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

8.1.1.1. Cognitive deficits

8.1.1.1.1. Poor attention span

8.1.1.1.2. Poor insight

8.1.1.1.3. poor judgement

8.1.1.1.4. poor safety awareness

8.1.1.2. Difficulty maneuvering environment

8.1.1.3. Poor dynamic standing and sitting balance

8.1.1.4. Static standing balance fair

8.1.1.5. Static sitting balance good

8.1.1.6. Fine and gross motor function/coordination impaired on L

8.1.2. Interview

8.1.2.1. Persona

8.1.2.1.1. Amiable

8.1.2.1.2. Humor

8.1.2.1.3. Interpersonal skills

8.1.2.2. Unaware of need for therapy/hospital

8.1.2.2.1. Stays because wife/doctor say so

8.1.3. MMT

8.1.3.1. strength not tested on L because of increased tone

8.1.4. Perceptual and Sensory testing

8.1.4.1. Perceptual deficits

8.1.4.1.1. Figure ground relations

8.1.4.1.2. Spatial relations

8.1.4.1.3. R/L Confusion

8.1.4.1.4. Profound L neglect

8.1.4.2. Sensory deficits

8.1.4.2.1. NO light touch

8.1.4.2.2. NO sharp/dull

8.1.4.2.3. Stereognosis

8.1.4.2.4. NO deficits in R UE

8.1.5. Barthel Index of ADLs

8.1.5.1. R/L discrimination difficulty

8.1.5.2. difficulty managing clothing

8.1.5.2.1. unable to determine front from back

8.1.5.2.2. unable to determine sleeve from neck hole

8.1.5.2.3. MAX ASSIST in dressing

8.1.5.2.4. dressing apraxia

8.1.5.3. Bathing (while sitting at sink)

8.1.5.3.1. L neglect completely

8.1.5.3.2. excessive verbal cueing

8.1.5.3.3. physical guidance

8.1.5.4. Ambulation

8.1.5.4.1. poor balance

8.1.5.4.2. hemi-walker

8.1.5.5. Transfers

8.1.5.5.1. poor safety awareness

8.1.5.5.2. verbal cues

8.1.6. ROM Assessment

8.1.6.1. NO AROM deficits in R UE

8.1.6.2. PROM L UE

8.1.6.2.1. Shoulder flexion = 85 degrees

8.1.6.2.2. Shoulder ABduction = 70 degrees

8.1.6.2.3. Elbow flexion = 100 degrees

8.1.6.2.4. Wrist = WNL

8.1.6.2.5. Hand = WNL

8.1.6.3. AROM L UE

8.1.6.3.1. Shoulder flexion/extension = 0-50 degrees

8.1.6.3.2. Shoulder AB/AD = 0-45 degrees

8.1.6.3.3. Shoulder ER = 0-15 degrees

8.1.6.3.4. Shoulder IR = 0-5 degrees

8.1.6.3.5. Elbow flexion/extension = 0-60 degrees

8.1.6.3.6. Forearm supination = 0-15 degrees

8.1.6.3.7. Forearm pronation = WNL

8.1.6.3.8. Wrist extension = 0-10 degreess

8.1.6.3.9. Wrist flexion = 0-45 degrees

8.1.6.3.10. Finger flexion = half normal range

8.1.6.3.11. Finger extension = weak

8.1.7. Muscle Tone

8.1.7.1. Neck/Trunk = 2

8.1.7.2. Fingers/Wrist = 2

8.1.7.3. LE = 1