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In this section, complete a well-organized narrative that illustrates the occupational profile of the client. This section allows the team to expand on the information provided in the template, as well as tying in information gleaned regarding neuroanatomy structure, function, and the effects on occupation as they relate to the client. Consider contextual factors affecting the engagement and participation of occupation for the client. These contextual factors include the client’s environmental factors, personal factors, and any relevant occupational justice factors. The client’s unique occupations, performance patterns, and performance skills must be addressed. Use (and cite) the Occupational Therapy Practice Framework to guide this section. Use of evidence from scientific literature is encouraged if appropriate. Only include relevant information. This section should be no more than three pages.
Lily is a 6-year-old Hispanic girl with a significant past medical history. She presented to the hospital after being hit by a car while crossing the street on her way to school. In the ER, she was reported to be unresponsive to all types of sensory stimulation. Imaging of Lily’s brain showed evidence of hemorrhagic contusions in the following areas: right frontal lobe, right motor cortex, and the right temporal lobe. Lily underwent a craniotomy with no complications. She spent a total of 3 weeks in acute care and then was transferred to the pediatric unit at a local Rehabilitation Hospital. At that time, Lily was breathing on her own, was fed through a gastrostomy tube (g-tube), and was started on the medication baclofen for the increased tone throughout the left side of her body. Lily was nonverbal. Lily’s parents reported that she was at times following simple verbal motor commands with her right arm, but not demonstrating consistent responses to any other type of sensory stimulation. Prior to her accident, Lily’s parents report that she was a healthy, happy kindergarten student. She excelled at writing and beginning reading skills; after school she went to dance lessons 1 day/week and played in a basketball clinic 2 days/week at the local YMCA. On the weekends, Lily and her family enjoyed being outdoors, camping and hiking and riding their bicycles. Lily loved playing with her friends, especially her toy bowling set, her miniature pony toys, and any kinds of arts and crafts. Lily’s favorite color is red. Lily has a 4-year-old sister named Adriana with whom she shares a bedroom at home and is very close. Lily’s mom used to work as a realtor but now works as a full-time stay-at-home mom. Lily’s dad is a firefighter who works three 24-hour shifts a week and then is home the other 4 days. They live in a 2 story floor with a half bathroom on the first floor, and both bedrooms and the only full bathroom is on the second floor. Lily’s parents are first-generation citizens. Lily’s parents are hoping that Lily will once again be as independent in her dressing, bathing, and grooming as she used to be. Prior to her accident, Lily did most of her self-care independently but needed some assistance at times with washing and drying her hair, tying shoes, and fastening her clothes. Lily’s parents report that their goals for Lily are for her to walk, play, and go back to her school. In terms of her physical abilities, Lily can visually fixate on objects but is unable to track objects past midline consistently. Lily’s right upper extremity (dominant) is inconsistent in purposeful use, presents with normal tone, has full passive range of motion, and limited active range of motion. Her left upper extremity presents with no active range of motion and significant increased flexor tone. Lily is unable to sit unsupported on the edge of bed without assistance, is unable to stand unsupported without maximal assistance and she leans to the left. Lily appears to enjoy being in therapy when other children are present and when she does not have to participate in self-care tasks. Lily also appears to be happiest when her father is actively engaged in therapy sessions. Lily’s mom appears more hesitant and reports feeling guilty for Lily’s injury