Case #2 Occupational Therapy Evaluation Patient: BRIGGS,

Case #2 Occupational Therapy Evaluation Patient: BRIGGS, THOMAS Account Number: BRI369 Date: 2/1/XX TREATMENT PLAN FOR OCCUPATIONAL THERAPY: Patient is a 59-year-old male who suffered a left CVA with right hemiparesis 1 week ago. ACTIVITIES OF DAILY LIVING (ADL) – Feeds self independently once tray is prepared – No swallowing difficulties noted – Washes self independently once set up in chair at bedside; does require assistance of one staff member to stand for pericare – Requires assistance for most aspects of dressing; to do buttons, to put on and fasten shoes and socks, to stand, to pull up pants MOBILITY: – Transfers with assist of one staff member – Able to propel wheelchair short distances – Ambulates with assistance of a therapist – Sitting balance poor, needs chair with armrests and supervision to reach down to feet – Standing balance poor, needs light assistance to ambulate UPPER EXTREMEITY MOBILITY: – Right hand is swollen, passive flexion of interphalangeal (IP) joints limited – Right arm Brunnstrom stage 1 PSYCHOSOIAL ISSUES: – Becomes frustrated over expressive communication problems – Comprehension seems inconsistent – Expresses concerns about his health and future – Speaks with daughter every week by telephone – Calls son weekly, SCIENCE HEALTH SCIENCE NURSING HEALTH MCOP108

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