Walt is a 38-year-old male who sustained a traumatic brain injury from a motor vehicle accident, resulting in right frontal, parietal, temporal, and occipital lobe lesions.
Walt is a 38-year-old male who sustained a traumatic brain injury
SOAP note assignments:
Based on the case details and Walt’s profile below, write a SOAP note for a treatment session that you would perform with Walt. There are many things that you could address. How would you assist Walt in achieving his occupational performance goals using remedial and adaptive approaches for his perceptual dysfunction?
To assist Walt in achieving his occupational performance goals of submitting a painting to a local art gallery, playing with his children, driving, and regaining computer skills in preparation for resuming part-time work as a graphic artist at an architectural firm, a therapist would need to use a combination of remedial and adaptive approaches to treat his perceptual impairments.
Remember the evidence shows that the most successful outcomes for treating visual perceptual impairments are through occupation-based activities that have meaning and offer the client the opportunity to generalize functional skills to multiple contexts through the remediation and adaptation of perceptual dysfunction.
SOAP note Visual Perception Deficits
Walt Case Study
Here is the case study details:
Walt is a 38-year-old male who sustained a traumatic brain injury from a motor vehicle accident, resulting in right frontal, parietal, temporal, and occipital lobe lesions. His occupational profile included a complex and varied occupational history that consisted of full-time work as a graphic artist in a prestigious architectural firm. Walt is a husband and the father of two young children, as well as an accomplished painter.
After the brain injury, Walt’s roles as worker, husband, father, and architect were affected because of impairments with motor and process performance skills and client factors, such as perceptual and cognitive dysfunction. Walt was unable to participate in his most valued areas of occupation, including painting, using a computer, sketching, and playing catch with his children. During the evaluation process, his visual foundation skills, including visual acuity, oculomotor control, and visual field function, were found to be intact.
However, he demonstrated difficulty initiating motor actions when playing with his children and interpreting visual information for meaningful visual-spatial relationships when painting, sketching, or using the computer. In addition, he exhibits clinical signs of unilateral neglect to the left half of his body and is unable to discriminate between different types of materials through touch alone.
During the initial assessment, the occupational therapist elected to use the Canadian Occupational Performance Measure to obtain client-centered goals that would assist Walt in achieving his occupational performance goals.
Walt identified his primary goals in occupational therapy: to submit a painting to a local art gallery, to play with his children, to drive, and to regain computer skills in preparation for resuming part-time work as an architect.
Walt presents with a visual perception disorder. He has difficulty recognizing and differentiating the faces of his two children; he also has difficulties identifying the differences in the brushes he uses for painting. Additionally, he requires verbal cues to identify the unique features that distinguish the faces of his two children. Also, to identify the appropriate paintbrush to use during an art project. He also has difficulty identifying and recognizing the significance of various traffic signs, which would prevent him from driving safely.
Walt presents with visual-spatial perception dysfunction. He has difficulty distinguishing the right and left sides of his body and often confuses right and left when given directions. He frequently gets lost and requires a family member to be with him at all times when he is in unfamiliar community environments. When painting, Walt has also been observed to have difficulty distinguishing the foreground and the background in his paintings and is unable to determine the differences between the amounts of paint in each of the cups next to him. In addition, he is often observed missing the canvas in front of him when attempting to apply the paint.
Walt presents with an impairment in tactile perception.
He is unable to identify the objects he uses for painting by touch alone. He is unable to discriminate between different types of materials or different forms and shapes by tactile means and must compensate visually to determine the objects he is using during occupational performance.
Walt demonstrates unilateral inattention to the left side of his body and his environment. He demonstrates asymmetric visual scanning to the left side of his environment. Misses details in his drawings on the left, and routinely neglects the functional use of his left upper extremity during functional tasks. Further, he often states that his left arm is owned by someone else. He has difficulty holding a painting utensil because of impairments with spatial relationships between his fingers.
Walt presents with a motor perception disorder that affects his motor planning.
When given a shirt to don, Walt attempts to put his legs through the sleeves of the shirt. During drawing and painting activities, he seems to hesitate and is unable to initiate a motor plan without physical cues. He knows that he is painting and knows what he would like to paint. But he is unable to translate this idea into a motor action. Walt is also unable to operate the mouse on the computer for a graphic design activity because of his difficulty with motor planning. In addition, when given a three-dimensional craft project, he is unable to use effective problem-solving strategies during the construction of the design.