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Szerző: Dave Laszlo Dela Cruz

PATIENT ILLNESS SCRIPT: Posterior Fossa Mass S/P Suboccipital Craniectomy

INITIAL PT DX/PT IMPRESSION: Impaired motor function & sensory integrity associated c non-progressive disorders of CNS-Congenital origin or acquired infancy or childhood

FINAL PT DX/PT IMPRESSION:

PT PROGNOSIS:

LONG-TERM GOAL:

PRIORITIZED PROBLEM LIST:

SHORT-TERM GOAL/S:

TREATMENT:

TREATMENT OUTCOMES (i.e. Summary or Line Graph of ICF Progress Monitoring Sheet):

CLINICAL BUNDLE E:

CLINICAL BUNDLE D:

CLINICAL BUNDLE C:

CLINICAL BUNDLE B:

CLINICAL BUNDLE A:

DIFFERENTIAL DX (i.e. Pattern Exclusion):

PERTINENT FINDING E

PERTINENT FINDING D

PERTINENT FINDING C

Clinical Bundle A: Impaired Motor Function 1. Difficulty in sit to stand, ambulation and stair negotiation

PERTINENT FINDING A (i.e. - Pattern iInclusion, Direct/Indirect Impairments, Activity Limitations, or Participation Restriction Including Other Associated Pertinent Postitive/Negative Findings per Clinical Bundle)

TESTS/MEASURES:

ASSESSMENT/EVALUATION (i.e. ICF-Based Interpretation):

MEDICAL DIAGNOSIS: Posterior Fossa Mass S/P Suboccipital Craniectomy

Clinical Presentation: -Impaired Balance and Tolerance, Postural Deviation, Difficulty in sit to stand, ambulation and stair negotiation, Weakness on the (L) side of the face

Duration: Clinically diagnosed on August 2015, 11 months since the initial presentation or signs and symptoms appeared

Epidemiology: Patient is full term of gestation, female and 3 years of age

MOI: -Exposure to radiation -Patient's mother had an UTI infection