March 21, 2009

Claims Adjuster

State Farm Mutual Insurance (BAR)

65 Cedar Pointe Drive, Suite 810

Barrie, ON

L4N7W7

Client Name:	-	Grace Yang
Address:	-	RR #3
		Ontario
Telephone Number:	-	(613) 012-3456
Claim No:	-	329076543
Date of Loss:	-	March 7, 2009
Occupational Therapist
Sibley File No.	-	1234567
Date of Referral:	-	March 12, 2003
Date of Initial Contact	-	March 12, 2003
Assessment Date:	-	March 13, 2003

OCCUPATIONAL THERAPY INSURER'S EXAMINATION REPORT

 

PURPOSE OF ASSESSMENT

(BAR) referred Mrs. Grace Yang to Sibley & Associates on March 11, 2009 following her motor vehicle accident (MVA) of March 07, 2009. The assessment was requested under Section 42 of the SABS, however, the 14-day written notice protocol was waived and it was requested by the adjuster that this therapist see the client as soon as possible. The referral was for an in home assessment specifically to address housekeeping and Attendant Care needs, as well as to:

1. Evaluate Mrs. Grace Yang's current ability to perform her essential, pre-accident activities of daily living.

 

2. Recommend any task modifications, education or assistive devices that may help Mrs. Grace Yang to achieve independence to complete tasks.

 

FILE ACTIVITY SINCE REFERRAL

 

--March 11, 2009 - Referral received late afternoon.

--March 12, 2009 - Client contacted and appointment booked. Adjuster informed of same via Acknowledgement form.

--March 13, 2009 - Assessment completed.

--March 14, 2009 - Adjuster contacted to gain approval for therapist to arrange delivery of equipment and to complete a follow-up visit to monitor same; verbal approval provided. Client contacted to gain verbal approval of this therapist to be treating therapist; verbal approval provided.

 

DOCUMENTS REVIEWED

-- No documents were made available to this therapist at the time of the assessment.

 

ASSESSMENT

--This assessment was conducted at Mrs. Grace Yang single dwelling home in Rural Town, Ontario on March 13, 2009.

-- At the time of this assessment, the following people were present: Mrs. Grace Yang and this therapist. Mrs. Yang's mother and husband were also present during a portion of the assessment. Mr. Yang acted as an interpreter for Mrs. Yang, as her first language is Mandarin. Mrs. Yang is not proficient in English.

TESTS ADMINISTERED

The following tests were administered during the course of this assessment:

--Clinical Interview

--General musculoskeletal evaluation

--Observation of functional tasks

--Jamar hand dynamometer calibrated date - April 2009.

--Graded muscle strength (1-5 scale) (Oxford Scale)

 

CONSENT

--Prior to this evaluation, Mrs. Grace Yang was informed that the assessment was requested by State Farm Mutual Insurance (BAR) to determine the impact of the MVA on her functional status.

--Mrs. Grace Yang was informed that the assessment was requested under Section 42 of the SABS and that the purpose of the meeting was for an assessment only and that no treatment would be provided by this therapist.

-- Mrs. Grace Yang chose to participate in the assessment process with this therapist.

--Mrs. Grace Yang was informed that a report would be completed documenting the assessment.

--The Waiver for Assessments Completed Under Section 42 (INSURER'S EXAMINATIONS) and the Consent to Assessment - Insurer's Examination (SECTION 42) forms were thoroughly reviewed with Mrs. Grace Yang.

--Mrs. Grace Yang provided written consent to complete and forward this report to State Farm Mutual Insurance (BAR).

--Please refer to the enclosed signed consent forms.

 

REPORTED ACCIDENT HISTORY

--Mrs. Grace Yang reported that she was the belted driver that was involved in a MVA on March 07, 2009. Mrs. Yang reported that she was at a stop sign in Merrickville, Ontario, waiting for an oncoming car to clear in order to make a left turn. Once in the intersection, she noted a car to the left approaching her. To avoid being hit she indicated that she decided to go straight. Mrs. Yang noted that the other car attempted to avoid being hit by veering left, and consequently they collided.

--The other vehicle involved hit Mrs. Yang's 2005 Windstar van on the driver's side door. Mrs. Yang's car then hit a pole on the passenger side door. At the moment of impact, Mrs. Yang recalled feeling intense pain in her chest and pelvis. She reported that she might have lost consciousness, as she was unable to see, and everything went white. She reported some recollection of calling for her husband and of trying to reach her mother's hand, who was in the passenger seat. She also recalled uncontrollable shaking in her legs. Her next recollection is of having a blanket on her head and a person saying not to move as the driver's side window was being broken. She indicated that the medical personnel on scene told her that 10 minutes had passed before she really responded to them. It was then that she reported her vision cleared.

--Mrs. Yang recalled having a collar on her neck and being transferred to hospital via ambulance. She indicated that her recollection of the events are sketchy but recalled the assessment of her blood pressure and pulse and of pain on the left side of her neck, left shoulder, left side of ribs, sternum, and groin area.

--Once at Kemptville Hospital, X-rays were taken, and Mrs. Yang was provided with medication and an IV. She was then transferred via ambulance to the Ottawa Civic Hospital for further tests. At the Ottawa Civic, she was given a CAT Scan and further X-rays. She was told that there were no broken bones but a lot of bruising and pulled muscles. She was then transferred back to Kemptville Hospital. At Kemptville Hospital, she was provided with a shot of Morphine for pain and asked if she would like to stay in hospital or return home. Mrs. Yang decided to return home. She was provided with a prescription for Oxycocet for pain.

--As client is unable to walk, she reported that her doctor plans to see her in her home on March 14, 2009.

 

PRESENT COMPLAINTS AND VIEW OF ABILITIES

Mrs. Grace Yang reported that she experiences the following complaints:

--Intense pain on left side of rib cage.

--Intense pain on left side of low back.

--Pain in middle of chest

--Groin pain on both sides that worsens when trying to move.

--Bruising left knee, no pain.

--Bruising left elbow, contact pain only.

--Mild neck pain that has improved.

--Mrs. Grace Yang quantified her level of pain using a scale from 0-10 (0 - no pain, 10 emergency level pain). Mrs. Grace Yang indicated her pain level reaches 10+ on a bad day and 7 on a good day.

--Pain worsens with movement in general but is at its worst when the client is trying to walk.

--Client is sleeping on/off throughout the day, reporting that the medication makes her very sleepy. Generally, she sleeps 10 pm until 5 am, reporting only one night where she woke up at 2 am in a cold sweat.

 

Medication

Name	Dosage / Frequency	Reason
Oxycocet	2 every 6 Hours- she has occasionally tried to take 1 every 6 hours but had found that the pain is not well relieved and for less time.	Pain

 

Client's Pain Management Strategies:

• Mrs. Grace Yang reported using the following for pain management

Strategy	Duration of Effectiveness
Laying down in a specific position on her back	5 hours in conjunction with medication
Medication	Lasts 5 hours if takes 2; lasts 2 hours if take only one pill.
Thera-P-Relief gel pads(heated in microwave)	5 hours

 

PRE-MVA FUNCTIONAL STATUS

 

Social History/Home Responsibilities:
--Mrs. Yang will be turning 55 on March 24, 2009. She lives with her husband and mother. She also has 3 cats, 1 dog and some fish. Prior to the MVA, the client was responsible for most housekeeping tasks including cleaning, laundry for self and husband, banking, grocery shopping, most meal preparation, and feeding the pets.

 

Self Care:
--The client reported independence with all personal care tasks pre-MVA.

 

Caregiving:
--The client provides meals for her mother, takes her to her medical appointments and provides transportation for other activities including church.

 

Home layout:
--Mrs. Yang lives in a two-storey fully detached home with a crawlspace in the basement. The front entrance has 2 steps, a small deck area and one step up (all wooden - no railing)., The side door most commonly used by Mrs. Yang has 3 steps up to a landing and one little step up (all wooden - no railing). This side door leads to the wood furnace room where coats and shoes are stored. Flooring is of rubber and carpeted mats.

--On the main level, are a two-piece bathroom and kitchen (both with vinyl flooring), dining and living rooms both with carpeting and rugs. The kitchen also has a door to outside that is rarely used.

--Wooden stairs lead upstairs (3 steps up to a landing with no railing, 10 steps up to a landing with a railing on the left side, and 4 steps up with a railing on the right side.

--On the upper level, there is a 3-piece bathroom (carpeted; tub with faucet on left), a hallway that leads to the laundry room and master bedroom (carpeting and vinyl), Mrs. Yang's mother has a living space upstairs that consists of a bedroom, a living room, and a spare room currently being used for storage.

--The client currently sleeps and spends all her time on the couch in the living room.

 

Pre-Accident Employment and Employment History:
-- Mrs. Grace Yang stated that, prior to the accident; she was employed privately to care for an elderly man in his home, for approximately 2 days a week, 6 hours each day. Her tasks included bathing the man (reportedly weighs 300 lbs.), transferring him into his wheelchair (with the assistance of a lift and another individual), making him breakfast, and completing housekeeping tasks including making the bed, laundry, doing dishes and vacuuming.

-- Prior to this job, Mrs. Yang worked for 1 year for the Township as a clerical worker. Previously, she worked for 20 years as an Administrative Assistant for the government.

 

Avocational/Social Activities:

Mrs. Grace Yang reported that, prior to the accident, she enjoyed the following:

-- Going to church daily (Monday, Tuesday, Friday -- 8 am, Saturday night and Sunday morning, Monday evening 9 pm and Thursday 10 am)

-- Volunteer work at the local nursing home (hours flexible, generally 2-5 hours per week).

 

Past Medical History:
Mrs. Grace Yang reported that, prior to her accident; she experienced the following health concerns:

-- Hiatus hernia - ongoing - taking medications

-- Asthma - Flovent 2 times daily

 

CURRENT FUNCTIONAL STATUS (Client's reports)
Self care:

-- Mrs. Grace Yang reported that she is mostly dressing herself independently, with someone else bringing her clothes to her. Assistance needed at times for socks/shoes.

-- Mrs. Yang reported that she sponge bathes herself, once her husband has set up the basin and all the supplies by the couch. She is unable to reach her back.

-- Mrs. Yang toilets independently using a port-a-potty from their camper beside the couch. Her husband raised the port-a-potty on a tire to make it at a reasonable height. The port-a-potty seemed sturdy to this therapist however there are no arms for added support. The potty is flushable and the client's husband cleans it regularly. The client has used a small basin to urinate in during times of urgency.

-- Noted however, that the groin pain does not seem to be any better since the accident, reporting that she thought she would have been able to walk by now.

 

PERCEIVED CAPACITIES / TOLERANCES

The following represents Mrs. Grace Yang's reported physical tolerances as compared to the observed physical tolerances:

 

MUSCULOSKELETAL FINDINGS

--Active Range of Motion (AROM) - Please refer to Appendix A (AROM chart) for details

-- A goniorneter and functional activities are used to measure the client's physical abilities.

-- All musculoskeletal findings were within normal limits (WNL) as noted during testing and functional activities with the exception of:

1. Cervical flexion and lateral flexion.

2. Shoulder flexion

3. Trunk flexion, extension, rotation and lateral flexion.

4. Hip flexion and extension

5. Knee flexion and extension

-- Client moved in slow, guarded manner with pain reported with most movements.

 

Strength - Please refer to Appendix B (strength chart) for details

-- Difficult to fully assess due to client's pain and fatigue. Client unable to remain in sitting.

-- The client has been unable to wash her hair since the accident due to her inability to walk. Bath/shower facilities are upstairs.

-- Client reported that self care tasks are personal to her and although she finds completing these tasks painful, she is determined to do them independently.

-- Client reported that her husband recently completed foot care for her.

 

Home Activities:

-- Mrs. Grace Yang reported that she is unable to complete any activities at this time due to inability to walk from pain. Her husband is off work helping with cleaning, cooking, grocery shopping, laundry, banking and feeding the animals. Her husband is concerned about how much more time he can take off work. He is generally out of the house Monday-Friday 6:10 am to 3:45 pm. Mrs. Yang's mother continues to complete task of washing dishes and is assisting with meals.

Caregiving

Mrs. Yang's mother and husband are providing meal preparation and clean up. Transportation for Mrs. Yang's medical appointments/pick-up of prescriptions is currently being completed by Mrs. Yang's husband or other family members.

 

Avocational/Social Activities:

-- Mrs. Grace Yang reported she is unable to engage in any regular activities at this time due to inability to walk from pain. She currently rests and watches TV.

 

Vocation:

-- Mrs. Grace Yang currently is not working.

 

CURRENT MEDICAL TREATMENT / INTERVENTION

 

Family Doctor:

-- Mrs. Yang indicated that her family doctor plans to visit her in her home on March 14, 2009. This will be the first time she has seen her doctor since the accident.

 

Client's Subjective Opinion:

-- According to Mrs. Grace Yang, she feels she is getting slightly better, indicating that the pain is slightly better; she can now shift her weight to move along the couch in sitting.

 

Grip Strength:

-- Mrs. Grace Yang is right - hand dominant.

-- Grip strength testing, using a hand-held dynamometer revealed a maximum grip strength of 38 lbs on the dominant (R) and 20 lbs on the (L) / (R) - see below.

-- As a measure of consistency, all scores should fall below the 10% coefficient of variation cut off level.

-- Mrs. Grace Yang scored coefficients of variation above the 10% level, at 17.94% on the right and 14.94% on the left respectively, which signifies that Mrs. Diane Yang was inconsistent with bilateral hand performance. However, inconsistencies can be due to pain, fatigue, anxiety, undiagnosed impairment, or symptom magnification.

-- When compared to her age group, Mrs. Grace Yang's grip strength was below the norms.

NOTE:

1. Average grip strength for Mrs. Grace Yang's age group (55-59 years) is 57.3 lbs in the (R) hand and 47.3 lbs in the (L) hand (Source: Archives of Physical Medicine and Rehabilitation, Volume 66, February 1985).

2. According to Hunter et. al. (Rehabilitation of the Hand, 1995, 4' edition) approximately 8.8 lbs of grip strength is required to perform 90% of activities of daily living.

PRE -- AND POST-MVA

For activities where observation was not possible (e.g. grocery shopping) professional opinions were made based on demonstrated physical and functional capacities.

I = Independent

U = Unable

PI = Partially Independent

N/A = Not Applicable

COGNITIVE STATUS

· Mrs. Grace Yang was oriented x3.

· Mrs. Grace Yang was able to recall the events leading to the accident. Events immediately following the accident are vague and client was not able to describe the accident or hospital events in detail.

PSYCHOSOCIAL STATUS

· Mrs. Grace Yang stated that it is frustrating with her current limitations as she described herself as very active prior to the accident. She indicated that she is coping fairly well with the support of family and friends, and with her religious faith.

 

BEHAVIOURAL PRESENTATION AND CONSISTENCY OF EFFORT

· Mrs. Grace Yang was pleasant and co-operative with this therapist as evidenced by her willingness to complete all musculoskeletal and functional testing.

· Mrs. Grace Yang demonstrated consistency of effort throughout the assessment although she became too fatigued and in pain to remain sitting. Once lying down, the client started to fall asleep during questioning, after having taken her pain medication.

 

BARRIER (S) TO REHABILITATION

· No barriers noted at this time.

 

SUMMARY

Mrs. Yang is a 55-year-old woman who was involved in a motor vehicle accident on March 07, 2009. She reported that she sustained soft tissue injury to her left side rib cage, groin area and bruising to left knee and elbow. Injuries result in intense pain on left side rib cage, low back and middle of chest, and intense groin pain. She was sent to hospital for assessment and released. On testing, all range of motion was within normal limits except for cervical flexion and lateral flexion, shoulder flexion, all trunk and hip movements and knee flexion. Strength was below normal except for right elbow flexion/extension and knee extension. She has not returned to most of her pre-MVA activities due to her injuries. Client can walk with a walker to complete transfers safely but requires a wheelchair for mobility. Assistance is required for same.

Based on the assessment and the client's reports, it is this therapist's opinion that the client requires assistance for personal care and housekeeping. There is a need for assistive devices to promote safety and independence with personal care and mobility.

 

RECOMMENDATIONS

1. One Occupational Therapy visit bi-weekly. As client is in an acute phase of her injury, it is important to closely monitor functional status and meet ongoing needs as required.

2. The assistive devices in bold print have been provided to Mrs. Yang effective March 15 & 17, 2009 for safety purposes. Verbal approval from adjuster obtained. The remaining assistive devices would be beneficial to facilitate the resumption of Mrs. Grace Yang's pre-accident activities of daily living:

ITEM	Approximate Cost	Explanation
Walker (2-wheeled)	Rental - $10 /month	Implemented immediately for safety with transfers and mobility. Bed to allow client to re-position self for comfort. Ramp and wheelchair provided to allow client to be exited from the house in an emergency.
Wheelchair (17" wide x 18" depth; 22" rear wheels, 8" casters; standard height; Bottomline cushion, sling back; 24" wide total)	Rental $40/month
Stationary Commode w/ arms	Rental $15 / month
Bucket for commode	Purchase $10
Electric Bed	Rental $150 / month
Ramps	Rental $165 / month + $130 installation
Female portable urinal	Purchase $13 + tax	Ease with urinating during time of urgency
Shampoo tray	Purchase $38 + tax	Allow for client to receive assistance for hair washing while seated in wheelchair.
Long -handled Sponge	Purchase $3.10 + tax	Independence with washing back.
Delivery	$16.95 + tax
TOTAL