1. Diagnosis
1.1. R CVA
1.2. L Hemiplegia
1.3. L Neglect
1.4. Coronary Artery Disease
2. Symptoms
2.1. Unbearable headache
2.2. Slurred speech
2.3. Loss of control on L side
3. Pre-Accident
3.1. Was very active
3.2. Recently retired from job from his job as a postal worker
3.3. Avid gardener and woodworker
3.4. Has always done all the maintenance tasks on his home
4. Family
4.1. Son
4.1.1. From previous marriage
4.1.2. Does not live nearby
4.2. Wife
4.2.1. Does meal preparation
4.2.2. Does laundry
4.2.3. Grocery shops (occasionally with Frank)
4.2.4. Makes Frank's breakfast and lunch when she is home
5. Home environment
5.1. Ranch-style
5.2. Suburban neighborhood
5.3. 5 steps into front door
5.4. Garage is not attached to house
6. Social Life
6.1. Friendly with some neighbors
6.2. Don't know newer neighbors well
6.3. Has many friends from the post office
6.3.1. has maintained his weekly bowling nights with them post retirement
7. Goals
7.1. Frank looks forward to picking up his life where it was before
7.2. Return home and resume previous hobbies
8. Healthcare professionals Frank is seen by: expected length is 3 weeks
8.1. OT
8.2. PT
8.3. Speech Therapist
8.4. Recreational Therapist
8.5. Nurse
8.6. Dietician
8.7. Psychiatrist
9. OT Evaluation
9.1. 2 intervention sessions
9.1.1. observation
9.1.1.1. completing daily routine
9.1.1.1.1. cognitive deficits
9.1.1.1.2. Difficulty maneuvering around his room and in the hospital environment
9.1.2. interview
9.1.3. manual muscle testing
9.1.4. perceptual and sensory testing
9.1.4.1. Sensation testing findings
9.1.4.1.1. impaired sensation for light touch and sharp-dull
9.1.4.1.2. impaired stereognosis on affected side
9.1.5. Barthel Index of ADLs
9.1.5.1. Scored a 10 of 20
9.1.5.1.1. difficulty with right-left dicrimination
9.1.5.1.2. difficulty managing clothing
9.1.5.1.3. unable to figure out the front from the back or the sleeve hole from the neck hole and needs max assist with all dressing tasks
9.1.5.1.4. Dressing apraxia
9.1.5.1.5. Bathing completed while sitting in sink
9.1.5.1.6. L side neglect completely
9.2. No deficits in hearing/vision
9.2.1. Wears glasses for distance
9.3. Deficits
9.3.1. Perception
9.3.1.1. Figure ground and spacial relations
9.3.2. Right-left confusion
9.3.3. profound L neglect
9.4. No AROM of Sensory deficits in right UE
10. Physical presentation
10.1. no AROM or sensory deficits in R UE
10.2. Right handed
10.3. weakness in L UE and LE
10.4. poor dynamic sitting and standing balance
10.5. Static standing balance is fair with good static sitting balance
10.6. PROM in L UE
10.6.1. Shoulder flexion = 85 degrees
10.6.2. Abduction = 70 degrees
10.6.3. Elbow flexion = 100 degrees
10.6.4. Wrist and hand = PROM WNL
10.7. AROM in L UE
10.7.1. Shoulder flexion/extension: 0 to 50 degrees
10.7.2. Adduction/abduction: 0 to 45 degrees
10.7.3. Internal Rotation: 0 to 5 degrees
10.7.4. External rotation: 0 to 15 degrees
10.7.5. Elbow flexion/extension: 0 to 60 degrees
10.7.6. Supination: 0 to 15 degrees
10.7.7. Pronation: WNL
10.7.8. Wrist extension: 0 to 10 degrees
10.7.9. Wrist flexion: 0 to 45 degrees
10.7.10. Finger flexion: half normal range
10.7.11. Finger extension: weak
10.7.12. unable to release objects
10.7.13. Strength not tested because of increased tone
10.7.14. Coordination on L is impaired for both fine and gross motor
10.8. Ambulation
10.8.1. hemi walker
10.8.1.1. min assist
10.8.1.1.1. poor balance
10.9. Transfer
10.9.1. min assist
10.9.1.1. moderate verbal cueing
10.9.1.1.1. poor safety awareness
11. Ashworth Scale
11.1. L Fingers and wrist
11.1.1. muscle tone of 2
11.2. L UE, neck, and trunk
11.2.1. tone of 2
11.3. L LE
11.3.1. Tone of 1