occupational therapy
Mini Case Study Analysis 1 Part 1
Case Study Scenario
Client: Maria Lopez
Age: 82
Dominant Hand: Right
Occupation: Retired, administrative assistant
Living Situation: Lives alone in a first-floor apartment with 4 STE and 1 rail
Medications: Tramdol 50 mg Q every 4 hrs, Tylenol 600 mg every 6 hrs PRN, Levothyroxine 75 mcg daily,
Lisinopril 10 mg daily, Vitamin D 2000 IU, Calcium 1200 mg daily
Medical History:
Maria sustained a right femoral neck fracture after slipping on ice 1 week ago. She underwent an open
reduction and internal fixation (ORIF) 6 days ago. She now presents to subacute inpatient rehabilitation
with PWB restrictions to maximize (I) and safety for safe transition to home environment.
Relevant Conditions:
• Post-surgical stiffness and pain in RLE, PWB restriction
• Increased pain R hip 7/10 w/ movement
• Mild edema R hip
• Significant fear of falling
• Osteoporosis
• Osteoarthritis
• Atrial fibrillation (on Eliquis)
Occupational Profile:
Maria reports difficulty completing self-care tasks, specifically LB dressing and toileting, as well as
difficulty with functional mobility and prolonged standing. She appears to be well “put together” and
supported already having her friend drop off toiletries (hair and makeup supplies) clothing, depends,
crosswords and reading materials.
She expresses frustration and anxiety about losing independence and falling, and is eager to return
home to her cat and active lifestyle. Maria reports still driving and is heavily involved in volunteering
with her church community, senior center, and regularly dines/socializes with friends.
Objective Findings:
• ROM: WFL, mild crepidus noted in bilateral shoulders
• Strength: 3+/5 grossly
• Pain: 7/10 R hip with movement and in standing, also 3/10 right torso
• Skin: ecchymosis R rib cage/torso secondary to fall on right side, Sx incision 3-4 in lateral R
hip with staple closure and dry dressing s/p ORIF
• Edema: Mild swelling R hip
Mini Case Study Analysis 2 Part 1
Case Study Scenario
Client: Borat Scaffa
Age: 69-year-old
Dominant Hand: Left hand
Occupation: Retired, cabinet maker
Living Situation: Senior living apartment, with partner
Medications: Vancomycin 500 mg QID orally x 7 days, Salmeterol 500mcg by oral nebulization 3−4 times
daily every 6−8h, Fluticasone PRN, 2LO2/min via n/c
Presentation/Medical History:
Patient presents home from hospital after 8-day stay for community acquired pneumonia (treated with
Ceftriaxone 1-2g IV daily x 7 days) and resulting COPD exacerbation with an order to continue long term
oxygen therapy (LTOT). Physical therapy hospital discharge note states Mr. Scaffa was ambulating 100 ft
3x/day with CGA, using continuous O2 therapy 2L/min. Occupational therapy discharge note indicates
he needed minimal assistance using AE to bathe and dress his lower body.
Relevant Conditions:
• COPD
• 25 pack year history
• Hypercholesterolemia
• CHF
• Depression
• Chronic lumbago
• Osteoarthritis, R knee
Occupational Profile:
Client stated goal: return to driving, shower by myself, taking care of things around the house (home
maintenance including fixing the broken wall light in the hallway), and playing poker with his friends on
Tuesdays.
Mr. Scaffa has a portable O2 tank and oxygen concentrator at home. Elise has been with Borat for 11
years and reports he is “bullheaded”. She fears he will not refrain from smoking or follow the Dr.’s
orders restricting physical activity outside the home. Homecare case was initiated by nurse case
manager who reviewed medication list and instructions with patient and caregiver, as well as the need
for doctor’s recommend restrictions (MET level 2-3 x 7 days. Referrals have been made for OT and PT to
go into the home. The initial homecare nursing note indicates Mr. Scaffa’s respiratory status was
essentially stable since discharge from the hospital. He expressed anger about his condition and his
restrictions on smoking and diet but was generally compliant with the nurse. The PT note indicates that
patients appear to have been sedentary since returning home and became significantly short of breath
OCTH 6055 Older Adults
Mini Case Study Analysis 2 Part 1
(O2 sats 89%) after ambulating 25 ft. A home exercise program (HEP) was initiated by PT to increase
strength and endurance.
Upon entering the home, you find Mr. Scaffa and his partner Elise in the kitchen. He is watching her
prepare his meal. He does not look happy. He immediately states “Oh boy, another person here for me. I
don’t know what you can do for me that the other young PT fella can’t. I am not happy about things and
that’s all there is to it!
Mini Case Study Analysis 3 Part 1
Case Study Scenario
Client: Kenneth Kunaya
Age: 71
Dominant Hand: Right
Occupation: Retired forestry
Living Situation: Home w/ spouse in 2 level home
Medications: Metformin 500 mg BID, Lisonopril 20 mg (ACE inhibitor), Spironolactone (Diuretic)
Presentation/Medical History:
The patient is a 71-year-old Asian male who was admitted to the inpatient rehabilitation unit following a
left-sided cerebrovascular accident requiring intensive care x 3 days and further medical management x
2 days. MRI scan demonstrates 1.5 cm clot in left cerebrum leading to ischemic vascular accident. Upon
admission to the rehabilitation unit, the patient presents with right-sided hemiparesis with neglect,
expressive aphasia, decreased sensation on right side, mild cognitive impairment, particularly in
attention and problem-solving, impaired balance and coordination, and deconditioning. Patient now
presents to this skilled nursing facility (SNF) for further medical management, short term rehabilitation
(STR), and discharge planning.
Relevant Conditions:
• Hypertension
• Type 2 diabetes mellitus
• Hyperlipidemia
• Family history of heart disease and stroke
Occupational Profile
Following the left CVA, Kenneth demonstrates significant changes in occupational performance,
including:
• ADLs: Requires moderate assistance for feeding, dressing, bathing, and toileting due to right-
sided weakness, ataxia and neglect
• IADLs: Currently dependent due to physical and cognitive limitations
• Functional Mobility: Requires assistance for transfers and ambulation; impaired balance and
endurance
• Communication: Expressive aphasia limits ability to clearly communicate needs, impacting
participation in daily routines
• Upper Extremity Function: Decreased strength, coordination, and fine motor control in the right
upper extremity
Prior to hospitalization, the client was retired and actively engaged in meaningful daily routines. His
typical day included self-care activities, light household responsibilities, and leisure pursuits such as
walking, watching television, and spending time with family. He also participated in culturally
OCTH 6055 Older Adults
Mini Case Study Analysis 3 Part 1
meaningful practices, including shared family meals and maintaining social connections within his
community. Prior to the stroke, he lived independently with his spouse in a two-story home and was
fully independent in activities of daily living (ADLs), instrumental activities of daily living (IADLs)
(including medication management) and driving. He is experiencing frustration with his current
functional status and difficulty communicating with his wife stating, “She won’t take me home!”
Objective Findings
• ROM: R UE impaired, LUE WNL
• Strength: 2+/5 R UE, 3+/5 R LE, Grip: 26 kg
• Pain: 0/10
• Sensation: impaired light touch, sharp/dull R UE
• Skin: Lesions/moles noted throughout thoracic spine, mild jaundice, reduced turgor
throughout
• Edema: n/a
Occupational therapy services are indicated to address deficits in motor, process, and communication-
related performance skills, with the goal of maximizing independence and facilitating a safe return to
the home environment with services to assist.
Mini Case Study Analysis 4 Part 1
Case Study Scenario
Client: Gertrude Hayes
Age/Gender: 86 years old, female
Dominant Hand: Right hand
Medical Diagnosis: Alzheimer’s disease (moderate stage)
Occupation: Retired, teacher
Living Situation: Resides at home with daughter (primary caregiver)
Medications: Donepezil (Aricept®) 5 mg PO qHS, sertraline 50 mg daily, aspirin 75 mg daily
Presentation/Medical History:
The client presents with:
• Short-term memory loss
• Disorientation to time and occasionally place
• Decreased problem-solving and judgment
• Difficulty sequencing multi-step tasks
• Occasional agitation and anxiety, particularly in unfamiliar situations
Functionally, she requires:
• Supervision to moderate assistance for ADLs (dressing, bathing) depending on time of day,
fluctuating
• Maximum assistance for IADLs (medication management, cooking, finances)
Occupational Profile:
The client is an 86-year-old female with a diagnosis of moderate Alzheimer’s disease. She is a retired
teacher who previously engaged in reading, cooking, and attending church. She values independence
and maintaining a structured daily routine.
Prior to cognitive decline, she was independent in all ADLs and IADLs. Over the past year, her daughter
has reported increasing difficulty with memory, task completion, and safety awareness requiring
increasing levels of assist including min A transfers in/out of bed. She has a significant history of
elopement from the house in which the police have had to be involved to return her home safely. The
client expresses frustration with her declining abilities but demonstrates limited insight into the extent
of her deficits.
Gertrude’s daughter (Sherri) reports the following observations:
• History of falls
• Frequently wanders and appears confused, lost
• Impaired attention and memory
• Decreased safety awareness
OCTH 6055 Older Adults
Mini Case Study Analysis 4 Part 1
• Difficulty with task initiation and completion during mealtime, bathing, and wake/sleep
routines
• Able to engage in simple conversation most days
• Word-finding difficulties
• She becomes withdrawn or frustrated when unable to communicate effectively
She is becoming increasingly concerned regarding her ability to care for her mom and keep her safe
within her home. Sherri reports she is moving her youngest daughter to college and is having difficulty
balancing her multiple roles of part time job as a paralegal, caregiver (for children and mother), spouse,
and community volunteer.