1. Symptoms:
1.1. Unbearable headache
1.2. Slurred speech
1.3. Loss of control on Left side
2. Hospital Timeline
2.1. Stabilized at Acute Care Hospital for 5 days
2.2. Rehabilitation Hospital
3. Pre-accident
3.1. Active lifestyle
3.2. Recently retired from postal worker position
3.3. Looked forward to traveling with wife
3.4. Hobbies: active gardener and woodworker
3.5. Does the grocery shopping alone/ with wife
3.5.1. Wife does meal preparation
3.5.2. Wife does laundry
4. Post-Accident/ Current
4.1. Can prepare own breakfast/lunch if wife isn't home
5. Therapy Services: (duration-3 weeks)
5.1. OT
5.2. PT
5.3. Speech
5.4. Recreational Therapy
5.5. Nursing
5.6. Dietary
5.7. Physiatry
6. Diagnosis: Right CVA, Left Hemiplegia, Left Neglect
6.1. Right CVA affected Internal Carotid Artery (ICA)
6.2. Left hemiplegia
6.3. Left Neglect
7. Coronary Artery Disease
8. Family/ Homelife/ Friends
8.1. Son (previous marriage): strained relationship
8.2. Currently married (strong marriage) and lives in a ranch-style home in suburban neighborhood.
8.2.1. 5 steps to front door
8.2.2. Garage unattached to house
8.3. Friends with some neighbors, strangers to others (new to neighborhood).
8.3.1. Friends from work at post office
8.3.1.1. Weekly bowling outings with work friends
9. Future/ Goals (supported by wife)
9.1. To return home
9.2. Resume hobbies
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)