2015 7월 환자

<a href='javascript:fileFilterViewer("http://cfile242.uf.daum.net/attach/24274E4F55B679D807DCAB", "/cfile242/24/274E4F55B679D807DCAB", "2011.hwp", "grpid%3D1SPQN%26fldid%3DV5QV%26dataid%3D5%26fileid%3D1%26regdt%3D20150728033759&url=http%3A%2F%2Fcfile242.uf.daum.net%2Fattach%2F24274E4F55B679D807DCAB")'><img src="https://t1.daumcdn.net/daumtop_deco/icon/icon.hanmail.net/editor/p_etc_s.gif" border="0" alt="첨부파일" class="vam"/> 2011.hwp</a> 2011.10.3. ICH 정금자 502 --> Lt.spastic hemiplgia Br. stage Lt IV-IV-V spasticity Lt. elbow MAS I Independent gait under supervision oral feeding (+) cognition - intact bladder & bowel - controlled state LT.shoudler painful LROM (+) ==> close observation & medication 하기로 함. cc: known paraplegia 김수진502 onset 2011.1.11 2011.1.17 인하대병원에서 op 2011.4.17 home discharge후 재가요양 2011.11.14 proper rehab위해 adm ind w/c ambulation moderate assist ADL last intact T12/T12 L/Ex MMT Z/Z 다음달에 간수치 소변검사 하기로 함. 김순옥601 2015.6.3 Lt.corona radiata, Lt.posterior lentiform nucleus, Lt.IC(posterior limb) acute infarction 1. Rt.hemiplegia (Rt.Br stage II-II-III) shoulder abduction : P flexion: P wrist extensor: T ankle DF: T 2. dysarthria 3. gait disturbance - come to sit: min. assist sitting balance : fair sit to stand: mod.assist 4. cognitive deficit 양순례601 HBV: 현재 GI f/u anti-viral medication(비리어드정) 2015.5.17 mental change --> Brain CT: Lt.temporal lobe ICH, SAH --> craniectomy 시행받음. Rt. hemiplegia Br.stage : Rt.III-II-III shoudler sling, AFO apply 중임. W/C ambualtion 1. gait disturbance 2, pood cognitive deficit (현재 간수치때문에 aricept 끊은상태임.) 3, aphasia (poor auditory comprehension, poor expression‎ abilty) 4. dependent ADL 5. visual field defect 이양구604 HTN (+) - po medication 2015.3.23 bilateral paramedian thalamus & midbrain infarction (Lt.ACA A2 severe stenosis, Lt. ICA stenosis, Lt.MCA stanosis , Rt.disatl MCA M1 stenosis, Rt.PCA P1 stenosis) oral feeding (pneumonia로 치료 중임) diaper voiding &defecation 1. both U/Ex & L/Ex weakness 2. both severe ptosis(Lt.side more severe) 3. dysarthria 4, dependent ADL 5, gait disturbance (W/C ambulation) 6. poor balance , dizziness 이부순604 2015.4.15 A.fib Tarchycardia-bradycardia syndrome--> 인하대 CV f/u 중임. 2015.4.15 Lt.MCA territory infarction Rt.hemiplegia Br. stage Rt. III-III-III AFO착용중 global aphasia L-tube feeding severe cognitive deficit diaper use W/C ambulation P/Hx: L3-4-5 posteior fusion & fixation Rt.femur Fx --> IF 전인분604 Atrial fibrillation --> warfarin 복용중 DM (+): 현재는 po med(-) HTN (+) : 30 years medication 2015.6.14 Rt.MCA, Lt.PCA acute infarction Lt.side weakness Br stage II-II-III poor sitting balance (Lt.side pushong syndrome (+) ) W/C ambulation orientation: T/P/P (-/+/+) derilium (+) severe cognitive deficit (Alzheimer ds) dysarthria 와파린 6월 14일부터 다시 들어갔음. 오영자605 A.fib HTN (+) MR, dyslipidemia 로 po medication 하던 중 2015.7.11 Multi-focal acute infarction ( both BG, Lt.corona radiata) & Lt.caudate head subacute infarction --> embolic infarction 1. Lt.hemiplegia 2. gait disturbance ( poor standing balance) W/C ambulation 3. dysphagia 4. cognitive deficit 5. dependent ADL 김혜경 804 Sacrum fx , pelvic ring Fx (superior & inferior ramus, both S1 joint) MRI: L1-2 herniated dis , conus medullaris compression --> 2015.3.16 anterior plating for pelvic bone Fx (ORIF) Lt.hip flexor : T knee extensor : P Lt.ankle DF : T PF : T W/C ambulation baldder catheter insertion state 1.Lt.L/Ex weakness 2.Lt. L/Ex neurotic pain & swelling 3. Lt.pelvic wound 4. neurogenic bladder 조재성501 MMT N/P~F- N/T~F- spasticity Gr 1~2 independent self gait with s-cane voiding & defecation - physiologic imp) #1. Lt. hemiplegia #2. facial palsy #3. tremor 노열희502 both shoudler LOM + - 수술 후 4개월간 누워있었다고함. 재활치료 시행이후 호전중인 상태. dysphagia - voiding & defecation - physiologic imp) #1.quadriparesis d/t T-EDH #2.s/p rt. radius fx 및 pelvis fx, Lt. tibia, fibula fx #3.r/o both shoulder adhesive capsulitis P) PT & OT 이의득 503 obey command : 3step possible dysphagia - MMT G/F+ G/F+ spasiticity G0/G0 G0/G0 voiding & defecation : physiologic LBP + / lt. upper ext, flank area sensory deficit(시리고, 차다) imp) #1. Lt. hemiplegia d/t Rt. cbr infarction #2. old infarction?(10YA) #3. sensory change. 이경순602 G1~2(ankle G3) voiding & defecation : physiologic functional level : independent self gait with supervision imp) #1.Rt. hemiplegia d/t cbr hemorrhage #2.s/p breast ca #3.thyroid ca #4.lower ext. skin rash -no itching sense / no pain ->경과관찰 P)PT & OT 허민수 702 G1~2(ankle G3) voiding & defecation : physiologic functional level : independent self gait with supervision imp) #1.Rt. hemiplegia d/t cbr hemorrhage #2.s/p breast ca #3.thyroid ca #4.lower ext. skin rash -no itching sense / no pain ->경과관찰 P)PT & OT 최의대702 대병원에서 6월 2일부터 6월 10일까지 입원치료 시행 후 퇴원하여 집에서 지내던 중 점점 힘이 빠지고 거동하지 못하게 되어 재활치료 위해 본원 입원한 환자임. alert mental status obey command : 3step possible MMT F+/F+ F+/F+ self gait with supervision with short distance no painful area imp) #1. quadreparesis #2. r/o chronic SDH 유영성806 MMT : N/N N/N rt. upper & lower ext dysmetria standing balance F/P voiding & defecation - physiologic headache & rt. upper tpz pain+ imp) #1.Rt. ilmbs and trunk ataxia #2.DM poor control, 비협조적, 인슐린으로 조절중 #3.headache 울트라셋 medi & modaliy apply 후 호전중. #4.Anxiety disorder 인하대 NP 협진 후 현재는 증상 없이 유지중.