Frank Case Study

Get Started. It's Free
or sign up with your email address
Frank Case Study by Mind Map: Frank Case Study

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 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 Cognitive deficits Poor attention span, insight, judgement, and safety awareness.

10.1.4. Difficulty moving around room/ hospital environment constantly bumping into things (on left side).

10.2. Interview

10.2.1. Amiable

10.2.2. Likes staff members 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 Poor dynamic setting/ standing balance static standing balance is fir w/ good static sitting balance.

10.3.3. PROM In left UE is shoulder: flexion to 85 degrees, abduction to 70 degrees, elbow flexion to 100 degrees. Muscle Tone: 2 (Asworth Scale) throughout UE, neck, and trunk Left Wrist/ hand within normal limits (WNL) Muscle Tone: 2 (Asworth Scale) in fingers / wrist Left LE Muscle Tone: 1(Asworth Scale)

10.3.4. AROM Left UE in shoulder: Flexion/extension: 0-50 degrees; Adduction/abduction: 0-45 degrees; Internal rotation: 0-5 degrees; External rotation: 0-15 degrees Elbow: Flexion/extension: 0-60; Supination: 0-15 Pronation: WNL Wrist/hand Extension: 1-10 degrees; Flexion:0-45 Finger flexion: half normal range Finger extension: weak (unable to release objects)

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

10.3.6. Coordination: Left side: 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 Needs maximum assistance w/ all dressing tasks. Has dressing apraxia

10.5.4. Bathing completed while at sink Neglect left side completely did not attend objects on left side of sink

10.5.5. Ambulates w/ semi walker Minimum assist (b/c of poor balance)

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