Occupational Therapy Discharge Summary
Occupational Therapy Discharge Summary
Mrs Sellicks was admitted to the Royal Adelaide Hospital on 28th February 2022 after her husband found her collapsed on the floor after trying to get out of bed. MRI revealed left MCA infarct which was thrombolysed at 1645 on 28/02/22. Mrs Sellicks spent 5 days in the intensive care unit before being transferred to the stroke ward B7.
Social Hx: Mrs Sellicks lives with her husband in their own home in Payneham. Mr Sellicks is in good physical health, however he does experience some back pain. He is very motivated to assist, but is worried about providing Mrs Sellicks with heavy physical assistance.
Previous Function: Mrs Sellicks previously ambulated independently unaided and was independent with all of her personal ADLs, standing to shower. She previously enjoyed playing bridge, scrabble and indoor lawn bowls with her friends at the Payneham over 50s club, and volunteered on the bar and helping out in the kitchen once a week. She walked to the club twice a week with her husband.
Mrs Sellicks previously attended to the majority of the household chores. Her husband is happy to do the cooking and laundry initially. However this is something that she is keen to get back to. Mrs Sellicks and her husband both drive. She is aware of the driving restrictions and is happy for her husband to drive after discharge.
The home comprises of an open plan lounge/kitchen area, two large bedrooms and a bathroom with a separate toilet. The bathroom has a shower alcove with a sliding shower screen fitted. Both the front and rear doors have 1 x step onto the verandah and 1 x step into the house. There have not been any modifications to the home.
On Admission to RAH: Mrs Sellicks initially had mild to dense hemiparesis of both the upper and lower R) limbs. Neurological assessment revealed:
Right hand dominant
Strength/ROM:Left Upper Limb (UL): all joints full AROM, strength - 5/5 on Manual Muscle Testing.
Right UL: Shoulder reduced AROM against gravity, decreased strength approx. 2/5.
Elbow, wrist and hand very limited AROM with gravity eliminated, strength approx. 1/5
Sensation: Right upper limb: reduced light touch and pressure. Pain and proprioception intact.
Vision:nil deficits noted.
Functional cognition:alert and oriented. Some issues identified with sequencing and planning when making a cup of tea.
Communication: Difficulty with expressing communication (both written and verbal). Understanding intact.
On Discharge: Mrs Sellicks lower limb hemiparesis has resolved to a degree, but requires a single point walking stick to ambulate due to balance issues when mobilising and during dynamic activities.
Mrs Sellicks continues to have difficulties with her R) upper limb. The strength and AROM in her elbow and shoulder movements have improved slightly. She is starting to get some movement against gravity (3-/5). Her wrist and hand strength remain at approx. (2/5). Mrs Sellicks has slightly reduced tone in her R) upper limb and is at risk of shoulder subluxation. Executive functioning mild planning and sequencing difficulty especially in new tasks or new techniques. Responds to cues.
Mr Sellicks communication has resolved to only be a minor issue. She now only has difficulty with complex or quick conversation.
Graded Therapy Plan 
