Complete Clinical Assignment Revision (BALIR)

ORIGINAL INSTRUCTIONS:

Assessment Plan Assignment

Below you will see a summary of two different 1 hour treatment sessions for the same patient as well as a section summarizing the patient’s information.Please write the Assessment portion of a SOAP note based on how the patient performs from treatment session 1 to treatment session 2.  Please also write the Plan section of the SOAP note including at least 2 ideas for treatment. The ideas need to be appropriate for the level of this patient.

Patient Information:Dx:  CVA  c L hemi.  Weakness noted t/o L UE and L LE.  Pt does have active movement in her L arm, but having difficulty grasping and manipulating objects.  Pt c 3- strength in her L quads and 2 in her L gluts.  Her static supported standing balance is F/F+, however, her dynamic supported standing balance is P.  She is using a LBQC for amb.

PMH: HTN, CAD, NIDDM, S/P THR in 2009

Home Information:  One story home with 3 STE with no HRs

Social Information:  Pt likes to play golf.

Treatment Session One:  January 31, 2010 at 1:32 p.m.

Pt arrived to Rx session in a w/c.  She was not feeling very well.  She said she was feeling very tired; hadn’t slept well the night a.  Pt noted to be very quiet t/o Rx session, and appeared sad.  The Rx session began with PTA t/f pt ? mat with pt using her LBQC.  PTA had to give mod.PA.  PTA noticed that pt puts all of her weight through her R LE and pushes post.during sit ? stand.  Once pt is on mat, PTA works c pt doing repeated sit ? stands focusing on proper technique.  PTA then has pt step ? on 4” step c R LE and reach ? and ? for bean bags c L UE, and toss into container.  Pt needed to rest after about 10 bean bags for each of attempts totaling 4 attempts because of fatigue and SOB.  O2 sat was89% after 1st attempt and noted to be 92% within 1 minute of sitting.  PTA completed gt. training having pt use her LBQC.  PTA had to give mod. –max. PA.  Ptamb 25’, was unable to advance her L LE I, consistently looked down and hyperextension of her L knee was noted 75% of the time.  1 significant LOB noted when pt’s family arrived and pt turned her head to the L.  After gt.training, PTA took pt back to her room.

Second Treatment Session:  February 1, 2010 at 2:40 p.m.  Pt arrived to Rx session in a w/c feeling better this date.  Stated she slept much better last pm.  The Rx session began c PTA t/f pt ? mat using LBQC.  PTA had to give mod PA.  PTA noted pt to have some post. pushing and pt putting more weight thru L LE during 

sit?stand.  PTA continued to have pt. practice sit ? stands at varying heights.  PTA also had pt put R LE on 4” step and throw ball against a wall at various targets.  Pt noted to be SOB with activity, taking frequent rest breaks.  O2 sat 93%.  PTA ended Rx c gt. training using LBQC.  Pt having difficulty remembering what foot to move first.  Pt looking down less with VC and TC from PTA.  Pt starting to advance L LE on her own, however, PTA still needing to clear her L foot.  Pt amb 30’ c mod PA – max PA from PTA, and pt able to control knee better.  Pt not sad during any of the Rx session.  P Rx was done, PTA took pt back to room.