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Medical and Psychosocial Aspects of Rehabilitation Counseling

Exam 3

DUE: TUESDAY, DECEMBER 7, 2004 1:55 PM

On my honor, I have neither given nor received unauthorized aid on this examination.

(Please print name, then sign)

Case Study #1

Ann is an 18-year-old female with cystic fibrosis. She has recently graduated from high school and did well in all her coursework. She has been hospitalized quite a bit during high school and is currently averaging three stays per year. Each hospital stay averages one week.

Ann has an intense interest in becoming a police officer and would like to pursue an Associate of Science degree in police science at a local community college. She has been referred to you because of the school counselor's concerns that Ann should not pursue this line of work given her disability.

Questions
  1. Describe Ann's possible functional limitations as related to a police officer position and give your opinion if this is a feasible vocational option for Ann.
  2. How would you describe cystic fibrosis to a potential employer?
  3. What recommendations would you give Ann and her employer regarding reasonable accommodations/assistive technology if she did pursue her dream of becoming a police officer?
Case Study #2

Mike is a single, 21-year-old who finished high school with a "B" average, completed real estate school, and received a real estate sales license. While in high school, he enjoyed mathematics and social science classes and was active in the drama department.

Immediately prior to the accident, Mike worked as a real estate salesperson for 4 months. Before this job, he worked for one year as a waiter in an expensive gourmet restaurant. Mike enjoys working with people and works well with others. He possesses the work personality needed to keep a job and had not had problems with co-workers or supervisors.

Six months ago, Mike sustained a cervical spine injury in a motor vehicle accident. The lesion is at C-6 and is incomplete. There has been a return of partial function in the lower extremities, but not enough to allow for independent ambulation. Mike's arms are affected, the left more than the right. There is spasticity and contractures of the left hand and an inability to perform any fine motor skills with that hand. His right, dominant hand has residual weakness with some impairment of fine motor skills. While Mike is continuing to show neurological recovery, there is no question he will have some permanent and irreversible paralysis of both upper and lower extremities.

Questions
  1. Describe Mike's possible functional limitations as related to his job.
  2. What recommendations would you give Mike related to independent living and activities of daily living (ADLs)?
  3. What recommendations would you give Mike and his employer regarding reasonable accommodations/assistive technology to help him continue employment?
Case Study #3

Emma is a 51-year-old married woman with progressive glaucoma. She and her husband have one grown child who is not dependent on them for support. Emma also has a back injury, which limits her to light work. For the past 10 years, she has been an elementary school teacher. Before receiving her Master’s degree in elementary education, she worked for 5 years as a teacher’s aide. Her first job within the school district was in the cafeteria where she worked as a cashier. She became a teacher’s aide after working for 1 year as a cashier.

Recently, Emma went on temporary disability because of deteriorating vision due to glaucoma. She is now considered legally blind. After her condition stabilized, she decided to return to her career as a schoolteacher. The school district is concerned about her returning, stating that they had a medical evaluation concluding that she was legally blind. She decided to seek the services of a rehabilitation counselor. Her desire is to return to classroom teaching.

Questions
  1. How would you describe Emma's condition to a potential employer (assuming she returns to teaching)?
  2. Describe Emma's possible functional limitations as related to her job.
  3. What recommendations would you give Emma and her employer regarding reasonable accommodations/assistive technology to help her continue employment as a teacher?
Case Study #4

Mary is a secretary for a large aerospace company. Her job is described below.

Secretary (clerical). Schedules appointments, gives information to callers, takes dictation, and otherwise relieves officials of clerical work and minor administrative and business detail. Reads and routes incoming mail. Locates and attaches appropriate file to correspondence to be answered by employer. Takes dictation in shorthand and transcribes notes on typewriter or word processor. Composes and types routine correspondence. Files correspondence and other records. Answers telephones and gives information to callers or routes call to appropriate official and places outgoing calls. Records minutes of staff meetings. Makes copies of correspondence or other printed material, using copying or duplicating machine. May prepare outgoing mail, using postage-metering machine. Delivers mail to various departments located in different buildings.

Although this job is classified as sedentary work, Mary is required to deliver mail to various departments in different buildings. This activity requires walking around the large aerospace facilities for about 1 hour per day.

This job took about 1-2 years to fully learn. The company has employed Mary in this position for 15 years. After finishing high school and receiving her diploma, she worked for several years in a restaurant as a short-order cook. Also, she worked in various manufacturing plants as an electronics assembler, tester, and packer. She is right-handed.

This case was referred to you by the employer. The medical file indicates that the day before Mary's 61st birthday, she had a stroke. Two weeks after the stroke, the company called you and requested vocational rehabilitation services. They authorized you to provide any and all services you felt would benefit this valued employee.

The stroke occurred on the right side of the brain. It was a moderate stroke that would cause some permanent functional limitations. Although unknown at the time of referral, Mary will recover about 80% functioning. The functional limitations would involve all the typical areas that could be affected by a stroke on the right side of the brain and would be considered mild to moderate. In reviewing the medical information of record, you note that Mary was hypertensive before her stroke; at this time, her physician is able to control her blood pressure with medication.

The company would like Mary to return to work as quickly as possible. They feel she has been an outstanding employee and is very loyal to the company. The company president understands the importance of early intervention and reasonable accommodation and is willing to consider all possibilities for rehabilitation.

Questions
  1. What functional limitations is Mary likely to have with a moderate stroke on the right-side of her brain?
  2. Do you think she can continue to work as a secretary? Why or why not?
  3. What accommodation recommendations would you give to Mary and her employer?
Case Study #5

Sylvia is a 28-year-old loan officer who worked for a bank at the time of her injury. Raised in Mexico, she immigrated to the United States with her family when she was 16 years old. While in the US, she learned English and received an Associate of Art (AA) degree at the age of 20. She began working for the bank as a teller when she was 20 and had been promoted consistently during her 8 years of employment.

Bank teller involves lifting and carrying a maximum of 15 pounds, with repetitive lifting and carrying of 5-10 pounds. Sylvia performed the job standing or sitting, as the bank provided a stool for the tellers that wanted or needed to sit. Most of the tellers alternated sitting and standing throughout the work shift. It typically takes 6-12 months to learn this job. The bank promoted Sylvia consistently during her 8 years of employment. Her most recent position at the bank was loan officer.

Sylvia was injured in a car accident when delivering some loan documents to a bank customer. Following the injury, she was unconscious for 4 days.

When referred for vocational assessment approximately 8 months after the injury, Sylvia reported that she was not able to return to work. She suffered headaches on a daily basis and spent most of the day lying down, rarely watching television or reading, because both activities increased her headaches. Sylvia could not walk for long periods because of dizziness, fatigue, and back pain. Noise and large groups of people gave her headaches, so she avoided people. Her speech was slow, but appeared fluent; physical movements were slow and she frequently touched walls or furniture for balance when walking. A housekeeper was paid by the workers' compensation carrier to clean her house, but Sylvia had resumed responsibility for shopping and cooking.

Medical reports indicated that she had a light work restriction due to a back injury that was diagnosed 6 months after the original injury. The cognitive assessment conducted 6 months after the accident showed problems with concentration, memory, attention, and word retrieval. Physical therapy, speech pathology, and other ancillary services had ended before the referral for vocational rehabilitation. Sylvia had participated in biofeedback to reduce her headaches and provide pain control; she refused to take medication for pain.

On untimed multiple-choice academic tests, Sylvia had above average skills in vocabulary, reading, spelling, grammar, arithmetic operations, and problem-solving. Especially strong in mathematics, she reported liking working with numbers. However, she took approximately three times the average amount of time to complete these tests. After an hour of concentration, she would have a headache and terminate the testing. She had typing skills but could not tolerate the noise of a typewriter.

The rehabilitation counselor conducted a thorough job analysis of her job as a loan officer shortly after the vocational referral. As a loan officer, Sylvia examined, evaluated, authorized, or recommended approval of customer applications for lines or extension of lines of credit, commercial loans, and real estate loans. This involved reviewing the loan application for completeness, analyzing the applicant's financial status, credit, and property to determine the feasibility of granting the loan request. She interviewed applicants applying for loans to elicit information, prepared the loan request papers, and obtained related documents from applicants, such as blueprints and construction reports. The loan officer corresponded with the applicant or creditors to resolve questions regarding applications and investigated the applicant's background to verify credit and bank references. The applicants were then informed whether the loan requests had been approved or rejected. If the loan was accepted, the loan office completed the loan agreement. Sylvia prepared forms for forwarding to insuring agencies. The job involved supervising a loan assistant and a secretary.

The work of a loan officer at the bank involves lifting and carrying a maximum of 20 pounds with frequent lifting of paperwork. It is primarily a seated job and takes over 2 years to learn.

Data analysis was a major part of the job, and there were continual interruptions, multiple ongoing projects, and complex interactions with applicants and loan agencies. The job involves decision-making and analysis with no clear-cut guidelines or standards. There were stringent deadlines that had to be met in funding or approving loans. Sylvia's secretary reported that the telephone rang 3-4 times per hour, and each call involved a new problem or task. Prior to her injury, Sylvia frequently worked 10 hours per day. A general survey showed that most banks were as fast-paced and stressful as where Sylvia worked.

Sylvia frequently drove to people's homes and to lenders' offices. Although she was able to drive, she reported that she was frightened when driving because it was difficult to pay attention to the cars, the road, the lights, and where she was going. The counselor observed that she drove slower than the speed limit and tended to stop too far behind stop signs and traffic lights.

Questions
  1. What are Sylvia's functional limitations as they relate to working as a loan officer?
  2. How would you explain Sylvia's disability to the employer?
  3. What accommodations can you recommend to Sylvia and her employer if she does return as a loan officer?
Case Study #6

Ricardo is a 22-year-old male who, while attempting to prime a carburetor with gasoline, had his shirt and coat catch fire. He suffered deep partial-thickness (2nd degree) and full-thickness (3rd degree) burns over 33% of his body. These burns involved his trunk from the waist up, both arms and hands, face, and neck. Treatment at a burn center required 3 months of hospitalization. Ricardo has contractures of his hands, elbows, and axillae. His facial features are deformed, and

there are contractures around the mouth, preventing full opening of the mouth. The physicians have kept his eyes closed to prevent the lids from scarring open. There is distortion of facial features, including the nose, which has been partially burned away. Fifty percent of his scalp has been burned causing baldness.

Ricardo was an apprentice baker prior to the injury and is married with one son, 3 years of age. He completed the 11th grade and a training program in baking. For the last month, he has been home from the hospital. There has just been a medical and vocational rehabilitation staff consultation with Ricardo, his wife, and child. Following careful interviews and assessment by all team members, the following problems are observed.

  • Physical problems
  • both eyes bandaged due to scar contractures of the upper and lower eyelids
  • perioral scar contracture of the mouth
  • deformity of the nose
  • flexion contracture of the neck
  • alopecia over 50% of the scalp
  • scar contractures flexion of the interphalangeal joints of both hands, all digits
  • first webspace contracture of both thumbs
  • flexion contracture of both elbows
  • contracture of both axillae, anterior and posterior
  • Emotional problems
  • anxiety and depression
  • inability to sleep regularly
  • impotence
  • fears be will be unable to see when his eye bandages are removed
  • concerns regarding inability to use his hands or return to work and earn a living
  • inability to keep up with rent payments
  • family seems more distant
  • his son is frightened of him
  • has had thoughts of suicide

The plastic and reconstructive surgeon has come up with a plan for surgical intervention. It is felt that after three surgical procedures, the top priority physical problems will be markedly improved.

Questions
  1. What type(s) of employment would you recommend to Ricardo, assuming that he will have marked residual decreases in strength and range of motion of the hands and arms?
  2. What would you tell an employer about Ricardo's disability?
  3. What types of accommodations/assistive technology would you recommend to Ricardo to assist in the job(s) that you have suggested?
Case Study #7

Joyce is 52 years old and currently married. Shortly after receiving her Master of Social Work (MSW) degree, she became employed as a children's social services worker.

This client has multiple disabilities. One year ago, after being diagnosed with coronary artery disease, she had heart bypass surgery, which was considered successful. Joyce is not taking any cardiac medication. Also, she has been taking insulin for the past 10 years to control diabetes. The diabetes is under good control. Joyce has mild to moderate anxiety and depression.

For the previous 9 years, Joyce has been working as a self-employed photographer. Her work involves lifting and carrying up to 40 pounds of equipment. Much of her work involved traveling to different locations for special assignments.

Before becoming self-employed, Joyce worked for various photographic studios, starting out as a photography assistant and working her way up to the level of photographer. She left each job within one year because she felt the manager was not satisfied with her work, although, on each occasion, the manager noted satisfaction with her abilities.

The first major job Joyce has was as a children's social worker. After 2 years, she left the position believing the clients were never satisfied with her work. Yet, her supervisors rated her work as excellent. She then obtained employment as an eligibility worker but resigned after one year because of client's complaints. The supervisor told her complaints happened to all eligibility workers and unsuccessfully encouraged her to remain on the job. Following these 2 social work positions, she decided to leave the field and secured employment as a photography assistant.