Case Study

Case Study: Evidence – Based Practice For PowerPoint Presentation

Case Study 1

A 54-year-old female childcare worker with 1-year history of lower back pain was diagnosed with degenerative spondylolisthesis and received a L4-L5 spinal fusion with instrumentation (interbody device, screws, rods). She was transferred from the hospital to a skilled nursing facility and evaluated by an occupational therapist. Information from evaluation revealed the client lives alone with a history of depression and anxiety, obesity, and COPD. The client was deconditioned and weak with poor motivation to get out of bed but upset and stressed about her disability. The goal was for the client to successfully return home alone safely and resume work as soon as possible. Client rapport was built by discussing her love of children and her job at a childcare, as well as by verifying her goals for increased independence, and reviewing the treatment plan, rehabilitation process, and the benefits of activity.

Case Study 2

Gail is a 54-year-old nurse who works in the neonatal intensive care unit of a hospital. She is married and the mother of three teenagers. She enjoys gardening, cooking, and crocheting in her spare time. For over a year, she has been experiencing pain in her right (dominant) thumb. She notices the pain during many of her everyday activities including using a syringe, writing, and opening various containers (e.g., medications, supplies) at work. She notices pain when lifting pots and casserole dishes as well as when she is gripping wet clothes to pull them out of the washer. Using her gardening tools has become too painful. She has basically had to give up most of the yard work and even the crocheting she enjoys. Gail discussed her concerns with her family physician during her yearly routine physical. Her physician took x-rays and examined her thumb. She tested positive for the “Grind test” (a provocative test used to determine CMC arthritis). Her physician diagnosed her with right thumb basal joint or CMC joint OA.

Case study 3

Lucille is a 77-year-old retired grade schoolteacher living in a two-bedroom senior housing unit. She became a widow in her 50s and never remarried. Lucille has two cats and occupies her time going to casinos, taking bus trips on weekends, and volunteering at the local library twice a week. One of her three children (her son), who remained single, lives nearby and routinely accompanies her to appointments and assists her with grocery shopping. Lucille had rotator cuff tears in both shoulders and received multiple cortisone injections. Her right (dominant) shoulder progressively worsened with pain and decreased range of motion because of advancing osteoarthritis. She was losing sleep because of pain and anxiety and was increasingly worried about her independence. Although her son was generous with his time, Lucille did not want to place any more burden on him. She and her orthopedic surgeon agreed on a trial of physical rehabilitation before resorting to surgery.

Case Study 4

Mr. Coffman is a 63-year-old male with a history of hypertension, osteoarthritis, and COPD. He recently had a COPD exacerbation and a moderately sized STEMI. Mr. Coffman has been a smoker for the last 40 years, but has recently considered quitting due to his worsening health condition. He is currently being treated in an acute care hospital setting for his recent MI and COPD exacerbation. At home, he wears 2 liters of oxygen at night, but he has been prescribed continuous oxygen at 4 liters since his hospitalization. Mr. Coffman spent 1 day in the intensive care unit and was then moved to the telemetry unit because his condition was improving. His physician has ordered OT evaluation and intervention to address the client’s decreased independence with ADLs and other occupations, shortness of breath, reduced functional activity tolerance, anxiety due to poor breathing patterns, and fatigue with daily activities.

Mr. Coffman has been married for 35 years to his wife Betsy, and they reside in a two-level house with three steps to enter the home. The main bedroom and bathroom are on the first floor, so he does not have to go upstairs when he first discharges home after his hospitalization. He has three children and seven grandchildren. His children live nearby and are willing and able to help him if needed. Mr. Coffman’s parents passed away several years ago, but all four of his siblings are still living and he visits with them often. He enjoys socializing with friends and customers at a local farmer’s market. Mr. Coffman has a high school education and has not completed any college courses.

Mr. Coffman was independent with all self-care activities, functional mobility, and driving until his most recent hospitalization. He was also able to help with light home-management tasks, although his wife does most of the cooking, cleaning, and laundry in their home. Mr. Coffman enjoys yard work, such as mowing and tending to his large garden, but he has found this to be increasingly difficult over the last few years. He enjoys spending time with his grandchildren, and he often attends their baseball games and other activities. Mr. Coffman had to retire early from his factory position due to his health conditions, but he still works for several hours 2 days a week at a local farmer’s market during produce seasons.

Case Study 5

Grace is a 49-year-old female client who is super obese. She was admitted to the hospital from a skilled nursing facility (SNF) where she had resided for the past 5 months. The client presented to the hospital with multiple medical problems that included acute respiratory failure requiring ventilation, obesity hypoventilation syndrome, obstructive sleep apnea, super obese with BMI of 82, sepsis, panniculitis, bipolar disorder, hypertension, chronic pain, and depression with an anxiety component.

Upon medical stabilization, a referral was made for OT to evaluate and treat. Prior level of functioning: Client was able to assist with approximately 50% of ADLs and transfer to wheelchair with Min A. Current level of functioning: Client noted to be dependent for all ADLs, transfers, and functional mobility, fatigue upon minimal exertion, BUE strength 2+/5. The OT course of treatment initially was to address safe handling for staff and client, begin UE ROM and increase to strengthening exercises as tolerated, tolerate EOB sitting for 5-minute intervals, and instruct in energy conservation techniques and adaptive equipment as indicated.

Case study 6

John is a 17-year-old male with a 30% TBSA burns (both deep partial and full-thickness) to chest, abdomen, right side of face, neck, back, and upper arms to wrist bilaterally (hands were spared). He was given fluid resuscitation and a nasogastric feeding tube immediately. The injury occurred at work during a fall on the ice while carrying hot grease to the oil dumpster. John, a high school senior, lives 2 hours from the Level I trauma and burn center and was transported from the local hospital.

The occupational therapists at the burn center completed an evaluation of John’s burn wounds and medical status within the first 24 hours of his arrival. The goal was for John to successfully return to being an independent high school senior. John’s parents were present at his bedside on the burn unit. They were divorced but had a good relationship in caring for their son.

Case Study 7

Pam is a 76-year-old female, diagnosed with stage III colorectal cancer with metastases to the nearby lymph nodes in her pelvis and groin. She is a retired waitress with a history of cigarette smoking (quit at age 50) and a family history of cancer. Pam lives alone in a rural town (except for her beloved pets). She has a two story house with a full bath on the first level, two bedrooms, and one bathroom upstairs. She has a daughter and grandchildren nearby and two daughters who live out of state. She has to travel over an hour to the closest hospital for health-care visits (oncology, radiotherapy, chemotherapy). Due to the location of her cancer, she is not a candidate for surgery and opted for intensive radiation and chemotherapy. Part way through her 6 weeks of almost daily radiation, and after her first week-long chemotherapy infusion, she is extremely fatigued, dehydrated, and has a very low blood pressure. She barely has energy to walk to the bathroom, talk on the phone, and can no longer walk up the stairs to her bedroom. She has no appetite, and is also experiencing very painful blisters in her mouth and throat from the chemotherapy. The home health nurse referred her for home health OT.

Case Study 8

Megan is a 35-year-old woman with CMT who is married, has two children 2 and 4 years of age, and works full time as a cashier at Walmart. She frequently has pain in her hands and feet, some numbness in her fingers and toes, and stands all day at her job. She wears bilateral ankle-foot orthoses and is beginning to have a slight claw deviation in her hands with hyperextension at the metacarpals, and flexion at the proximal and distal finger joints. She is having difficulty with fastening her own clothing as well as her children’s and struggles to perform the evening cooking and other chores after a long day at work. She has messy writing, and her hand cramps when texting or using the computer. She has difficulty opening jars and bottles, and some difficulty bagging heavier items at work such as gallons of milk and juice.

Case Study 9

Marty, a 27-year-old man, was involved in a motor vehicle collision. He was not wearing a seatbelt and was ejected from the vehicle he was driving. Marty’s injuries included a TBI with diffuse axonal injury, right clavicle fracture, right tibia fracture, and vertebral fractures at C4 and C5. He was intubated at the scene and had an initial GCS score of 3. Marty underwent a craniectomy, with the bone flap removed to manage intracranial pressure. A tracheostomy was placed, and Marty was dependent on the ventilator for 4 weeks. A gastrostomy tube was placed for nutrition and medication. Marty had a cervical collar to stabilize his spine and a temporary brace to immobilize his right leg.

Case Study 10

Candace is a 20-year-old college student living at home with her parents. She is in nursing school and a personal trainer at her local gym. She is a weight lifter and exercise enthusiast. During a girls’ night out, Candace and three of her friends were in a motor vehicle collision (MVC). Candace was the restrained driver. During the scene of the accident, it was determined that Candace required specialized medical care, and she was emergently flown to the nearest trauma hospital, 2 hours from her home and the scene of the accident. At the hospital, physicians determined Candace’s injuries resulted in a T5 complete SCI.

Candace’s parents work full time to support their family and remain at her side during her entire acute stay and alternate time staying overnight during her inpatient rehabilitation stay.

During her 4 weeks on the inpatient rehabilitation unit, she works with OT and PT 3 hours or more per day to relearn all aspects of her daily living in preparation for discharge back home.

Case Study 11

Jasmine is an 18-year-old female status post car accident as an unrestrained driver, resulting in subarachnoid hemorrhage, intracranial hemorrhage, rib fractures, pulmonary contusion, acute respiratory failure, right distal radius fracture, and right femur fracture. Jasmine underwent a left craniotomy, tracheostomy placement, right distal radius repair, and right femur intramedullary (IM) nail placement. She is on restrictions for non–weight-bearing (NWB) through her right UE and weight-bearing as tolerated (WBAT) through her right LE. She is beginning to follow simple commands 75% of the time, tolerate tracheostomy collar trials off the ventilator, and move her extremities purposefully. Jasmine has been cleared for progressive mobility by both neurosurgery and trauma physicians.

Jasmine is in her first semester at college, where she was living in the dorms on the first floor with elevator access. She has a very supportive family and an older brother who is also attending the same college. Jasmine enjoys music, spending time with her friends, and volunteering with the Humane Society.

Case Study 12

Mr. Young, a 65-year-old African American male, has come to the hospital for an above-the-knee amputation because of complications from insulin-dependent diabetes (type 2 diabetes). He lives with his spouse, who is unable to assist with any ADLs or functional mobility tasks because of her own medical complications. Mr. Young has children who live out of state. Although his children can provide some financial assistance, they are unable to provide physical assistance. When the occupational therapist evaluates client factors, she discovers that he has peripheral neuropathy in his upper extremities (UE) and left lower extremity. He has functional UE ROM and 3+/5 BUE strength.

Mr. Young is a retired minister and hopes to return to ministry on a voluntary basis. His goals also include becoming independent with ADLs and functional mobility tasks at the wheelchair level.

Case Study 13

Phyllis is a 79-year-old female who resides in an assisted living facility. She was diagnosed with Parkinson’s disease (PD) approximately 20 years ago, and as her disease progressed, she required more assistance, resulting in a move from her daughter’s home with family assistance to an assisted living facility. Before the onset of PD, Phyllis worked as an art and theater instructor at a local college. She was often involved in creating props for theatrical events, instructing students in role play, and leading musical arrangements. According to her daughter, Phyllis always prided herself on her social and acting skills; however, because of the changes in her physical status with the disease progression and the change in her environment, she has had to modify her favorite activities. At this time, Phyllis’ favorite hobbies at the facility include spending time in the gardens, joining the chorus club, and attending meals with friends in the dining room.

Phyllis recently noticed a significant increase in right hand weakness and difficulty swallowing. Nursing staff also reported decreased safety with her power mobility device. Because of her increasing difficulties, Phyllis has had consultations for skilled occupational and speech therapy. An occupational therapist has completed her evaluation, and an OTA is scheduled to work with her in her next therapy session.

While preparing for the session and reviewing her goals, one goal noted by the OTA is for Phyllis to address self-feeding. Phyllis is on a modified diet of mechanical solids and nectar-thick liquids.

Case Study 14

M. W. is a 74-year-old woman who was recently diagnosed with leiomyosarcoma (a soft tissue sarcoma or cancer). She has been told that her tumor is progressive and untreatable surgically, and her oncologist estimates that she has less than a year to live. M. W. has agreed to receive palliative chemotherapy to manage her symptoms and pain. She has no children, but her friends and neighbors (all approximately her age) are willing to provide assistance around the clock so that she is able to spend the remainder of her life at home and not in a nursing facility.

The home health OTA has been asked to recommend the best transfer methods for fall prevention and caregiver education and training on safety for assisting client with transfers, including potential assistive device needs that the caregivers are likely to need as her condition worsens and she becomes weaker. M. W. is currently able to perform functional mobility using a single-point cane, although her ambulation has become slower and more unsteady, and she recently fell in the bathroom in her home.

Case Study 15

Kara is a 24-year-old who has Charcot-Marie-Tooth disease, which causes her to have hand pain and weakness, ankle weakness, and pain with use of ankle-foot orthotics (AFOs). She has fair balance in standing and difficulty performing her work tasks as an administrative assistant at a large law firm. The master bedroom with a tub/shower combination is upstairs in her townhouse and she has no bedroom and only a half bath downstairs. She works the day shift, and has two young children, ages 1 and 3. Her spouse is a truck driver, but is local and is usually home by 7 pm at night. She is having difficulty with many ADL and IADL tasks, including laundry, cleaning, childcare, cooking, and food preparation. She enjoys shopping and reading.