1.

CASE:-

DEMOGRAPHIC DATA :-

Name : Master Nathaniel

Age/sex : 4½ / Male

Date of evaluation :

30/10/2023 Diagnosis : ??

Associated problem : Speech problem

Date of birth : 12/06/2019

CHIEF COMPLAINTS :-

✓ screaming all the sudden

✓ Needs to hold something in hand

✓ Ecolaila

✓ Problem in sustainable attention

HISTORY :-

PRE-NATAL HISTORY:-

✓ No h/o complication

PERINATAL HISTORY :-

✓ Normal delivery

✓ Full term baby

POST NATAL HISTORY :-

✓ cried immediately after birth.c

Family History :

Mother 39 Years Fa-

ther 43 Years
4 ½ years
ON EXAMINATION :-

1) GROSS MOTOR SKILLS :-

A) High skills/ Advanced mobility skills:-

✓ Jumping - Present

✓ Hopping - Present

✓ Obstacle crossing - Present

✓ Balance beam walking - Present

✓ Tandam walking - Present

✓ Stair climbing - Present

✓ Slop walking - Present

✓ One leg standing - Present

B. BALANCE & POSTURAL CONTROL- Present

2) FINE MOTR SOKILLS :-

✓ Hand dominance/hand preference - Right hand

✓ Bilateral co-ordination: Symmetrical & Asymmetrical - Present

✓ In hand-manipulatio Present

✓ ON OBSERVATION :-

✓ General behaviour : Calm & composed

✓ Eye contact : Sustaining

✓ Interaction with the environment : Positive (+)

✓ Stereotypical behaviour : Absent

✓ Locomotion : [ Tip-toe walking , slapping foot ] No

✓ Posture : Good

✓ Body built : Mesomorphic

✓ Active play : Yes

✓ Passive irritable : No

✓ Social smile : Fair

3) COGNITIVE PERCEPTUAL &SKILLS

✓ Attention : Fair

✓ Concentration : Fair

✓ Memory : Fair

BASIC COMPONENTS :-

✓ Colour - can identify

✓ Shape - can identify

✓ Size -can identify

✓ Numbers - can identify

✓ Alphabet - can identify

✓ Spatial orientation - oriented

✓ Body part - can identify

✓ Identification - good

RIGHT - LEFT DISCRIMINATION , READING......

IN THE ORDER OF SMINGA :-

✓ Sorting - good

✓ Matching - good

✓ Identification - good

✓ Naming - good

✓ Generalization - good

✓ Abstract thinking - good

4) SOCIAL & EMOTIONAL SKILLS :-

✓ Eye contact - Present [slightly distracted]

✓ Social smile - Present

✓ Recognises parents/ familiar members/strangee - yes

✓ Attachment to mother - yes

✓ Stranger fear - No fear

✓ Response to emotions - yes

✓ Reacts when scolded -yes

✓ Asking for needs - yes

✓ In appropriate mannerisms - No

✓ Peer group - peer group play is present

✓ Wishing , greeting. ; Shaking hands spontaneously - yes

5) COMMUNICATION & LANGUAGE SKILLS :-

✓ Limited speech

✓ Ecolaila - Immediate [✓]

✓ Literal meaning of words [ can comprehend ]

EXPRESSIVE LANGUAGE :-

*DEVIANT LANGUAGE PATTERNS :-

✓ Ecolaila - Present

✓ Reversals - No

*CONCRETE LANGUAGE PATTERNS : No

6) SENSORY MODULATION PROBLEMS :-

✓ Tactile - Normal

✓ Vestibular - Normal

✓ Proprioceptive - Normal

✓ Auditory - Normal

✓ Visual - Normal

7) STEREOTYPICAL BEHAVIOUR :-

✓ Clapping

✓ Body locking

✓ Finger gazing

✓ Flapping

✓ Slapping

✓ Rubbing self

✓ Fidgeting movement of fingers -

No stereotypical behaviour is present

8) PLAY EVALUATION :-

✓ Productive/ non-productive use of toys - Productive use of toys

✓ Perseverance in play - yes

✓ Pretend play - yes

✓ Object play - yes

✓ Group play - yes

9) WRITING SKILLS :-

✓ Tripod grasp (+)

Can able to write 1-20,A-Z

✓ Pressure is less while writing.

✓ Quadrupod grasp while catching or writing is present .

*Pre-writing skills - scribbling , colouring - Present

*Pre-basic figures - Present

*Writing - alphabets , numbers - Present

*Pencil grasp - Present [ quadrupod grasp ]

10) BEHAVIORAL PROBLEMS :-

Screaming all of a sudden.

11) ADL EVALUATION :-

✓ Brushing : Knows to brush

✓ Bathing : Scrubs soap on body.

✓ Dressing : Pulls up garmats.

✓ Eating : Eats snacks by himself.

✓ Grooming : Dependent

✓ Toileting : Indicates dependent.

✓ Feeding : Partial dependent.

12) PROBLEM IDENTIFIED :-

✓ Behaviour issue

✓ Attention span is quite less

✓ Handwriting pressure is less while writing

13) TREATMENT AIMS :-

✓ To improve attention span

✓ To improve handwriting skills

✓ To improve adaptive behaviour

14) TREATMENT APPROACHES AND INTERVENTIONS :-

✓ Sensory integration therapy

✓ Behaviour fram of reference

✓ Task Oriented ap-

proach SCALES :-
✓ Childhood autism rating scale [ CARS ]

✓ Takata scale

✓ WEE FIM scale for ADL

 2.CASE
DEMOGRAPHIC DATA

 Name:Nethan
 Age: 3 and half years

 Gender:male
 Seizures- yes ,he had seizures when he was a 5 month old baby
 Diagnosis:Austim spectrum disorder

Chief complaints:
 mother complained that her child is not sitting in one place
 He is not responding to name call and not interacting or playing with other children

Birth History:

 Prenatal- No complicaions

 Perinatal- No complications
 Postnatal- No complications
 FTND (Full Term Normal Delivery)
 No H/O any illness immediately after birth
ON OBERVATION:
1. Hygiene: Good
2. Body built: Adequate
3. Mobility to Department: Walking
EVALUATION:

1.Senses

 Vision-Normal
 Speech-Affected ,the child was not speaking adequate to his age

 Hearing-Normal
2.Gross motor Development:
The milestones was delayed for about 3 months

3.Fine motor Development:

 Hand Dominance:
The child was using his right hand for the activity .so the hand dominance is right hand

 Reach:

The reach was fair

 Grasp:
The child was fair in cylindrical and spherical grasp

Hook grasp is present but fair

 Prehension:
Pulp to pulp- Good Tripod – Fair Cascading –
Fair

 In hand manipulation:

Shifting and Translation are present

 Release:
Voluntary release is present4.

4.Co-ordination:

 Eye-coordination- Fair

 Bilateral coordination-fair

5.Cognitive and Perceptual skills

• Orientation- To place and person is present

• Attention- poor ,the child needed constant verbal prompting for finishing the activity

• Concentration- Fair, the child needed constant verbal prompting for finishing the activity

• Memory- Fair

• Problem solving- Poor ,the child needed prompting for finishing the activity

6.Concepts:

• Color-Absent

• Time- Absent

• Right-Left Discrimination: Present but not consistent

7.Behavior:

• Self injuries behavior- absent

• Stereotyped behavior-Present ,hand falpping

• Temper tantrum-Present

8.Social and Emotional skills :

• Eye contact- deviating

• Social smile- Absent

• Peer interaction- Absent

• Respond to emotions- shows inappropriately

• Wishing , Greeting , Shaking hands spontaneously – Absent

• Engage in self-stimulating emotions

 9.Sensory Problems
auditory hypersentivity: he will cover his ears when hearing sounds of mixie and horns and
gets irriated of loud music

10.Activities of daily living :

• Feeding : needs assistance

• Dressing : dependent

• Bathing : dependent

• Brushing : dependent

• Toileting : needs assistance

• Grooming : dependent

11.Play skills :

• Explorative play: affected

• Dramatic play : affected

• Peer play: affected

12.Task skills:

• Concentrate despite distraction : poor

• Self directed in unstructured activity : poor

• Appropriate speed in activity : poor

• Tolerate frustration : poor

Problems relevant to OT

• Lack of ADL skills

• No respond to name call

 • Poor eye contact

• Attention span is poor

• Stereotypical behavior like hand flapping

• Lack of social skills

• Lack of coordination

• Lack of play skills

• Lack of sitting tolerance

• Poor hand function skills

• Lack of cognitive skills

• Auditory hypersentivity

• Behavioural issues

SHORT TERM GOALS

• Improve eye contact

• Improve attention and concentration

• Reduce behavioural issues

• Improve fine motor skills

• Reduce stereotypical behaviour

• Respond to name call

LONG TERM GOALS

• To make them independent in ADL

• Improve cognitive components

• Improve perceptual skills

• Engage in peer interaction and group skills

• To over come sensory issues

APPROACHES AND INTERVENTION:

• Sensory intergeration therapy

• Task oriented approach

• Cognitive disability frame of reference

• Behavioral frame of reference

• Acquisitional frame of reference

• Model of human occupation

• Play therapy
 3. CASE:-

CHILD PSYCHIATRY ASSESSMENT :-

DEMOGRAPHIC DATA:-

1)Name : Baby Athivika

2)Age : 3 years/ Female

3)Diagnosis: ASD(Autism spectrum disorder)

4)Associated problems:

-No name calling response.

-No eye contact

-Poor sitting tolerance

5)Reason for referral:-

-Low sitting tolerance

-No social interaction

-Mal adaptive behaviour

6)Chief Complaints :-

-No name calling response no sitting tolerance at one place for prolonged period of time.

7) Date of birth : 20/12/2019

HISTORY:-

BIRTH HISTORY:-

-Pre term baby( 8 months ), the child is the second twin born to non- consanguine parents.
She was deliy(31 weeks) through c-section with the birth weight of 1.2kg.
 -Cry immediately after the birth.

MEDICAL HISTORY:-

Therapy undergone (OT, Speech, and PT)

FAMILY HISTORY:-

32Years
41Year

3Years

No significant family history as reported by the mother.

DEVELOPMENTAL HISTORY:-
MOTOR DEVELOPMENT:-

✓ Gross motor : age appropriate

✓ Fine motor : age appropriate.

EDUCATIONAL HISTORY :-

✓ No complaints from the teachers

-✓Main stream school

SOCIO-ECONOMIC HISTORY:-

Middle class.

ON OBSERVATION:

General behaviour:-

Eye contact:-

✓ No eye contact fluting initiating, eye contact only

Stereotypical behaviour:-

✓ No stereotypical behaviour.

Locomotion:-

✓ Tip-toe walking

Posture: Normal, good

Body build : ectomorph

Social smile : good

SOCIAL AND EMOTIONAL DEVELOPMENT:-

 ✓ No exposure ' Social environment

✓ No attachment/ going other than parents

COGNITIVE DEVELOPMENT:-

✓ Mild delay in cognitive functioning , does not understand the concept of alphbets and
number.

LANGUAGE AND COMMUNICATION DEVELOPMENT:-

✓ Verbal communication ,she gave spontaneous sound ,non-verbal gesture like pointing
at things.

PLAY ACTIVITY:-

✓ Functional use of object ( uses combs to comb doll's hair )

ON EXAMINATION:-

GROSS MOTOR SKILLS:-

✓ Jumping : good

✓ Hoping : good

✓ Obstacle crossing : good

✓ Balance : good

✓ Stair climbing : good

✓ Slop walking : good

BALANCE AND POSTURAL CONTROL : Good (Present)

FINE MOTOR SKILLS :-

✓ Hand dominance : right hand

✓ In hand manipulation : present

✓ Bilateral coordination : present

COGNITIVE And Perceptual Skills:-

✓ Attention and concentration : good

✓ Orientation and memory : good

BASIC CONCEPTS :-

✓ Alphabets : not present/not identified

✓ Numbers : not present/not identified

✓ Colours : identified

✓ Body parts identified : present

✓ Orientation : identified/present

Right/left discrimination : present

✓ Sorting : Present

✓ Matching : Present

✓ Identification : Present

✓ Name : Present

✓ Generalization : Present

✓ EXPRESSIVE LAGUAGE

:-Concrete language pattern :-

Tone : monotonous

SENSORY MODULATION PROBLEMS :-

✓ Visual : no identified abnormalities

✓ Tactile : no identified abnormalities

✓ Auditory : avoiding certain sound like (starting of bike sound)

STEREOTYPICAL BEHAVIOUR :-

✓ Clapping : absent

✓ Body rocking : absent

✓ Finger gazing : absent

✓ Flapping : absent

✓ Slapping : absent

PLAY EVALUATION:-

✓ Pretend play : Present

✓ Productive use of toys

✓ Perseverance in play

✓ Object play is present

✓ Peer play is absent

✓ Group play is absent

WRITING SKILLS :-

✓ Pre written skill : scribbling and colouring

✓ While writing : right hand

✓ Pencil grasp : present

BEHAVIORAL PROBLEMS :-

Has behavioral issue

ADL EVALUATION :-

Feeding : dependent

Bathing : dependent

Toileting : dependent

Grooming : independent

Dressing : independent

PROBLEM IDENTIFIED :-

Behavioral issue

Sensory issues

No name call response

Poor ADL skills (not initiating)

Poor social behaviour (due to lack of exposure)

AIMS :-

✓ To improve ADL and cognitive skills

✓ To promote adaptive behavioural skills

✓ To normalise sensory dysfunction skills.

TREATMENT APPROACHES :-

✓ group therapy

✓ Sitting activity
✓ Behavioral modification
 4.CASE:-

DEMOGRAPHIC DATA:-

* Name : Master. Gokul

* Age/Sex : 3yrs 3 months old / Male

* Diagnosis : ADHD (Attention Deficit Hyperactive Disorder)

Date of birth : 20/12/2020

CHIEF COMPLAINTS:-

a. Distractions in school.

b. Hitting himself and others as well.

HISTORY:-

1.BIRTH HISTORY:-

a. ANTENATAL HISTORY:-

i. Primi baby.

ii. No h/o miscarriages.

iii. No h/o pregnancy complications

b. PERINATAL HISTORY:-

a. Normal delivery.

b. Cried immediately after birth.

c. Birth weight - 3kgs.

c. POSTNATAL HISTORY

a. No h/o NICU admission.

b. No such postnatal complications.

FAMILY HISTORY:-
 26 YERS

31 YEARS

3 YEARS

3.PAST MEDICAL HISTORY

* Child had fever when he was 1 year old on

the duration of 1 week along with allergies for 3

day

* 4.DEVELOPMENTAL HISTORY

* Age appropriate milestones achieved.

* no delay as such.

5.EDUCATIONAL HISTORY

* Child goes to Bridges Play school from 2.5 years.

He is about to finish his Pre-KG.

ON OBSERVATION

* General behavior - Self- hitting behavior

* Eye-contact - Sustaining

* Body build - good

* Active play - yes

* Social smile - present

* Posture – good

ON EXAMINATION

1.GROSS-MOTOR SILLS

a. High skills/ Advanced mobility skills

◦ running

◦ jumping

◦ stair jumping

b. Balanced and Posture Control - present.

2.FINE MOTOR SKILLS

* Hand dominance - right hand

* Reach - reach functions achieved

* Grasp - Tripod, cylindrical, spherical functions achieved

* Prehension - tip to tip, pulp to pulp functions achieved

* Non-prehensile functions- clapping, flapping, slapping

* In-hand manipulation - shifting achieved

* Release - voluntary release.

3.COGNITIVE AND PERCEPTUAL SKILLS

* Attention and concentration - fair (distracted)

* Basic concepts - Numbers

* Orientation - present

* Memory

a. Immediate memory- present (activity he did

5mins ago)

b. Recent memory- present.

4.SOCIAL AND EMOTIONAL SKILLS

* Eye contact - present but distracted too much

* Social smile - present

* Recognizes his parents and family

* Attached towards his mother

* Stranger fear/ No fear - No stranger fear

* Response to emotions - yes

* Reacts when scolded and petted as well

* Asks to be comforted when in discomfort

* Wishing, Greeting, Shaking hands when he is ready to go home after therapy session

* Peer play is present but does not share his objects with others

5.Communication and Language skills

* Limited speech

* Conversational speech- can able to comprehend

* Literal meaning of words - can comprehend

EXPRESSIVE LANGUAGE

* self stimulants

DEVIANT LANGUAGE PATTERN

* One - word utterance

CONCRETE LANGUAGE PATTERN

* Tone and pitch variations

NON-VERBAL COMMUNICATION / GESTURE

* Eye contact is present but too much distracted REPETIVE LANGUAGE (understanding)

* Can comprehend, recognize whether the speaker is sad orangry and responds accordingly

6.SENSORY MODULATION PROBLEMS

* Tactile - previously issues were present but now he is alright.

* Vestibular - runs, climbs in bed and windows

* Proprioceptive - runs and climbs on bed and windows

* Auditory - previously had issues but now he is alright

* Visual - skills present

* Gustatory - doesn’t like milk products

7.STEREOTYPICAL BEHAVIOR

* CLAPPING

* flapping

* slapping

all these three present.

8.PLAY EDUCATION

* Pretend play - present

* productive use of toys

* object play - present

peer play present but does not share his play objects with

others.

9.WRITING SKILLS

* Tripod grasp present

* While writing - right hand

* pre- writing skills - scribbling, coloring.

10.BEHAVIORAL PROBLEMS

* Has behavioral issues

11.ADL EVALUATION

* Eating - partial dependence

* Feeding - partial dependence

* Dressing - dependent

* Toileting -indicates but dependent

* Grooming -dependent

* Bathing –dependent

12.PROBLEMS IDENTIFIED

* Behavioral issues

* cognitive problems

* ADL skills

13.TREATMENT AIMS

* To improve the cognitive skills.

* To organize ADL scheduling.

* To promote adaptive behavioral skills.

14.TREATMENT APPROACHES

* Behavioral modification.

* Task - oriented approach.

* Handwriting skills.
 5.CASE

DEMOGRAPHIC DATA

Name- Master Ezhumalai

Age – 17 years Sex- Male

Hospital no- 0021810216

Bed no – 41021

Date of admission – 15/06/2024

Date of assessment – 01/07/2024

Diagnosis – Left femur osteosarcoma

Chief complaints – Complaint of pain and swelling in left femur site.

Informant – Mother

Reliability – reliable

BIRTH HISTORY

 Prenatal – no prenatal complications

 Perinatal – normal vaginal delivery
 Postnatal – no post-natal complications
PRESENT MEDICAL HISTORY

Client came for chemotherapy with complaints of increased pain and swelling in left femur site. Pa-
tient has been taking chemotherapy admitted at SRMC for the past 3 months.

PAST MEDICAL HISTORY

 h/o pathological fracture while playing volley ball

 K/c/o chemotherapy
FAMILY HISTORY
EDUCATIONAL HISTORY

The patient is currently pursuing 12th standard is on break since 3 months due to ongoing chemo-
therapy.

OCCUPATIONAL HISTORY - Student

ON OBSERVATION

 Attitude of the limb- patient in supine lying on chemo

 Upper extremity – Shoulder adduction, elbow flexed, wrist flexion.
 Lower limb – Hip abduction, knee extension, ankle extension and eversion.
 Gait – Poor
 Deformities – no other deformities
 Mobility – completely dependent
 Posture – fowlers position
DROOPING OF SALIVA- ABSENT

BLADDER AND BOWEL DISTENTION - NORMAL

ON EXAMINATION

GROSS MOTOR DEVELOPMENT

All gross motor skills achieved (age appropriate)

FINE MOTOR DEVELOPMENT

Fine motos skills are achieved

CRANIAL NERVE EXAMINATION

 Olfactory – Normal
 Optic – Normal
 Oculomotor – Normal
 Trigeminal – Normal
 Fascial – Normal
 Auditory – Normal
 Glossopharyngeal – Normal
 Accessory – Normal
 Hypoglossal – Normal
MOTOR COMPONENTS

SYNERGY PATTERN – Absent

RANGE OF MOTION -

MUSCLE DEGREE
SHOULDER
Flexion 0-135°
Extension NA
Abduction NA
Adduction NA
ELBOW
Flexion 0-130°
Extension 0°
Supination 0-78°
Pronation 0-70°
WRIST
Flexion 0-90°
Extension 0-90°
Radial deviation 0-30°
Ulnar deviation 0-30°

MUSCLE STRENGTH
UPPER LIMB – 4 Full range of motion against gravity with moderate resistance

LOWER LIMB – Not applicable

COORDINATION

 Finger to nose test- present

 Heel to shin test – not applicable
SENSATION

 Light touch - Intact

 Pressure - Intact
 Superficial pain- Intact
 Temperature - Intact
 Proprioception - Intact
 Kinesthesia - Intact
 Stereognosis - Intact
 2-point discrimination - Intact
 Vibration – Intact
HAND FUNCTION

REACH

 Forward - Present
 Back ward - Present
 Sideward - Present
 Upward - Present
Grasp

 Cylindrical- Present
 Diagonal- Present
 Transverse- Present
 Spherical- Present
 Spanning - Present
PREHENSION

 Opposition- Present
 Tip to tip- Present
 Pulp to pulp- Present
IN HAND MANIPULATION

 Translation – Present
 Finger to palm- Present
 Shift - Present
 Rotation- Present
BALANCE

Grade – 1 Able to perform with maximum assistance

PROBLEMS RELEVANT TO OCCUPATIONAL THERAPY

 Range of motion affected

 Muscle power affected
 Activities of daily living affected
 Stress
GOALS

SHORT TERM GOALS

  To Improve range of motion
 To Improve muscle strength
 To reduce stress
LONG TERM GOALS

 To promote independency in ADL

 To improve balance
APPROACHES

 Biomechanical approach
 Acquisitional frame of reference
 Rehabilitative frame of reference
 Task oriented approach
INTERVENTION

 Assistive devices
 Environmental modifications
 Strengthening techniques
 Leisure activities
 6.CASE

DEMOGRAPHIC DATA:-

Name : Mr.Perumal

Age : 26/ Male

Diagnosis: L2,L3,L4,L5,S1 - IVDP

D.O.A : 18/06/2024

Marital Status : Unmarried

Educational History : BCA

Occupational History : 2 wheeler Driver

Source of History/ Reliability : self/ Reliable

Chief Complaints : C/O low back pain radiating to b/t Lower limbs for past 4 months.

HISTORY

PRESNT MEDICAL HISTORY :-

This 26 years old man was apparently normal 4 month back and was later developed low back for past 4
months radiating to b/c Lower limbs. R>L , aggravated with walking & relieved by medication. Pain was
aggravated for past 2 days H/O difficulty in walking for past 2 days.
Past Medical History : Nil

Surgical History : Nil

Pain Score : 3/10

FAMILY HISTORY :

50

60

35 28

26

Socio- economic status : Middle class

ON OBSERVATION :-
✓ Hygiene : good

✓ Body build : ✓Mesomorphic

✓ Mobility : walking

✓ Position of the patient : lying-supine.

ATTITUDES OF THE LIMB :-

UPPER LIMB :-

RIGHT LEFT

Shoulder Abducted Flexed

Elbow Extended Flexed

Forearm Pronated supinated

Wrist Extented Flexed

Fingers Slightly Flexed

Flexed
LOWER LIMB :-

RIGHT LEFT

Hip Extended Extended

Knee Extended Extended

Ankle Neutral Neutral

Gait : Normal

Deformity : Nil Pos-

ture : supine- lying

Drooping of saliva : Nil

OT EVALUATION :-
ON EXAMINATION :-

ROM:- ( UPPER LIMB )

RIGHT LEFT REMARKS

SHOULDER :-

Flexion 170° 170°

Extension 60° 50°

Abduction 170° 175°

Adduction 0° 0°

HIP

Flexion 110° 110°

Extension 20° 15°

Abduction 40° 40°

Adduction 0° 0°

KNEE :-
130° 130° Tolerating the pain
Flexion

Extension 0° 0°
ANKLE :-

Plantar flexion 45° 45°

Dorsi flexion 20° 30°

Inversion 25° 30°

Eversion 20° 20°

LUMBER :-

Flexion 30° 30° while doing he's tolerating the pain

Extension 25° 25°

Lateral 15° <15°

Flexion

MMT :-

R L

Hamstring muscle 3/5 3/5

Quadriceps muscle 3/5 3/5

BALANCE:-

BERG BALANCE SCALE :-

1) Sitting to standing -4

2) Standing unsupported -4
3) Sitting unsupported -4

4) standing to sitting -4

5) Transfer -4

6) Standing with eyes -4 closed

7) Standing with feet together -4

8) Reaching forward with outstretched arm -3

9) Retrieving objective from floor -3

10) Turning to look behind -3

11) Turning to 360° -3

12) Placing alternative foot on stool -4

13) Standing with one foot front -4

14) Standing on one foot -3

Total score : 51/56

He's tolerating the pain and able to do.

ADL :-

FIM( FUNCTIONAL INDEPENDENT MEASUREMENT )

SELF CARE :-

1) Eating - 7

2) Grooming - 7

3) Bathing - 7

4) Dressing - upper body - 7

5)Dressing - lower body - 7

6)Toileting - 7

SPHINCTER CONTROL :-

7)Bladder management - 7

8)Bowl management - 7

MOBILITY/TRANSFER :-

9) Bed-chair-wheelchair - 7

10)Toilet - 6

11) Tub shower - 7

LOCOMOTION :-

12) Walk-wheelchair - 7

13) Stair - 6

COMMUNICATION :-

14) Comprehension - 7

15) Expression - 7

SOCIAL COGNITION :-

16) Social interaction - 7

17)Problem solving - 7

18)Memory - 7

Total score : 124/126

MEASURABLE GOAL :-

✓ To make the patient walk without discomfort.

✓ To improve ROM.
LONG TERM GOAL :-

✓ To make the patient to do walk without discomfort.

SHORT TERM GOAL :-

✓ To improve ROM for lumbar

✓ To improve muscle power

APPROACHES & FOR :-

✓ Task Oriented ✓approach

✓ Biomechanical FOR

✓ MOHO

✓ Neurodevelopment approach

SCALE :-

✓ ADL - FIM Scale

✓ Berg balance scale

✓ Muscle Manual testing (MMT) Muscle strength.

 7.CASE

DEMOGRAPHIC DATA:-

Name : Mr.suresh

Age : 51/ Male

Diagnosis : Right neck of femur (Non union 6weeks old)

D.O.A : 26/06/2024

Marital Status : Married Edu-

cational History : 10th Occupa-

tional History : Nil

Source of History/ Reliability : Self/ Reliable

Chief Complaints :

✓ Pain over right hip × 2 months.

✓ Normal sleep ( If intake of tablets due to pain.

HISTORY

PRESNT MEDICAL :-

Patient has alleged history of RTA ( skid & fall from 3 wheeler on 17/04/2024 ) near chengalpattu
& sustained closed injury to right hip. He was not able to weight bearing often injury. Patient initially
went to outside hospital and he was treated with skin traction.

Past Medical History : SHTN, CVA- 2017 - 2022 Surgi-

cal History : Nil

Pain Score : 3/10

FAMILY HISTORY :

51 45

24 20

call cutes dives

Socio- economic status : Mid-

dle class
 ON OBSERVATION :-

✓ Hygiene : good

✓ Body build : Mesomorphic

✓ Mobility : walking

✓ Position of the patient : Hight heel sitting.

ATTITUDES OF THE LIMB :-

UPPER LIMB :-

RIGHT LEFT
Shoulder Adducted Adducted

Elbow Extended Slightly Flexed

Forearm Pronated Pronated

Wrist Flexed Flexed

Fingers Slightly Flexed Flexed

LOWER LIMB :-

RIGHT LEFT

Hip Extended Extended

Knee Extended Extended

Ankle Plantar Flexed Plantar Flexed

Gait : Normal De-

formity : Nil

Posture : Sitting ( high sitting)

Drooping of saliva : Nil

OT EVALUATION :-

ON EXAMINATION :-

ROM:- ( LOWER LIMB )

RIGHT LEFT REMARKS

HIP :-
Flexion 90° 110°

Extension 20° 0°

Abduction 10° 40°

Adduction 0° 0°

Internal rotation 10° 45°

External rotation 20° 45°

KNEE :-

Flexion 110° 135°

Extension 0° 0°

ANKLE :-

Plantar flexion 40° 40°

Dorsi flexion 20° 25°

 Inversion 20° 30°

Eversion 20° 20°

MMT :-

Cannot be assed due to pain.

BALANCE:-

BERG BALANCE SCALE :-

1) Sitting to standing -4

2) Standing unsupported -4

3) Sitting unsupported -4

4) standing to sitting -4

5) Transfer -3

6) Standing with eyes -3 closed

7) Standing with feet together -3

8) Reaching forward with outstretched arm -4

9) Retrieving objective from floor -3

10) Turning to look behind -4

11) Turning to 360° -4

12) Placing alternative foot on stool -0

13) Standing with one foot front -0

14) Standing on one foot - 0

Total score : 40/56

He's tolerating the pain and able to do.

ADL :-
FIM( FUNCTIONAL INDEPENDENT MEASUREMENT )

SELF CARE :-

1) Eating - 7

2) Grooming - 7

3) Bathing - 7

4) Dressing - upper body - 7

5) Dressing - lower body - 6

6)Toileting - 7

SPHINCTER CONTROL :-

7) Bladder management - 7

8) Bowl management - 7

MOBILITY/TRANSFER :-

9) Bed-chair-wheelchair - 7

10) Toilet - 6

11) Tub shower - 7

12) LOCOMOTION :-

13) Walk-wheelchair -
14) Stair - 4
COMMUNICATION :-

15) Comprehension - 7

16) Expression - 7

SOCIAL COGNITION :-

17) Social interaction - 7

18) Problem solving - 7

19) Memory - 7

Total score : 120/126

MEASURABLE GOAL :-

✓ To make the patient walk without discomfort.

✓ To improve ROM.

LONG TERM GOAL :-

✓ To make the patient to do walk without discomfort.

SHORT TERM GOAL :-

✓ To improve ROM for lower limbs

APPROACHES & FOR :-

✓ Task Oriented ✓approach

✓ Biomechanical FOR

✓ MOHO

✓ Rehabilitation FOR

SCALES :

✓ FIM

✓ Berg balance scale

✓ MMT ( Muscle Manual testing )

 8.CASE

DEMOGRAPHIC DATA:-

Name : Mr.Elumalai.P

Age : 53/ Male

Diagnosis: Degenerative joint disease (OA

knee) D.O.A : 28/06/2024

Marital Status : Married Edu-

cational History : 5th std Oc-

cupational History : Farmer

Source of History/ Reliability : self/ Reliable

Chief Complaints :

✓ C/O lower back pain × 4 years

✓ Large joint pain only off × 1 year

✓ Left heel pain × 1 month

✓ Normal sleep while tablet is taken.

HISTORY

PRESNT MEDICAL HISTORY :-

Patient was apparently asymptomatic 4 years ago often which he complained of lower back pain , which
began insidious in onset, gradually progressive. No relieving factors.pain is present during walking - non
radiating pain.

Past Medical History :

NilSurgical History : Nil

Pain Score : 3/10

part Medical History :

NILL Surgical History : Nil

Pain Scove : 3/10 Uncomfortable pain

ADL -- Independent
FAMILY HISTORY :-

50

60

26

28

35

Socio -- economic status.......

Middle Class

Socio- economic status : Middle class

ON OBSERVATION :-

✓Hygiene : good

✓Body build : endomorph

✓Mobility : walking

✓Position of the patient : lying-supine.

ATTITUDES OF THE LIMB :-

UPPER LIMB :-

RIGHT LEFT

Shoulder Adducted Adducted

Elbow Flexed Flexed

Forearm Pronated Pronated

Wrist Flexed Flexed

FingersSlightly fleded Flexed

LOWER LIMB :-

RIGHT LEFT
Hip Extended Extended

Knee Extended Extended

Ankle Neutral Neutral

 Gait : Normal Deform-

ity : Nil Posture : su-

pine - lyingDrooping

of saliva : Nil OT

EVALUATION :-

ON EXAMINATION :-

ROM:- ( LOWER LIMB )

RIGHT LEFT REMARKS

HIP :-

Flexion 90° 110°

Extension 20° 20°

Abduction 40° 35°

Adduction 0° 0°

Internal rotation 40° 45°

External rotation 40° 40°

KNEE :-

Flexion 120° 130°

Extension 0° 0°

ANKLE :-

Plantar flexion 40° 40°

Dorsi flexion 20° 15°

Inversion 30° 30°

Eversion 20° 15°

LUMBAR :-

Flexion unable to

Extension perform due

Lateral to pain in

Flexion lower back

Region

MMT :- ( Manual muscle testing )

Muscle strength:-

HIP RT LT

Flexion 3/5 3+/5

Extension 3/5 3/5

Abduction 3/5 3/5

Adduction 3/5 3/5

KNEE
Flexion 3+/5 3/5

Extension 3/5 3/5

ANKLE

Dorsi 2+/5 2+/5

Flexion

Plantar 3+/5 3/5

Flexion
 BALANCE:-

BERG BALANCE SCALE :-

15) Sitting to standing -4

16) Standing unsupported -4

17)Sitting unsupported -4

18)standing to sitting -4

19)Transfer -4

20)Standing with eyes -4 closed

21)Standing with feet together -4

22)Reaching forward with outstretched arm -4

23)Retrieving objective from floor -3

24)Turning to look behind -3

25)Turning to 360° -3

26)Placing alternative foot on stool -4

27)Standing with one foot front -3

28)Standing on one foot - 4

Total score : 52/56 ADL :-

FIM( FUNCTIONAL INDEPENDENT MEASUREMENT )

SELF CARE :-

1)Eating - 7

2)Grooming - 7

3)Bathing - 7

4)Dressing - upper body - 7

5)Dressing - lower body - 6

 6)Toileting - 7

SPHINCTER CONTROL :-

7)Bladder management - 7

8)Bowl management - 7

MOBILITY/TRANSFER :-

9)Bed-chair-wheelchair - 7

10)Toilet - 6

11)Tub shower - 7

LOCOMOTION :-

12)Walk-wheelchair - 7

13)Stair - 6

COMMUNICATION :-

14)Comprehension - 7

15)Expression - 7

SOCIAL COGNITION :-

16)Social interaction - 7

17) Problem solving - 7

18)Memory - 7

Total score : 123/126

APPROACHES & FOR :-

✓Task Oriented approach

✓Biomechanical FOR

✓MOHO

✓Rehabilitation FOR

SCALES :

•FIM

•Berg balance scale

•MMT
 9.CASE

DEMOGRAPHIC DATA:-

Name – Mr. Kajaha Mohideen

Age/ Gender – 78years/ Male

Chief complaints

- Complaint of weakness of left upper and lower limb past 1week.

- Complaint of reduced urine output for 1 month

- Complaint of reduced and loss of appetite for 1 week

Diagnosis – Left CVA / HTN / DM

Date of admission – 25/ 03/ 2024

HISTORY

History of present illness

- Deviation of angle of month on right side

- Sudden onset weakness of left upper limb and lower limb

- Slurring of speech

- History of dysuria and irrelevant speech

Past medical history

- Patient was admitted in Thiruvallur Government hospital on 18/03/24 since

he had weakness on both upper limb and lower limb on left side of the body
Past surgical history- history of Herniorraphy procedure

Present medical history

- Patient was normal a week before due to weakness of the limbs of left side
of the body he was admitted in SRMC
Family history

66y

41y 43y
45y 47y

Occupational history – patient has a history of working at a jewelry shop when he was in his 50’s,
for 5years

ON OBSERVATION

Gait – NA
Mobility – Wheel chair
Deformities – NIL
Posture- supine lying
POSITION OF THE PATIENT
Attitudes of the limb

UPPER LIMB
Shoulder Adducted Horizontal adduction
Elbow extended extended
Forearm pronated pronated
Wrist Neutral Neutral
Fingers extended flexed

LOWER LIMB
Hip adducted Adducted
Knee Extended Extended
Ankle Neutral Neutral
Tarsals extended extended

ON EXAMINATION

 CRANIAL NERVE EXAMINATION

 Olfactory
  Optic

 Oculomotor

 Trochlear

 Abducens
Both right and left affected
 Trigeminal

 Facial

 Auditory

 Glossopharyngeal

 Vagus

 Accessory

 Hypoglossal

 MOTOR COMPONENTS

Muscle tone not assessed since the patient was in flaccid tone

- Upper extremity – hypotone

- No synergy pattern

- Brunnstorm stages – stage 1- flaccid

 RANGE OF MOTION

Right side of the upper extremity range of motion was assessed lower limb not assessed

i) Shoulder flexion– 80

i) Horizontal adduction- 60

ii) Internal rotation- 60

iii) Elbow flexion- 55

iv) Forearm supination – 75

v) Forearm pronation- 70

vi) Radial deviation – 12

 viii)ulnar deviation – 22

ix)wrist flexion – 64

x)wrist extension – 60

 MUSCLE STRENGTH

- Not assessed since there’s no muscle tone

 VOLUNTARY MOTOR CONTROL

- Grade 1 poor- limb movement is absent

 Co- ordination

 SENSATION

Light touch

Pressure

Superficial pain absent

Proprioception

Kinesthesia

Stereognosis

2pointdiscrimination

Vibration

 HAND FUNCTIONS

a) Reach

 Forward

 Sideward

b) Grasp

 Cylindrical

 Spherical

c) Prehension

 Pinch
  Lateral prehension
Right side of the body is intact
 Tip to tip Left side of the body is impaired

 Pulp to pulp tripod

d) In-hand manipulation

 Translation

 Palm to finger

 Finger to palm

 Shifting

 Rotation

e) Release

 Involuntary release

 BALANCE
Berg- balance scale
1. Sitting to standing - 0
2. Standing to Unsupported- 0
3. Standing to sitting -0
4. Transferring -0
5. Standing -0
6. Stand with feet Together- 0
7. Reaching object from floor-0
8. Turning to took behind -0
9. Placing alternate foot -0
10. Standing with one foot in front-0
11. Standing on one foot -0

 FUNCTIONAL INDEPENDENCE MEASURE

SELF CARE
1)Eating - 7
2)Grooming – 7
3)Bathing - 7
4)Dressing - upper body – 7
5)Dressing - lower body – 6
6)Toileting - 7
SPHINCTER CONTROL
7)Bladder management - 7
8)Bowl management – 7
MOBILITY/TRANSFER
9) Bed-chair-wheelchair - 7
10)Toilet – 6

11)Tub shower - 7

LOCOMOTION

12)Walk-wheelchair – 7

13)Stair - 6

COMMUNICATION

14)Comprehension - 7

15)Expression – 7

SOCIAL COGNITION

16)Social interaction – 7

17)Problem solving - 7

18)Memory - 7

Total score - 123/126

PROBLEMS IDENTIFIED

 Hand function skills are lacking

 Range of motion of both the upper and lower extremities

 No muscle tone

 No muscle strength

 ADL skills are lacking

 Sensory issues present

Co-ordinated movements are absent

GOALS

 To improve Hand function skills

 To improve Range of motion in both the upper and lower extremities

 To normalize muscle tone

 To improve muscle strength

 To make the person independent is his activities of daily living

 To normalize the sensory issues

 To help the person gain his Co-ordinated movements

SCALES

Functional Independence Measure (FIM)

Pittsburg sleep quality index (PSQI)

APPROACHES

 Motor relearning program

 Neurodevelopmental treatment

 Rehabilitative frame of reference

 Sensory integration frame of reference

 Task oriented approach

 10.CASE

DEMOGRAPHIC DATA:-

Name : Ms.sandhiya M

Age /sex : 21/Female Mar-

ital status : Unmarried Lan-

guage : Tamil

Diagnosis : OCD 2° Amenorrhea

D.O.A : 03/06/2024

Informant : Mother Relia-

bility : Reliable Religion :

Hindu Educational history

: 12th

Chief Complaints:

SUBJECTIVE :-

Patient feels ill & know that she is admitted by her mother due to anger outburst.

OBJECTIVE :-

Mother reported tha she overthinking,anger outbursts ,sleep disturbances, & fearfulness About her
future.
 DURATION OF THE TOTAL ILLNESS :-

Since 7 yrs h/o anger outburst, breaking things.

Progress of illness : Static

Periodicity : Unknown

Model of onset : Acute

HISTOR Y-

PRESENT ILLNESS :-

✓ K/C/O Psychiatric illness since 7 years , with h/o anger outburst , breaking things, crying spells
esteem , h/o disinhibitory behaviour, h/o wandering behaviour . Overfamiliarity (+) h/o muttering talking
to self.

✓ h/o intensive thought, partial insight (+)

✓ h/o expressed emotions in family.

✓ decrease sleep

PAST ILLNESS :-

✓ K/C/O Psychiatric illness since 7 years.

From 8th std
 ✓ FAMILY

HISTORY :-

51
44

24

21

25

PERSONAL HISTORY :-

PRENATAL & PERINATAL HISTORY :-

✓ No h/o prenatal & perinatal problems

✓ No h/o substance abuse

EARLY CHILDHOOD :-

✓ Good interaction of the mother and child

✓ No head banging or body rocking

 MIDDLE CHILDHOOD :-

✓ She has no friends

✓ She studied well

✓ No h/o of nightmare, phobia,bed wetting.

LATE CHILDHOOD :-

✓ Relationship with teachers was good

✓ No emotional & physical problems

✓ School history - good

HABITS AND HOBBIES :-

• She likes to cook & drawings.

PREMORBID PERSONALITY :-

18) STANDARDS :-

• Aspiration : To lead a happy life with her family

• Flexible

• Hopeful

• Theistic

19) MOOD :-

• Stable

• Placid

• Responsive

• Despondent
20) INTERPERSONAL SKILLS :-

• Affable

• Trusting

• Extrovert

• Independent

21) INTRAPERSONAL SKILLS :-

• Accepting

• Active

• Arbitrary

• Self confident

NATURE OF PERSONALITY :-

Schizotypal

OT EVALUATION :-

APPEARANCE :-

Physical appearance : endomorphic Hy-

giene : good

Posture : supine-lying

Clothing : good
 Gait : normal gait Groom-

ing : good

OVERT BEHAVIOUR & PSYCHOMOTOR ACTIVITY :-

No abnormal overt behaviour & psychomotor activity when noticed

ATTITUDE TOWARDS EXAMINER :-

Co-operative, friendly, attentive, interested.

SENSORY PERCEPTUAL EXAMINATION :-

• Body image : she was able to identify -good

• Right/left discrimination : she was ables to find -god

• Spatial orientation : good

• Figure ground perception : identified -good

• Apraxia : absent

• Hallucination/illusions : Not present

• THOUGHT DISORDER :-

Worrying about her future ( overthinking about her future due to she has 2° Amenorrhea)

COGNITION :-

ORIENTATION :-

She is well oriented about the place ,time and pers

 MEMORY :-

REMOTE MEMORY :-

Asked about her memorable memories of past years.she said that she & her sister went out.

RECENT MEMORY :-

Asked what you ate in tha morning, she said idli.

IMMEDIATE MEMORY :-

I said 4 numbers to her to keep in her mind. At end of the session I asked the number to say ,she
said correctly.

ATTENTION & CONCENTRATION :-

The patient was attentive while doing the activity ( free drawing ) without any distraction.

READING, WRITING & CALCULATION :-

• She read very well & write her name and about her favourite actor

• She was ables to do sum

ABSTRACT THINKING :-

Asked her meaning about "DON'T JUDGE A BOOK BY IT'S COVER" she said the meaning about
it.

EMOTIONS :-

Mood : fluctuating

Stability : stable Af-

fect : low tone

 INSIGHT :-

She is aware about the illness.

TASK BEHAVIOUR :-

ATTENTION :-

Able to atten & follow instructions.

CONCENTRATION :-

Able to concentrate & completed the activity.

INITIATION :-

Shows interest, and perform well.

INTERST :-

Shows interest & completed the task.

MOTIVATION :-

Engages in task.

FOLLOW INSTRUCTIONS :-

She follows the instructions while doing the activity.

 PLANNING & ORIENTATION :-

She planned and well oriented about the time and finished according the time.

PROBLEM SOLVING :-

• Use of appropriate tool.

• Speed of performance : good

Quality of performance : neat

• INTERPERSONAL BEHAV-

IOUR :-

6) NON-VERBAL BEHAVIOUR :-

• Eye contact : initiates, maintains

• Proximity : maintained appropriate proximity.

• Posture : appropriate for situation

• Orientation : awareness about the surroundings.

• Facial expressions : she expressed according to the situation.

• Gestures : maintain gestures

• Paralanguage : good, maintained

7) VERBAL BEHAVIOUR :-

• Initiation : good

• Maintenance : good

• Termination : good

• Pitch : good

• Speed : good

• Tone : good

PROBLEM RELEVANT TO OT :-

• Lack of sleep

• Anger outburst

• Fearfulness

GOALS :-

LONG TERM GOAL :-

• To reduce Anger outburst.

SHORT TERM GOAL :-

20) To improve sleep

21) To reduce fear

though APPROACH &

FOR :-

22) Behaviour modification techniques

23) MOHO

24) CBT
 11.CASE

DEMOGRAPHICDATA:-

Name : Ms.Malarvizhi

Age /sex : 40/Female

Maritalstatus:Married

Language : Tamil Di-

agnosis : F20

D.O.A:25/06/2024

Informant : Husband

Reliability:Non-Relia-

ble Religion : Hindu

Educational history : 12th STD Occupationalhistory:Home-

maker

ChiefComplaints:

✓ C/osuspicioustowardsherhusband

✓ Angeroutburst

✓ Sleepdisturbances

✓ talking/smilingtoherself.

DURATIONOFTHETOTALILLNESS:-

Thepatientk/c/oPsychiatryillnessforpast4-5yearswasonmedication-on&off(August-2019)
HISTORY :-

PRESENTILLNESS:-

✓ ThepatientK/C/OPsychiatricillnesssince4-5years,wasonmedicationon&off(August-2019)

✓ Tab.Resperidone&THP(3/2)HSTLibrium25mghy.12/December2020thenstopped.Relapsed in 2
months 2nd Psychiatric consultation 2021, was admitted in outside hospital for 1week , later stopped
Rx often discharge relapsed within 1 week.

PASTILLNESS :-

✓ Noknowmedicalcomorbidities.

SURGICALHISTORY:-

✓ Prev.2Cs.

FAMILYHISTORY:- 20 Consanguinous

45

Husband

45

11th 8th

OccupationHistory:Housewife Educa-

tion History: 12 th std

PERSONALHISTORY:-

HABITSANDHOBBIES:-

✓ Shelikestocook&docraftsthings.

PREMORBIDPERSONALITY:-

 STANDARDS:-

o Aspiration:Unknown

o Sloppy

o Pessimistic

o Theistic

 MOOD :-

o Fluctuating

o Placid

o Responsive

o Despondent

 INTERPERSONALSKILLS:-

o Affable&Irritable

o Suspicious

o Ambivert

o Depende
 INTRAPERSONALSKILLS:-

o Avoiding

o Sluggish

o Arbitrary

o Selfconfident

NATUREOFPERSONALITY:-

Paranoid

OTEVALUATION :-

APPEARANCE:-

Physicalappearance:ectomorph Hygiene

: good Posture:su-

pine-lying

Clothing : fair Gait:nor-

malgait Grooming : fair

ATTITUDETOWARDSEXAMINER:-

Co-operative,attentive.
SENSORYPERCEPTUALEXAMINATION:-

o Bodyimage:shewasabletoidentify -good

o Right/leftdiscrimination:shewasablestofind-god

o Spatialorientation:poor-notawareofit.

o Figuregroundperception:poor

o Hallucination/illusions:shehasSuspiciousthough.

THOUGHTDISORDER:-

Sheisverysuspiciousonherhusbandthathehasafaironsomeone

COGNITION:-

ORIENTATION:-

SheisNotorientedabouttheplaceandtime

MEMORY:-

REMOTEMEMORY:-

Poor

RECENTMEMORY :-

Askedwhatyouateinthamorning,shesaid,idli.
IMMEDIATEMEMORY:-

Isaid4numberstohertokeepinhermind.AtendofthesessionIaskedthenumbertosay,she said wrongly.

ATTENTION&CONCENTRATION:-

Shewasattentivewhiledoingtheactivitybutconcentrationwasgoodatthebeginningnot prolonged
period of time.

ABSTRACTTHINKING:-

Askedhermeaningabout"Menuvanthuyelamponala"shesaidthemeaningaboutit.

EMOTIONS :-

Mood: fluctuating Affect:Amount&rangeofexpressivebehav-

iour.

INSIGHT :-

Completedenialofillness.

TASKBEHAVIOUR:-

ATTENTION:-

Abletoatten&follow instructions.
CONCENTRATION:-

Abletoconcentrate&notprolongedperiodoftimebutcompletedthe activity.

INITIATION :-

Showslessinterest,andperformed.

INTERST :-

Showslessinterest&completedthetask.

MOTIVATION:-

Shemotivatedherselfthatshe'lldobetternexttime.

FOLLOWINSTRUCTIONS:-

Shefollowstheinstructionswhiledoingtheactivity.

PLANNING&ORIENTATION:-

Sheplannedbutnotorientated.

PROBLEMSOLVING:-

o Useofappropriatetool.

o Speedofperformance:Fair

o Qualityofperformance:Fair
INTERPERSONALBEHAVIOUR:-

✓ NON-VERBALBEHAVIOUR:-

✓ Eyecontact:initiateswhen required.

✓ Proximity:maintainedappropriateproximity.

✓ Posture:appropriateforsituation

✓ Orientation:notawareofit.

✓ Facialexpressions:Noexpression.

✓ Gestures:maintaingestures

✓ Paralanguage:good,maintained

✓ VERBALBEHAVIOUR:-

✓ Initiation:good

✓ Maintenance:good

✓ Termination:good

✓ Pitch: low

✓ Speed:good

✓ Tone:good PROB-

LEMRELEVANTTOOT:-

✓ Sleep disturbance

✓ Angeroutburst

✓ decreasinADL

✓ Cognitiveskill
✓ Inter & intrapersonal skill AP-

PROACH&FOR:-✓Behaviour-

FOR

✓ MOHO

✓ CBT

✓ Taskorientedapproach
 12.CASE

Demographic Data

Name of the patient: Baby Megala Rajak

Age: 4 year old

Sex: Female

Date of Admission: 15th of March, 2024

Diagnosis: Osteogenesis Imperfecta

Chief complaints:

✓ Unable to walk without support

✓ Severe pain when walking for past 3 months

Date of evaluation: 27th of March, 2024Reliability: MotherLanguage: Bengali and

Hindi
History :

✓ Birth history

a) Pre natal:

Type of marriage: non-consanguineous

The patient is the first and only child
Mother was pregnant after six years of marriage

The patient has Femoral Length discrepancy (1 1/2 inches-left leg)-

IUGR in patientb)
Peri natal:
Type of delivery: (NSVD) normal spontaneous vaginal delivery - Birthweight: 2.25 kgs
Cried immediately after birth (CIAB)
c) Post natal:
History of jaundice after 5 days of delivery - No h/o seizures
✓ Family history :

38
35YEARS
YEARS

4Years

✓ Occupational History:

Mother- Homemaker

Father- Business man (drop shipping)

✓ Developmental historya) Gross
motor:

Head control: 7-8 monthsRoll

over: 8-9 months
Sitting with support: 9 months
Sitting without support: 10 months Standing with-
out support: 16 monthsWalking without support:
18 months

b) Fine motor

Reaching (ineffective) : 2-3 monthsReach and

grasping: 5 months Pincer grasp: 12 months
Clasping hands: 12 months

Relaxing objects crudely: 14-15 monthsControlled re-

lease: 15-16 months

✓ Medical history

- Past medical history:

The patient had a total of 12 fractures in the past

First fracture was at the age of 1 month on left thigh bone Second fracture was at the
age of 3 months on right thigh bone

* Deformities- the patient developed Shepherd crook deformity at theage of 2 year.

Present medical history

The patient had multiple falls (2-3 times) which resulted in recurrent

fracture of bilateral thigh bones and was unable to walk without supportfor the past three months.
The patient has come to SRMC for further management.

✓ Surgical history
 *Past surgical history

Femur osteotomy and rush nail fixation on 27th of December, 2021 fordistal fibulae fracture.

*Present medical history

8) Femur operative bilateral stabilization on 19th of March, 2024. - Thepatient is Immobilized
with Hip Spica
✓ Socio- economic history
9) Father is the bread winner of family

10) The family is a lower middle class family- Unstable financial situation
On Observation Hygiene: Satis-
factory Body built: ectomorphic
Social smile: present
Position of patient: attitudes of limb

Lying in supine position

Head and trunk neutrally positioned with pillows

Hip and lower extremities secured and immobilized with Hip Spica

On Evaluation
Gross Motor skills: cannot be assessed due to immobilization (hip spica)Cognitive and perceptual
skills:
Attention, concentration, memory, problem solving, abstract thinkingpresent (based on assess-
ment)
Perceptual skills present with no impairment (based on assessment

Social and emotional skills:

Eye contact: presentSocial
smile: present
Response to emotions: present Asking for needs: presentCo-ordination
(based on assessment)
:Eye-hand co-ordination: present Bilateral
co-ordination: present Balance: unable to as-
sess

ADL assessment-
WEE FIM SCALE:
Scoring:
25) (total assistance)
26) (maximal assistance)
27) (moderate assistance)
28) (minimal contact assistance)5
(supervision or set-up)

✓ (modified independence)

✓ (complete independence)

SELF CARE:-

 Eating : 5

 Grooming : 3

 Bathing : 1 4.Dressing -
upper : 35.Dressing - lower :
1
 ✓ Toileting : 1

✓ Bladder management : 3

8.Bowel management : 3 MOBIL-

ITY :-
9.Transfer chair|wheelchair : 110.Trans-
fer toilet :1 11.Transfer Tub shower:1
12.Locomotion : walk/wheel chair/crawl : 113.Locomotion
stairs: 1 COMMUNICATION :-

15) Comprehension : 6

16) Expression : 7

SOCIAL COGNITION :-
17) Social interaction :7
17.Problem solving : 7
18.Memory : 7
Problems relevant to OT:
11) Inability to perform ADLs- Difficulty in transfer skills- Range ofMotion affected
OT management strategies :
12) To prevent worsening of deformity, customized splints can be given. -
Establishing a routine and educating parents, care givers on properbed positioning, transfers,
wheelchair training.
13) Activities can be given to engage and distract patient from pain.
14) ADL scheduling
Tools and scales which can be used:-WEE FIM
Pain measurement scale

Treatment Approaches/FOR:-:
15) Task oriented Approach
16) Acquisitional Frame of Reference
17) Biomechanical Frame of Reference

- Rehabilitation Frame of Reference

18) Neurodevelopmental treatment