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Posterior Fossa Syndrome

Progress Note 4 Month 6

Physical Therapy

Therapeutic exercise: standing independently for 24 seconds; sidestepping and backwards walking with contact guard assistance.

Transfers: independent sit to stand from a chair.

Gait: walked in the parallel bars independently x 50 feet with 5 rest breaks; walks with stand-by assistance with reverse rolling walker x 1000 feet; took 3-4 steps independently.

Occupational Therapy

Gross motor: reaching with arms in quadruped position with minimum assistance; able to take off shoes independently; crawled 100 feet with 3 rest breaks with reciprocal movements; floor to toilet with stand-by assistance.

Fine motor: poor coordination for stacking cones; moderate assistance for cutting; can unzip pants, but not unbutton; able to fill in hangman blanks with proper letters.

Speech Therapy

Breathing: presents with adequate breath support.

Reading: reading and comprehension accuracy is 90% with minimum cues.

Verbalization: able to complete a sentence with a subject and verb independently.

Problem solving: requires supervision to pick out a word that does not belong in a select group of words; able to answer questions about a poem with minimum assistance.

Math: maximum assistance for counting by fives and coin addition.

Memory: moderate assistance to name coins and their value.