물��치료실습 soap note (hemiparesis, quadriplegia, TBI, SCI, 소아, TKA)

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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