復健科標準病歷範本
【Stroke (腦中風)】
This 65 y/o woman has an acute infarction with Rt hemiparesis that occurred on
99-11-30. 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, oral motor 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.