Interview & Evaluation Note

Elizabeth Clinch
Utica College

OCCUPATIONAL THERAPY OCCUPATIONAL PROFILE AND EVALUATION PLAN

BACKGROUND INFORMATION
Clients name: TC
Date of report: 11/11/15
Date of referral: 11/6/15
Date of birth: 12/15/64
Gender: Female
Primary intervention diagnosis/concern: Systematic lupus erythematosus (SLE)
Secondary diagnosis/concern: Fibromyalgia & myopathy
Reasons for referral to OT: Managing symptoms and the impact of Lupus on her life as well as
advocating for herself at work
Therapist: Elizabeth Clinch, OTS
Assessments performed: Interview
FINDINGS
Occupational Profile:
TC is a 50 y/o woman with Lupus (SLE), diagnosed approximately 2 years ago. She began presenting
with symptoms such as joint inflammation and pain around the age of 28 y/o and diagnosed with
rheumatoid arthritis. She experienced varying levels of symptoms until moving to New York at the age of
38 y/o, when her symptoms went into remission. She questions whether the decreased sun exposure
played a role in her remission. Around the age of 48 y/o she experienced a relapse of symptoms that led to
her diagnosis of Lupus and secondary diagnosiss of myopathy and fibromyalgia. Symptoms included
chronic fatigue, heart palpitations, inflammation, pain, muscle weakness throughout her body as well as
nausea and vomiting. Currently these symptoms are present varying in levels of severity from day to day.
She rates her pain on a good day at a 5/10.
TC lives in a 2 story home in a rural town with her husband, her cat Maggie and their dog Speedy; they
have 4 children. Her 2 sons and step daughter live in the surrounding area and her daughter lives in
California. At this time no accommodations have been needed around the home although she is aware that
this may be a realistic adaptation in the future.
She expressed that one major battle thus far has been finding qualified specialists in her rural area. She
voiced that she often gets told by her rheumatologist that she does not know or understand the results of
lab tests. For the past 6 months she has been on the wait list to see a new rheumatologist at the Lupus
Clinic in Syracuse, which is 50 miles one way, and is concerned that they will be no better than her
current doctor. Financially, she has found the course of her condition to be quite costly between visiting
multiple medical providers, purchasing specialty OTCs and maintenance medications. She stated the cost
of one medication to be over $500. She describes experiencing some shame and embarrassment due to
recently being prescribed anti-anxiety/depression medications that are successful in treating lupus
symptoms such as muscle pain and insomnia. She shared that her sleeping patterns have improved.
Deciding which part of the body to preserve the longest is a huge factor since she has found that her
medication impacts her vision but it slows progression of the heart, lungs and kidney failure. The most
relief she receives lies in contemporary medicine, specifically acupuncture, providing care to the mind,
body and spirit. She wishes that her insurance would cover more of these holistic treatments above the 10
visits per year.
In general she feels emotionally exhausted from the constant attack on her body and also with the social
perception of a condition that you cannot visually identify. She expressed the issue of everyone having a
magic cure for her, whether it being eating a certain diet or exercise, which becomes frustrating since she
knows that there is no cure for Lupus. She finds that having to cancel plans with friends has lead to
somewhat of a social isolation, while following through with plans when she is not feeling well means
she will pay for it later.

Happiness is found in her craft room, making beautiful quilts to share with her loved ones, a handmade
quilt can always be found on the comfy couches around her home. Couponing is another one of her
hobbies but, she sometimes runs into problems with fatigue during lengthy grocery shopping trips. In
living by the spoon theory she is generally able to prioritize and complete her most important daily
activities without over exerting herself (see attached for more information on the spoon theory).
TC makes accommodations when traveling to California to visit her many family members and friends.
She has found that wearing a sun hat and protective clothing washed with an additive sunscreen element
gives her the best protection from the harsh effects of sun exposure. In addition, she uses larger pens, craft
tools and occasionally wears wrist braces to aid the intense inflammation and pain in her hands. As well
as a loving wife and mother, TC is also a caring grandmother who enjoys spending time with her
grandson. She has found napping ahead of time serves as a beneficial energy conservation technique to
get the most out of her time with him.
Her work environment gives her a certain amount of freedom to structure her day as she sees fit allowing
for a successful work performance at this time. Monday, the day after she comes home from her 2 day
work shift is her recovery day she says. The internal battle of whether or not to tell her employer about
her condition is on her mind. On one hand she does not want to be treated differently, but on the other she
would like her supervisor to understand that she has embraced her limits at work and simply cannot
surpass them while remaining healthy at the same time. Her supervisor makes her feel like she is not a
dedicated team player since she is unable to pick up overtime when asked. At this time her husband is
supportive in bringing and picking her up from work when she needs it due to decreased vision and
anxiety especially when driving at night and in the snow. While at work she does not have a choice but to
drive even when she does not feel well, it is dark and/or snowy. She does have a level of understanding
and comfort in her supportive coworkers that are aware of her condition at this time.
PLAN
Specific areas of Occupational Performance to assess:
1.
2.
3.
4.
5.

Symptom management (via journal of emerging symptoms/decrease in function)

Advocacy & impacts in the workplace
Visual function
Social relationships & supports
Impact of fatigue on mobility (traveling, shopping, driving)

Specify Assessment of client factors, performance skills, performance patterns, contexts and
activity demands:
Assessment
Systemic Lupus Erythematosus Needs
Questionnaire (SLENQ)
(Contexts, Performance skills & patterns, client
factors)
Modified Fatigue Impact Scale (MFIS)
(Performance skills, client factors)
Work Environment Impact Scale
(Performance skills & patterns, contexts)
Modified Social Supports Survey (MSSS)
(Performance skills, context)

What it specifically assesses

Needs are expressed by client
(health services/info, spiritual, physical, social
supports, daily living, employment/finances)
Identify effects of fatigue on cognition,
psychosocial and occupational performance
Physical and social impacts in the work place
Social supports in her life (emotional, tangible,
affective, positive)