Frank Case study

Frank Case study

by Jacob Campo

1. Right CVA -of internal carotid artery

2. Symptoms: Left hemiplegia and left neglect.

3. Before CVA: very active , avid gardener, woodworker, and worked as a postal worker before retiring.

4. Family/ home life: 1 son from a previous marriage, and a current wife. Frank and his current wife live in a ranch style house with steps upon entering the home. Franks relationship with his wife is very strong.

5. Social interaction: Bowling night, traveling with his wife, and seeing friends from the post office.

6. Assessment tools used on Frank:

6.1. MMT

6.2. Perceptual

6.3. Sensory

6.4. Barthel index of ADL's

7. Franks deficits

7.1. Left Neglect

7.2. Left hemiplegia

7.3. No visual loss

7.4. no hearing loss

7.5. Needs glasses for far distances

7.6. defects in perception

7.7. poor: judgement, insight , safety, and attention.

7.8. Left/ right confusion

7.9. Steriagnosis

7.10. Sensory deficits

7.11. loss of sensation: light touch,sharpe, and dull.

8. Range of motion:

8.1. No loss of range in Right side.

8.2. Left weakness in UE and LE

8.3. muscle grade is a 2 on the left side fingers and wrist.

8.4. PROM- L. UE shoulder flexion is 85 degrees

8.5. Elbow flexion -100 degrees

8.6. Shoulder abduction 70 degrees

8.7. Wrist/ hand are WNL

8.8. Grade of 2 on his UE, Neck, and Trunk.

8.9. grade of 1 on his L LE

8.10. AROM- flexion extension - 0- 50 degrees

8.11. Adduction/abduction - 0-45 degrees

8.12. internal/ external rotation 0-5 degrees, 0-15 degrees.

8.13. elbow flexion / extension 0-60 degrees

8.14. supination 0-15 degrees

8.15. Pronation WNL

8.16. Wrist flexion 0-45 degrees/ extension 0-10 degrees

8.17. finger extension is weak

8.18. Strength not being tested because of increased tone.

9. ADL Evaluation:

9.1. Difficulty with right/ left discrimination

9.2. Difficulty managing clothing

9.3. Max assisted for dressing

9.4. Ambulated with hemi walker

9.5. poor balance

9.6. needs moderate verbal cueing

9.7. poor safety awareness

10. Franks personality

10.1. great sense of humor

10.2. likes to joke and tease the staff members

10.3. Frank does not know why he needs so much therapy.