물리치료실습, soap note, 일일실습일지

목차

1.tetraplegia d/t C4/C4(s) (ASIA - D)
2.Rt. hemiplegia d/t BG ICH
3. Rt. hemiplegia d/t SAH, Lt IC-pcom aneurysm rupture
4. quadriplegia d/t ICH, IVH ,hydrocephalus
5. quadriplegia d/t traumatic ICH
6. Rt. hemiplegia d/t BG ICH
7. Quadriplegia d/t TBI ICH
8. tetraplegia C7/C7(m), C8/C8(s) ASIA-a
9. tetraplegia C6/C6(m), ASIA-B
10. Rt. hemiplegia d/t BG ICH, motor aphagia
11. spastic quadriplegia d/t cerebral palsy (소아)
12. arthrosis of knee, unilateral (TKR)

본문내용

1. Subjective
1) Name : 탁 O O, Sex : M , Age : 65
2) Dx : tetraplegia d/t C4/C4(s) (ASIA - D)
3) PI : 자전거 타다가 Fall down
4) PHx : Rt. knee TKR

2. Objective
1) Cognition : M/S alert ,
Orientation (time/place/person) -(intact/intact/intact_

3) ROM : Full ROM except Rt shoulder 160
4) Spasticity : G0/ G0
5) Sensory
- last intact : C4/C4
- hypesthesia : C5↓/C5↓
- anesthesia : -/-
6) balance
- Sitting static/dynamic balance : F/P
- standing static/dynamic balance : F/P

7) Functional skills
- Side rolling (-/+)
- come to sit (-)
- sit alone (+)
- standing alone(-)

8) ambulation
- dependent W/C ambulation

3. Assessment
1) Problem list
- muscle weakness
- balance↓
- Rt knee stability↓
2) Short term goal
- minimal assist 로 come to sit 가능
- balance grade F→G, P→F
3) Long term goal
- sitting, standing dynamic balance P→G
- minimal assist에서 gait 가능

4. Plan
① balance training
- core muscle strengthening
- weight bearing 경험

<이하생략>

참고 자료

없음