Categories: All - weakness - motor - balance - radiation

by Keone Haling 8 years ago

232

Kim

A young female patient, aged three, is presenting with a complex set of symptoms following a posterior fossa mass and subsequent suboccipital craniectomy. Her clinical presentation includes impaired balance, postural deviations, difficulty with movements such as sitting to standing, ambulation, and negotiating stairs, as well as left-sided facial weakness.

Kim

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