FRANK: RCVA, LeftHemi, Left Neglect

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FRANK: RCVA, LeftHemi, Left Neglect by Mind Map: FRANK: RCVA, LeftHemi, Left Neglect

1. Patient History: 68yr old, White man, diagnosed with R cva, left neglect, coronary artery disease and diabetes

2. Chief complaint: unbearable headache, slurred speech, and loss of control on L side.

3. Occupations

3.1. Daily Occupations: performs maintenance activities, wife in charge of meal prep and laundry, Frank shops for grocery and runs errands. Cooks breakfast and lunch when wife is not at home.

3.2. Active man, recently retired from postal job.

3.2.1. Pt. wants to travel world w/wife.

3.3. Hobbies: Pt. enjoys gardening and wood crafting.

4. Home & Family Life

4.1. Frank has Son from previous marriage & have no communication.

4.2. Frank & his wife live in a ranch style home in a suburban area.

4.2.1. Home has five steps outside of door. Garage is not attached to the house.

5. Patient Goals

5.1. Pt. wants to maintain his weekly bowling night.

5.2. Pt wants to return home with wife after being discharged.

5.3. Pt. wants to resume all hobbies after being discharged.

6. Rehab Plan

6.1. Pt. will receive OT,PT,ST and recreational therapy services.

6.2. Frank will also be seen by Nursing, Dietary, & Psychiatry professionals.

7. ADLs:

7.1. Pt. transfers with MINA and requires MOD verbal cueing due to poor safety awareness.

7.2. Pt. has dressing apraxia. Pt need MAXA w/dressing.

7.3. Pt. needs verbal cueing and physical assistance to complete L side bathing.

7.4. Pt. ambulates with a hemiwalker and requires MINA due to poor balance.

8. Occupational Performance Deficits

8.1. Pt. also has difficulty maneuvering around his environment due to L neglect. Pt has impaired sensation of light touch, sharp and dull touch. Impaired stereognosis on affected side.

8.2. AROM: no deficits in RUE. Pt. is R hand dominant. Presents w/weakness in LUE and LLE. Poor dynamics in sitting and standing elements.

8.3. Lacks perception w/difficulty in figure ground and spatial relations.

8.4. R/L confusion, profound L neglect.

8.5. Pt. has cognitive difficulties when performing ADLs.

8.6. Pt. has poor attention span, insight, judgement and lacks safety awareness.