SCENARIO: 1 (Cardiac conditions)

A 57-year-old male presents to his local A&E department complaining of chest pain.
Prepare a presentation for this condition on the physiotherapy management for this
patient.
Subjective:
The pain is in the middle of my chest and came on suddenly an hour ago whilst I was
watching TV. It feels like I’ve got an elephant sat on my chest doctor, it’s awful! I had a
bit of tingling in my neck and jaw, but that’s gone now. I feel really sick, I vomited once
at home before the ambulance arrived. I do feel a little short of breath, which is weird,
I’ve never had that before, maybe I’m just anxious. The pain isn’t affected by my
position or by taking in a deep breath, it’s just always there. The pain has improved but
it’s still aching and feels heavy, I’d say it was 8/10 at the start and it’s now about 5/10.”
“I’ve never had chest pain like this before, maybe a few niggles every few months over
the last few years, but nothing like this! I didn’t bother going to the doctor about the
niggles, as they always settled on their own and I’ve never been diagnosed as having
any heart trouble.”

“I’ve got high blood pressure and cholesterol, I’m on tablets for those though.”

“I do smoke, about 20 a day and have done for the last 30 years.”

“I’m not a drinker doctor, I like to stay healthy so I stay away from it.”

“I don’t really do much exercise, but I get from the shops and back without any trouble.”

Objective:

 The patient has a regular pulse, is tachycardic at 105 bpm and is hypertensive with a
BP of 160/110 mmHg.
 He has some xanthelasma around his eyes and also has corneal arcus.
 Heart sounds are normal and his chest is clear.
 There is no evidence of peripheral oedema.
 The abdomen is soft and non-tender. There is no organomegaly. There is no
expansile mass on palpation of the aorta.
 Differential Diagnosis:

 Acute coronary syndrome

 Pulmonary embolism
 Pericarditis
 Dissecting aortic aneurysm
 Oesophageal spasm

Investigations: The below investigations were done on the patient.

12-lead ECG:

 Looking for acute ischaemic changes

Blood tests:

 FBC (e.g. severe anaemia can cause a myocardial infarction)

 U&Es (e.g. abnormal electrolytes could cause arrhythmias)
 Troponin T – baseline + 3/6 hours from presentation (>20% rise suggest acute
myocardial infarction)
 Lipid profile – useful for informing long-term cardiovascular risk reduction (e.g. statin
dose)
 Serum glucose:
 Identifying hyperglycaemia can help to inform long-term management of modifiable
risk factors.
 It is also important to identify hyperglycaemia in the acute setting. NICE
recommends keeping blood glucose <11mmol/L whilst avoiding hypoglycaemia
(e.g. dose-adjusted insulin infusion).

Chest x-ray:

Assess for signs of heart failure (e.g. cardiomegaly, pulmonary oedema)

Interpretation:

The ECG reveals ST-segment elevation in Leads II, III and aVF suggesting an inferior
myocardial infarction.

A block in the right coronary artery was diagnosed and the patient was posted for
cardiac bypass surgery.
Post- operatively he is more complaining about the incisional pain during cough with
slight pain & swelling over the affected peripheral limbs. He is positioned in supine lying
with pillow under the left leg. He is reluctant to move his limbs.
On examination, he has diminished thoracic movements during breathing and reduced
peripheral movements was observed. He himself is anxious to take a deep inspiration.
Lung auscultation reveals secretion retention on his periphery lung fields.

SCENARIO: 2 (Respiratory)

History
A 33-year-old African American male without significant past medical history, was
transferred for evaluation of acute onset of dyspnea (< 48 hours), wheezing and a
cough productive of blood-tinged sputum. The patient denied a personal or family
history of pulmonary disease. He was previously able to participate in athletic events
without symptoms. He denied the use of tobacco, alcohol or drugs. He was employed
as an industrial insulation application specialist. Approximately one day prior to
presentation, he admitted to an unprotected exposure to a maleic anhydride gas cloud
(used as a resin in fiberglass insulation). The patient denied any history of previous
exposures. At the time of presentation, the patient did not have a fever or chills and did
not report recent weight gain or lower extremity swelling. He had no chest pain, but did
complain of chest tightness. He denied nausea, vomiting, diarrhea or abdominal pain.
The remainder of his review of systems was unremarkable.
Physical Exam
The patient's weight was 229 pounds. Blood pressure 138/86 mm Hg, pulse 92
beats/minute and oxygen saturation 95% on room air. His initial respiratory rate was
28/min in the Emergency Department and had improved to 22/min at the time of
examination. In general, he appeared stable without the use of accessory muscles for
respiration. He was able to give us his history without significant dyspnea. Head and
neck exam was within normal limits and without evidence of stridor. His lungs revealed
fair air movement without wheezing or rhonchi. His cardiac exam was regular rhythm
without an S3 gallop or evidence of peripheral edema.
Lab

 Serum chemistry panel and liver function tests were normal.

 Autoimmune serologies including: erythrocyte sedimentation rate (ESR),
antinuclear antibodies (ANA) and anti-neutrophil cytoplasmic antibody (ANCA)
were negative.
 Complete blood count (CBC) was unremarkable with a normal cellular
differential.
 Urinalysis was normal.

Figures
See chest radiograph in Figure 1.
A CT scan of the chest was unremarkable.

Transthoracic echocardiogram during the acute presentation showed mild left

ventricular dilation with no evidence of pericardial effusion and an ejection fraction of
25%. A follow-up echocardiogram at 3 months showed resolution of previous
abnormalities and a normal ejection fraction.

Pulmonary function testing (PFT) obtained 48 hours after his acute presentation showed
a forced vital capacity (FVC) of 3.59 L (88%), a forced expiratory volume in 1 second
(FEV1) of 3.10 L (91%), and an FEV1 / FVC of 86.4%. Lung volumes were normal. The
diffusing capacity for carbon monoxide was 59%. On 6-minute walk testing, he
ambulated 1658 feet with an oxygen saturation of 98% at rest and 94% during exercise.

Figure 1. PA and lateral chest radiographs from the patient. The images show mild
elevation of right hemi-diaphragm, normal lung fields and cardiomegaly.

ABG's:

PFT 0100 (RA) 0300 (2 LPM) 0800 (2 LPM) 0800 (RA)

Ph 7.38 7.37 7.42 7.42
Pa02 44 60 62 60
PaC02 58 63 44 36
HC03 (calc) 31 32 30 24
Normal: Ph 7.40+0.05; Pa02 80+10; PaC02 40+4; HCO2 24+2
Scenario:

SCENARIO: 1 (Cardiac conditions)

SCENARIO: 2 (Respiratory)

Guidelines:

You are expected to prepare on any one (1) of the above scenarios with power point
slides. The font size used should be easily readable. The power point can be structured
as you wish, but take care not to over-crowd it. Remember that you have a
presentation, which will allow you to expand on points, so make sure your key points
are represented on the power point, but don’t try to put too much detail into it. You
should include citations and a reference list in the presentation.
You will have 10 minutes to present your power point and your presentation should
include:

 Introduction: Background of condition and brief explanation of scenario based on

pathophysiology.
 Case Summary and Problem Listing: Summary of Subjective Assessment and
Objective Assessment and Problem Listing.
 Management of Patient: Plan of treatment, Rationale for selected treatment and
Progression of treatment.
 Outcome measures: Appropriate outcome measure and Reliability of the
outcome measure.
 Presentation Skills: Structure of Presentation, Organisation of Ideas, Clarity of
Presentation and Creativity of Slides

The assessment contributes 30% to your overall credit for this module.

The Assessment Procedure

You will be assessed on the content and quality of your slides and presentation style in relation
to the areas outlined above.

The weightage of marks is given below:

1. Introduction: (20%)
2. Case Summary and Problem Listing: (30%)
3. Management of Patient: (30%)
4. Outcome measures: (10%)
5. Presentation skills: (10%)