Fluency: Good/Fair/Poor, Comprehension: Good/Fair/Poor

復健科標準病歷範本

【Stroke (腦中風)】

This 65 y/o woman has anacute infarction with Rt hemiparesis that occurred on99-11-30. Her past history includes HTN, DM, and dyslipidemia.

CONS:clear. Rt limbs Br. stage:4-5/4-5/5, MAS:1/1, muscle power:3/3. Swallowing evaluation: Dysarthria:+/-, dysphagia:+/-, Swallowing reflex:normal/ delayed/absent during oral/pharyngeal phase, clean water test:wet voice:+/-, choking:+/-, in liquid/ soft diet/ solid food, oralmotor function: Good/Fair/Poor, tongue movement: Good/Fair/Poor, cough function:Good/Fair/Poor. Speech evaluation: paraphasia:+/-,

Fluency: Good/Fair/Poor, Comprehension: Good/Fair/Poor,

Naming: Good/Fair/Poor, Repetition:+/-, Reading:+/-, Writing:+/-. Aprexia of speech:+/-. Gross motor: rolling to R/L:(+-/+-), sitting/balance S/D:+/-, with minimal assist/Fair/Fair, Standing/balance S/D:+, with moderate assist/Poor/Poor, walk:+ with support for 5M, balance:poor, locomotion: W/C with mod. assist transfer. RLt hand: FLE/EXT(+/+), OPP(+-), pinch(+-). ADL:eat/dress/hygiene L/H: Partial dependent/Partial dependent/Partial dependent/Partial dependent. PLAN:arrange PT/OT/ST rehabilitation program, including ambulation, balance, hand function, and ADL training, tactile stimulation, oralmotor tr and phonetic placement.Goal: Maintain range of motion, improve gross motor function and prevent further deconditioning. Gross motor: keep ambulation balance fair and walk independently.

【spinal cord injury】

Chief Complain:
Four-limb weakness and numbness after falling from 5 meters high this morning.

Present Illness:
This 50 years-old man suffered from four-limb weakness and numbness after falling during work from 5 meters high this morning. He was brought to our ER by EMT within 15 minutes after injury. At the ER, he showed clear consciousness, but limb weakness was noted with a fair grade in manual muscle testing. A PE revealed intact anal reflex and tone. A Cervical MRI ordered by the ER doctor showed cord contusion at C5-6with edema. Conservative treatment including high-dose steroid and neck collar protection was given at ER. Under the impression of SCI(ASIA scale C), he was admitted to rehab unit for further management.
PE

Conscious : clear, GCS: E4V5M6,

Chest : smooth respiratory pattern, breathing sound: clear

Abdomen: soft without distension, no tenderness,

MMT C5-T1: R/L 44443/44444; L2-S1: 44333/44343.

ASIA impairment scale : C

Anal tone:intact, Anal contraction:(+), Anal sensation(+).

anal reflex:(+), bulbocavernosus reflex:(+)

Paresthesia and pain over four limbs.

Current functional status is as followed:

ASIA impairment scale : C, incomplete injury

MMT C5-T1: R/L 55555/44444; L2-S1: 55555/32143.

MAS: 1/1

Gross motor:

Rolling to R/L:+/+

Sitting up: (+), with minimal/moderate/maximal assist

sitting balance Static/Dynamic：G/F

Standing up: (+),with minimal/moderate/maximal assist

standing balance Static/Dynamic：G/F

Transfer: with rotation/ rolling board

Locomotion：W/C bound/ transfer bed
Ambulation：(+/-), walking with quadricane, spastic gait, moderate assist for 20 meters/ without device under supervision for 100M, balance fair

Device: regular cane, quadricane, walker

Gait: spastic gait, circumductive gait, limping gait

Assist: +, minimal, moderate, maximal, -

Distance: 100M

Up stair/down stair : +/+, with support, fair balance

without device and assist, with non-alternative gait

Device: regular cane, quadricane,

Gait: alternative, non-alternative

Assist: minimal, moderate, maximal

Right/Left hand function:

Finger flexion /extension: +-/+-, Grasp:+-, Lateral prehension:+-,

Opposition:+-, Pinch:+-, Writing:+-

ADL function:

Eating/dressing/Light hygiene/Heavy hygiene: ID/PD/ID/PD

Speech and swallowing evaluation:

Speech: fluency:(-+), repetition:(-+), comprehension:(-+) partial impaired, can obey

simple order. expression:paraphasia

Swallowing: removed NG with improved oral motor function,

Impression: spinal cord injury, level C6, incomplete injury (ASIA scale C)

Plan and management: Arrange aggressive rehab program to improve the patient's gross motor and fine motor function. Physical therapy with facilitation training, strengthening, posture, PROM-> AAROM, balance training, tilting table training and occupational therapy with posture, PROM-> AAROM, balance training, hand function, moving and ADL training.

Physical modality with IFC, TENS, SSP for focal S/S relief.

Current rehabilitation program:

PT : strengthening, posture or positioning training, PROM-> AAROM, ambulation training, facilitation training, balance training

OT: balance training, positioning or postural training, PROM-> AAROM ,strengthening exercise, moving training, ADL training.

ST: comprehension training, verbal production, communication augmentation, tactile

Physical modality:IFC, TENS, SSP

Goal: walk without supervision, keep balance fair.

ADL partial dependent/independent; transfer independently with supervision(transfer function independent. );

walk under supervision, keep balance fair.