RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.

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Anna Rastatter, Eunjin Choi
I. What are the medical issues/conditions?
List the medical issues and to what extent they impair the individual (BE SPECIFIC: For
example don't just state "heart" explain how severe medical issue is: "severe heart
attack requiring stent"
Use following as a guide: mild (less 25%), moderate (less 50%), severe (more 50%), complete
(more 95%)
Consider the Following Areas
1. Mental functions (ex: intellect, energy, sleep, attention, memory, emotions, perceptions, cognitive fx,
language)
2. Sensory functions & pain (eyes, ears, touch, balance, etc)
3. Voice & speech functions
4. Fx cardiovascular, hematological, immunological and respiratory systems (ex: heart, blood pressure,
respiratory, etc)
5. Fx digestive, metabolic & endocrine systems (ex: weight maintenance, bowel functions, etc)
6. Genitourinary & reproductive fx
7. Neuromusculoskeletal & Movement (ex: mobility of joints, muscle power, muscle tone, involuntary
movements, etc)
8. Fx skin & related structures

Current Medical Issues

1) Getting into trouble as a teenager; falling asleep in class
Periods of fatigue
2) NA
3) NA
4) NA; currently blood pressure is normal
5) Type II Diabetes
Recently experienced diabetic coma
Increased urination
Adolescent-unexplained weight loss
Ongoing increase in appetite and food intake
6) NA
7) Type II Diabetes which requires regular exercise
8) NA

RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.0
a. Future Medical Issues (what would doctor recommend person watch out for or be
aware of)
b.
c. 1) Pent up emotions, feeling pressure to please fianc and family through overeating
d.
Psychological, social effects due to diabetes
e. 2) Possible eye complications due to diabetes: Cataracts, blindness, retinopathy
f. 3) Possible oral infections due to diabetes
g. 4) High/low blood sugar due to diabetes which can cause diabetic coma or insulin shock
h.
Circulatory and cardiovascular complications due to diabetes: poor circulation, stroke,
high blood pressure, arteriosclerosis
i.
Possible complications due to diabetes: peripheral vascular system
j. 5) Organ damage due to diabetes: kidney/heart
k. 6) NA
l. 7) Possible lower extremity amputation due to diabetes
m.
Joint problems due to obesity
n.
Possibility for diabetic neuropathy due to diabetes
o. 8) NA

II. Activities and Participation in daily living tasks and social roles
Capacity
List anything person has problems doing as a result of their health condition (ADL's,
communication, mobility, learning/applying knowledge, interpersonal
interactions/relationships, working, social life)
-

Fatigue impairs activities of daily living

Restrictions in consumption of food and drink, especially alcohol
Inability to communicate emotions
Inability to communicate health risks due to condition

RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.0

Performance
List anything person CAN do but chooses (or is told) not to do. Not medically based but
rather environmental.
-

Dieting
Exercise
Communication to family and friends about health conditions
Development of interpersonal skills with family and peers
Disregard for the severity of risks of condition (doesnt care about need to monitor diet
and exercise)

C. Contextual Factors
C. Environmental Factors

Physical, social and attitudinal environment that makes up a persons life: these are not
within a persons control (support/relationships, family, work, govt agencies, laws,
cultural needs, access services, etc)
-

Inadequate support system (family and friends; especially fiancs family)

Cultural barrier between clients family, causes pressure to be accepted
Demanding job could potentially cause problems to health (extremes of temperature

RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.0
could affect blood pressure and cardiovascular system; noise could cause hearing
problems; hazardous occurrences could affect overall health)
-

B. Personal Factors
These include (but are not limited to): lifestyle, habits, social background, education, life
events, demographics (race, gender, marital status, etc), coping styles, etc.
-

Age: 21
Tall and big boned meets the criteria for obesity
Doesnt enjoy exercise
During adolescence experienced trouble-making phase: frequently scolded, falling asleep
in class
Marital status: Engaged; plans to marry within the year
No children
Lives with fianc
Fianc of different race
Associates degree in criminology; accepted into police academy
Likes unpredictable nature of police work, excites him
Doesnt want desk job, too boring, predictable, and sedate
Good terms with immediate family, but not so close
Coping mechanisms: eating at fiancs family restaurant,

RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.0

IV. REHABILITATION GOALS

C. MEDICAL TREATMENTS
-

Exercise
Diet control
Monitor blood pressure
Monitor blood sugar; blood sugar testing
Insulin
Oral Hypoglycemic agents
Counseling/therapy
Implement SIMPLE method:
Stop smoking (or continue not to)
Inspection
Monitor
Blood pressure
Lose weight
Exercise

B. ACCOMMODATIONS & ASSISTIVE TECHNOLOGY

- scale
- diet programs to monitor nutrition
- supportive programs to motivate physical activities (Wii Fit, gym membership, club
sports, in-home fitness equipment)
-blood pressure monitor

RHS 403 (Dr. Coduti)- ICF HEALTH ASSESSMENT CASE STUDY OUTLINE 2.0
C. COUNSELING GOALS
-

Individual counseling to work on interpersonal skills

Family counseling
Diet and exercise counseling
Group therapy
Awareness group about diabetes
Vocational counseling

D. VOCATIONAL/EDUCATIONAL GOALS
-

Wants to become police officer; finish police academy

Backup employment opportunities in case police force doesnt work out
Controlling health in order to maintain demanding job on police force