Frank Case Study

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Frank Case Study by Mind Map: Frank Case Study

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 No AROM deficits in R UE L UE Shoulder flexion/extension: 0 to 50 degrees Adduction/Abduction: 0 to 45 degrees Internal rotation: 0 to 5 degrees External rotation: 0 to 15 degrees Elbow flexion/extension: 0 to 60 degrees Supination: 0 to 15 degrees Pronation: WNL Wrist extension: 0 to 10 degrees Wrist flexion: 0 to 45 degrees Finger flexion: half normal range Finger extension: weak, unable to release objects, increased tone Coordination on left is impaired for fine and gross motor

2.3.2. PROM L UE Shoulder flexion: 85 degrees Shoulder abduction: 70 degrees Elbow flexion: 100 degrees Wrist/hand: WNL

2.3.3. Weakness/Balance L UE weakness L LE weakness Poor dynamic sitting and standing balance 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

3. Personality during treatment:

3.1. Amiable and likes staff members

3.2. Teases and good humor

4. Diagnosis:

4.1. R CVA

4.2. L Hemiplegia

4.3. L Neglect

5. Symptoms:

5.1. Unbearable headaches

5.2. Slurred speech

5.3. Loss of control of left side

6. Pre-Accident:

6.1. Active

6.2. Retired postal worker

6.3. Wants to travel with wife

6.4. Avid gardener and woodworker

6.5. Does all home maintenance

6.6. Meal preps for breakfast and lunch

7. Family/Home/Social Life:

7.1. Ranch style home

7.2. Suburban neighborhood

7.3. 5 steps into front door

7.4. Garage not attached

7.5. Son from previous marriage

7.6. Married

7.7. Friendly with neighbors

7.8. Multiple friends from post office

7.9. Weekly bowling night

8. Goals:

8.1. Return home

8.2. Return to previous hobbies

9. Ambulating/Transfers:

9.1. Hemiwalker with minimum assist because of poor balance

9.2. Transfers with minimum assist and moderate verbal cueing because of poor safety awareness