1. Therapy Services:
1.1. OT
1.2. PT
1.3. Speech Therapy
1.4. Recreational Therapy
1.5. Nurses
1.6. Dietitians
1.7. Physiatrists
2. OT Evaluations:
2.1. Observation
2.1.1. No hearing or vision deficits other than wearing glasses for distance
2.1.2. Cognitive deficits when observing daily routine like: poor attention span, insight, judgment, and safety awareness
2.1.3. Difficulty moving around his room and hospital environment
2.1.4. Bumps into things on left side
2.2. Interview
2.3. MMT
2.3.1. AROM
2.3.1.1. No AROM deficits in R UE
2.3.1.2. L UE
2.3.1.2.1. Shoulder flexion/extension: 0 to 50 degrees
2.3.1.2.2. Adduction/Abduction: 0 to 45 degrees
2.3.1.2.3. Internal rotation: 0 to 5 degrees
2.3.1.2.4. External rotation: 0 to 15 degrees
2.3.1.2.5. Elbow flexion/extension: 0 to 60 degrees
2.3.1.2.6. Supination: 0 to 15 degrees
2.3.1.2.7. Pronation: WNL
2.3.1.2.8. Wrist extension: 0 to 10 degrees
2.3.1.2.9. Wrist flexion: 0 to 45 degrees
2.3.1.2.10. Finger flexion: half normal range
2.3.1.2.11. Finger extension: weak, unable to release objects, increased tone
2.3.1.2.12. Coordination on left is impaired for fine and gross motor
2.3.2. PROM
2.3.2.1. L UE
2.3.2.1.1. Shoulder flexion: 85 degrees
2.3.2.1.2. Shoulder abduction: 70 degrees
2.3.2.1.3. Elbow flexion: 100 degrees
2.3.2.1.4. Wrist/hand: WNL
2.3.3. Weakness/Balance
2.3.3.1. L UE weakness
2.3.3.2. L LE weakness
2.3.3.3. Poor dynamic sitting and standing balance
2.3.3.4. Static standing fair, static sitting good
2.4. Perceptual and sensory testing
2.4.1. Difficulty in figure-ground and special relations
2.4.2. Right-left confusion
2.4.3. Profound left neglect
2.4.4. Impaired sensation for light touch and sharp-dull
2.4.5. Stereognosis
2.5. Barthel Index of ADL's
2.5.1. 10 of 20 score
2.5.2. Difficulty right-left discrimination
2.5.3. Difficulty managing his clothing
2.5.4. Unable to figure out the front from the back or the sleeve hole from the neck hole
2.5.5. Maximum assist with all dressing tasks-dressing apraxia
2.5.6. Bathing completed while sitting at sink
2.5.7. Neglected left side completely
2.5.8. Needed verbal cueing and physical guidance