SOAP Note 21세기 병원 윤 아 진
1. Subjective information Name : 최 * * Age : 20 Sex : Female Job : 대학생 (칠예과 재학중)
1. Subjective information Dx : Scoliosis (Cobb’s angle 22˚) Onset : 2005년에 학교에서 실시한 x-ray에서 처음 발견. Attitude : 운동을 잘 하지는 못하는 편이나, 치료에 적극적이고 열심히 임함. C/C : 미관상 좋지 못한 자세와 어깨 결림.
2. Objective X - ray
2. Objective Posture
2. Objective gait 동영상
2. Objective ROM - Cervical Right Left Flexion 50˚ Extension 70˚ Lat. Flex. 35 ˚ 20 ˚ Rotation 65˚
2. Objective Information ROM - trunk Right Left Flexion 60 ˚ Extension 30 ˚ Lat. Flex. 30˚ 40˚ Rotation 45˚ 55˚
2. Objective Information ROM – Shoulder Rt Lt Hor. Abd. 105˚ Hor. Add. 30 30˚ Int. Rot. 45˚ 50˚ Ext. Rot. 80˚ Rt Lt Flex. 180˚ Ext. 45˚ 50˚ Abd. Add.
2. Objective Information MMT - Cervical Right Left Flexion G Extension Lat. Flex. F+ F Rotation
2. Objective Information MMT - trunk Right Left Flexion N Extension G Lat. Flex. F F+ Rotation
2. Objective Information MMT – Shoulder Rt Lt Hor. Abd. G Hor. Add. Int. Rot. F+ Ext. Rot. Rt Lt Flex. G Ext. Abd. Add.
2. Objective Information One leg test Rt. Side ; 23’’ 85 Lt. Side ; 20’’ 19
3. Assessment Problem list - Vertebra instability (deep muscle weekness) - muscle imbalance Trunk Lat. Flex ; Rt < Lt Rot ; Rt > Lt Cervical Lat. Flex ; Rt > Lt Cervical Rot. ; Rt Lt
3. Assessment Problem list - muscle tightness Lt. upper trapezius, Rt. Latissmus dorsi, Rt. oblique abdominis) - trunk & rib immobilization
3. Assessment Short term goal - Educating ideal posture - Strengthening trunk deep muscle - Trunk & rib mobilization - Balancing muscle length Long term goal - 일상생활 속에 바른 자세 유지하기