Frank Case Study

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Frank Case Study by Mind Map: Frank Case Study

1. Diagnosis: Right CVA, Left Hemiplegia, Left Neglect

1.1. Right CVA affected Internal Carotid Artery (ICA)

1.2. Left hemiplegia

1.3. Left Neglect

2. Coronary Artery Disease

3. Symptoms:

3.1. Unbearable headache

3.2. Slurred speech

3.3. Loss of control on Left side

4. Hospital Timeline

4.1. Stabilized at Acute Care Hospital for 5 days

4.2. Rehabilitation Hospital

5. Pre-accident

5.1. Active lifestyle

5.2. Recently retired from postal worker position

5.3. Looked forward to traveling with wife

5.4. Hobbies: active gardener and woodworker

5.5. Does the grocery shopping alone/ with wife

5.5.1. Wife does meal preparation

5.5.2. Wife does laundry

6. Family/ Homelife/ Friends

6.1. Son (previous marriage): strained relationship

6.2. Currently married (strong marriage) and lives in a ranch-style home in suburban neighborhood.

6.2.1. 5 steps to front door

6.2.2. Garage unattached to house

6.3. Friends with some neighbors, strangers to others (new to neighborhood).

6.3.1. Friends from work at post office

6.3.1.1. Weekly bowling outings with work friends

7. Post-Accident/ Current

7.1. Can prepare own breakfast/lunch if wife isn't home

8. Future/ Goals (supported by wife)

8.1. To return home

8.2. Resume hobbies

9. Therapy Services: (duration-3 weeks)

9.1. OT

9.2. PT

9.3. Speech

9.4. Recreational Therapy

9.5. Nursing

9.6. Dietary

9.7. Physiatry

10. Occupational Performance Analysis:

10.1. Observation

10.1.1. Right-Left confusion

10.1.2. Profound Left neglect

10.1.3. Deficits in daily routine completion observations

10.1.3.1. Cognitive deficits

10.1.3.1.1. Poor attention span, insight, judgement, and safety awareness.

10.1.4. Difficulty moving around room/ hospital environment

10.1.4.1. constantly bumping into things (on left side).

10.2. Interview

10.2.1. Amiable

10.2.2. Likes staff members

10.2.2.1. Teases them/ good at involving humor in interactions w/ others

10.2.3. Doesn't understand why he needs so much therapy/ why he has to be in the rehab hospital

10.2.4. Wife told him that the doctor said he needed to be there=why he stays.

10.3. Manual Muscle Testing (MMT)

10.3.1. No AROM / Sensory deficits on Right UE (is right handed)

10.3.2. Weakness in Left UE and LE

10.3.2.1. Poor dynamic setting/ standing balance

10.3.2.1.1. static standing balance is fir w/ good static sitting balance.

10.3.3. PROM

10.3.3.1. In left UE is shoulder:

10.3.3.1.1. flexion to 85 degrees, abduction to 70 degrees, elbow flexion to 100 degrees.

10.3.3.1.2. Muscle Tone: 2 (Asworth Scale) throughout UE, neck, and trunk

10.3.3.2. Left Wrist/ hand

10.3.3.2.1. within normal limits (WNL)

10.3.3.2.2. Muscle Tone: 2 (Asworth Scale) in fingers / wrist

10.3.3.3. Left LE

10.3.3.3.1. Muscle Tone: 1(Asworth Scale)

10.3.4. AROM

10.3.4.1. Left UE in shoulder:

10.3.4.1.1. Flexion/extension: 0-50 degrees;

10.3.4.1.2. Adduction/abduction: 0-45 degrees;

10.3.4.1.3. Internal rotation: 0-5 degrees;

10.3.4.1.4. External rotation: 0-15 degrees

10.3.4.2. Elbow:

10.3.4.2.1. Flexion/extension: 0-60;

10.3.4.2.2. Supination: 0-15

10.3.4.2.3. Pronation: WNL

10.3.4.3. Wrist/hand

10.3.4.3.1. Extension: 1-10 degrees;

10.3.4.3.2. Flexion:0-45

10.3.4.3.3. Finger flexion: half normal range

10.3.4.3.4. Finger extension: weak (unable to release objects)

10.3.5. Strength: not being tested b/c of increased tone

10.3.6. Coordination:

10.3.6.1. Left side:

10.3.6.1.1. Impaired for both fine/gross motor

10.4. Perceptual & Sensory testing

10.4.1. No deficits in hearing or vision (expect for glasses for distance)

10.4.2. Does have perception deficits (difficulty in figure-ground and spatial relations)

10.4.3. Sensation Testing: impaired sensation for light touch/ shirt-dull, as well as impaired stereognosis (on affected side).

10.5. Barthel Index of ADLs (Scored 10/20)

10.5.1. Difficulty w/ right-left discrimination

10.5.2. Difficulty managing clothing

10.5.3. Unable to figure out front-back or sleeve hole-neck hole

10.5.3.1. Needs maximum assistance w/ all dressing tasks.

10.5.3.1.1. Has dressing apraxia

10.5.4. Bathing completed while at sink

10.5.4.1. Neglect left side completely

10.5.4.1.1. did not attend objects on left side of sink

10.5.5. Ambulates w/ semi walker

10.5.5.1. Minimum assist (b/c of poor balance)

10.5.6. Transferes w/ min assist and mod verbal cuing (b/c of poor safety awareness)