Case presentation

VIJAI KUMAR.Y
MPT-1styear(sports)
Subjective assessment
 Name: Mrs. Ayisha begum
 Age:45
 Sex: Female
 Occupation: house wife
 IP No : 59520 ( CT ward)
 Date of admission:17.10.11
 Date of assessment:4.11.11
 Address: Chennai
Subjective assessment
Chief complaints
 Patient complaints of chest pain
over the suture site, difficulty in
taking deep breathing since
28.10.11.
Subjective assessment
Present history
 Patient was a post operative case of
coronary artery bypass graft 8th pod who
came here with complians of severe chest
pain and got admitted on 17.10.2011 &
they posted for surgery on 26.10.11. now
reffered to physiotherapy post operatively.
• Past history
• Patient gave a history of chest pain
on 2006 and got admitted in hospital
and thrombolysed and under went
for angiogram and diagnosed to
have multiple blocks & at the time
the physician suggested her to
under go for surgery, but due to her
personal reasons she dint under
went for surgery at that time.
• From that time she was on continious
medication. Then the second attack was
on 17.10.2011 and came to srm hospital
and they diagnosed as unstable angina
and have to under go for surgery
immediately.
 Subjective assessment

Medical history :
• k/c/o diabetic from past 6 years and taking
regular medication.
Subjective assessment
Personal history/social
&health habits
• DIET: mixed diet
History to allergens:
 Nil
Vital signs
• Body temperature : 98.6 (degree
Fahrenheit)

• Heart rate: 98 beats/min

o Blood pressure : 116/70 mm/hg

o Respiratory rate: 24 breaths/min

o Spo 2: 98%
Objective data
• GENERAL OBSERVATION:

 CONSCIOUSNESS: Oriented

 BODY BUILT: Endomorphic

 EXTERNAL APPLIANCES: Peripheral

lines present.
Objective data
• LOCAL OBSERVATION:

EVALUATION OF LIMBS:-
 COLOUR OF LIMB- normal
 CLUBBING – absent
 OEDEMA – absent
Objective data
• COMMUNICATION:

 Conscious
 Oriented
 Obeying oral commands

• SPEECH:

 Patient felt dysponic while talking

 Dyspnoea of phonation –present( felt while
counting 8)
Objective data
• EVALUATION OF HEAD AND NECK

 CHANGES IN FACE: nil

 SCAR: absent

 SIGNS OF RESPIRATORY DISTRESS:

 NASAL FLARING- absent
 ACCESORY MUSCLE USAGE – present.
• Breathing :

 BREATHING PATTERN: Abdomino-

Thoracic
 INSPIRATORY EXPIRATORY RATIO:
1:2
 RATE: normal
o ON PALPATION:
 Tracheal shift not present
 Accessory muscle usage is there due to increase
demand(sternocleido-mastoid and scalene)
 Tenderness present in and around the suture site
while coughing and inspiration

o ON EXAMINATION:
 chest expansion

 Axillary level : 1 cm
 Nipple level : 0.6 cm
 Ximphisternum level : 0.8 cm
• EVALUATION OF COUGH:

 COUGH : absent

SPUTUM

 Not present
• Incentive spirometry:
 900 cc
o Expiratory technique ( paper blown
technique used):
 good

o ON AUSCULTATION:
 Breath sound: decreased air entry in b/l
lower lobes & mild wheeze present
 Heart sound : s1+ s2+ normal. No
murmurs
Systemic Review
• INTEGUMENTARY SYSTEM:
No scars present, suture present at incision
site ( mid-sternal, medial aspect of both
calf).

• MUCULOSKELETAL SYSTEM:
 DEFORMITY- absent
 ASSYMETRICAL ALLIGNMENT OF
BODY- absent
 MUSCLE WASTING- absent
Systemic review
• RANGE OF MOTION(pain free range)
• (AROM)
• Shoulder : Rt LFT
• Flexion : 0°-90 ° 0°-90°
• Extension : 0°-20° 0°-20°
• abduction : 0°-70° 0°-70°
Systemic review
o NEUROLOGICAL SYSTEM:
o No abnormality detected
 Functional assessment scale

Fim score: 6
INVESTIGATIONS
PRE OPERATIVE :
 ECG- shows evidence of ST wave
depression in leads v2-v6 & lead I & AVL
CHEST X –RAY- shows evidence of
cardio megaly
 ANGIOGRAM : shows evidence of multiple
blocks

 POST OPERATIVE
 ECG-shows sinus tachycardia present
Provisional diagnosis
 CAD-TRIPPLE VESSEL DISEASE,TYPE-
II DM.
Physiotherapy diagnosis
• Retention of secretions in B/L lower lobe
• PROBLEM LIST:
 Reduced chest expansion
 Breathlessness while speaking
 Reduced shoulder mobility b/l
 Impaired ADLs
AIMS
to make the patient functionally independent

 Short term goal :

• Improve chest expansion
• Improve shoulder ROM.
 Long term goal :
to make the patient indepedent perform his
daily activities without any difficulties.
 Physiotherapy treatment

Day 1 :relaxed diaphragmatic breathing

huffing technique
splinted coughing
thoracic mobility exercises(up to pain free range)
incentive spirometry
coastal expansion exercises
walking encouraged under supervision.

Day 2 : continued the same treatment of day 1

static marching
stair climbing for 6 steps
 Physiotherapy treatment

Day 3 : continued the same treatment of day 2

stair climbing for 10 steps.
Home advice
 Do regular exercises
 Don’t under go for undue exerction
 Don’t lift heavy objects
 Use western toilets
limitations
• No photos and videos
Clinical rationale
THANK YOU