case presentationy课件

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1、临床病案汇报20140611Casepresentation--SCITheoccupationaltherapyprocess资源开发利用污染及生态破坏ReferralandInitialassessmentName:wangXXAge/sex:58y/maleChiefComplaint:afallleadtothefeelingandmovementdisorders,oflowerlimbs,22days.Referral:fromlocalhospitalCareer:constructionworkersEducationdegree:ju

2、niorhighschoolInterestandleisurehobbies:readinganovelInitialassessmentMaritalstatus:marriedMaincharacters:father(adaughter)Themaincaregivers:wifeExpectations:self-reliance,returntothefamilyLivingenvironment：livewithwife、Nobarrier-freefacilities、Aladderandslopeonthewaytothebuildi

3、ng、Ceramictilefloor、Showerbath、ThesquaturinalInitialassessmentDiagnosis:spinalcordinjury (T3 AIS A)T5,T6,thoracicvertebralfracturedislocationinternalfixationwithparaplegiaaftertheoperation,T7thoracicvertebralcompressionfracturesBilateralmultipleribfractureselectricallydamagingdo

4、ublelungcontusionwithpleuraleffusiononbothsides,theleftsideofthechestaftercloseddrainageneurogenicbladderneurogenicrectumDetailedassessmentThehandedness:righthandednessInjuriesonsettime:2014/3/3Theoperationtime:2014/3/8ASIAgrade:T3/ACareer:constructionworkersEducationdegree:juni

5、orhighschoolInterestandleisurehobbies:readinganovelMaritalstatus:marriedDetailedassessmentExistingproblemand advantageExistingproblemNosittingabilityWeakmusclestrengthNoabilitytotransferIndependenceofADLAdvantageNormalupperlimbsTreatmentplanShorttermgoals:Balance:Ⅰgradeinshort o

6、rlongsittingpostureMusclestrength:canPullupfourbricksTransferableskills:cantransferfromonesidetotheotheronthebedTreatmentplanMediumtermgoals:Balanceability:Ⅱgradeapproximatelyinshort orlongsittingpostureMusclestrength:canPullupsixbricksTransferableskills:cantransferfromonesideto

7、theotheronthebedADLindependentlyTreatmentplanLongtermgoals:CandoADLindependently,returnhomeTreatmentimplementationMediumtermgoals:BalanceabilityTreatmentimplementationMediumtermgoals：MusclestrengthTreatmentimplementationMediumtermgoals:Transferableskills:TreatmentimplementationM

8、ediumtermgoals:ADLindependentlyTreatmentreviewP