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



B. Problem Statements

  1. Client demonstrates difficulty with lower body dressing due to impaired motor skills and restricted RLE weight-bearing related to post-surgical R hip pain (7/10), 3+/5 muscle strength, and PWB restrictions s/p ORIF.

  2. Client demonstrates difficulty with toilet transfers and functional mobility due to decreased standing balance and transfer deficits related to R hip pain, lower extremity weakness (3+/5), and fear of falling.

  3. Client demonstrates difficulty with IADLs due to inability to tolerate prolonged standing related to RLE post-surgical stiffness and PWB restrictions.


Long-Term Goal 1: Within 3 weeks, client will independently complete lower body dressing while seated using adaptive equipment while adhering to right lower extremity partial weight-bearing precautions with reported hip pain ≤2/10, in order to safely resume independent self-care prior to discharge home.

Short-Term Goal 1: Within 1 week, client will complete lower body dressing with Contact Guard Assist while seated, utilizing adaptive equipment with 100% adherence to precautions, to progress toward dressing independence.

Long-Term Goal 2: Within 3 weeks, client will perform toilet transfers independently using a raised toilet seat with bilateral armrests and a front-wheeled walker while maintaining restrictions, in order to independently and safely manage toileting at home.

Short-Term Goal 2: Within 1 week, client will perform sit-to-stand and stand-to-sit toilet transfers using a front-wheeled walker and raised toilet seat with Minimal Assistance and no more than 1 verbal cue for proper PWB foot placement and sequencing.