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Saint Mungo's Hospital

Occupational Thearpy Initial Evaluation

Acute Care Setting (Setting 1)

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NAME: James Krum 

MRN: H07311980

AGE: 64 year old               DOB: 12/25/1960

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SUBJECTIVE: 

Patient reports that he feels ready to discharge home. He agrees to participate in occupational therapy evaluation. States that he has been getting up out of bed to go to the bathroom with CNA in the room, but not holding onto his gait belt. He denies pain.

Precautions: fall risk 

Lines/Drains/Airways: IV and Telemetry 

Usual Living Arrangement:

  • Lives with: adult child

  • Discharge Support System: adult son who works during the day. Daughter is currently living 2 hours away while attending college. Does have a few other siblings and friends who live locally, but does not see them on a regular basis.

  • Usual Living Arrangement: 2 story house, bedroom is on the second level. Full bathroom on each level. 

  • Steps to enter home:  2 steps with single railing ascending on right

  • Bathroom setup: walk-in shower, grab bars, raised toilet, shower chair

  • Durable medical equipment owned: none

 Prior Level of function:

  • Activities of Daily Living: independent

  • Instrumental Activities of Daily Living: independent, responsible for his yard work including snow removal

  • Prior mobility status: independent, without use of adaptive equipment or assistive devices

  • Job Status: retired truck driver, but continues to work part-time. Owns several dairy cows and teaches commercial driver’s license courses on the weekend at a local community college.

  • Falls in the past year: yes – reason for hospitalization, occurred due to a trip while going up the stairs.

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 OBJECTIVE:

Cognition

  • Mental status: 13/15 on Brief Interview for Mental Status (required cuing for 2 out of 3 words for delayed word recall)

  • Orientation: oriented x 4

  • Ability to follow commands: fair.

  • Comment: Has a tendency to attempt transferring sit to stand with improper positioning of left foot and requires frequent cuing to correct positioning, requires cuing to wash hands following toileting and to turn water off following hand washing.

Communication

  • No deficits

Vision

  • Wears glasses for distance only at baseline, eyewear not present at hospital. Reports being scheduled to see ophthalmologist for repeat eye exam due to risk for diabetic retinopathy.

  • Denies diplopia or blurred vision

  • Unable to correctly read clock on wall, however, was able to locate it. Able to read therapist’s name badge accurately.

  • Impaired left visual field, reduced ocular range of motion noted with left horizontal gaze

Sensation

  • Light touch sensation and sharp/dull discrimination intact about bilateral upper extremities

  • Denies numbness/tingling

Balance

  • Sitting within functional limits

  • Standing: demonstrates a wide base of support in static standing without upper extremity support, demonstrates increased lateral postural sway and need for minimum-moderate assistance for dynamic balance activities 

Musculoskeletal

  • Right upper extremity range of motion within functional limits actively and passively

  • Left upper extremity range of motion within functional limits passively, actively limited 

    • Shoulder flexion < 45 degrees

    • Elbow flexion/extension nearly full

    • Wrist and digit flexion/extension minimal active movement noted

  • Right upper extremity strength within functional limits

    • Grip strength 85 pounds, 87 pounds, and 92 pounds (average of 88 pounds)

  • Left upper extremity strength impaired, unable to assess grip strength with handheld dynamometry 

Neurologic

  • Decreased muscle tone to left upper extremity 

  • Coordination: difficulty completing fingertip-to-nose on left upper extremity, but able to bring hand to nose with significant hypometria

  • Inattention to left upper extremity noted with transfers, scanning to left to locate paper towel holder on wall after washing hands

Cardiovascular

  • Activity tolerance: fair

Functional Activities:

  • Lower body dressing- dons/doffs bilateral socks with minimum assistance to maintain left lower extremity in figure four positioning

  • Toileting- requires contact guard assistance to maintain standing balance in order to urinate, requires up to minimum assistance for anterior balance control when reaching to flush toilet

  • Transfers- requires moderate assistance at left side for sit to stand from recliner chair

  • Functional mobility- requires moderate assistance to ambulate to/from bathroom x 25 feet with handheld assistance at right upper extremity. Requires cuing for left foot positioning due to difficulty clearing foot off of floor. 

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ASSESSMENT:

Patient is a 64 year old male hospitalized for stroke work up due to left upper extremity numbness/tingling and slurred speech. Significant past medical history includes: hypertension, type II diabetes, CAD, please see electronic medical record for additional detail.  Prior level of function and patient home set up are listed above. Patient currently presents to Occupational Therapy with impaired left upper extremity range of motion, strength, and coordination with inability to actively grip. He has difficulty attending to his left side and appears to demonstrate a left visual field cut, impaired balance, and impaired cognition that are ultimately impacting his safety and stability with activities of daily living and functional mobility. He is requiring up to moderate assistance for transfers and ambulation to/from bathroom and minimum assistance to complete toileting tasks, which is a significant decline since last mobilized by nursing earlier today (standby assist level). Writer notified RN of examination findings, and she called a code stroke given increase in distal left upper extremity weakness, difficulty with mobility, and decline in vision status. Patient is currently not safe to discharge home and will benefit from continued Occupational Therapy plan of care to address aforementioned deficits to facilitate improved independence and ease of activities of daily living.  

Discharge Recommendations: post-acute rehab - questionable ability to tolerate 3 hours of therapy

 

Equipment Recommendations: to be determined

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Prognosis: good 

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Strengths Facilitating Progress: high motivation, strong support system, previously independent

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Occupational Therapy Frequency/Plan: 5-6 times/week

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Next Treatment Plan: keep with OTR to assess safe mobility options to bathroom, standing balance with ADLs, reassess vision as necessary

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Occupational Therapist delegates full plan of care to an occupational therapist assistant. Communication topics include plan of care, patient update and precautions/contraindications through written communication. 

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Interventions: ADL training, Adaptive equipment training, Functional training, Health education/training, Manual therapy, Neuromuscular re-education, Therapeutic exercise, Transfer training

 

Electronic signature: Luna Chang, OTR/L 10/3/2024

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