Frank:

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