교과목: 임상생체역학실습 교수명: 황성수 교수님 날짜: 성명: 조현호

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Presentation transcript:

교과목: 임상생체역학실습 교수명: 황성수 교수님 날짜: 2007. 6 .7 성명: 조현호 사례 보고서 교과목: 임상생체역학실습 교수명: 황성수 교수님 날짜: 2007. 6 .7 성명: 조현호

General information Name: 김 O O Age: 만 49세 Sex: 남 Dx: Rt. Hemiplegia d/t Lt.BG ICH On set: 2006. 5.10 Job: 전자 회사 직원 Hobby: Health <weight traning>

Subject information Present illiness - 트럭과 충돌후 stuporus mentality로 인하대 ER 방문하여 ICH, LT. BG 진단받고 craniotomy & hematoma removal 시행 후 재활치료 받다가 본원 입원 치료 후 러스크 병원 거쳐 본원 재입원. Past medical history -Non specipic 현재 본 병원에서 물리/작업치료 각각 2회씩 실시.

Object information Neurologic Examination 1. Metal status: alert Object information Neurologic Examination 1. Metal status: alert 2. Orientation (T/P/P):+/+/+ 3. Language: Motor aphasia 양상 4. MMT => upper->proximal: fair , Distal: poor~trace / N lower->proximal: fair+ , Distal: poor / N 5.ROM =>큰 제한은 없으며 Lt. shoulder Jt.에서 flex & abd. 130~140도 사이에서 pain 발생.

Object information sensory Superficial sense Deep sense Cotical sense Pain : impair Temperature: impair Touch: impair Pressure: impair Proprioception <movement & position>: absent에 가까운 impair two point discrimination : impair Muscle tone MAS: upper-G1~2 lower-G1

Object information Functional ability 1. roll-over: independent 로 가능 2. sit-up: independent로 가능 3. sit to standing: independent로 가능 4. gait: indoor 상에서 supervision하에 independent로 수행 가능 5. sitting balance: static,dynamic-good 6. standing balance: static-good dynamic-fair~good

Assessment <Problem list> Siitting position 시 1. shoulder stability 저하, scapular depression 상태 => (rotator cuff m. weakness & pectoralis m. and latissimus dorsi 등의 internal rotator m.의 shortening이 보임)

Assessment Standing position시 1. pelvic anterior tilting & hip jt. external rotation 2. trunk right side로 mild한 bending & weight bearing unaffected side로 치우침.< knee jt. Slight flex.>

Assessment Gait시 1. trunk Lt/Rt sway 현저하게 나타남(Rt. arm position으로 rotation mov`t 방해) 2. circumduction gait 양상( hip. Anterior tilting상태에서 elevation&flex.을 이용하서 swing. Dorsi flexion limit.)

Assessment Short term goal => trunk sway 감소와 rotation movement 증진 A: patient B: Rt. shoulder의 stability increase를 통해 scapular & jt. Position 변경 (elevation & external rot.)=> affected arm을 reference로 이용 C: sitting, standing position-manual & activity use D: 치료시간 내에 여러 세트 반복 실시

Assessment Long term goal => outdoor상에서 stable한 independent gait ( gait 속도 증진) A: patient B: pelvic posterior tilting education & weight transfer training C: supine, sitting, standing-manual D: 치료시간 내에 여러 번 반복실시

Plan adm. 2times/day (40분) 치료실에서 치료사와 함께 운동치료. ward ex. education 3개월 후에 재평가

Treatment 1.affected side pelvic posterior tilting education

Treatment 2. affected side shoulder stability increase

Treatment 3.standing weight bearing traning

Treatment 4. Gait traning

Thank You For Your Attention! The End