-bedroom accessible apartment located just 2 miles from the hospital. Her building is elevator
equipped and is compliant with the Americans with Disabilities Act (P. L. 101-336). Her apartment has
an open floor plan for its living room, dining room, and kitchen. Florence reported never being married
and having only one close friend, Mary, who also has a disability. Florence identifies as a follower of the
Anglican Church. She identifies as asexual.
Florence was referred for outpatient services. She is to receive occupational therapy services 2 times
per week for 10 weeks. Occupational therapy services are to progress the patient to Phase 2 of the TSA
protocol.
45
Occupational Therapy Initial Evaluation Findings: Outpatient Rehabilitation
Florence’s preadmission occupational history and experiences included requiring the assistance
of a home health aide (HHA) for the past 5 years to bathe and perform her hair care. She reported
being independent with modifications in dressing, toileting, and feeding. Shopping, care of the
home, and meal preparation were completed by her HHA. Her patterns of daily living most com-
monly included being washed by her HHA by 9:30 a.m. and eating her prepared breakfast by 10:30
a.m. Her days are usually filled with escorted trips to local stores, medical appointments, and the
senior citizens club. The club is located in the building where she resides, and it is where she com-
monly eats lunch with her friend Mary; dinner is eaten at home. Her interests include reading
romance novels, collecting figurines, and spending time with her cat. She values honesty and clean-
liness. Florence reported her greatest current need is to be able to stay in her own home and receive
needed outpatient services. She reported being very afraid of placement in a nursing home.
ADLs
Regarding self-care, Florence was able to feed herself using her right upper extremity when foods
were cut first and presented to her. Florence required maximal assistance to dress both upper ex-
tremities and both lower extremities and to don and doff her left shoulder immobilizer support
brace. She was able to independently perform the grooming tasks of brushing her hair and teeth.
The Quick Disability Arm Shoulder Hand (DASH) Questionnaire (Hudak et al., 1996) was adminis-
tered, and she obtained a score of 63.7%.
Regarding functional mobility, Florence was able to independently roll, bridge, and move be-
tween supine and short sit in bed. Florence transferred on and off the bed, chair, and raised toilet
using a wide-base quad cane. She required moderate assistance to transfer in and out of the tub
using a transfer tub bench similar to the one in her home.
IADLs
Florence can manage her communications and handle her finances, but she is dependent in main-
taining her home, preparing meals, cleaning up, and shopping.
In regard to rest and sleep, Florence reports not being able to find a comfortable position to sleep.
MENTAL FUNCTIONS
Cognitive assessment found Florence to be alert and oriented to person, place, time, and situa-
tion, and short- and long-term memory were intact. She was able to follow three-step commands
and make her needs known. Affect appeared appropriate, and no gross deficits in perception were
observed.
FLORENCE: RHEUMATOID ARTHRITIS | 47

No gross deficits were observed with hearing, vestibular, taste, smell, proprioceptive, and cutane-
ous functions. Florence reported being nearsighted and required eyeglasses. Use of the numerical
rating scale (0–10) indicated 7/10 pain in her left shoulder. The pain was described as “miserable.”
No edema was noted.

Florence presented with a metabolic equivalent of task value of 2.5–3.0.
MOVEMENT FUNCTIONS
Passive range of motion, active range of motion, and muscle strength in both upper extremities
were within functional limits, except for the left shoulder. The left shoulder was positioned in a
soft immobilizing shoulder adduction sling that was not removed. Flexible, swan neck deformities
in Digits 2–5 and Boutonniere deformities of Digit 1 in both hands were observed. Gross grasp
strength was not assessed.
Static and dynamic sitting balance were 5/5, and static and dynamic standing balance were 4/5.
Muscle tone was normal, and reflex integration was grossly intact.
PLAN FOR DISCHARGE

At the conclusion of her 10 weeks of outpatient occupational therapy services, Florence will be
discharged with a home exercise program.

1. Provide a summary of the Phase 2 TSA postsurgical protocol.
2. At the time of the evaluation, what precautions must be observed after her TSA?
3. Create a handout identifying precautions needed to be followed by patients with an unhealed surgical
wound.
4. It is initially contraindicated for Florence to shower. Why?
5. To maintain safety, what other factors should be considered?
2. What strategies can be used to improve Florence’s ability to dress?

3. What strategies can be used to improve Florence’s ability to cut her own food?
4. When would it be appropriate for Florence to once again shower in her bathroom?
5. What strategies can be used to improve Florence’s ability to have a more continuous and restful sleep?
6. What strategies can be used to improve Florence’s ability to prepare a simple light meal when the
HHA is absent?
7. Briefly describe what the first treatment session with Florence would be like.
Florence’s occupational performance.
selection.
mote, establish/restore, maintain, modify and/or prevent?

1. Identify Florence’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Florence’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Florence’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Florence’s current level of

1. What common affective issues related to TSA may Florence face?
3. To address these issues, what other disciplines could you refer Florence to?
4. What strategies or techniques would be available to help minimize the postsurgical pain Florence is
experiencing?
5. Given the information provided, which additional mental function considerations need to be addressed?

1. Given the information provided, identify neuromusculoskeletal and movement-related functions that
need to be addressed. Justify your selections.
2. What are the exercises identified to be performed with the left upper extremity during Phase 2 of the
TSA?
3. Explain how these exercises match Florence’s current level of postsurgical healing.
4. Identify and summarize all previous and subsequent phases of the TSA protocol.
5. Compare and contrast total shoulder replacement with a reverse shoulder replacement.
6. Create an exercise program for Florence based on occupational performance.

1. Given the information provided, identify cardiovascular, hematological, immunological, and respira-
tory functions that need to be addressed. Justify your selections.
2. What are common cardiovascular and respiratory conditions that have been associated with the later
stages of RA?

1. What are common trophic changes that have been associated with the later stages of RA?

Describe how Florence’s diagnoses may affect her voice, speech, and occupational performance.

1. What assistive technologies and adaptations might be used or made for Florence while she is receiving
outpatient occupational therapy services? Why?
2. Florence has Medicaid and Medicare; which one would serve as the primary payer for her outpatient
occupational therapy services?

1. Florence confides in you that her HHA leaves 1 hour early every day, during her assigned time, to pick
up her son. How should this situation be addressed?
2. Florence confides in you that she was so desperate for a good night’s sleep that she slept two evenings
not wearing her left shoulder immobilizer support brace. How should this situation be addressed?
PHARMACOLOGY
Florence is currently taking Celebrex.

1. Given Florence’s profile, examine how your own culture and beliefs affect your interaction with her.
case.

1. What is the purpose of the Quick DASH?
5. What is the reliability of the Quick DASH?
6. What is the validity of the Quick DASH?
7. What functional inference can be deduced from Florence’s score of 63.7%?

2. Identify roles of the occupational therapy assistant (OTA) that could be used in the occupational ther-
apy process for this case.
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Florence’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Florence to deter-
3. What are the challenges you foresee if attempting to integrate telehealth services with this client?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Florence and mem-
bers of the interprofessional team. Review the needs of Florence, her caregiver, family members, and
significant others. The plan must match needs with available resources and the discharge environment.
REFERENCES
Americans with Disabilities Act of 1990, Pub. L. 101-336, 42 U.S.C. §§ 12101–12213 (2000).
Hudak, P. L., Amadio, P. C., Bombardier, C., Beaton, D., Cole, D., Davis, A., . . . Wright, J. (1996). Development of an upper
extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder, and Head). American Journal of Industrial
Medicine, 29, 602–608. https://doi.org/10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L
7
Brian: Traumatic Above-Elbow Amputation

Brian (he, him, his, himself)
MEDICAL HISTORY
Brian is a 31-year-old native Hawaiian male who is 6' 2" and weighs 180 pounds. He was brought to the
emergency department by emergency medical services after being attacked by a great white shark while
recreational surfing. He presented with a severed right upper limb, multiple lacerations, and severe blood
loss. He was stabilized by the administration of isotonic fluids and 4 units of blood. Once stabilized, he
was sent to the operating room, where vascular and plastic surgeons addressed his lacerations and per-
formed an emergency closed above-elbow amputation (AEA). Brian’s medical history was unremarkable.
He reported no tobacco, caffeine, or drug use. He reported commonly having three to four alcoholic drinks
over the course of a weekend. Brian has no known allergies. After his surgery, Brian spent 1 week on the
medical-surgical floor. From there, he completed 2 weeks in in-patient rehabilitation, where he received
wound care, self-care retaining, preprosthetic training, and assessment by a prosthetist.
SOCIAL HISTORY
Brian lives with his girlfriend Asia in their beachfront apartment. Brain and Asia met while both worked
as accountants at the same firm. Their apartment is located on the seventh floor of an elevator-equipped
building. It has a living room, dinette, kitchen, bathroom, and small balcony with ocean views. Currently,
Brian’s family lives in California, and he has no close relatives on the island. Brian and Asia both have a
large network of friends. Asia has two brothers and parents who live within an hour’s drive. Brian’s goal
is to get back home to Asia and return to his career and the lifestyle that he loves. He wishes to be able
to use his myoelectric arm with enough skill to be able to perform his ADLs, prepare a meal, and use his
computer. He is scheduled to return to work after his 6 weeks of outpatient occupational therapy services.
Brian reports that his parents are devout Buddhists; however, he does not identify with any religion.
Brian was referred for outpatient services. He is to receive occupational therapy services 2 times per week
for 10 weeks.
53
Brian’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Brian has been employed as a tax accountant for the past 6 years and was recently
promoted to manager of the tax department. He holds a bachelor’s degree in accounting and a mas-
ter’s in business administration. During the tax season, he typically worked 60–70 hours per week.
His most common patterns of daily living include being up and out of his home by 6:00 a.m. and re-
turning home by 8:00 p.m. His interests include mountain biking, surf sailing, hiking, climbing, and
rappelling. Brian values his relationship with Asia, an active and healthy lifestyle, and professional
and financial success. He reported his greatest current need is to return to his job as an accountant
and be able to support himself and Asia.
ADLs
Regarding self-care, Brian was able to feed, dress, groom, and toilet independently using one-hand
techniques. Brian required moderate assistance to wash his right upper extremity. Regarding func-
tional mobility, Brian was able to independently roll, bridge, scoot, and transition between supine
and sitting. Brian transferred independently from all surfaces without using a device.
IADLs
Brian can manage his communications, handle his finances, perform simple household chores, and
shop using his left upper extremity. He reports being hesitant to cook because of concern that he
will burn his uninjured arm. Regarding rest and sleep, Brian reported frequently waking up in the
middle of the night reliving the horrors of the shark attack.
MENTAL FUNCTIONS
Cognitive assessment found Brian to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. He is able to follow three-step commands and make his
needs known. Affect appeared appropriate, and no gross deficits in perception were observed.

No gross deficits were observed with visual, hearing, vestibular, taste, smell, and proprioceptive
functions. Using the Numeric Rating Scale (0–10), Brian reported pain at a 4. Cutaneous sensation
assessment using a calibrated paper clip indicated that two-point discrimination was 10 mm at the
distal end of the residual limb. Brian reported experiencing phantom limb sensation in his right
residual limb. He stated, “It feels like my arm is still there.”
BRIAN: TRAUMATIC ABOVE-ELBOW AMPUTATION | 55

There were no deficits with cardiovascular and respiratory systems function.
MOVEMENT FUNCTIONS
Passive range of motion (PROM) and active range of motion (AROM) in all joints of Brian’s left
upper extremity and both lower extremities are within normal limits (WNL). At his right shoul-
der, PROM and AROM are WNL. Muscle strength of all groups of both lower extremities and the
left upper extremity were 5/5. Muscle strength to the right shoulder was 4/5. His residual limb is
well shaped and adequately healed to accommodate the prosthetic socket. Gross grasp strength
in Brian’s left hand was 88 pounds, and left gross grasp, pinch, and in-hand manipulation abilities
were within defined limits.
Static and dynamic sitting and standing balance were 5/5. Muscle tone was normal, and reflex in-
tegration was intact.
PLAN FOR DISCHARGE

After the completion of 10 weeks of outpatient rehabilitation, Brian will be discharged and return
to work.
1. During the first session, it is customary to check out and evaluate the prosthesis before initiating train-
ing. What should be evaluated? Explain why.
2. Create a handout indicating the signs of a poorly fitted prosthesis and actions that need to be taken if
one is identified.
3. What has Brian reported that could an indication he may be experiencing posttraumatic stress disor-
der (PTSD)?
4. If you have a concern that Brian may be experiencing PTSD, what should you do?
2. Identify goals that would reflect Brian’s ability to care for his prosthesis.
3. Identify goals that would reflect Brian’s ability to manage the controls of the prosthesis.
4. Brian wishes to perform his ADLs in a bilateral manner. Identify a progression of dressing tasks he can
perform, from simple to complex, while integrating the use of his prosthesis. Provide an explanation
for your choices.
5. Brian wishes to be able to prepare a meal. Describe a treatment session that takes into consideration
the basic use of his prosthesis and his concern about burning his left upper extremity.
Brian’s occupational performance.

1. Identify Brian’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Brian’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Brian’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
How can the identified values, beliefs, and spirituality be used within this case?
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and current level of occupa-
tional performance.

1. What common affective issues related to Brian’s amputation may he have to face?
3. To address these issues, what other disciplines could you refer Brian to?
4. Given the information provided, which additional mental function considerations need to be
addressed?

2. Given that Brian has undergone a right AEA, which muscle groups were likely lost, and which were
retained?
3. How can the retained muscle groups be strengthened?
4. A myoelectric prosthesis was selected over a body-powered prosthesis. Identify the pros and cons of
this selection.
5. Given Brian’s lifestyle, what would be the best choice for a terminal device?
6. Compare and contrast open amputation with closed amputation.
7. Create an exercise program for Brian based on occupational performance.

2. How can the use of a myoelectric prosthesis influence the energy cost of an activity?

Describe how Brian’s diagnosis may affect his voice, speech, and occupational performance.

1. Identify two adjunctive modalities that can be used to reduce the hypersensitivity to light touch in the
distal portion of Brian’s residual limb. Describe both the precautions and recommended application
for each.
2. Create a handout identifying the wearing schedule for Brain to build up his tolerance of his upper-
extremity prosthesis.
3. What are the components of a myoelectric prosthesis?
4. How often should Brian’s prosthesis be cleaned? How should it be cleaned?

What assistive technologies or adaptations might be used or made for Brian while he is receiving occupa-
tional therapy services as an outpatient?

1. Asia informs you that immediately after his discharge from the rehabilitation center Brian has re-
turned to driving his car. Based on your state’s Department of Motor Vehicle laws, how should this
information be addressed?
2. Asia informs you that the previous night Brian screamed for more than 10 minutes because he believed
the shark was attacking him. How should this situation be addressed?
3. Brian privately informs you that he has not been intimate with Asia since he has returned home. He is
concerned that she may no longer find him attractive. How should his concerns be addressed?
PHARMACOLOGY
Brian is currently taking amoxicillin.

1. Given Brian’s profile, examine how your own culture and beliefs affect your interaction with him.
case.

1. What is the purpose of the two-point discrimination test?
5. What is the reliability of the two-point discrimination test?
6. What is the validity of the two-point discrimination test?
7. What functional inference can be deduced from Brian’s score of 10 mm?
8. What additional standardized cutaneous assessments could have been used in this case? Why?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) code for Brian’s diagnosis.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Brian to determine
3. What challenges do you foresee if attempting to integrate telehealth services with this client?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Brian and members
of the interprofessional team. Review the needs of Brian, caregivers, family members, and significant oth-
REFERENCES
8
Yvonne: Breast Cancer

Yvonne (she, her, hers, herself)
MEDICAL HISTORY
Yvonne is a 44-year-old Black female who is 5' 11" and weighs 209 pounds. She was electively admitted
to the surgical service with a diagnosis of Stage 2 breast cancer. She underwent a left radical mastec-
tomy. Her medical history included being diagnosed with lupus 24 years ago and having a herniated disc
between the second and third lumbar vertebrae. Past medical procedures included decompression and
fusion of the second and third lumbar vertebra 10 years ago. She reported living an active lifestyle, with
occasional use of alcohol and tobacco and no drug use. Yvonne reported drinking 2 to 3 large cups of cof-
fee per day. She reported being allergic to pollen.
SOCIAL HISTORY
Yvonne lives with her spouse Tiffany in a one-bedroom apartment in a full-service high-rise building in
the city center. Her apartment has an open floor plan for its living room, dining room, and kitchen. Yvonne
and her spouse have been together for 15 years and married for 2 years. She reports being a member of the
African Methodist Episcopal Church.
Yvonne was referred for outpatient services. She is to receive occupational therapy services 2 times per
week for 8 weeks.
61
Yvonne’s occupational history and experiences included being a police officer for the past 21 years.
She reported being independent in all ADLs and IADLs before surgery. Her patterns of daily living
most commonly included picking up breakfast on the way to work, working the day shift from 9:00
a.m. to 5:00 p.m., and picking up dinner for herself and her spouse on the way home. During the
week, they go to the gym or pool in their building. Weekends are dedicated to friends, day trips, and
a busy schedule of social events. Yvonne’s interests include Tae Kwon Do, microbrewing, and mo-
torcycle riding. She values love, honesty, and acceptance. Yvonne reported that her greatest current
need is to get her arm moving well and to prepare for retirement from her job.
ADLs
Regarding self-care, Yvonne was independent in feeding, grooming, toileting, and bathing. She was
able to dress but required assistance to don and doff her bra. Regarding functional mobility, Yvonne
was able to independently roll, bridge, and transition between supine and short sit in bed. Yvonne
transferred to and from all surfaces independently. Yvonne was able to ambulate independently but
was observed with postural guarding of her left upper extremity.
IADLs
Yvonne’s spouse has taken over full responsibility of cooking, shopping, and care of the home while
Yvonne recovers. Regarding rest and sleep, Yvonne reported waking up each night, going to the
bathroom, and looking at the surgical site.
MENTAL FUNCTIONS
Cognitive assessment found Yvonne to be alert and oriented to person, place, time, and situation,
and her short- and long-term memory were intact. She is able to follow three-step commands and
make her needs known. Regarding affect, Yvonne reported frequently crying when she looked at
the surgical site. No gross deficits in perception were observed.
SENSORY FUNCTION AND PAINS

functions. Use of the numerical rating scale (NRS; 0–10) for pain indicated a score of 7 for Yvonne’s
left shoulder before taking pain medication and a 4 after taking pain medication. She also reports
having a sensation of her left breast still being present. Her surgical incision was fully closed, sta-
ples were removed, and the scar was flat. Light touch and localization were impaired; edema was
unremarkable.
YVONNE: BREAST CANCER | 63

Assessment of cardiovascular and respiratory systems function indicated no deficits.
MOVEMENT FUNCTIONS
Passive range of motion (PROM), active range of motion (AROM), and muscle strength in Yvonne’s
right upper extremity and both lower extremities were within normal limits. Her AROM was
within normal limits throughout the left upper extremity (LUE) except to the shoulder. PROM
at the left shoulder was as follows: shoulder flexion, 0–102°; abduction, 0–88°; external rotation,
0–60°; and internal rotation, 0–80°. AROM at the left shoulder was as follows: shoulder flexion,
0–102°; abduction, 0–88°; external rotation, 0–60°; and internal rotation, 0–80°. Muscle strength
in the LUE was not evaluated. Yvonne held her LUE in a guarded position. No gross defects were
found in prehension.
PLAN FOR DISCHARGE

After completion of outpatient occupational therapy services, Yvonne will be discharged to a home
program.

1. Create a precaution handout identifying the precautions and contraindications after a radical
mastectomy.
2. Compare and contrast radical mastectomy with general postsurgical precautions.
3. Identify the common emotional reactions associated with mastectomy that may affect the treatment
process.
2. What strategies or assistive devices can be used to improve Yvonne’s ability to dress?
3. What strategies or assistive devices can be used to improve Yvonne’s ability to have a more restful
sleep?
4. What strategies or assistive devices can be used to improve Yvonne’s ability to prepare a simple meal?
5. Briefly describe what the first treatment session with Yvonne would be like.
Yvonne’s occupational performance.
selection.

1. Identify Yvonne’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Yvonne’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Yvonne’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Yvonne’s current level of

1. What common affective issues related to her radical mastectomy may Yvonne have to face?
3. To address these issues, what other disciplines could you refer Yvonne to?
4. Given the information provided, which additional mental function considerations need to be
addressed?

2. Identify the structural changes that have led to the limited range of motion (ROM) in Yvonne’s left
shoulder girdle.
3. Which model or frame of reference would be the best choice to address Yvonne’s limitation of ROM?
4. Which type of exercise would be the best choice to address Yvonne’s limitation in ROM? Justify your
selection?
5. During a subsequent visit, you noticed that Yvonne’s right hand had become swollen. What would be
your concern? How should her hand be assessed?
6. Create an exercise program for Yvonne based on occupational performance.

2. How may the radical mastectomy affect Yvonne’s respiratory function?

1. Compare and contrast a simple mastectomy with a radical mastectomy.
2. What phenomena would explain Yvonne’s continued sensation of her left breast being present? How
may this situation be addressed?
3. What are common trophic changes to be expected along and around her surgical site?
4. Does Yvonne’s ethnicity pose an increased risk for these changes?
5. What intervention would you select to minimize or prevent these changes?

Describe how the diagnosis may affect Yvonne’s voice, speech, and occupational performance.

1. Yvonne chose to have a prosthesis versus reconstructive surgery. What are the advantages and disad-
vantages of each?
2. Identify and discuss the various breast forms or prosthesis that may be available to Yvonne.
3. Yvonne’s insurance is a health maintenance organization. Would it cover the cost of her prosthesis?

1. Yvonne has arrived for her occupational therapy session, and you observe the occupational therapy as-
sistant (OTA) taking Yvonne’s blood pressure in her LUE. Identify what is wrong and the best manner
to address the situation.
2. During a treatment session, you observed that Yvonne’s surgical site is red and warm to the touch.
Identify what your concern would be and the best manner to address this situation.
3. Yvonne informs you that she has become aware of a mass in her right breast but pleads with you not to
tell anyone. What are your ethical and legal responsibilities in this situation?
4. During a treatment session, an associate from housekeeping looks at Yvonne and makes a disparaging
remark concerning her sexual orientation. How would you address this behavior?
5. Yvonne has confided in you that her spouse is reluctant to resume sexual intimacy with her. How can
you best address this situation?
PHARMACOLOGY
Yvonne is currently using Voltaren.

1. Given Yvonne’s profile, examine how your own culture and beliefs affect your interaction with her.
case.

1. What is the purpose of NRS?
2. What are the psychometric properties of this instrument?
3. For which population were the norms developed?
5. What is the reliability of the NRS?
6. What is the validity of the NRS?
7. What functional inference can be deduced from Yvonne’s score of 7/10?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Yvonne’s diagnoses.

Explain why.
practice setting?
ADVOCACY
privacy, confidentiality, informed consent, awareness building, accessing education and/or benefits/
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Yvonne to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Yvonne and mem-
bers of the interprofessional team. Review the needs of Yvonne, caregivers, family members, and signifi-
REFERENCES
9
Chin: Carpal Tunnel Syndrome

CLOVER HUTCHINSON, OTD, MA, OTR/L
Chin (he, him, his, himself)
MEDICAL HISTORY
Chin is a 62-year-old Chinese American male who is 5' 4" and weighs 140 pounds. Recently, he received
a diagnosis of carpal tunnel syndrome (CTS). He was seen by the orthopedic service for an ambulatory
right endoscopic carpal tunnel release. After surgery, he was fitted with an anterior wrist splint. He was
scheduled to begin occupational therapy at the outpatient department 10 days postsurgery. He reported
no alcohol, tobacco, caffeine, or drug use and being allergic to sulfa-based medications.
SOCIAL HISTORY
Chin lives with his wife, son, daughter-in-law, and three grandchildren. His apartment is located on the
fourth floor of a walk-up building. The apartment consists of a living room, kitchen, bathroom, three bed-
rooms, and a dining room that has been converted into two additional bedrooms. His building is in a part
of a town in which many recent Chinese immigrants reside. Chin identifies as a Confucianist.
Chin was referred for outpatient services. He is to receive occupational therapy services 2 times per week
for 6 weeks.
69
Chin’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. He has been employed as a waiter in a well-known Chinese restaurant for the past
18 years. His patterns of daily living most commonly included arriving to work at 11:00 a.m. and re-
turning home by 12:00 a.m. Chin works 6 days per week to support his family and was traditionally
off only on Mondays. He is deeply concerned that if he does not return to work in 6 weeks he will
lose his job. His interests include fishing and walking about his community. He values providing his
children and grandchildren with the opportunity to pursue college-level education and allow them
to achieve the American dream. Chin reported his greatest current need is to return to work in no
later than 6 weeks.
ADLs
Regarding self-care, Chin reported no difficulties except for opening a variety of containers.
Regarding functional mobility, Chin reported no difficulties with bed mobility and transfers.
IADLs
Chin’s wife has taken on the responsibility to maintain the home, prepare meals, clean up, and shop
while her husband is recovering. Regarding rest and sleep, Chin reported sleeping comfortably and
uninterrupted.
MENTAL FUNCTIONS
Cognitive assessment found Chin to be alert and oriented to person, place, time, and situation, and
his short- and long-term memory were intact. He is able to follow three-step commands and make
his needs known. Chin has a fair command of the English language but reported difficulty under-
standing technical medical terms. Affect appeared appropriate, and no gross deficits in perception
were observed.

functions. Impaired light touch, deep pressure, and thermal senses were identified in distal volar
portions of the thumb, dorsal portions of the index and middle fingers, and a radial portion of the
ring finger. Edema was observed in his right hand. Circumferential measurements taken at the
distal palmar crease indicated 19.5 cm for the right hand and 17.8 cm for the left. Use of the numer-
ical rating scale (0–10) for pain indicated a score of 2 for Chin’s right anterior wrist. The pain was
described as “tolerable.”
CHIN: CARPAL TUNNEL SYNDROME | 71

No deficits were noted in cardiovascular and respiratory systems function.
MOVEMENT FUNCTIONS
Passive range of motion (PROM) and active range of motion (AROM) in all four extremities except
right wrist and digits were within normal limits. The PROM of the digits of the right hand was
within normal limits. Goniometric measurements of the AROM of the digits of the right hand are
shown in Table 9.1. In addition, strength was measured in both hands (Table 9.2). Chin scored a
73 on the Jebsen–Taylor Hand Function Test (Jebsen et al., 1969). Observation of the surgical site
revealed the presence of two closed flat and dry incision sites, covered in scabs. Sutures were still
present.
TABLE 9.1. Active Range of Motion (Degrees) of Right-Hand Digits
Joint Digit 1 Digit 2 Digit 3 Digit 4 Digit 5
Metacarpophalangeal joint 0–46 0–70 0–76 0–76 0–90

Interphalangeal joint 0–68
Proximal interphalangeal joint 0–83 0–85 0–85 0–100
Distal interphalangeal joint 0–40 0–40 0–52 0–60
Total active motion 114 193 201 213 250
TABLE 9.2. Hand Strength Measurements (lb)
Test Right Hand Left Hand
Gross grasp 46 70
Tripod pinch 12 17
Lateral pinch 15 20
Tip pinch 10 15
PLAN FOR DISCHARGE

Chin will be discharged from outpatient occupational therapy services with a home exercise pro-
gram and plans to return to work.
Questions and Activities Guiding Critical Thinking

1. Create a handout identifying the postsurgical precautions after a carpal tunnel procedure.
2. Identify and explain the splint-wearing schedule and precautions that Chin must follow.
3. What are the common signs and symptoms of an infected wound?
4. If you have a concern that Chin’s wound is infected, what actions must be taken?
5. Identify the common emotional reactions associated with not being able to work that may affect the
treatment process.
2. Identify assistive devices or strategies that will allow Chin to open containers.
3. Identify the areas of education that would be appropriate to engage in with Chin and explain why.
4. Briefly describe what the first treatment session with Chin would be like.
Chin’s occupational performance.

1. Identify Chin’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Chin’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Chin’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Values, beliefs, spirituality
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Chin’s current level of

1. What common affective issues related to his surgery may Chin have to face?
2. What does the literature identify as common concerns of people who must miss work for an extended
period of time?
4. To address these issues, what other disciplines could you refer Chin to?

2. Locate an occupational therapy protocol for clients who have undergone an endoscopic carpal tunnel
release procedure. Identify and explain each phase of intervention.
3. What are the expected norms for AROM at the wrist and digits?
4. Which assessment tools should be used to assess gross grasp and pinch strength?
5. When should tools to assess gross grasp and pinch strength be used?
6. Are the gross grasp and pinch strength for Chin’s right and left hands within the normative range for
his age and gender?
7. Compare and contrast CTS with cervical radiculopathy.
8. Create an exercise program for Chin based on occupational performance.

2. How can pain affect an individual’s vital signs?

1. How can the edema in Chin’s right hand be best addressed during his therapy sessions?
2. How can Chin address the edema in his right hand when he is not actively engaged in his therapy
sessions?
3. Identify an alternative edema assessment tool or method other than circumferential measurements.
4. What are the risks and benefits of an endoscopic release versus an open surgical release?

Describe how Chin’s diagnosis may affect his voice, speech, and occupational performance.

What assistive technologies or adaptations might be used or made for Chin while he is receiving occupa-
tional therapy services? Why?

1. Chin frequently asks to take a break during the therapy session to smoke a cigarette. How would you
address smoking and its effect on wound healing?
2. Chin informs you that he missed his follow-up appointment with the surgeon because he did not have
the copayment. How can you best address this situation?
3. Chin shows you a recent photograph of him lifting his 4-year-old grandson with both hands. How can
you best address this situation?
PHARMACOLOGY
Chin is currently taking Naprosyn.

1. Given Chin’s profile, examine how your own culture and beliefs affect your interaction with him.
case.

1. What is the purpose of the Jebsen–Taylor Hand Function Test?
5. What is the reliability of the Jebsen–Taylor Hand Function Test?
6. What is the validity of the Jebsen–Taylor Hand Function Test?
7. What functional inference can be deduced from Chin’s score of 73?


BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) code for Chin’s diagnosis.

1. Who would be the authorized individuals that you could share the occupational therapy findings with?
Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Chin to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Chin and members
of the interprofessional team. Review the needs of Chin, caregivers, family members, and significant oth-
REFERENCES
Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. J., & Howard, L. A. (1969). An objective and standardized
test of hand function. Archives of Physical Medicine and Rehabilitation, 50, 311–319.
10
Patricia: Laceration of Flexor Digitorum

Profundus and Superficialis Tendons
Patricia (she, her, hers, herself)
MEDICAL HISTORY
Patricia is a 36-year-old Danish American female who is 5' 11" and weighs 140 pounds. She was brought
in by emergency medical services to the emergency department after lacerating her left index finger with
a box cutter while working as a sales associate. Physical examination and X-rays were performed, and
Patricia received a diagnosis of complete tendon laceration to her left second flexor digitorum profundus
and flexor digitorum superficialis. She was taken to the operating room, where the tendons were surgi-
cally repaired. She was placed in a protective posterior fiberglass splint and discharged from the hospital
the same day. Her medical history was unremarkable. She reported no alcohol, drug, tobacco, or coffee
use and has no known allergies.
SOCIAL HISTORY
Patricia lives as a single mother with her 8-year-old son in the basement apartment of her parents’ home.
There are 12 steps to descend to enter her apartment from the hallway. Her apartment includes a kitch-
enette, a combined living room and dinette space, two small bedrooms, and a bathroom. Patricia does not
own a car. Her home is a 15-minute bus ride to work and is 20 minutes from the medical center. Patricia
reported just ending a 6-month relationship with her last boyfriend, and her parents have been active in
watching her son while she is at work. Patricia identifies as an Evangelical Lutheran.
Patricia was referred for outpatient services. She is to receive occupational therapy services 2 times per
week for 10 weeks.
77
Patricia’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Patricia has been employed full time for the past 8 months as a sales associate
for a national chain store. She reported that this job has been her first with a comprehensive ben-
efits package. Her patterns of daily living most commonly included having breakfast with her son,
putting him on the school bus, and then going to work. Her mother usually picked up her son from
the bus and assisted him with his homework. Once Patricia arrived home, she usually cooked din-
ner, helped her son complete his homework, and then chatted to friends on social media. Weekends
usually included playdates for her son on Saturdays and church on Sundays. Her interests include
spending time on social media and going out with friends on occasion. She values the love of her
parents and the gift of her son. Patricia reported her greatest current need is to get her hand better
and get back to work.
ADLs
Regarding self-care, Patricia is able to feed herself but requires assistance to cut her food. She is
able to don and doff all garments but requires assistance with fasteners. She is not able to blow dry
her hair without assistance. Regarding functional mobility, Patricia is able to be independent in all
bed mobility, transfer, and ambulation.
IADLs
Patricia can manage her communications, handle her finances, prepare simple meals, and perform
light cleanup tasks and light shopping. Regarding rest and sleep, Patricia reported that she fre-
quently awakes at night secondary to the presence of “throbbing pain” in her surgically repaired
finger.
MENTAL FUNCTIONS
Cognitive assessment found Patricia to be alert and oriented to person, place, time, and situation,
and her short- and long-term memory were intact. She is able to follow three-step commands and
make her needs known. Regarding affect, she reported feeling anxious because of not having money
coming in to pay her bills. She scored 58 out of 100 on the Zung Self-Rating Anxiety Scale (Zung,
1971). No gross deficits in perception were observed.

cutaneous functions. A 2.5-cm scabbed incision with six external stitches was observed over the
PATRICIA: LACERATION OF FLEXOR DIGITORUM PROFUNDUS AND SUPERFICIALIS TENDONS | 79
anterior base of Patricia’s left index finger. Circumferential measurements were taken over the
proximal phalanx; the left was 8.0 cm, and the right was 7.2 cm. Use of the numerical rating scale
(0–10) for pain indicated a score of 3 for Patricia’s left index finger, and she described the surgical
area as “sensitive to touch.”

No deficits were noted in cardiovascular and respiratory systems function. Patricia reported that
she performs all ADLs and IADLs without experiencing fatigue.
MOVEMENT FUNCTIONS
All four extremities are intact for passive range of motion, active range of motion, and muscular
strength. Movement of the left wrist and digits was contraindicated and not assessed at the time
of evaluation. Patricia has a left dorsal protective fiberglass splint with a bulky dressing and ace
bandage wrap.
Static and dynamic sitting and standing balance were both 5/5. Muscle tone was normal, and reflex
integration was intact.
PLAN FOR DISCHARGE

Following completion of outpatient occupational therapy services, Patricia will be discharged to a
home program.

1. Create a handout that identifies and explains precautions and contraindications to be followed after
tendon repair.
2. Patricia has an unhealed wound. Identify and explain the precautions to be followed.
3. Identify and explain the splint-wearing schedule and the precautions that Patricia must follow.
4. Identify the common emotional reactions associated with hand injuries that may affect the treatment
process.
2. What strategies or assistive devices can Patricia use that can lead her to independent dressing?
3. What strategies or assistive devices can Patricia use that can lead her to independently blow dry her
hair?

Patricia’s occupational performance.

1. Identify Patricia’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Patricia’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Patricia’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Patricia’s current level of

1. What common affective issues related to her laceration and repair may Patricia have to face?
3. To address these issues, what other disciplines could you refer Patricia to?
4. To address Patricia’s anxiety, what other disciplines could you refer Patricia to?
5. Which stress reduction techniques may benefit Patricia? Why?
6. Patricia is concerned about the cost of all her medical services. What service may assist her with this
concern?

2. Identify two sources to obtain a protocol for a flexor tendon repair. Select one and apply it to Patricia’s
zone of injury.
3. Identify biweekly time frames for the following: required splint wearing, exercises, and allowed activ-
ities. Explain why.
4. Create an exercise program for Patricia based on occupational performance.

2. Identify the physical manifestation of anxiety on cardiovascular and respiratory functions. Explain the
physiological mechanisms.

1. Compare and contrast laceration and abrasion.
2. What is the expected time frame for the sutures to be removed?
3. How long does it take for a tendon to heal after surgery?

Describe how Patricia’s diagnosis may affect her voice, speech, and occupational performance.

Explain the function of the protective splint that the surgeon placed on Patricia after her surgery.

1. You observed a male aide ask Patricia out on a date. Identify what would be your concern, and explain
the best manner to address this situation.
2. During the session, you became aware that Patricia smelled of marijuana. Identify what would be your
concern, and explain the best manner to address this situation.
3. At the end of the session, Patricia asked to borrow bus fare to return home. Identify what would be
your concern, and explain the best manner to address this situation.
4. During Week 2, Patricia confides to you that she removes her protective splint for hours at a time.
Identify what would be your concern, and explain the best manner to address this situation.
PHARMACOLOGY
Patricia is currently taking Amcill.

1. Given Patricia’s profile, examine how your own culture and beliefs affect your interaction with her.

1. What is the purpose of the Zung Self-Rating Anxiety Scale?
5. What is the reliability of the Zung Self-Rating Anxiety Scale?
6. What is the validity of the Zung Self-Rating Anxiety Scale?
7. What functional inference can be deduced from Patricia’s score of 58?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Patricia’s diagnosis.

Explain why.
practice setting?
4. Which insurance covers individuals injured during the performance of their duties at work?
ADVOCACY
privacy, confidentiality, informed consent, awareness building, accessing education and/or benefits/
resources?
TELEHEALTH
1. How can telehealth be integrated as a component of the occupational therapy process into this case?
2. Before launching telemedicine services, what questions would be essential to ask Patricia to determine
3. What are the challenges you foresee if attempting to integrate telehealth services with this client?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Patricia and mem-
bers of the interprofessional team. Review the needs of Patricia, caregivers, family members, and signifi-
REFERENCES
Zung, W. W. (1971). A rating instrument for anxiety disorders. Psychosomatics, 12, 371–379. https://doi.org/10.1016/
S0033-3182(71)71479-0
Rehabilitation Unit SECTION III
or Rehabilitation Hospital
85
11
Fetu: Cerebral Vascular Accident

Fetu (he, him, his, himself)
MEDICAL HISTORY
Fetu is a 71-year-old New Zealander male living in the United States who is 5' 11" and weighs 235 pounds.
He was brought by emergency medical services to the emergency department (ED) after being found by
his wife on the bathroom floor. He was unable to move his right side and had difficulty speaking. A com-
puted axial tomography scan, magnetic resonance imaging, and electrocardiogram were performed. He
was diagnosed with a left ischemic cerebral vascular accident (CVA) of the middle cerebral artery. Fetu
received acute treatment with thrombolytic agents and was stabilized. From the ED, he was transferred
to the stroke unit. His medical history included treatment for hypertension, diabetes mellitus, and high
cholesterol. Upon admission, he reported living a sedentary lifestyle and drinking 4–5 cups of coffee per
day. He reported no alcohol, drug, or tobacco use and an allergy to aspirin.
SOCIAL HISTORY
Fetu is a retired customer service agent who lives with his wife of 43 years, who is also retired. They live
in a one-story ranch home. There are three steps to enter his home, which consists of a living room, dining
room, three bedrooms, a half bathroom, and an eat-in kitchen. They have three adult children living close
by with their families. Fetu identifies as Presbyterian.
Fetu has been transferred to the acute rehabilitation floor. He was referred for occupational therapy,
physical therapy, speech therapy, and dietary services. The length of stay will be 21 days.
87
Occupational Therapy Initial Evaluation Findings: Rehabilitation Unit
Fetu’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. His patterns of daily living most commonly included babysitting his youngest grand-
child with his wife during the week. He also enjoys day trips and dining out with his wife on week-
ends. His interests include watching sports on television and hosting barbecues. Fetu values his
independence and family life. He reported his greatest current needs are to be able to go home and
not be a burden to his wife.
ADLs
Regarding self-care, Fetu was able to use a spoon and fork and drink from a cup independently, but
he was dependent with cutting his food. Fetu was dependent with all dressing, bathing, grooming,
and toileting. Regarding functional mobility, Fetu was able to roll independently to his right but re-
quired moderate assistance to his left. Moderate assistance was required to transition from supine
and short sit in bed. Fetu was dependent on performing stand pivot transfers between the bed and
commode and the bed and wheelchair. Tub transfers were not attempted. He showed noticeable
signs of fatigue after transfers.
IADLs
Fetu was dependent in all areas of IADLs. Regarding rest and sleep, a review of the medical chart
indicated that Fetu was able to sleep through the night.
MENTAL FUNCTIONS
Fetu was alert. Assessment of cognition, perception, and affect status could not be completed at the
time of the evaluation because of Fetu’s severe expressive aphasia.

No gross deficits were observed with visual, vestibular, taste, smell, proprioceptive and cutaneous
functions. Fetu’s wife reported that he was “hard of hearing.” He scored pain as a 0/10 on the Wong-
Baker FACES® Pain Rating Scale (Wong-Baker FACES Foundation, 2018).

Assessment of cardiovascular and respiratory systems function indicated Fetu presented at a value
of 4.0 on the metabolic equivalent of task.
FETU: CEREBRAL VASCULAR ACCIDENT | 89
MOVEMENT FUNCTIONS
Active range of motion (AROM), passive range of motion (PROM), and muscle strength were within
normal limits (WNL) for Fetu’s left upper extremity (LUE). His right upper extremity (RUE) was
WNL for PROM. No AROM was present in his RUE. Left grasp strength was 41 pounds, and right
grasp strength was not able to be assessed.
Fetu required moderate assistance to maintain static sitting and maximal assistance with dynamic
sitting. He was dependent when standing and walking. Both the RUE and right lower extremity
(RLE) were flaccid and without active movement. Deep tendon reflexes in the LUE were absent.
The Fugl-Meyer Assessment for Upper Extremity (FMA–UE; Fugl-Meyer, 1975) was administered,
and the scores were as follows: motor function, 2/66; sensation, 5/12; passive joint motion, 24/24;
and joint pain, 24/24.
PLAN FOR DISCHARGE

Fetu will be discharged with home care services. Services will include nursing, occupational ther-
apy, physical therapy, and speech therapy.

1. What would be the safest transfer method to transition Fetu from his bed to and from his wheelchair?
Why?
2. Create a handout that identifies actions that can be taken to minimize the risk of a fall.
3. Which vital signs should be taken when working with Fetu? What are their norms? When should they
be taken?
4. Fetu has been prescribed an anticoagulant. What are the precautions that need to be followed?
5. To effectively communicate with Fetu, what strategies would you use? Support your selection.
6. What common emotional reactions are associated with stroke that may affect the treatment process?
1. Briefly describe what the first treatment session with Fetu would be like.
2. Briefly describe how Fetu would be able to cut food.
3. Briefly describe how Fetu would be able to propel a wheelchair.
4. Identify the areas of education that would be appropriate to engage in with Fetu and explain why.
5. Would work, play, socialization, or sleep be addressed for Fetu? Why or why not?
Fetu’s occupational performance.

1. Identify Fetu’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Fetu’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Fetu’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Fetu’s current level of oc-
cupational performance.

1. What common affective issues related to his stroke might Fetu have to face?
3. To address these issues, what other disciplines could you refer Fetu to?
4. What common challenges related to his expressive aphasia may Fetu experience?
5. How would these challenges be addressed in occupational therapy?

2. What negative changes can occur as a result of Fetu not being able to actively move his flaccid RUE and
RLE? What can be done during his stay at the acute care facility to prevent these changes?
3. Which frames of reference can address Fetu’s motor control deficits? Which one would you select?
Justify your selection.
4. Compare and contrast a CVA with a brain tumor.
5. Create an exercise program for Fetu based on occupational performance.

tory function(s) that need to be addressed. Justify your selection(s).
2. Identify the signs and symptoms of overexertion Fetu may display while engaged in his treatment
sessions.

1. Fetu has great difficulty changing his position in bed. What are the concerns and how can these be best
addressed?

Describe how Fetu’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made to assist Fetu while he is receiving
occupational therapy services on the acute rehabilitation floor? Why?
2. What assistive technologies or adaptations might be issued before Fetu’s discharge home? Why?

1. You overhear Fetu’s wife asking the nurse whether he will ever be able to use his arm and leg again.
The nurse assures her he will be as good as new in a matter of weeks. How should this situation be best
addressed?
2. During Fetu’s preparation for discharge to home, you observe his wife placing five hospital towels in
her shopping bag. How should this situation be best addressed?
PHARMACOLOGY
Fetu is currently taking Plavix.


1. Given Fetu’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the FMA–UE?
5. What is the reliability of the FMA–UE?
6. What is the validity of the FMA–UE?
7. What functional inference can be deduced from Fetu’s motor function score of 2/66?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Fetu’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Fetu to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in (hypothetical) collaboration with Fetu
and members of the interprofessional team. Review the needs of Fetu, caregivers, family members, and
REFERENCES
Fugl-Meyer, A. R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient: 1. A
method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13–31.
Wong-Baker FACES Foundation. (2018). Wong-Baker FACES® Pain Rating Scale.
12
Bianca: Spinal Cord Injury, Complete C5

Bianca (she, her, hers, herself)
MEDICAL HISTORY
Bianca is a 47-year-old Dominican American female who is 5' 1" and weighs 165 pounds. She was brought
by emergency medical services to the emergency department after a diving accident. She presented with
paralysis in all four extremities. A physical examination, X-rays, computerized tomography scan, and
magnetic resonance imaging were performed. She received a diagnosis of a complete C5 spinal cord in-
jury (SCI). She was placed on a ventilator and treated to prevent shock, and her cervical spine was immo-
bilized. Bianca was taken to the operating room (OR), where she underwent spinal cord decompression
and stabilization. From the OR, she was transferred to the neurological intensive care unit. Her medical
history included breast augmentation, tummy tuck, and gluteal enhancement. Upon admission, she re-
ported living an active life. She and her boyfriend enjoyed dining out, traveling, and dancing. She reported
no caffeine, nicotine, drug, or alcohol use and has no known allergies.
SOCIAL HISTORY
Bianca lives with her boyfriend of 2 years in her boyfriend’s pre–World War II two-story townhouse.
There are 8 steps to the landing of the first floor and an additional 15 steps between the first and second
floors. The townhouse includes a small bathroom, galley kitchen, large living room, dining room, and a
single bedroom. The townhouse is located just five blocks from the salon where Bianca works. Bianca
reported having a 23-year-old son who is serving in the military and has no other blood relatives in the
United States. She reports being a member of the Church of Scientology.
Bianca was transferred to an acute rehabilitation hospital specializing in SCIs. She will receive occupa-
tional therapy; physical therapy; social work; and registered nursing, psychology, and nutritional services.
Her length of stay will be 21 days.
95
Occupational Therapy Initial Evaluation Findings: Rehabilitation Hospital
Bianca’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Bianca has been employed as a cosmetologist for more than 20 years and has
a very large clientele in the neighborhood where she lives. Her patterns of daily living most com-
monly included waking up at 10:00 a.m., arriving at work by 12:00 noon, and then working to 8:00
p.m. Tuesday through Saturday. She and her boyfriend frequently dined out and enjoyed going to
the movies. Her interests include fashion, Latin music, and dance. She values her clients’ satisfac-
tion with her work and reported her greatest current need is to be able to walk again.
ADLs
Regarding self-care, Bianca was dependent in all areas of self-care. Regarding functional mobility,
Bianca was dependent in bed mobility and transfers. During a dependent transition from supine to
short sit, she reported a brief period of lightheadedness.
IADLs
Bianca was dependent on her ability to handle her finances, maintain her home, prepare meals,
clean up, and shop. Regarding rest and sleep, Bianca reported that since her SCI she was sleeping
between 3 and 4 hours per night.
MENTAL FUNCTIONS
Cognitive assessment found Bianca to be alert and oriented to person, place, time, and situation,
make her needs known. Affect appeared appropriate, except Bianca has not accepted the prognosis
for her complete SCI. No gross deficits in perception were observed.

No gross deficits were observed with visual, hearing, vestibular, taste, and smell functions. Cutaneous
and proprioceptive sensations below the C5 sensory level were absent. Use of the numerical rating
scale (0–10) for pain indicated a score of 0 when medication is taken and 5 in the upper cervical
spine without medication. The pain was described as “cramping.” The Spinal Cord Independence
Measure–III (Catz, 2001) was administered and resulted in a score of 20.

Bianca presented with low endurance and vital capacity.
BIANCA: SPINAL CORD INJURY, COMPLETE C5 | 97
MOVEMENT FUNCTIONS
There was active bilateral movement of shoulder flexion, abduction, and extension; scapular ab-
duction and adduction; elbow flexion; and forearm supination. There was total paralysis of the
wrists, digits, trunk, and lower extremities. Passive range of motion in all extremities was within
normal limits.
Bianca is dependent in sitting and standing. The muscle tone below the site of injury was flaccid,
and deep tendon reflexes were absent.
PLAN FOR DISCHARGE

Bianca will be discharged to home with home care services. She will receive occupational therapy;
physical therapy; and social work, registered nursing, and home health aide services.

1. Create a handout identifying the signs and symptoms of orthostatic hypotension or postural
hypotension.
2. If Bianca experiences an episode of orthostatic hypotension or postural hypotension, what steps
should be taken? Support your decision.
3. What are the signs and symptoms of autonomic dysreflexia to be aware of while working with Bianca?
4. If Bianca experiences an episode of autonomic dysreflexia, what immediate actions need to be taken?
5. What are the signs and symptoms of deep vein thrombosis (DVT)?
6. If Bianca develops DVT, what immediate actions need to be taken?
7. Bianca is at risk to acquire a pressure ulcer. Why? What are the most common sites where pressure
ulcers form? How can occupational therapy play a role in the prevention of pressure ulcers?
8. Which vital signs should be taken when working with Bianca? What are their norms? When should
they be taken?
9. Performing the manual muscle test was contraindicated at the time of the initial evaluation. Why?
10. After her SCI, Bianca now presents with a weak cough. What risks does this cough pose?
11. Identify the common psychological reactions associated with a SCI that may affect the treatment
process.
2. Bianca’s priority is to be able to make and receive calls and texts from her cell phone. What strategies
can be used to accomplish this?
3. Bianca is at high risk for developing bed sores. Explain why.
4. What can be implemented to quickly allow Bianca to gain greater independence in self-feeding?
5. It was determined that a universal cuff would allow Bianca to use a spoon and fork. Identify three dif-
ferent cuffs. Evaluate them and select one. Justify your selection.
6. How can Bianca participate in self-grooming?
Bianca’s occupational performance.
selection.

1. Identify Bianca’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Bianca’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Bianca’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Bianca’s current level of

1. What common affective issues related to her SCI might Bianca have to face?
3. To address these issues, what other disciplines could you refer Bianca to?
4. What would be the expected stages of acceptance that Bianca would transition through? Describe the
dominant characteristic of each.
5. How can each stage best be addressed?
6. Define learned dependence, and identify how it can be prevented.

2. Identify the shoulder, scapula, elbow, and forearm movement that would be expected.
3. Identify the expected innervated muscles.
4. Create an exercise program for Bianca based on occupational performance.

2. Describe the impact of a C5 SCI on the respiratory system. Identify two scholarly sources.
3. How would the impact of her SCI on the respiratory system manifest while Bianca is engaged in her
daily activities?

1. Which autonomic functions would be affected by Bianca’s C5 SCI?
2. How would the changes in these functions affect the occupational therapy process?

Describe how Bianca’s diagnosis may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Bianca while she is receiving
occupational therapy services in the rehabilitation hospital? Why?

1. Bianca’s boyfriend confides in you that he will be breaking up with Bianca. How can this situation be
best addressed?
2. Bianca’s boyfriend confides in you that he will not be able to accept Bianca back into his apartment.
How can this situation be best addressed?
PHARMACOLOGY
Bianca is currently receiving morphine.

1. Given Bianca’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the Spinal Cord Independence Measure III?
4. Provide a brief description of this assessment
5. What is the reliability of the Spinal Cord Independence Measure III?
6. What is the validity of the Spinal Cord Independence Measure III?
7. What functional inference can be deduced from Bianca’s total score of 20?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) code for Bianca’s diagnosis.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Bianca to determine
vices with this client?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Bianca and members
of the interprofessional team. Review the needs of Bianca, caregivers, family members, and significant
REFERENCES
Catz, A. (2001). The Catz-Itzkovich SCIM: A revised version of the Spinal Cord Independence Measure. Disability
and Rehabilitation, 23(6), 263–268. https://doi.org/10.1080/096382801750110919
13
Derrick: Traumatic Brain Injury

Derrick (he, him, his, himself)
MEDICAL HISTORY
Derrick is a 19-year-old Polish American male who is 6' 3" and weighs 185 pounds. He was brought to the
emergency department of his regional medical center by emergency medical services after a skateboard-
ing accident. Reports from the scene indicated that he had been drinking beer and not wearing a helmet at
the time of the accident. Upon arrival, he was disoriented, complained of a headache and nausea, and was
vomiting. Observable abrasions and contusions were present on his right forehead. After a physical ex-
amination, he was sent for imaging. Magnetic resonance imaging indicated a traumatic brain injury (TBI)
with the presence of a large right-side hematoma that was compressing the brain. Derrick was taken im-
mediately to the operating room for evacuation of the hematoma. Derrick’s medical records indicated no
significant medical history, no known allergies, and a history of alcohol and marijuana use. After surgery,
he was taken to the neurological intensive care unit (NICU) for 3 days and then moved to the neurology
unit for 4 days. He was then transferred to the inpatient rehabilitation unit.
SOCIAL HISTORY
Derrick is a first-year college student attending a community college; his intended major is cyber security.
Derrick resides with his mother and three siblings in a three-bedroom ranch-style home. Derrick’s recre-
ational interests include skateboarding in the warmer months and snowboarding in the winter with his
friends. His mother refers to him as a “daredevil.” Derrick’s girlfriend also enjoys skateboarding and was
present at the time of the accident. They share agnostic beliefs. Derrick identifies as a pansexual.
After Derrick was transferred to the rehabilitation unit, he was referred for occupational therapy, physical
therapy, social work, psychology, and nursing services. The length of stay will be 3 weeks.
103
Occupational Therapy Initial Evaluation Findings: Rehabilitation Unit
Derrick’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Derrick was in his first year at the local community college. He was employed
as a part-time independent contractor in food service delivery. His patterns of daily living most
commonly included waking up at 8:00 a.m. and attending classes 4 days a week. After school, he
commonly worked for 2–3 hours, returned home, and then completed his school work. On week-
ends, he worked and spent time with his friends and girlfriend. His interests include making and
posting skateboarding videos. He values living on the edge and not putting off happiness. He re-
ported his greatest need was to return to college.
ADLs
Regarding self-care, Derrick presented as highly distractible and needed to be frequently redi-
rected to dress, bathe, groom, and toilet. Weeping, he frequently yelled out, “Why the f*** is this so
hard?” Regarding functional mobility, Derrick was able to roll, transition between supine and sit,
and bridge independently. He used a straight cane and required contact guard assist and verbal cues
to transfer on and off the bed, chair, and toilet equipped with a versa frame.
IADLs
Derrick made several unsuccessful attempts to log on to his computer, write, make a voice call, and
send a text. Regarding rest and sleep, Derrick reported not being able to sleep in a “flat position”
because doing so triggered severe headaches. Each night, he slept intermittently for no more than
2 hours at a time.
MENTAL FUNCTIONS
Cognitive assessment indicated that Derrick was alert and oriented to person, place, and situation,
but not time. He was unable to report the correct month. While he was in the NICU, he presented
with no memory of the day of his accident and the 3 days that preceded it. His long-term mem-
ory appeared grossly intact. Derrick was highly distractible and was unable to filter out common
environmental stimuli during all ADLs and IADLs. Assessment of affect revealed he often cried
and reported feeling anxious about missing classes. During testing, he scored a Level VII on the
Ranchos Los Amigos Scale (Hagen et al., 1972). No gross perceptual deficits were noted at the time
of evaluation.
SENSORY FUNCTION AND PAIN

No gross deficits were observed with hearing, taste, cutaneous, and smell functions. Blurred vision
in both eyes was reported, and quick head movements resulted in reports of vertigo. Use of the
DERRICK: TRAUMATIC BRAIN INJURY | 105
numerical rating scale (0–10) indicated a score of 7 for pain in the head and cervical spine. The pain
was described as “splitting.”

During self-care activities, Derrick needed to stop secondary to reports of fatigue.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion in all four extremities were within defined lim-
its (WDL). Muscle strength in both the right upper extremity (RUE) and the right lower extremity
(RLE) was 5/5 using the manual muscle test. Both the left upper extremity (LUE) and the left lower
extremity (LLE) was 3+/5. Coordination in the RUE appeared to be WDL, and the LUE appeared to
have a mild reduction in speed and accuracy of movement. Gross grasp strength in the right hand
was 79 pounds and in the left 16 pounds. Derrick presented with difficulty manipulating objects
between the palm of the left hand to the tip of his left fingers.
Using clinical observation, Derrick’s static and dynamic sitting balance were good, and his static
and dynamic standing balance were fair. Muscle tone in the RUE and RLE was normal, and the LUE
and LLE were mildly hypertonic. No primitive reflex activity was observed.
PLAN FOR DISCHARGE

Derrick will be discharged to an outpatient rehabilitation service. He will be receiving occupational
and physical therapy services.

1. Identify the postsurgical precautions and contraindications that need to be followed. Justify your
choices.
2. Given Derrick’s impulsivity, what precautions should be followed?
3. Given Derrick’s anxiety, what precautions should be followed?
4. Derrick has impaired standing balance. How will you keep him safe during upright activities?
5. Create a handout that identifies the precautions to be followed for individuals with impaired balance.
6. Identify the common psychological reactions associated with a TBI that may affect the treatment
process.
OCCUPATIONS: ADL, IADLs, EDUCATION, WORK, PLAY, SOCIAL PARTICIPATION, AND REST AND SLEEP
2. What strategies should be considered to allow Derrick to perform his self-care more independently?
3. What strategies should be considered to allow Derrick to use his phone and computer with less
frustration?
4. What recommendations could be made to allow Derrick to experience more restful sleep?
5. What strategies should be considered to allow Derrick to transfer safely with a cane?
Derrick’s occupational performance.

1. Identify Derrick’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Derrick’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Derrick’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Derrick’s current level of

1. What common affective issues related to his TBI might Derrick have to face?
3. To address these issues, what other disciplines could you refer Derrick to?
4. What models are available to address Derrick’s cognitive challenges?
5. Which models would you choose and why?
6. What activities could Derrick engage in using your selected models?
7. What models are available to address Derrick’s affective challenges?
8. Which models would you choose and why?
9. What activities could Derrick engage in using your selected models?
NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTIONS

2. What models are available to address Derrick’s balance challenges?
3. Evaluate these models, select one, and justify your selection.
4. What activities could Derrick be engaged in using the selected model?
5. What models are available to address Derrick’s strength challenges?
6. Evaluate these models, select one, and justify your selection.
7. What activities could Derrick be engaged in using this model?
8. Create an exercise program for Derrick based on occupational performance.

2. Infer the reason for Derrick reporting fatigue during self-care activities.
3. What are the observable signs and reported symptoms consistent with generalized anxiety disorder in
Derrick? Identify two scholarly sources.

1. What is an abrasion?
2. What is the common medical treatment for an abrasion?
3. What is a contusion?
4. What is the common medical treatment for a contusion?

Describe how Derrick’s diagnosis may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Derrick while he is receiving
occupational therapy services in the rehabilitation unit? Why?

1. You reviewed the referral for services, and it was signed by a physician’s assistant (PA) from the neu-
rology unit. What is a PA, and can the referral be accepted?
2. During treatment, Derrick, in the presence of his mother, says to the therapist, “You look fat and really
should go on a diet!” His mother quickly informs you that before his accident Derrick has never been
rude. What might be the reason for Derrick’s comment? How should it be addressed?
3. During a treatment session, Derrick’s girlfriend emits a strong odor of alcohol. How should this situa-
tion be addressed?
4. During multiple treatment sessions, Derrick states that he needs to return to college so he does not fail
the semester. How should this situation be addressed?
PHARMACOLOGY
Derrick is currently taking warfarin.

1. Given Derrick’s occupational profile, how may your own culture and beliefs affect your interaction
with him?
2. Based on this self-examination, what areas of cultural knowledge do you need to pursue?
case.

1. What is the purpose of the Ranchos Los Amigos Scale?
5. What is the reliability of this scale?
6. What is the validity of this scale?
7. What functional inference can be deduced from Derrick’s score of Level VII?
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Derrick’s diagnoses.

Explain why.
practice setting?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Derrick to determine

ADVOCACY
resources?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Derrick and mem-
bers of the interprofessional team. Review the needs of Derrick, caregivers, family members, and signifi-
REFERENCES
Hagen, C., Malkmus, D., & Durham, P. (1972). Rancho Los Amigos Levels of Cognitive Functioning Scale. Communication
Disorders Service, Rancho Los Amigos Hospital.
14
Sharon: Peripheral Vascular Disease

Sharon (she, her, hers, herself)
MEDICAL HISTORY
Sharon is a 59-year-old transgender Jamaican female living in the United States. Sharon is 6' 1" and weighs
160 pounds. She was electively admitted to the hospital with gangrene on her right foot. Magnetic res-
onance imaging scans, X-rays, and computerized tomography scans were used to confirm the presence
and spread of gangrene. Sharon underwent a right below-knee amputation (RBKA). Her medical history
included peripheral vascular disease (PVD), hypertension, diabetes mellitus, and gender reassignment
surgery. Upon admission, she reported smoking one to two packs of cigarettes per day and consuming 4
to 5 cups of coffee per day. She reported being sober for 10 years but reports a history of both cocaine and
alcohol abuse. She is allergic to ampicillin.
SOCIAL HISTORY
Sharon is the owner of a popular florist shop with three full-time employees. She currently lives alone and
reported recently breaking up with her boyfriend. She lives in a luxury three-bedroom, two-bath high rise
just two blocks from her shop. Her building is new construction and is compliant with the Americans with
Disabilities Act of 1990 (P. L. 101-336) regulations. She is an active member of the LBGTQIA+ community
and has a broad network of friends. Her only living relatives are her mother and sister, who reside in a
different state. Sharon identifies as a member of the United Church of Christ.
Sharon was transferred to the local rehabilitation hospital. She has been referred for occupational ther-
apy, physical therapy, social work, psychology, and nursing services. The length of stay will be 6 days.
111
Occupational Therapy Initial Evaluation Findings: Rehabilitation Hospital
Sharon’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Her patterns of daily living most commonly included picking up flowers at the whole-
saler between 8:00 a.m. and 9:00 a.m., picking up breakfast, and opening her shop by 10:00 a.m. Her
shop hours are from 10:00 a.m. to 7:00 p.m., Tuesday through Saturday. Her interests include listening
to jazz music in the evening, dining out with friends on weekends, traveling, and engaging in the arts.
Sharon values her independence and the business she has created. Her reported greatest needs are to
be able to return home, live independently, and get back to her florist shop as soon as possible.
ADLs
Regarding self-care, Sharon was able to feed herself independently, manage her clothes, clean her-
self on the toilet, dress while seated on the side of the bed when clothing was placed within her
reach, and sponge bathe in bed when bathing items were made available. Tub bathing was not
attempted.
Regarding functional mobility, Sharon was able to perform stand pivot transfers with contact
guard assist between the bed and wheelchair, wheelchair and toilet, and wheelchair and armchair.
Tub transfers were not attempted. She was able to independently propel, position, and manage
components of her wheelchair. Transfers using a rolling walker were not attempted. The Amputee
Mobility Predictor (AMP; Gailey et al., 2002) without prosthesis was administered, and Sharon
scored a 31 (Functional Level K3).
IADLs
Sharon was able to manage her communications and handle finances. She was aware that currently
she would not be able to maintain her home, prepare meals, or shop. Regarding rest and sleep,
Sharon reported not being able to obtain restful sleep due to pain in her right residual limb.
MENTAL FUNCTIONS
Cognitive assessment found Sharon to be alert and oriented to person, place, time, and situation,
make her needs known. Assessment of affect was performed. Sharon reported feeling depressed
over the loss of her leg and presented noticeably teary eyed. She does not think that she will be able
to walk with a prosthesis. No gross deficits in perceptual function were observed.

functions. The terminal end of her right residual limb presented with impaired touch localization
SHARON: PERIPHERAL VASCULAR DISEASE | 113
and touch awareness. She reports pain at the terminal end of the residual limb. The pain was re-
ported as a 5 using the Numerical Rating Scale (0–10). The pain was described as “tender.”

Sharon was able to perform all self-care and transfers without signs of fatigue.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion of both upper extremities (BUE) and the left
lower extremity were within functional limits. Muscle strength in BUE was 4/5 using the manual
muscle test (MMT). The RBKA, presented with a closed surgical wound, and has had surgical sta-
ples removed and adhesive surgical tape strips applied. The end of the residual limb was edema-
tous, with the circumferential measurement of the right mid–calf at 17.6 inches and the left at 15.1
inches. Gross grasp strength in the right hand was 38 pounds and in the left hand was 36 pounds.
No gross deficits in prehension were observed.
Static and dynamic sitting balance were normal and good, respectively. Static and dynamic standing
balances were fair + and fair, respectively. Muscle tone was normal, and no deficit in reflex integra-
tion was observed.
PLAN FOR DISCHARGE

Sharon will be discharged home after completion of her 6-day stay and receive home care services.
She will receive occupational therapy, physical therapy, social work, registered nursing, and home
health aide services.

1. Given that Sharon has PVD, what precautions and contraindications should be considered?
2. For this case, what postsurgical precautions need to be followed?
3. Create a handout identifying precautions to be followed for individuals with impaired cutaneous
sensation.
4. Identify the risks that Sharon faces when showering and bathing. How can these risks be mitigated?
5. Compare and contrast appropriate sadness over losing a limb and clinical depression.
6. Identify the common psychological reaction associated with an amputation that may affect the treat-
ment process.
addressed. Justify your decisions
2. What would be the recommended position(s) for Sharon during sleep?
3. What would be the recommended position of Sharon’s right residual limb while she is seated in a
wheelchair?
4. During patient education, what topics should be included to maximize Sharon’s function and maintain
her health and wellness?
5. Identify at least two strategies that can facilitate Sharon’s ability to independently bathe and shower.
6. Which IADL tasks are essential to be addressed before Sharon returns home?
Sharon’s occupational performance.

1. Identify Sharon’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Sharon’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Sharon’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Sharon’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Sharon’s current level of

1. What common affective issues related to her amputation might Sharon have to face?
3. To address these issues, what other disciplines could you refer Sharon to?
4. Identify the stages of grief.
5. Which stage do you believe Sharon is experiencing? Support your selection.
6. How can you support Sharon through the grieving process?
7. How could the amputation affect Sharon’s body image?

2. What common techniques can be used to reduce edema in Sharon’s residual limb?
3. Explain what a score of 4/5 on the MMT represents.
4. Does the muscle strength in Sharon’s upper extremities need to be remediated? Justify your decision.
5. Compare and contrast phantom limb pain with residual limb pain.
6. Provide three options in addressing Sharon’s residual limb pain. Explain the process you would use to
select one.
7. Create an exercise program for Sharon based on occupational performance.

2. Compare the metabolic equivalent of task (MET) value for ambulating with both lower extremities
and the MET value for hopping with a single lower extremity while using a rolling walker.
3. Calculate the estimated maximal heart rate for Sharon’s age. Explain how you made this determination.

1. What are the skin changes related to PVD?
2. Compare and contrast PVD with coronary artery disease.
3. What factors would be considered when addressing skin integrity for Sharon’s residual limb?

Describe how Sharon’s diagnosis may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or devices might be used, adapted, or fabricated for Sharon while she is
receiving occupational therapy services in the acute rehabilitation unit? Why?
2. What assistive technologies or devices might be recommended for when she returns home? Why?

1. You walk past two coworkers having a private conversation. You overhear them say that according to
their religion, transgender individuals are “sinners.” How should this situation be best addressed?
2. You walk past Sharon’s room and see her take medication out of her mouth and throw it in the garbage.
How should this situation be best addressed?
PHARMACOLOGY
Sharon is currently taking cilostazol.

1. Given Sharon’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the AMP?
5. What is the reliability of the AMP?
6. What is the validity of the AMP?
7. What functional inference can be deduced from Sharon’s score of 31?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Sharon’s diagnoses.

Explain why.
practice setting?
ADVOCACY
privacy, confidentiality, informed consent, awareness building, accessing education, or benefits/
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Sharon to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Sharon and members
of the interprofessional team. Review the needs of Sharon, caregivers, family members, and significant
REFERENCES
Americans With Disabilities Act of 1990, Pub. L. 101-336, 42 U.S.C. §§ 12101–12213 (2000).
Gailey, R. S., Roach, K. E., Applegate, E. B., Cho, B., Cunniffe, B., Licht, S., . . . Nash, M. S. (2002). The Amputee Mobility
Predictor: An instrument to assess determinants of the lower-limb amputee’s ability to ambulate. Archives of
Physical Medicine and Tehabilitation, 83, 613–627. https://doi.org/10.1053/apmr.2002.32309
15
Zachary: Burn
Zachary (he, him, his, himself)
MEDICAL HISTORY
Zachary is a 75-year-old Australian American male living in the United States who is 6' 0" and weighs 179
pounds. He was brought by his neighbors to the emergency department (ED) after sustaining burns while
burning leaves on his property. His neighbors heard him screaming and covered him to put out the flames
but did not call 911.
Physical examination findings indicated that he was alert and oriented to person, place, time, and situ-
ation but suffered full-thickness, third-degree burns to the volar aspect of his right hand, wrist, and fore-
arm as well as the lateral aspect of his right trunk. Second-degree burns were noted to his face and left
hand and forearm. Initial treatment in the ED included intravenous fluids for tissue resuscitation, tetanus
prophylaxis, and wound irrigation and cooling. An electrocardiogram was normal. His vital signs were
within normal range except for his blood pressure, which was 180/100 mmHg. Zachary has 27% burns
to his body. This percentage of total body surface area burned was assessed using the Rule of Nines tool
(Wallace, 1951). His medical history included diabetes mellitus and cataract removal in both eyes. He uses
bifocals. He reports drinking 2 to 3 cups of coffee and smoking 6 to 8 cigarettes daily. He reported no drug
or alcohol use and has no known allergies.
Zachary has been transferred from the ED to the burn center located 1 hour from his home. At the burn
center he received a split-thickness skin graft to the volar aspect of his wrist. The donor site is his left
thigh. The graft and hand were protected with a splint.
SOCIAL HISTORY
Zachary is a widower who lives with his adult children in a rural community. They reside in a large split-
level cabin-style house on a vast and wooded property. There are four bedrooms, three bathrooms, and an
open floor plan consisting of the kitchen, living room, and dining area. His bedroom is on the upper floor,
accessible by 10 steps with a right-sided banister, and includes a full bathroom. There are 5 steps to enter
the home. Zachary enjoys being surrounded by his family. Zachary identifies as an Orthodox Christian.
119
Zachary was transferred to the burn intensive care unit. He has been referred for occupational therapy,
physical therapy, social work, and nursing services. The length of stay is 14 days.
Occupational Therapy Initial Evaluation: Burn Intensive Care Unit
Zachary’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. He is the owner of a small propane gas company, where the day-to-day opera-
tions are handled by his children. His patterns of daily living most commonly included weekly visits
to his business for updates, maintaining his yard and his small vegetable garden, preparing dinner
1 or 2 times per week, and attending church on Sundays. Zachary was able to drive to the grocery
store and church. His interests include planting a variety of vegetables and sharing them with his
church family. He values his independence and reports his greatest current needs are to return
home and restore his prior functions, especially attending church.
ADLs
Regarding self-care, Zachary required moderate to maximum assistance to don and doff his upper
body and lower body garments. He had difficulty manipulating all fasteners. He required minimal
assistance with oral and facial care. After setup, he was able to feed himself with modified inde-
pendence using his left nondominant hand. Toilet transfers were independent but performed with
guarded movements. Toileting required minimal assistance with perineal care.
Regarding functional mobility, Zachary was able to perform bed mobility with minimal assis-
tance, primarily requiring assistance to roll from right to left, transition to the edge of the bed, and
reposition himself at the top of the bed. He ambulated independently but slowly. Zachary com-
plains of difficulty sleeping because of pain.
IADLs
Zachary was not able to safely hold utensils to prepare meals or tools to perform yard work. Driving
independently was unsafe at this time. Regarding rest and sleep, Zachary reported being a loud
snorer and needing 10–15 minutes to gain focus after awakening in the morning.
MENTAL FUNCTIONS
Cognitive assessment found Zachary to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. He is able to follow three-step commands and make
his needs known. Affect appeared appropriate, but he expressed concerns about not being able to
care for himself and is afraid of being alone at home when his children are at work. No gross deficits
in perception were observed.
ZACHARY: BURN | 121
SENSORY FUNCTIONS
functions. He reported constant pain in his right hand, forearm, and trunk, with a score of 8 on the
numeric rating scale (NRS; 0–10), and in his left hand and forearm, with a score of 5–6 on the NRS.
The Semmes-Weinstein Monofilament Test (Bell-Krotoski & Tomancik, 1987) revealed loss of pro-
tective sensation to the volar aspect of his right hand and diminished protective sensation to his left
hand. The pain was described as “punishing.”

Assessment of sensory functions indicated no deficits in cardiovascular or respiratory functions.
Zachary’s blood pressure has been stabilized.
MOVEMENT FUNCTIONS
Active range of motion (AROM) and passive range of motion (PROM) were within functional
limits in the left upper extremity. Muscle strength (assessed using the manual muscle test) was
scored as a 4/5 for the left upper extremity. AROM and PROM to the right shoulder were limited
as follows: shoulder flexion, 0–100°; shoulder abduction, 0–110°; shoulder external rotation, 0–75°;
shoulder internal rotation, 0–70°; horizontal shoulder abduction, 0–95°; horizontal shoulder ad-
duction, 0–120°; elbow flexion/extension, 30–125°; forearm supination, 0–75°; and forearm prona-
tion, 0–85°. Wrist and digits were unable to be evaluated. Left lateral flexion of the torso was 0–15°,
with left rotation of the torso at 0–20°. Edema was noted to the dorsum of the right hand, with a
grade of 2 on the Pitting Edema Rating Scale (Brodovicz et al., 2009). Additionally, circumferential
measurements were taken using the Figure-of Eight Method (Dewey et al., 2007): right hand, 30
cm, and left hand, 23 cm.
Zachary’s static sitting balance was good (G), and dynamic sitting balance was G−. His static stand-
ing balance was G−, and dynamic standing balance was fair+. Muscle tone was within normal limits.
He was guarded, secondary to pain in his trunk. Muscle tone was normal, and reflex integration
was grossly intact.
PLAN FOR DISCHARGE

Zachary will be discharged to an outpatient facility and will receive occupational therapy services.

1. Generally, how long should the graft be protected?
2. Create a handout identifying the signs and symptoms of a graft failure.

3. To protect the integrity of Zachary’s graft, what instructions should you provide?
4. List the signs and symptoms of an infected wound.
5. Identify the common psychological reactions associated with a severe burn that may affect the treat-
ment process.
6. To keep Zachary and others safe, what other factors should be considered?
2. What recommendations can you make to allow Zachary to experience a more restful and less painful
sleep?
3. What areas of basic ADLs need to be addressed for Zachary to return home? Explain your choices.
Zachary’s occupational performance.

1. Identify Zachary’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Zachary’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Zachary’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Zachary’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Zachary’s current level of
ZACHARY: BURN | 123

1. What common affective issues related to his burns might Zachary have to face?
3. To address these issues, what other disciplines could you refer Zachary to?
4. What are the potential psychological effects of a facial burn?

2. Identify the stages of burn rehabilitation. Explain the focus of occupational therapy for each stage.
3. What positions should Zachary’s right hand be splinted in? Justify your selected positions.
4. What is a plausible rationale for why the therapist did not perform manual range-of-motion and mus-
cle strength testing on Zachary’s injured wrist and digits?
5. Explain the importance of early scar management and how it affects future movement.
6. Identify remediation activities that could be implemented to improve Zachary’s range of motion.
7. Create an exercise program for Zachary based on occupational performance.

2. Given the burn to Zachary’s trunk, infer what effect it may have on respiratory function.
3. Describe the impact that severe pain has on vital signs.

1. Compare and contrast a split-thickness skin graft with a full-thickness skin graft.
2. Zachary has diabetes mellitus. What impact can it have on his recovery? Explain.
3. List the common signs and symptoms of a full-thickness, third-degree burn.
4. List at least three objectives for skin grafting.
5. Explain how the severity or extent of a burn is assessed.
6. Several methods are used to assess edema. Why did the therapist select the circumferential method?
7. Identify the types and mechanisms of burn injuries. Which type did Zachary sustain? What was the
mechanism of injury?

Describe how Zachary’s diagnosis may affect his voice, speech, and associated occupational performance.

Does Zachary need any assistive technologies or adaptations? If yes, identify which ones and explain why.

1. You have been observing the nurse’s treatment sessions with Zachary and you notice that the nurse is
not observing universal precautions or maintaining a sterile environment during his wound care. How
would you address this situation?
2. You notice a smell of smoke originating from Zachary’s room. When questioned, he admits to smoking
in his bathroom. What actions need to be taken?
PHARMACOLOGY
Zachary is currently being treated with silver sulfadiazine.

1. Given Zachary’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the Figure-of-Eight method and the Pitting Edema Scale (Brodovicz et al.,
2009)? Briefly describe how these measurements are performed.
2. Which population are these tests designed for?
3. How much time is required to administer them?
4. Provide a brief description of each assessment.
5. What is the reliability of the Figure-of-Eight method and the Pitting Edema Scale?
6. What is the validity of the Figure-of-Eight method and the Pitting Edema Scale?
7. What other methods may be used to assess edema? Explain why?

2. Identify interventions that can be performed by the OTA for this case.
3. What other professionals would be part of Zachary’s care and what would be their primary focus?
ZACHARY: BURN | 125
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Zachary’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Zachary to deter-
mine whether it is appropriate for him to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Zachary and mem-
bers of the interprofessional team. Review the needs of Zachary, caregivers, family members, and signifi-
REFERENCES
Brodovicz, K. G., McNaughton, K., Uemura, N., Meininger, G., Girman, C. J., & Yale, S. H. (2009). Reliability and fea-
sibility of methods to quantitatively assess peripheral edema. Clinical Medicine and Research, 7, 21–31. https://doi.
org/10.3121/cmr.2009.819
Dewey, W. S., Hedman, T. L., Chapman, T. T., Wolf, S. E., & Holcomb, J. B. (2007). The reliability and concurrent va-
lidity of the Figure-of-Eight Method of measuring hand edema in patients with burns. Journal of Burn Care and
Research, 28, 157–162. https://doi.org/10.1097/BCR.0b013e31802c9eb9
Subacute Rehabilitation SECTION IV
127
16
Isaura: Lupus
Isaura (she, her, hers, herself)
MEDICAL HISTORY
Isaura is a 38-year-old Puerto Rican female who is 5' 4" and weighs 183 pounds. She was assisted by her
friend to her rheumatologist because she was experiencing fever, extreme fatigue, painful and swollen
joints, and difficulty walking. Isaura has a history of systemic lupus erythematosus (SLE). After seen by
the rheumatologist, she was admitted electively to the community hospital for the acute flare-up of lupus,
where she was treated with azathioprine and Plaquenil, glucocorticoids, and cytotoxic agents. Medical
history includes chronic renal failure resulting in kidney transplant, diabetes mellitus, high cholesterol,
and depression. Isaura reports no alcohol, drug, caffeine, or nicotine use. She has no known allergies.
SOCIAL HISTORY
Isaura reports being a lapsed Roman Catholic. She is a single mother who resides in a townhouse with
her 13-year-old son and is a physical education teacher in a junior high school. She coparents with her
ex-husband, who resides a mile away. Isaura recently lost her mother tragically in a motor vehicle acci-
dent. She has two sisters who live close by, and they all often spend time with each other.
Isaura was transferred to a subacute rehabilitation facility. She has been referred for occupational ther-
apy, physical therapy, and social work services. The length of stay will be 10 days.
129
Occupational Therapy Initial Evaluation Findings: Subacute Rehabilitation
Isaura’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. She has been a gym teacher for 15 years. Her patterns of daily living most
commonly included waking at 6:00 a.m., dressing, eating, and taking her medications. She takes her
son to school and arrives at work at 8:00 a.m. Isaura typically returns home by 4:00 p.m., prepares
dinner, and oversees her son’s homework. On weekends, she cares for her home, takes her son to
baseball practice, and socializes with her sisters. Isaura’s interests include shopping, online dating,
and exploring new restaurants with her sisters. She values her coparenting relationship with her
ex-husband, time spent with her son and sisters, and her stretches in remission. Her immediate
goals are to return home and care for her son and to return to work.
ADLs
Regarding self-care, Isaura was able to feed, dress, groom, and toilet independently. Regarding
functional mobility, Isaura was able to independently roll, bridge, scoot, and transition between
supine and sit; however, she required frequent breaks because of fatigue and pain. She required
minimal assistance to transfer on and off the bed, chair, and toilet using a rolling device.
IADLs
Isaura was able to manage her communications and finances. She believed that currently she would
be unable to care for her home, prepare meals, or shop without assistance. Regarding sleep, Isaura
reported being unable to obtain restful sleep, and she was sleeping no more than 2 hours at a time
as a result of pain.
MENTAL FUNCTIONS
Cognitive assessment found Isaura to be alert and oriented to person, place, time, and situation,
make her needs known. Assessment of affect revealed that Isaura was feeling sad, experiencing low
energy, and being easily mentally fatigued. No gross deficits in perception were observed.

cutaneous functions. Isaura reported generalized pain, with the most severe pain in her fingers,
wrist, and elbows. Using the numerical rating scale (0–10), she scored her pain as a 7 and described
it as “continuous and throbbing.”
ISAURA: LUPUS | 131

Isaura’s overall endurance was scored as a 3–4 using the metabolic equivalent of task (MET).
MOVEMENT FUNCTIONS
Full passive range of motion and active range of motion were present in both upper extremities
(BUE). The manual muscle test indicated strengths of 3+/5 in BUE. A dynamometer was used to
evaluate grasp strength, which was 14 pounds in her right dominant hand and 12 pounds in her left
hand. Gross grasp and pinch abilities were within functional limits in both hands.
Isaura demonstrated good static balance and dynamic sitting balance. Her static standing and dy-
namic balance were fair+. Standing tolerance with a walker was 5 minutes before a break was re-
quested. Muscle tone in BUE was normal, and coordination was intact. Muscle tone in both lower
extremities was normal. Reflex integration was grossly intact.
PLAN FOR DISCHARGE

Isaura will be discharged home with outpatient rehabilitation services. She will receive occupa-
tional and physical therapy.

1. Create a handout identifying precautions and contraindications for individuals diagnosed with lupus.
2. When working with an individual with lupus, the practitioner should be mindful to avoid fatigue.
Explain why.
3. Given Isaura’s reported pain level, what considerations should be taken when creating an intervention
program?
4. Identify the common emotional reactions associated with lupus that may affect the treatment
process.
5. To keep Isaura and others safe, what other factors should be considered?
2. Identify the factors that affect Isaura’s current level of performance.
3. How can energy conservation and work simplification concepts be incorporated into self-care, func-
tional mobility, and IADLs?
4. What strategies can be used to facilitate restful sleep for Isaura?
Isaura’s occupational performance.
5. Isaura is easily fatigued. Should this challenge be addressed through remediation or compensatory
strategies, or both?
6. Isaura is experiencing pain. What physical agent modalities (PAMs) should be considered? Support
your decision.
7. In addition to PAMs, what other strategies could be used to address Isaura’s pain?
8. Isaura presents with 3+/5 muscle strength in BUE. Should this level of strength be addressed?
9. Given Isaura’s acute flare-up of lupus, what types of exercises would be indicated, and which would
be contraindicated?

1. Identify Isaura’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Isaura’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Isaura’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Isaura’s current level of
ISAURA: LUPUS | 133

1. Compare and contrast sadness with clinical depression.
2. Identify three depression screens that could be used to evaluate Isaura. Evaluate them, select one, and
justify your decision.
3. Search the literature to determine how pain affects motivation. Provide a brief summary.
5. To address these issues, what other disciplines could you refer Isaura to?

2. Compare and contrast muscular fatigue with cardiovascular fatigue.
3. Before Isaura’s flare-up, she reported normal standing balance. What factors would you infer may be
contributing to her current change in balance?
4. Create an exercise program for Isaura based on occupational performance.

2. Identify the estimated MET value that would be required for Isaura to return to work safely as a gym
teacher.
3. Describe the long-term impact of lupus on the cardiovascular system.
4. Describe the long-term impact of lupus on the respiratory system.

1. Compare and contrast discoid lupus erythematosus with SLE.
2. What are some initial skin changes noted in patients with lupus?
3. Explain the association between Raynaud’s disease and SLE.

Describe how Isaura’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Isaura to use in her home while she
is receiving outpatient occupational therapy services? Why?

1. Isaura approaches you and confides that she finds the physical therapist “sexy” and requests that you
pass on her phone number. How should this situation be addressed?
2. Isaura’s roommate in the rehab facility complains to you that Isaura is up all night watching television,
which prevents the roommate from obtaining restful sleep. How should this situation be addressed?
PHARMACOLOGY
Isaura is currently taking Plaquenil.

1. Given Isaura’s profile, how may your own culture and beliefs affect your interaction with her?
5. Discuss how a lack of understanding in the areas of discrimination and stigma, implicit bias, social iden-
tity, or racism may contribute to disparities in the delivery of occupational therapy services in this case.

1. What is the purpose of the MET?
5. What is the reliability of the MET?
6. What is the validity of the MET?
7. What functional inference can be deduced from Isaura’s score of 3–4?

ISAURA: LUPUS | 135
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Isaura’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Isaura to determine

patterns.
modify, or prevent.

attention?

Create a plan for discharge from occupational therapy services in collaboration with Isaura and members
of the interprofessional team. Review the needs of Isaura, caregivers, family members, and significant
REFERENCES
17
Pierre-Louis: Osteoarthritis
BEBE HANIF, MS, OTR/L
Pierre-Louis (he, him, his, himself)
MEDICAL HISTORY
Perre-Louis is an 82-year-old Haitian American male who is 6' 2" and weighs 172 pounds. He underwent
an elective posterior lateral total hip replacement after a long history of right hip pain. Pierre-Louis’s
medical history includes osteoarthritis, diabetes mellitus, enlarged prostate gland, and glaucoma. He re-
ported no tobacco, caffeine, or drug use. He reported social alcohol use on weekends. He has no known
allergies. After surgery, he was admitted to the orthopedic floor.
SOCIAL HISTORY
Pierre-Louis’s wife passed away 10 years ago. He lives alone on the first floor of a two-family house. His
son lives on the second floor with his wife and two children. Pierre-Louis takes his 6-year-old twin grand-
children to school in the morning, picks them up after school, and watches them until their parents return
home. His son is expecting a third child in 2 months. Many of the families on the block have lived there for
more than a generation. Pierre-Louis practices Haitian Vodou.
Pierre-Louis was transferred to a subacute rehabilitation facility. He has been referred for occupational
therapy, physical therapy, registered nursing services, and social work services. The length of stay will be
10 days.
137
Pierre-Louis’s preadmission occupational history and experiences included being independent in
all ADLs and all IADLs. Pierre-Louis is a retired chef and army veteran. His most common pattern
of daily living includes waking up at 6:30 a.m., preparing his breakfast, taking the kids to school
at 8:00 a.m., shopping, cleaning, picking up the kids after school, and assisting them with their
homework. His interests include reading the daily newspaper, watching television, attending choir
rehearsals on Friday nights, attending church on Sundays, and having dinner with his girlfriend
after church. Pierre-Louis values spending time with his grandchildren and sharing time with his
girlfriend. His greatest needs are to be independent and to be active in his grandchildren’s lives.
ADLs
Regarding self-care, Pierre-Louis was able to feed himself independently. While seated, Pierre-
Louis required supervision to don and doff upper-body clothing and maximal assistance to don and
doff lower-body garments. During grooming tasks, he was able to brush his teeth and comb his hair
independently. He required moderate assistance to manage clothing during toileting. Pierre-Louis
scored a 60 on the Barthel Index (Mahoney & Barthel, 1965) for ADLs.
Regarding functional mobility, Pierre-Louis required moderate assistance to roll and transition
from supine to sit at the edge of the bed. He reported difficulty experiencing restful sleep while
supine and using an abduction wedge. He required moderate assistance and verbal cues to transfer
with a walker on and off the bed, chair, raised toilet, and tub bench.
IADLs
Pierre-Louis was independent in telephone use and money management. He required moderate
assistance for simple meal preparation and clean-up tasks. Regarding rest and sleep, Pierre-Louis
reported sleeping on average 5 hours per evening and napping for 1 or 2 hours each afternoon.
MENTAL FUNCTIONS
Cognitive assessment found Pierre-Louis to be alert and oriented to person, place, time, and situ-
ation, and short- and long-term memory were intact. He was able to follow three-step commands
and make his needs known. Affect appeared appropriate, and no gross deficits in perception were
observed.

cutaneous functions. Using the Numerical Rating Scale (0–10), Louis-Pierre scored a 4 for pain in
his right hip at rest and an 8 with movement. Pain was described as “sharp.”
PIERRE-LOUIS: OSTEOARTHRITIS | 139

MOVEMENT FUNCTIONS
Full passive range of motion and active range of motion were present in both upper extremities
(BUE), and the manual muscle test indicated strength of 4/5 in BUE. Gross grasp strength in the
right hand was 48 pounds and in the left hand 51 pounds. No deficits were noted in fine motor skills.
Pierre-Louis had a precaution of weight bearing as tolerated (WBAT) for his right lower extremity.
Pierre-Louis demonstrated good static sitting balance and fair (F)+ dynamic sitting balance. His
static standing balance was F, and his dynamic standing balance was F−. Standing tolerance with
a walker was 5 minutes before a break was requested. Muscle tone in BUE was normal, and coor-
dination was intact. Muscle tone in both lower extremities was normal. Pierre-Louis presented
with limited right hip and knee extension. During functional ambulation, he was observed using a
narrow base gait pattern.
PLAN FOR DISCHARGE

Pierre-Louis will be discharged home without services.

1. Create two handouts, the first identifying precautions to be followed after a posterolateral total hip
arthroplasty (THA) and the second after an anterolateral total hip arthroplasty.
2. Pierre-Louis is afraid to put weight on his right leg. How would you explain WBAT?
3. What safety concerns do you anticipate?
4. The physician directed Pierre-Louis to sleep with an abduction pillow. What is it? What is its function?
How long do you estimate he will need to use it?
5. Identify the common psychological reactions associated with a THA that may affect the treatment
process.
6. To keep Pierre-Louis and others safe, what other factors should be considered?
2. What clothing choices would you recommend for Pierre-Louis?
3. What areas of functional mobility need to be addressed for Pierre-Louis to return home? Explain.
4. What areas of basic ADLs need to be addressed to return home? Explain.

5. What equipment and strategies can be used to assist Pierre-Louis in maintaining precautions?
6. Pierre-Louis complains of difficulty cleaning himself after “doing number two.” How do you address
his complaint?
7. How could Pierre-Louis’s lack of restful sleep be addressed?
Pierre-Louis’ occupational performance.

1. Identify Pierre-Louis’s useful habits, routines, roles, and rituals that support valued occupations. How
can you make use of this information?
2. Identify Pierre-Louis’s impoverished habits, routines, roles, and rituals that do not support valued oc-
cupations. How can you make use of this information?
3. Identify Pierre-Louis’s dominating habits, routines, roles, and rituals that interfere with valued occu-
pations. How can you make use of this information?
CLIENT FACTORS
Body structures
Considering Pierre-Louis’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Pierre-Louis’s current
level of occupational performance.

1. Explain how the lack of restful sleep affects participation. Identify your sources.
2. Explain how unaddressed pain may affect participation. Identify your sources.

2. Pierre-Louis presents with 4/5 muscle strength in all groups of BUE. Does this strength level need to
be addressed? Justify your decision.
3. Pierre-Louis presents with F static standing balance and F− dynamic standing balance. How may this
ability level affect his participation in daily activities?
4. Pierre-Louis’s standing tolerance with a walker is 5 minutes. How may this ability level affect his par-
ticipation in daily activities?
5. Compare and contrast osteoarthritis with rheumatoid arthritis.
6. Create an exercise program for Pierre-Louis based on occupational performance.

2. Which vital signs should be taken when working with Pierre-Louis?
3. When should Pierre-Louis’s vital signs be taken? Identify the norms for these vital signs. Identify two
scholarly sources.

1. Given Pierre-Louis’s age and medical condition, how long is it expected for his surgical wound to be
fully healed?
2. Identify the factors that will promote or delay wound healing.
3. You notice Pierre-Louis’s pants have a wet red spot just over his right hip. What could be a concern and
what action would you take?

Describe how Pierre-Louis’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Pierre-Louis while he receives
occupational therapy services? Support your choices.
2. What assistive technologies or adaptations might be recommended when he returns home? Support
your choices.

1. According to the surgeon, Pierre-Louis has a stay of 10 days in subacute rehabilitation. Given the set-
ting and the projected length of stay, how would you prioritize his therapeutic needs?
2. Pierre-Louis speaks English with a heavy Creole accent, and at times you find it difficult to understand
him. How could this situation be addressed?
3. During an occupational therapy session, Pierre-Louis’s girlfriend inquired about his blood pressure.
How should you address this question while maintaining compliance with the Health Insurance
Portability and Accountability Act of 1996 (P. L. 104-191)?
4. Pierre-Louis’s abduction pillow is missing. Identify your options, make a selection, and support your
decision.
PHARMACOLOGY
Pierre-Louis is currently taking Sectral.

1. Given Pierre-Louis’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the Barthel Index?
5. What is the reliability of the Barthel Index?
6. What is the validity of the Barthel Index?
7. What functional inference can be deduced from Pierre-Louis’s score of 60 on the Barthel Index?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for this individual’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Pierre-Louis to de-
termine whether it is appropriate for him to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Pierre-Louis and
members of the interprofessional team. Review the needs of Pierre-Louis, caregivers, family members, and
REFERENCES
Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191, 42 U.S.C. § 300gg, 29 U.S.C. §§
1181–1183, and 42 U.S.C. §§ 1320d–1320d9.
Mahoney, F. I., & Barthel, D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14,
56–61.
18
Rosalind: Multiple Sclerosis

EVA RODRIGUEZ, PH D, OTR
Rosalind (she, her, hers, herself)
MEDICAL HISTORY
Rosalind is a 51-year-old Ukrainian American female who is 5' 3" and weighs 111 pounds. She was elec-
tively admitted to her regional hospital by her neurologist for observation and assessment because she
reported weakness and difficulty ambulating with her straight cane. Magnetic resonance imaging scans
of the brain showed gadolinium-enhancing lesions in the cerebrum, parietal, and temporal areas. These
scans also indicated lesions on thoracic vertebrae 1 and 2. Rosalind was diagnosed with an acute episode
of multiple sclerosis (MS). Her medical history includes primary progressive relapsing MS (onset at age
30) and optic neuritis with a right homonymous hemianopsia visual field loss of 5° peripherally. Rosalind
reported the use of dimethyltryptamine (DMT) and medical marijuana in liquid form. She reported no
tobacco, drug, or caffeine use. Rosalind reported being allergic to codeine-based medications.
SOCIAL HISTORY
Rosalind is a speech–language pathologist in the local school district. She lives with her spouse, Sarah,
and their three dogs in a ranch-style home in the suburbs. Sarah is a nurse practitioner with a private
practice and works long hours, 3 days a week. Rosalind’s family (three siblings, and their partners and
children) live within walking distance of her home. Rosalind identifies as an Orthodox Christian and
Sarah identifies as Jewish.
Rosalind was transferred to a subacute rehabilitation facility. She has been referred for occupational ther-
apy, physical therapy, registered nursing services, speech therapy, and social work services. The length of
stay will be 20 days.
145
Rosalind’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. She has a master’s degree in speech-language pathology. Her primary role
at home includes caring for her dogs, which is shared with Sarah during the weekends. Her daily
routine begins at 6:00 a.m. with preparing her fair-trade coffee and walking the dogs for about
20 minutes. After their walk, Rosalind prepares herself for work, which includes preparing her
vegan lunch. After work, she shops for any last-minute ingredients and prepares weeknight din-
ners. On the weekends, Rosalind shares shopping and laundry responsibilities with her spouse.
They have a cleaning service for the home twice a week. Her interests include cooking, machine
quilting, and volunteering for activities related to LGBTQIA+ issues. Rosalind values her family
and friends and enjoys socializing with them. She enjoys preparing large meals with her spouse for
social gatherings.
ADLs
Regarding self-care, Rosalind was able to feed herself independently. She was able to don and doff
loose-fitting clothing, including socks, but required short rest periods, specifically for lower body
dressing. She was able to manage various clothing fasteners (zippers, buttons, snaps, hooks, laces)
but with reported difficulty because of mild decreased tactile awareness. When standing in front of
the bathroom sink, she required contact guard assist (CGA) while brushing her teeth, washing her
face, applying makeup, and brushing her hair. During bathing, she required CGA for both upper-
and lower-extremity hygiene.
Regarding functional mobility, Rosalind was able to independently roll and transition between
prone and supine. She needed minimal assistance to transition to a short sit in bed. She required
CGA to transition from short sit from the edge of the bed to standing with a narrow-base quad
cane. Rosalind required minimal assistance and redirection to attention to tasks during transfers
on and off the chair, toilet, and tub secondary to verbally over engaging with the therapist. After
transfer evaluations, she expressed fatigue and required a brief rest period before the evaluation
could continue.
IADLs
Rosalind expressed concerns about her ability to shop, prepare meals, take care of the dogs, and
return to work upon discharge. Regarding rest and sleep, Rosalind reported frequently having diffi-
culty falling asleep and being consumed with worry.
MENTAL FUNCTIONS
Cognitive assessment found Rosalind to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. She presented with a delayed response during verbal
ROSALIND: MULTIPLE SCLEROSIS | 147
pragmatic communication and reported “brain fog.” Rosalind was distractible and impulsive and
required verbal redirection and repetition of instructions. Her Mini-Mental Status Examination
(Folstein et al., 2010) was scored at 22. She presented with a pseudobulbar affect. No gross percep-
tual deficits were noted.

No gross deficits were observed with hearing, vestibular, taste, smell, and proprioceptive functions.
Cutaneous sensory testing indicated impaired tactile awareness and tactile localization in both
hands. Visual testing indicated decreased peripheral visual field loss (5° right homonymous hemi-
anopia). No pain was reported.

No deficits were noted in these areas.
MOVEMENT FUNCTIONS
Rosalind presented within normal limits for both active range of motion and passive range of
motion in all extremities. Rosalind was able to form all gross grasp patterns of the hand but had
difficulty with hand manipulation skills. She presented with impaired bilateral gross grasp, with
strength measured at 10 pounds on the right dominant side and 8 pounds on the nondominant
side, using the Jamar dynamometer.
Rosalind was able to maintain balance against moderate resistance during both static and dynamic
sitting. While standing, she presented with minimal weight shifting and difficulty crossing the mid-
line. Deep tendon reflex testing in all four extremities yielded brisk responses.
PLAN FOR DISCHARGE

Rosalind will be discharged to home with home health services that include occupational therapy;
physical therapy; speech therapy; and registered nursing, social work, and home health aide services.

1. Create a handout identifying the precautions and contraindications addressing an acute flare-up of
MS.
2. Considering Rosalind’s current level of balance, what precautions should be followed?
3. Compare and contrast balance and equilibrium.
4. What precautions should Rosalind follow during engagement in ADLs given her cutaneous sensory
deficits?
5. Given Rosalind’s cognitive status, what precautions should be followed?
6. Identify the common emotional reactions associated with MS that may affect the treatment process.
7. To keep Rosalind and others safe, what other factors should be considered?
2. Rosalind has difficulty managing fasteners. What strategies would you use to address this challenge?
3. Rosalind currently requires assistance to bathe. What strategies would you use to address this situation?
4. Rosalind is currently unsafe transferring independently. What strategies would you use to address this
situation?
5. During a treatment session, Rosalind states, “I would give anything to obtain a good night’s sleep.”
How would you address this challenge?
6. Before her admission, Rosalind shopped for food by walking to her local supermarket but is aware it
will not be possible when she returns home. What options would you offer her to consider?

Rosalind’s occupational performance.

1. Identify Rosalind’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Rosalind’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Rosalind’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Rosalind’s primary and secondary diagnoses, identify the related body structures.
Body Functions
structures.
2. Explain the relationships between the structural and functional factors and Rosalind’s current level of

1. Identify common cognitive changes associated with progressive MS. Identify your source.
2. Identify common affective changes associated with progressive MS. Identify your source.
3. Identify how the pseudobulbar affect may affect the occupational therapy process.
4. What measures and strategies are available to address Rosalind’s impulsivity and distractibility?

2. Identify three different assessments or scales that can be used to evaluate Rosalind’s balance. Evaluate
them and then select one. Justify your decision.
3. Use the selected assessment or scale to determine the rating for Rosalind’s sitting and standing balance.
4. Identify the tool that was most likely used to measure Rosalind’s gross grasp strength.
5. Given her current gross grasp strength, what areas of ADLs or IADLs would be most affected?
6. Compare and contrast MS with myasthenia gravis.
7. The muscle strength in all muscle groups has been estimated at 3+/5. Should Rosalind’s strength be
addressed through a remediation or compensation model? Defend your selection.
8. Create an exercise program for Rosalind based on occupational performance.

2. Rosalind experiences fatigue, which is typical for individuals with MS. Is the fatigue that she is expe-
riencing muscular or cardiovascular?
3. Are there immunological changes associated with MS? If so, identify and explain what they are.
4. Are there any cardiopulmonary changes associated with MS? If so, identify and explain what they are.

1. Given Rosalind’s diminished cutaneous sensation, identify and describe the appropriate test or tests
that could be used to assess touch localization and touch awareness.

Describe how Rosalind’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Rosalind while she is receiving
occupational therapy services in subacute rehabilitation? Why?

1. Rosalind has informed you that she intends to return to work immediately upon discharge. How could
this situation be addressed?
2. How could implicit bias affect your interaction with Rosalind?
PHARMACOLOGY
Rosalind is currently taking DMT.

1. Given Rosalind’s profile, how may your own culture and beliefs affect your interaction with her?

1. What is the purpose of the Jamar dynamometer?
5. What is the reliability of the Jamar dynamometer?
6. What is the validity of the Jamar dynamometer?
7. What functional inference can be deduced from Rosalind’s measures of grasp strength?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Rosalind’s diagnoses.

Explain why.
practice setting?
ADVOCACY
1. Which of the following areas of advocacy would beneficial for this case: patient rights, matters of
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Rosalind to deter-

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Rosalind and mem-
bers of the interprofessional team. Review the needs of Rosalind, caregivers, family members, and signifi-
REFERENCES
Folstein, M. F., White, T., Folstein, S. E., & Messer, M. A. (2010). Mini-Mental State Examination (MMSE–2). PAR.
19
Aki: Congestive Heart Failure

FREDERICK WOLODIN, MS, OTR/L
Aki (he, him, his, himself)
MEDICAL HISTORY
Aki is a 91-year-old Japanese American male who is 6' and weighs 175 pounds. He was brought in by emer-
gency services from subacute rehabilitation with shortness of breath, pedal edema, productive cough,
and confusion. Upon arrival, Aki was alert and oriented to person and place. His blood pressure (BP) was
160/82, heart rate (HR) was 88, respiration rate (RR) was 24, and temperature was 97.5°. An X-ray of his
lungs and heart revealed bilateral pleural effusion and an enlarged heart. An electrocardiogram revealed
a left thickened ventricle and arrhythmia. He received a diagnosis of congestive heart failure (CHF) with
an ejection fraction of 20%.
His medical history includes coronary artery disease, hypertension, atrial fibrillation, diabetes mellitus,
Stage 4 chronic kidney disease, osteoarthritis after a right total hip replacement (THR) 13 years ago, and a
left THR 15 years ago. He was admitted to the telemetry care unit for 3 days. Upon medical stabilization,
he was sent to the stepdown unit and then to the medical floor. Aki reported no drug, alcohol, tobacco, or
caffeine use. He has no known allergies.
SOCIAL HISTORY
Aki lives alone in an assisted living facility (ALF) located in a Japanese community. He has two male
adult children and four grandchildren and enjoys weekly visits from his family. Aki identifies as practicing
Shinto.
Aki was transferred to a subacute rehabilitation facility. He has been referred for occupational therapy,
physical therapy, registered nursing services, and social work services. The length of stay will be 21 days.
153
Aki was independent with all ADLs and all IADLs. He grew up with his immigrant parents, who
spoke only Japanese. He had one sister, who passed away from breast cancer at age 30. Aki worked
for his father, who owned and managed a tailor shop, which Aki inherited upon his father’s retire-
ment. His mother was a homemaker. He has a bachelor’s degree in liberal arts. Aki’s most common
pattern of daily living includes waking up at 6:00 a.m., performing his self-care, and eating break-
fast. His interests include watching the local and international news from Asia. Aki was active at
the ALF and was the ombudsman. He values work, education, family, and individual independence.
His reported greatest needs are to return to the ALF and to be able to care for his own needs.
ADLs
Regarding self-care, Aki performed his upper-body dressing with minimal assistance sitting at the
edge of the bed. He attempted to initiate lower-body dressing; however, he required total assistance
for that task. Aki was able to feed himself with setup. He required moderate assistance for anterior
hygiene and maximal assistance for posterior hygiene. Bathing was not assessed at this time.
Regarding functional mobility, Aki transitioned to and from supine to sit with maximal assis-
tance and rolled side to side with moderate assistance with the use of the bed rail. He transferred to
and from the bed, armchair, wheelchair, and toilet with maximum assistance with use of the rolling
walker. Aki required verbal cuing 50% of the time to maintain proper hand placement.
IADLs
Aki required moderate assistance to manage his cell phone, medication, and finances. He was un-
able to prepare a simple meal and perform light housekeeping tasks. Regarding rest and sleep, Aki
reported a life-long pattern of going to bed at 9:00 p.m. and awakening at 5:00 a.m. and obtaining
restorative sleep.
MENTAL FUNCTIONS
Cognitive assessment found Aki to be alert and oriented to person, place, time, and situation, and
long-term memory was intact. He presented with mild impairment in short-term memory. Aki
demonstrated a lack of safety awareness by attempting to perform transfers unassisted. He was able
to follow two- and three-step commands and make his needs known. Affect appeared appropriate,
and no gross deficits in perception were observed.

No gross deficits were observed with visual, hearing, vestibular, taste, and smell functions. Light
touch, deep pressure, and thermal sensation were grossly intact to both upper extremities (BUE)
AKI: CONGESTIVE HEART FAILURE | 155
and were moderately impaired in the distal portions of both lower extremities (BLE). Aki reported
experiencing no pain.

Aki’s vital signs at rest were as follows: BP, 148/70; RR, 18; HR, 82; and oxygen saturation (SpO2),
98% on room air. His vital signs after transferring from the bed to the commode using a rolling
walker were as follows: BP, 160/82; RR, 26; HR, 96; and SpO2, 95% on room air. His metabolic
equivalent task value was 3.0. Aki presented with pitting edema of 2+ to BLE. He was functionally
classified as Class III using the New York Heart Association (NYHA) Classification of Heart Failure
(Criteria Committee of the New York Heart Association, 1994).
MOVEMENT FUNCTIONS
Active range of motion and passive range of motion in BUE were within normal limits. Aki’s muscle
strength was estimated to be 3+/5 for BUE. His fine motor abilities were grossly intact for gross
grasp formation, pinch pattern formation, and in-hand manipulation.
Aki’s static and dynamic sitting balance were good. His static standing balance was fair−, and his
dynamic standing balance was poor+. Standing tolerance was 2 minutes. Muscle tone was normal,
and reflex integration was grossly intact.
PLAN FOR DISCHARGE

Upon discharge, Aki will return to the ALF.

1. Create a handout identifying the signs and symptoms of CHF.
2. What are the signs and symptoms of cardiac distress?
3. Identify the cardiac precautions that need to be observed while working with Aki.
4. What are the precautions to follow for a THR? Does Aki need to follow them?
5. Identify factors that would support Aki being classified as a fall risk.
6. Why did the therapist estimate Aki’s muscle strength instead of performing a manual muscle test?
7. To keep Aki and others safe, what other factors should be considered?
2. What articles of clothing would make Aki most comfortable during his stay at subacute rehabilitation?
3. What areas of functional mobility need to be addressed for Aki to return to the ALF? Explain.
4. What areas of basic ADLs need to be addressed for Aki to return to the ALF? Explain.
5. Aki is diagnosed with diabetes mellitus. What are the dietary considerations he should observe?
6. Aki is diagnosed with hypertension. What are the dietary considerations he should observe?
7. Which areas of IADLs need to be addressed for Aki to return to the ALF? Explain.
Aki’s occupational performance.
2. Which of these skills would be appropriate to address in this service delivery site?

1. Identify Aki’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Aki’s impoverished habits, routines, roles, and rituals that do not support valued occupations.
3. Identify Aki’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Aki’s primary and secondary diagnoses, identify the related body structures.
Body Functions
structures.
2. Explain the relationships between the structural and functional factors and Aki’s current level of

1. Identify common affective changes that may be associated with CHF. How would they be addressed in
occupational therapy?
2. Identify common cognitive changes that may be associated with CHF. How would they be addressed
in occupational therapy?
3. What other services would be available for Aki to address these changes?
4. Given the information provided, what additional mental function considerations need to be
addressed?

2. Compare and contrast right heart failure with left heart failure.
3. Identify remediation activities that could be implemented to improve Aki’s muscular strength.
4. Identify remediation activities that could be implemented to improve Aki’s standing balance.
5. Identify remediation activities that could be implemented to improve Aki’s standing tolerance.
6. Create an exercise program for Aki based on occupational performance.

2. Given Aki’s current level of cardiac function, what strategies should be considered to optimize his par-
ticipation? Justify your selection.
3. What remediation strategies should be considered to improve Aki’s cardiovascular endurance? Justify
your selection.

1. Aki presented with reduced cutaneous sensation in BLE. Identify possible contributing factors.

Describe how the diagnoses may affect Aki’s voice, speech, and associated occupational performance.

Does Aki need any assistive technologies or adaptations? If yes, identify them and explain why he needs
them.

1. On several occasions, you observed Aki consuming a bag of potato chips. How can this situation be best
addressed?
2. In the therapy gym, a colleague says to you, “Why do you give him so much of your time? He is old and
is going to die soon.” How should this statement be best addressed?
PHARMACOLOGY
Aki is currently taking Diucardin.

1. Given Aki’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the NYHA Classification of Heart Failure?
5. What is the reliability of the NYHA Classification of Heart Failure?
6. What is the validity of the NYHA Classification of Heart Failure?
7. What functional inference can be deduced from Aki’s functional Class III classification?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Aki’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Aki to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Aki and members of
the interprofessional team. Review the needs of Aki, caregivers, family members, and significant others.
The plan must match needs with available resources and the discharge environment.
REFERENCES
Criteria Committee of the New York Heart Association. (1994). Nomenclature and criteria for diagnosis of diseases of
the heart and great vessels (9th ed.). Little, Brown and Company.
20
Ting: Osteoporosis
Ting (she, her, hers, herself)
MEDICAL HISTORY
Ting is a 72-year-old Malaysian American female who is 5' 2" and weighs 165 pounds. She arrived at the
emergency department (ED) of her local community hospital reporting a slip and fall in her bathtub. She
presented with stooped posture and complained of severe back pain. After a physical examination, she
was sent for X-rays and a computerized axial tomography scan. She was diagnosed with compression
fractures of her second and fourth thoracic vertebrae. She was fitted with a thoracic lumbar sacral ortho-
sis (TLSO) and prescribed pain medication.
Her medical history includes hypertension, peripheral vascular disease, osteopenia, myocardial infarc-
tion, and blindness in her left eye secondary to a motor vehicle accident. She reported no alcohol, drug, or
nicotine use and has no known allergies. From the ED, she was sent to the orthopedic floor for 24 hours
of observation.
SOCIAL HISTORY
Ting is a retired custodial worker. She lives alone in a modest one-bedroom, fifth-floor apartment in a
building without an elevator. She has no living relatives in the United States and lost her only child in a
car accident. She is a practicing Buddhist and socializes with other members of the temple after days and
nights of meditation and study.
Ting was transferred to a subacute rehabilitation facility. She has been referred for occupational therapy,
physical therapy, registered nursing services, and social work services. The length of stay will be 10 days.
161
Ting’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. She is a retired mall custodial worker and has lived alone since the passing of her
husband 10 years ago. Her patterns of daily living most commonly included having a light breakfast
in the morning and spending at least 3 days at the temple engaged in meditation and study. Her
interests include visiting friends and watching game shows on television. Ting values truth and
understanding. She reported her greatest needs are to be able to return home, live independently,
and be able to once again attend her temple.
ADLs
Regarding self-care, Ting was able to independently feed herself and dress both upper extremities
(BUE), but she needed moderate assistance to don and doff her pants, shoes, and socks. She was
able to independently wash BUE but required moderate assistance washing both lower extremities
(BLE). She was able to manage her clothing and clean herself after toileting. Regarding functional
mobility, Ting was able to independently roll side to side and required minimal assistance to tran-
sition between supine and sitting. She used a rolling walker and required minimal assistance to
transfer on and off the bed, chair, toilet, and tub.
IADLs
Ting independently managed her communications and finances. She was aware that currently she
would not be able to maintain her home, prepare meals, or shop. Regarding rest and sleep, Ting
reported being unable to find a comfortable sleeping position and sleeping intermittently at night.
MENTAL FUNCTIONS
Cognitive assessment found Ting to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. She was able to follow three-step commands and make
her needs known. Her affect appeared appropriate, and Ting stated that she is “highly motivated”
to start therapy. No gross deficits in perception were observed.

No gross deficits were observed with hearing, vestibular, taste, smell, proprioceptive, and cutane-
ous functions. Ting reported visual acuity of 20/20 in her right eye and legal blindness in her left.
She was unable to detect light or movement in her left eye. Pain in the thoracic spine was reported
to be an 8 using the Numerical Rating Scale (0–10). Ting reported fluctuating pain levels between 7
and 10. The pain level at the time of evaluation was reported as an 8. Pain was described as “sharp
TING: OSTEOPOROSIS | 163
and continuous.” An eye exam was administered using the Snellen Eye Chart (Hetherington, 1954),
and a score of 20/400 was obtained.

Ting experienced intermittent claudication during ambulation.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion in BUE were within defined limits. Testing
muscle strength with the manual muscle test (MMT) was contraindicated at the time of evaluation.
Prehension was intact for gross grasp, pinch, and in-hand manipulation skills.
Coordination, tone, and reflex integration in BUE and BLE were intact.
PLAN FOR DISCHARGE

Ting will be discharged home and receive services through a certified home health agency. Services
will include occupational therapy, physical therapy, social work, nursing, and home health aide
services.

1. Create a handout identifying precautions for individuals with spinal fractures.
2. What wearing schedule will Ting most likely follow with her TLSO?
3. Identify the risks of wearing a TLSO. How can these risks be mitigated?
4. The MMT was contraindicated at the initial evaluation. Why?
5. Identify the common psychological reactions associated with osteoporosis that may affect the treat-
ment process.
6. To keep Ting and others safe, what other factors should be considered?
2. What strategies can be used to allow Ting to regain independence in lower body dressing?
3. What strategies can be used to allow Ting to regain independence in lower body bathing?
4. What recommendations can you make to allow Ting to experience more restful sleep?
5. What strategies can be used to allow Ting to gain independence transitioning between supine and
short sitting?
6. What areas of functional mobility need to be addressed and how?
7. Because Ting will be living alone when she returns home, identify areas of IADLs that need to be ad-
dressed. Explain how they should be addressed.
Ting’s occupational performance.

1. Identify Ting’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Ting’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Ting’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Ting’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Ting’s current level of

1. How may high levels of pain affect Ting’s motivation over time?

2. Compare and contrast osteoporosis with osteopenia.
3. List the common lifting restrictions for individuals with spinal fractures.
4. Which of Ting’s tasks or activities may need to be modified as a result of lifting restrictions?
5. Create an exercise program for Ting based on occupational performance.

1. Given the information provided, identify cardiovascular, hematological, immunological and respira-
tory functions that need to be addressed.
2. Explain how severe pain affects cardiovascular, hematological, immunological, and respiratory functions.

1. What would be the visible signs and reported symptoms of a poorly fitted TLSO?
2. If you become aware of a poorly fitted TLSO, what steps should be taken?

Describe how Ting’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Ting while she is receiving oc-
cupational therapy services at the subacute rehabilitation center? Why?

1. While performing a functional ambulation task, a patient with a known brain injury pinches Ting on
her buttocks as he wheels his wheelchair past her. How should this action be addressed?
2. In preparation for discharge, Ting informs you that she has no food in her home. How should this sit-
uation be addressed?
PHARMACOLOGY
Ting is currently taking Oxycontin.


1. Given Ting’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the Snellen Eye Chart?
5. What is the reliability of the Snellen Eye Chart?
6. What is the validity of the Snellen Eye Chart?
7. What functional inference can be deduced from Ting’s score of 20/400 in her left eye?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Ting’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Ting to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Ting and members of
the interprofessional team. Review the needs of Ting, caregivers, family members, and significant others.
REFERENCES
Hetherington, R. (1954). The Snellen Chart as a test of visual acuity. Psychologische Forschung, 24, 349–357. https://
doi.org/10.1007/BF00422033
Skilled Nursing Facility SECTION V
or Long-Term Care
169
21
Jacob: Alzheimer’s Disease

BEBE HANIF, MS, OTR/L
Jacob: (he, him, his, himself)
MEDICAL HISTORY
Jacob is a 94-year-old Israeli male living in the United States, who is 5' 11" and weighs 193 pounds. He
was brought in by emergency medical services to the emergency department after a fall. He was found
by the certified nursing assistant on the floor on the right side of his bed at the skilled nursing facility
(SNF). A computed tomography scan of the head, X-rays, and blood tests were performed. The scan and
X-ray results were negative. His blood test revealed a urinary tract infection. Medical history includes
Alzheimer’s disease, renal disease, diabetes mellitus, chronic obstructive pulmonary disease, and con-
gestive heart failure. There is no reported alcohol, drug, caffeine, or tobacco use, and he has no known
allergies.
SOCIAL HISTORY
Jacob has been a resident in the SNF for the past 6 years. He is a retired delicatessen owner who pre-
viously lived and worked in Brooklyn, New York. His wife passed away 15 years ago. He has a son, two
grandchildren, and three great-grandchildren who visit occasionally. Jacob practices Hasidic Judaism.
Jacob was transferred back to the SNF for restorative care. He has been referred for occupational and
physical therapy. The length of treatment will be 30 days.
171
Occupational Therapy Initial Evaluation Findings: Skilled Nursing Facility
Jacob’s preadmission occupational history and experiences included requiring assistance in all
ADLs. He is nonverbal and follows commands inconsistently. His common pattern of daily living
includes being fed, cleaned, and dressed by the nursing assistant and then transferred to his wheel-
chair and placed in the dining room with the other residents. Daily activities in the dining room in-
clude current affairs, games, music, and movies. He is toileted after lunch and returns to bed before
dinner. Jacob is not able to state his values, interests, or greatest need.
ADLs
Regarding self-care, Jacob required maximum assistance to feed himself and to dress his upper
body. He was dependent with grooming, toileting, bathing, and lower body dressing. The FIM®
(Uniform Data System for Medical Rehabilitation, 1997) was completed, and a total score of 51 was
obtained. Regarding functional mobility, Jacob required maximum assistance to roll and transition
from supine to sit at the edge of the bed. He transferred to and from all surfaces with maximum
assistance.
IADLs
Jacob was dependent in all areas. Regarding rest and sleep, the medical record indicated that Jacob
frequently falls asleep during the day, frequently awakens during the evening, and at times can be-
come agitated.
MENTAL FUNCTIONS
Jacob is alert and oriented times 1 to self. Short- and long-term memory were both impaired. He
was able to follow one-step commands but not two-step commands.

cutaneous functions. Use of the Wong-Baker FACES® Pain Rating Scale (Wong-Baker FACES
Foundation, 2018) indicated a score of 4 in the right upper extremity. No description of pain was
able to be obtained.

Jacob’s blood pressure was 143/92 mm Hg, oxygen saturation on room air was 93%, and heart rate
was 84 beats per minute.
JACOB: ALZHEIMER’S DISEASE | 173
MOVEMENT FUNCTIONS
Limited active range of motion and passive range of motion were noted in all extremities; gonio-
metric assessment was unable to be performed. The manual muscle test (grossly) indicated a score
of 3 to 3+/5 for both upper extremities (BUE) and both lower extremities (BLE).
Jacob was able to sit at the edge of the bed with maximum assistance. Static and dynamic sitting
balance were 3−/5 (F-), and static and dynamic standing balance were 2/5 (P). Muscle tone in BUE
and BLE was rigid. Bradykinesia and tremors were present.
PLAN FOR DISCHARGE

Jacob will be discharged to his home at the SNF.

1. Create a handout that provides recommendations to maximize communication with Jacob.
2. What safety concerns do you anticipate because Jacob has a history of falls?
3. What safety concerns do you anticipate because Jacob presents with impaired vision and hearing?
4. To keep Jacob and others safe, what other factors should be considered?
2. What clothing choices would you recommend for Jacob to avoid discomfort?
3. What equipment and strategies do you anticipate can be used to increase Jacob’s safety in bed and in
the wheelchair?
4. Would you address any functional mobility skills with Jacob?
5. Would you address socialization or sleep with Jacob? Why or why not?
Jacob’s occupational performance.

1. Identify Jacob’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Jacob’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Jacob’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
How can the identified values, beliefs and spirituality be used in this case?
Body structures
Considering Jacob’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and current level of occupa-
tional performance.

1. Compare and contrast Alzheimer’s disease with Lewy body dementia.
2. Identify three strategies that could be used to maximize effective communication with Jacob. How
would you evaluate them?
3. Identify sources that could provide effective strategies to maximize Jacob’s ability to use his available
vision and hearing.

2. Based on the finding “patient was able to sit at the edge of the bed with maximum assist,” should
Jacob’s static balance be assigned a grade of poor or poor+? Provide your reference.
3. Based on the finding “patient was unable to stand/pivot for transfer bed to a wheelchair,” which com-
mercial device or devices are available to assist?
4. Create an exercise program to be provided to Jacob’s care providers that is based on occupational
performance.

2. Which vital signs should be taken when working with Jacob? Identify the norms for each of these vital
signs and when they should be taken.

1. On arrival at the occupational therapy area, you notice a swelling on Jacob’s right arm. What would be
a concern and what possible actions would you take?

Describe how Jacob’s diagnoses may affect his voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Jacob for comfort or positioning?
Why?

1. Jacob becomes agitated and restless in the evenings. What strategies would you use to calm him?
2. Jacob’s grandson comes to you, uses a racial slur, and demands that you place his grandfather in a
restorative occupational therapy program. What is your reaction, what do you say, and how do you
support your decision?
PHARMACOLOGY
Jacob is currently taking Aricept.
6. How may this drug affect client participation during basic ADLs?

1. Given Jacob’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the FIM?
5. What is the reliability of the FIM?
6. What is the validity of the FIM?
7. What functional inference can be deduced from Jacob’s score of 51?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Jacob’s diagnoses.

Explain why.
practice setting?
ADVOCACY
1. Which of the following areas of advocacy would be beneficial in this case: patient rights, matters
of privacy, confidentiality, informed consent, awareness building, accessing education, or benefits/
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Jacob’s caregivers to
determine whether it is appropriate for him to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Jacob and members
of the interprofessional team. Review the needs of Jacob, caregivers, family members, and significant oth-
REFERENCES
Uniform Data System for Medical Rehabilitation. (1997). Guide for the Uniform Data Set for Medical Rehabilitation
(including the FIM® instrument), version 5.1. Author.
22
Aretha: End-Stage Renal Disease

VIKRAM PAGPATAN, OTR/L, ATP, BCP, CLA
Aretha (she, her, hers, herself)
MEDICAL HISTORY
Aretha is a 78-year-old Trinidadian American female who is 5' 9" and weighs 230 pounds. Aretha was
found unresponsive in a pool of blood by her daughter, who called emergency medical services, and she
was subsequently taken to her community hospital’s emergency department (ED). A physical examina-
tion, X-rays, and blood tests were done. The exam revealed that Aretha’s right bicep had an arteriovenous
fistula and was in a deconditioned state. From the ED, she was sent to the operating room, and a surgical
repair of the fistula was performed. Her medical history includes end-stage renal disease, Type 2 diabetes
mellitus, generalized anxiety disorder, ovarian cancer, and osteoarthritis. Aretha has a surgical history of
a complete hysterectomy and a humeral fixation after a mechanical fall. Aretha undergoes hemodialysis
three times a week. She reported no alcohol, drug, tobacco, or caffeine use. She reported a wheat allergy.
SOCIAL HISTORY
Aretha is originally from Trinidad and Tobago and has resided in the Bronx, New York, for more than 20
years. Aretha has two sons who are both employed full time in the city’s sanitation department as shift su-
pervisors, and a daughter who is a school principal. Aretha has been a widow for 7 years and resides alone
in a cooperative building. Her unit is a studio apartment with elevator access. Aretha has been retired for
12 years but is employed as a substitute teacher on a per diem basis for a contract agency. She owns a ve-
hicle that is used by her neighbor to drive her to her medical and hemodialysis appointments. Aretha is a
member of Jehovah’s Witnesses and has weekly religious obligations at her place of worship.
Aretha was transferred to a skilled nursing facility (SNF) for restorative care. She has been referred for
occupational therapy, physical therapy, social work, and registered nursing services. The length of stay
will be 30 days.
179
Aretha’s preadmission occupational history and experiences included being independent in all
ADLs and requiring minimal assistance for homemaking tasks such as laundry, house cleaning, and
food shopping. Before her hospitalization, Aretha hired a neighbor to help her with these tasks.
She is also driven by her neighbor to and from the dialysis center 3 days per week. Her daily rou-
tine on the remaining 4 days included waking early, bathing, eating breakfast, and then traveling to
and spending the day at the Kingdom Hall. She values her time, family, and spiritual community.
Her interests include tutoring at-risk children in her community and cooking traditional Caribbean
dishes. She reported her greatest needs are to return home and reestablish her previous level of
independence and to be healthy enough to receive a kidney transplant.
ADLs
Regarding self-care, Aretha required contact guard assistance (CGA) for upper- and lower-body
dressing as well as minimal to moderate assistance for bathing and toileting. Regarding functional
mobility, Aretha was able to roll, transition between supine and short sit, and bridge independently.
She requires CGA to transfer, using a wide-based quad cane on and off the chair, bed, and toilet.
When standing, Aretha reports feeling dizzy and anxious. She disclosed a history of falling on three
separate occasions at home when transferring out of her bathtub.
IADLs
Aretha was able to manage her finances, use her mobile device, and prepare meals but was unable
to clean her home, shop, and do laundry. Regarding rest and sleep, Aretha reported waking up fre-
quently during the night because of “intense throbbing” sensations in her knees.
MENTAL FUNCTIONS
Cognitive assessment found Aretha to be alert and oriented to person, place, time, and situation,
make her needs known. Her affect appeared appropriate. Aretha was found to be calm and coop-
erative but was in denial of her limitations. The Beck Anxiety Inventory (BAI; Beck & Steer, 1993)
was administered, and a score of 25 was recorded. No gross deficits in perception were observed.

No gross deficits were observed with visual, hearing, taste, smell, and proprioceptive functions. A
vestibular assessment revealed that sudden transitions resulted in dizziness. She presented with
a diminished light touch in both upper extremities and reported tingling sensations in her right
ARETHA: END-STAGE RENAL DISEASE | 181
dominant hand, localized to digits 1–3. Aretha reported “tenderness and hypersensitivity” to touch
at the fistula site. She reported pain as a 5 in both knees using the Numerical Rating Scale (0–10).

Aretha’s resting blood pressure is 162/93 mmHg, and her heart rate is 103 beats per minute. She
experienced shortness of breath when ambulating for a distance greater than 200 feet. Her baseline
oxygen saturation is 96%, and her respiration rate is 18 breaths per minute.
MOVEMENT FUNCTIONS
Aretha’s active range of motion (AROM) in all extremities was within defined limits (WDL) with
the exception of the right upper extremity, which had shoulder flexion of 0–110°, shoulder abduc-
tion of 0–105°, shoulder external rotation of 0–70°, shoulder internal rotation of 0–80°, and shoul-
der horizontal adduction of 0–95°. Muscle strength in both upper extremities was grossly 3–/5 in
shoulder groups and 3+/5 in distal groups. Gross grasp strength was 11 pounds on the right and 9
pounds on the left. Fine motor abilities were intact for grasp formation, pinch formation, and in-
hand manipulation.
Aretha’s static and dynamic sitting balance was 4/5 (good). Her static and dynamic standing bal-
ance was 3+/5 (fair+). Her standing tolerance was 3–5 minutes. Abrupt movements resulted in diz-
ziness. Muscle tone was found to be WDL in both upper and lower extremities. Reflex integration
was grossly intact.
PLAN FOR DISCHARGE

Aretha is expected to be discharged home with home care services. Services will include occupa-
tional therapy; physical therapy; and registered nursing, social work, and home health aide services.

1. Create a handout that identifies the general precautions for an individual with a fistula.
2. Can blood pressure be taken on the right upper extremity? Why or why not?
3. What resting blood pressure threshold would make occupational therapy treatment contraindicated?
4. What resting heart rate would make occupational therapy treatment contraindicated?
5. To keep Aretha and others safe, what other factors should be considered?
2. How does a fistula affect self-care activities?
3. What recommendations can you make to allow Aretha to obtain more restful sleep?
4. What strategies can be used for Aretha to gain independence during bathing?
5. What strategies can be used for Aretha to gain independence during dressing?
Aretha’s occupational performance.

1. Identify Aretha’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Aretha’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Aretha’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
How can Aretha’s values, beliefs, and spirituality be used in this case?
Body structures
Considering Aretha’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Aretha’s current level of

1. Identify a current theory or theories to address Aretha’s anxiety. Briefly explain your choice.
2. Describe an approach you would use with Aretha to gain a more realistic view of her physical capabil-
ities. Justify your proposed approach.

2. Identify strategies that can be used to address the restoration of AROM of the right shoulder given the
presence of the fistula.
3. Describe how impaired standing balance can contribute to the risk of falls. Site two sources to support
your position.
4. List at least three activities that Aretha may have difficulty performing given her current standing
tolerance.
5. Create an exercise program for Aretha based on occupational performance.

2. Compare and contrast end-stage renal disease with acute renal failure.
3. Identify the metabolic equivalent of task value that you would currently assign to Aretha. Support your
decision.
4. Explain how Aretha’s baseline blood pressure could affect treatment.
5. Compare and contrast the signs and symptoms of vertigo with orthostatic hypotension.

1. What skin care should be provided in the area of the fistula?
2. Identify the possible explanation for the report of tingling sensations to digits 1–3.
3. Identify the long-term skin changes related to diabetes.

Describe how Aretha’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Aretha while she is receiving
occupational therapy services in the SNF? Why?
2. What assistive technologies or adaptations might be recommended for Aretha when she returns
home? Why?

1. During treatment, a staff member mistakenly identifies Aretha as African American. How would you
address this mistake?
2. After a treatment session, Aretha provides you with literature about her religion. What would you
think or feel? What would you do?
PHARMACOLOGY
Aretha is taking erythropoietin.

1. Given Aretha’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the BAI?
5. What is the reliability of the BAI?
6. What is the validity of the BAI?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Aretha’s diagnoses.

1. Who would be the authorized persons you could share the occupational therapy findings with? Explain
why.
2. Who would be the unauthorized persons with whom you could not share the occupational therapy
findings without written permission? Explain why.
3. What forms of documentation will be required for this case?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Aretha to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Aretha and members
of the interprofessional team. Review the needs of Aretha, caregivers, family members, and significant
REFERENCES
Beck, A. T., & Steer, R. A. (1993). Beck Anxiety Inventory manual. Psychological Corporation.
23
Epa: Diabetes
Epa (she, her, hers, herself)
MEDICAL HISTORY
Epa is a 72-year-old Polynesian American who is 5' 4" and weighs 178 pounds. She was admitted to a
skilled nursing facility (SNF) after an above-knee amputation of her right lower extremity. At age 3, she
was diagnosed with juvenile-onset diabetes mellitus. Her medical history includes diabetic retinopathy,
which has led to legal blindness; renal failure requiring dialysis; and left ventricular congestive heart fail-
ure. She reported no alcohol, substance, nicotine, or caffeine use. Epa reported being allergic to animal
dander.
SOCIAL HISTORY
Epa has lived with her spouse, Roger, for 42 years. They own a loft together in lower Manhattan. The loft
has served as both a home and working studio for both her and Roger. For the past 2 years, they have eaten
all meals out and had a cleaning service for their home. Epa and Roger have a large community of friends,
who mostly include photographers as well as performing and studio artists. They have traveled the world
together pursuing their photographic endeavors and have been fixtures in the New York art community.
Epa identifies as an animist.
Epa was transferred to a SNF for restorative care. She has been referred for occupational therapy, physical
therapy, social work, and registered nursing services. The length of stay will be 30 days.
187
Epa’s preadmission occupational history and experiences included requiring assistance to perform
most of her ADLs and all IADLs. Epa is a renowned photographer who was forced to retire as a
result of her failing vision and health. Her works are on display at both the Museum of Modern Art
and the Smithsonian. For the past 10 years, Epa and Roger have hired people to care for their home.
Her failing health has required Roger to assist her with most of her basic ADLs. Epa is on hemodi-
alysis and frequently finds herself without energy. Epa values her contribution to the art world, her
marriage to Roger, and notions of equality and equity. Her interests include spending quality time
with Roger. She reported her greatest needs are not to be a burden on Roger, being as independent
as possible, and being able to engage remotely with the members of her art community.
ADLs
Regarding self-care, Epa was able to self-feed when food and utensils were placed within her reach.
With moderate assistance, she could dress and bathe her upper extremities but needed total assis-
tance with lower extremities. She was able to brush her teeth but required moderate assistance to
shave. Epa required moderate assistance to manage clothing after toileting. Regarding functional
mobility, Epa was able to roll in bed independently but required maximal assistance to transition
between supine and both short and long sitting positions. She required maximal assistance to per-
form stand pivot transfers between the bed and wheelchair and the wheelchair and commode.
IADLs
Epa was not able to manage her home or finances and required assistance with communication de-
vices. The Lawton IADL Scale (Lawton & Brody, 1969) was administered, and Epa obtained a total
score of 2 (i.e., 1 point for answers phone but does not dial and 1 point for is responsible for taking
medication in correct dosages at correct time). Regarding rest and sleep, Epa reported sleeping only
2 hours at a time secondary to hypersensitivity in her right residual limb.
MENTAL FUNCTIONS
Cognitive assessment found Epa to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. She was able to follow three-step commands and make
her needs known. Affect appeared appropriate, but she became noticeably teary-eyed when she
referred to the burden she has placed on Roger. No gross deficits in perception were observed.

No gross deficits were observed with hearing, vestibular, taste, smell, and proprioceptive functions.
Epa reported a corrected visual acuity of 20/200 in both eyes. She presented with diminished light
EPA: DIABETES | 189
touch, deep pressure, and thermal sensation in both hands. All digits presented with a delayed cap-
illary refill and shiny skin. No pain was reported.

Epa’s cardiovascular endurance was assessed at 2.5 using the metabolic equivalent of task (MET).
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion were within defined limits. Muscle strength in
all groups of the left upper extremity (LUE) was 3+/5. The manual muscle test (MMT) of the right
upper extremity (RUE) was not performed because of the presence of an arteriovenous fistula.
Assessment of fine motor abilities identified difficulty using palmar pinch and tip-to-tip pinch and
manipulating small objects.
The Balance Grading Review was used to assess Epa’s static and dynamic sitting balance, which
were good, and her static and dynamic standing balance, which were poor. She could tolerate short
sitting for up to 30 minutes before complaints of fatigue. Standing tolerance was not assessed, and
muscle tone was normal. Reflex integration was grossly intact.
PLAN FOR DISCHARGE

After completion of her subacute stay, Epa will transition to become a resident at the SNF.

1. Create a handout identifying the postsurgical precautions to be followed after a lower extremity
amputation.
2. Given that Epa presents with impaired cutaneous sensory loss in both hands, what precautions need
to be considered?
3. Because Epa has been diagnosed with left ventricular heart failure, what precautions need to be
followed?
4. Identify the precautions that should be followed for legal blindness. Cite your source and justify your
selection.
5. Compare and contrast legal blindness with low vision.
6. Identify the common emotional reactions associated with an amputation that may affect the treatment
process.
7. To keep Epa and others safe, what other factors should be considered?
2. How is legal blindness defined?
3. How would you maximize Epa’s residual vision during engagement in the occupational therapy
process?
4. Considering Epa’s MET value, which self-care task would be the least and most challenging for her?
5. Considering Epa’s MET value, what areas of functional mobility should be addressed first?
6. Transfers commonly can be performed using a sliding board, sliding method, squat pivot method,
stand pivot method, or an ambulation device. Which method would be the most appropriate for Epa?
Explain why.
7. What recommendations can be made to facilitate more restful sleep for Epa?
Epa’s occupational performance.

1. Identify Epa’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Epa’s impoverished habits, routines, roles, and rituals that do not support valued occupations.
3. Identify Epa’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Epa’s primary and secondary diagnoses, identify the related body structures.
Body Functions
structures.
2. Explain the relationships between the structural and functional factors and Epa’s current level of oc-
EPA: DIABETES | 191

1. Search the literature and identify how amputation affects body image. Provide a brief summary of the
findings.

2. How has Epa’s right above-knee amputation affected her center of gravity?
3. What considerations should be made when designing a treatment plan for an individual with a
lower-extremity amputation that accounts for a shift in the center of gravity?
4. The MMT was contraindicated for Epa’s RUE. Explain why.
5. Is Epa a candidate to remediate muscle strength in her LUE? Explain why.
6. Create an exercise program for Epa based on occupational performance.

2. Compare and contrast Type 1 diabetes with Type 2 diabetes.
3. Do you believe Epa will be a candidate to receive a prosthetic leg? Justify your decision.
4. Create a handout identifying energy conservation principles.
5. Identify the type or types of monitoring required when working with a person who has ventricular
heart failure.
6. Identify the signs and symptoms of hyperglycemia and hypoglycemia.
7. What must be done for a client who experiences an episode of hyperglycemia or hypoglycemia?

1. What is an indication of a prolonged capillary refill?
2. What might be an explanation for Epa’s diminished light touch, deep pressure, and thermal sensation
in both hands?

Describe how Epa’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Epa while she is receiving occupa-
tional therapy services? Why?

1. Epa informs you that she and Roger have not engaged in any sexual intimacy for more than 3 months.
She asks you how the facility would ensure their privacy if they choose to be sexually intimate. What
is required to best address her question?
2. You observe that because of Epa’s celebrity status, she receives a higher level of care than others. How
should this situation be addressed?
3. Without prompting, during a treatment session Epa expresses her belief that God is only a creation of
man’s imagination. How should this situation be addressed?
PHARMACOLOGY
Epa is currently taking Humalog.

1. Given Epa’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the Lawton IADL Scale?
5. What is the reliability of the Lawton IADL Scale?
6. What is the validity of the Lawton IADL Scale?
7. What functional inference can be deduced from Epa’s score of 2 on the scale?

EPA: DIABETES | 193
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Epa’s diagnoses.
priate. Justify your section.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Epa to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Epa and members of
the interprofessional team. Review the needs of Epa, caregivers, family members, and significant others.
REFERENCES
Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of
daily living. The Gerontologist, 9, 179–186. https://doi.org/10.1093/geront/9.3_Part_1.179
24
Mohammad: Chronic Obstructive

Pulmonary Disease
Mohammad (he, him, his, himself)
MEDICAL HISTORY
Mohammad is a 77-year-old Iranian American male who is 6' 2" and weighs 144 pounds. He experienced
an episode of respiratory distress while working a shift as a building maintenance supervisor and was
rushed to a hospital emergency department by coworkers. A physical examination, X-rays, and blood tests
were performed. He received a diagnosis of chronic obstructive pulmonary disease (COPD). Mohammad’s
medical history includes Type 2 diabetes mellitus, a right rotator cuff tear, osteoarthritis of the left knee,
and major depressive disorder. Mohammad reported no alcohol or drug use but reported smoking two to
three packs of cigarettes per week for 50 years. He has no known allergies. Mohammad was stabilized and
transferred to a skilled nursing facility (SNF) for short-stay rehabilitation.
SOCIAL HISTORY
Mohammad practices the Islamic faith. He resides with his two wives and his four youngest children in
a 12th-floor apartment that has elevator access. The apartment consists of four bedrooms, a living room,
two bathrooms with a walk-in shower, and a kitchen with an electric stove. Mohammad is the primary
caregiver for his eldest wife, who requires medical assistance for medication management secondary to
altered mental status and early-onset dementia. Mohammad identifies as a Sunni Muslim.
Mohammad was transferred to a SNF for restorative care. He has been referred for occupational therapy,
physical therapy, social work, and registered nursing services. The length of stay will be 14 days.
195
Mohammad’s preadmission occupational history and experiences included being independent in
all ADLs and all IADLs. He is employed as a full-time building maintenance supervisor in a condo-
minium complex. His patterns of daily living most commonly included arriving to work at 6:00 a.m.
and returning home by 6:00 p.m. Mohammad works 4 days per week, Monday through Thursday, to
support his family. He is deeply concerned that if he does not return to work by the end of 30 days,
he will lose his job. Mohammad is a religious Muslim and prioritizes praying at least 5 times a day.
Each prayer session takes up to 10–15 minutes, so he often takes short breaks throughout the day.
Mohammad values his family and ensures that he is able to spend time with his wives and children.
He reported his greatest needs are to return home and care for his family.
ADLs
Regarding self-care, Mohammad was able to independently dress and bathe his upper body but
required minimal to moderate assistance with the lower body. Mohammad became noticeably anx-
ious and experienced shortness of breath (SOB) during lower body care. Regarding functional mo-
bility, Mohammad was able to independently roll from side to side and transition from supine to
sit but experienced mild SOB. During functional ambulation and transfers with the use of a rolling
walker, he required supervision.
IADLs
Mohammad’s younger wife has assumed responsibility to care for the elder wife, maintain the
home, prepare meals, and shop. Mohammad was independent in financial management and use of
communication devices. Regarding rest and sleep, for comfort during sleep, Mohammad required
the head of the bed to be elevated.
MENTAL FUNCTIONS
Cognitive assessment found Mohammad to be alert and oriented to person, place, time, and situ-
ation, and short- and long-term memory were intact. He was able to follow three-step commands
and make his needs known. Mohammad has a fair command of the English language but reported
difficulty understanding technical medical terms. Assessment of affect revealed that he feels anx-
ious during periods of SOB and does not feel completely comfortable when providers of the oppo-
site gender physically examine him. No gross deficits in perception were observed.

cutaneous functions. Use of the Universal Pain Assessment Tool indicated a score of 6/10 for pain
in his right glenohumeral joint. The pain was described as “gnawing.”
MOHAMMAD: CHRONIC OBSTRUCTIVE PULMONARY DISEASE | 197

Mohammad has been prescribed supplemental oxygen at 2 liters per minute through a nasal can-
nula while at the SNF and has been exhibiting a daily oxygen saturation of 95%. His heart rate at
rest is 90 beats per minute (BPM) and exceeds 100 BPM during basic ADLs. His respiration rate at
rest is 20 breaths per minute and exceeds 26 breaths per minute with basic ADLs. The Borg Rating
of Perceived Exertion (RPE) Scale (Borg, 1982; Williams, 2017) was administered, and a score of 17
was obtained.
MOVEMENT FUNCTIONS
Mohammad’s active range of motion (AROM) of the left upper extremity is within defined limits
(WDL), and the right upper extremity is WDL except for shoulder motions. AROM measurements
for his right shoulder are flexion, 0–90°; abduction, 0–95°; internal rotation, 0–60°; and external
rotation, 0–40°. Muscle strength in all muscle groups in both upper extremities was 4/5 except
right shoulder musculature, which was 3−/5. Fine motor abilities for grasp patterns, pinch patterns,
and in hand manipulation skills were grossly intact. Standing tolerance was 5–6 minutes.
Coordination, muscle tone, and reflex integration in both upper extremities were intact.
PLAN FOR DISCHARGE

Mohammad will be discharged home without service.
1. Identify precautions to follow with the use of supplemental oxygen. Cite your source and justify your
selection.
2. How may the use of supplemental oxygen affect the occupational therapy process?
3. Create a handout identifying precautions to be followed by people with COPD.
4. What are the signs of respiratory distress? If these signs are observed or reported, what actions should
be taken?
5. Identify the common emotional reactions associated with COPD that may affect the treatment process.
6. To keep Mohammad and others safe, what other factors should be considered?
2. Identify assistive devices or compensatory strategies that will allow Mohammad to perform the ADL
of bathing.
3. Identify the areas of education that would be appropriate to engage in with Mohammad and explain
why.
4. Would work, leisure, socialization, or sleep be addressed? Why or why not?
5. Given Mohammad’s current functional status, estimate his current metabolic equivalent of task (MET)
needed and determine which MET value would be required to return to work safely.
Mohammad’s occupational performance.

1. Identify Mohammad’s useful habits, routines, roles, and rituals that support valued occupations. How
2. Identify Mohammad’s impoverished habits, routines, roles, and rituals that do not support valued oc-
cupations. How can you make use of this information?
3. Identify Mohammad’s dominating habits, routines, roles, and rituals that interfere with valued occu-
CLIENT FACTORS
Body structures
Considering Mohammad’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Mohammad’s current
level of occupational performance.

1. What concerns related to Mohammad’s medical history may affect the occupational therapy process?
2. Identify cognitive changes associated with COPD over time. Name your source or sources.
3. What other disciplines would be available to address Mohammad’s reported anxiety?


2. Describe the signs and symptoms of a rotator cuff tear.
3. Identify the motions of the shoulder and provide the AROM norm for each.
4. Which assessment methods would have been used to assess AROM?
5. Identify three physical agent modalities that are appropriate for the management of Mohammad’s
pain. Select one and justify your selection.
6. Create an exercise program for Mohammad based on occupational performance.

1. Given the information provided, identify cardiovascular, hematological, immunological and respira-
2. Describe how pain affects vital signs.
3. Compare and contrast the norm values of vital signs for a resting adult with the norm values for children?
4. Explain critical values for vital signs.

1. What is cyanosis and how is it related to COPD?
2. If Mohammad exhibits cyanosis, what are the appropriate steps to take?

Describe how Mohammad’s diagnoses may affect his voice, speech, and associated occupational
performance.

What assistive technologies and adaptations might be used or made for Mohammad while he is receiving
occupational therapy services? Why?

1. Mohammad frequently asks to take a break during the therapy session to pray. How would these breaks
affect the occupational therapy process?
2. Mohammad informs you that he is being provided with meals that are not Halal. How would this sit-
uation be addressed?
3. You have been asked to titrate Mohammad’s oxygen. Is this within the scope of practice?
PHARMACOLOGY
Mohammad is currently taking Duaklir.

1. Given Mohammad’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the Borg RPE Scale?
5. What is the reliability of the Borg RPE Scale?
6. What is the validity of the Borg RPE Scale?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Mohammad’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Mohammad to de-
termine whether it is appropriate for him to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Mohammad and
members of the interprofessional team. Review the needs of Mohammad, caregivers, family members, and
REFERENCES
Borg, G. A. (1982). Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14, 377–
381. https://doi.org/10.1249/00005768-198205000-00012
Williams, N. (2017). The Borg Rating of Perceived Exertion (RPE) Scale. Occupational Medicine, 67, 404–405. https://
doi.org/10.1093/occmed/kqx063
Home and Community Health SECTION VI
203
25
Eileen: Amyotrophic Lateral Sclerosis

Eileen (she, her, hers, herself)
MEDICAL HISTORY
Eileen is a 57-year-old Irish American female who is 5' 1" and weighs 103 pounds. She was wheeled into
the emergency department by her husband. She reported experiencing fever and chills for 3 days. Blood
tests, urine tests, X-rays, and pulse oximetry were done. She reported receiving a diagnosis of amyo-
trophic lateral sclerosis (ALS) 1.5 years prior and has no other significant medical history. She reported no
alcohol, tobacco, or drug use but reported consuming up to 5 cups of coffee per day. Eileen has no known
allergies. She received a diagnosis of aspiration pneumonia and was transferred to a medical floor, where
she received a course of intravenous antibiotics.
SOCIAL HISTORY
Eileen lives with her recently retired husband and adult son. They live in a three-bedroom ranch with
two bathrooms, one of which is wheelchair accessible. Eileen recently moved into this home after her
diagnosis of ALS. Eileen has a twin sister Maureen, two brothers, and another adult son serving in the U.S.
Marines. She identifies as a Catholic.
Eileen was transferred home with home and community health care services. She has been referred for
occupational therapy, physical therapy, social work, and registered nursing services. The length of stay
will be 4 weeks.
205
Occupational Therapy Initial Evaluation Findings:

Community Health Care Services
Eileen’s preadmission occupational history and experiences included being dependent in all ADLs
and all IADLs. Eileen has been an occupational therapist for more than 30 years. She provided
home health occupational therapy services for most of her career before she retired early as a result
of the progression of her illness. Eileen has a bachelor’s degree in occupational therapy and had
worked for several years as an adjunct faculty member.
Her most common pattern of daily living includes waking up at 7:00 a.m., being washed and fed
by her husband, and then being transferred into her manual wheelchair for a stroll through their
quiet suburban neighborhood. A private aide usually stays with her in the afternoons while her
husband performs chores. In the early evening, she is fed, washed, and transferred into bed by her
husband, where they watch television together.
Her interests include spending time with her family and close friends. She values her family,
Irish heritage, strong Catholic faith, and the little time she has left. Eileen reported her greatest
needs are not to be a burden to her husband and not to be placed on a ventilator or a feeding tube.
She has asked her husband and close family members if they ever see her choking or struggling to
breathe, to please leave the room for 15 minutes before returning.
ADLs
Regarding self-care, Eileen was dependent for all feeding, grooming, dressing, bathing, and toi-
leting. She was observed to have frequent coughs and notable gurgling while being fed soup. The
ALS Functional Rating Scale−Revised (ALSFRS−R; Cedarbaum et al., 1999) was administered, and
a score of 18/48 was achieved. Regarding functional mobility, Eileen was dependent for all bed
mobility, transfers, functional ambulation, and wheelchair use. Her husband physically transfers
Eileen between the bed and wheelchair and power recliner.
IADLs
Eileen was unable to manage her cellphone, text, browse the Internet, manage money, and care for
her home. Regarding rest and sleep, Eileen reported difficulty falling asleep when placed in a su-
pine position and reported finding it very difficult to breathe.
MENTAL FUNCTIONS
Cognitive assessment found Eileen to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. She was able to make her needs known. Affect as-
sessment indicated that Eileen felt sad but was accepting of impending death. No gross deficits in
perception were observed.
EILEEN: AMYOTROPHIC LATERAL SCLEROSIS | 207

cutaneous functions. Eileen reported no pain.

Eileen’s oxygen saturation while seated in her wheelchair, erect, was 94% on room air. Her respira-
tion rate was 24 breaths per minute.
MOVEMENT FUNCTIONS
Passive range of motion in all extremities was within defined limits. The manual muscle test in-
dicated strengths of 2−/5 in all groups in both upper extremities and in both lower extremities.
Assessment of fine motor (prehension) abilities indicated that Eileen was unable to form gross
grasp and pinch patterns.
Eileen required external support to maintain a short sitting position. She was dependent in stand-
ing. Muscle tone in all extremities was hypotonic, and all deep tendon reflexes were depressed.
PLAN FOR DISCHARGE

Eileen will be discharged to the care of her husband and private aide.

1. When working with a client with ALS, what precautions and contraindications must be considered?
2. Create a handout that identifies feeding precautions for people with dysphagia.
3. Compare and contrast aspiration pneumonia with pneumonia.
4. Eileen is at high risk for developing a decubitus ulcer. Explain why. Identify the areas of her body at
greatest risk. How can these ulcers be prevented?
5. Identify the common psychological reactions associated with ALS that may affect the treatment
process.
6. To keep Eileen and others safe, what other factors should be considered?
2. What areas of custodial care can be explored to ease the burden on her husband and private aide?
3. Eileen wishes to gain a higher level of independence with electronic communications with her friends
and family. How can this goal be addressed?
4. What recommendations would allow Eileen to have more restful and safer sleep?
Eileen’s occupational performance.

1. Identify Eileen’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Eileen’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Eileen’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Eileen’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Eileen’s current level of

1. How does Eileen view her illness? Provide evidence to support your view.
2. Identify your thoughts and emotions that were evoked while reading this case.
3. What challenges would you face working with a person who is terminally ill?

2. Compare and contrast ALS with Huntington’s disease.
3. Eileen’s muscle strength in her four extremities is 2−/5. Explain what this muscle grade is.
4. Should Eileen’s reduction in muscle strength be addressed through a remediation program? Why or
why not?
5. If Eileen’s extremities are not passively ranged on a daily basis, it will result in accommodative short-
ening of the muscles. Explain the physiology of accommodative shortening.
6. How can accommodative shortening interfere with the care being provided to Eileen?
7. Create an exercise program based on occupational performance for Eileen’s care providers.

2. Identify the normal values for oxygen saturation.
3. Make an inference concerning an oxygen saturation of 94%.
4. Identify the normal range of respiration at rest.
5. Compare and contrast the signs and symptoms of respiratory distress with respiratory failure.

1. During your initial evaluation, you found a decubitus ulcer with partial-thickness loss of the dermis
with a shallow opening in the skin. What stage does this description represent?
2. What would be your concerns?
3. What actions or actions need to be taken?

Describe how Eileen’s diagnoses may affect her voice, speech, and occupational performance.

What assistive technologies and adaptations might be used or made for Eileen while she is receiving oc-
cupational therapy services at home? Why?

1. Eileen has told you that if she begins to choke during your session, just leave the room; however, she
does not have a do not resuscitate or do not intubate order. How should you address this situation?
2. Should occupational therapy services be delivered to a terminally ill person? Why or why not?
3. Eileen was provided with a choice between home health services or hospice care upon discharge.
Compare and contrast home care with hospice care.
PHARMACOLOGY
Eileen is currently taking Radicava.

1. How may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the ALSFRS−R?
5. What is the reliability of the ALSFRS−R?
6. What is the validity of the ALSFRS−R?
7. What functional inference can be deduced from a score of 18/48?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Eileen’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Eileen to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Eileen and members
of the interprofessional team. Review the needs of Eileen, caregivers, family members, and significant
REFERENCES
Cedarbaum, J. M., Stambler, N., Malta, E., Fuller, C., Hilt, D., Thurmond, B., & Nakanishi, A. (1999). The ALSFRS–R:
A revised ALS functional rating scale that incorporates assessments of respiratory function. Journal of the
Neurological Sciences, 169, 13–21. https://doi.org/10.1016/S0022-510X(99)00210-5
26
José: Alcohol Abuse

José (he, his, him, himself)
MEDICAL HISTORY
José is an 81-year-old Salvadoran American male who is 5' 6" and weighs 140 pounds. He fell in his home
and was found by his son on the apartment floor with a deep laceration on his forehead. He was driven to
the emergency department, where a physical examination, electrocardiogram, magnetic resonance imag-
ining, and urine and blood tests were performed. Blood tests indicated that he was intoxicated. It was
determined that José’s fall was attributed to tripping over an area rug in his home that he did not see.
José’s medical history includes diabetes mellitus, bilateral carpal tunnel syndrome, hypertension, and
poorly managed progressive primary open-angle glaucoma. He denied drug or tobacco use but reported
consuming 5 to 6 bottles of beer since the death of his wife and 2 to 3 cups of coffee daily. He also revealed
that he has not consistently followed his medication regimen. José has no known allergies.
SOCIAL HISTORY
José is a recent widow and lives alone in his three-bedroom, 8th-floor apartment in a city-owned building.
His wife Rosa lost her battle to cancer 6 months prior. He is a retired garment worker and has one son,
Edgar, who lives 5 miles from his home. Edgar and his wife are both employed and are raising their three
children. José is an observer of Dominican Santeria.
José was transferred home with community health care services. He has been referred for occupational
therapy, physical therapy, social work, registered nursing, and home health aide services. The length of
stay will be 5 weeks.
213

José’s preadmission occupational history and experiences included being independent in all ADLs
and requiring assistance with most IADLs. His most common pattern of daily living includes wak-
ing at 7 a.m., showering, and making breakfast of coffee and bread by 9:00 a.m. Since the death of
Rosa, his son Edgar would see him every Saturday morning to take him shopping, clean the apart-
ment, and help pay bills. José used to call Edgar each evening, but because José has a reduction in
vision and subsequent difficulty using his phone, Edgar now calls him. José spends most days lis-
tening to Latin music and going to the senior citizens center in his building with his friend Hector.
He receives meals from Meals on Wheels. José’s interests include reminiscing about when he lived
in El Salvador and playing bingo with Hector. He values the time and care he receives from Edgar
and reported that his greatest needs are to remain sober and not disappoint his family.
ADLs
Regarding self-care, José was independent in bathing, feeding, and toileting, but he reported feeling
unsatisfied with his ability to shave. Regarding functional mobility, José was able to independently
roll, transition between prone and supine, and transition from supine to short sit. In the area of
transfers, José was independent in sit-to-stand and toilet transfers; however, he reported feeling
unsafe transferring into his tub.
IADLs
José reported that he no longer feels safe using the oven or the stove. He expressed frustration that
he can no longer keep his home clean, pay his bills, use his phone, or search the Internet on his
computer. Regarding rest and sleep, José reported sleeping between 10 and 12 hours per day.
MENTAL FUNCTIONS
Cognitive assessment found José to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. He was able to follow three-step commands and make
his needs known. Affect assessment indicated that José was frustrated and at times angry over
needing help with his IADLs. No gross deficits in perception were observed.

No gross deficits were observed in hearing, vestibular, taste, smell, proprioceptive, and cutaneous
functions. A gross assessment of visual acuity using a Snellen Chart revealed 20/200 corrected
vision, and a Confrontation Test (Reader & Harper, 1976) to assess field of vision revealed tunnel
vision. José reported no pain.
JOSÉ: ALCOHOL ABUSE | 215

MOVEMENT FUNCTIONS
Passive range of motion, active range of motion, and muscular strength in all four extremities were
within normal limits. Prehension assessment indicated that José was able to effectively form the
hook, cylindrical, power, and spherical grasps. He was also able to effectively form lateral, tripod,
scissor, palmer, and tip-to-tip pinch patterns. An awkwardness in hand manipulation skills was
observed when he moved small objects between his palm and the tips of his fingers.
Both static and dynamic standing and sitting balance were normal. Muscle tone in all four extrem-
ities was normal. Reflex integration was grossly intact.
PLAN FOR DISCHARGE

José will be discharged into his own care and remain in his home.

1. Create a handout that identifies precautions that must be followed by people with progressive primary
open-angle glaucoma.
2. Given José’s laceration, what precautions must be considered?
3. Identify the risks associated with impaired cutaneous light touch and temperature sense in all digits.
Cite your source and justify your selection.
4. Identify the common emotional reactions associated with advancing glaucoma that may affect the
treatment process.
5. To keep José and others safe, what other factors should be considered?
2. How can José feel safer and become more independent in preparing meals using his stove and oven?
3. How can José clean his home more independently?
4. How can José become more independent in making calls on his phone?
5. How can José become more independent using his computer to search the Internet?
José’s occupational performance.

1. Identify José’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify José’s impoverished habits, routines, roles, and rituals that do not support valued occupations.
3. Identify José’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering José’s primary and secondary diagnoses, identify the related body structures.
Body Functions
structures.
2. Explain the relationships between the structural and functional factors and José’s current level of oc-

1. What strategies should be used if José becomes frustrated or angry during a therapy session?
2. Should a referral to another discipline be considered to help explore José’s feelings? If so, which
discipline?

2. Compare and contrast essential tremor with symptomatic palatal tremor.
3. Given José’s history of a fall, what measures can be taken to allow him to move about his home in a
safer manner?

2. Explain the physiological impact that anger and frustration have on heart rate, respiration rate, and
intraocular pressure. Cite your sources and justify your selections.

1. What is the most probable explanation for the impaired cutaneous light touch and temperature sense
in José’s digits? How can these conditions affect his occupational performance?
2. Identify risks that are associated with impaired cutaneous light touch and temperature senses.
3. What preventive measures can be taken to mitigate these risks?

Describe how José’s diagnoses may affect his voice, speech, and associated occupational performance.

What assistive technologies and adaptations might be used or made for José while he is receiving occupa-
tional therapy services at home? Why?

1. Upon reviewing the referral or prescription for occupational therapy services, you see it is not signed
by a doctor of medicine, or MD, but rather by a DO. What does DO stand for? Can occupational therapy
services be referred or prescribed by a DO?
2. José reports to you that he is not taking his medication because of a lack of funds. How should this
situation be addressed?
3. During your second visit, you observe that José’s right wrist is swollen. When asked about it, José tells
you that he tripped and fell the previous evening. He requests that you do not report it. How should
4. When you enter José’s apartment, you notice a strong odor of marijuana. He informs you that he
smokes it to reduce “eye pain.” How should this situation be addressed?
PHARMACOLOGY
José is currently taking Timolol eye drops.

1. Given José’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the Confrontation Test?
5. What is the reliability of the Confrontation Test?
6. What is the validity of the Confrontation Test?
7. What functional inference can be deduced from José’s score of corrected vision of 20/200?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for José’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask José to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with José and members of
the interprofessional team. Review the needs of José, caregivers, family members, and significant others.
REFERENCES
Reader, A. L., & Harper, D. G. (1976). Confrontation visual-field testing. JAMA, 236, 250−250. https://doi.org/10.1001/
jama.1976.03270030010002
27
Katrina: Huntington’s Disease

Katrina (she, her, hers, herself)
MEDICAL HISTORY
Katrina is a 38-year-old Georgian American female who is 5' 7" and weighs 129 pounds. Katrina was taken
to the emergency department (ED) by her daughter after falling and experiencing pain in her right wrist
and digits. After a physical examination and X-rays, she received a diagnosis of a right distal ulnar-radial
fracture. The fracture was manually reduced and externally fixated with a plaster cast. Katrina’s medical
history includes Huntington’s disease (HD), posttraumatic stress disorder from spousal abuse, hyperten-
sion, major depressive disorder, and aspiration pneumonia. Katrina reported no alcohol, drug, tobacco, or
caffeine use. She has no known allergies. From the ED, she was transferred to a medical floor for obser-
vation and discharge planning.
SOCIAL HISTORY
Katrina recently separated from her husband and has relocated with her two high school–aged daughters
to live with her 60-year-old mother. Katrina is presently on short-term disability from her telemarketing
managerial position at a well-known firm. Katrina has moved into her mother’s first-floor living space
with two bedrooms and one bathroom. Katrina’s daughters share a bedroom with their family golden
retriever. Her social support has narrowed to a single lifelong friend on whom she relies heavily for moral
support. Katrina was born into the Russian Orthodox church but reports not being active since being for-
mally diagnosed with HD.
Katrina was transferred home with community health care services. She has been referred for occupa-
tional therapy, physical therapy, social work, home health, speech, and registered nursing services. Home
services are prescribed for 6 weeks.
221

Katrina’s preadmission occupational history and experiences included needing assistance with
bathing, dressing, and toileting from her mother and children. Additionally, she relied on them to
shop, manage the home and medications, and care for their pet. Katrina had been employed for the
past 10 years at the telemarketing firm, where she had been promoted to a senior-level position
before she began short-term disability. She currently reports a need to apply for long-term dis-
ability. Her patterns of daily living most commonly included waking up at 5:00 a.m. and receiving
assistance for bathing and self-care from a family member. She was then assisted to her home of-
fice, where she worked remotely. While Katrina worked, her mother left for work and her daugh-
ters went to school. Upon returning from school, her daughters would feed and walk the dog and
prepare dinner. Katrina’s interests include online shopping and researching online forums for the
treatment of HD. She values her daughters and their education. She reported her greatest needs are
to increase her independence and to reduce the burden on her daughters.
ADLs
Regarding self-care, Katrina was able to manage loose-fitting, pull-over garments but required total
assistance for managing fasteners. In the area of feeding, Katrina required food and utensils to be set
up. During toileting, she needed moderate assistance to manage lower-body garments and hygiene.
For sleep and rest, Katrina reported experiencing insomnia and unrelenting fatigue. Regarding func-
tional mobility, Katrina was able to roll and transition between supine to short sitting independently;
however, she required either contact guard assistance or minimal assistance when transferring with-
out a device. She required the same level of assistance moving within her home.
IADLs
Katrina reported that she recently was no longer able to effectively use her voice to manage her
computer and phone. During the past several years, Katrina has relied on her daughters to care for
their dog, manage her appointments, and maintain the home. She has been unable to drive since ex-
periencing symptoms after her formal diagnosis. Katrina also relied on her daughters for shopping
and meal preparation. Regarding rest and sleep, Katrina reported a history of insomnia, difficulty
falling asleep, frequent nocturnal awakening, and often experienced daytime sleepiness.
MENTAL FUNCTIONS
Cognitive assessment found Katrina to be alert and oriented to person, place, time, and situation,
and long-term memory was intact. Her short-term memory was impaired. She presented with diffi-
culty in concentrating, planning, and sustaining attention. Assessment of affect found that Katrina
appeared angry and irritable toward the end of the evaluation. Katrina reported contemplating
KATRINA: HUNTINGTON’S DISEASE | 223
thoughts of suicide in the past but denied an active plan. No gross deficits in perceptual function
were observed.

cutaneous functions. Katrina reported pain in her right wrist as a 5 on the Numerical Rating Scale
(0−10). She described the pain as “throbbing and constant.”

Katrina’s resting vital signs were blood pressure of 156/90 mm Hg, heart rate of 92 beats per min-
ute, respiration rate of 22 breaths per minute, and temperature of 97.6°.
MOVEMENT FUNCTIONS
Katrina presented with choreiform movements of all extremities, torso, and head. An assessment
of active range of motion through observation revealed no gross deficits in all extremities. Her
dominant right wrist was immobilized in a fiberglass cast and unable to be assessed. Her right hand
presented as edematous and was only able to form 75% of a gross grasp. An assessment of muscle
strength was unable to be performed, but she was able to mobilize all extremities against gravity.
Katrina’s static and dynamic sitting balance were fair (F)+, and her standing static and dynamic
were F−. She presented with involuntary bilateral ocular movements, impaired coordination, slow
repetitive movements, and abnormal posturing. She reported experiencing frequent painful mus-
cle spasms, difficulty swallowing, and difficulty effectively verbally communicating. The Johns
Hopkins Fall Risk Assessment Tool (JHFRAT; Poe et al., 2005) was administered, and a score of 12
was obtained.
PLAN FOR DISCHARGE

Upon discharge, Katrina will remain at home with long-term-care services.

1. Create a handout that identifies precautions for people at high risk for aspiration pneumonia.
2. Is Katrina a fall risk? Identify three tools to assess fall risk. Evaluate them and determine which would
be most appropriate in this case.
3. Identify precautions to consider when working with people at high risk for a fall.
4. Katrina exhibits involuntary movements. What precautions need to be followed during the perfor-
mance of ADLs?
5. Katrina has shared thoughts of suicide. How should this information be addressed?
6. Katrina is wearing a cast. Identify the risks related to wearing a cast. Explain how these risks can be
mitigated.
7. Identify the common psychological reactions associated with HD that may affect the treatment process.
8. To keep Katrina and others safe, what other factors should be considered?
2. What positional strategies would you recommend for self-feeding for Katrina?
3. Compare and contrast occupational therapy with speech-language pathology regarding the scope of
practice for each for self-feeding.
4. Identify the forms of caregiver education that would be necessary for reducing Katrina’s risk of falls
during functional mobility tasks.
5. How can Katrina maximize her engagement in self-care given her progressive condition?
Katrina’s occupational performance.
mote, establish/restore, maintain, modify, and prevent. How can you make use of this information?

1. Identify Katrina’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Katrina’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Katrina’s dominating habits, routines, roles and rituals that interfere with her valued occupa-
CLIENT FACTORS
Body structures
Considering Katrina’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Katrina’s current level of

1. How can major depressive disorder exacerbate the symptoms of HD?
2. Katrina was observed to be angry and irritable during the end of the evaluation. How could this obser-
vation affect the delivery of treatment?
3. Katrina exhibited impairment of her short-term memory. How will this impairment affect your choice
of instruction during treatment?
4. Given that Katrina has difficulty sustaining attention, how would you organize the environment to
minimize distractions?

2. Compare and contrast choreiform with athetoid movements.
3. People with HD commonly experience significant weight loss. Explain why.
4. What recommendations can be made to minimize the risk of falls in the home?
5. Create an exercise program based on occupational performance for Katrina.

2. Do you foresee accurately obtaining Katrina’s vital signs? Explain why or why not.
3. Identify the signs and symptoms of aspiration.
4. Compare and contrast aspiration pneumonia with viral pneumonia.

1. What are the signs and symptoms of an improperly fitted cast?
2. How can skin integrity be compromised by involuntary movement?

Describe how Katrina’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Katrina while she is receiving oc-
cupational therapy services at home? Why?

1. Katrina has recently stated, “Life is not worth living.” How should this statement be addressed?
2. During treatment sessions, Katrina frequently asks you for marital advice. How should you respond?
3. As you left Katrina’s home after a treatment session, her mother approached you. She shared feeling
overwhelmed and emotionally drained. How should this situation best be addressed?
PHARMACOLOGY
Katrina is currently taking Celexa.

1. Given Katrina’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the JHFRAT?
5. What is the reliability of the JHFRAT?
6. What is the validity of the JHFRAT?
7. What functional inference can be deduced from Katrina’s score of 12?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Katrina’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Katrina to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Katrina and mem-
bers of the interprofessional team. Review the needs of Katrina, caregivers, family members, and signifi-
REFERENCES
Poe, S. S., Cvach, M. M., Gartrell, D. G., Radzik, B. R., & Joy, T. L. (2005). An evidence-based approach to fall risk
assessment, prevention, and management: Lessons learned. Journal of Nursing Care Quality, 20, 107−116. https://
doi.org/10.1097/00001786-200504000-00004
28
Ivy: SARS-CoV-2 (COVID-19)

Ivy (she, her, hers, herself)
MEDICAL HISTORY
Ivy is a 66-year-old Nigerian American female who is 5' 2" and weighs 195 pounds. She was brought into
the emergency department (ED) by her family after a complaint of persistent coughing and difficulty
breathing. While in the ED, she was placed on oxygen through a nasal cannula. She had an oral tem-
perature of 102.6° and reported a loss of smell and taste. Ivy was given a reverse transcription real-time
polymerase chain reaction test, which confirmed that she was positive for the 2019 novel coronavirus
(COVID-19). A high-resolution computed tomography scan was performed and revealed acute and orga-
nizing diffuse alveolar damage. Her medical history included obesity, chronic asthma, and osteoarthritis
in both knees. She reported no alcohol, drug, tobacco, or caffeine use. No allergies were reported. Ivy was
transferred to the general medical service ward, where she was treated for 22 days.
SOCIAL HISTORY
Ivy is employed as an office manager and disclosed that she plans to retire in 1 year. She lives with her
spouse, Tricia, of 10 years in a seventh-floor apartment. Tricia has been retired for 2 years. Tricia has a
son, who visits often with his two children, ages 10 and 13. All members of the family have been COVID-19
tested and reported being negative. Ivy identifies as a member of the Baptist faith.
Ivy was transferred home with community health care services. She has been referred for occupational
therapy, physical therapy, social work, and registered nursing services. Home health services are pre-
scribed for 4 weeks.
229

Ivy’s preadmission occupational history and experiences included being independent in all ADLs
and all IADLs. Her patterns of daily living most commonly included waking up at 5:00 a.m., taking
the train, and arriving at work by 8:00 a.m. At home, she enjoyed cooking and did most of the gro-
cery shopping and meal preparation. Tricia performed most of the house cleaning and paid the
bills. Ivy enjoyed walking with Tricia at least 3 times per week in the neighborhood park. On the
weekends, they enjoyed going to the movies or local comedy shows. Ivy’s interests include cooking
meals from different cultures, and she values her marriage and spending time with Tricia’s grand-
children. She reported her greatest need is to return to work at full capacity.
ADLs
Regarding self-care, Ivy was able to dress while sitting at the edge of the bed but required assistance
with setup and frequent rest breaks. Ivy was independent in toileting and could feed herself while
taking incremental breaks. She reported needing assistance from Tricia to sponge bathe. Regarding
functional mobility, Ivy was able to roll from supine to her right and left side as well as transition
between supine and sit and bridge in a slow effort-filled manner. She was able to transition from
short sitting to stand and perform transfers with an adult rolling walker with minimal assistance.
IADLs
At the time of the evaluation, shopping, meal preparation, and care of the home were being per-
formed by Tricia. Ivy reported feeling uncomfortable with technology used for financial man-
agement, such as online banking and bill paying. Ivy required assistance to manage the oxygen
concentrator. Regarding rest and sleep, Ivy reported that since her diagnosis she had been experi-
encing insomnia, excessive sleepiness, restless leg syndrome, and nightmares.
MENTAL FUNCTIONS
Cognitive assessment found Ivy to be alert and oriented to person, place, time, and situation, and
long-term memory was intact. She reported having difficulty with short-term memory for 1–2 years
before admission. She was able to follow three-step commands and make her needs known. Affect
appeared appropriate, but she expressed regret that she declined COVID-19 vaccination. No gross
deficits in perception were observed.
SENSORY FUNCTIONS
No gross deficits were observed with hearing, vestibular, smell, proprioceptive, and cutaneous
functions. Ivy reported diminished taste and smell. Visual, tactile, and auditory functions were
IVY: SARS-COV-2 (COVID-19) | 231
grossly intact. The Numerical Rating Scale (0−10) revealed a pain score of 5 in both knees and a
6 for a Stage 2 decubitus ulcer located over her coccyx. The pain was described as “excruciating.”

Ivy frequently complained of fatigue and shortness of breath. Her oxygen saturation at rest was 91%
and with supplemental oxygen was 96%. The Borg Rating of Perceived Exertion Scale (Mathias et
al., 1986) was completed by Ivy, and she reported a score of 11 during dressing while seated and 14
during tub transfers.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion in all four extremities were within normal
limits. Muscle strength in both upper extremities (BUE) and both lower extremities was 3+/5.
Coordination for BUE was within defined limits. Fine motor abilities were intact for gross grasp,
fine pinch, and in-hand manipulation.
Ivy’s static and dynamic sitting balance were good. Her static standing balance was fair (F)+, and
her dynamic standing balance was F. Ivy’s muscle tone in all four extremities was normal, and re-
flex integration was grossly intact. The Timed Up and Go (TUG) Test (Podsiadlo & Richardson,
1991) was administered, and Ivy completed it in 17 minutes.
PLAN FOR DISCHARGE

Upon discharge, Ivy will transition to outpatient rehabilitation services. She will receive occupa-
tional and physical therapy.

1. According to current Centers for Disease Control and Prevention guidelines, what precautions must
be followed when working with a person with active acute symptoms of COVID-19?
2. Create a handout identifying the early signs and symptoms of a COVID-19 infection.
3. Ivy is currently using supplemental oxygen. How is the optimal flow rate determined? What precau-
tions must be followed?
4. Identify the signs and symptoms of respiratory distress.
5. Identify the common emotional reactions associated with a COVID-19 infection that may affect the
treatment process.
6. To keep Ivy and others safe, what other factors should be considered?
2. Ivy wishes to bathe in the tub. What recommendations would you make?
3. Ivy wants to know when it would be safe to resume sexual relations with her partner. How should you
proceed?
4. How would you incorporate energy conservation or work simplification concepts for this case?
Ivy’s occupational performance.

1. Identify Ivy’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Ivy’s impoverished habits, routines, roles, and rituals that do not support valued occupations.
3. Identify Ivy’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Ivy’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Ivy’s current level of oc-

1. Ivy reports feeling frustrated with her slow recovery. How should her frustration be addressed?
2. Identify mental health concerns that have been associated with people who have been infected with
COVID-19. Identify your sources.
3. At each session, Ivy pressures you to provide an estimated time frame for when she can return to work.
How should this situation be addressed?

2. Compare and contrast muscular fatigue with cardiovascular fatigue.
3. Identify three fall risk assessment tools that would be appropriate for the home care practice setting.
Evaluate them and select one. Defend your selection.
4. Create a list of recommendations to minimize risk of falls within the home.
5. Create an exercise program based on occupational performance for Ivy.

2. Identify the expected range of oxygen saturation levels for an adult population. Reference your source.
3. People with respiratory diseases commonly experience shortness of breath after the consumption of
large meals. Explain why.
4. Compare and contrast supplemental oxygen with ventilator support.
5. Compare and contrast asthma with bronchitis.

1. What are the signs and symptoms of cyanosis?
2. What actions must be taken when signs or symptoms of cyanosis are observed?
3. What considerations should be made given the presence of the Stage 2 decubitus ulcer over Ivy’s
coccyx?

Describe how Ivy’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Ivy while she is receiving occupa-
tional therapy services at home? Why?

1. Ivy reports that before your arrival, she had a fall. What are the appropriate steps that must be taken?
2. During a treatment session, you observe Ivy’s partner Tricia spanking her grandchild. How should this
situation be addressed?
PHARMACOLOGY
Ivy is currently taking albuterol.

1. Given Ivy’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the TUG Test?
5. What is the reliability of the TUG Test?
6. What is the validity of the TUG Test?
7. What functional inference can be deduced from Katrina’s performance time of 17 minutes?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Ivy’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Ivy to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Ivy and members of
the interprofessional team. Review the needs of Ivy, caregivers, family members, and significant others.
REFERENCES
Mathias, S., Nayak, U. S., & Isaacs, B. (1986). Balance in elderly patients: The “Get-Up and Go” Test. Archives of
Physical Medicine and Rehabilitation, 67, 387–389.
Inpatient Behavioral Health SECTION VII
Hospital or Unit
237
29
Zoran: Depression
Zoran (he, him, his, himself)
MEDICAL HISTORY
Zoran is a 63-year-old German American male who is 5' 9" and weighs 210 pounds. He was taken to the
emergency department by emergency medical services after a suicide attempt. Upon arrival, he presented
with a self-inflicted laceration of his right distal anterior forearm at his wrist. He was rushed into surgery
and had a repair of tendons of flexor digitorum profundus, flexor digitorum superficialis, flexor digito-
rum, flexor carpi radialis longus, flexor carpi radialis longus, and flexor carpi radialis brevis, as well as the
radial artery and radial nerve. In the recovery room, he was seen by psychiatry and diagnosed with major
depressive disorder (MDD). His medical history included hypertension, high cholesterol, and surgical
repair of a hernia. He reported no drug, tobacco, or caffeine use, but he reported heavy alcohol use after
his wife’s passing. Zoran also has a history of sleep apnea but does not use any sleep aids. He has no known
allergies or behavioral health history. From the surgical recovery room, he was involuntarily transferred
to the inpatient behavioral health unit.
SOCIAL HISTORY
Zoran is a bus driver who owns and lives in a two-story, two-family brownstone. He planned to work until
age 66 years, so he could collect maximum Social Security benefits. He and his spouse, Edna, both became
infected with the 2019 novel coronavirus. Zoran survived and Edna did not. Zoran blames himself for his
wife’s death. He stated, “I brought that [expletive] virus home.” He has one child, an engineer who lives in
California. Zoran reported enjoying visits to his weekend home in the mountains and spending time with
friends and family. Zoran is an observer of the Yazidi religion.
Zoran was transferred to an inpatient behavioral health unit. He has been referred for occupational ther-
apy, physical therapy, social work, psychology, and registered nursing services. He will also be seen by a
second occupational therapist who is a certified hand therapist from the Department of Physical Medicine
and Rehabilitation. The length of stay will be 4 weeks.
239

Inpatient Behavioral Health Unit
Zoran’s preadmission occupational history and experiences included being independent in all
ADLs and IADLs. His patterns of daily living most commonly included waking on weekdays at 6:00
a.m., making himself breakfast, and working the 7:00 a.m. to 3:00 p.m. shift. He has been driving
the same route for more than 25 years. He usually returns home by 4:00 p.m. and then cooks din-
ner. Edna usually returned home at 6:00 p.m. from work, and then they ate together. Most evenings
were spent sitting in the yard, watching television, or doing household chores. Each Friday night,
they would load up their car and head to their mountain home for the weekend. Zoran’s interests
include fishing, and he values spending time with those he cares about and being surrounded by
nature. He stated, “I am a creature of habit. Routines make me comfortable.” Zoran reported his
greatest need is to get out of the “psych hospital.”
ADLs
Regarding self-care, when Zoran was seen for the initial evaluation, he was sedated. His hair was
uncombed; his breath reeked; and he wore a stained sweatshirt, pants, and sneakers. The pants and
sneakers did not have laces. It was reported by the nurse that Zoran had declined being washed
up and eating since his arrival. His right hand was placed in a thermoplastic dorsal block splint.
Regarding functional mobility, Zoran was observed rolling and transitioning from supine to short
sit independently. He required close supervision to transfer between bed and chair.
IADLs
Information pertaining to this area was unable to be gathered at the time of the initial evaluation.
Regarding rest and sleep, the medical chart indicated that since Zoran’s arrival, he had been fre-
quently found in bed asleep during unstructured times on the unit. Medical records indicate a his-
tory of sleep apnea.
MENTAL FUNCTIONS
Cognitive assessment found Zoran to be alert and oriented to person, place, time, and situation, and
short- and long-term memory were intact. He was able to follow three-step commands and make
his needs known. Assessment of Zoran’s affect revealed flat affect and answering questions slowly
using short responses. His eyes remained fixed to the ground, and he seldom made eye contact.
The following statement was repeated three times, “All this is just a big waste of time. I just want
to die.” No gross deficits in perceptual function were observed. The Beck Depression Inventory–II
(BDI–II; Beck et al., 1996) was administered, and a score of 22 was obtained.
ZORAN: DEPRESSION | 241

functions. Zoran was evaluated using the Numerical Rating Scale (0–10) and reported that the
pain in his right hand was a 7. The pain was described as “unbearable.” He also reported that his
right hand felt “numb.” No gross cutaneous sensory testing was performed at the time of initial
evaluation.

Zoran’s vital signs were as follows: heart rate at 61 beats per minute, respiration rate at 12 breaths
per minute, and blood pressure at 96/60 mm Hg.
MOVEMENT FUNCTIONS
Passive range of motion and active range of motion in all extremities were within normal limits.
The right wrist and digits were not assessed. Zoran is right-hand dominant and held his right upper
extremity in a guarded position.
While seated Zoran slouched in his chair, and while standing he required close supervision to
transfer and ambulate. Static and dynamic sitting balance were estimated to be Fair (F)+ and static
and dynamic standing balance were F−. Muscle tone was normal, and reflex integration appeared
intact.
PLAN FOR DISCHARGE

Zoran will be discharged to the care of a community-based psychiatrist, psychologist, and occupa-
tional therapist.

1. Given Zoran was placed on suicide watch, what precautions must be followed?
2. Create a handout that identifies the precautions and contraindications that must be followed regard-
ing the surgical repairs made to Zoran’s right wrist.
3. Identify three up-to-date, reliable, and valid sources to obtain precautions for working with clients
with MDD. Evaluate them, select the strongest source, and justify your selection.
4. Identify the common emotional reactions associated with an unsuccessful suicide attempt that may
affect the treatment process.
5. To keep Zoran and others safe, what other factors should be considered?
2. This case presents the unusual circumstance of two occupational therapists working with the same
client in the same institution. Create a list that identifies the roles and responsibilities of each occupa-
tional therapist.
3. Zoran is right-hand dominant. What areas of basic ADLs do you believe Zoran will have difficulty per-
forming as a result of his right hand being immobilized and his pain level of 7 in that extremity?
4. In the context of delivering occupational therapy services on a behavioral health unit, will your inter-
action and intervention with Zoran be delivered in a group format, individually, or a combination of
both?
5. Which of Zoran’s problems may be addressed in a group format?
6. What makes a group run by an occupational therapist distinctly different from one run by a social
worker, recreational therapist, or psychologist?
7. Which of Zoran’s problems may be addressed in an individual session?
Zoran’s occupational performance.

1. Identify Zoran’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Zoran’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Zoran’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Zoran’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Zoran’s current level of

1. Compare and contrast the rate of suicide attempts between males and females.
2. Create a handout identifying the signs and symptoms of MDD.
3. Explain the chemical changes that occur in the brain as a result of MDD.
4. Identify and select a model(s) or frame(s) of reference you would use to treat Zoran. Support your
selection(s).
5. Given the information provided, what other mental function considerations need to be addressed?

2. What forms of nonverbal communication would indicate that Zoran’s condition is improving?
3. What forms of nonverbal communication would indicate that Zoran’s condition is worsening?
4. Create an exercise program for Zoran based on occupational performance.

2. Provide your insights on Zoran’s vital sign measurements.
3. When Zoran transitions from sitting to standing, he usually closes his eyes and braces his body. Given
his resting blood pressure, what would be your concern?

You observe the tips of Zoran’s right fingers protruding from the applied splint. What physical signs and
reported symptoms would suggest a poorly fitted device?

Describe how Zoran’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Zoran while he is receiving oc-
cupational therapy services on the behavioral health unit? Why?

1. You observe Zoran trying to remove his applied splint. How should this situation be addressed?
2. Zoran asked you if you could leave him one of the plastic knives from the occupational therapy area.
How should this request be addressed?
3. One of the residents on the ward informs you that they find you attractive. How should this situation
be addressed?
4. Explain the concept of transference.
5. You glance into a patient room, and you observe two patients engaging in sexual intercourse. How
PHARMACOLOGY
Zoran is currently taking Lexapro.

1. Given Zoran’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the BDI–II?
5. What is the reliability of the BDI–II?
6. What is the validity of the BDI–II?
7. What functional inference can be deduced from a score of 22?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Zoran’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Zoran to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Zoran and members
of the interprofessional team. Review the needs of Zoran, caregivers, family members, and significant
REFERENCES
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory−II. Psychological Corp.
30
Gabriela: Bipolar Disorder

Gabriela (she, her, hers, herself)
MEDICAL HISTORY
Gabriela is a 22-year-old female Honduran citizen residing in the United States. She is 5' 4" and weighs
119 pounds. Her concerned coworkers took her to the emergency department after she experienced a
manic breakdown at her workplace. Gabriela’s colleagues reported that she was hyperactive for a period
of 2 days, laughing uncontrollably and “appearing very off from her usual self.” She was evaluated by a
psychiatrist, who recommended an inpatient stay in the behavioral health unit, which Gabriela agreed to.
Gabriela’s medical history includes treatment for posttraumatic stress disorder (PTSD), bipolar disorder
type I (BPD), and chronic sciatica. She reported no drug and tobacco use but occasional use of alcohol
during social occasions and stated that she is an avid coffee drinker. Gabriela has no known allergies.
SOCIAL HISTORY
Gabriela enlisted in the U.S. Army when she was 20 after completing her associate’s degree in psychology
from a local institution. She served 6 years, and since her discharge from the army, she has been employed
full time as an administrative assistant at a community college. She is also pursuing a bachelor’s degree
in psychology. She resides with her boyfriend Jason and their two dogs in a two-bedroom apartment.
He is employed full time as an armed guard transport officer. Jason is currently taking online courses to
complete his bachelor’s degree. All of Gabriela’s family lives in Honduras. Gabriela identifies as Catholic.
Gabriela was transferred to the inpatient behavioral health unit of her regional Veterans Administration
(VA) hospital. She has been referred for occupational therapy, physical therapy, social work, psychology,
and registered nursing services. The length of stay will be 4 weeks.
247

Gabriela’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Her patterns of daily living most commonly included leaving for work at 7:00
a.m. and returning home by 6:00 p.m. She usually eats dinner that Jason prepares, then together
they take the dogs for a walk. Gabriela’s interests include dining out and weekend excursions. She
values time spent with Jason, pursuing her bachelor’s degree, and becoming a U.S. citizen. Her
greatest current needs are to restore her health and return to the activities she enjoys doing the
most.
ADLs
Regarding self-care, Gabriela was independent in feeding, grooming, toileting, and bathing. She
reported being up for 2–3 days at a time without bathing or sleeping. Regarding functional mobility,
no gross deficits in bed mobility, transfers, or functional ambulation were observed.
IADLs
Gabriella’s boyfriend had taken full responsibility for shopping, home management, finances, and
cooking. She reported that during her manic periods she texts excessively and spends a lot of time
on the Internet purchasing items that she does not need. Regarding rest and sleep, Gabriella re-
ported insomnia and not being able to obtain a night of restful sleep.
MENTAL FUNCTIONS
Cognitive assessment found Gabriela to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. Gabriela exhibited delays in insight and awareness,
sequencing, and problem solving. She stated that she was “unable to focus for long periods of time”
and that “little things” easily frustrated her. Assessment of affect was performed. Gabriela reported
frequently crying over emotional topics of conversation with her colleagues and boyfriend and
often finding it difficult to remember important activities such as taking her medications. Gabriela
was evaluated using the Global Assessment of Functioning (GAF; Aas, 2011) and received a score of
38. No gross deficits in perceptual function were observed.

cutaneous functions. Use of the Numerical Rating Scale (0–10) indicated a score of 5 for pain in
Gabriela’s lower back and of 2 after taking medication for the pain. The pain was described as
“jolting.”
GABRIELA: BIPOLAR DISORDER | 249

Assessment of cardiovascular and respiratory system functions indicated no deficits.
MOVEMENT FUNCTIONS
Active range of motion and passive range of motion were intact for both upper extremities and both
lower extremities. Fine motor abilities were intact for gross grasp, pinch, and in-hand manipulation.
Sitting and standing were within defined limits. Muscle tone was normal, and reflex integration
was grossly intact.
PLAN FOR DISCHARGE

Gabriela will be discharged home with follow-up psychiatric and psychological services at a VA
satellite site.

with mania. Evaluate them, select the strongest source, and justify your selection.
2. Create an informational handout that identifies common triggers that are associated with PTSD.
3. What activities and positions should be encouraged, and which should be avoided as a result of
Gabriela’s history of sciatica?
4. Identify the common emotional reactions associated with inpatient hospitalization that may affect the
treatment process.
5. To keep Gabriela and others safe, what other factors should be considered?
2. Prioritize the areas of occupation you have identified. Support your choices.
3. Select the top two areas of occupation from your list and provide strategies to address them.
Gabriela’s occupational performance.

1. Identify Gabriela’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Gabriela’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Gabriela’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Gabriela’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Gabriela’s current level of

1. Compare and contrast the affective signs and symptoms of BPD with those of PTSD.
2. Compare and contrast the cognitive and perceptual signs and symptoms of BPD with those of PTSD.
3. While working with Gabriela, what environmental considerations should be made? Justify your
selection.
4. While working with Gabriela, how would you effectively use the therapeutic use of self?

2. Should Gabriela’s sciatica be addressed in the behavioral health unit?

2. How may vital signs be affected when a person is experiencing a manic episode?
3. Explain how the “fight or flight” response is associated with PTSD.

What are some sympathetic skin changes that may occur during a manic or PTSD episode?

Describe how Gabriela’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Gabriela while she is receiving
occupational therapy services on the behavioral health unit? Why?

1. Gabriela reports that another patient on the unit has been making sexual advances toward her. How
would you address this situation?
2. Gabriela confides in you that she is attracted to her psychiatrist. How would you address this
disclosure?
3. Gabriella projects intimate and emotional feelings toward her health care providers. What phenome-
non could this represent?
PHARMACOLOGY
Gabriela is currently taking Latuda.

1. Given Gabriela’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the GAF?
5. What is the reliability of the GAF?
6. What is the validity of the GAF?
7. What functional inference can be deduced from Gabriela’s score of 38?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for this Gabriela’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Gabriela to deter-

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Gabriela and mem-
bers of the interprofessional team. Review the needs of Gabriela, caregivers, family members, and signifi-
REFERENCES
Aas, I. H. (2011). Guidelines for rating Global Assessment of Functioning (GAF). Annals of General Psychiatry, 10, 1–11.
31
Samuel: Schizophrenia
MARY DEVADAS, MS, OTR/L, DBA, AND KERRON BLUNTE, MS, OTR/L, CLT
Samuel (he, him, his, himself)
MEDICAL HISTORY
Samuel is a 62-year-old Black male who is 6' 1" and weighs 185 pounds. He was brought into the emergency
department (ED) by emergency medical services and accompanied by his wife, Ellen. Ellen stated that
her husband has been off his medication for 1–2 weeks, has not slept for the past 3 days, and was hearing
voices and speaking to people who did not exist. The voices were telling him he should kill himself. In the
ED, Samuel had blood drawn, received magnetic resonance imaging (MRI) of his head, and was assessed
by both a neurologist and a psychiatrist. He received a diagnosis of an acute psychotic episode secondary
to schizophrenia. MRI imaging indicated an atypical corpus callosum and cortical atrophy. Both a sed-
ative and an antipsychotic were administered in the ED. Samuel has a medical history of schizophrenia,
hypertension, diabetes mellitus, and tardive dyskinesia. Samuel has had four admissions to an inpatient
behavioral health unit since he was first diagnosed with schizophrenia; he was initially diagnosed with
undifferentiated schizophrenia because of a lack of positive symptoms His wife reported that there is no
caffeine, nicotine, alcohol, or substance use. He has no known allergies. Samuel was referred from the ED
to an inpatient psychiatric unit because of his positive symptoms.
SOCIAL HISTORY
Samuel has been married to Ellen for 35 years. They live in a fifth-floor condo in downtown Brooklyn. They
are the parents of two adult children and have four grandchildren. Samuel is a prominent self-employed
artist, and his studio is in his home. Samuel enjoys traveling with his wife, spending time with his chil-
dren and grandchildren, and teaching art at his community center as a volunteer. Samuel identifies as a
born-again Christian.
Samuel was transferred to an inpatient behavioral health unit. He has been referred for occupational ther-
apy, social work, psychology, and registered nursing services. The length of stay will be 10 days.
255

Samuel’s preadmission occupational history and experiences included being independent in all
ADLs and IADLs. He is a mixed-media artist best known for his oil paintings, pottery, and sculp-
tures. Samuel stated that, over the years, his ability to create a detailed oil painting has declined
because of tremors; however, he still enjoys other aspects of his work. His most common pattern
of daily living includes waking up at 8:00 a.m., cooking and sharing breakfast with his wife, and
then working in his home studio. He teaches 3 evenings per week at the community center. Other
interests include traveling, cooking, gardening, spending time with his family, and socializing with
friends. He values creating, sharing, and teaching art. His immediate goals are to return home and
resume his typical pattern of living.
ADLs
Regarding self-care, Samuel was independent in feeding and toileting. He was unshaven and poorly
groomed, and it was reported that he had not bathed in 5 days. His wife reported that Samuel had
not slept for 3 days before his ED visit. Regarding functional mobility, he had no gross deficits in
bed mobility but required supervision during transfers and functional ambulation since receiving
the sedative in the ED. The Barthel Index (Mahoney & Barthel, 1965) for ADLs was used to assess
Samuel’s ADL functioning and functional mobility.
IADLs
Samuel was assessed using the Kohlman Evaluation of Living Skills (KELS; Thomson & Robnett,
2016) tool and received a total score of 6.
MENTAL FUNCTIONS
Samuel exhibited disorganized thinking and speech, having difficulty staying on topic. He was ori-
ented to person and location but not time and situation. He acknowledged he was hearing voices.
His emotions shifted between calm, anger, and agitation.

Assessment of sensory functioning indicated that his vision, hearing, cutaneous, olfactory, and pro-
prioception were grossly intact. No pain was reported.
SAMUEL: SCHIZOPHRENIA | 257

No deficits in cardiovascular and respiratory system functions were observed. Vital signs during
the initial evaluation were blood pressure at 155/80 mm Hg, respiration rate at 16 breaths per min-
ute, and heart rate at 61 beats per minute.
MOVEMENT FUNCTIONS
Samuel presented with lip smacking and mild uncontrollable movements of his left hand. Range of
motion and muscle strength in all four extremities appeared to be within functional limits.
Muscle tone and reflex integration appeared intact. Samuel’s static and dynamic sitting balance
were 4/5, and his static and dynamic standing balance were 3+/5 according to a clinical assessment
of balance.
PLAN FOR DISCHARGE

Samuel will be discharged to the care of a community-based psychiatrist, psychologist, and occu-
pational therapist.

1. Identify precautions and contraindications when working with clients who are agitated.
experiencing psychosis. Evaluate them, select the strongest source, and justify your selection.
3. Create a handout that identifies the precautions and contraindications that must be followed when
interacting with a client who is experiencing psychosis.
4. To keep Samuel and others safe, what other factors should be considered?
action and intervention with Samuel be delivered in a group format, individually, or a combination of
both?
3. Which of Samuel’s problems may be addressed in a group format?
4. Identify the names and goals of patient intervention groups offered at your local inpatient behavioral
health facility.
5. What makes a group run by an occupational therapist distinctly different from one run by a social
6. Which of Samuel’s problems may be addressed in an individual session?
7. Would work or sleep be addressed? Support your decision.
Samuel’s occupational performance.

1. Identify Samuel’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Samuel’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Samuel’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Samuel’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Samuel’s current level of

1. Compare and contrast disorganized type schizophrenia with paranoid type schizophrenia.
2. Create a handout identifying the signs and symptoms of psychosis.
3. Search the literature for the etiology of schizophrenia. Briefly summarize your findings and cite your
sources.

2. What forms of nonverbal communication would indicate that Samuel’s condition is improving?
3. What forms of nonverbal communication would indicate that Samuel’s condition is worsening?

2. Given Samuel’s history of hypertension, what must be considered in relation to hematological, immu-
nological, or respiratory functions?

What should Samuel consider regarding his skin when he engages in gardening outdoors? Explain why.

Describe how Samuel’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Samuel while he is receiving

1. Samuel’s friend Janice, from the community center, has called the occupational therapist to inquire
about Samuel’s status. Janice stated that she is very concerned about Samuel and heard he is in the
hospital. Identify your options to maintain compliance with the Health Insurance Portability and
Accountability Act of 1996 (P. L. 104-191) when communicating with Janice. Support your options.
2. Samuel shares with you that he hates taking his antipsychotic medication. He states that it makes him
sleepy, numbs his emotions, and contributes to obsessive thoughts. How does this information make
you feel, what thoughts does it stimulate, and what action may be required?
PHARMACOLOGY
Samuel is currently taking Risperdal.


1. Given Samuel’s profile, how may your own culture and beliefs affect your interaction with him?
case.
1. What is the purpose of the KELS?

5. What is the reliability of the KELS?
6. What is the validity of the KELS?
7. What functional inference can be deduced from Samuel’s total score of 6?
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Samuel’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Samuel to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Samuel and mem-
bers of the interprofessional team. Review the needs of Samuel, caregivers, family members, and signifi-
REFERENCES
Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191, 42 U.S.C. § 300gg, 29 U.S.C. §§
1181–1183, and 42 U.S.C. §§ 1320d–1320d9.
Mahoney, F. I., & Barthel, D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14,
56–61.
Thomson, L. K., & Robnett, R. H. (2016). KELS: Kohlman Evaluation of Living Skills (4th ed). AOTA Press.
32
Emmanuel: Posttraumatic Stress Disorder

Emmanuel (he, him, his, himself)
MEDICAL HISTORY
Emmanuel is a 31-year-old Moroccan American male who is 6' 2" and weighs 173 pounds. He was admitted
to the behavioral health inpatient unit of the Veterans Administration (VA) hospital with a diagnosis of
posttraumatic stress disorder (PTSD) after a visit to his psychiatrist. Emmanuel reported that he had as-
saulted his wife and had convinced her not to report it. He complained of being anxious, having difficulty
sleeping, and experiencing vivid nightmares of being in combat. He expressed that he was “out of control”
and feared that he would hurt himself or his family. Emmanuel’s medical history includes PTSD, anxiety,
depression, alcohol abuse disorder, and suicide attempts. Emmanuel reported drinking 1–2 liters of bour-
bon per week but reported no drug, tobacco, or caffeine use. He has no known allergies.
SOCIAL HISTORY
Emmanuel is a veteran who was discharged medically with a diagnosis of PTSD after serving 10 years in
the U.S. Marine Corps. Since his discharge, he has not been able to work and is supported by his military
disability income. Emmanuel has been married to his wife Alia for 6 years. Alia is an elementary school
teacher, and together they have a 5-year-old daughter and reside in a two-bedroom townhouse. Socially,
Emmanuel engages in activities only with Alia’s friends and family. The family identifies as Shia Muslim.
Emmanuel was transferred to an inpatient behavioral health unit. He has been referred for occupational
therapy, physical therapy, social work, psychology, and registered nursing services. The length of stay will
be 30 days.
263

Emmanuel’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. His patterns of daily living most commonly included waking at noon, doing
chores around the house, and walking to pick up his daughter from school. Emmanuel joined the
Marines several years after graduating high school. Since being discharged from the military, he
spends most of his time at home and inconsistently attends a veterans support group that was rec-
ommended by his psychiatrist. He sometimes prepares dinner and helps his daughter with her
homework. Emmanuel’s interests include watching sci-fi movies and playing video games. He val-
ues spending time with his daughter and wife. Emmanuel’s goal is to be a better husband and father.
ADLs
Regarding self-care, Emmanuel was independent in feeding, dressing, grooming, toileting, and
bathing. Regarding functional mobility, no deficits in bed mobility, transfers, or functional ambula-
tion were observed.
IADLs
Before admission, Emmanuel was responsible for paying household bills, but because he missed
payments, his wife has taken over this task. He also reported that he is no longer able to partici-
pate in grocery shopping because he experiences feelings of anxiety in large and crowded spaces.
Regarding rest and sleep, Emmanuel reported a history of waking up frequently during the night,
having difficulty falling back to sleep, and waking up earlier than he intended. He frequently sleeps
on the living room couch because he disturbs his wife’s sleep by moving about, talking, and yelling
while asleep.
MENTAL FUNCTIONS
Cognitive assessment found Emmanuel to be alert and oriented to person, place, time, and situ-
ation, and short- and long-term memory were intact. He reported difficulty attending and being
easily angered. Assessment of affect was performed. Emmanuel expressed extreme remorse for
assaulting his wife. Emmanuel was evaluated using the Suicide Assessment Five-Step Evaluation
and Triage (SAFE–T; U.S. Department of Health and Human Services, 2009) assessment and scored
in the moderate range. No gross deficits in perception were observed.

cutaneous functions. Use of the Numerical Rating Scale (0–10) indicated a score of 0, or no pain.
EMMANUEL: POSTTRAUMATIC STRESS DISORDER | 265

Assessment of cardiovascular and respiratory system functions indicated no deficits.
MOVEMENT FUNCTIONS
Active range of motion and passive range of motion were intact in both upper extremities and both
lower extremities. Fine motor abilities were intact for grasp, pinch, and in-hand manipulation.
Movements were well coordinated.
Sitting and standing balance were within defined limits. Muscle tone was normal, and reflex inte-
gration was intact.
PLAN FOR DISCHARGE

Emmanuel will be discharged home with follow-up psychiatric and psychological services at a VA
satellite site.

1. What specific considerations should be made regarding Emmanuel’s history of suicide attempts?
2. Create a handout identifying the behavioral changes associated with nonrestorative sleep.
experiencing PTSD. Evaluate them, select the strongest source, and justify your selection.
4. Identify the common emotional reactions associated with the perpetration of spousal abuse that may
affect the treatment process.
5. To keep Emmanuel and others safe, what other factors should be considered?
2. Identify areas of occupation that Emmanuel needs to address.
3. Provide strategies for Emmanuel to obtain more restful sleep.
4. After discharge, Emmanuel wishes to participate in grocery shopping. Identify three methods that can
help him accomplish this goal.
5. Provide strategies to support Emmanuel’s engagement in the recommended VA support groups.
6. Emmanuel expressed a desire to once again take on the responsibility of managing household finances
along with his wife. How can this goal be best addressed?
Emmanuel’s occupational performance.
2. Which of these skills would be appropriate to address in this service delivery site? Justify your
selection.

1. Identify Emmanuel’s useful habits, routines, roles, and rituals that support valued occupations. How
2. Identify Emmanuel’s impoverished habits, routines, roles, and rituals that do not support valued occu-
3. Identify Emmanuel’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Emmanuel’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Emmanuel’s current level
of occupational performance.

1. Compare and contrast the affective signs and symptoms of PTSD with those of intermittent explosive
disorder.
2. Emmanuel reports being easy to anger. What environmental considerations should be made? Support
your selection.
3. Identify compensatory strategies that can be used to address Emmanuel’s deficit in attention.
4. Emmanuel expressed extreme remorse for assaulting his wife. How should remorse be addressed
within practice?
addressed?

2. Identify nonverbal indicators of anger.

2. Explain the relationship between the fight-or-flight response and PTSD.
3. Describe the long-term effects of alcohol abuse on these system functions.

What sympathetic skin changes may occur during an anxiety episode and a PTSD episode?

Describe how Emmanuel’s diagnoses may affect his voice, speech, and associated occupational
performance.

1. What assistive technologies or adaptations might be used or made for Emmanuel while he is receiving
occupational therapy services in the inpatient behavioral health unit? Why?

1. Emmanuel reported that his roommate snores loudly and stated, “I can’t take him anymore.” How
2. Do you have either a legal or an ethical responsibility to report that Emmanuel had assaulted his wife?
3. Walking by Emmanuel’s room, you overhear him pressuring his wife to bring in alcohol. How should
PHARMACOLOGY
Emmanuel is currently taking Zoloft.

1. Given Emmanuel’s profile, how may your own culture and beliefs affect your interaction with him?

1. What is the purpose of the SAFE–T assessment?
5. What is the reliability of the SAFE–T assessment?
6. What is the validity of the SAFE–T assessment?
7. What functional inference can be deduced from Emmanuel’s score of moderate?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Emmanuel’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Emmanuel to deter-
mine whether it is appropriate for him to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Emmanuel and
members of the interprofessional team. Review the needs of Emmanuel, caregivers, family members, and
REFERENCES
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
(2009). SAFE–T: Suicide Assessment Five-Step Evaluation and Triage. https://www.samhsa.gov/resource/dbhis/
safe-t-pocket-card-suicide-assessment-five-step-evaluation-triage-safe-t-clinicians
33
Andres: Alcohol and Substance Use

Disorders
Andres (he, him, his, himself)
MEDICAL HISTORY
Andres is a 57-year-old Colombian American male who is 5' 10" and weighs 138 pounds. He was electively
admitted to the behavioral health unit of his local hospital for treatment of alcohol and substance use dis-
orders. Upon admission, he reported drinking a minimum of a liter of vodka per day and snorting cocaine
daily for the past 3 months. His medical history includes relapsing alcohol and substance use disorders
for 10 years. Andres reported smoking one pack of cigarettes and drinking up to 10 cups of coffee daily.
Surgical history included gender reassignment and multiple facial cosmetic procedures over the past 15
years. Andres has no known allergies.
SOCIAL HISTORY
Andres has worked as an Internal Revenue Service forensic agent for the past 25 years and has been
able to maintain employment despite his long history of alcohol and substance use disorders. He lives
alone in a one-bedroom rented apartment, which is a 20-minute bus ride from his office; however, he
primarily works remotely. Andres had his driver’s license revoked 2 years ago as a result of a second
driving-while-intoxicated conviction. His current relationship is with Jill, whom he met at an Alcoholics
Anonymous meeting. Jill is also currently in a state of relapse. Andres has reported that his alcohol and
substance use has strained the relationship with his mother and three siblings and has depleted all his
savings and retirement funds. In the past, he spent most of his free time at bars and clubs and in Miami
vacationing. Andres identifies as a Pentecostal Christian.
Andres was transferred to an inpatient behavioral health hospital. He has been referred for occupational
be 30 days.
271

Inpatient Behavioral Health Hospital
Andres’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Andres holds a bachelor’s degree in accounting and a master of business ad-
ministration degree. As a forensic agent, he reported being extremely skilled at his job and has
received several commendations for his outstanding work. His patterns of daily living most com-
monly included waking up by 10:00 a.m. and working without break until 4:00 p.m., consuming
only coffee and cigarettes. Thereafter, he usually showered, went to dinner with friends, and would
begin to drink. His drinking would continue when he returned home and only stopped once he fell
asleep. Cocaine use was usually added to his drinking each Friday and Saturday evening. Andres
reported that if he continues his current lifestyle, he will most likely die young and further hurt his
family. Andres’s interests include watching detective movies and spending time with his family. He
reports his greatest needs are to stop using alcohol and drugs, learn to make better life choices, and
try to rebuild his relationship with his mom and three siblings.
ADLs
Regarding self-care, at the time of initial evaluation, Andres presented as well dressed and
groomed. He reported being independent in self-dressing, bathing, grooming, feeding, and toilet-
ing. Regarding functional mobility, Andres reported performing bed mobility, transfers, and func-
tional ambulation independently.
IADLs
Andres reported that he is able to independently manage his home, effectively communicate, shop,
and prepare meals. He reported having a negative effect on his mother’s emotional health, difficulty
managing his finances, and managing and maintaining his health. Regarding rest and sleep, Andres
reported being a light sleeper and repeatedly waking throughout the night.
MENTAL FUNCTIONS
Cognitive assessment found Andres to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. He was able to follow three-step commands and
make his needs known. He reported that his thoughts are filled with relentless cravings for alcohol.
He acknowledged the negative effect that alcohol has had on him but reported feeling helpless.
He was evaluated using the Revised Clinical Institute Withdrawal Assessment of Alcohol Scale
(CIWA–Ar; Sullivan et al., 1989) and received a score of 18. Affect appeared appropriate, and no
gross deficits in perception were observed.
ANDRES: ALCOHOL AND SUBSTANCE USE DISORDERS | 273

cutaneous functions. Pain was denied.

No gross deficits were observed.
MOVEMENT FUNCTIONS
Active range of motion in all four extremities, prehension, and in-hand manipulation skills were
within functional limits. Mild cerebellar tremors were observed in both hands, the right greater
than the left. Andres reported finding it “challenging” at times to manage fine fasteners.
Andres was able to maintain static and dynamic sitting and standing balance against maximal ex-
ternal resistance. His sitting and standing tolerance appeared to be sufficient to perform all tasks in
his identified roles. His muscle tone was normal.
PLAN FOR DISCHARGE

Andres will be discharged home and referred to a substance abuse counselor, clinical psychologist,
and psychiatrist.

1. Andres is receiving services on a locked behavioral health unit. Compare and contrast this setting with
a general medical unit.
2. Create a handout identifying the precautions that must be followed when working with a client who
abruptly stops using alcohol and cocaine.
3. Explain the detoxification process that Andres will most likely undergo.
4. To keep Andres and others safe, what other factors should be considered?
action and intervention with Andres be delivered in a group format, individually, or a combination of
both? Explain why.
3. What makes a group led by an occupational therapist distinctly different from one led by a social
4. What effect does substance or alcohol abuse have on sleep?
Andres’s occupational performance.

1. Identify Andres’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Andres’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Andres’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Andres’s primary diagnoses, identify the related body structures.
Body functions
1. Identify how the primary diagnoses have affected the function of the identified body structure.
2. Explain the relationships between the structural and functional factors and Andres’s current level of

1. Identify the focus of a psychiatrist, psychologist, social worker, nurse, recreational therapist, and oc-
cupational therapist working with a client experiencing alcohol and substance use disorders on a be-
havioral health unit.
2. Explain the chemical changes that occur in the brain that cause Andres to crave alcohol, cigarettes,
and cocaine.
3. Andres and Jill are in a codependent relationship. Explain codependency.

2. Identify observable signs and reported symptoms that would indicate that Andres is experiencing
withdrawal.
3. Identify at least two approaches to address the cerebellar tremors in both of Andres’s hands. Evaluate
them and select one. Defend your selection.

2. Describe the long-term effects of chronic alcohol, cigarette, and cocaine use on each of the follow-
ing functions: cardiovascular, hematological, immunological, and respiratory. Identify and justify your
sources.

What is the long-term effect of nicotine use on the skin?

Describe how Andres’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Andres while he is receiving

1. Andres is the first transgender person you have worked with. You have a sincere interest in under-
standing the process he underwent. Is this a topic that could be broached with Andres? Why or why
not? If yes, what would be the guiding principles to do so?
2. You see one of Andres’s visitors hand him a cigarette. You are aware that smoking is strictly prohibited
in the hospital. How should this situation be addressed?
3. One of your coworkers lets you know that he is one of Andres’s drinking buddies. He asked you not to
tell anyone. How should this situation be addressed?
PHARMACOLOGY
Andres is currently taking naltrexone.


1. Given Andres’s profile, how may your own culture and beliefs affect your interaction with him?
case.
1. What is the purpose of the CIWA–Ar?

5. What is the reliability of the CIWA–Ar?
6. What is the validity of the CIWA–Ar?
7. What does a score of 18 indicate?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Andres’s diagnoses.
Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Andres to determine

patterns.
modify, or prevent.

attention.

Create a plan for discharge from occupational therapy services in collaboration with Andres and mem-
bers of the interprofessional team. Review the needs of Andres, caregivers, family members, and signifi-
REFERENCES
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal:
The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA–Ar). British Journal of Addiction,
84, 1353–1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x
34
Brianna: Anorexia Nervosa

TIFFANY CORDERO-VELEZ, MS, OTR/L
Brianna (she, her, hers, herself)
MEDICAL HISTORY
Brianna is an 18-year-old Armenian American female who is 5' 10" and weighs 101 pounds. She was
taken to the school nurse, who noticed that Brianna appeared “gaunt.” She had blotches of dry skin, low
blood pressure, and complained of dizziness. The school nurse immediately called Brianna’s mom, Kate,
and suggested she take Brianna to the pediatrician. While at the pediatrician, Kate was directed to take
Brianna to a nearby emergency department (ED) for an evaluation. In the ED, Brianna was evaluated by
cardiology and neurology. Findings from both services were unremarkable. At that time, a psychiatric
evaluation was ordered and concluded that Brianna was experiencing anorexia nervosa. A recommen-
dation was made for an inpatient stay in the behavioral health unit, which was consented to by Brianna
and Kate. Medical history included nondiabetic hypoglycemia, two episodes of fainting, and a history of
purging. Since adolescence, Brianna has been below the norm for weight. Brianna reported allergies to
eggs, wheat, and nuts.
SOCIAL HISTORY
Brianna is a senior in high school and resides in a small town in South Carolina. She currently lives with
her parents and two younger twin sisters. Kate is an accountant, and Brianna’s father is a data analyst
and is very involved with work, leaving little time to spend with his family. Kate described Brianna as a
straight-A student who is internally motivated and highly competitive. She is a cheerleader, president
of the student government, and active member of the National Honor Society. However, Brianna’s aca-
demic performance has recently declined and she has become socially withdrawn. Brianna identifies as a
Christian and as bisexual.
Brianna was transferred to an inpatient behavioral health unit. She has been referred for occupational
be 10 days.
279

Brianna’s preadmission occupational history and experiences included being independent in all
ADLs and all IADLs. Brianna works at a local coffee cafe 15 hours per week over 3 days. Her pat-
terns of daily living most commonly included getting up at 6:30 a.m., skipping breakfast, arriving at
school by 8:30 a.m., attending classes until 2:30 p.m., and participating in extracurricular activities
until 4:30 p.m. Her interests include fashion and going to the gym as often as she can. Brianna used
social media platforms as an influencer and uses Instagram™ and TikTok™ to post fitness-related
content. She discloses that she is often careful of what she posts because she does not want to show
her “bad angles.” She values family traditions and prioritizes her appearance. Her current needs are
to return to school and the gym as soon as she can.
ADLs
Regarding self-care, findings revealed that Brianna struggled with balancing her ADLs because she
spent most of her time in physical activities rather than eating and preparing meals, as a means to
avoid eating. She was preoccupied with her weight and body image. She had difficulty choosing
what to wear, stating that she feels “fat” and “nothing fits right.” Regarding functional mobility, no
gross deficits in bed mobility, transfers, and functional ambulation were observed.
IADLs
Brianna reported that recently she has been having difficulty concentrating and organizing her
assignments and schedule. She sometimes forgot when assignments were due and took exams that
she was not prepared for. In food-related activities, Brianna spent most of her time preoccupied
with calorie counting. Regarding rest and sleep, the medical chart indicated that Brianna had a his-
tory of short sleep duration, low sleep quality, and inadequate time spent in restorative deep sleep
and REM sleep stages.
MENTAL FUNCTIONS
Cognitive assessment found Brianna to be alert and oriented to person, place, time, and situation,
and short- and long-term memory were intact. Throughout the interview, however, Brianna said
she was feeling tired and appeared lethargic. She was able to follow three-step commands and
make her needs known. Her affect appeared appropriate, and no gross deficits in perception were
observed.
Brianna reported that she is often preoccupied with the thought of food and plans her day in
a way to avoid food. She stated that she is careful about how many calories she consumes, trying
to limit herself to 500 a day, and that she avoids eating at social events that involve food. She also
reported that when she looks in the mirror she thinks she looks “fat” and uses this perception to
BRIANNA: ANOREXIA NERVOSA | 281
justify taking diet pills. Brianna has also been spending less time with her friends and engaging in
activities that she once enjoyed. Kate reported that Brianna was moody and irritable during family
gatherings. In addition, Brianna reported that in school she was having difficulty keeping up with
her assignments, making decisions, following directions, and staying awake in class. She was begin-
ning to worry because she knows that she will soon take the SAT for college admissions. Brianna
was assessed using the SCOFF (sick, control, one, fat, food) Questionnaire (Morgan et al., 2000) and
received a total score of 3.

cutaneous functions. Brianna described that her hands often feel cold despite the warm tempera-
tures outside. Kate reports that Brianna would often complain of abdominal pain and constipation
when confronted with skipping several meals.

Brianna’s resting heart rate was 48 beats per minute, blood pressure was 80/52 mm Hg, and res-
piration rate was 12 breaths per minute. During the interview, Brianna reported that she had been
feeling fatigued and dizzy since her admission to the ED.
MOVEMENT FUNCTIONS
Range of motion and muscle strength in muscle groups in all four extremities were within defined
limits (WDL). Fine motor abilities were WDL for grasp formation, pinch formation, and in-hand
manipulation.
Static and dynamic sitting and standing balance were WDL. Muscle tone was normal, and reflex
integration was grossly intact.
PLAN FOR DISCHARGE

Brianna will be discharged home and seen by a community-based psychiatrist and psychologist.

1. What forms of monitoring are required for Brianna’s blood pressure and heart rate levels?
2. Given Brianna’s body image, what types of activities should be avoided in therapy?
3. Is Brianna a fall risk? Support your answer.
with anorexia nervosa. Evaluate them, select the strongest source, and justify your selection.
5. Create a handout that identifies the precautions for working with clients with anorexia nervosa.
6. Identify the common emotional reactions associated with challenging a client’s strongly held belief
that may affect the treatment process.
7. To keep Brianna and others safe, what other factors should be considered?
2. How will Brianna keep up with her school assignments while in the behavioral health unit?
3. What coping strategies do you anticipate can be used to promote Brianna’s performance in her
occupations?
4. What are some home and school recommendations that you can give Brianna and her mother to help
her complete assignments on time?
5. Brianna avoids eating in the presence of others. How can this behavior be addressed?
Brianna’s occupational performance.
2. Which of these skills would be appropriate to address in this service delivery site? Justify your
selection.

1. Identify Brianna’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Brianna’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Brianna’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Brianna’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Brianna’s current level of

1. Identify the signs and symptoms of anorexia nervosa.
2. Create a plan to develop a therapeutic rapport with Brianna.
3. Brianna has a distorted body image. How may her perception affect her occupational performance?
4. Brianna has reported difficulty with time management. Identify three assistive technologies that may
allow her to manage her time more effectively.
addressed?

2. How can Brianna’s current endurance level affect her occupational performance?
3. Create an exercise program for Brianna based on occupational performance.

2. Explain how low caloric intake can affect vital signs and cognitive function.
SKIN AND RELATED STRUCTURE FUNCTION

What is the physiological explanation of Brianna’s dry blotchy skin as it relates to anorexia nervosa?

Describe how Brianna’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Brianna while she is receiving
occupational therapy services on the inpatient unit floor? Why?
2. What assistive technologies or adaptations might be recommended for when she returns home?
Why?

1. Brianna will miss school during her stay in the behavioral health unit. The psychiatrist calls the school
and speaks with the principal to negotiate a plan for an extension on assignments. The principal re-
quests a letter and wants to know what the reason for admission was. What act or law does providing
this information violate?
2. As you are walking to Brianna’s room to pick her up for group therapy, you hear her purging her break-
fast in the bathroom. What is the next step that you should take and who should be notified?
3. After a group therapy session, Brianna tells you that she began to have thoughts of harming herself.
She requested that you not disclose this information to anyone as she reiterated that it was “nothing
serious.” What next steps should you take?
PHARMACOLOGY
Brianna is currently taking Prevacid.
7. What foods should Brianna avoid while taking this drug, if any?

1. Given Brianna’s profile, how may your own culture and beliefs affect your interaction with her?
5. What difficulties may Brianna face when she goes home to her family’s Armenian traditions around
meals?
6. Why is it important to understand Brianna’s family cultural traditions around food?
case.

1. What is the purpose of the SCOFF Questionnaire?
5. What is the reliability of the SCOFF Questionnaire?
6. What is the validity of the SCOFF Questionnaire?
7. What functional inference can be deduced from Brianna’s total score of 3?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Brianna’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Brianna to deter-

patterns.
modify, or prevent.
attention.

Create a plan for discharge from occupational therapy services in collaboration with Brianna and mem-
bers of the interprofessional team. Review the needs of Brianna, caregivers, family members, and signifi-
REFERENCES
Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF Questionnaire: A new screening tool for eating disorders.
The BMJ, 319, 1467. https://doi.org/10.1136/bmj.319.7223.1467
Pediatric Services SECTION VIII
287
35
Victoria: Spina Bifida

PAULA STEWART, MS, OTR/L
Victoria (she, her, hers, herself)
MEDICAL HISTORY
Victoria is a 10-year-old Venezuelan American female born full term. She is 4' 4" and weighs 85 pounds.
At birth, she was diagnosed with spina bifida (SB) myelomeningocele with comorbidities of hydroceph-
alus, urinary tract infections, and scoliosis. In early infancy, as a complication of hydrocephalus, Victoria
underwent surgery for a shunt placement to drain the fluid. Victoria is transitioning to middle school
and will be reevaluated to update her individualized education plan (IEP). She currently receives occu-
pational therapy, physical therapy, and speech therapy services in school and occupational and physical
therapy at home. Victoria has no known allergies.
SOCIAL HISTORY
Victoria is a very friendly and cooperative child with a great sense of humor. The majority of family mem-
bers are bilingual. She is currently in a fifth-grade general education class and gets along well with her
classmates. She resides in a two-bedroom basement apartment with her parents and older sister. The
apartment is not wheelchair accessible. She recently joined Girl Scouts at her local church. Victoria’s
family follows the Catholic faith.
INDIVIDUALIZED EDUCATION PLAN

Victoria’s IEP has identified the need for occupational and physical therapy services. These services will
be provided until she achieves maximal function or ages out.
289

Pediatric Services in the School Setting
Victoria’s preadmission occupational history and experiences included requiring assistance with
ADLs and all IADLs. Victoria’s parents work at a prominent hotel chain, where her father is a sous
chef and her mother is a manager for the housekeeping department. Victoria enjoys playing online
video games and watching teen television. Her patterns of daily living most commonly include
waking at 7:00 a.m. and being dressed by her parents to save time. She is escorted to the bus by her
older sister and arrives at school by 8:30 a.m. Victoria finishes school by 3:00 p.m. and arrives home
by 4:00 p.m. A family member is home when she arrives. Her interests, which she shares with her
sister, include exploring different types of nail polish and lip gloss. She values spending time with
her sister and her family, and she values her friendships from school. Her needs include being able
to complete dressing independently in a timely manner and making new friends.
ADLs
Regarding self-care at school, Victoria is able to don and doff her outer garments. Her paraprofes-
sional, however, will place them in and retrieve them from her assigned cubby, which is outside her
reach. In the cafeteria, she can make her food selection, which is then brought to the lunch table
by her paraprofessional. She is able to independently open containers and feed herself. Victoria
requires moderate assistance with toileting. She wears an incontinent garment and can communi-
cate when a change is needed. After toileting, she is able to wash and dry her hands independently.
Regarding functional mobility, Victoria uses the wheelchair-accessible stall in the bathroom and
transfers with supervision using a sliding method. She uses a lightweight manual wheelchair to
move between and in classrooms but requires assistance to open doors. Victoria is able to manipu-
late items in her book bag and requires minimal assistance to place the bag on the wheelchair.
IADLs
Victoria is able to use an accessible computer to perform Internet searches, complete homework
and classroom assignments, and send and receive emails. Classroom materials are retrieved by her
paraprofessional; however, Victoria tends to keep a messy workspace. Victoria’s paraprofessional
usually escorts her to the school nurse’s office daily, where she receives her medications from the
nurse. Victoria is able to use a microwave for small, prepackaged meals at school. Regarding rest
and sleep, Victoria’s mother reports it takes approximately 1 hour for her daughter to fall asleep,
but once asleep, she sleeps well.
MENTAL FUNCTIONS
Victoria is alert and oriented to person, place, time, and situation. She is able to verbally commu-
nicate her needs and follow multistep verbal instructions. However, she struggles with spelling,
VICTORIA: SPINA BIFIDA | 291
reading, and math at her grade level. Victoria periodically requires reminders to lock her wheel-
chair brakes.

No gross deficits were observed with visual, hearing, vestibular, taste, and smell functions. Victoria
has intact cutaneous functions to the upper extremities, but she has diminished cutaneous and
proprioceptive sensations to the lumbar spinal nerve (L)2−L4 dermatome distribution. Victoria
has no reflexive control over her bowel and bladder. She periodically reports pain in her lower
back during prolonged sitting in her wheelchair. Using the Wong-Baker FACES® Pain Rating Scale
(Wong-Baker FACES Foundation, 2018), she reports a score of 4. She reports her pain as “feeling
like being stabbed with a knife.”

MOVEMENT FUNCTIONS
Passive range of motion (PROM), active range of motion, and muscle strength in the upper extremi-
ties were in defined limits. Victoria is right-hand dominant. No deficits were found in her fine motor
abilities. PROM in both lower extremities were at functional levels. Manual muscle testing (MMT)
revealed strength for all muscle groups below the level of the 12th thoracic vertebrate was assessed
to be 2/5. Victoria has bilateral foot drop and ankle inversion, and she wears bilateral ankle−foot
orthotics (AFO) at school. At bedtime, she is placed in a full hip−knee−foot−ankle orthotic.
Both lower extremities (BLE) presented with hypotonicity. MMT for static sitting balance was 4−/5,
and her dynamic sitting balance was 3+/5. Static standing balance was not assessed. The Bruininks−
Oseretsky Test of Motor Proficiency (BOT–2; Bruininks & Bruininks, 2005) was administered, and
Victoria’s standard score was 31.
PLAN FOR DISCHARGE

Victoria will be periodically reevaluated for the continuation of occupational therapy and other
services by the IEP team.

1. Victoria sits in a wheelchair for the entire school day. What concerns does this situation raise?
2. Identify the risks associated with Victoria’s impaired sensory awareness in BLE. How can these risks
be mitigated?
3. Create a handout that identities the proper sitting posture in a wheelchair.
4. Victoria is predisposed to osteopenia and muscle atrophy in BLE. Compare and contrast these two
conditions.
with spina bifida. Evaluate them, select the strongest source, and justify your selection.
6. Identify the common emotional reactions associated with being wheelchair bound that may affect the
treatment process.
7. To keep Victoria and others safe, what other factors should be considered?
2. How can SB affect Victoria’s occupations?
3. Which basic ADL deficits should be addressed in the school setting? Explain why.
4. Which areas of functional mobility should be addressed in the school setting? Explain why.
5. Identify the behaviors of the paraprofessional that may hinder the development of Victoria’s ADL
performance.
6. Which IADL deficits should be addressed in the school setting? Explain why.
7. Identify strategies to facilitate the carryover of skills achieved in school to home.
8. What other areas of occupation would you address? Explain why.

1. Identify Victoria’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Victoria’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Victoria’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Victoria’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Victoria’s current level of

1. What are some mental health concerns for a preadolescent with incontinence?
2. How can a transition to a new school affect Victoria’s mood and behavior?
3. Victoria requires reminders to lock her wheelchair brakes. Identify three cognitive strategies that can
be used to address this oversight. Evaluate them, select one, and defend your choice.

2. Compare and contrast SB with spinal stenosis.
3. Victoria has significant weakness in BLE. Should this weakness be addressed by an occupational ther-
apist? Support your decision.
4. Given the diagnosis of SB, does Victoria have the potential to attain normal static and dynamic sitting
balance? Justify your response.
5. Identify the types of forces that come into play during sliding transfers. How can they be addressed to
minimize risk to skin integrity?
6. What biomechanical factors may contribute to Victoria’s back pain?
7. Create an exercise program based on occupational performance for Victoria.

2. Identify common cardiac and respiratory comorbidities for people with SB. How may they affect oc-
cupational performance?

1. What are some skin integrity concerns while wearing an AFO?
2. Identify the factors that can lead to skin breakdown when wheelchair bound.
3. Describe two pressure relief techniques that Victoria can use while seated in her wheelchair at school.

Describe how Victoria’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Victoria while she is receiving
2. What assistive technologies or adaptations might be recommended for when she is in class? Why?

1. You believe that Victoria may benefit from a motorized wheelchair. What factors should you consider
when recommending this type of technology?
2. Victoria reported a painful blister on her buttocks. How should it best be addressed?
3. Victoria expresses that she is being bullied at school. How should this situation best be addressed?
PHARMACOLOGY
Victoria is currently taking oxybutynin hydrochloride.

1. Given Victoria’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the BOT–2?
2. Which population is the test designed for?
4. Provide a brief description of the assessment.
5. What is the reliability of the BOT–2?
6. What is the validity of the BOT–2?
7. What functional inference can be deduced from Victoria’s standard score of 31?

1. Identify the other professions that would make up the IEP team. Identify the scope of each member.
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Victoria’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Victoria to deter-

patterns.
modify, or prevent.

attention.

Create a three-paragraph transition summary. In the first paragraph, identify areas of assessment and
significant findings. In the second paragraph, identify barriers to be addressed. Justify their selection. In
the third paragraph, identify the goals that have been developed.
REFERENCES
Bruininks, R. H., & Bruininks, B. D. (2005). BOT−2: Bruininks−Oseretsky Test of Motor Proficiency: Manual (2nd ed.).
Pearson Assessments.
36
Abigale: Autism Spectrum Disorder

Abigale (she, her, hers, herself)
MEDICAL HISTORY
Abigale is a 9-year-old Peruvian American female who was born weighing 7 pounds, 2 ounces. She was
treated as high risk because of advanced maternal age. Abigale was delivered by C-section because of pro-
longed labor. Her medical history included being placed under bili lights right after birth for 1 day to treat
mild jaundice. She was discharged from the hospital at 3 days old as a healthy baby.
By 11 months, her mother expressed concern to the pediatrician about Abigale’s development. She re-
ported that Abigale cried inconsolably, was difficult to diaper, did not babble or give eye contact, and was
not pulling to stand. Abigale sat and crawled at 8 months, stood at 13 months, and walked at 15 months. At
the age of 1, she was diagnosed with autism spectrum disorder (ASD).
Abigale has known allergies. Food allergy testing was conducted at age 7, and after being placed on an
elimination diet, allergies to dairy and gluten were identified. School officials were informed and, subse-
quently, at school she was served only food provided by her family. She is currently taking podophyllum,
an herbal supplement.
SOCIAL HISTORY
Abigale is an only child who resides with both of her parents in a private home. Her mother is a stay-
at-home mom, and her dad is a restaurant owner. Abigale is in the fourth grade in a self-contained class
that includes six children, one teacher, and three paraprofessionals. Abigale’s family follows the Roman
Catholic tradition.

Abigale’s individualized education plan (IEP) has identified the need for occupational therapy, physical
therapy, speech therapy, and special instruction with applied behavioral analysis. Services will be pro-
vided until she achieves maximal function or ages out.
297

Abigale’s preadmission occupational history and experiences included requiring assistance with
ADLs and all IADLs. Her patterns of a daily living most commonly include being awoken by 7:00
a.m., dressed, and transported to school by a school bus staffed with a driver, matron, and para-
professional. She typically arrives home by 4:30 p.m., has a snack, takes a nap, and then completes
homework with the assistance of her mom. On weeknights, Abigale’s interests include screen time
for an hour. She is usually in bed by 9:00 p.m. On weekends, Abigale is involved with aqua and
music therapy. She values cuddle time with her mother. Her mother’s current need for Abigale is to
dress independently in a timely manner.
ADLs
Regarding self-care, Abigale was independent in toileting skills; however, she required constant
supervision to prevent her from turning the faucet on and off, placing items in the toilet, and at-
tempting to run away. Abigale was able to remove food items from the lunch bag and unscrew a top
from her water bottle to feed herself; however, she required constant supervision to remain seated
and prevent her from grabbing food from other children. Abigale was able to dress but required
frequent redirection to stay on task. Regarding functional mobility, no gross deficits in bed mobility,
transfers, or functional mobility were observed.
IADLs
Abigale required verbal and visual prompts to participate in cleaning up and to manage classroom
items, such as placing books on her desk and returning them to her book bag.
MENTAL FUNCTIONS
Abigale was alert and oriented to person, place, and time. She was easily distracted and had moder-
ate difficulty following a one-step verbal command and transitioning from task to task. Abigale re-
quires supervision or redirection of tasks in a timely manner. At times, she has a tantrum if a task is
interrupted. She presents with fleeting eye contact as well as limited ability to interact with others
and verbally express herself. During the evaluation, she attempted to climb over and crawl under
tables as well as run out of the room. Abigale demonstrated a strong preference for routine and had
difficulty with novel experiences.

No gross deficits were observed with visual, vestibular, taste, smell, and proprioceptive functions.
Abigale exhibited several hypersensitive behaviors. She covered her ears in response to loud noises,
ABIGALE: AUTISM SPECTRUM DISORDER | 299
avoided touching glue, was hesitant walking downstairs, and retreated to a corner when placed in
a room with many people. She reported no pain.

MOVEMENT FUNCTIONS
Active range of motion and passive range of motion were within defined limits in all extremities.
Abigale presented with bilateral shoulder strength of 3+/5. Assessment of fine motor skills was
assessed using a subtest of the Peabody Developmental Motor Scales (2nd ed.; PDMS–2; Folio &
Fewell, 2000), which found that Abigale held a pencil and crayon using a very immature supi-
nate-palmar grasp. She was unable to copy basic vertical, horizontal, and circular lines; trace; color
a picture; cut using scissors; and manipulate buttons and laces. She demonstrated the ability to hold
a small container with one hand and remove the twist-off top with the other hand. Her fine motor
skills appeared to be equivalent to those of a child between ages 18 and 26 months.
Abigale ambulated using a toe-walking gait pattern. Muscle tone in her trunk and all four extrem-
ities was low.
PLAN FOR DISCHARGE

Abigale will be periodically reevaluated for the continuation of occupational therapy and other
services by the IEP team.

1. Given Abigale’s impulsivity, what safeguards should be put into place?
2. Abigale has difficulty transitioning. How may this challenge affect the safety of her and those in her
class?
3. Abigale has been placed on a strict nutritional diet and can eat only the foods that are sent by her par-
ents. What concerns may you have? What are specific precautions to follow?
4. Create a handout that identifies common foods that contain gluten.
5. Compare and contrast sensory-seeking behavior with sensory-avoiding behavior.
6. Abigale is experiencing a tantrum during a therapy session. How should this situation be handled?
7. Identify three up-to-date, reliable, and valid sources to obtain precautions for working with children
with nut allergies. Evaluate them, select the strongest source, and justify your selection.
8. Identify the common emotional reactions associated with medical complications during labor and
delivery that may affect the treatment process for both the client and their family.
9. To keep Abigale and others safe, what other factors should be considered?
OCCUPATIONS: ADLs, IADL, EDUCATION, WORK, PLAY, SOCIAL PARTICIPATION, AND REST AND SLEEP
2. As a school-based therapist, what areas of occupation should you focus on to optimize Abigale’s ability
to participate in school?
3. How would you ensure that the acquired skills during a treatment session are carried over into the
classroom?
4. Abigale is also receiving occupational therapy services in the home. How would the focus of these ser-
vices differ from occupational therapy services in the school?
Abigale’s occupational performance.

1. Identify Abigale’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Abigale’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Abigale’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Abigale’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Abigale’s current level of

1. Compare and contrast autism with intellectual disability.
2. Create a plan to develop rapport with Abigale.
3. Identify three verbal and three nonverbal strategies to optimize communication with Abigale.
4. Identify three models that can be used to guide you in addressing Abigale’s negative behaviors. Evaluate
them, select one, and defend your selection.
5. Examine the literature and identify two strategies to minimize impulsiveness.
6. Identify Abigale’s areas of hypersensitivity. What recommendations would you make to her classroom
teacher to create a classroom that provides a tolerable sensory experience?

2. Muscle strength in Abigale’s shoulder groups is 3+/5. Does this level of strength need to be addressed?
Support your decision.
3. Create an exercise program based on occupational performance for Abigale.

Given the information provided, identify cardiovascular, hematological, immunological, and respiratory
functions that need to be addressed. Justify your selections.

Upon initiating therapy with Abigale, you noticed a bruise on her knee. What would be your concern, and
what possible action or actions would you take?

Describe how Abigale’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Abigale while she is receiving
2. What assistive technologies or adaptations might be recommended for when she is in class? Why?

1. You have only treated Abigale one time; however, a progress report is due for her the following week.
What should you do?
2. During the occupational therapy session, Abigale falls and hits her arm. Upon clinical observation, she
is able to move her arm and does not appear to be in pain, but she has a bruise. What would be your
concern, and what possible action or actions should you take?
3. During a push-in treatment session, Abigale is engaged in a feeding activity while sitting with her
peers. You notice that she quickly snatches food from the child next to her and puts it in her mouth.
What would be your concern, and what immediate action or actions must be taken?
PHARMACOLOGY
Abigale is currently taking podophyllum, a nutritional supplement.
1. Is there a brand name?
2. Does this supplement have an alert status?
3. What is the classification of this supplement?
4. What is the indication for this supplement?
5. What is the action of this supplement?
6. How may this supplement affect client participation during a therapy session?

1. Given Abigale’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the PDMS–2?
3. Was the subtest used in this case an appropriate selection? Explain.
6. What is the reliability of the PDMS–2?
7. What is the validity of the PDMS–2?
8. Is the PDMS–2 a norm-referenced or criterion-referenced assessment tool?
9. What functional inference can be deduced from Abigale’s developmental age of 18–26 months?
10. What additional standardized assessment was used or can be used in this case? Why?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Abigale’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Abigale to determine

patterns.
modify, or prevent.

attention.

REFERENCES
Folio, M. K., & Fewell, R. (2000). Peabody Developmental Motor Scales: Examiner’s manual (2nd ed.). PRO-ED.
37
Andrei: Dyslexia
TIFFANY CORDERO-VELEZ, MS, OTR/L; SUSAN QUINTIN, MS, OTR/L;
AND TIFFANY ALMONTE, MS, OTR/L
Andrei (he, him, his, himself)
MEDICAL HISTORY
Andrei is a 13-year-old Belarusian American male who is 5' 5" and weighs 138 pounds. He was diagnosed
with a learning disability, dyslexia. He was born full term, weighing 8 pounds, 5 ounces, by normal spon-
taneous vaginal delivery. Andrei has a medical history of a generalized anxiety disorder. He takes no
prescribed medications other than multivitamins, Vitamin D3, and flaxseed oil. Andrei received a com-
prehensive eye exam, and the results were unremarkable. All milestones were achieved at age level except
for expressive language. Andrei has no known allergies.
SOCIAL HISTORY
Andrei and his brother were adopted by his aunt and uncle after the death of his parents 5 years ago. They
reside in a six-bedroom home along with three older cousins. The primary language in school is English
and at home it is Belarusian. Andrei’s uncle is the owner of multiple car dealerships, and his aunt is a
manufacturer of women’s wigs. He is currently placed in an integrated coteaching seventh-grade class
in a private school and is transported by a chauffeur. Andrei reports that he loves music, computers, and
electronics. He is good at art, and his interests include karate, dancing, and superheroes. In school, Andrei
prefers to work on group assignments, in which he is able to share ideas but is reluctant to contribute any
written components. His classmates consider him to be a class clown. Andrei is disruptive at times, lacks
motivation, and is easily discouraged and frustrated. Outside of school, Andrei is dedicated to his karate
and reports feeling accomplished when he earns new belts. Andrei’s family follows the Orthodox Catholic
faith.

Andrei’s individualized education plan (IEP) has identified the need for occupational therapy and speech
therapy services. These services will be provided until he achieves maximal function or ages out.
305

Andrei’s preadmission occupational history and experiences included being independent with all
ADLs and requiring assistance with IADLs. His patterns of daily living most commonly include
waking at 7:00 a.m., dressing, being driven to school, and having breakfast with his friends at school.
His afterschool activities include fencing and karate. Andrei arrives home by 6:30 p.m. Monday
through Thursday and before sunset on Fridays. Upon arriving home, he is served dinner and then
is assisted by a tutor, whom he is dependent on for helping him complete his homework. In the eve-
nings, his interests include competitive online gaming and social networking through popular so-
cial media sites. He values his image and his growing designer watch collection. His current needs
are to feel comfortable reading and writing and to no longer be mocked in school.
ADLs
Regarding self-care, Andrei is independent in all self-care activities. Regarding functional mobility,
no gross deficits were observed in bed mobility, transfers, or functional mobility.
IADLs
According to Andrei’s aunt, he is able to independently prepare a snack and walk the dog. Andrei
finds texting on his smartphone to be challenging because it takes him a long time to figure out
which words are abbreviated and instead prefers to use animated forms of language such as emojis.
Regarding rest and sleep, Andrei reported that if he does not get a good night’s sleep, he has greater
difficulty attending to tasks in school.
MENTAL FUNCTIONS
Andrei was alert and oriented to person, place, time, and situation. He was pleasant and neatly
dressed and demonstrated insight into his diagnosis. Andrei has higher-level oral-language skills
but difficulty with written language; specifically, reading and spelling in class. Doing these types of
tasks commonly results in Andrei having episodes of stomach pain and headaches. Letter reversal
has been observed in his handwritten and typed assignments. During a writing task, he was ob-
served putting his head on the desk and fidgeting with his pencil. Andrei reports that he is often
frustrated during writing assignments, lacks self-confidence, and projects his frustration onto his
peers. As a result, he struggles to maintain positive relationships with peers. For scheduled oral
presentations and examinations, Andrei will often feign illness to avoid attending school. Andrei
scored 72 on the Oral and Written Language Scales (2nd ed.; OWLS−II; Carrow-Woolfolk, 2011).
ANDREI: DYSLEXIA | 307

No gross deficits were observed with visual, vestibular, taste, smell, cutaneous, or proprioceptive
functions. Andrei presented with appropriate sensory processing skills. He reported no pain.

MOVEMENT FUNCTIONS
Andrei’s range of motion, muscle strength, and endurance were within defined limits. His fine
motor skills were age appropriate, and he was able to manipulate classroom tools and instruments.
Andrei presented with normal muscle tone, posture, and balance.
PLAN FOR DISCHARGE

Andrei will be periodically reevaluated for the continuation of occupational therapy and other ser-
vices by the IEP team.

1. Given that Andrei has dyslexia, what are the most common psychological concerns?
2. What are the most common social concerns for children with dyslexia?
3. How could dyslexia affect self-confidence and academic performance?
4. What are the possible short- and long-term effects of insisting that Andrei read out loud in class?
with dyslexia. Evaluate them, select the strongest source, and justify your selection.
6. Create a handout that identifies precautions for working with clients with dyslexia.
7. Identify the common emotional reactions associated with dyslexia that may affect the treatment
process.
8. To keep Andrei and others safe, what other factors should be considered?
2. Identify areas of difficulty that affect Andrei’s performance in school.
3. What classroom strategies do you anticipate can be used to increase Andrei’s school performance?
4. What home recommendations can be provided for the family and Andrei to decrease his dependence
on his tutor for the completion of his homework?
5. When recommending occupational therapy services, what would be the service delivery method (con-
sidering frequency, duration, and location) that would promote the least restrictive environment?
Andrei’s occupational performance.

1. Identify Andrei’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Andrei’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Andrei’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Andrei’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Andrei’s current level of

1. Compare and contrast dyslexia with attention deficit hyperactivity disorder.
2. Create a plan to develop rapport and maximize communication with Andrei.
3. Search the literature and identify two strategies to encourage Andrei’s active participation during oc-
cupational therapy sessions.
4. How could you measure the level of carryover of skills from therapy to Andrei’s guardians and teacher?
5. Describe methods or strategies that can be used to increase Andrei’s self-efficacy, self-monitoring, and
determination.

2. Is there a correlation between visual impairment and dyslexia? Identify the source used to answer this
question.

2. Identify the signs and symptoms that a person may display when experiencing anxiety.

During writing tasks, Andrei’s skin becomes flushed and sweaty. What could be the cause?

Describe how Andrei’s diagnoses may affect his voice, speech, and associated occupational performance.

1. What school-based assistive technologies or adaptations might be used or made for Andrei while he is
receiving occupational therapy services at school? Why?
2. What assistive technologies or adaptations might be recommended for the home? Why?
3. Categorize the recommendations mentioned above as either low or high forms of assistive technology.
4. What websites or online tools can be recommended for Andrei to support his classroom and home-
work performance?

1. During your therapy session with Andrei, he begins to engage in negative self-talk. At one point, he
makes comments about wanting to hurt himself. Identify the necessary steps needed to address this
concern, and support your decision.
2. Andrei does not like to be “pulled out” of class for occupational therapy because he feels embarrassed
and, at times, he refuses to attend his session. How can this situation be addressed?
3. You overheard Andrei’s English teacher say the following to Andrei: “You are lazy, and you do not
try hard enough to improve your reading and writing.” What would be the best way to address this
situation?
4. During the holidays, Andrei’s family gives you a very expensive timepiece. How should this gift be
addressed?
PHARMACOLOGY
Andrei is currently taking flaxseed oil.
1. Does this oil have a high alert status?
2. What is the classification of this oil?
3. What is the indication for this oil?
4. What is the action of this oil?
5. How may this oil affect client participation during a therapy session?

1. Given Andrei’s profile, how may your own culture and beliefs affect your interaction with him?
case.

1. What is the purpose of the OWLS–II?
5. What is the reliability of the OWLS–II?
6. What is the validity of the OWLS–II?
7. What functional inference can be deduced from Andrei’s OWLS–II score of 72?

4. Who would be involved in the collaborative process? List four ways to promote collaboration in the
team to increase Andrei’s functional performance and carryover of intervention.
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Andrei’s diagnoses.

Explain why.
practice setting?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Andrei to determine

patterns.
modify, or prevent.

attention.

REFERENCES
Carrow-Woolfolk, E. (2011). Oral and Written Language Scales, second edition (OWLS–II). Western Psychological
Services.
38
Dara: Down Syndrome

IVY RENTZ, EDD, MSA, OTR/L
Dara (she, her, hers, herself)
MEDICAL HISTORY
Dara is a 5-year-old British American female who is 4' 3" and weighs 77 pounds. She has been diag-
nosed with Down syndrome (DS). Her medical history includes an atrioventricular septal defect and
Hirschsprung disease. She was born full term, weighing 7 pounds, 6 ounces, by normal spontaneous vag-
inal delivery to a mother of advanced maternal age. Dara’s development milestones were significantly
delayed. She sat up at 12 months, crawled at 20 months, stood at 3 years, and began walking at 4 years.
Dara has no known allergies.
SOCIAL HISTORY
Dara resides with her mother and stepfather, ages 44 and 49, respectively, in a three-bedroom high-rise
cooperative apartment building along with her two stepbrothers, ages 16 and 18 years. Dara’s mother is a
freelance advertising consultant, and her stepfather is a blog editor. Dara’s parents share the responsibil-
ity of dropping her off at and picking her up from school. Dara attends a school that specializes in students
with ongoing medical needs. Dara’s parents follow a Pentecostal Christian faith.

Dara’s individualized education plan (IEP) has identified the need for occupational therapy, physical
therapy, and speech therapy. Services will be provided until she achieves maximal function or ages out.
313
Occupational Therapy Initial Evaluation Finding:

Dara’s preadmission occupational history and experiences included requiring assistance with
ADLs and all IADLs. Her patterns of daily living most commonly include being awoken by 7:00
a.m., being dressed and fed by one of her parents, and then being driven to school. Dara is picked
up from school at 2:45 p.m. by one of her parents. Once home, she has a snack and takes a nap. After
dinner, she completes her homework with her mom and is read a story by her dad. She is in bed
by 8:00 p.m. On Saturday mornings, Dara participates in hippotherapy. On Sundays, she attends
church with her family. Her parents value providing Dara with the opportunity to live a life as inde-
pendently as possible. Dara’s interests include watching children’s programs on the television. Her
parents’ current need for Dara is to use a spoon and cup independently.
ADLs
Regarding self-care, Dara is able to drink from a sippy cup and feed herself finger food. She re-
quires hand-over-hand (HOH) assistance to drink from a cup and to use a spoon and fork. With
minimal assistance, she can doff pullover tops and elastic-waist pants, but maximal assistance is
needed to don them. She requires maximal assistance in donning and doffing her backpack. She
requires HOH assistance when manipulating large, adapted pencils and crayons. She is unable to
manipulate scissors. Dara is not toilet trained and wears elastic-waist diapers. Regarding functional
mobility, Dara is able to independently transfer on and off desk chairs, the cafeteria bench, and the
school toilet. She can ambulate independently throughout the classroom but requires supervision
for safety throughout the school. Her gait is wide based, and she uses a step-to-step pattern when
ascending and descending stairs. Activities needed that provide day-to-day quality of life and rel-
ative independence were explored. Dara requires maximal assistance to place items in her cubby
and to manage books and materials on or in her desk.
MENTAL FUNCTIONS
Dara presents with impaired attention, judgment, sequencing, planning, and problem solving. She
is able to follow one-step commands with periodic prompts and demonstrations. She scored a 49
on an Intelligence Quotient examination administered by the school psychologist. Her affect is gen-
erally pleasant, and she is commonly observed smiling and giggling. She consistently responds to
simple one-step commands. Her expressive language is limited to one- or two-word responses.

No gross deficits were observed with visual, taste, smell, and proprioceptive functions. No indica-
tions of pain were observed, and none were indicated by the use of the Wong-Baker FACES® Pain
DARA: DOWN SYNDROME | 315
Rating Scale (Wong-Baker FACES Foundation, 2018). Dara presented with vestibular insecurity
during engagement in rapid gross body movements such as playing on a swing or slide.

Dara presents with labored breathing during rigorous outdoor play.
MOVEMENT FUNCTIONS
Dara presents with hypermobility in all joints of all extremities. Muscular strength in all extremities
is within functional limits. Observed functional movements appear to be slow and lack precision.
Dara presents with low tone throughout the trunk, all extremities, and hands. The Beery−Buktenica
Developmental Test of Visual−Motor Integration (6th ed.; Beery VMI−6; Beery et al., 2010) was ad-
ministered. In the area of visual–motor integration, Dara received a raw score of 6, a standard score
of 61, and a percentile rank of 0.9%.
PLAN FOR DISCHARGE

Dara will be periodically reevaluated for the continuation of occupational therapy and other ser-
vices by the IEP team.

1. Create a handout that identifies precautions for working with a client with DS.
2. Because Dara has a diagnosis of an atrioventricular septal defect, what precautions and contraindica-
tions should be followed?
3. Given Dara’s cognitive deficits, what safety issues should be considered?
with Hirschsprung disease. Evaluate them, select the strongest source, and justify your selection.
5. Identify the common emotional reactions associated with not being toilet trained that may affect the
treatment process?
6. To keep Dara and others safe, what other factors should be considered?
2. What adaptive strategies should be used to facilitate independence in using an open cup, spoon, and
fork?
3. What adaptive strategies should be used to facilitate independence in using pencils and crayons?
4. Identify an alternative form of communication that Dara could use to indicate a need for toileting.
Dara’s occupational performance.

1. Identify Dara’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Dara’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Dara’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
Body structures
Considering Dara’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and Dara’s current level of

1. Compare and contrast Down syndrome with Fragile X syndrome.
2. What strategies would you use to improve Dara’s ability to understand directions?
3. People with an IQ score of 49 present with difficulties in expressive language. Identify compensatory
strategies to maximize communication.
4. Identify and explain two strategies that can be used to improve Dara’s ability to attend. Cite your
source or sources.

2. Dara cries and avoids play-based activities that involve rapid gross body movements. How may this
behavior be addressed?
3. Identify grasp patterns that are expected for a 5-year-old. Identify your source.

2. Compare and contrast cardiac distress with respiratory distress.
3. Identify the school-based activities that may place the greatest cardiac demand on Dara’s cardiovas-
cular system.
4. Based on your findings, identify which school-based activities need to be closely monitored or avoided.

During treatment sessions, you notice that Dara has bruises, scratches, and minor abrasions to her arms
and legs. What would be the concern and what possible actions would you take?

Describe how Dara’s diagnoses may affect her voice, speech, and associated occupational performance.

1. What assistive technologies or adaptations might be used or made for Dara while she is receiving oc-
cupational therapy services at school? Why?
2. What assistive technologies or adaptations might be recommended for when she is at home? Why?

1. Dara requires adult supervision outside of the classroom. You observe her frequently going to the
water fountain alone in the hallway. How should this situation be addressed?
2. During lunchtime, you notice that most of Dara’s food remains uneaten. Who should this situation be
reported to? Why?
3. Dara has a peanut allergy and is often unaware of what items contain peanuts or similar ingredients.
After accidental ingestion, what steps should be taken to prevent future accidents?
PHARMACOLOGY
Dara is currently taking acebutolol.


1. Given Dara’s profile, how may your own culture and beliefs affect your interaction with her?
4. How can you foster cultural interaction and awareness among Dara’s teachers, parents, and other
members of the IEP team?
case.

1. What is the purpose of the Beery VMI–6?
5. What is the reliability of the Beery VMI–6?
6. What is the validity of the Beery VMI–6?
7. What functional inference can be deduced from Dara’s standard score of 61 and percentile rank of
0.9%?

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Dara’s diagnoses.

Explain why.
practice setting?
4. Dara is expected to transition to a 12:1:2 classroom setting. What does this ratio represent?
ADVOCACY
resources?
2. Create a plan to advocate for this client based on the selected area(s) of advocacy.
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Dara and her parents
to determine whether it is appropriate for her to engage in telemedicine services?

patterns.
modify, or prevent.

1. Based on your intervention plan, identify which goals and objectives require more immediate attention.

REFERENCES
Beery, K. E., Buktenica, N. A., & Beery, N. A. (2010). The Beery–Buktenica Developmental Test of Visual–Motor
Integration: Administration, scoring, and teaching manual (6th ed.). Pearson.
39
Chi-Ling: Cerebral Palsy

Chi-Ling (she, her, hers, herself)
MEDICAL HISTORY
Chi-Ling is a 10-year-old Taiwanese American female who is 4' 10" and weighs 98 pounds. She was di-
agnosed at age 4 months with hemiplegic cerebral palsy (CP) affecting her left upper and left lower ex-
tremities. She was born full term, weighing 5 pounds, 1 ounce, by a complicated vaginal delivery. Chi-Ling
has a medical history of seizure disorder, which is controlled through medications, and a history of con-
stipation, which is treated with Pedia-Lax. No surgical history was reported. Chi-Ling sat at 10 months,
crawled at 13 months, and walked at 16 months. She recently started her menstrual cycle. She has no
known allergies.
SOCIAL HISTORY
Chi-Ling is a fifth-grader who attends public school and receives occupational therapy, physical therapy,
and speech–language pathology services. She is an only child and resides with both her parents in a pri-
vate home. Their house has 6 steps to enter the first floor and 12 steps to access the second floor. She and
her family are practicing Taoists. Her mother works part-time in a department store, and her father is a
full-time computer technician. Chi-Ling enjoys helping her father in the kitchen when cooking meals.
She enjoys watching television and using social media to connect with her friends and family abroad.
She also enjoys taking selfies and often uses her mother’s tablet to watch online videos. Chi-Ling avoids
outdoor physical activities.
PRESCRIPTION OR REFERRAL
Chi-Ling was referred by her pediatrician for non−school based occupational therapy services, which will
be delivered in her home. Services are expected to last until the maximal potential is achieved.
321

Community-Based Pediatric Services
Chi-Ling’s preadmission occupational history and experiences included requiring assistance with
ADLs and IADLs. Her patterns of daily living most commonly include being awoken by her mother
at 6:30 a.m., dressing with assistance, eating a cold breakfast, and boarding the school bus by 7:30
a.m. She arrives at school by 8:00 a.m. and returns home by 3:30 p.m. Her father meets her at the
bus, provides her with an afternoon snack, and assists with homework while her mother starts her
shift at work. In the evenings, she values the time cooking with her father and socializing with her
friends on social media. Her interests include playing with her mother’s makeup and watching
music videos. Her current goals are to be able to dress and bathe without the assistance of her par-
ents. Her parents stated that their main concerns were her weakness to the left side of her body,
which affects her ability to play with her peers and to independently care for herself.
ADLs
Regarding self-care, Chi-Ling is able to feed herself using a fork or spoon with her right hand but
has difficulty with bilateral cutting. She is able to drink from an open cup and sip from a straw. She
tolerates eating foods of various textures but often coughs when consuming thin liquids. Chi-Ling
brushes her teeth and requires minimal assistance for applying toothpaste. She requires moderate
assistance to wash her unaffected side and prefers to take baths over showers. She can don and
doff pull-on and pull-over garments but requires moderate assistance for managing fasteners. She
prefers to wear slip-on shoes. Her mother reported that Chi-Ling is unable to adequately secure
her menstrual pad and is uncomfortable when assistance is offered. Chi-Ling is able to toilet in-
dependently but reports feeling uncomfortable when having to use a public restroom. Regarding
functional mobility, Chi-Ling is able to independently roll right to left and transition between su-
pine and sit. She is able to transfer independently with the use of a posterior walker on and off from
a sofa, chair, and toilet, but she requires contact guard assistance to and from the tub.
IADLs
Chi-Ling is able to assist her father with meal preparation but requires moderate assistance to
open containers and transport large items from the refrigerator to the stove. She is able to manage
a smart device and often uses the voice-to-text feature to search the Internet. Chi-Ling is aware
of her medication schedule but is unable to open her medication bottle. Regarding rest and sleep,
Chi-Ling has difficulty sleeping through the night and often awakes multiple times. Her parents
report her bedtime is typically at 8:00 p.m.; however, they report that “we are concerned that she is
addicted to her phone” because they frequently find her using it to access social media for hours at
a time. Upon waking, she is irritable and drowsy.
CHI-LING: CEREBRAL PALSY | 323

Chi-Ling was alert and oriented to situation, person, place and time. She was able to follow multi-
ple-step commands. She provided intermittent eye contact and was apprehensive about initiating
activities, but she was responsive to verbal prompts. No perceptual deficits were noted.

No deficits were noted in vision, auditory, and gustatory functions. During play-based activities
that required swift movements, an increase in left-side muscle tone was observed. Noxious smells
elicited the same response. Hypertactile sensitivity was noted on her left upper extremity when in
contact with objects that were not in her visual field. During static sitting and standing activities,
Chi-Ling was observed assuming asymmetrical postures with greater weight bearing toward her
unaffected side. No pain was reported.

MOVEMENT FUNCTIONS
Passive and active range of motion were within normal limits in the right upper and lower ex-
tremities. In the left upper and lower extremities, there was a mild increase in muscle tone. The
Modified Ashworth Scale (Ashworth, 1964) indicated a score of 1. Left-foot clonus was also noted.
Chi-Ling tended to use her right side more than her left. When she was presented with activities
that required her to use both sides of her body, she would sometimes use her left side as a stabilizer.
In the areas of grasping and visual−motor skills, Chi-Ling was able to sort basic shapes on a shaped
board, place pegs in peg holes, and hold a pencil with a gross static tripod grasp but had writing
challenges in spacing and letter formation. She exhibited difficulty in performing bilateral tasks,
such as cutting with scissors. She was assessed with the Beery−Buktenica Developmental Test of
Visual−Motor Integration (6th ed.; Beery VMI−6; Beery et al., 2010), and her standard score was 82.
Chi-Ling’s static sitting was good, and her dynamic sitting was fair (F)+. Her static standing balance
was F+, and her dynamic standing was F. Upon exertion, she was noted to exhibit a mild asymmet-
rical tonic labyrinthine reflex and a tonic labyrinthine reflex, which became more prevalent when
she was excited. Movement in the left upper and lower extremities was limited in accuracy, speed,
and overall motor coordination.
PLAN FOR DISCHARGE

Chi-Ling will be discharged to the care of her parents and will continue to receive school-based
services.

1. Because Chi-Ling is a minor, can services be rendered without the presence of her parents? Explain
your response.
2. What type of consent, and from whom, is required for this case?
3. Because Chi-Ling presents with decreased balance, what are the safety concerns you anticipate?
with CP. Evaluate them, select the strongest source, and justify your selection.
5. Create a handout that identifies the precautions to use when working with children who ambulate
with a walker.
6. Identify the common emotional reactions associated with movement difficulties that may affect the
treatment process.
7. To keep Chi-Ling and others safe, what other factors should be considered?
2. Compare and contrast Chi-Ling’s roles and occupations.
3. Would it be appropriate to address sleep with Chi-Ling? Why or why not?
4. How could the presence of primitive reflexes affect ADL performance? How can these effects be best
addressed?
5. Identify the type of strategy that Chi-Ling presently uses when dressing with pull-over or pull-up
garments.
6. What strategies can be provided to facilitate Chi-Ling’s use of both hands when manipulating her most
commonly used technologies? Support your strategies.
Chi-Ling’s occupational performance.

1. Identify Chi-Ling’s useful habits, routines, roles, and rituals that support valued occupations. How can
2. Identify Chi-Ling’s impoverished habits, routines, roles, and rituals that do not support valued occu-
3. Identify Chi-Ling’s dominating habits, routines, roles, and rituals that interfere with valued occupa-
CLIENT FACTORS
Body structures
Considering Chi-Ling’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and her current level of occu-
pational performance.

1. Create a plan to maximize rapport and socialization with Chi-Ling.
2. Search the literature and identify two strategies to address her phone “addiction.” Summarize each
strategy.
3. Explain the relationship between sleep hygiene and mental function. Identify your sources.
4. Search the literature, and identify and explain two strategies to maximize the carryover of skills that
Chi-Ling learned in therapy to her parents.

2. Compare and contrast spastic diplegia, spastic paraplegia, and spastic quadriplegia.
3. Identify strategies that can be used to address postural instability.
4. Identify strategies that can be used to address motor control.
5. Identify Chi-Ling’s numerical grades assigned to her static and dynamic sitting balance. Explain each
grade.
6. Identify Chi-Ling’s numerical grades assigned to her static and dynamic standing balance. Explain
each grade.

2. Identify the typical ranges for heart rate, blood pressure, and respiration rate for children of Chi-Ling’s
age. Name and justify your source.

1. Upon clinical observation, you notice mild muscle tightness of the wrist and digit flexors of Chi-Ling’s
left hand. What would be the concern and what possible actions would you take?
2. What hygienic considerations should be made to address skin integrity during the menstrual cycle?

Describe how Chi-Ling’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Chi-Ling while she is receiving

1. During a treatment session, Chi-Ling reports that she is being touched in school by her paraprofes-
sional and it makes her feel “weird.” How must this situation be addressed?
2. During a treatment session with Chi-Ling, you notice an odor of marijuana in the household. How
3. During a treatment session, Chi-Ling’s mother states that she needs to go to the store, which leaves
only you and Chi-Ling in the home. How should this situation best be addressed?
PHARMACOLOGY
Chi-Ling is currently taking Pedia-Lax.

1. Given Chi-Ling’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the Beery VMI−6?

5. What is the reliability of the Beery VMI−6?
6. What is the validity of the Beery VMI−6?
7. Is the Berry VMI–6 a norm-referenced or criterion-referenced assessment tool?
8. What functional inference can be deduced from the Beery VMI−6 standard score of 82?
9. What additional standardized assessment was used or can be used in this case? Why?
INTERPROFESSIONAL RELATIONSHIPS AND EFFECTIVE INTRAPROFESSIONAL COLLABORATION

BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for this client’s diagnoses.

Explain why.
2. Who would be the unauthorized individuals that you could not share the occupational therapy find-
ings with without written permission? Explain why.
3. For this case, what forms of documentation will be required?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Chi-Ling to deter-

patterns.
modify, or prevent.

attention.

REFERENCES
Ashworth, B. (1964). Preliminary trial of carisoprodol in multiple sclerosis. Practitioner, 192, 540–542.
Beery, K. E., Buktenica, N. A., & Beery, N. A. (2010). The Beery–Buktenica Developmental Test of Visual–Motor
Integration: Administration, scoring, and teaching manual (6th ed.). Pearson.
40
Dion: Fetal Alcohol Syndrome

CAROL BROWN-WASSINGER, MS, OTR/L
Dion (she, her, hers, herself)
MEDICAL HISTORY
Dion is a 2.5-year-old Liberian American female who was diagnosed with fetal alcohol syndrome (FAS)
at her 12-month wellness check-up. She is currently 2' 5" and weighs 45 pounds. Her mother has a history
of alcohol use disorder but claims she stopped drinking when she found out she was pregnant. There
were no complications during pregnancy or delivery. Dion’s past medical history includes being born full
term by natural delivery, weighing 5.8 pounds. She weighed 19 pounds at the check-up and had a below
average occipitofrontal circumference with the presence of facial dysmorphia. Dion’s facial features are
present with a smooth philtrum, a thin vermillion border, and small palpebral fissures. There is no history
of seizures, ear infections, or allergies. Dion is not taking any medications but takes a choline supplement
as recommended by her pediatrician. Dion rolled from supine to prone at 4 months, sat up unsupported
at 7.5 months, crawled at 6 months, and walked independently at 18 months. She has no known allergies.
SOCIAL HISTORY
Dion lives with her 25-year-old mother, 54-year-old maternal grandmother, and 28-year-old maternal
aunt on the fourth floor of an apartment building with an elevator. Dion’s grandmother and aunt assist
with child care. Dion’s mother has been sober since her pregnancy and currently is enrolled in a local
technical training program to become a medical biller and coder. She also works part-time as a sales asso-
ciate. Dion’s grandmother is a registered nurse, and her aunt is an emergency medical technician. Dion’s
father, who is 22, does not live with the family and struggles with alcohol use disorder. He is not an active
participant in his daughter’s life. Although there is a park at the corner, Dion’s family does not take her
there because of criminal activity. Once a month, the family takes Dion to an indoor amusement center to
play and interact with other children. Dion’s family practices the African Methodist Episcopal Zion faith.
Dion was referred for early intervention (EI) services for occupational therapy, which will be delivered in
a developmental center. Services will be provided until she achieves maximal function or ages out.
329

Early Intervention Pediatric Services
Dion’s preadmission occupational history and experiences included requiring assistance with ADLs
and all IADLs. Her patterns of daily living most commonly include being awoken by 7:00 a.m. and
dressed and fed by her grandmother. Dion is taken to day care so she may socialize with peers and
receive developmental services. She arrives at the center by 8:30 a.m. and returns home by 3:30 p.m.
Her interests include watching cartoons and playing games on a tablet device. Her mother values
being able to provide the developmental services that Dion requires and reported that her current
need is for Dion “to be more like children her age.”
ADLs
Regarding self-care, Dion can drink from an open cup with frequent spillage but mainly uses a sippy
cup. She can feed herself with a spoon but prefers to finger feed. Dion can doff her socks and pull-
over shirts and untie her laces but is unable to take off any other items. She is dependent on donning
all garments. Dion is not toilet trained and does not indicate when she needs toileting. Regarding
functional mobility, she has no gross deficits in bed mobility, transfers, or functional ambulation on
level surfaces. She ascended and descended stairs in a nonreciprocal pattern while holding onto a
rail.
IADLs
Dion often tries to remove her car seat restraint, which overwhelms her caregivers. She is able to
swipe and answer her mother’s smartphone. Regarding rest and sleep, it has been identified that
Dion experiences fragmented sleep with elevated nonrespiratory arousal indices.

Dion presented with fleeting eye contact. She inconsistently followed one- or two-step commands
and was easily distracted by visual and auditory stimuli. She frequently required redirection to stay
on task. Dion exhibited separation anxiety when her mother was not in arm’s reach and had diffi-
culty being seated and would frequently stand.

Deficits were noted in vestibular, tactile, auditory, and olfactory functions. Dion demonstrated quick
and abrupt movements that resulted in bumping into objects, tripping, and occasionally falling.
She demonstrated avoidance in touching rice, Play-Doh, shaving cream, and lotion as well as when
presented with strong odors. Dion eats a limited menu of items from home such as cereal, muffins,
chicken nuggets, fries, and yogurt. She was distracted by auditory stimuli during the evaluation,
DION: FETAL ALCOHOL SYNDROME | 331
often stopping to see where sounds were coming from or asking, “What was that?” According to
her mother, Dion becomes upset around loud noises such as fire trucks and will cover her ears. No
pain was reported.

MOVEMENT FUNCTIONS
Passive and active range of motion for all extremities was within functional limits. The Peabody
Developmental Motor Scales (2nd ed.; PDMS−2; Folio & Fewell, 2000) was administered. For the
test’s Grasping subtest, her results were raw score of 37, standard score of 4, and description of poor.
For the test’s Visual−Motor Integration Skills subtest, her results were raw score of 90, standard
score of 7, and description of below average. Dion scored a 73 on the test’s composite Fine Motor
Quotient. Regarding grasp, Dion demonstrated a right-hand preference but throughout the eval-
uation demonstrated a variety of immature grasp patterns. She also demonstrated difficulty with
stabilizing objects with her nonpreferred hand. Dion used a three-jaw chuck grasp pattern to pick
up 1-inch blocks and attempted unsuccessfully to use the same pattern to pick up small pellets. She
was able to string four large beads but required stabilization of her trunk, forearms, and wrists on
the table for support. During the graphomotor portion of the evaluation, Dion alternated between a
fisted grasp and brush grasp pattern when holding a marker. She was able to imitate horizontal and
vertical strokes, but the lines were angled. Dion was unable to independently hold scissors with a
thumb-up grasp or to snip paper. She was able to complete a five-piece insert puzzle and imitate a
tower of 10 blocks.
Dion presented with low muscle tone in her trunk and extremities. When seated at the table, she
presented with a rounded back and a posterior pelvic tilt with a wide base of support. Protective
reactions are intact but delayed in all directions when seated upright on a vestibular board.
PLAN FOR DISCHARGE

Dion will continue to receive EI services until she maximizes function or reaches age 3 years.

1. Identify the common comorbidities associated with FAS.
2. When traveling in a car, in which location and position should Dion’s car seat be set?
3. In your state, when would it be appropriate to discontinue the current use of a car seat with Dion? Cite
your source.
4. Given Dion’s hypersensitivity to smell and touch, what considerations should be made during the oc-
cupational therapy process?
with FAS. Evaluate them, select the strongest source, and justify your selection.
6. Identify the common emotional reactions associated with FAS that may affect the treatment process.
7. To keep Dion and others safe, what other safety factors should be considered?
Dion’s occupational performance.

1. Identify Dion’s useful habits, routines, roles, and rituals that support valued occupations. How can you
2. Identify Dion’s impoverished habits, routines, roles, and rituals that do not support valued occupa-
3. Identify Dion’s dominating habits, routines, roles, and rituals that interfere with valued occupations.
CLIENT FACTORS
How can identified values, beliefs, and spirituality be used in this case?
Body structures
Considering Dion’s primary and secondary diagnoses, identify the related body structures.
Body functions
structures.
2. Explain the relationships between the structural and functional factors and her current level of occu-
pational performance.

1. Compare and contrast FAS with child developmental delay.
2. Describe the correlation between intelligence quotient and FAS.
3. How can Dion’s separation anxiety impede her daily activities?

4. Explain the effect of Dion’s sleep hygiene on her mental functions.
5. Identify strategies that can be used to maximize Dion’s attention.

2. Provide a probable explanation of why Dion leaned on the table during the performance of fine motor
activities.
3. Dion exhibits a rounded back posture. How could it affect her socialization?
4. Explain in biomechanical terms how Dion’s sitting posture may affect her handwriting.
5. Create an exercise program based on occupational performance for Dion.

2. Identify the typical ranges for heart rate, blood pressure, and respiration rate for children of Dion’s age.

1. What are the common skin concerns with children who are not toilet trained?
2. Given Dion’s sitting posture, which structure may be at greater risk for skin breakdown?

Describe how Dion’s diagnoses may affect her voice, speech, and associated occupational performance.

What assistive technologies or adaptations might be used or made for Dion while she is receiving occu-
pational therapy services? Why?

1. Does toilet training fall within the scope of practice in occupational therapy?
2. Dion’s mother reports that Dion’s father would like to observe a therapy session. What steps must be
taken given this request?
3. Toward the end of the school day, you informed the teacher’s aide that Dion is soiled and needs to be
changed. The aide states, “Just leave her; she will be going home soon.” How should this situation best
be addressed?
PHARMACOLOGY
Dion is currently taking a choline supplement.
2. Does this nutrient have a high alert status?
3. What is the classification of this nutrient?
4. What is the indication for this nutrient?
5. What is the action of this nutrient?
6. How may this nutrient affect client participation during a therapy session?

1. Given Dion’s profile, how may your own culture and beliefs affect your interaction with her?
case.

1. What is the purpose of the PDMS−2?
5. What is the reliability of the PDMS−2?
6. What is the validity of the PDMS−2?
7. Is the PDMS–2 a norm-referenced or criterion-reference assessment tool?
8. What functional inference can be deduced from Dion’s fine motor quotient score of 73?

2. Given your state’s policies and procedures on EI services, can OTAs play a role in the delivery of EI
occupational therapy services?
BILLING AND CODING

1. Identify the International Classification of Diseases (ICD) codes for Dion’s diagnoses.

1. Who would be the authorized persons you could share the occupational therapy findings with? Explain
why.
2. Who would be the unauthorized persons you could not share the occupational therapy findings with
without written permission? Explain why.
3. For this case, what forms of documentation will be required?
ADVOCACY
resources?
TELEHEALTH
2. Before launching telemedicine services, what questions would be essential to ask Dion’s mother to
determine whether it is appropriate for Dion to engage in telemedicine services?

patterns.
modify, or prevent.

attention.

REFERENCES
Folio, M. K., & Fewell, R. (2000). Peabody Developmental Motor Scales: Examiner’s manual (2nd ed.). PRO-ED.
Appendix A. Educator’s Guide
This educator’s guide is a practical reference resource for academic and clinical educators using this text
as a dynamic instructional tool in developing occupational therapy students’ interpersonal, professional,
clinical, and critical reasoning skills as they prepare for entry-level practice.
Universal Themes Presented Throughout the Text

This text includes the following themes:
• The interrelationship of the uniqueness of the individual, practice setting, length of stay, diagnosis,
available resources, and discharge plan must remain in focus.
• Varied views help identify what works best in treating diverse individuals, contributing to effective
development of critical thinking.
• Personal reflection contributes to the development of occupational therapy practitioners for contem-
porary practice.
Tenets
TENET: DIVERSITY, EQUITY, AND INCLUSION

A tenet of this text is the intentional integration of diversity, equity, and inclusion (DEI) principles as
a guiding framework for developing critical thinking skills related to the occupational therapy process
through a variety of practice areas and client populations. Academic and clinical educators can incorpo-
rate this text as an instructional strategy to promote students’ cultural humility, foster awareness, and
build competency. Each case gives students the opportunity to critically acknowledge their own implicit
and explicit biases and discuss grounded strategies with their instructors, supervisors, and peers through
a collaborative process.
TENET: INTERDISCIPLINARY AND INTRADISCIPLINARY PRACTICE

A tenet of this text involves occupational therapy students learning principles of intradisciplinary and
interdisciplinary practice through a variety of practice areas and client populations. Through facilitation
and modeling, students explore the integration of teamwork through a multi-contextual model, expand
interpersonal and soft skills, learn the intricacies of conflict resolution, and appreciate of the versatility
of leadership skills.
337
TENET: FROM CLASSROOM TO PRACTICE

A tenet of this text is balancing occupational therapy theory and practice. This balance is an important
aspect of the developing student and entry-level practitioner and is outlined through the intentional in-
clusion of the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; American
Occupational Therapy Association, 2020) and a variety of practice areas and client populations. Academic
and clinical instructors can integrate guiding questions from case studies through the lens of the OTPF–4
domain and process to allow students to bridge their own understanding and interpretation of theory and
practice.
Section I. Acute Care

Dominant themes in Section I, “Acute Care,” include
• use of the medical model,
• acknowledgement of a fast-paced environment,
• short length of stays,
• prioritizing which problems or barriers to address, and
• transition planning.
Cases have been designed to present the medical history, social history, referral or prescription, and
initial evaluation findings of diverse individual. Questions and activities then guide critical thinking. Case
content can be matched to Accreditation Council of Occupational Therapy Education (ACOTE®; 2018)
standards, course outcomes, or learning objectives (see Table A.1). Portions of a case, or a case in totality,
can be assigned, depending on course need. In addition, text content can be used to unify courses being
offered during a semester, or interconnect past, present and future courses. Case questions and activities
have been constructed to parallel Bloom’s Taxonomy of Learning (Bloom et al., 1956). This section focuses
on principles of safety, promotes interdisciplinary practice, emphasizes addressing outcomes related to
functional and discharge readiness, and highlights the value of therapeutic education.
Section II. Outpatient Rehabilitation

Dominant themes in Section II, “Outpatient Rehabilitation,” include
• acknowledging that the individuals receiving services live in community,
• use of biomechanical and medical models,
• use of bottom-up approaches, and
• interspersed treatment sessions.
content can be matched to ACOTE (2018) standards, course outcomes, or learning objectives. Portions of
a case, or a case in totality, can be assigned, depending on course need. In addition, text content can be
used to unify courses being offered during a semester, or interconnect past, present, and future courses.
APPENDIX A. EDUCATOR’S GUIDE | 339
The section highlights lengths of stay, frequency and duration of services, clinical emphasis of commu-
nity reintegration, and outcomes focused on enhancing functional engagement in community-oriented
IADLs.
Section III. Rehabilitation Unit or Rehabilitation Hospital

Dominant themes introduced in Section III, “Rehabilitation Unit or Rehabilitation Hospital,” include
• transfers from another unit or facility;
• hospital-based facilities;
• individuals demonstrating potential for functional improvement;
• individuals who are medically stable;
• short-term, intense therapy; and
• a focus on skills needed to return home.
This section emphasizes principles of length of stay, reimbursement-specific documentation, biomechan-
ical and rehabilitative frames of references, interdisciplinary and intradisciplinary approaches to care,
and occupational-centered outcomes.
Section IV. Subacute Rehabilitation

Dominant themes introduced in Section VI, “Subacute Rehabilitation,” include
• transfers from another unit or facility,
• typically non hospital–based facilities,
• individuals demonstrating potential for functional improvement,
• individuals who are medically stable,
• extended periods of less intense therapy, and
• a focus on skills needed to return home.
This section emphasizes principles of discharge planning, client- and occupation-centered goal develop-
ment, occupational adaptation and therapeutic educational approaches to care, and strategies on measur-
ing functional outcomes.
Section V. Skilled Nursing Facility or Long-Term Care

Dominant themes introduced in Section V, “Skilled Nursing Facility or Long-term Care,” include
• transfers from another unit, facility, or community;
• individuals who are unable to live in the community independently;
• facilities serving as residences;
• individuals who demonstrate potential for limited functional improvement;
• individuals who are medically stable; and
• a focus on comfort and maintenance.
content can be matched to ACOTE (2018) standards, course outcomes and or learning objectives. Portions
of a case, or a case in totality, can be assigned, depending on course need. In addition, text content can be
This section emphasizes principles of maintenance and restorative care, holistic consideration of mental
health needs through a traditional rehabilitative lens, principles of geriatric care and occupational adap-
tation, interdisciplinary and intradisciplinary care, consideration of hospice and palliative care.
Section VI. Home and Community Health

Dominant themes introduced in Section VI, “Home and Community Health,” include
• interfacility transfers;
• individuals who are residing in the community;
• understanding the homebound status and its impact on occupations;
• multiple services and managing expectations;
• individuals who demonstrate potential for functional improvement;
• medical stability and perceived health and wellness outlooks;
• short-term, intermittent therapy delivered in the home;
• a focus on skills needed for independent living; and
• accessing community resources.
content can be matched to ACOTE (2018) standards, course outcomes, or learning objectives. Portions of a
case, or a case in totality, can be assigned, depending on course need. In addition, text content can be used
to unify courses being offered during a semester, or interconnect past, present and future courses. This
section emphasizes principles of community-centered interventions, community reintegration, socioeco-
nomic factors related to disparities and resources, case management, familial and nontraditional support
systems, and exploration of contemporary community-centered and culturally sensitive resources.
Section VII. Behavioral Health

Dominant themes introduced in Section VII, “Behavioral Health,” include
• individuals who may be considered a danger to self or others,
• individuals who may be hospitalized with or without their consent,
• skills development,
• establishing positive health habits and promoting wellness,
• developing positive routines from a DEI approach to practice, and
• exploring benefits of using community resources that are important to the client.
used to unify courses being offered during a semester, or interconnect past, present and future courses.
This section emphasizes principles of safety and quality of life, positive behavioral supports, varying
forms of hospitalization and the impact towards recovery, and the micro and macro impacts of mental
illness.
Section VIII. Pediatric Services

Dominant themes introduced in Section VIII, “Pediatric Services,” include
• migrating through the variety of service delivery sites,
• use of the development model,
• the impact of age on available resources,
• balancing best practices and institutional influences,
• play as an occupation,
• skill acquisitional approaches and DEI principles of practice, and
• acknowledgment of the role of a guardian and or nontraditional care provider.
initial evaluation findings of diverse individual. Questions and activities then guide critical thinking.
Case content offers can be matched to ACOTE (2018) standards, course outcomes, or learning objec-
tives. Portions of a case, or a case in totality, can be assigned, depending on course need. In addition, text
content can be used to unify courses being offered during a semester, or interconnect past, present, and
future courses. This section emphasizes development and contextual influence, academic and occupa-
tional-centered practice, expansion of the student’s occupational profile through a DEI lens, and the inte-
gration of pediatric practice from a sociocultural and institutionally inclusive approach.
Bloom’s Taxonomy
ACADEMIC EDUCATORS
The “Questions and Activities Guiding Critical Thinking” parts of this text were carefully crafted using
Bloom’s Taxonomy, a hierarchical classification of different levels of thinking (Bloom et al., 1956; see Table
A.1). Course instructors can use this organizational hierarchy to
• systematically require deeper thinking of students,
• support course learning goals and objectives,
• classify learning goals,
• provide structure to the teaching and learning process,
• create lesson plans,
• assess students’ comprehension of course materials, and
• foster intellectual growth.
CLINICAL EDUCATORS
The “Questions and Activities Guiding Critical Thinking” parts of this text were carefully crafted using
Bloom’s Taxonomy (see Table A.1). Clinical educators can use this organizational hierarchy to
• systematically require deeper levels of knowledge, greater skill, and appropriate attitude from students;
• support fieldwork learning goals and objectives;
• classify learning goals that support entry-level practice;
• provide structure to the teaching and learning process;
• create periodic benchmarks or targets;
• assess students, knowledge, skill, and attitude; and
• foster growth toward entry-level practice.
TABLE A.1. “Questions and Activities Guiding Critical Thinking” According to Bloom’s Hierarchical Progression of Learning
Hierarchical
Progression of
Learning Remembering Understanding Applying Analyzing Evaluating Creating
Learning out- Students recall Students ex- Students use Students distin- Students justify Students
come in the cog- or remember plain ideas or information in a guish between a stand of produce a new
nitive domain information. concepts. new way. different parts or decision. product or point
components. of view.
Look for ques- list, state, repro- explain, describe, choose, inter- compare, con- defend, select, create, design,
tions that start duce, repeat, select, translate, pret, demon- trast, criticize, argue, judge, sup- construct, de-
with or contain memorize, dupli- recognize, locate, strate, employ, differentiate, port, evaluate, velop, formulate,
any of these cate, define report, discuss, operate, sched- discriminate, judge, write
keywords. classify ule, illustrate, distinguish, ex-
amine, question,
test
Classification 1 2 3 3 5 6
Level Lowest Highest
Note. The higher the classification level, the high the level of clinical reasoning skill the student has obtained.
REFERENCES
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process
(4th ed.). American Journal of Occupational Therapy, 74(2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives:
The classification of educational goals. Vol. Handbook I: Cognitive domain. David McKay Company.
Appendix B. Matching ACOTE® Standards
and Learning Outcomes With Text
Questions and Activities Tool
Identify the Page(s), Section(s),

Identify Your Course, Lecture, and Questions or Activity
or Assignment That Addresses B Standard Content Numbers You Want to Assign
a Related ACOTE Standard Requirement Learning Outcome to Your Students
B 1.0. FOUNDATIONAL B.1.1. Human Body,

CONTENT REQUIREMENTS Development, and Behavior
Program content must be
B.1.2. Sociocultural,
based on a broad foundation
Socioeconomic, Diversity
in the liberal arts and sciences.
Factors, and Lifestyle Choices
A strong foundation in the
biological, physical, social, and B.1.3. Social Determinants of
behavioral sciences supports Health
an understanding of occu-
B.1.4. Quantitative Statistics and
pation across the lifespan. If
Qualitative Analysis
the content of the Standard
is met through prerequisite
coursework, the application
of foundational content in the
sciences must also be evident
in professional coursework.
B 2.0. OCCUPATIONAL B.2.1. Scientific Evidence,
THERAPY THEORETICAL Theories, Models of Practice,
PERSPECTIVES and Frames of Reference
Current and relevant interpro-
B.2.2. Theory Development
fessional perspectives including
rehabilitation, disability, and
developmental as well as per-
son/population–environment–
occupation models, theories
and frameworks of practice.
The program must facilitate the
development of the perfor-
mance criteria listed.
(Continued)
345

B.3.0. BASIC TENETS OF B.3.1. OT History, Philosophical

OCCUPATIONAL THERAPY Base, Theory, and Sociopolitical
Coursework must facilitate de- Climate
velopment of the performance
B.3.2. Interaction of Occupation
criteria listed.
and Activity
B.3.3. Distinct Nature of

Occupation
B.3.4. Balancing Areas of

Occupation, Role in Promotion
of Health, and Prevention
B.3.5. Effects of Disease

Processes
B.3.6. Activity Analysis
B.3.7. Safety of Self and Others

B.4.0 REFERRAL, SCREENING, B.4.1. Therapeutic Use of Self
EVALUATION, AND
B.4.2. Clinical Reasoning
INTERVENTION PLAN
The process of referral, screen- B.4.3. Occupation-Based
ing, evaluation, and diagnosis as Interventions
related to occupational perfor-
B.4.4. Standardized and
mance and participation must
Nonstandardized Screening and
be client centered; culturally
Assessment Tools
relevant; and based on theo-
retical perspectives, models of B.4.5. Application of
practice, frames of reference, Assessment Tools and
and available evidence. Interpretation of Results
B.4.6. Reporting Data
B.4.7. Interpret Standardized

Test Scores
B.4.8. Interpret Evaluation Data
B.4.9. Remediation and

Compensation
B.4.10. Provide Interventions

and Procedures
B.4.11. Assistive Technologies
and Devices
(Continued)
APPENDIX B. MATCHING ACOTE® STANDARDS AND LEARNING OUTCOMES WITH TEXT QUESTIONS AND ACTIVITIES TOOL | 347

B.4.12. Orthoses and Prosthetic

Devices
B.4.13. Functional Mobility
B.4.14. Community Mobility
B.4.15. Technology in Practice
B.4.16. Dysphagia and Feeding

Disorders
B.4.17. Superficial Thermal,
Deep Thermal, and
Electrotherapeutic Agents and
Mechanical Devices
B.4.18. Grade and Adapt

Processes or Environments
B.4.19. Consultative Process
B.4.20. Care Coordination, Case

Management, and Transition
Services
B.4.21. Teaching–Learning
Process and Health Literacy
B.4.22. Need for Continued or

Modified Intervention
B.4.23. Effective
Communication
B.4.24. Effective
Intraprofessional Collaboration
B.4.25. Principles of
Interprofessional Team
Dynamics
B.4.26. Referral to Specialists
B.4.27. Community and Primary

Care Programs
B.4.28. Plan for Discharge
B.4.29. Reimbursement Systems

and Documentation
(Continued)

B.5.0 CONTEXT OF SERVICE B.5.1. Factors, Policy Issues, and

DELIVERY, LEADERSHIP, Social Systems
AND MANAGEMENT OF
B.5.2. Advocacy
OCCUPATIONAL THERAPY
SERVICES B.5.3. Business Aspects of
Context of service deliv- Practice
ery includes knowledge and
B.5.4. Systems and Structures
understanding of the various
That Create Legislation
contexts, such as professional,
social, cultural, political, eco- B.5.5. Requirements for
nomic, and ecological, in which Credentialing and Licensure
occupational therapy services
B.5.6. Market the Delivery of
are provided. Management and
Services
leadership skills of occupational
therapy services include the B.5.7. Quality Management and
application of principles of Improvement
management and systems in
B.5.8. Supervision of Personnel
the provision of occupational
therapy services to persons,
groups, populations, and orga-
nizations. The program must
facilitate development of the
performance criteria listed.
B.6.0. SCHOLARSHIP B.6.1. Scholarly Study
Promotion of science and
B.6.2. Quantitative and
scholarly endeavors will serve
Qualitative Methods
to describe and interpret the
scope of the profession, build B.6.3. Scholarly Reports
research capacity, establish
B.6.4. Locating and Securing
new knowledge, and interpret
Grants
and apply this knowledge to
practice. The program must B.6.5. Ethical Policies and
facilitate development of the Procedures for Research
B.6.6. Preparation for Work in
an Academic Setting
(Continued)
APPENDIX B. MATCHING ACOTE® STANDARDS AND LEARNING OUTCOMES WITH TEXT QUESTIONS AND ACTIVITIES TOOL | 349

B.7.0. PROFESSIONAL B.7.1 Ethical Decision Making

ETHICS, VALUES, AND
B.7.2. Professional Engagement
RESPONSIBILITIES
Professional ethics, values, B.7.3. Promote Occupational
and responsibilities include an Therapy
understanding and appreci-
B.7.4. Ongoing Professional
ation of ethics and values of
Development
the profession of occupational
therapy. Professional behaviors B.7.5. Personal and Professional
include the ability to advocate Responsibilities
for social responsibility and
equitable services to support
health equity and address social
determinants of health; commit
to engaging in lifelong learning;
and evaluate the outcome of
services, which include client
engagement, judicious health
care utilization, and popula-
tion health. The program must
facilitate development of the
Source. Standards from ACOTE (2018). Copyright © 2018 by the American Occupational Therapy Association. Used with permission.
Note. ACOTE = Accreditation Council for Occupational Therapy Education; OT = occupational therapy.
REFERENCE
Appendix C. Diversity Represented
Through Individuals Presented in Cases
Sexual Disability Race and

Chapter # Name Age Gender Orientation Nationality Religion Status Ethnicity
1 Juan 67 Male Homosexual Guatemalan Catholic Physical Hispanic/

American Latino
2 Song 69 Female Heterosexual Korean Taoism Physical, Asian
American cognitive
3 Ethan 26 Male Heterosexual African Black Physical, Black
American Hebrew sensory
Israelite
4 Hannah 81 Female Heterosexual Chippewa Ojibwa Physical Native
American
5 Howie 84 Male Heterosexual Filipino Catholic Physical Pacific
Islander
6 Florence 69 Female Asexual Irish Anglican Physical White
American
7 Brian 31 Male Heterosexual Native Buddhist Physical Native
Hawaiian Hawaiian
8 Yvonne 44 Female Homosexual African African Physical Black
American Methodist
Episcopal
Church
9 Chin 62 Male Heterosexual Chinese Confucianist Physical Asian
American
10 Patricia 36 Female Heterosexual Danish Evangelical Physical White
American Lutheran
11 Fetu 71 Male Heterosexual New Presbyterian Physical, Pacific
Zealander cognitive Islander
12 Bianca 47 Female Heterosexual Dominican Church of Physical, Hispanic/
American Scientology sensory Latina
13 Derrick 19 Male Pansexual Polish Agnostic Physical, White
American cognitive
(Continued)
351

14 Sharon 59 Female Heterosexual Jamaican United Physical, Black

(Transgender) Church of emotional
Christ
15 Zachary 75 Male Heterosexual Australian Orthodox Physical Pacific
Christian Islander
16 Isaura 38 Female Heterosexual Puerto Rican Catholic Physical, Hispanic/
emotional Latina
17 Pierre-Louis 82 Male Heterosexual Haitian Haitian Physical Black
American Vodou
18 Rosalind 51 Female Homosexual Ukrainian Jewish Physical, White
American cognitive,
sensory
19 Aki 91 Male Heterosexual Japanese Shinto Physical, Asian
American cognitive
20 Ting 72 Female Heterosexual Malaysian Buddhist Physical, Asian
American sensory
21 Jacob 94 Male Heterosexual Israeli Hasidic Physical, White
Judaism cognitive
22 Aretha 78 Female Heterosexual Trinidadian Jehovah Physical Black
American Witness
23 Epa 72 Female Heterosexual Polynesian Animism Physical, Pacific
American Sensory Islander
24 Mohammad 77 Male Heterosexual Iranian Sunni Muslim Physical White
American
25 Eileen 57 Female Heterosexual Irish Catholic Physical White
American
26 José 81 Male Heterosexual Salvadoran Dominican Physical, Hispanic/
American Santeria sensory Latino
27 Katrina 38 Female Heterosexual Georgian Russian Physical, White
American Orthodox cognitive
28 Ivy 66 Female Homosexual Nigerian Baptist Physical Black
American
29 Zoran 63 Female Heterosexual German Yazidi Emotional, White
American physical
30 Gabriela 22 Female Heterosexual Honduran Catholic Emotional Black/
Hispanic
(Continued)
APPENDIX C. DIVERSITY REPRESENTED THROUGH INDIVIDUALS PRESENTED IN CASES | 353

31 Samuel 62 Male Heterosexual African Born Again Emotional Black

American Christian
32 Emmanuel 31 Male Heterosexual Moroccan Shia Muslim Behavioral Black
American
33 Andres 57 Male Heterosexual Columbian Pentecostal Behavioral Hispanic/
American Christian Latino
34 Brianna 18 Female Bisexual Armenian Christian Behavioral White
American
35 Victoria 10 Female Unassigned Venezuelan Catholic Physical, Hispanic/
American sensory Latina
36 Abigale 10 Female Unassigned Peruvian Roman Cognitive, Hispanic/
American Catholic physical Latina
37 Andrei 13 Male Homosexual Belarusian Russian Cognitive, White
American Orthodox sensory
Catholic
38 Dara 5 Female Unassigned British Pentecostal Intellectual, White
American Christian Physical
39 Chi-Ling 10 Female Unassigned Taiwanese Yinguidoa Physical, Asian
American sensory
40 Dion 2.5 Female Unassigned Liberian African Cognitive, Black
American Methodist sensory,
Episcopal physical
Zion
Case Studies for Contemporary Occupational Therapy Practice
Edited by Donald Auriemma, MS ED, OTR/L; Yves Roseus, OTD, OTR/L; Clover Hutchinson, OTD, MA, OTR/L;
and Vikram Pagpatan, OTR/L, ATP, BCP, CLA
R
ealistic case studies are a critical part of occupational therapy education to strengthen students’ clinical reasoning
skills, challenge their assumptions and biases, and expose them to the complexities of real clients. Case Studies for
Contemporary Occupational Therapy Practice comprises 40 case studies across eight practice settings. Appropriate for
use throughout the occupational therapy curriculum, cases guide critical thinking and bridge contemporary practice with the
Occupational Therapy Practice Framework and ACOTE® education standards.
Occupational therapy practitioners, students, and educators will find thoughtful case studies that reflect the diversity of clients
encountered in practice and incorporate principles of equity, justice, inclusion, and belonging through a model of cultural
awareness, humility, and empathy. Guided questions challenge students to develop analytical, pragmatic, inferential, and
clinical reasoning skills, equipping them for entry-level practice. New and seasoned practitioners can hone their clinical
reasoning skills as they gain expertise in their current practice setting or prepare to transition to a new one.
Contents include—
• Section I. Acute Care ALSO AVAILABLE
• Section II. Outpatient Rehabilitation FROM AOTA PRESS
• Section III. Rehabilitation Unit or Rehabilitation Hospital Clinical Reasoning in
• Section IV. Subacute Rehabilitation Occupational Therapy
• Section V. Skilled Nursing Facility or Long-Term Care By Anne Cronin, PhD,
• Section VI. Home and Community Health OTR/L, ATP, FAOTA; and
• Section VII. Inpatient Behavioral Health Unit or Hospital Garth Graebe, MOT, OTR/L
• Section VIII. Pediatric Services Order #900388.
• Appendixes: Educator’s guide, tool for matching ACOTE Also available as an ebook!
standards and learning outcomes with test questions Order #900480.
and activities, and an overview of diversity represented
through cases.
Each case study includes a detailed medical and social history that reflects clients’ occupational identities; initial evaluation
findings that draw on culturally centered occupational profiles and occupation-centered evaluation of cognitive, mental, and
physical function; and thought-provoking questions that address aspects of community reintegration, social determinants of
health, and disparities. An educator’s guide supports integration of the text in occupational therapy curriculum.
Comprehensive and contemporary, this new text guides and prepares students and practitioners to enter practice in a diverse
and rapidly changing world.
Realize Your Boundless Potential With AOTA Membership

No matter where you are in your professional journey, AOTA lifts you up so that you can achieve your boundless potential and
create life-changing solutions for those you serve. The American Occupational Therapy Association represents more than
230,000 occupational therapy professionals and students in the U.S. to advance occupational therapy practice, education,
and research. Membership empowers you to stay current on best practices and grow continuously, with flexible membership
options including access to online continuing education courses, savings on publications, and much more. Feed your creativity,
power your boundless potential, and change lives today. Visit www.aota.org/membership to learn more.
6116 Executive Boulevard, Suite 200

North Bethesda, MD 20852-4929
To order, call 800-729-AOTA (2682).
Shop online at store.aota.org

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Case Studies for Contemporary

Occupational Therapy Practice

Edited by Donald Auriemma, Yves Roseus,

Edited by Donald Auriemma, MS ED, OTR/L; Yves Roseus, OTD, OTR/L;

Elizabeth Dooley, Vice President, Strategic Marketing & Communications

Rebecca Rutberg, Director, Marketing

American Occupational Therapy Association, Inc.

Cover art by Darlyn Mora Almonte, Jamaica, NY

Section I. Acute Care......................................................................................................................1

Section II. Outpatient Rehabilitation ....................................................................................43

Section III. Rehabilitation Unit or Rehabilitation Hospital .............................................85

Chapter 12. Bianca: Spinal Cord Injury, Complete C5 ...........................................................................................95

Section IV. Subacute Rehabilitation ..................................................................................... 127

Section V. Skilled Nursing Facility or Long-Term Care .................................................... 169

Section VI. Home and Community Health ..........................................................................203

Chapter 27. Katrina: Huntington’s Disease............................................................................................................. 221

Section VII. Inpatient Behavior Health Hospital or Unit ................................................ 237

Section VIII. Pediatric Services.............................................................................................. 287

Appendix A. Educator’s Guide ..................................................................................................................................337

Donald Auriemma, MS ED, OTR/L

Kerron Blunte, MS, OTR/L, CLT

Carol Brown-Wassinger, MS, OTR/L

Tiffany Cordero-Velez, MS, OTR/L

Mary Devadas, MS, OTR/L, DBA

Bebe Haniff, MS, OTR/L

Clover Hutchinson, OTD, MA, OTR/L

Vikram Pagpatan, OTR/L, ATP, BCP, CLA

Susan Quintin, MS, OTR/L

Ivy Rentz, EdD, MSA, OTR/L

Eva Rodriguez, PhD, OTR

Yves Roseus, OTD, OTR/L

Paula Stewart, MS, OTR/L

Frederick Wolodin, MS, OTR/L

—Darlyn Mora Almonte, OTS

How This Text is Organized

Juan: Myocardial Infarction

Juan (he, him, his, himself)

Occupational Therapy Initial Evaluation Findings: Acute Care

CARDIOVASCULAR AND RESPIRATORY SYSTEMS FUNCTION

PLAN FOR DISCHARGE

Questions and Activities

SAFETY OF CLIENT AND OTHERS: PRECAUTIONS AND CONTRAINDICATIONS

PERFORMANCE SKILLS: MOTOR, PROCESS, AND SOCIAL INTERACTION SKILLS

PERFORMANCE PATTERNS: HABITS, ROUTINES, ROLES, AND RITUALS

MENTAL FUNCTIONS: AFFECTIVE, COGNITIVE, AND PERCEPTUAL

NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS

CARDIOVASCULAR, HEMATOLOGICAL, IMMUNOLOGICAL, AND RESPIRATORY FUNCTIONS

SKIN AND RELATED-STRUCTURE FUNCTIONS

VOICE AND SPEECH FUNCTIONS

ASSISTIVE TECHNOLOGIES AND DEVICES

SOCIOCULTURAL, SOCIOECONOMIC, AND DIVERSITY FACTORS AND LIFESTYLE CHOICES

ASSESSMENT TOOLS AND INTERPRETATION OF RESULTS

INTERPROFESSIONAL RELATIONSHIPS AND EFFECTIVE INTRAPROFESSIONAL COLLABORATION

BILLING AND CODING

REIMBURSEMENT SYSTEMS AND DOCUMENTATION

ETHICAL DECISION MAKING

Intervention Plan Formulation and Implementation

INTERVENTION PLAN FORMULATION

INTERVENTION PLAN IMPLEMENTATION

Transition and Discontinuation