Dom (case study)
By: Dian Herron ota/s

Diagnosis
• Dom has a CVA
• He has a history of hypertension
• Dom also had a coronary bypass
• His CVA has affected his left side

Demographics
• Dom is 56yrs old
• He lives with his wife of 30yrs in a first floor condominum on Miami beach. • Dom's primary residence is in NY, but lives in FL during the winter months. • He is on disability from the NY fire department due to cardiac problems and a CVA 3yrs ago.

Etiology
• Stroke can affect many aspects of vision, and visual losses after stroke decrease safety.

• As in Dom's case he has a left visual field cut and left side inattention. Tactile deficits in touch, pain, pressure, temperature, and proprioception are common after a stroke.
Body awareness deficits affects knowledge of body construction, spatial relationships, awareness of body parts in relation to one another and right and left discrimination.

• Dom's sensation in his left upper extremities are mildly impaired for light touch, superficial pain, and stereognosis.

• Dom suffered a CVA during surgery for a coronary bypass. A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells to die.

Medications, medical management, surgical intervention
Dom's case makes no mention of any medications in the past or currently that he is taking. For scenario process a doctor may probably subscribe several medicines after you have had a stroke. Medicines to prevent blood clots are typically used. The types of medications that prevent clotting are anticoagulant, antiplatelet medicines. Other medications that may be subscribed would be used to treat depression and pain.

Medications, medical management, surgical intervention continued...
For medical management the development of dedicated stroke center has improved survival rates and reduced secondary complications from stroke in the period immediately after the CVA. Medical treatment of CVA includes maintain an open airway, establishing fluid balance, and treating medical problems. Surgery may be indicated to repair damaged blood vessels to reduce bleeding and to prevent additional damage to intact cerebral tissues.

Signs and symptoms of patient
• Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.

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Sudden confusion
Sudden difficulty speaking or understanding, slurred speech
Sudden blurred vision or loss of vision
Sudden diifficulty walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause

Prognosis of patient
The recovery of a patient after a CVA has been determining factors:

• neurologic recovery depends on the cause, location, and size of the lesion.
• Function recovery depends on the personal and socioeconomic circumstances of the person as much as on the injury itself.

• Prognosis is highly dependent on the anatomical location and size of the lesion, neurorecovery, complications, occupational context, and activity demands. Prognosis continued...
Dom's prognosis seems to be going in a positive direction. He is very cooperative with the therapist . He is able to do a full session of therapy.
He also has a strong will to getting back to the activities he loves. I believe he will continue to improve if his treatment includes bilateral integration, motor retraining, and the use of compensatory techniques .

Precautions of patient
• Depression is common after a stroke and may impede recovery.
• Watch for signs of shoulder dislocation.
• Watch for signs of shoulder hand syndrome.
• Observe for safety considerations in home and community.

Psychosocial impact on patient
A lack of independence may affect the clients performance patterns and distrubt daily habits and routines. Dealing with the effects of a stroke can be difficult, it may take months to learn to cope with the many personal and social changes.

• Depression is often a result of cerebral damage,
• Strokes on the left hemisphere are more likely to result in major depression.
• Dom is very frustrated he can barely use his left upper extremity for light ADL.

Psychosocial (continued)
• Dom used to help with the cooking but doesn't anymore.
• He especially enjoyed making homemade pasta and different types of homemade bread.

• Dom also enjoyed collecting fire department patches and building and flying model airplanes.

OT intervention

Comprehensive problem list
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Cva has affected his left side.
He has cardiac problems
Dom is not oriented in time.
He has left visual field cut and left side inattention.
Requires supervision with most functional transfers.
He requires contact guard assist when ambulating with a quad cane.
He complains of occasional pain in his right shoulder due to arthritis.

Comprehensive problem list continued
• He attempts to use his upper extremity for light ADL, however, not always with success or efficiency.
• Gross and fine motor coordination is poor.
• Sensation in his left upper extremity is mildly impaired for light touch, superficial pain, and stereo gnosis.
• He needs assistance to manage all clothes closures( ex. buttons, zippers, and shoelaces).
• He needs constant reminders to attend to the left side of his face when shaving with his electric razor.
• Dom's food has to be pre cut in order for him to feed himself.
• He no longer does activities that he enjoys.

Dom's strengths
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Dom is still able to drive.
He is cooperative.
He is oriented X2 (person & place).
Long term memory intact
He is alert
He is pleasant.
He is cooperative.
Dom can follow most simple commands.
He is able to attend for a full 50 minute therapy session.

Dom's strength continued
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He requires min. assists of shower transfers.
He has good sitting balance.
His right upper extremity is functional.
He needs minimal assistance donning and doffing clothes.
He needs minimal assistance to bathe himself. minimal assistance to brush teeth and to comb his hair.
He also able to feed self when his food is cut up.

Top 3 problems for Dom
1. Increase functional endurance to increase ABL performance and leisure participation. 2. Increase gross motor coordination for increased safety with out of chair
ADLs, include functional transfers.

3. Increase functional motor coordination, bilaterally, to increase functional use of upper extremity for ADLs and leisure projects.

First long Term goals
• pt. will increase functional endurance with standing tolerance of fair (+) with little to no rest breaks performing hygiene tasks.

First two short term goals
• pt. will be able to shower @ moderate assist maintain standing balance
@ mod, with rest breaks.

• pt. will be able to stand sink side while grooming and demonstrating good body mechanics and increased safety awareness.

Second long term goal
• pt will increase gross motor coordination when functionally transferring with limited supervision while using quad cane to tube chair transfers by
4 weeks.

Second short term goals
• pt. will increase gross motor coordination to fair when functionally transferring with quad cane to tube bench with stand by assist by
2weeks.

• pt. will increase gross motor coordination when functionally transferring with quad cane from kitchen to bedroom with stand by assist by 2 weeks

Third long term goal
• Pt will increase fine motor coordination by completing personal hygiene tasks and grooming with assistive devices.

Third short term goals
• pt. will be able to perform dressing of upper extremity using adaptive equipment to button shirt using fine motor skills with few verbal cues.

• pt. will be able to perform hygiene task of shaving without neglect and encouraging scanning through verbal prompts.

Home modifications
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grab bars in the bathroom, for getting in and out of tub. non skid rugs throught home. transfer tube, used for sitting and sliding into tub without actually having to step in to the tub. three in one commode
Dining aids such as a big grip weighted rocker knife.
Dressing aids like grip free button and zipper aid. reorganize personal items so that they are accessible.
Make sure there is adequate lighting, clear pathways.

Home modifications continued
• Changing handles to doors or drawer from one that require fine finger movements to one such as a cabinet handle or d-loop which can be opened with a fist.

• keeping bed spread clear of walking paths.
• putting things in arms reach in kitchen.

Pt./family education & home program
• information on better understanding of the emotional and behavioral changes of the patient.

• the physical aspects of care, and the need for support for "case management" aspect of care.

• home based programs benefit patients at home and they receive rehabilitation services from visiting profesionals.The patient gets to learn skills in the same place were they will use them.

• Helps the person with activities performed before the stroke in adaptive ways

Treatment Ideas

Reference
Bracy, D. (2012, Nov. 14). Therapy session for left neglect.mov. [video file]. Retrieved http://www.youtube.com/watch?v=35ggDdoRAKO.

Early, M.B. (2013). Physical dysfunction practice skills for the occupational therapy assistant (3rd ed). St. Louis, Missouri: Elsevier Inc.

Little light house (2013, Jan. 24). Therapy minute: homemade fine motor activities [video file]. Retrieved from http://www.youtube.com/watch?v=ps5nbUA84g.

Reed, K. (2014). Quick reference to occupational therapy (3rd ed). Austin TX: Pro-ed Inc.

Robins, G. (2016). CVA chapter 24. [class handout]. Department of occupational therapy, Keiser university, Melbourne, FL.

Vitaliko (2009,April 5). Hemiplegia treatment Bobath pnf stroke therapy and physiotherapy motor relearning. [video file]. Retrieved from http://www.youtube.com/watch? v=3ncjF3Gt6JE.