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Medical Case Study: Occupational Profile

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Evaluation Client Name: Xavier
Age: 48
Diagnosis: Left forearm structure, stress fracture to Lower, Thoracic and upper lumbar.
Medical/Surgical history: Mild concussion (mild TBI) at the injury.
Occupational Profile Xavier is a 48-year Latino male, speaks Spanish primarily but also English. He lives with his wife who is 7 months pregnant and 8-year-old twin boys. As a head of the house, he works as a printer for a large commercial company. When not working, he enjoys socializing with family and friends, going fishing, and working around his house and yard. After recent fell from the ladder, Xavier fractured his left forearms, sustained a stress fractures to his lower/thoracic/upper lumbar vertebrae and the mild concussion. As a medical …show more content…
Bathing and shower are restricted until external fixator is removed or replaced with internal fixator. Toileting needs max to moderate assist from the limited functional mobility and difficulty dressing with using one arm. Along with ADLs, IADLs limited as well. Limited body mobility limits him from performing a role as a father of 8-year-old twin boys and a husband of 7 months pregnant. Limited Upper limb (UE) movement using left and trunk support make him unable to drive or commute with ease. Meal preparation or clean up may need extra times due to difficulties in mobilization one side of the arm and reduced trunk support. Sleep and rest may be influenced from pain and immobilization. Education and work are also negatively influenced by current body condition, he might present fatigue, limited concentration. Also, pain causes him to perform work with max function. Play and leisure participation should be monitored from not to develop secondary conditions and consideration must be made with his physical condition prior to play/leisure. Social participation might be limited in environment he need to make vigorous movement or assistive device cannot be worn. COPM will be used to evaluate Xavier to understand issues related to self-care, productivity, and leisure. During the assessment, Xavier will indicate the areas where he is experiencing difficulties such as ADL s including self-care such as dressing, eating, personal hygiene, grooming and functional mobility. After the assessment, the therapist is able to see in which area client needs services

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