MG

Comprehensive OT Notes & Hypothesis – Alex (53 y/o, Post-Op Left THA)

Patient Profile

  • Name: Alex (male)

  • Age: 53 yrs (DOB: June 1, year not specified)

  • Marital / Living situation: Lives with wife in two–story colonial home; plans to recover in first-floor guest bedroom & half-bath

  • Occupation: High-school science teacher of 15 years

  • Hobbies/leisure:

    • Swimming (primary goal for return to activity)

    • Nature hikes with grandchildren

    • Playing cards, general family time

  • Driving status: Drives own car; drove self to surgery

  • Social supports: Wife at home; grandchildren nearby

History of Present Illness (HPI)

  • Chief complaint: Progressive L-hip pain × 1 yr (although verbally later states ≈ 10 yrs)

  • Pain location & quality: Deep left groin pain; causes perceived instability

  • Aggravating factors: Sit→stand, stairs, uneven ground, prolonged physical activity

  • Alleviating strategies: OTC NSAIDs (Aleve, Advil) PRN; swimming perceived helpful

  • Sleep: Interrupted by pain; currently uses abduction wedge while supine post-op

  • Conservative care attempted: Physical therapy (unspecified regimen) without sustained relief

  • Surgical recommendation: Left total hip arthroplasty (THA) → completed last night via posterior approach; allowed full weight bearing

Past Medical & Surgical History

  • Hypertension x ≈3 yrs ➔ controlled on lisinopril 10\,\text{mg PO QD}

  • Right rotator-cuff repair (successful recovery)

  • Colonoscopy at age 50 (“routine”; no complications)

  • No known drug allergies (NKDA); no anesthesia complications historically

  • Denies alcohol use; no smoking documented

Family History

  • Father: CAD & diabetes; deceased age 72

  • Mother: Deceased age 83 (cause not specified)

Medications

  • Lisinopril 10\,\text{mg}\,\text{daily}

  • Post-op: Analgesic (unspecified); took 1 hr prior—pain now 8/10

  • Anticoagulation: Warfarin (dose unspecified) per ortho protocol

Review of Systems (ROS) — negatives unless stated

  • ENT: No nasal congestion

  • Respiratory: No SOB, cough

  • Cardiovascular: No chest pain, edema

  • GI: No diarrhea/constipation/heartburn/abdominal pain

  • GU: No dysuria/hematuria

  • Endocrine: No thermal intolerance, no fevers

  • Musculoskeletal: L-hip pain; otherwise denies back or muscle pain

  • Skin: Intact, no rash/lesions

  • Neuro: AO×4, no focal deficits

Physical Examination (last 24 h)

  • Vitals:

    • Temp 36.9\,°C

    • Resp rate 16\,/\text{min}

    • Pulse 76\,/\text{min}

    • BP 150/84\,\text{mmHg}

    • Weight 79.5\,\text{kg}

    • Height 182\,\text{cm}

    • BMI \approx 24 (normal)

  • General: Pleasant, alert, cooperative, mood/affect appropriate

  • HEENT: PERRL

  • Cardio: RRR, no murmurs, peripheral pulses equal

  • Resp: Clear bilaterally

  • Extremities: No swelling or deformity; gait “normal” pre-op; current L-hip ROM restricted by pain

  • Neuro: Speech clear, cognition intact; remembers name, DOB, hospital, surgery type

Laboratory Values (post-op panel)

  • \text{WBC}=6.1\times10^9/\text{L} (normal)

  • \text{RBC}=4.98\times10^{12}/\text{L}

  • \text{Hgb}=14.5\,\text{g/dL}

  • \text{Hct}=43.4\%

  • INR/other coag results: Not specified; to verify before ambulation due to warfarin

  • Estimated blood loss during THA: \approx150\,\text{mL} (within safe limits)

Home & Environmental Context

  • Entry: 3 exterior steps

  • Stairway to 2ⁿᵈ floor: ~12 straight steps; railing on L side only

  • Bedrooms/Baths:

    • 2ⁿᵈ-floor master bed & bath (raised toilet)

    • 1ˢᵗ-floor guest bed & half-bath (standard height toilet) – will use during recovery

  • Shower: Walk-in shower + separate tub; no grab bars

  • DME on hand: Non-wheeled (standard) walker from mother; no other equipment

Occupational Profile & Prior Level of Function (PLOF)

  • Mobility: Independent community ambulator pre-surgery; occasional pain-limited activity

  • ADL/IADL:

    • Self-care independent; occasional sock assist from wife on “bad days”

    • Cooking: Shared with spouse

    • Cleaning: Wife doing majority recently

  • Work: Full-time teacher; intends to resume

  • Leisure: Swimming, hiking, cards; participation limited “sometimes” pre-op due to L-hip pain

  • Falls: “Almost never”; no recent history

Surgery & Immediate Post-Op Status

  • Procedure: Left THA via posterior approach

  • Weight-bearing: FWB allowed

  • Hip precautions (standard posterior):

    • No hip flexion > 90^{\circ}

    • No adduction past midline

    • No internal rotation

  • Devices: Indwelling catheter removed; no other lines noted

  • Pain: Current 8/10 despite med 1 hr ago; RN anticipates analgesia peak shortly (30 min post-dose)

  • Fall risk flagged; standard + hip precautions ordered

Interprofessional Collaboration Notes

  • RN: Med timing, labs in chart, catheter removed, eager to ambulate to bathroom

  • Orthopedic PA: Confirms precautions, low blood loss, FWB, possible discharge tonight or tomorrow AM

  • Case Manager: Coordinating discharge; liaising with wife; wants OT/PT input at rounds

  • PT: Will test gait, balance & strength; collaborating with OT to avoid duplicate DME orders; bringing rolling walker & vitals equipment

  • OT: Will bring hip-kit tools for dressing assessment

OT Evaluation — Strengths

  • Cognition intact (AO×4) ➔ understands & can learn precautions

  • Good upper-body strength (confirmed verbally) ➔ facilitates ADL with hip kit & potential NWB transfers if needed

  • Motivated, goal-oriented (“eager to get moving,” return to swimming/hiking)

  • Social support: Wife available for assistance; no environmental barriers inside main living level once downstairs

  • Prior independence in ADLs/IADLs and driving ➔ high baseline function to build upon

OT Evaluation — Challenges / Performance Limitations

  • Acute post-op pain 8/10 ➔ interferes with mobility & participation in therapy

  • Posterior hip precautions restrict common movements used in self-care (bending to don socks/shoes, tub entry, low-chair transfers)

  • Home environment:

    • 3 exterior steps without details of handrail(s)

    • Second-floor master bed/bath inaccessible until stair safety cleared

    • No grab bars; standard-height toilet on recovery floor may be too low (hip flex > 90^{\circ})

    • Existing walker lacks wheels ➔ sub-optimal for efficient indoor ambulation; may impede gait mechanics

  • Warfarin therapy ➔ increased bleeding risk from falls or transfer mishaps

  • Pain-related disrupted sleep ➔ fatigue may limit therapy tolerance

  • Reports occasional light-headedness/nausea post-op (needs monitoring during mobility)

Hypothesis: Gap Between Current & Desired Occupational Performance

  1. Underlying factors

    • Post-surgical pain & inflammation

    • Hip ROM restrictions + posterior precautions

    • Limited adaptive equipment (no wheeled walker, no raised toilet on 1ˢᵗ floor, no grab bars, lacks hip-kit supplies at home)

    • Potential deconditioning from pre-op activity avoidance

  2. Resulting functional gap

    • Inability to perform lower-body dressing & bathing within precautions

    • Unsafe toilet/shower transfers due to low seat height & absence of grab bars

    • Ambulation limited to bed-to-chair; stairs not yet trialed

    • Leisure/work participation (swimming, teaching, driving) currently halted

  3. Consequence if unresolved

    • Risk of fall or hip dislocation

    • Delayed discharge or readmission

    • Reduced quality of life & prolonged caregiver burden

Plan for Further OT Assessment & Services

  1. Inpatient (today–discharge)

    • Pain management check-ins; schedule sessions 30–60 min post-analgesic

    • Educate & practice posterior hip precautions with demonstrations & teach-back

    • ADL training with hip-kit (reacher, sock aid, long-handled shoehorn, dressing stick)

    • Bed mobility & supine-to-sit using abduction wedge

    • Transfer training: Raised chair, toilet, tub bench; recommend bedside commode over standard toilet if no riser available

    • Ambulation within room & hallway with rolling walker; monitor hemodynamics (BP, HR, SpO₂) given antihypertensive & warfarin

    • Stair simulation once pain controlled; verify ability to manage 3 exterior steps and 12-step staircase with railing (L side ascending, R side descending per precaution)

    • Home safety education: Remove throw rugs, ensure adequate lighting, set up recovery area on 1ˢᵗ floor

    • Coordinate with PT to issue DME orders:
      • Rolling walker (2-wheel or front-wheel per PT gait findings)
      • 3-in-1 bedside commode or elevated toilet seat (1ˢᵗ floor)
      • Tub transfer bench + non-skid mat
      • Grab bar installation recommendations (bath & near exterior steps)

    • Initiate energy-conservation & pacing techniques for teaching duties

  2. At Discharge

    • Provide written HEP: Precaution review, LE gentle isometrics, UE strengthening to assist with transfers

    • Arrange outpatient OT (or home-health if mobility/stairs not safe): focus on advanced ADL, IADL (meal prep, cleaning), community re-integration, driving readiness

    • Target timeline: Outpatient OT 2–3×/wk × 4–6 wks, then re-evaluate

    • Set measurable goals:
      • Within 1 wk: Independent UB/LB dressing with adaptive equipment, pain ≤ 4/10 during task
      • Within 2 wks: Independent ambulation \ge 200\,\text{ft} with rolling walker on level surfaces
      • By 4 wks: Safe navigation of 12 stairs with railing using appropriate sequence
      • By 6 wks: Resume driving pending MD clearance & pain ≤ 2/10 on brake reaction test
      • By 8–12 wks: Return to swimming laps 3×/wk, 30-min duration, no pain > 3/10

  3. Monitor & Communicate

    • Daily team huddles with RN/PT/case manager

    • Verify INR values each morning prior to therapy sessions (warfarin)

    • Document progress & update goals; adjust DME requests to avoid duplication with PT

Key Numerical / Statistical Data (Quick Reference)

  • Age: 53\,\text{yrs}

  • Height/Weight/BMI: 182\,\text{cm},\;79.5\,\text{kg},\;BMI\approx24

  • Vitals: T=36.9\,°C\;|\;HR=76\,/\min\;|\;RR=16\,/\min\;|\;BP=150/84

  • Labs:
    \text{WBC}=6.1 \text{RBC}=4.98 \text{Hgb}=14.5 \text{Hct}=43.4\%

  • EBL during THA: 150\,\text{mL}

  • Pain ratings: Pre-session 8/10; goal ≤ 4/10 for ADL tolerance

Ethical / Practical Considerations

  • Informed decision-making: Alex is cognitively intact; include him in all goal setting

  • Fall prevention vs. independence: Balance autonomy with precaution adherence

  • Home safety modifications: Discuss cost, insurance coverage, and feasible DIY vs. professional installation (e.g., grab bars)

  • Teaching obligations: Coordinate gradual RTW plan to avoid extended sitting/standing that violates precautions