病歷報告-kiki~│愛情公寓交友網站與聊天室

還沒登入愛情公寓嗎？還沒加入愛情公寓嗎？馬上進入公寓和 10,554,689 個住戶交朋友～

紅包抽抽樂！小資變土豪！

素人也能成為明日之星！

移除此區廣告請加入VIP

檔案狀態:

住戶編號:1574896

kiki~ 的日記本

快速選單

jonural~ 《前一篇

後一篇》未來的物理治療師走向

回應

給他日記貼紙

給他愛的鼓勵

檢舉

篇名: 病歷報告
作者: kiki~	日期: 2010.04.14　　天氣: 　心情:

病例書寫

Evaluation form of spinal disorder

General Data

病歷號 :____________ 登記號 :____________ 病房號 :_____________

Name: ______________ Age:______ Sex:______ 聯絡電話:___________

Diagnosis: _______________________________________________________

Past history: _____________________________________________________

OP date: ________________________________________________________

PT starting date:________________ PT ended date: _________________

I. Subjective:

Chief complain:

II. Objective

1. Onset

Where did it start?_________________________________________________

When did it start?__________________________________________________

How did it start? Spontaneous or injury_______________________________

2. Symptoms (One or more):

□□□ Soreness □□□ Pain □□□ Nocturnal tenderness

□□□ Numbness □□□ Paraesthesia □□□ Weakness

□□□ Intermittent claudication □□□Others: _____________________

3. Location:

□□□ Neck □□□ Upper Thorax □□□ U/E

□□□ Back □□□ Buttock □□□ L/E

□□□ Central □□□ Unilateral ( □□□ L’t / □□□ R’t )

□□□ Bilateral □□□ Alternative □□□ Others:____________

Test 1 Test 2 Test 3

4. Evoluation:

5. Functional Examination:

Test 1 Test 2 Test 3

□□□FAP □□□PAP □□□ Myofascial pattern

Test 1
Test2
Test3

Pain distribution

(Dermatome)

Numbness

Muscle weakness

(Myotome)

Hypermobility/

Hypomobility

AROM: Pain/

Limitation

PROM: Pain/

Limitation

End-feel

Resisted ROM

Pain/Weakness

DTR

Neurodynamic Test

Other Tests

Radiological

Finding

III. Assessment

Problem List

Test 1 Test 2 Test 3

□□□ Postural syndrome □□□ Radiculopathy (□□□L’t /□□□R’t )

□□□ Myelopathy □□□ Spinal stenosis

Others:_____________________________________________________________

Short-term Goal:

Test 1 Test 2 Test 3

Long-term Goal:

Test Test 2 Test 3

IV. Treatment Plan

1( / / ) 2 ( / / ) 3 ( / / )

V. Comment

Sign: ________________ Sign: ______________ Sign: ________________

標籤:

瀏覽次數:158 人氣指數:1758 累積鼓勵:80

切換閱讀模式

回應

給他日記貼紙

給他愛的鼓勵

檢舉

給本文愛的鼓勵：