Issues, Goals, SOAP, and DAP Letter

Issue List

• Adjustment disorder with mixed anxiety and depressed mood secondary to recent CVA and loss of functional independence.
• History of mild Generalized Anxiety Disorder (GAD), previously managed in 2019.
• Left MCA ischemic CVA (12/01/2026) resulting in right-sided hemiparesis; HTN; hyperlipidemia.

Client Goals

• Goal 1: Client will independently perform upper body dressing using adaptive one-handed techniques in 4 out of 5 trials. Goal 2: Client will prepare a simple cold meal while standing at the kitchen counter for 10 minutes with minimal assistance for RUE stabilization.
• Goal 1 Actions: Practice hemi-dressing techniques daily, utilize button hook, and engage in RUE weight-bearing exercises. Goal 2 Actions: Implement energy conservation strategies, use a rocker knife and non-slip Dycem mat, and practice graded standing tolerance tasks.
• Goal 1 Time frame: 4 weeks (by 15/03/2026). Goal 2 Time frame: 6 weeks (by 29/03/2026).

SOAP Notes

Subjective

• Client presents for outpatient OT evaluation and treatment following a L MCA CVA on 12/01/2026. Reports high frustration with RUE weakness and inability to perform basic ADLs, specifically dressing and meal prep. States, "I hate relying on my husband for everything."
• PMH: HTN, hyperlipidemia, L MCA CVA (12/01/2026). PSH: Laparoscopic cholecystectomy (2015).
• clopidogrel (Plavix®) 75 mg PO daily, atorvastatin (Lipitor®) 40 mg PO daily, lisinopril (Prinivil®) 10 mg PO daily, sertraline (Zoloft®) 50 mg PO daily, cholecalciferol (Vitamin D3) 25 mcg PO daily.
• Lives in a single-story home with spouse. Employed full-time as an accountant, currently on medical leave. Former smoker (quit 2010), denies alcohol or illicit drug use.
• Penicillin (hives).

Objective

• RUE AROM: Shoulder flexion 0-70 degrees, abduction 0-60 degrees; elbow flexion 0-110 degrees; wrist/digit extension trace (1/5 MMT). Mild spasticity in R elbow flexors (Modified Ashworth Scale 1+). R grip strength: 4 kg via dynamometer (L grip: 28 kg). Requires Mod A for upper body dressing due to difficulty manipulating fasteners and threading RUE. Dynamic standing balance is fair; fatigued after 6 minutes of standing during simulated kitchen task.
• A&O x4. Cooperative but tearful when discussing loss of independence. Affect is constricted; mood is anxious and frustrated. Speech is fluent with no receptive or expressive aphasia noted. Intact judgment and insight into deficits.

Assessment

• 58 yo female presenting with R hemiparesis, impaired fine motor coordination, decreased standing activity tolerance, and adjustment anxiety post-L MCA CVA, resulting in functional deficits in ADLs and IADLs.
• Client demonstrates good cognitive carryover for adaptive hemi-dressing strategies learned today, reducing assistance level from Mod A to Min A with verbal cues on the second trial. Tolerated 10 minutes of therapeutic activity with one 2-minute seated rest break.

Plan

• Continue outpatient OT 2x/week for 6 weeks focusing on neuromuscular re-education, RUE functional integration, ADL retraining, and adaptive equipment training.
• Practice donning/doffing button-up shirt daily using the hemi-dressing technique and button hook. Perform 2 sets of 10 RUE tabletop weight-bearing shifts daily.
• Next session scheduled for 19/02/2026 at 09:30 MST.

DAP Notes

Goal Letter to Client

Dear Sarah Jenkins,

I am writing to summarize the goals we have discussed and agreed on during our sessions. These goals are intended to help you reach the outcomes you want and promote your overall well-being.

1. Dress your upper body by yourself using one-handed methods and a button tool 4 out of 5 times.

• Steps to achieve: Practice putting your weak arm in the sleeve first every morning, use the button hook for shirts, and do your daily arm stretching and leaning exercises.
• Timeline: 4 weeks (by 15/03/2026)

2. Make a simple cold meal while standing at the kitchen counter for 10 minutes with only a little help.

• Steps to achieve: Use the non-slip mat to hold items steady, use the special rocker knife for cutting with one hand, and take short sitting breaks before you get too tired.
• Timeline: 6 weeks (by 29/03/2026)

Keep this letter for reference and as a reminder of the goals we are pursuing. If you have questions or require clarification, please reach out.

Sincerely,

Marcus Vance, MOT, OTR/L Occupational Therapist