Case 1
|
| Gross Muscular Function | 28/36 |
| Fine Movement | 10/16 |
| Locomotion | 12/16 |
| Motor Skills | 14/20 |
| Sensory | 15/20 |
| Cognition | 35/44 |
| Communication | 17/20 |
| Behavior | 19/24 |
| Total Score | 151/200 |
|
Client becomes visibly out of breath when writing and while walking distances of about 10 feet. |
|
He had difficulty holding a pen and picking up pieces of paper. It took him several attempts to grab hold of notebook paper. Reaction time is slow requiring preparation time for even slow speed reactions. |
|
Attention span limited if he is not
interested in the topic or if he has not initiated it. He enjoys speaking
about his life experiences and can attend to this topic for extended
periods of time (10-15 minutes). He has difficulty keeping focused on
topics for which he lacks familiarity.
He appears oriented to time and space. He has good long-term memory and no apparent problem solving difficulties. There are no apparent problems with right –left discrimination, laterality, figure ground discrimination or depth perception. |
|
He has good receptive skills. Expressive skills are limited. He is, at times difficult to understand. When speaking he appears to have difficulty controlling the movement of his tongue. His dentures may also need to be refitted. |
|
Client appears to have adjusted well to his limitations. He expresses concern over his mobility limitation especially as they relate to get out of the house and visiting friends. He also wishes he could drive during the winter months. He said that he is not confident on traveled roads and that he does not like to drive in the winter because the cold air effects his hear and he does not think he would be able to get help if he needed it. |
|
Client becomes emotional (cracking voice and teary eyes) when talking about his wife and his accomplishments. |
|
He enjoys being around people but his opportunities are limited to his home health aid, food net worker and a neighbor who visits two times a week. He really enjoys talking about himself and the writing that he does. He frequently tells stories about how well liked he is and how easy he was as a patient. It seems that these stories confirm his sense of self worth. |
|
Limited to sedentary activities such as writing and visiting. He used to raise animals and ride horses but is no longer able to keep up with this physical activity. He spends much of his free time watching television, preparing peppers and onions for his daily omelet that he prepares himself and in doing his writing. His barriers to participation in leisure activities include: lack of physical endurance, fear of going out into cold weather, and lack of transportation. His social network is also very limited. |
1. To provide more opportunities for involvement in socially based leisure activities.
2. To identify and adapt activities to compensate for physical limitations.
3. Recommend Speech Evaluation
4. Maintain cognitive skills through creative writing and problem solving games and activities.
|