Freddy, 59-year-old male, 2 weeks post thrombotic stroke.

Subjective:
The patient, Freddy, is a 59-year-old male who suffered a thrombotic stroke two weeks ago. The
patient’s wife reports that there has been a sudden onset of weakness and numbness on his right
side and has been experiencing difficulty speaking. The patient's wife reports that the patient has
been experiencing what she thinks is Broca's aphasia, and he is unable to express himself
effectively. The patient is experiencing frustration and sadness due to his inability to
communicate, as well as experiencing hemiparesis on the entire right side of his body.

Objective:
After observing the patient in a 60-minute session, the patient presents with weakness and loss of
movement on his right side. He is unable to lift his right arm or leg and is experiencing difficulty
with his balance and coordination. When given a light weighted plastic cup, the cup was
dropped, and the patient was unable to for a grip on it with his right hand. The patient's speech is
slow and labored, and he struggles to form complete sentences. The patient has begun receiving
physical therapy and speech therapy this week but has not yet shown improvement in his ability
to move and communication.

Assessment:
The patient has suffered a thrombotic stroke and has developed right-sided hemiparesis and
Broca's aphasia. The patient is at risk of further complications, such as falls and learned non-use
due to his immobility. The patient is experiencing emotional distress due to his inability to
communicate effectively.

Plan:
The patient will continue to receive occupational therapy, physical therapy and speech therapy to
improve his mobility and communication abilities. The patient will be monitored closely for
signs of complications and will receive appropriate treatment as needed. The patient's emotional
well-being will also be addressed through counseling and support services. The patient's wife
will be educated on strategies to communicate effectively with the patient, practice interventions
at home, and on ways to provide the proper care and support for Freddy.