1. Performance patterns
1.1. Roles: husband, friend, father
2. Client Factors and Performance skills
2.1. Cognitive deficits: perception, attention, insight, judgement, safety awareness
2.2. Sensory deficits on L side: light touch, sharp-dull touch, impaired stereognosis, L neglect, proprioception, Right and left confusion
2.3. Motor deficits: L UE & LE weakness, dynamic sitting, standing balance, unable to release objects, coordination on L is impaired for fine & gross motor, weak finger extension & flexion
2.3.1. Ashworth Scale assessment
2.3.1.1. Tone of 2: L UE, neck, trunk
2.3.1.2. Tone of 1: L LE
2.3.2. Strength not tested because increased tone
2.3.3. L UE-AROM
2.3.3.1. Shoulder flexion/ext: 0/50 degrees
2.3.3.2. Adduction/abduction: 0/50 degrees
2.3.3.3. Internal/external rotation: 5/15 degrees
2.3.3.4. Elbow flexion/extension: 0/60 degrees
2.3.3.5. Supination/pronation: 15/ WNL
2.3.3.6. Wrist flexion/extension: 45/10 degrees
2.3.3.7. Finger flexion is half of normal range, Extension is weak
3. Comorbities
3.1. Coronary artery disease and diabetes
4. Diagnosis: Right CVA of ICA, Left hemiplegia, Left neglect
4.1. Symptoms: unbearable headache, slurred speech, loss of control on left side (2 weeks ago)
5. Occupations
5.1. ADL
5.1.1. Dressing
5.1.1.1. Dressing apraxia, unable to differentiate front/back and sleeve/neck hole, MAX ASSIST
5.1.2. Bathing
5.1.2.1. Completed at the sink, requires verbal cues and physical guidance
5.1.3. Functional mobility
5.1.3.1. Ambulates with hemiwalker and is Min Assist because of poor balance; transfers with Min Assist and moderate verbal cueing because of poor safety awareness
5.2. Social participation
5.2.1. Weekly bowling with friends
5.3. IADL
5.3.1. Home management
5.3.2. Meal preparation
5.3.3. Laundry
5.4. Leisure
5.4.1. Woodworking
5.4.2. Gardening
5.4.3. Travel
5.5. Work
5.5.1. Retirement