물리치료실습 soap note (hemiparesis, quadriplegia, TBI, SCI, 소아, TKA)
- 최초 등록일
- 2013.10.30
- 최종 저작일
- 2010.06
- 16페이지/
한컴오피스
- 가격 2,000원
소개글
물리치료실습 soap note (hemiparesis, quadriplegia, TBI, SCI, 소아, TKA)
목차
1. Quadriplegia d/t T-SAH
2. Quadriplegia d/t TA-TBI
3. Lt. hemiplegia d/t SAH, IVH, Rt MCA aneurysm rupture
4. Paraplegia d/t T11/T11 (ASIA - B)
5. Tetraplegia d/t C8/C8(s) SCI ASIA - D
6. hemiplegia d/t infarction ( 부위 모름 )
7. Guillian barre syndrome
8. Quadriplegia d/t TBI (소아)
9. cancer, lung, stage IV
10. arthrosis of knee, unilateral (TKR)
본문내용
1. Subjective
1) Name : 박 O O , Age : 61세 , Sex : F
2) Dx : Quadriplegia d/t T-SAH
3) PI : 10.05.05 4륜 오토바이 운전 중 넘어져 오토바이에 깔려 철원 길병원 ER 내원. Brain CT 상
SAH 소견 관찰, 10.05.05 본원 NS 입원, decompressive craniectomy &hematoma removal 시행.
10.05.12 GW로 이동. 10.05.17 PMR 전과
2. Objective
1) Cognition : M/S near alert , MMSE UC d/t poor coordination
Orientation (time/place/person) -(UC/UC/UC)
2) MMT : F+ / G 7) functional level
3) ROM : Full PROM , Shoulder pain (+) - side rolling (+/+)
4) Spasticity : G0 / G0 - come to sit (+)
5) Sensory - sit alone (+)
- Touch : UC d/t poor coordination - sit to stand (+)
- Pain/ temperature : pain withdrawal - stand alone (+)
- Proprioception : UC d/t poor coordination
3. Assessment
1) Problem list
- Rt. U/E, L/E Muscle weakness
- standing dynamic balance ↓
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참고 자료
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