VYTWAS | Evaluation and Intervention (Week 2) Background Info Date of report: 01-24-2018, and 2-2-2018 Age: 62 DOB: 04/03/1955 Date of referral: 01-24-2018 Primary Diagnosis: Diagnosis of Antiphospholipid Syndrome (APS), which caused client to have Cerebrovascular Accident (CVA) on the right side of the distal basal ganglia. Secondary Diagnosis: Anxiety Medications: Currently taking Coumadin Precautions/Contraindications: Precautions related to anxiety with driving, as well as her blood thinning medication that can create issues with her blood not clotting appropriately. Reason for Occupational Therapy (OT) Referral: The client was referred to OT due to negative effects ofa phenol alcohol injection in her proximal right arm 3 months and 2 weeks ago at time of initial evaluation. The results of this shot caused the client to have increased tone in her left arm, as well a stiffness in her hands and lack of ability to bend and grasp with her left hand. S:"T my and do all things tha can with « work-around’-referring to adapting her tasks on her own Oo: Occupational Profile: Clients a 62-year-old female receiving outpatient occupational therapy j Services as result of side CVA at the distal Basal Ganglia that occurred on 11/6/16 | en ™ on i hot Following her stroke client was diagnosed with APS, that ‘eportedly resulted ina stroke. Client pos oF La ‘taking Coumadin o reduce the isk of stoke reoccurrence. Clint hasbeen receiving leetintermittent outpatient occupational and Physical therapy services as well as attending a two- Week treatment at Stroke Camp at the University of Utah since her initial stroke. Client reported {hat she had improved coordination, as well as Erip and arm strength of her upper extremity (GE), however due to increased tone and at the recommendation of her doctor she received an “suection in her Left (L) UE. Client also recurrently receives a shot in her left leg to help with her iced decreased use of her L ‘Sait. She stated that as a result of these injections the client ex ‘UE due to increased tone, as well as decreased grip and Strength in her arm. Other negative results included 2 falls, 10 broken ribs, and a deep hematoma near injection site of her L lower “xtremity (LE)@hese issues, as reported by the client are resolving. Following a diagnosis of a scizure disorder at the age of 35, which came about as a result of a viral infection, client stated that she is on disability. Before she was on disability she Worked as a pediatric nurse at Primary Children’s Hospital for 15 years and enjoyed this positon. Currently she lives alone in a single story home in Salt Lake City, Utah. Client has never been married, and does not have any children or pets. Reportedly, her typical day includes getting up, showering, getting dressed, and then making herself a protein shake for breakfast. Her reported hobbies include: reading, going to movies, walking, hiking, and playing Liverpool Rummy with her friends. She reports that she is able to do her own laundry, including her sheets. Client reported the desire to independently make her bed by using her fitted sheet at home and decreasing the time, which would be recorded by self-report. She also reports that she does her own cooking, does her own dishes, and doesn’t spend time watching TV. She is able to drive independently but gets anxious when there is a lot of traffic. Client presented functional daily calendar printed on a piece of paper with some events listed. Assessments Performed:The client was evaluated in an outpatient setting atthe University of Utah, The ‘assessments that were performed included an informal interview, the Chedoke Arm and Hand Inventory (CAHAD Version 9, as well as the Upper Extremity Functional Index, and a portion of the Berg Balance Test. The client was also observed completing a baking task during the first Session. This activity was selected because the client only informed the therapists that she had {rouble with her left hand, and nothing else was known about her current level of occupation. to apes This task was picked-ae-treoukHtIp Zive More-otapicture of how the client used objects that Peter iorol required bimanual UE use, as well as arm erat) and cognitive skills when following a recipe. She was asked to take a prepackaged muffin mix and measure and mix in the needed ingredients (water, oil and 2 eggs) and follow the recipe. After mixing the muffin mixture, she placed the liners into the muffin tin and then placed ‘the muffin batter into the muffin tin liners and baked them for 15-20 minutes. The client said 2 that she would try and complete the task mostly using her left hand, as she knew we wanted to watch how she implemented the use of her left hand into everyday activities. She was able to adapt the tasks when needed and could use her left hand to hold items, like the bowl when she stirred with her right hand. She could also use her left hand to hold items like the measuring cup and to dump it into the bowl when filled with liquid. She was unable to hold the muffin tin with her left hand as she stated it would be too heavy for her and did not try to hold it with her left hand. She also was unable to open the refrigerator and oven with her left hand, as demonstrated by the client trying to unsuccessfully open and release her hand from the refrigerator and oven. She initially placed her left hand on both of the handles but was unable to pull and release the handles with her left. She required manual release of her fingers by using her right hand.