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Posterior Fossa Syndrome

Progress Note 2 Month 4

Physical Therapy

Therapeutic exercise: focus on increasing core strength, leg strength and balance; sit-ups with minimum assistance; 90/90 static sitting with contact guard assistance; dynamic sitting balance with minimum to moderate assistance; standing while holding parallel bars for 23 seconds.

Transfers: floor mobility with verbal & minimum physical cues; able to maintain sitting and side-lying independently; floor to tall kneel to half kneel with moderate assistance; to and from floor with chair with moderate assistance; sit to stand with minimum assistance.

Gait: ambulating 600 feet with moderate assistance at pelvis with no rest breaks; posterior lean and foot placement is improving; wheelchair propulsion independently for 50 feet.

Occupational Therapy

Gross motor: tailor sitting with stand-by assistance; able to sit in chair without support; wheelbarrow walking with support at the hips, poor shoulder strength; crawling with support at hips; able to play catch with bilateral hands; propelled arm bike for 100 feet independently; propelled wheelchair 200 feet; took off shoes and socks independently.

Fine motor: able to complete 10-piece puzzle; drew picture of family with a large marker using a quadruped grasp; wrote numbers with a large marker using a two-finger gross grasp.

Speech Therapy

Breathing: minimum assistance for controlled breathing.

Reading: read a book aloud with minimum assistance.

Verbalization: generating 6-8+ word sentences independently given a single word; minimum assistance for compound sentences.

Problem solving: requires moderate to maximum assistance for problem solving; answers “wh” questions with 90% accuracy.

Math: add and subtract with supervision to minimum assistance, moderate assistance for multiples.

Memory: follows directions with moderate assistance; quickly learns new games.