Case 1

Occupational Therapy Assessment

COPM Findings  (Canadian Occupational Performance Measure)

ADL Assessment

• Independent with all dressing tasks but reduced endurance and SOB

• Independent with breakfast meal preparation but reduced endurance and frequent rest periods required

• Able to complete tub transfer/toilet transfer safely with use of equipment which is already available in the home

Driving Evaluation

Signed release by Andy that results of testing will be shared with physician

Visual Assessment:

• Visual Acuity-  Corrected with glasses to 20/50

• Contrast sensitivity – Poor

• Color Vision – Normal

• Depth Perception – Poor

• Visual Fields – Poor

• Visual Processing and Cognitive Assessment

• Good Traffic Symbol recognition

• Severely Decreased Brake Reaction Time

Andy is questioning his ability to continue to drive and has already self limited himself to driving only short distances in the daytime and not driving in winter weather

ROM/MMT

Shoulder Extension   140  R      120  L      

Elbow                         WNL        WNL

Wrist                          WNL        WNL

Fingers                       WFL         WFL          (arthritic changes)

Strength:                    4/5  Upper Extremity Strength

Home Evaluation:

It appears that re-arrangement of the furniture may be indicated to allow increased mobility safety and to provide rest areas secondary to endurance problems.  Additionally sitting surfaces need to be adjusted for ease of transfers from sit to stand.

Goals:

1. Andy will learn energy conservation strategies to allow independence in home for breakfast meal preparation.  Assist in arranging for meals to be brought in at other times.
2. Andy will use writing, computer skills for one way of increasing socialization-access adaptive equipment for ease of writing with arthritic hands.
3. Andy will improve functional mobility in his home as noted by decreased falls and  improved ability to transition form sit to stand and prone to sit.