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Sophia Case: Occupational Profile (Gabriela Morrell-Zucker, Alyssa…
Sophia Case: Occupational Profile (Gabriela Morrell-Zucker, Alyssa Trapasso, Mitzi Salz, Peyton Dooley)
Personal interests and values:
Sophia enjoys going out with her boyfriend of 3 years as well as her friends. She also enjoys cooking dinners, shopping running and swimming.
Occupational history:
Prior to the car accident, Sophia worked as a financial advisor for Wells Fargo bank.
Performance patterns (habits, routines, roles, rituals):
Some of Sophia's roles are being a girlfriend, friend, and coworker. Her routines include cooking dinners, shopping, running, swimming, and spending time with her boyfriend and friends.
Reason client is seeking services and concerns related to occupational engagement:
Sophia was involved in a car accident and suffered several fractured ribs and a L humerus fx. She is being seen bedside in the acute care setting. Patient reports being unable to user her LUE to feed herself, open containers, brush her teeth, as well as difficulty managing toilet hygiene and donning/doffing clothing.
Occupations in which client feels successful:
Patient is not able to report occupations that she currently feels successful. Barriers to the patient's performance in feeling successful include her inability to feed herself with her LUE, open containers, and brush her teeth. She also presents with difficulty managing toilet hygiene and donning/doffing clothing.
Client Goals
Sophia would like to be able to complete her ADL's including feeding herself, dressing, brushing her teeth, and toileting independently. She would also like to be able to resume IADL's including cooking dinners, shopping, running, and swimming.
Environment
Physical:
She lives in a one-bedroom apartment with her boyfriend. No barriers were specifically stated in the OT evaluation.
Social:
Because Sophia lives with her boyfriend, she will have the support from him in the home. She also has friends that serve as a strong support system. No barriers were stated in the OT evaluation.
Context
Client is a 32-year-old female who is middle-class. She will likely have a smooth and manageable physical recovery and have the means to afford adaptive equipment if needed.
Client experiences more pain in the morning making it difficult for her to engage in morning ADL's.
Client values her relationship with her boyfriend and cooking dinners for him which may be difficult and pose a safety risk due to her inability to use both UE's.
Client utilizes an electronic system at work that she can operate with her right UE while her left UE is immobilized. She is also able to communicate through text and chats on her cell phone rather than writing by hand. No virtual barriers were reported.
Client Report
Cultural
Personal
Virtual
Temporal