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Name: Rebekah Strobel Case: 6 Date: 4/8/18

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Primary diagnosis for admission is pneumonia. His medical history includes CHF, COPD, Type II
diabetes, OA, gout, TKA (x3 years ago). He was referred from a community hospital.
The setting is a Salt LAke City Transitional Care Unit
Services being paid for through Medicaid
Physician predicts he'll go home after 3 weeks of treatment with O2 use at night and for exerting

2. Pragmatic Factors to Consider

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He lives alone in a single wide trailer, he wants to continue to live alone
His age- he is older and that can affect his activity tolerance
Undetermined exact length of stay
He has a lengthy medical history with lots of other coexisting conditions
His weight- he is obese so that makes it difficult to move and get around
He has difficulty regulating his blood sugars, important to consider his diabetes management
Fatigues quickly and has decreased strength
Vision is declining and is affecting his ability to drive at night
Tingling in toes and fingertips
Prefers to wear woman's clothes. He is having difficulty dressing himself in nylons and bras as they
are hard for him to put on
He is struggling to bath himself and views this as a top priority
The therapy team that is working with him
Consider how often Philip comes to visit him
He has a lot of pets to take care of at home
Important to consider his osteoarthritis and gout and which joints it is affecting
He smokes occasionally and drinks three light beers a day. Important to consider how smoking
affects his COPD.
His health is continuing to decline
Having difficulty getting into the tub
Has difficulty cleaning his trailer
Has difficulty cooking but doesn't view this as all too important
Important to consider his ADLs and how he is performing them
Important to consider his hobbies and interests which include the fact that he likes to horseback ride
and he is a retired electrician
Important to consider his diet which could be affecting his heart condition
MOCA score in the below normal range, important to consider his cognition, and possibily further
test that
Important to consider the type of pneumonia he has
Important to consider his medication management, we don't know anything about how he is doing
with that
It is imprtant to promore gradual resumption of activity slowly or else he could have another episode
of CHF.
Multiple conditions contributing to lack of energy and SOB
Consider if it's primary or secondary OA, and type of gout (if it is recurrent or not)
Psychological factors in his life from aging and having so many complications

3. Context: Occupational Profile & Current Occupations

Cultural: SKIP



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Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities




5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:
Pneumonia is Barriers to success for pneumonia include fatigue, coughing, SOB, chills,
inflammaion of the and fever. The role of OT for pneumonia includes increasing activity
airspaces in the lungs, tolerance, education on energy conservaiton, modifying tasks and
commonly due to environment, promoting a healthy lifestyle.
infection. Signs and
symptoms include fever, Barriers to success of CHF include shortness of breath, fatigue,
chills, cough, SOB, and diminished exercise capacity, and swelling. The role for OT includes
fatigue. There are two grading tasks, education on diet, education on energy conservation, and
types- community- promoting a healthy lifestyle. (Pedretti, ch 44)
acquired or hospital-
acquired, with the later Barriers to success for COPD include shortness of breath, wheezing, chest
being more serious. It is tightness, excess mucus in lungs, chronic cough, blueness of
diagnosed most lips/fingernail beds, frequent respiratoy infections, lack of energy,
commonly through a swelling. The role of an OT includes education on breathing techniques
physical exam or a chest like dyspnea control posture, pursed-lip breathing, diaphramtic breathing,
x-ray. Antibiotics treat and relaxation. It can also include other task grading, other energy

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pneumonia by controling conservation techniques, promoting a healthy lifestyle like cessation of
the bacterial or fungal smoking, and envionrmental modifications to reduce pollution, stagnant
infection. It is important air, or extremes of temperature. (Pedretti, ch 44).
to drink plenty of fluids,
rest, control fever, and to Barriers to success for Diabetes type 2 include increased thiry and
not take cough medicine. frequent urination, increased hunger, weight loss, fatigue, blurred vision,
Admission to hospital slow healing sore/frequent infections, areas of darkened skin, loss of
happens if you have sensation. The role of OT in diabetes includes health promotion through
another serious medical education on healthy food choices, education on physical activity, and
problem, severe educatoin on appropraite weight loss.
symptoms, older than 65,
have been taking Barriers to success for OA and gout include joint pain, stiffness,
antibiotics at home and tenderness, limited movement/ROM, vatiable degrees of local
not getting better. inflammation, and crepitus. The role of OT is to decrease pain, protect
joints, and increase function. This includes maintaining or increasing the
CHF progresses overtime ability to engage in meaningful occupations, maintaining or increasing
with the heart becoming joint mobility and strength, maximizing physical endurance, protect
weaker and weaker. It against or minimize effects of deformities, and increase understanding of
occurs when the heart is the disease and the best methods of dealing with it, and assist with
unable to pump adjustment to diability. (Pedretti, chap 38)
effectively enough to
meet the demand and Barrier to success for a TKA include possible psychological factors,
fluid backs up in the possible loosening, increased risk of infection, and lessening strain on
lungs and the body. THis knee. The role of the OT is to maximize performance skills in daily
fluid overload causes a occupations, with all movement precautions observed during activites.
greater workload on the The OT should teach the client ways and means of performing daily
heart as the heart strains occupations safely. (Pedretti, chap 40).
while attempting to clear
the excess fluid, which
may result in further
congestion. Heart size is
often enlarged when this
happens. Diuretics can be
prescirbed to promote
fluid loss. It is also
important to have low
sodium diets and to have
fluid restrictions to
reduce overal amount of
fluid in the body. It can't
be cured but it can be
managed with diet,
medications, and rest.
Heart transplants are
sometimes done. Risk
factors include heredity,
gender, age, HBP,
smoking, cholosteral
levels, inactivty lifestyle,

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diabetes, stress, and
obesity. It can develop
from CAD and also

COPD is characterized
by damage to the alveolar
wall and inflammation of
the conducting airways
and includes emphysema,
peripheral airway
disease, and chronic
bronchitis. Cigarette
smoking is the primary
cause of COPD. Other
environmental irritants
such as air pollution,
chemical exposure, and
dust are contributory
factors. COPD is a
progressive, chronic
disease. In order to be
diagnosed a medical
history evaluation will be
conducted. Blood work
and an x-ray will also be
performed. Medications
will be prescribed.

Type 2 Diabetes is a
chronic condition that
affects the way the body
metabolizes sugar. It is
cuased when the body
becomes resistant to
insulin when the
pancreas stops producing
enough insulin. This is
could be caused by
factors, and weight
gain/inactivity. In order
to diagonse it, a patient
will be given a blood test.
Treatment includes
healthy eating, regular
exercise, diabetes

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therapy, and blood sugar

OA, also referred to as

degenerative joint
disease, classified as
primary or secondary.
Primary OA has no
known case and may be
localized or generalized.
Secondary OA is realted
to an identifable cause.
IT is a disease that causes
the cartiliage in joints to
break down with
resultant joint pain and
stiffness. It is diagnosed
on the basis of the
patient's history and
through physical
examination. There is no
cure for OA. THere is
medication to manage

Gout is a complex form

of arthritis. It is
characterized by sudden,
severe attacks of pain,
swelling, redness, and
tenderness of joints. It is
caused from urate
csystals accumulating in
joints from high levels of
uric acid in blood.

TKA is indicated when

two or more
compartments of the
knee are damaged. A
prothesis can be
cemented to the bone.
With this, a client is
usually able to bear
weight as tolerated on the
operated leg. With
noncemented, initial
weight bearing is
avoided. Clients can staty

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out-of-bed activities 1 to
3 days after surgery.
They sometimes use a
knee immobilizer. They
should avoid rotation at
the knee for up to 12
weeks after surgery.

7. Practice Models Guiding Assessment and Rationale

1. PEO PEO addresses the person, enviornment, and
occupation in a holisitic manner to help a client
with basic ADLs or more complex tasks and
occupations. PEO addresses these 3 areas to
determine where change can be made to
improve occupational function. This model
would be appropriate for Wendell because it
allows us to view his life completely and take
into account all factors. We could use this model
to make changes in his enviornment. For
example, we could adapt his home trailer to
make certain ADLs easier for him to complete.
2. Lifestyle Redesign Lifestyle redesign is the process of acquring
health promoting habits and routines, based on
underlying occupational science foundation. The
goal is to increse independence, health, well-
being, life satisfaction, and occupational
functioning. This model is appropraite for
Wendell as he smokes, drinks, and is
overweight. We will use this model for patient
education on health and well being and ways to
increase these. This will hopefully cause him to
change some of his destructive habits and
3. Occupational Adaptation The outcome for OA is to increase adaptability,
relative mastery, and self-evalutation. This
model applies to Wendell because he needs to
learn how to adapt to his current level of
functioning with his diabetes and pnemonia.
This model would be incorporated to learn how
to adapt and perform his occupations differently
and effectively.

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8. Specific Areas of Occupation
What do you know? What do you need to know?

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9. Performance Skills
What do you know? What do you need to know?

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?

11. Activity Demands for the Client Goals and Priorities

What do you know? What do you need to know?

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?

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14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

Cleaning the counters, sweeping the floor, doing I would want to observe his cleaning abilities
the dishes because he is in transitional rehab in order to
regain strength to return home. He also views
cleaning as one of his top priorities. It is
therefore important to assess the reason he is
here, his decreased strength. I would have him
do a cleaning task like cleaning the kitchen at the
facility including doing the dishes. This is a task
that involves strength and endurance. I would
use this task to evalute his activity tolerance. It
would help me understand how long he can
tolerate standing and working. It would help me
understand the MET level he can endure and for
how long. It would also help me understand how
he is able to grip and manipulate objects like
plates and cleaning supplies. I would use this
information to plan goals and treatment sessions
for him.
Method/Tool Rationale/What is being Assessed
1. Modified Fatigue Impact Scale Wendell has multiple diagnoses that causes him
to be fatigued and have SOB. I would want to
assess his level of fatigue to understand how it is
impacting his daily life habits, role, and routines
including his ADL performance. The fatigue
scale will help us know which specific areas we
should address to help him compensate for
2. Vision screen/ visual acuity Wendell mentioned that his vision is decreasing.
On the COPM, he mentioned that it is getting
harder for him to drive at night. I would want to
assess his vision to see what specific problems
he is having with it. This could help us know
what enviornmental modifications we could
make for him or what compensatory strategies
would be useful for him.
3. Monofilament testing This is a quick and easy to use test to understand
loss of protective sensation. Wendell mentioned
that he is feeling a tingling sensation in his
fingertips and toes. This test will help us
determine the loss of his sensatition which will
allow us to determine client education and
strategies for him to use at home to address this.

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4. AROM and PROM and MMT on both UE Arthritis can lead to decreased A/PROM. He
also mentions that he has decreased strength. He
mentions pain in his joints. I would assess all the
joints in his UE including shoulder, elbow, wrist,
and all finger joints to see the A/PROM. I would
assess his muscle strength in his arms and
shoulders. I would then test the sensation on his
hands and fingertips to see how impaired it is.
This will help us have a better understanding of
how he is functioning and how his body
mechanics are inferring with his ADLs.

5. Medication management portion of the PASS Wendell has a lot of medications to take with all
his coexisting conditions. I would want to assess
how he is doing with managing his medications
by adminitering that portion of the PASS. He has
a hard time managing his diabetes so this could
help us understand why he is having a hard time
with that. This would also tell us a bit about his
vision, his cognition, and his fine motor skills. It
would be especially important to assess his
cognition because he scored in the mild
cognitive impairment range on the MOCA.
Being able to complete his medications is really
important to consider for sending him home
from transitional care.
6. Arthritis hand function test Wendell suffers from both OA and gout. It
would be important to assess how his arthritis
affects his ability to use hands using this
assessment. The information gathered from this
assessment would help us undersand the strength
and fine motor skills he has in order to better
understand how this interfers with his ADLs
such as donning his bra, opening bottles,
manipulating and gripping items, etc.

15. CPT Evaluation Code: Justification

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High I would say this is a high CPT code because he has so many other
coexisiting conditions. They are also pretty serious conditions so this
should qualify as being high.

16. Projected Outcomes: Type of Outcome


17. Resources and Team Members

Team members: OT, PT, physician, nurse, possibly Philip, nutritionist, opthalmologist possibly

Education and information about diabetes management, breathing techniques, healthy eating
Health tips and videos that can help educate him on how to manage his conditions
Suggestions for home health and future OT services that would benefit him
Recommended home eval

18. Intervention Plan

Barriers Supports

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- Lives alone
- Philip comes to stay with him but only because he needs - He is insured via medicaid
money or doesn’t have a place to live - Retired mechanic so he has or had
- Smoking and drinking skills and hopefully had retirement
- Possible poor eating habits money saved up
- He is overweight - has the company of his pets
- He isn't very active - interests and hobbies like horses
- Lots of coexisitng conditions - at transitional care for 3 weeks
- His age, he is old
- Lives in a trailer which probably doesn't give him much
space to move around
- doesn't seem to have much for social support
- health is declining and continuing to get worse
- his pets are probably getting hard for him to take care of
- Bad at managing his diabetes

Goals Practice Model for each goal

1. LTG:
In 3 weeks, client will independently complete dressing using OA
compensatory strategies

In 1 week, client will don bra with min assist PEO

In 1 week, client will don nylons seated at EOB with min PEO

2. LTG:
In 3 weeks, client will shower using mod I. PEO

2a. STG:
In 1 week, client will transfer to shower tub with SBA using PEO
adaptive equipment

2b. STG:
In 1 week, client will independently complete LB washing PEO
using adaptive equipment

3. LTG:

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In 3 weeks, client will independently prepare and clean up a Lifestyle Redesign
healthy simple meal using compensatory strategies

In 1 week, client will independently use energy conservation OA
techniques while preparing a simple meal

3b. STG:
In 1 week, client will independently identify healthy recipes Lifestyle redesign
he can make at home

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
For this session, we will work on showering as this Modify, Adapt 2, 2a, 2b
is a concern for him and he mentions on the COPM
that getting into the tub can be difficult for him. We
will work on his transfers into his shower using a
shower chair. He will be educated on how to safely
enter the shower and sit on the shower chair to
wash himself. Having the shower chair is good
energy conservation technique for him. He will be
provided and educated on more adaptive equipment
like a long horned brush to wash his lower
extremeties for energy conservation. During this
activity, we will also educate him on the importance
of daily diabetic foot care to make sure he is
washing and inspecting his feet so that he doesn't
risk getting infections. We could recommend to him
that he should put a full length mirror in his
bathroom or right outside of it if there is room and
to do this as part of his showering routine. With his
decreased vision we will also educate him about fall
risk and prevention strategies like non-slippery
surface and adequate lighting.
2. What will you do? Identify Approaches Based on which
For this session, we will work on increasing his Modify, adapt 3, 3a, 3b
activity tolerance by cooking a simple meal and
cleaning up after it. This session will incorporate
both education and strategies to increase endurance.
We will make a healthy meal and he will be
educated on calorie counting, nutritional food
choices, food to eat for diabetes management and
porition control. Throughout the task, his O2 levels
will be monitered and taken to make sure they don't
drop too low. We will also monitor his blood sugar
levels before, during, and after exercising and he
will be educated on the importance of doing this at
home. He will be instructed to stand throughout the
activity and he will be given rest breaks as he
needs. He will be educated on breathing techniques
such as pursed lip breathing to increase his oxygen
and endurance levels when he gets tired. He will
also be educated on compensatory techniques and
safety measures for the sensory defecits in his
fingertips to address avoiding burns in the kitchen
and always wearing shoes in the kitchen. After the
meal is prepared, he will be instructed to clean up.

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He will practice using energy conservation
techniques. Having him clean up will also be in a
way, exercise for him, and will increase his activity
tolerance. The task will be graded up and down
according to his needs. If he gets too tried, I will
have him put the dishes back in one cuppord. If he
has enough energy, I will have him but the dishes
back in cuppords that he has to walk multiple steps
to get to. In this way, the activity will be graded to
provide him with the just right challenge.

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