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Posterior Fossa Syndrome

Progress Note 3 Month 5

Physical Therapy

Therapeutic exercise: sit-ups, bridges, leg abduction exercises improving; minimum assistance for sidestepping in the parallel bars; squats in parallel bars with moderate assistance; balance activities in parallel bars with foam and rocker board; up and down 4 stairs with step-to pattern with moderate assistance.

Transfers: supine to sit independently; in and out of wheelchair with minimum assistance.

Gait: crawling independently 10 feet unsteadily; ambulating 1000 feet with reverse rolling walker with bilateral hand-held assistance; took 5 steps independently in parallel bars; walked without trunk support for the first time.

Occupational Therapy

Gross motor: crawling 10 feet unstable but independently; reaching and bending at hips; needs verbal cues to use both hands during activities; reaching overhead & sideways, needs cues for use of left hand.

Fine motor: moderate assistance to brush teeth, stand-by assistance with electrical toothbrush; tripod grasp for writing & coloring; able to place beads on a string.

Speech Therapy

Breathing: moderate assistance for breath support.

Reading: comprehension of stories requires minimum assistance.

Verbalization: recalls words with moderate assistance; requires minimum assistance for spelling; able to carry on a conversation using an appropriate mean length of utterances and breath support.

Problem solving: generate correct answers independently 75-80% of the time; sequencing of words requires minimum assistance.

Math: basic math word problems require minimum assistance.

Memory: marked improvement with memory games this month.