Intensive Care Unit Portfolio:

CORONARY ARTERY DISEASE:

PATIENT NAME REHANA

AGE 22 YEARS
GENDRE FEMALE
WARD MICU 4
D.O.A 31-12-2022

MEDICAL DIAGNOSIS : PUERPERAL SEPSIS

PHYSIOTHERAPY DIAGNOSIS: Sepsis results when an infectious insult precipitates a

localized inflammatory reaction that goes on to cause systemic symptoms of fever or
hypothermia, tachycardia , tachypnea, and leukocytosis or leukopenia (a clinical symptoms
called systemic inflammatory response syndrome).  

SOCIAL AND MEDICAL OUTLINE: According to pati ent’s att endant pati ent has
normal vaginal delivery without any complicati ons. She was discharged to home
aft er 2 days she developed fever, conti nuous low grade relieved by anti pyreti c. She
complained lower abdominal pain and burning micturiti on. She also had loose
moti ons multi ple ti mes. She also complains of shortness of breath, more on
exerti on relieved by rest. She is mother of 3 children with no past and surgical
history was found. Her GCS was 15/15.

PAST MEDICAL AND SURGICAL HISTORY : no past and surgical history

MEDICATIONS:

Inj. Vancomycin 1g (IV) BD

Inj. Meropenem 1g (IV) TDS
Inj. Risek 40mg (IV) OD
Inj. Flagyl (IV) TDS
Inj. Tromol + Metadon (IV) SOS
Inj. Normal Saline 60cc/hr (IV)
Inj. Neurobion in 100ml N/S
Tab. Folic Acid 1+0+0

INVESTIGATION:

OBJECTIVE ASSESSMENT:

VITALS:

Blood pressure: 120/80 mmHg

Heart rate: 92 beat per mint

Respiratory rate: 26 breaths per mint

Temperature: A/F

Saturation: 98.9 %

SUBVITALS:

Anemia: positive

Edema: negative

Clubbing: negative

Cyanosis: negative

Jaundice: negative

Jugular venous pressure: negative

Lymph nodes: negative

GLASGOW COMA SCALE : 15/15

SYSTEMIC REVIEW:

RESPIRATORY SYSTEM:

I: On Inspection, patient was conscious. His extremities were warm with no sign of clubbing. No
chest deformity was found.

Patient’s respiratory rate was 26 breaths per mint. Abdomin-thoracic breathing pattern was
found. Oxygen saturation (SpO2) level was 98.9%.

P: On Palpation, patient’s chest expansion was normal. There was no tracheal shift, Capillary
refill was normal: less than 3 sec

P: On percussion, a pleural effusion classically sounds 'stony' dull. 

A: breath sounds, and vocal resonance are reduced or absent over an effusion.
INTEGUMENTARY SYSTEM:

Patient had warm, mild pale skin, no clubbing and no edema was found .

CARDIOVASCULAR SYSTEM:

Patient’s BP was 120/80 and pulse was 92 beats per mint. No clubbing and cyanosis were seen.

NEUROLOGICAL SYSTEM:

Patient was conscious, she was fully aware of his surrounding with a GCS of 15/15. All limb
sensation was intact. Strength was moderate in all limbs.

PAIN : she had no pain.

BIOCHEMISTRY AND HEMATOLOGY:

HEMOGLOBIN 9.4 g/dL 

PLATELETES TEST 686 x 109 / L
POTASSIUM 3.5 mmol/L
SODIUM 133 mEq/L
CHLORINE 97 mEq/L
BLOOD UREA NITROGEN 4 mmol/L
TOTAL BILIRUBIN 0.5 mg/dL
PROBLEM LIST:

IMPAIRMENTS:

Shortness of breath 

Decrease lung compliance 

Burning Micturition

Loose motion

Fever

Abdomen pain

FUNCTIONAL LIMITATIONS:

Patient cannot sit or stand for longer period.

Patient cannot walk for longer distance.

She cannot feed her baby.

She feels discomfort.

SHORT TERM GOALS:

The physiotherapy care plan for patient involves eliminating infection, maintaining adequate
tissue perfusion or circulatory volume, preventing complications, and providing information
about disease process, prognosis, and treatment needs.

LONG TERM GOALS:

 Optimal Coping.
 Absence of Infection Signs and Symptoms.
 Optimal Nutrition Delivery.

TREATMENT:

SESSION 1:

S: 22 years old female pt. NKCM, married since 4 years having 3 children 20 days back she had
NVD, presented with fever, loose stool and Shortness of breath after delivery she is diagnosed
with puerperal sepsis.
O: VITALS:
Blood pressure: 120/80 mmHg

Heart rate: 92 beats per mint

Respiratory rate: 26 breaths per mint

Temperature: A/F

Saturation: 98.9% %

CHEST X-RAY: pleural effusion was present

SPO2: 98.9%

LAB FINDINS:

Hb: 9.4 g/dl

Rx:
 Percussion, manual suctioning technique to mobilize and dislodge the secretions and to
aid in expectorations.
 Positioning to decrease the work of breathing.
 Active range of motion exercises to maintain blood flow and muscle strength in upper
and lower limbs.
 Active stretching: to prevent edema

SESSION 2:

Rx:
 Percussion, manual suctioning technique to mobilize and dislodge the secretions and to
aid in expectorations.
 Positioning to decrease the work of breathing.
 Active range of motion exercises to maintain blood flow and muscle strength in upper
and lower limbs.
 Active stretching: to prevent edema
 ACBTs: to improve lung function
OUTCOME: My pati ent is very acti ve and cooperati ve she easily performs her
acti viti es.
REFLECTION : she is a gynae pati ent. We do not cover gynae subject in our DPT
course so I can’t perform any gynae related exercises.