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Case Study Template Student Name: Kylie Cook Client: Emily Diagnosis & Major Symptoms: moderate TBI following an MVA. Right tibia-fibula fracture. Level IV on RLA. Agitation was severe at first but has calmed down. She is disoriented. Poor posture control. Moderate to severe spasticity is reported.

(Brief) Description of the Client and their History: 20-year-old female. Relies on previous medical record and interview with mother for occupational background. 2 weeks in ICU and 4 weeks in acute medical unit following MVA. No other remarkable medical history was provided via the mother.

APPLICATION TO DOMAIN (50 points) Performance in Areas of Occupation:        

ADL: Assistance with showering and dressing, greatest strength in self-care, verbal cues for eating IADL: Fixes her car, hangs out with friends, Rest and Sleep: Requires assistance getting into and out of bed because of fracture. Education: None provided Work: 3 secretarial jobs in the last 2 years Play: None listed Leisure: Hangs out with friends and fiancé, fixing old car Social Participation: Hanging out with friends, working

Client Factors:   

Values, Beliefs, and Spirituality: Values friends and her car Body Functions: dependent in all areas of occupation, moderate assistance getting into bed, moderate assistance for showering and clothing Body Structures: moderate to severe spasticity, eye patch for eye not focusing

Performance Skills (Motor, Process, & Social Interaction):   

Motor Skills: difficulty with all gross motor skills (walking, bathing, dressing, etc) due to spasticity and limited movement from fracture Process Skills: calls OT by the wrong name, processes verbal ques very well, especially for eating Social Interaction Skills: heavily impaired due to agitation and swearing

Performance Patterns: 1

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Habits: Fixing her car Routines: Morning routine, gets tired easily of routines and likes to ‘switch it up’ Roles: Employee, daughter, friend, fiancé, patient Rituals: None provided

Context and Environment:      

Cultural: None provided Personal: lives in 2 bedroom apartment with mom and assists with rent Temporal: responds to ques and can follow instruction Virtual: secretary job, cell phone Physical: fixes car, limited information provided from mother Social: Hanging out with friends, working, fiancé

APPLICATION TO THE PROCESS (25 pts) Occupational Therapy intervention choices using types & approaches to treatment (OTPF Tables 6 & 8) &

Why those were the interventions you chose. 

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Type or Approach A: o For Emily’s first approach, I would focus on the Occupations approach. This would help Emily be able to perform her 8 areas of occupation as normally as she could before her MVA accident. This could include use of adaptive devices while she recovers from her fracture, taking time for self-care since that is one of her stronger aspects right now, or using leisure activities to drive her motivation for therapy. Type or Approach B: o For her second approach, I would use prevention. Since Emily seems highly agitated, I would use the prevention approach until she becomes a higher level on the RLA scale. This could include making sure she is not sedentary, ensuring she has the proper assistance she needs to perform her 8 areas of occupation, and making sure she has proper therapy for her spasticity and fracture. Type or Approach C: o For Emily’s last approach, I would go with activities. This way, the OT can monitor her improvement each time she performs a certain activity. For example, since Emily likes fixing her car, she could start with something car related until she is able to fully comprehend and perform car repairs or remodels. This would help the OT see how she is improving from week to week. For something more simple, Emily could ‘work in a mock secretary office since that was a apart of her last 3 jobs. The OT could have her answer fake phone calls to see how she would react. This could also help monitor her agitation levels and see if they decrease from day to day.

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