Te Whare Tapa Wha

Clinician Specialty: Occupational Therapist Taha Hinengaro (Mental Health): Patient reports fluctuating mood with periods of low energy and increased anxiety, particularly when contemplating returning to work. She expresses feelings of inadequacy and a decreased sense of accomplishment since her accident. Cognitive state appears intact, though she reports difficulty concentrating on complex tasks for extended periods. Taha Tinana (Physical Health): Patient presents with ongoing right shoulder pain (rated 6/10 on a visual analogue scale) exacerbated by overhead movements and lifting, following a rotator cuff injury six months prior. She experiences reduced range of motion, particularly abduction and external rotation. Functional status is limited, impacting her ability to perform activities of daily living (ADLs) such as dressing, showering, and preparing meals independently. She is unable to return to her previous role as a factory worker due to the physical demands. She reports occasional numbness and tingling radiating down her right arm. Past medical history including previous diagnoses, surgeries and hospitalisations: * Rotator cuff repair, right shoulder (6 months ago) * Mild hypertension, diagnosed 3 years ago, well-controlled with medication Current medications including dose and frequency, over-the-counter supplements and allergies: * Amlodipine 5mg once daily * Paracetamol 1000mg as needed, up to four times daily * Ibuprofen 400mg as needed, up to three times daily * Multivitamin once daily * Allergies: Penicillin (rash) Physical examination findings and vital signs: * Right shoulder active range of motion: Flexion 90 degrees, Abduction 80 degrees, External Rotation 30 degrees (pain-limited) * Right shoulder passive range of motion: Flexion 110 degrees, Abduction 100 degrees, External Rotation 45 degrees (end-range pain) * Palpation of right deltoid and supraspinatus elicits tenderness. * Muscle strength (right upper extremity) 4/5 against resistance for shoulder flexion, abduction, and external rotation. * Vital signs: BP 128/82 mmHg, HR 72 bpm, RR 16 breaths/min, SpO2 99% on room air. Taha Wairua (Spiritual Health): Patient identifies as Catholic and finds solace in prayer, though she has not been attending church regularly due to her physical limitations. She expresses a strong desire to regain her independence and sense of purpose, feeling that her current physical state is hindering her spiritual well-being. She values connection with her community, which she feels she is losing. Taha Whanau (Family): Patient lives with her husband and two adult children who provide significant practical support with household chores and personal care. Relationships appear supportive, though she expresses guilt about her reliance on them. Her husband works full-time, and children are available evenings and weekends. The family is concerned about her prolonged recovery and emotional state. Patient is currently on sick leave from her factory job, which is causing financial strain. She is actively involved in a local community garden group but has been unable to participate since her injury. Family history relevant to presentation including mental health and physical health conditions: * Mother: Hypertension * Father: Osteoarthritis * Paternal Aunt: Depression Plan: 1. Occupational Therapy Assessment and Intervention: * Conduct comprehensive ADL assessment to identify specific areas of difficulty and compensatory strategies. * Develop a graded exercise programme focused on improving right shoulder range of motion, strength, and endurance for functional tasks. * Provide education on joint protection techniques and ergonomic principles for home and potential work environments. * Explore adaptive equipment needs for dressing, bathing, and meal preparation. 2. Multidisciplinary Team Referral: * Refer to Physiotherapy for focused manual therapy and advanced strengthening exercises. * Refer to Social Worker for assistance with navigating return-to-work programmes and exploring financial support options. * Consider referral to Pain Management Clinic if current pain levels remain uncontrolled after 4 weeks of therapy. 3. Mental Health Support: * Encourage patient to re-engage with her spiritual community for emotional support. * Recommend exploring local support groups for individuals recovering from physical injuries. * Liaise with GP regarding patient's mood concerns and potential for psychological therapy referral. 4. Follow-up: * Schedule weekly occupational therapy sessions for the next 6 weeks to monitor progress and adjust intervention plan. * Reassess functional abilities and pain levels at 4-week interval. * Discuss potential vocational rehabilitation options at next review.