Occupational Therapy
Initial Assessment / Surname: Templar
Given Name:Duncan DOB:1/05/87 Sex:Male
Address: 24 Ethel Street, Forrestville, SA 5035
Case Number: PHY001
MEDICAL INFORMATION
Diagnosis: Left leg, below knee amputation and removal of spleen due to trauma related to a indoor rock climbing injury. There was also some damage to the ‘rib area’. Placed in Acute Orthopaedic/Vascular Unit approximately 2 months ago
Relevant Medical History: Previously he was very healthy (states there was nothing really wrong with him)
Is experiencing both phantom pain where his leg used to be and pain in the stump (more will be discussed within the pain section.
Wound has re-opened at leg, due to rubbing associated with over use of the prosthesis.
Due to damage to the spleen he is currently on multiple anti-biotics but is unsure of the specific names of anti-biotics (FOLLOW UP ON THIS)
Anti-biotics are also utilised for the open wound
Vision: NO ISSUES Hearing: NO ISSUES
SOCIAL SITUATION: Lives alone: Yes X No☐ With whom:
-In a (new) relationship - very close. Girlfriend is very supportive
-Parents come to visit, but they are older and currently not as active.
-Was married, now divorced. Has a 1 year old son- Currently sees his child every fortnight on weekends
-Enjoys taking son to the park and spending time at home
-Has a large group of close friends (does not want to ‘burden’ them too much)
-Although he lives alone, girlfriend could be helpful around the house
-Has a Pet (cat) with his girlfriend (could possibly be a tripping hazard but also could be utilised to manage stress) . Cat does not live at his house
-Spoke of his work colleagues (Wouldn’t ask them for support but enjoys Friday drinks after work with them)
Services: Personal Care Assistance ☐ Home Help ☐ MOW ☐ Other ☐
Social activities/Interests/Employment:
- Enjoys ‘Outdoor’ activities such as hiking and walking
-Mount Lofty was brought up several times as a major interest for Duncan
-Enjoys Gardening (Has vegetables in the back garden along with other projects)
-Academic at Flinders University (does some lecturing but is mainly there as a consultant)
-His area of research was in Environmental Studies, this is majorly connected to his love with the outdoors
-Indoor rock-climbing was an interest of his, but this was also the cause of the trauma hence he was not too comfortable in talking.
-Very quickly brought up that he was an Adelaide Crows fan and enjoys watching the game on TV
-Finally he very quickly indicated that he enjoyed going out for coffees and this is something that he would like to get back into (Mentioned in goals)
HOME ENVIRONMENT Previous Home Visit: Yes ☐ No ☐
Own ☐ Rented X House ☐ Flat/ Unit ☐ Storey: Single ☐ Double ☐
Front Access: / There were two small steps leading into the house, a removable ramp has been placed on the front steps. There is also some railing on the front door. Car park is behind the apartment. Follows a short path around the apartments to the front door
Back Access: / There is a garden at the back but there are no steps leading out to the backyard
Internal: / Wooden floor boards. One rug, this is placed under the coffee table and Duncan has stated that it is not a tripping hazard. But this should be further assessed
Bathroom: / As stated in initial referral form there have been some rails placed inside of his bathroom. Duncan has stated that there wont be any issues getting into his shower (no tripping hazards)
Toilet: / Nothing more was addressed other than what was stated on the referral form
Bedroom: / Queen sized bed, was considered to be ‘high. Duncan stated that he believes this would be highly beneficial in order for transfers onto and out of bed
Seating: / Most of the seating is fine around the house. Except there is an issue with 2 couches that may be difficult to move. These are propped up against the wall. They create an issue in regards to clearance through the
Other:
Transport: Drives Yes X No ☐ Manual ☐ Auto X
Public Transport: Tram ☐ Train ☐ Bus ☐ Disabled Parking Permit ☐
Other: Utilises car to get to and from work, hence it is extremely important to get him back into driving as soon as possible
CURRENT LEVEL OF FUNCTION
Ambulation Weight bearing status: FWB ☐ PWB X NWB ☐
Independent X Supervision ☐ Assistance ☐
No Aid ☐ Crutches X PUF ☐ SPS ☐ 2/4 wheel frame ☐
Independent wheelchair X Dependent wheelchair ☐
Comments: -Prothesis has led to issues with skin integrity (scarring has reopened and become infected)
-Does not want to be seen in a wheel chair or with a crutch, hence he wants to transition as quickly as possible.
-Duncan stated that he had issues with his dominant hand overpowering when self-propelling his wheelchair. (Right hand dominant causing him to continually push left).
UPPER LIMB FUNCTION
Dominance: Right X Left ☐ Precautions: ☐
Impaired: Yes ☐ No X ROM ☐ Sensation ☐ Coordination ☐
PAIN Yes X No ☐
-Phantom Limb pain has been a major issue.
-According to Duncan is felt where the foot initially was
-There is a sharp stabbing pain that begins where his foot once was and progresses up the leg
-The pain comes in waves throughout the day and sleep has been affected due to pain durinf the night
OCCUPATIONAL PERFERFORMANCE AREAS
Key: I = Independent A = Assistance required S = Supervision/Prompts
Previous Status
Comments (Aids used) Key / Current Status
Comments (Aids used) Key
Bed mobility / I / I & S
Transfers / I / Duncan stated that at home he would feel comfortable transferring into bed and into wheel chair. This should still be assessed / I & S
Personal care ADL
Eating / I / I
Grooming / I / I
Dressing / I / I
Bathing / I / I
Toileting / I / States that he has some troubles getting onto the toilet. But is very much against having others assist with his transfer. As he doesn’t wish to be a burden (Refer to goals) / S & A
Other / I
Domestic ADL
Meal Preparation / I / His girlfriend can possibly help with meal preparation. He has had some difficulties cooking in the OT kitchen as seen in the referral form. He states that he feels as if he is juggling a lot and gets very overwhelmed / S & A
Housework
Laundry / I
Garden/Home Maintenance / I
Community ADL
Shopping / i
Other / I
COGNITION NAD X Impaired ☐
Comments: There was no major issues but has experienced some difficulty with memory. Duncan states that it could be due to the fact that he has been in hospital and is still trying to comprehend everything that has happened to him.
Also some issues with balance- this should be followed up on
PATIENT GOALS
1.  Independence is his major goal in all areas. Duncan does not want to be a burden or treated differently than those around him. He wants independence in all aspects of life, especially in regards to getting outdoors
2.  Free standing without crutches for an extended period of time (while lecturing)
3.  Return to work as soon as possible (sick leave has run out, hence is paying for hospital stay using savings)
4.  Return to independent driving as soon as possible
5.  Reduction of frustration and stress, wants to try a variety of techniques
ISSUES IDENTIFIED
1.  Phantom and stump pain
2.  Skin wound associated with overuse of prosthesis, we want to avoid this becoming a constant issue as it could lead to major infections and loss of motivation
3.  Frustration and stress- Duncan was very clear that his levels of frustration have been high since he’s been inside the ward. As he can see the outside but isn’t able to be involved in outdoor activities. Duncan is open to stress management practices and would like to have a look at a variety of methods. An example of a social group (both online and in person) is Limbs4Life
4.  Limited mobility associated with prosthesis and the crutch. Duncan finds it difficult to perform tasks such as cooking. This again has led to major frustration and stress
5.  Following on from issue 2, Duncan also does not want to be seen in a ‘disabled state’ and wishes to transfer to a ‘proper’ prosthesis as soon as possible. Duncan has also brought forward the fact that there is some uncomfortable rubbing occurring on the back of his knee and this is something he wishes to deal with. Furthermore, another issue for further research is in regards to prosthetics came up in conversation regarding comfortable prosthetics for hiking and lecturing. Need to understand further about costs surrounding this.