Occupational Therapy Functional Profile Assessment

Recognised Disability, Other Conditions & Current Health

PMHx: Right MCA ischaemic stroke (12/01/2026) resulting in left-sided hemiparesis, T2DM, HTN, hyperlipidaemia, and bilateral knee OA. PSHx: Right total knee arthroplasty (2021), laparoscopic cholecystectomy (2015).

Client presents for a community functional review following discharge from inpatient rehabilitation on 18/02/2026. Primary concerns include reduced UL function, high falls risk, and difficulty completing PADLs and IADLs independently at home.

Hx of mild reactive depression post-CVA; currently stable and managed via GP.

Ex-smoker (ceased 2010, 20 pack-year Hx). Consumes 1-2 standard alcoholic drinks per week. Denies illicit substance use.

Admitted to Sir Charles Gairdner Hospital (12/01/2026 – 28/01/2026) for acute stroke management, followed by inpatient rehabilitation at Osborne Park Hospital (28/01/2026 – 18/02/2026).

Medication Management

• clopidogrel (Plavix®) 75 mg PO daily
• perindopril (Coversyl®) 5 mg PO daily
• atorvastatin (Lipitor®) 40 mg PO nocte
• metformin (Diabex®) 1,000 mg PO BD
• escitalopram (Lexapro®) 10 mg PO daily
• paracetamol (Panadol®) 1,000 mg PO QID PRN

Medications are prescribed by the GP and packed into a weekly Webster-pak by the local pharmacy. Stored in a high kitchen cupboard. Client's wife provides verbal reminders and physical assistance to pop foils due to reduced left hand dexterity.

Social History and Supports

Lives with wife, Margaret (66 yo, retired), in their own home.

Wife acts as primary informal carer, providing daily assistance with PADLs and all IADLs. Formal supports currently include Silver Chain domestic assistance (fortnightly, 1.5 hours). Son lives 15 km away and assists with heavy garden maintenance monthly.

Maintains strong relationships with family and neighbours. Appropriate interpretation of social cues; however, reports reduced social participation recently due to fatigue and mobility limitations.

Nil forensic history or legal restrictions.

Education and Employment

Completed Year 10 high school followed by a trade certificate in carpentry.

Worked as a self-employed carpenter for 40 years; retired at age 65 prior to CVA.

Cognition

MoCA score 25/30 (assessed 14/02/2026), indicating mild cognitive impairment post-CVA.

Oriented to person, place, and time (3/3).

Delayed recall mildly impaired (3/5 words without cues, 5/5 with category cues).

Long-term memory intact. Short-term working memory mildly reduced when fatigued or multitasking.

Mild left-sided visual neglect noted during complex scanning tasks; intact depth perception.

Sustains attention for 20-30 minutes during structured therapy tasks; easily distracted in noisy environments.

Intact object and facial recognition; nil agnosia.

Communication

Expressive and receptive language intact. Mild dysarthria noted when fatigued, though speech remains intelligible. Uses spectacles for reading and written communication.

Behaviour

Nil aggressive or wandering behaviours reported.

Occasional episodes of frustration and verbal swearing when unable to complete fine motor tasks with left UL. Triggered by task failure or fatigue; occurs 2-3 times per week, lasting < 5 minutes.

Mood generally euthymic with congruent affect. Demonstrates good insight into deficits. Motivation for rehab is high, though post-stroke fatigue occasionally limits afternoon participation.

Self-management via rest breaks, deep breathing, and task segmentation. Wife provides calm verbal reassurance.

Sensation and Sensory

Corrected vision with bifocal spectacles. Mild left visual field inattention.

Reduced light touch and proprioception in left UL (distal > proximal) and left LL (foot/ankle). Intact sensation on the right side.

Hearing intact bilaterally; nil aids required.

Intact taste; nil dysphagia.

Intact olfaction.

Reduced awareness of left UL position in space when not visually attending; requires verbal prompting to protect left arm during transfers.

Mild hypersensitivity to cold temperatures in left hand.

Nil hallucinations.

Mobility

Mobilises indoors using a quad stick in right hand with standby assistance or supervision due to left foot drop (wears left prefabricated AFO) and neglect.

Mobilises outdoors using a 4-wheeled walker (4WW) for short distances (up to 50 m) with 1x physical assist to help steer and manage kerbs. Uses a manual transit wheelchair pushed by wife for longer community distances.

Static sitting balance independent. Dynamic standing balance impaired (Berg Balance Scale 38/56); demonstrates rightward weight-bearing bias.

High falls risk. Hx of 1 non-injurious fall in inpatient rehab (02/02/2026) due to catching left toe during pivot transfer.

Right-hand dominant (intact function). Left UL demonstrates grade 3/5 shoulder abduction, 3/5 elbow flexion, and 2/5 wrist/finger extension. Gross grasp present; nil functional pinch grip on left.

Right UL/LL AROM WNL. Left UL PROM WNL; AROM limited by weakness. Left ankle dorsiflexion PROM limited to neutral (0 degrees) due to mild gastrocnemius spasticity (Modified Ashworth Scale 1+).

Reports mild left shoulder ache (VAS 3/10) on passive overhead movement, likely secondary to mild glenohumeral subluxation. Relieved by positioning on pillows and paracetamol.

Transfers

Requires 1x standby assistance and verbal cueing for bed mobility. Uses an adjustable bed stick on the right side to sit to stand.

Independent sit-to-stand from high-back armchair with armrests using right UL push-off; slow and deliberate.

Transfers into hobless shower recess over a 15 mm lip using quad stick and grab rails with 1x standby assistance, sitting on a height-adjustable shower chair.

Independent transfers on/off toilet using an over-toilet aid (OTA) raised to 500 mm.

Transfers into front passenger seat of SUV with 1x minimal physical assistance to lift left leg into footwell. Uses a swivel cushion and handybar.

Pressure Management

Nil history of pressure injuries.

Skin intact globally. Low-to-moderate risk of pressure injury (Waterlow score 12) due to reduced mobility and left LL sensory loss. Currently uses a standard foam mattress and shifts weight independently when seated.

Personal Activities of Daily Living

Requires 1x minimal assistance for showering to wash right arm, back, and lower limbs, and for drying. Uses a stationary shower chair, handheld showerhead, and grab rails.

Requires 1x moderate assistance for upper and lower body dressing using a one-handed dressing technique. Struggles with fasteners (buttons, zippers) and fitting the left AFO and shoe.

Independent with perineal hygiene using right hand when seated on OTA.

Continent of bladder and bowel. Experiences occasional functional urinary urgency due to slow mobility to the bathroom.

Completes tooth brushing (using electric toothbrush) and hair brushing one-handed while seated at vanity. Requires 1x assistance from wife to apply toothpaste, shave (electric razor), and complete nail care.

Eats independently using right hand. Requires assistance to cut up meats; trialling a rocker knife and non-slip dycem mat.

Sleeps 7 hours per night (22:00 to 05:00). Wakes once nocturnally to void; uses a bedside commode to reduce falls risk overnight.

Decreased libido and intimacy reported post-CVA due to fatigue and body image changes; couple open to GP counselling if persistent.

High motivation to regain independence in showering and dressing; frustrated by reliance on wife.

Instrumental Activities of Daily Living

Independent with meal planning and writing shopping lists in collaboration with wife.

Unable to prepare hot meals independently due to safety risks and bilateral task demands. Can make a cold sandwich and use a kettle tipper one-handed with supervision.

Unable to complete major grocery shopping independently; accompanies wife in transit wheelchair once weekly.

Unable to complete laundry tasks due to heavy lifting and carrying requirements.

Unable to complete vacuuming or mopping. Assists with light dusting of low surfaces from a seated position.

Unable to perform lawn mowing or gardening; previously his primary role, now managed by son.

N/A (adult children live independently).

Manages online banking and bill payments independently on an iPad with wife double-checking inputs due to mild left visual neglect.

Requires 1x assistance from wife for all community access due to outdoor mobility limitations and inability to propel wheelchair one-handed.

Current medical suspension of driver's licence for minimum 6 months post-CVA. Travels as a passenger in wife's private vehicle; unable to access public transport.

Previously enjoyed woodworking and bowls. Currently enjoys listening to audiobooks, watching cricket, and completing word puzzles.

Motivated to return to light kitchen tasks (making tea/toast) to reduce carer burden on wife.

Home Environment

Single-storey detached brick house.

Privately owned (no mortgage).

3 bedrooms, 1 bathroom, 1 separate toilet, open-plan living/dining, kitchen, and laundry.

Front entrance has 2 concrete steps (rise 160 mm each) with a bilateral galvanised steel handrail installed. Rear patio access has 1 step (180 mm) with no rails; currently avoided.

Level access throughout internal living areas; carpeted bedrooms/lounge and tiled wet areas.

Spacious layout; rug removed to reduce trip hazards. Uses a supportive high-back armchair (seat height 480 mm) with blocks fitted.

Master bedroom fits queen bed with adequate circulation space (900 mm) on right side for quad stick and bedside commode.

Hobless shower recess (900 mm x 900 mm) with vertical and horizontal grab rails installed. Separate toilet room is narrow (850 mm wide), fitted with an OTA.

Standard u-shaped kitchen; heights non-adjustable. Kettle tipper and non-slip mat in situ on benchtop.

Large flat lawn at rear with concrete pathways; currently inaccessible to client without physical assistance down rear step.

Other

Wife reports mild carer strain and lower back discomfort; requires education on safe manual handling and access to respite options.

Anglo-Australian background; English is primary language. Nil specific cultural or religious barriers to therapy identified.

Goals

1. Dress upper and lower body (including AFO application) independently within 6 weeks.

2. Prepare a hot beverage and light lunch (toast/sandwich) independently and safely within 4 weeks.

3. Mobilise safely to the rear garden to sit outdoors with supervision within 8 weeks.

4. Upper limb functional retraining and task-specific practice for one-handed ADLs.

5. Kitchen safety assessment and provision of one-handed adaptive culinary equipment (e.g., spike board, rocker knife).

6. Minor home modifications: installation of grab rail and wedge ramp at rear patio step.

7. Carer training in safe manual handling and energy conservation strategies.

Home-based Occupational Therapy sessions: 1x weekly for 60 minutes over 8 weeks, followed by functional re-evaluation.

• Community Physiotherapy (ongoing gait retraining, balance, and spasticity management).
• My Aged Care (MAC) assessment for increased domestic assistance and carer respite services.