OCCUPATIONAL THERAPY INITIAL EVALUATION

January 19, 2017

GENERAL INFORMATION
Name: F.C.
Age/Sex: 68
Date of Birth: 8/28/1948
Date of IE: 1/12/2017
Date of Referral:
Diagnosis: Diabetic Nephropathy/ Chronic Kidney Disease 2 DM Type II
o

Doctor-in-charge:
Referring Doctor:
OT-in-charge:
Precautions:
Present Medications: Systane, Clopidogrel, Folic Acid, Amlodipine, Ivetra, Fluimucil, Micardis, Iterax
(PRN), Paracetamol (PRN)

HISTORY OF PRESENT ILLNESS

This is the case of F.C., a 68 y/o F, married (+) HTN, (+) DM, (-) Smoker, dxd c Chronic
Kidney Disease 2 DM Type II c L UE monoparesis d/t Stroke. Client was referred to Occupational
o

Therapy for ADL Evaluation.

Pt.s first hospitalization was on October 2014, at the Sacred Heart Hospital in Malolos
d/t HTN. She was admitted for 1 week. By December 2014, Pt. complained of dizziness and had
an accident where she fell on her head, face first in their bathroom. The pt. went to the hospital
for check-up because of her dizziness on January 5, 2015 and was admitted on the same day d/t
to high creatinine levels, she was discharged on January 11, 2015. During admission, Pt. had a
perm. cath. placed on her R chest, started undergoing dialysis. She was prescribed for dialysis 2x
a wk. After two weeks, Pt. refused to eat and take her meds. On January 28, 2015, Pt. was
scheduled for dialysis, and was admitted again because pt. had general weakness of the LE and
was unable to close her left eye. She stayed in a private room and CT scan was performed to
assess for stroke. She was transferred to the ICU the next day d/t high WBC. CSF fluid was
collected via Lumbar Tap to r/o sepsis, was given an NGT for intake of food and meds., and was
aided by respirator for breathing. She stayed in the ICU for 4 days and was moved to a private
room with an ICU set-up because she is not properly attended to, she also developed ulcerations
on her gluteal region d/t unobserved turning schedule. She stayed in the private room for 1
month and 1 week, and was attended to by PDNs 24 hr/day. By the 3rd week of February, her
pressure sores were debrided and was given albumin vials as protein source for muscle recovery
and wound healing. During her stay in the hospital, her IV line was transferred to her R leg
because her forearm was developing edema. This then became a point of infection which
 resulted to a major wound. By March 2015, she was discharged. She has her PDN and caregiver
with her at home.
After discharge, Pt. underwent dialysis 3x a week. After 2 weeks, pt. was admitted back
to the hospital d/t absence seizures. She was admitted for 5 days and was prescribed with
Dilantin as medications. In between the months of April and June 2015, her wound on the R leg
was debrided twice, having a 2-3 week interval. At this time, pt. also developed a wound on her
forehead d/t to incessant and habitual scratching. Pt. started receiving PT once a week as
tolerated, which started on August 2015 until November 2015. Her therapy sessions were held
in between the days of her schedule for dialysis. Her PT treatment was stopped when she
started developing a cough. She went back to the hospital for check-up, and her trache was
evaluated and was recommended for replacement. On January 2016, pt. underwent surgery for
trache replacement and was confined for 3-4 days. Pt treatment was continued on March 2016
but was stopped after 4 sessions because pt. was beginning to have a cough.
By the last week of May 2016, pt. had several low-grade fevers, lost appetite, and
general weakness. Pt. was admitted again for 3 weeks d/t pneumonia and sepsis. Blood C&S was
performed and MRSA were found and treated. NGT was placed for the 2nd time and her perm.
cath. was transferred to the L chest. NGT was removed by the pt. on August 2016.

Ancillary Procedures
CT Scan - revealed stroke
Wound debridement - remove infected/necrotic flesh on R leg
Tracheostomy
Permanent Catheterization
Blood C&S
Lumbar Tap/CSF Fluid Examination
PERSONAL AND SOCIAL HISTORY
The client is a retired chemistry teacher at Holy Spirit Academy where she spent 25 years
teaching. She retired when she was 50 years old. She studied at Holy Spirit Academy and College of the
Holy Spirit-Mendiola.
She often accompanies her apos to and from the school. She likes to go to market and visit
family and friends. She often rides a tricycle to visit them. She lives with her husband, nurse, caretaker
and granddaughter. She prefers caregiver to assist her so she doesnt feel like nakakaabala siya.
Client likes to cook and informant stated that she liked cooking menudo. She often brought food
to her daughters house.
Client likes to read the bible and watch EWTN and also loves listening to music
HOME ASSESSMENT
Client lives in a 1 storey house. She often stays inside her air-conditioned room and is bed
bound. She uses a hospital bed and lies in special mattress that prevents bedsores to occur. The house
has 1 bath and 3 rooms. The door leads to a small receiving area. The kitchen is separated from the
receiving area by a shelf. There are a few steps that lead to the main living room and dining area.
SUBJECTIVE:
Informant: Ma. Carmina
Relation to client: Daughter
Chief Complaint:
Goal in OT:
According to Client: Gusto ko makalakad when prodded if she wanted to use a
wheelchair Ayun din
According to Informant/Caregiver: Gusto ko siyang maiupo at makapagwheelchair man
lang para maiikot sa loob ng bahay at saka madala sa dialysis ng hindi naka stretcher
OBJECTIVE:
I. Vital Signs:
BP 140/90
RR 20
HR/PR 64
Temperature: 36
II. ROM

UE AROM PROM Normal Values Endfeel Cause

(L)SH Flex 0-90 0-90 0-170 Empty Needs further assessment.

(R)SH Flex 0-140 0-150 0-170 Empty Needs further assessment.

(L)SH Abd 0-70 0-80 0-170 Empty Needs further assessment.

(R)SH Abd 0-100 0-100 0-170 Empty Needs further assessment.

(L)SH Horizontal Add. 0-130 0-130 0-130 Soft

(R)SH Horizontal Add. 0-130 0-130 0-130 Soft

(L) SH I.R. 0-70 0-70 0-70 Firm

(R) SH I.R. 0-70 0-70 0-70 Firm

(L) SH E.R. 0-20 0-20 0-90 Empty Needs further assessment.

(R) SH E.R. 0-30 0-40 0-90 Firm

(L)Elbow Flex. 0-140 0-150 0-150

(R)Elbow Flex. 0-150 0-150 0-150 Soft

(L)Elbow Ext. 0 0 0 Hard

(R)Elbow Ext. 0 0 0 Hard

(L) FA pron. 0-50 0-90 0-90 Firm

(R) FA pron. 0-40 0-90 0-90 Firm

(L) FA sup. 0-40 0-90 0-90 Firm

(R) FA sup. 0-40 0-90 0-90 Firm

(L)Wrist Ext. 0 0 0-70 Empty Needs further assessment.

(R)Wrist Ext. 0-60 0-70 0-70 Firm

(L)Wrist Flex. 0-60 0-70 0-80 Firm

(R)Wrist Flex. 0-70 0-80 0-80 Firm

*For ROM of Hands, client was asked to make a full fist, and open her hand. Client was
able to do so with her R hand only.

L Hand:
Extension limitation of 2nd to 4th MCP joints: 80-90
Flexion limitation of 2nd to 4th MCP joints: None
Extension limitation of 5th MCP joint: None
Flexion limitation of 5th MCP joint: 0-20
IP joints were not assessed d/t pain upon movement, pt. rated pain as 10
LE:
Knee ROM: L and R
Normal: 0 - 135
Extension limitation: 80-135
Flexion limitation: None
 Flexion and Extension limitation: 80-135

Ankle ROM: LOM in R Foot d/t wound contracture; foot is held in plantarflexion and
inversion. Pain upon passive movement of the foot.

III. MMT
Needs further assessment

IV. Gross Motor Skills

Head Control/Trunk/Pelvic

Balance:
Sitting Balance - Needs further assessment

Standing Balance - N/A

Tolerance:
Sitting Tolerance - Pt. can tolerate long sitting for 1 min only.

Standing Tolerance - N/A

V. Hand Evaluation
Handedness/Dominant Hand:
Client is R handed

RGR pattern

Grip Strength
There is no standardized grip assessment tool used? Needs further assessment?

Pinch Strength
Needs further assessment

Gross prehension patterns

Gross R L
a. Cylindrical Good Absent
b. Spherical Good Absent
c. Hook Good Absent

Fine prehension patterns

Fine R L
a. Lateral Prehension Good Absent
b. Tripod Good Absent
c. Pad to Pad Good Absent
 d. Tip-to-tip Good Absent

Fine motor skills

Clients fine motor skills in her L side were poor.

Bilateral eye hand/arm coordination

Needs further assessment

Writing skills
Needs further assessment

VI. Sensory-Perceptual Skills

Tendon Reflexes
Needs further assessment

Impaired or intact:
Auditory - Intact
Visual - Intact but needs glasses because of low vision
Tactile - Intact
Gustatory - Intact
o Olfactory - Intact

Impaired or intact: Visuo-spatial skills

Drawing or copying objects - Needs further assessment
Recognizing objects - Intact
Telling left from right - Intact
Analyzing and remembering visual information - Intact
Unilateral neglect - Intact
Constructional Apraxia, Awareness of body in space, motor planning, etc -
Intact

VII. Cognitive and Communication Skills

Orientation - Clients orientation was intact when asked about her name, age, and date.
Memory - Clients memory was intact, she was able to able to recognize and remember
the names of her family and was able to recall information after the injury.
Comprehension - Client was able to comprehend verbal instructions.
(-) Aphasia
(+)Dysarthria
(-)Dysphagia

VIII. Other Pertinent Findings/Other Physical Findings

(+) Tracheostomy
(+) Spasticity
(+) Tremors
(+) NGT

IX. Oral-Motor Skills

 (-) drooling
(-) tongue thrust
(-) hypertrophy of tongue

Clients jaw opening, closing, and side movements of jaw are intact. It was observed
when the client was eating her merienda

X. Dysphagia Evaluation
Clients NGT was removed last November 2016. Client presents no problem in
swallowing.
XI. ADL
During the assessment FIM, COPM and DPA was used. (See attached COPM and FIM
assessment)
ASSESSMENT:
OT Diagnosis:
Client has difficulty in maintaining upright position d/t poor trunk muscles and poor
sitting tolerance
Client is mod A x1 in performing bed mobility d/t poor trunk muscles, decreased muscle
strength and LOM in L Hand
Client makes use of a diaper for Toileting
Client has decreased ROM d/t contractures and pain, leading to a difficulty in performing
gross motor movement
Client is mod A x1 in dressing in upper and lower body d/t
Problem list:
1. Client has difficulty in bed mobility
2. Client has difficulty in dressing
3. Client has difficulty in toileting
4. Client has difficulty in feeding
1. Client has difficulty breathing... (?) -j
2. Client has difficulty in (managing emotions towards her family that affects performance)

Prioritized Problem List:

1. Difficulty in functional mobility
1. Bed Mobility
2. Transfers
b. Difficulty in bathing
c. Difficulty in Toileting
d. Difficulty in Dressing
e. Difficulty in Grooming
Dynamic Performance Analysis
Task: Functional Mobility
- Transfers
 - Bed mobility
o Bedside sitting

o Sidelying position

Turning to side
Turning of head toward caregiver.
Turning of trunk.
Abduction of legs to allow caregiver to place pillow in between legs.
Task: Feeding
- Setting up food
- Bringing food to mouth
o Breaking of crackers

o Getting of crackers

Locating crackers
Reaching for crackers
Grasping of Crackers
Lifting crackers to mouth

Plan:
LTG: Pt. will be able to maintain sitting position with minimal assistance on a wheelchair after 6
months of OT sessions.
STG1: Pt. will be able to pull self up from supine into maintain long sitting position for 5 mins
after 10 OT sessions.

POA
TUA

Preparatory Activity Purposeful Activities Occupation Based

Pt. will be asked to Pt.s bed will be inclined Watching TV in

reach for objects to mimic an almost Upright long
 placed in front/ at her upright position for long sitting for 3 mins,
sides and will be asked sitting. Pt. will be asked without backrest/
to transfer onto the to maintain sitting support
other side position for 3 mins.
Trunk Rotation
Exercises

TUS: Active Friendliness, Kind Firmness

TUG: Dyadic type
BMT: Positive Reinforcement such as verbal praises will be given when finishing assigned task?*
EMT: Accessible space, well lit and ventilated room? *edit nyo nalang kung mali*