The Clinical Application of ICF Model for Occupational Therapy

Assignment Task

Case Study 1

Medical history

Mrs Smith is a 75 year old widower who has been admitted to the Neuro Ward with an acute stroke and left sided-paralysis which developed three days ago. She is conscious and is able to talk and make her needs known. She has no visual problems but wears glasses. Her blood pressure was high on admission but is now under control with appropriate medication. She complains that she is very tired and that the ward is very noisy. She is unable to get to the toilet and finds it very difficult to use the bed-pan. She enjoys sitting out in the chair next to the bed.

Social history

She has two daughters, both of whom live in Cape Town and who visit her daily. She lives on her husband’s pension which allows her to stay in a ground floor apartment by herself. She has already had a wheel chair ordered for her.

On observation ,

She is lying in bed, with her head turned to the right. She is over-weight but not obese. Her left arm is lying in an awkward position. She is assymetrical with trunk flexion to the right. Her left leg is lying in flexion/abduction/lateral rotation.

On examination

Mrs Smith is able to follow instructions but gets easily confused and disoriented. Her chest is clear. She complains of some pain in her left shoulder when her arm is moved but this is minimal. She has proprioception in her distal joints but is unable to identify the position of her ankle/foot, ankle/wrist on the left. The tone on her left hand side is decreased in the trunk and both limbs but the range of movement is full. She has some active movement in her left hip and can flex up the hip, but only with hip abduction. She has no active movement of the shoulder but can do scapula elevation and protraction.

She has difficulty in rolling to the right but can roll to the left. She is unable to get up into sitting. In sitting she has static balance and is able to sit alone. However she has poor dynamic balance and cannot be left sitting by herself unless supported. She is only able to get into standing with the support of two people and cannot transfer independently into a wheelchair. She can feed herself using her right hand, provided that she is supported in sitting and that the food is cut up for her.

Case study 2

Medical history

Mrs Smith is a 75 year old widower who has been admitted to the Neuro Ward with an acute stroke and left sided-paralysis which developed three weeks ago. She is conscious and is able to talk and make her needs known. She has no visual problems but wears glasses. Her blood pressure was high on admission but is now under control with appropriate medication. She is continent but cannot get to the toilet on her own. She enjoys sitting out in the chair next to the bed..

Social history

She has two daughters, both of whom live in Cape Town and who visit her daily. She lives on her husband’s pension which allows her to stay in a ground floor apartment by herself. She has already has her wheel chair. She is to be discharged in three days time to stay with her daughter who lives in a large double-story house in Rondebosch. Unfortunately the only bedroom that is available is on the first floor. Her daughter works all day but a nurse-aid will be employed to assist Mrs. Smith. Mrs. Smith was a keen Bridge player.

Observation

She is lying in bed, with her head turned to the right. She is over-weight but not obese. Her left arm is lying in an awkward position. She is assymetrical with trunk flexion to the right. Her left leg is lying in flexion/abduction/lateral rotation.

On examination

Mrs Smith does not appear to be cognitively affected, although she does get tired at the end of the treatment session. Her chest is clear. She complains of some pain in her left shoulder when her arm is moved but this is minimal. She has proprioception in her distal joints but is unable to identify the position of her ankle/foot, ankle/wrist on the left. The tone on her left hand side is decreased in the trunk and both limbs but the range of movement is full. She has some active movement in her left hip and can flex up the hip, but only with hip abduction. She has no active movement of the shoulder but can do scapula elevation and protraction.

She has difficulty in rolling to the right but can roll to the left. She is unable to get up into sitting. In sitting she has static balance and is able to sit alone. However she has poor dynamic balance and cannot be left sitting by herself unless supported. She is only able to get into standing with support and cannot transfer independently into a wheelchair. She can feed herself using her right hand, provided that she is supported in sitting and that the food is cut up for her. She is able to brush her teeth, comb her hair and groom herself, provided that she can reach the brush, mirror, etc. She still needs considerable help in dressing.

Once in the wheelchair, she is able to push herself for very short distances with her right arm. She does get very tired.

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