[2019] [의약학] Case study soap - hemiplegia
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작성일 19-05-22 20:46
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Download : [의약학] Case study soap - hemiplegia.hwp
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[의약학] Case study soap - hemiplegia
[의약학] Case study soap - hemiplegia
레포트/의약보건
Case study
S O A P
Ⅰ. Subjective information
Client profile
Name
: 김 0 0
Sex
: Male
Onset
:
Age
: 70
Diagnosis
: Lt. hemiplegia d/t Rt. BG CR infarction
History
Lt. hemiplegia d/t Rt. BG CR infarction
HTN(+)
DM(+)
Hepatitis/pulmonary Tbc/cardiac Disease(-)
Seizure(-)
Dysarthria
CC
Lt. side weakness
PI
sudden Lt. side weakness Dysarthria Lt. FNP 로 한림대 ER 보전적 치료 받은 후 에 금일 퇴원후 본원 입원함
SI
Caregiver :아내
Smoking : -
Alcohol : -
Address : 경기도 의왕시
General impression
의사소통에 크게 제한이 없었음.
휠체어를 타고, 보호자와 동행함.
차분히 치료에 참여하고, 평가에 적극적임
Ⅱ. Objective information
1. Mental Status
- Alert
2. Physical Status
(1) Range of Motion Date :
Motion
Normal range
PROM
Rt.
Lt.
Shoulder
Flexion
0-180°
170°
110°
Extension
0-60°
50°
45°
Abduction
0-180°
170°
90°
Internal rotation
0-70°
65°
60°
External rotation
0-90°
80°
75°
Elbow
Flexion & Extension
0-145~155°
130°…(省略)
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![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_01.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_01.gif)
![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_02.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_02.gif)
![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_03.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_03.gif)
![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_04.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_04.gif)
![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_05.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_05.gif)
![[의약학]%20Case%20study%20soap%20-%20hemiplegia_hwp_06.gif](http://www.allreport.co.kr/View/%5B%EC%9D%98%EC%95%BD%ED%95%99%5D%20Case%20study%20soap%20-%20hemiplegia_hwp_06.gif)
다.
