물리치료 SOAP 반신마비 Hemiplegia

목차

1. Subjective
2. Objective
3. Assessment
4. Plan

본문내용

P.I
- C/C : Rt side weakness
- 자가약 : 소화기내과(본원)
- 기타약 : 고혈압, 당뇨, 고지혈증
- 문진 : fever (-), headache (-), dizziness (-)

P.H
- 당뇨 (+), 고혈압 (+), 결핵 (-)
해외여행 (-), 알러지 (-)
- 흡연여부 : X
- 음주여부 : X
- 입원·수술력 : 본원 O
chronic gastritis(2016), 위염(2016), fever(2017)
타 병원 X

Functional ability
- Side rolling : independent
- Come to sit : independent
- Sit to stand up : independent
- Transfer : independent
- Sitting balance - Static : Normal
- Dynamic : Good

Problem list
1. Rt. U/E muscle weakness (Poor grade)
2. Abnormal standing balance
- Rt. side stance를 잘 하지 못하고,
BBS score 25점으로 중등도의 낙상위험
3. Gait ability decreased

Long Term Goal
1. Rt. U/E muscle strengthening (Poor→Normal)
2. Standing balance increase
Rt.(affected side)로 W/B 하도록 함
- Static : Good- → Normal
- Dynamic : Fair+ → Normal
- BBS score 25점 → 41점 이상

참고 자료

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