Client: Janis Melbourne

Background: 45 y/o female with R hemisphere TBI as a result of MVA 4 weeks ago

S: When asked what the instructions were, client replied “I was distracted and wasn’t listening.
I’m sorry.”

O: Client was seen April 7, 2020 in her home to complete a comprehensive occupational
therapy evaluation, including an occupational profile interview, the Canadian Occupational
Performance Measure (COPM), an observation of occupational performance, and
administration of the Performance Assessment of Self-Care Skills (PASS) and Fugl-Meyer
Assessment of Upper Extremity (FMA-UE).

Occupational Profile: The client lives with her husband who she has been married to for 2 years.
They have a total of four children from previous relationships, and her 15-year-old son is the
only one that lives with them. Prior to her accident, she was working full time as a Human
Resources representative for a large technology company. Her husband works full time as a
firefighter and is using his FMLA benefits to stay home with her for three more weeks. The client
reports she is having difficulties with house cleaning, laundry, and grocery shopping. Her
husband has taken over the household chores, but she does not think he does a good job. She
wants to get back to volunteering at the local SNF with her therapy dog. The client also enjoys
going to a weekly spiritual group, mountain biking, hiking with her dog, and camping.

The client’s current priorities for therapy include going back to work, increasing her
independence in medication management and showering, spending time with her dog, and
getting in and out of her hot tub.

COPM: The Canadian Occupational Performance Measure (COPM) is a semi structured

interview used to gather information on the client’s top priorities as well as their current
performance and satisfaction in those areas. The results can be seen below.

Occupational Performance Priorities Performance Satisfaction

Return to work 3 2
Medication 8 8
Shower/dress 7 5
Time with dog 1 1
Hot tub 1 1
20 17
TOTAL 4 3.4

Observation of occupational performance:

The client was observed preparing a snack of cheese and crackers. Client was seated in her
w/c and independently propelled it using her R leg and R UE, bumping into furniture on her way
to the kitchen. The client asks the therapist several times if she had seen her dog’s trick. She
tried the light switch several times and required a direct prompt to try a different one. The client
gets distracted by her string lights and dog multiple times, and required direct cues to stay on
task. The client does not realize she is very close to the stairs until the therapist provides a
warning. The client required 2 direct cues to open the other side of her fridge in order to get the
drawer open. The client starts pulling random items out of her fridge, requiring 3 direct cues to
find the cheese. The client required an indirect cue to notice the fridge door is still open and 2
direct cues to turn on the kitchen lights. The client started aimlessly looking in kitchen drawers
and was unsure what she was looking for. She used her teeth and RUE to independently open
the bag with the cheese in it. She pulled out five large knives and required a direct cue to
choose one for cutting the cheese. She used her R hand to cut the cheese. The client opened
the pepperoni package with her teeth and then went back to cutting the cheese even though
she was already finished. The client’s counter was slightly too tall for her and she sat on the
edge of her seat to reach items toward the back. She used her L hand to hold onto the cracker
box, while her R hand placed some on the plate. Client offered the therapist a utensil, though
one was not needed. The client independently used the knife to transfer the sliced pepperoni
and cheese from the cutting board to the plate. When finished preparing the snack, the client
leaned too far forward when playing with her dog and nearly fell out of her chair.

PASS: The client completed 4 tasks of the Performance Assessment of Self-Care Skills (PASS)
in order to gather information on her independence, safety, and adequacy during common tasks
that require physical and cognitive skills. Her performance can be seen below.

Task Independence Safety Adequacy

Medication 1.67 2 2
Grocery Shopping 2.2 3 2
Dressing 2.56 2 1
Bingo 1.5 - 1
Observations during PASS:

The client is seated in her w/c and does not independently initiate use of LUE at all during tasks.

Medication Management: The client required direct cues to determine when the next pill should
be taken both times and needed frequent redirection to stay on task, as she keeps talking about
unrelated topics. She is unable to open the child proof pill bottle with her R hand and the
therapist opens it for her. The client begins eating M&Ms, despite therapist warnings. She opens
the non-child proof bottle with ease.

Grocery Shopping: the client requires indirect cues to check she has the right items and a direct
cue to notice she had the wrong brand. She gets distracted by the coins and requires indirect
cues to continue task and a repetition of task instructions to pay the therapist exact amount.

Dressing: the client dressed her RUE first and then could not get her LUE in the sleeve and had
to start over. She required a cue to stabilize with her LUE so she could button up the sweater
easier. She took a considerable amount of time to don her socks. The client was shown how to
use her LUE to hold the laces of her shoe while she tied with her R.

Playing Bingo: The client required cues to listen to the caller and kept missing numbers. She
missed calling out Bingo and did not notice it on her card despite being told to look.
The Fugl-Meyer was used to gather information regarding the motor ability, sensory ability, and
joint mobility of the client’s affected upper extremity (left side) in order to create appropriate
treatment interventions and track progress.

A. Upper Extremity 16/36

B. Wrist 2/10
C. Hand 5/14
D. Coordination/ Speed 3/6
Total A-D (motor function) 26/66

H. Sensation 12/12
I. Passive Joint Motion 24/24
J. Joint Pain 24/24
On affected left side, the client has some active shoulder movement within flexor synergy and
full elbow flexion within extensor synergy. She has partial shoulder abduction outside of the
synergistic patterns, but no other movements. Client has partial wrist movement if the shoulder
is not involved (shoulder at 0 degrees). She has full mass hand flexion and partial extension, but
no isolated finger movements and a weak cylindrical grasp. Client has a slight tremor and her L
side is markedly slower than her R.

A: The client is cheerful, cooperative, and motivated to get back to doing things on her own. She
demonstrates adequate abilities to use her w/c and complete tasks one handed. Despite her
Fugl Meyer scores reflecting some active movement in her LUE, she does not initiate any
movement or functional use on her own, which could indicate a preference of nonuse or a lack
of strategy training. The client lacks judgement and displays little awareness of her environment
and safety, as seen by bumping into furniture, getting close to the edge of the stairs, and
leaning too far forward in her w/c, as well as reflected in the PASS safety scores. She tries the
same approach multiple times even if it is not working, which could indicate deficits in problem
solving and error recognition. Her low independence scores on the PASS and decreased
performance during snack preparation are likely due to her distractibility and inability to stay on
task and remember what she is supposed to be doing. Her repetitive conversations could also
indicate some memory deficits. The client has adequate support from her family and is a good
candidate for therapy services.

P: The client will be treated 3/week for 4 weeks to address deficits in attention, memory,
problem solving, judgement, safety, and use of her LUE, in order to improve her occupational
performance and increase her independence. Skilled OT services are required for appropriate
grading of activities that will address her performance deficits and to provide appropriate home
modification recommendations. Her complex condition requires advanced clinical judgement to
adjust the presentation of activities that will properly challenge her while also teach her to
generalize strategies beyond the treatment session.
LTG1: By d/c, client will independently manage medications using compensatory strategies

STG1: In 2 weeks, client will independently open pill bottle using compensatory
strategies

STG2: In 3 weeks, client will use a memory aid to independently take medications

LTG2: By d/c, client will independently shower using AE

STG1: In 1 week, client wash LB using AE with Min A

STG2: In 3 weeks, client will use L UE as functional assist with Min VC during showering

Kelsey Brooks, OTS

4/7/2020