FRANK, 68-year-old

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FRANK, 68-year-old by Mind Map: FRANK, 68-year-old

1. Symptoms

1.1. unbearable headache

1.2. slurred speech

1.3. loss of control on L side

2. Diagnosis

2.1. R CVA, L Hemiplegia, L Neglect

3. Pre-Accident

3.1. Active

3.2. Retired from job (postal worker)

3.3. Looking forward to traveling with wife

3.4. Gardner

3.5. Woodworker

3.6. Weekly bowling night with work friends

3.7. Home maintenance

3.8. Grocery shopping

3.9. Meal preparation

4. Family

4.1. Son

4.1.1. lives far

4.2. Wife

4.2.1. meal preparation

4.2.2. laundry

5. Home Environment

5.1. Five steps to front door

5.2. Garage not attached to house

5.3. Friendly neighbors

6. Goals:

6.1. Return home

6.2. Resume hobbies

7. Services

7.1. OT

7.2. PT

7.3. Speech Therapy

7.4. Recreational therapy

7.5. Nursing

7.6. Dietary

7.7. Physiatry

8. Occupational Therapy

8.1. Evaluation/Assessment

8.1.1. Observation Cognitive deficits Poor attention span Poor insight poor judgement poor safety awareness Difficulty maneuvering environment Poor dynamic standing and sitting balance Static standing balance fair Static sitting balance good Fine and gross motor function/coordination impaired on L

8.1.2. Interview Persona Amiable Humor Interpersonal skills Unaware of need for therapy/hospital Stays because wife/doctor say so

8.1.3. MMT strength not tested on L because of increased tone

8.1.4. Perceptual and Sensory testing Perceptual deficits Figure ground relations Spatial relations R/L Confusion Profound L neglect Sensory deficits NO light touch NO sharp/dull Stereognosis NO deficits in R UE

8.1.5. Barthel Index of ADLs R/L discrimination difficulty difficulty managing clothing unable to determine front from back unable to determine sleeve from neck hole MAX ASSIST in dressing dressing apraxia Bathing (while sitting at sink) L neglect completely excessive verbal cueing physical guidance Ambulation poor balance hemi-walker Transfers poor safety awareness verbal cues

8.1.6. ROM Assessment NO AROM deficits in R UE PROM L UE Shoulder flexion = 85 degrees Shoulder ABduction = 70 degrees Elbow flexion = 100 degrees Wrist = WNL Hand = WNL AROM L UE Shoulder flexion/extension = 0-50 degrees Shoulder AB/AD = 0-45 degrees Shoulder ER = 0-15 degrees Shoulder IR = 0-5 degrees Elbow flexion/extension = 0-60 degrees Forearm supination = 0-15 degrees Forearm pronation = WNL Wrist extension = 0-10 degreess Wrist flexion = 0-45 degrees Finger flexion = half normal range Finger extension = weak

8.1.7. Muscle Tone Neck/Trunk = 2 Fingers/Wrist = 2 LE = 1