SOAP肌骨康复病例

SOAP肌骨康复病例

ApplicationofSOAPinWritingMusculoskeletalRehabilitationCases

I.BasicInformation

PatientName:XXXGender:MaleAge:39Occupation:OfficeWorkerClinicalDiagnosis:ShoulderDislocationOnsetTime:January5,2021ConsultationTime:March19,2021ContactNumber:XXXXXXXXXXXXX

II.S(SubjectiveData)

Reporter:Self√FamilyMember(Relationship)Caregiver

1.ChiefComplaint:Leftshoulderjointpain6/10,weaknessinflexionandabduction,limitedmovementformorethan2months.

2.PresentIllness:

OnsetTime:January5,2021RehabilitationTreatmentStartTime:March19,2021

RehabilitationTreatment:Ultrasoundtherapy,activejointmovementtraining,shortwavetherapy,lighttherapy,high-energylasertherapy,TreatmentEffect:Good

3.PastMedicalHistory:

Historyofpastillnesses:None

Installationofpacemaker:None,Pasthealthstatus:GoodVaccination,trauma,surgicalhistory:None

Mobility:Nomobilityrestrictions.

1

ADLfunction:Fullyself-sufficient.

Cognitiveability:Normal,Mentalstatus:Normal

Other:None

4.PersonalHistory:

Smoking:None,Drinking:None,Sleepschedule:RegularOccupation:OfficeWorker,Hobbies:None

5.SocialHistory:

Livingsituation:LivingwithwifeandsonElevator:YesToilet(squatting/sitting):Squatting,Bathroom(shower/bathtub):Shower

6.EmotionalorAttitudinal(PersonalandFamily):

Positivecooperation√Sometimesuncooperative

Easilyirritableordepressed

7.Patient'sRehabilitationGoals:Leftshoulderjointcanflexnormallyupto150°,andextendbackwardsby30°.

III.O(ObjectiveData)

1.VitalSigns

Heartrate:71beats/minBloodpressure:120/87mmHg

Respiratoryrate:23times/minBodytemperature:36.8℃

2.Limbcircumference:Upperarmcircumference:23Forearmcircumference:15Thighcircumference:40Calfcircumference:28Edema/atrophy:Atrophy

3.Muscletension(R/L)

Neck:Normalmuscletensiononbothsidesoftheneck.

Shoulderjoint:Normalmuscletensionontherightside,1+levelofflexormuscleontheleftside.

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50°.

Elbowjointandforearm:Normalmuscletensiononbothsidesoftheelbowjointandforearm.

Wristjoint/fingerjoint:Normalmuscletensiononbothsidesofthewristjointandfingerjoint.Hipjoint:Normalmuscletensiononbothsidesofthehipjoint.

Kneejoint:Normalmuscletensiononbothsidesofthekneejoint.

Anklejoint:Normalmuscletensiononbothsidesoftheanklejoint.

4.Jointmobility(ROM,R/L)

Neck:Normaljointmobilityonbothsidesoftheneck.

Shoulderjoint:90°offlexionontheleftside,160°ontherightside.

Elbowjointandforearm:Normaljointmobilityonbothsidesoftheelbowjointandforearm.Wristjoint/fingerjoint:Normaljointmobilityonbothsidesofthewristjointandfingerjoint.Hipjoint:Normaljointmobilityonbothsidesofthehipjoint.

Kneejoint:Normaljointmobilityonbothsidesofthekneejoint.

Anklejoint:Normaljointmobilityonbothsidesoftheanklejoint.

5.Musclestrength(MMT,R/L)

Neck:Normalmuscl