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Background Information
Date of report: April 13, 2018 Date of initial referral: January 24, 2018
Primary intervention diagnosis/concern: Right Cerebral Vascular Accident (CVA) in the basal
phenol alcohol injection that was used in an attempt to help relieve LUE spasticity/tone.
Subjective (S): “I am very lucky to have had this experience with you both, I was the person that
got the last spot in stroke camp last year and the last spot in this OT student treatment. I am so
lucky to have Jeanette here to encourage me and provide me with these opportunities.”
Objective (O): The client was seen at the University of Utah student outpatient therapy clinic
1x/wk for 6 sessions and discharge. The client’s initial performance and ending performance
related to her long-term and short-term goals are documented below in the following table:
STG2: By March 30, 2018, The client required The client continues to
the client will bend down to significantly more time to require significantly more
grab one sheet form the obtain an item from the floor time to obtain an item from
laundry basket on the floor with her L hand as compared the floor with her L hand. The
with her left hand, with no to her right. Additionally, the client continues to perform a
loss of balance. client held onto the table wide base of support and
tightly with her right hand support from the environment
while bending and reaching to obtain items.
to the ground with her left
hand.
By April 13, 2018, the client The client used a lateral key The client continues to use a
will use her left hand for pinch with her left hand to lateral key pinch for
more than 50% of the gather the ingredients, to hold obtaining most items. The
the measuring cup while client is able to perform L
unilateral tasks performed measuring the ingredients, thumb abduction to release
during meal preparation. and dumping the ingredients lateral key pinch. The client
into the bowl. continues to require active
Goal Met 04/13/18 The client used the R hand to assist from her R hand to
hold the L hand onto the position items in her left hand
spoon as she stirred the prior to use of the object. The
ingredients together and to client is able to perform
scoop and put the muffin mix approximately 60% of
into the muffin pan. unilateral tasks with the L
Overall, the client used her hand.
left hand for approximately
40% of the unilateral tasks
during meal preparation.
STG1: By February 23, 2018, Client was unable to produce Discontinued 03/02/18
the client will be able to ulnar and radial deviation to The goal was discontinued
break 50% of the ice out of twist ice cube tray. because the client has an ice
the ice tray with left wrist maker in her home; therefore,
rotation. this goal was no longer a
priority for therapy.
STG2: By March 30, 2018, The client was unable to As the client grasps the fridge
the client will open the fridge produce any active finger or the oven, she still requires
with the left hand and release extension of the L hand. After assistance from her R hand to
grasp from handle by completing full flexion of the pry her fingers from the
producing 50% of complete L hand, she required active handle on 3/5 attempts. The
finger extension. assist from her R hand to pry client demonstrates
the fingers from the handle on approximately 20° of active
5/5 attempts. finger extension when extra
time and focus is dedicated to
the movement.
Analysis (A): The client was a very sweet and optimistic individual, that was very dedicated to
improving her LUE function in tasks related to meal preparation and home management. The
client demonstrates improvement with active finger extension and forearm supination; however,
the client’s tone continues to be a barrier while participating in functional activities. The client
demonstrated excellent potential to make progress in therapy; but the client was unable to make
all therapy sessions and the inconsistency of therapy, due to fieldwork and spring break, may
have been a barrier that interfered with the client’s success. The client’s tone and priorities
caused treatment to be solely focused on the LUE; therefore, leaving little time to address the
Plan (P): OT services for this client will be discontinued as the adult OT semester is coming to
an end. Upon discharge, it is recommended that the client continues to receive skilled OT
services at the U of U Sugar House Health Center to improve left upper extremity function in
order to enhance occupational performance in all meaningful and desired ADLs and IADLs. The
client would benefit from continued OT services in order to improve active extension of the
fingers, full supination of the forearm, as well as isolated finger movements in the left hand. The
client demonstrates excellent potential to further improve within all the movements mentioned
above. The client would also continue to benefit by continuing to participate in the music glove
as part of her home exercise program, in addition to completing as many ADLs and IADLs as