물리치료 soap note

목차

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

참고문헌

본문내용

Subjective
DX.
Lt. hemiplegia d/t Rt. hemorrhage(Sequelae of ICH)
C/C
좌측 어깨 굽힘시 통증과 시림을 느끼며 종종 어지럼증을 느끼면서 넘어짐
PI
2015.02에 뇌경색으로 진단받고 청주 재활병원에서 5개월간 치료를 받으시다가 2016.10.12 날씨가 추워지면서 좌측에 시림 증상과 경직이 나타나 신경과 입원하여 보행장애로 재활의학과 내원
PHx
고혈압(+)
Past medical history
혈압약, 항응고제 복용중, Hip dislocation
Living environment
아파트 1층 거주
Motivation
치료에 적극적임
Dominant hand
오른손

<중 략>

Assessment
<problem list>
1. 좌측 어깨부위의 경직으로 인한 통증
2. 보폭비대칭으로 인해 오래 서있지 못함
3. 보조도구(워커) 없이 보행 어려움
4. 좌측 손으로 물건을 들지 못함

참고 자료

development of weight shifting training system using biofeedback for post-stroke hemiplegic patients with step length asymmetry_ 김세은 외 6명
The Effects of Task-Oriented Training Program on Balance, Activities of Daily Living Performance and Self-Efficacy in Stroke Patients : A Pilot Study_ Choi Jinuk, PTǂ Kang Soonhee, PT, Ph.D
A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation._ Visintin M1, Barbeau H, Korner-Bitensky N, Mayo NE.
Constraint-induced movement therapy for people following stroke in an outpatient setting_ Karen Porter, Dip Phys, MHSc
Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study._ Sterr A1, Elbert T, Berthold I, Kölbel S, Rockstroh B, Taub E.
The Effect of Visual Feedback Training Using a Mirror on the Balance in Hemiplegic Patients_ Sang-Goo Ji, PT 외 3명
The effects of action observation training and mirror therapy on gait and balance in stroke patients_Ho Jeong Lee, Young Mi Kim, Dong Kyu Lee