Neuro Rehabilitation Reports | Occupational Therapy Reports
Occupational Therapy Report 2 | Occupational Therapy Home Assessment
OCCUPATIONAL THERAPY ASSESSMENT REPORT
Dated April 5, 2006.
"SUMMARY OF FINDINGS
[Christa] is a 37-year-old right dominant mother of twin boys, age 22 months, who has sustained injuries in 2 motor vehicle accidents, the first on September 15, 2005, and second on February 10, 2006. At the time of the first accident she was self employed. As a result of the first accident, she suffered dizziness, headaches, vertigo, low back pain, sharp neck pain, pain in the right shoulder blade, pain in the right hip radiating down the right upper leg to below the knee, cognitive problems related to memory, concentration, ability to maintain a train of thought and ability to focus, and depression and anxiety. She was diagnosed with post concussion syndrome by her family doctor. A CT scan showed a mild disc bulge at L4-5. She reported that she had recovered approximately 30% at the time of the second accident which exacerbated the above injuries. She reported the following as a result of the second accident: increased depression and anxiety, increased dizziness with poor balance, headaches, shoulder tendonitis with pain and decreased range of motion in both shoulders, intermittent tremor in the neck, decreased hearing, increased pain in the right hip and upper leg referring into the low back, pain referring from the low back into the left buttock, numbness in the hands and feet, and increased cognitive problems including short term memory, word finding, attention, concentration, insight and problem solving, and bilateral TMJ pain and dysfunction. She was diagnosed with right iliotibial band syndrome by an orthopedic specialist.
Prior to the 2 accidents, [Christa] was responsible for all of the indoor housekeeping tasks, was self employed, working at home and was the primary caregiver of her twin boys.
On assessment, [Christa] demonstrated significantly decreased range of motion of the shoulders, neck and low back, and decreased strength in her upper extremities. Due to pain, the decreased range of motion, decreased strength, decreased activity tolerance and cognitive problems she is experiencing, she requires assistance with self care including, bathing, dressing, grooming, hygiene, and meal preparation. She also requires assistance with all aspects of housekeeping."
"History of Present Injury
Accident of September 16, 2005
[Christa] reported that on September 16, 2005 she was rear ended while driving on Hwy. 401. She did not see the car coming. She reported that her head hit the steering wheel and she lost consciousness. As a result of this accident, she suffered dizziness, headaches, vertigo, low back pain, sharp neck pain, pain in the right shoulder blade, pain in the right hip radiating down her leg to below the knee, and fear of driving. She reported cognitive and memory problems, difficulty concentrating and maintaining a train of thought, and difficulty focusing. She also reported some depression and anxiety. As a result of this accident, she was diagnosed with post concussion syndrome and a referral was made to a neurologist by her family doctor. A CT scan showed a mild disc bulge at L4-5.
[Christa] reported that the injuries and symptoms from this accident had improved approximately 30%, but had not resolved at the time of the second accident which occurred on February 10, 2006.
Accident of February 10, 2006
[Christa] reported that she was stopped in traffic on the 401 when she was rear-ended by a vehicle that was traveling 80-90 km per hour. She was aware of the vehicle’s approach and braced herself for the impact. She immediately experienced a sharp pain at the base of the head and in the neck, headache, increased pain in the low back (went from 3 out of 10 up to 8 out of 10), she felt nausea, dizziness, and had difficulty standing, walking and orienting herself. She was taken by ambulance to Credit Valley Hospital where spinal injury was ruled out, and was sent home to follow up with her family doctor, whom she saw several days later. She reported that her pain became more acute and she experienced increased difficulty with attention and concentration, memory, word finding (both speaking and writing), problem solving and increased anxiety as a result of these problems. She experienced increased pain in the right leg and hip, and reported that she was diagnosed by an orthopedic specialist with ilio-tibial band syndrome. As a result of this exacerbation, she experienced decreased mobility and flexibility, and increased pain in the leg radiating into the low back. She has increased pain and loss of range of motion of both shoulders. Her physiotherapist told her she had shoulder tendonitis. She also has pain and dysfunction of the right TMJ joint which causes problems with eating. She reported that she had a CT scan last week for the TMJ problem. Her dentist has referred her to [Dr. X], an oral / maxillofacial surgeon at Mount Sinai Hospital whom she will be seeing the week of April 10. She has been referred to a neurologist [Dr. X], by her family doctor and is scheduled for a consultation on June 14. [Christa] reported that she had been seen by a psychologist at the physiotherapy clinic that she attends, and that this psychologist recommended to her that she be assessed by a neuropsychologist, as her problems are beyond his scope of practice. She has not been referred for a neuropsychology assessment yet."
Current Symptoms were described as follows:
- "Increased pain in the low back.
- Pain in the right thigh and hip. This radiates into the low back. She reports decreased mobility and flexibility of the right leg. Any movement of the right leg causes increased pain in the low back.
- Headaches. The nature of the pain is described as sharp and sometimes debilitating.
- Disturbed sleep due to back pain and pain in the right leg and hip, and TMJ pain. She reports experiencing frequent repetitive dreams about car accidents. Has to nap for 1-2 hours per day due to fatigue from lack of restorative sleep.
- Increased dizziness and vertigo. She has fallen due to dizziness and disorientation.
- Poor balance. [Christa] reports that she has fallen forward off of her chair and fallen over while squatting for no apparent reason.
- Pain referring down the back into the left buttock.
- Bilateral shoulder pain that is described as "wrenching", and increases from 0 out of 10 to 9 out of 10 with movement to end range, repetitive movement and lifting.
- Bilateral temporomandibular joint injury with pain. She reports that her jaw locks every half hour and she has to pry it open. This causes difficulty eating as her jaw tires very quickly.
- Pain and decreased range of motion in both shoulders.
- Tremor in the head and neck. This is intermittent.
- Numbness in the first 3 digits of both hands. This is intermittent and lasts about 4 hours. She reports increased numbness in the right thumb this week.
- Numbness in the lateral 4 toes of both feet, or the big toe of both feet. This occurs several times per week.
- Word finding problems with both speaking and writing.
- Problems with memory, attention, concentration, problem solving and insight. She reports experiencing confusion when performing some simple tasks, For example, she went to a gas station to get Gatoraid, and instead, lined up for gas, even though the tank was full. It was 5 minutes before she realized she did not need gas and that she had originally come for Gatoraid.
- Decreased hearing. She has to ask people to repeat things a lot.
- More emotional than usual.
- Feels increasingly anxious and depressed about her condition. Experiences frustration and embarrassment when she makes mistakes in front of other people.
- Driving anxiety and decreased confidence when driving. Reports that she is totally unable to drive the car in which she had the accident due to the memory of the accident, however she is able to drive her minivan. She reports that she often gets lost when driving and has to call her husband to get herself back on track."
Functional Status Pre-MVA
"[Christa] reported that, prior to the two motor vehicle accidents, she was very fit and active. She had worked full time in an intellectually demanding job as a pharmaceutical copy writer prior to birthing her twins, and was responsible for all of the housekeeping tasks with the exception outdoor tasks, and home maintenance.
Functional Status Post-MVA
Since the first accident of September 15, 2005, [Christa] has been unable to perform her normal housekeeping duties due to pain, dizziness, limited standing, walking and sitting tolerance, limited ability to lift and carry, and cognitive difficulties. She is also limited in her ability to play with and care for her children. She reports difficulty performing even basic activities and communicating, due to problems with attention, concentration, word finding, and memory."
"Clinical Observation and Interview
Emotional
- [Christa] reported that she is much more emotional than normal since the accidents and that she tends to be quite agitated and confrontational with people. She worries especially about her cognitive deficits, and feels frustrated with herself and embarrassed when she makes mistakes in front of other people. She reports feeling increasingly anxious and depressed about her condition.
Cognitive
- [Christa] reports that she has difficulties with word finding, attention, concentration, memory, and problem solving. She reports that has difficulty remembering things from one moment to the next. She reports that she forgets what she is doing, easily gets lost when driving, and mixes up words when writing or speaking. She reports that she has been told that she repeats herself without realizing it. This therapist observed [Christa] to have word finding problems and difficulty with attention, memory and concentration during the interview."
"ACTIVITIES OF DAILY LIVING
Home Environment
Family
- [Christa] lives with her husband and twin sons, age 22 months. Her husband and in-laws are very supportive, and assist with the care of the children and the housework."
OCCUPATIONAL THERAPY REPORT
Dated: July 14, 2006
"MEDICAL
Clinical Observations
Emotional
[Christa] has difficulty adjusting to her disabilities as she was very fit and active prior to the accident.
Cognitive
[Christa] was observed to experience word finding problems during the visit."
"FUNCTIONAL STATUS
Dressing
[Christa] reports that she find[s] it easier to put on her shoes and socks with the assistive devices provided, however, she still requires assistance with putting on her shoes and socks 4-5 times per week due to pain and vertigo/dizziness exacerbated by bending forward.
Grooming
[Christa] continues to require assistance for shaving her legs, shampooing and blow drying her hair, brushing her hair, and trimming her toenails as per attached Form 1 due to balance problems, low back pain, and decreased range of motion of and pain in shoulders.
Eating
[Christa] continues to require assistance for preparing her food due to fatigue and limited activity tolerance. She needs all of her food soft cooked as she is unable to chew due to her TMJ dysfunction and pain.
Mobility
As [Christa] is unable to walk outside without accompaniment due to her poor walking tolerance and dizziness/vertigo, her mobility needs have increased significantly since the previous visit, May 26, 2006. She reports 2 hours per day total accompaniment required.
Hygiene
[Christa] continues to require assistance for hygiene for bathroom, bedroom and clothing care, due to pain, fatigue and limited activity tolerance.
Exercise
[Christa] continues to require assistance to perform her home exercise program.
Bathing
[Christa] continues to require supervision for bathing and for assistance in applying creams and lotions due to her balance problems, shoulder pain and decreased range of motion."
"Attendant Care
[Christa] continues to require attendant care as per the attached Form 1 for dressing/undressing for assistance with her shoes and socks, grooming, meal preparation, mobility, hygiene, exercise, bathing and skin care. The assistance with dressing/undressing for shoes and socks and assistance with mobility for walking outdoors new needs."
OCCUPATIONAL THERAPY REPORT
Dated: May 17, 2007
"MEDICALCurrent Therapy and Medical Status
Social Work
[Christa] had been referred for Social Work intervention to Neuro Rehabilitation Services. The insurer has denied the request for assessment. Due to [Christa’s] difficulty in coping with her disabilities and the increased burden on her husband in looking after her, the twin boys and the housekeeping/home maintenance tasks, [Christa’s] relationship with her husband, and the family dynamics are such that social work intervention is strongly recommended at this time in order to assist in maintaining the functioning of the family and her relationship with her husband."
"Poor balance. [Christa] reported that she continues to lose her balance when squatting to attend to her children and often falls when in a squatting position. She reports that she tends to sway when standing unsupported. She does not feel secure when walking out of doors due to her dizziness and vertigo and continues to use a cane when walking outdoors. No change."
"Intermittent tremor in the head and neck. This is intermittent several times per day. It is worse when she is fatigued. No change. She reports that this is psychologically upsetting."
"Clinical ObservationsEmotional
[Christa] reported that she continues to be traumatized over the situation with her front tooth."
"Cognitive
[Christa] was again observed to experience word finding problems during the visit. She reports that her use of the wrong words in social situations is extremely embarrassing to her."
"CARE GIVING
[Christa’s] twin sons are now almost 3 years old, and weigh approximately 30 - 35 lbs each. They continue to be very demanding due to their stage of development. [Christa] reports a significant increase in pain after caring for her children in the morning and has to lay down either at the top of the stairs or on her bed to rest due to exacerbation of pain before continuing her own morning hygiene routine and getting dressed. Her morning care giving activities include waking her children, changing diapers and dressing them while they are in the crib, washing their faces, brushing their hair, feeding them, gathering their toys and extra clothes for daycare. Her husband is assisting more with driving the children to daycare. While she is performing these activities, her children are often resisting her. She reports that after performing this morning childcare routine, she feels complete exhaustion and increased pain. As her twin boys are getting bigger and stronger, the task of looking after them is gradually becoming more challenging and physically demanding for her."
"FAMILY
[Christa] reports that her relationship with her husband is becoming increasingly strained due to her disabilities and the increased burden on her husband in looking after her, the children and the housekeeping. She reports that her children are being negatively affected by her husband’s irritability due to the pressure he is experiencing."
"Social Work Intervention
Due to [Christa’s] difficulty in coping with her disabilities and the increased burden on her husband in looking after her, the twin boys and the housekeeping/home maintenance tasks, [Christa’s] relationship with her husband and the family dynamics are becoming increasingly strained." "Social work intervention to assist in dealing with these family issues is strongly recommended."
OCCUPATIONAL THERAPY HOME ASSESSMENT
Report Date: October 19, 2005
"CLIENT PRESENTATION
[Christa] was pleasant and co-operated during the in home occupational therapy assessment. Pain behaviors were observed during the assessment and she constantly moved and changed positions in order to relieve pain symptoms. Positive findings include guarded rounded shoulders posture. At this time, she is confined to the main level of the house and descends and ascends steps only once a day. She was observed to walk with below average speed and an overall reduced functional tolerance for sitting, standing and walking. Her in-laws are currently assisting her with essential housekeeping tasks and care giving for her 15 month old twins.
COGNITIVE/EMOTIONAL STATUS
The client reports increased mood changes, agitation and anxiety after the MVA. She reports being forgetful with reduced concentration when attending to tasks."