1. Symptoms
1.1. Unbearable headache
1.2. Slurred speech
1.3. Loss of control on L side
2. Family
2.1. Son
2.1.1. From previous marriage
2.1.2. Does not live nearby
2.2. Wife
2.2.1. Does meal preparation
2.2.2. Does laundry
2.2.3. Grocery shops (occasionally with Frank)
2.2.4. Makes Frank's breakfast and lunch when she is home
3. Home environment
3.1. Ranch-style
3.2. Suburban neighborhood
3.3. 5 steps into front door
3.4. Garage is not attached to house
4. Goals
4.1. Frank looks forward to picking up his life where it was before
4.2. Return home and resume previous hobbies
5. OT Evaluation
5.1. 2 intervention sessions
5.1.1. observation
5.1.1.1. completing daily routine
5.1.1.1.1. cognitive deficits
5.1.1.1.2. Difficulty maneuvering around his room and in the hospital environment
5.1.2. interview
5.1.3. manual muscle testing
5.1.4. perceptual and sensory testing
5.1.4.1. Sensation testing findings
5.1.4.1.1. impaired sensation for light touch and sharp-dull
5.1.4.1.2. impaired stereognosis on affected side
5.1.5. Barthel Index of ADLs
5.1.5.1. Scored a 10 of 20
5.1.5.1.1. difficulty with right-left dicrimination
5.1.5.1.2. difficulty managing clothing
5.1.5.1.3. unable to figure out the front from the back or the sleeve hole from the neck hole and needs max assist with all dressing tasks
5.1.5.1.4. Dressing apraxia
5.1.5.1.5. Bathing completed while sitting in sink
5.1.5.1.6. L side neglect completely
5.2. No deficits in hearing/vision
5.2.1. Wears glasses for distance
5.3. Deficits
5.3.1. Perception
5.3.1.1. Figure ground and spacial relations
5.3.2. Right-left confusion
5.3.3. profound L neglect
5.4. No AROM of Sensory deficits in right UE
6. Ashworth Scale
6.1. L Fingers and wrist
6.1.1. muscle tone of 2
6.2. L UE, neck, and trunk
6.2.1. tone of 2
6.3. L LE
6.3.1. Tone of 1
7. Diagnosis
7.1. R CVA
7.2. L Hemiplegia
7.3. L Neglect
7.4. Coronary Artery Disease
8. Pre-Accident
8.1. Was very active
8.2. Recently retired from job from his job as a postal worker
8.3. Avid gardener and woodworker
8.4. Has always done all the maintenance tasks on his home
9. Social Life
9.1. Friendly with some neighbors
9.2. Don't know newer neighbors well
9.3. Has many friends from the post office
9.3.1. has maintained his weekly bowling nights with them post retirement
10. Healthcare professionals Frank is seen by: expected length is 3 weeks
10.1. OT
10.2. PT
10.3. Speech Therapist
10.4. Recreational Therapist
10.5. Nurse
10.6. Dietician
10.7. Psychiatrist
11. Physical presentation
11.1. no AROM or sensory deficits in R UE
11.2. Right handed
11.3. weakness in L UE and LE
11.4. poor dynamic sitting and standing balance
11.5. Static standing balance is fair with good static sitting balance
11.6. PROM in L UE
11.6.1. Shoulder flexion = 85 degrees
11.6.2. Abduction = 70 degrees
11.6.3. Elbow flexion = 100 degrees
11.6.4. Wrist and hand = PROM WNL
11.7. AROM in L UE
11.7.1. Shoulder flexion/extension: 0 to 50 degrees
11.7.2. Adduction/abduction: 0 to 45 degrees
11.7.3. Internal Rotation: 0 to 5 degrees
11.7.4. External rotation: 0 to 15 degrees
11.7.5. Elbow flexion/extension: 0 to 60 degrees
11.7.6. Supination: 0 to 15 degrees
11.7.7. Pronation: WNL
11.7.8. Wrist extension: 0 to 10 degrees
11.7.9. Wrist flexion: 0 to 45 degrees
11.7.10. Finger flexion: half normal range
11.7.11. Finger extension: weak
11.7.12. unable to release objects
11.7.13. Strength not tested because of increased tone
11.7.14. Coordination on L is impaired for both fine and gross motor
11.8. Ambulation
11.8.1. hemi walker
11.8.1.1. min assist
11.8.1.1.1. poor balance
11.9. Transfer
11.9.1. min assist
11.9.1.1. moderate verbal cueing
11.9.1.1.1. poor safety awareness