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Posterior Fossa Syndrome

Progress Note 1 Month 3

Physical Therapy

Therapeutic exercise: sit-ups with moderate assistance; static balance in 90/90 sitting requires contact guard assistance; placement of basketballs through the net with both hands; standing at walker, not using arms for support, relies on hips for support, pushes posteriorly, minimum assistance; tolerating standing with minimum support for 4 to 5 minutes; standing balance with moderate assistance at hips; AmTryke® for 10 minutes with minimum assistance.

Transfers: rolling from supine to prone with minimum to moderate assistance; dependent for supine to sit; side-lying to sit with moderate assistance; sit to stand with moderate assistance.

Gait: 4 to 5 steps independently before taking big, floppy steps, improved to ambulating 400 feet with moderate assistance at the pelvis with 3 rest breaks; improving decreased step length; assistance for heel strike.

Occupational Therapy

Gross motor: pulled self up to sit, sat unsupported but fell several times; reaching side to side and overhead with both hands; bilateral hand activity in tailor sitting, tendency to not use left hand during activities; tolerating increased gravitational insecurity on bolster swing.

Fine motor: isolated finger movement; gross grasp of markers; wrote name with hand-held assistance with pronator grasp; places blocks on pegs with good manipulation; finger foods independently; spoon fed with verbal cues and assistance for proximal stability once fatigued.

Speech Therapy

Breathing: maximum assistance for pursed lip breathing and whistling.

Reading: now able to read a medium length story in small print aloud; comprehension of story is 80%.

Verbalization: repeating sentences and adding new ones to the story. Katie presents with improved expressive and receptive language.

Problem solving: increased processing time for answering questions; minimum assistance for sequencing tasks; answers yes/no questions with 100% accuracy, true/false with 90 - 100% accuracy with supervision.

Math: add and subtract ones and tens with minimum assistance.

Memory: great for rules to games.