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T6 Spinal Cord Soap Note

Essay by   •  January 5, 2012  •  Essay  •  284 Words (2 Pages)  •  7,122 Views

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SOAP Note 11/24/11

Pt. is a 24 y.o. male w/ a T6 spinal cord injury suffered in a MVA, S/P 4 weeks . Prior to accident, Pt. was independent and lived alone in an apartment and was also an amateur weight lifter. Pt. currently lives at home with parents in a single level ranch style house where a ramp has been constructed recently for ingress/egress.

S. Pt. says "I am still pissed at the other idiot driver for putting me in this situation". Pt says he is willing to do what it takes to be independent again.

O. Pt. seen for 40 min tx. on this date w/ focus transfer training and UE strengthening to aide in transfers and later in w/c mobility. w/ Pt. seated in w/c, w/c pushups 2x10. Instructed proper technique of moving from w/c to mat table using sliding board. Pt. performed 5x. Using small scales (x2), Seated on mat in long sitting pos, instructed pt to push down on scales through his hands and try lifting his buttocks off the table using scales as feedback 1x10. Instructed Pt. proper technique for transferring back to w/c using sliding board, Pt. performed 5x

A. Pt. tolerated tx very well making steady progress requiring min verbal cues for transfer activities. Pt. has good understanding of strengthening exercises as well as very good upper body strength to aide in transfers and future advanced w/c activities.

P. Advance w/c transfer w/out aide of sliding board. Instruct proper technique of moving from floor→stool→w/c using backwards approach. ↑ UE strengthening and trunk rotation and progress to more advanced w/c activities. Recommend OT consult for proper outfitting of home to make more accessible.

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