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
