1st Case Presentation

November 28th, 2023

Optimizing Cardiac Rehabilitation for a Patient with

Left Atrial Myxoma and Stroke Infarct in the Sub-Acute Phase

Presented by: Adi Tri Pamungkas

Supervised by :

Dr. dr. Dian Marta Sari, Sp.K.F.R., K.R. (K), M.Kes

Examined by :

dr. Farida Arisanti, Sp.K.F.R., N.M. (K)

PHYSICAL MEDICINE AND REHABILITATION DEPARTMENT

FACULTY OF MEDICINE PADJADJARAN UNIVERSITY BANDUNG

2023
 Case Report

I. IDENTITY

Name : Mr. AS

Sex : Male

Date of birth : 09th June 1975

Religion : Islam

Status : Married

Occupation : IT Programmer and Maintenance

Address : Sanggar Indah, Banjaran

Education : D3

Date of Refferal : 25th September 2023

Referral Diagnosis :Post Evakuasi LA Myxoma + Asymptomatic

bradikardia ec SND + Riwayat stroke infark KE

II. ANAMNESIS (Autoanamnesis, Allo-anamnesis,

Medical Record) September 25th, 2022

1. Chief Complaint

Patient complained easily tired while doing daily activities

2. History of Present Illness

1
 The patient undergone evacuation LA myxoma surgery on 21st August 2023

at Hasan Sadikin Hospital. Patient was referred by his cardiologist to physical

medicine and rehabilitation department to get the phase 2 cardiac rehabilitation.

Patient complained easily tired while walking around 300 meter, his complained

improved when he take a rest. The patient also reported that there is no chest pain,

radiating pain to upper left arm, fever or chills and shortness of breath.

He used to complain easily tired since April 2023. He felt easily tired when

climbing 1 storey stairs and when he was doing badminton. He used to play

badminton for 3 set (around 2 hours) but since the complaint comes he only can do

1 set and felt exhausted. On 20th June 2023 he was hospitalized due to sudden loss

of consciousness and woke up with weakness on left extremities, slurred speech,

and memory loss. While he was hospitalized, there was some examination done to

him and the cardiologist discovered there is LA myxoma and the doctor told him to

do cardiac surgery. He scheduled for cardiac surgery August 2023. He was

discharged form hospital and was hospitalized for 8 days. Most of his activities at

home done on bed. He cannot walk and standing by himself used diapers for

defecate and urinate for 2 weeks after discharged from hospital. Then, he began to

stand and walk with help of his caregiver for his daily activity. He was not doing

any rehabilitation program although he regularly went to neurologist and

cardiologist at RSHS to get checked for his condition. On 21st August 2023 he got

sternotomy for evacuation of LA myxoma. After the surgery the weakness didn’t

get worse although the patient felt improved for his condition. He can standing and

2
walking after discharged from hospital after the surgery. ADL independent. He

didn’t perform any home program exercise until the phase 2 cardiac rehabilitation.

The patient has not been working in his office since he was get hospitalized at

June. He used to be IT programmer and maintenance at private company. He work

for almost 12 hours a day and got sleep around 4-5 hours a day. His job involves a

lot of sitting in front of the computer and using his both hands to repair IT hardware.

After first hospitalization on June, he got trouble to using his left hand because he

feel cannot control the left hand smoothly to pick a screw and repairing the

hardware.

3. History of Past Illness

Patient did not have any chronic illness like hypertension, diabetes mellitus,

heart disease, dyslipidaemia or kidney disease.

4. History of Family Illness

No prior history of cardiopulmonary, autoimmune, or cancer disease in the

family

5. Medication

• Aspilet 1x80 mg

• Atorvastatin 1x40 mg

• Clopidogrel 1x75 mg

6. History of Functional Ability

3
 Before he had his illness in June, the patient can perform activities

independently without complaints other than easily fatigue from April 2023 as in

Table 1 below.

Table 1. Twenty-four hours daily activities before illness

Time Activity METs

08.30-09.00 Wake up 1

Take a bath 2

Wearing clothes 1.5

09.00-09.30 Breakfast 1.5

09.30-10.00 Riding motorcycle to 3.5

office

10.00-12.00 Working 1.3

12.00-13.00 Rest 1.3

Religious purpose : 2.0

Dzuhur prayer

Lunch 1.5

13.00-19.00 Working 1.5

19.00-20.00 Riding motorcycle to 3.5

home

20.00-21.00 Take a bath 2

Dinner 1.5

21.00-04.00 Working 1.5

4
 04.00-04.30 Religious purpose : 2.0

Subuh prayer

04.30-08.30 Sleep 0.95

Average METs 1.7

Highest METs 3.5

After his first hospitalization on June 2023, the patient not return to work

and perform daily activities as listed in Table 2 below.

Table 2. Twenty-four hours daily activities after illness

Time Activities METs

4.30-06.00 Wake up 1

Religious purpose :

Subuh prayer 2

Take a bath 2

06.00-08.00 Breakfast 1.5

Sitting on couch 1.3

08.00-09.00 Walking 2

09.00-12.00 Sitting on couch 1.3

Working on computer 1.3

Watching TV 1

12.00-13.00 Religious purpose : 2

Dzhuhur prayer

5
 Lunch 1.5

13.00-15.00 Sleep 0.95

15.00-16.00 Religious purpose : Ashr 2

prayer

Take a bath

16.00-17.00 Walking 2

17.00-19.00 Watching TV 1

Gather with family 1.3

19.00-21.00 Dinner 1.5

Watching TV 1

Religious purpose : Isya 2

Prayer

21.00-04.30 Sleep 0.95

Average METs 1,5

Highest METs 2

7. History of Habit

The patient had been smoking since 30 years ago ranging from 20-35 piece

per day (Brinkman index : heavy smoker) and stopped smoking since he was first

hospitalized on June 2023. The patient has a habit to sleep at dawn around 3-4 AM

and wake up at 8 am, because he was doing his work at home. This habit continued

until before the patient was hospitalized.

8. History of Nutrition

6
 The patient eats 3 times a day that consist of rice, protein (eggs, fish,

chicken, meat), vegetables and fruits. His Appetite is normal and there is no

unintentional weight loss.

9. Psychosocial and Economic Status

The patient is open person and calm. He easily tell his problems to his family

and try to solve the problem calmly. He felt easily afraid to perform daily task like

weight lift and exercise after he got stroke.

He is married, he lives with his wife and his 2 children, one who is 22 years

old and one who is 15 years old. Patient has a good relationship with his family.

He work on private company as IT programmer and also had a job as freelancer

technician at home. After the first hospitalization, patient is not working at his office

anymore and he continue to do side project as a freelance hardware technician at

his house. He got monthly income up to 4 million per month from his side project.

Even though he previously got 8 million rupiah from his job. The patient’s wife is

a housewife.

He has not had any sexual activity since he got stroke. His main caregiver is

his wife. Before patient got first hospitalization, he used to attend religious activity

once a week at his neighbour. But after the first hospitalization he never attend it

anymore.

10. Environmental Status

The patient lives in a 1-storey house with 3 bedrooms, and 1 bathroom with

squatting toilet. There are obstacles about 7 cm height at the front porch to the

7
entrance of the house, his bedroom and at the bathroom entrance. The patient can

ambulate around the house easily

8
11. Hope

The patient hope to do daily activities without easily tired

III. PHYSICAL EXAMINATION (25th September 2023)

1. Vital Signs

Consciousness : Compos Mentis (E4M6V5)

Contact : Adequate, cooperative

Blood Pressure : 106/57 mmHg

Pulse Rate : 73 x/minute

Respiratory Rate : 20 x/minute

Temperature : 37,1 oC

Pain Scale : NRS 0 Mid Sternal

Oxygen Saturation : 97 % Room air at rest

2. Nutritional Status

Body Weight : 60.9 kg

Body Height : 169 cm

Body Mass Index : 21,3 (Normoweight)

Mobilization : Independent

3. Medical General Status

Head region : Deformity (-), conjunctiva anaemic (-)

Neck Region : JVP 5+1 cm H2O, enlargement of lymph nodes (-)

9
Thorax region : Symmetrical shape and movement

Breathing pattern abdominothoracic

Retraction (-)

Post surgical wound a.r linea mediana ( 22,5 cm

hypertrophic scar with keloid scarring, adhesion (+)

minimal)

Heart : Ictus cordis not seen, normal heart sound S1, S2, murmur

(-), gallop (-)

Lung : Vesicular breath sound, right = left

Vocal fremitus right = left

Percussion sonor / sonor

Ronchi - / -, wheezing - / -, secrete - / -

Abdomen : Flat, soepel

Liver and spleen : no enlargement

Normal bowel sound

Extremities : Clubbing fingers (-), cyanosis (-), oedema (-)

Normal pulsation of bilateral popliteal artery

Normal pulsation of bilateral dorsalis pedis artery

Capillary refill time < 2 seconds

10
 IV. BODY FUNCTION

1. CRANIAL NERVE EXAMINATION

Cranial Nerve Interpretation

VII Motoric :

- Facial symmetry

- Facial muscle strength :

- Eyebrow raising

symmetric

- Eye closing

symmetric

- Nasolabial fold

symmetric

Sensorics : Normal

IX, X Normal

XII Tongue ataxia (-)

Tongue tremor (-)

Tongue atrophy (-)

Tongue deviation (-)

Tongue move to every direction (+)

11
 2. MENTAL FUNCTION

MoCA-INA Visuospatial and executive function 5/5

Naming 3/3

Attention and concentration 2/2

1/1

3/3

Language 2/2

1/1

Abstraction 2/2

Delayed recall memory 4/5

Orientation 6/6

Total 29/30

(Normal)

MoCA-INA : 29 (Normal)

3. EMOTIONAL FUNCTION

Assessment Items Results Normal Interpretation

Tools Value

DASS Depression 4 0-9 Normal

Anxiety 2 0-7 Normal

Stress 2 0-14 Normal

12
 4. SENSORY AND PAIN FUNCTION

Function Items Result

Tactile, touch Light touch Upper extremity : Normal / ¯ 30 %

Lower extremity : Normal / ¯ 30

Pin prick Upper extremity : Normal / ¯ 20 %

Lower extremity : Normal / ¯ 20 %

Proprioception Join position Normal

Musculoskeletal Pain in body part (-)

Pain

Pain in multiple body (-)

part

Neurogenic pain Radiating pain in (-)

dermatomes

Radiating pain in a (-)

segment or a region

5. FUNCTION OF THE CARDIOVASCULAR, HAEMATOLOGICAL,

IMMUNOLOGICAL AND RESPIRATORY FUNCTION

5.1 Functions of the cardiovascular system

Functions Items Results Interpretation

13
Heart Functions Heart Function Murmur (-), Gallop Normal

(-)

Heart Rate 73 beat/m Normal

Heart rhythm Regular, sinus Normal

rhythm

Contraction Normal heart sound Normal

force of

ventricular

muscles

Blood vessel Functions of CRT<2 seconds Normal

functions capillaries

Functions of JVP 5+2 cmH2O Normal

veins

Blood pressure Blood pressure 106/57 mmHg Normal

functions functions

5.2 Functions of the haematological and immunological system

Function Items Results Interpretation

Haematological Production of Haemoglobin : Anemia

system functions blood 13.2 g/dL

Haematocrit :

41.3 %

14
 Leukocyte :

9.66 103/uL

Thrombocyte :

300 ribu/uL

Oxygen-carrying Haemoglobin : Anemia

functions of the 13.2 g/dL

blood Saturation :

97% on

room air

Immunological Leukocyte : Normal

system functions 9.66 103/uL

5.3 Functions of the respiratory system

Function Items Results Interpretation

Respiratory Respiration rate 20 times/min Normal

functions Respiratory Regular Normal

rhythm Inspiration :

Expiration = 1 : 2

Depth of Chest expansion Normal

respiration 3,5 cm / 4 cm / 4

cm

15
 5.4 Additional functions and sensations of the cardiovascular and

respiratory systems

Function Items Results

Exercise tolerance General physical Entry Test

functions endurance : ECG baseline : sinus

Cardiopulmonary bradycardia,

endurance test BP : 106/63 mmHG

using Modified HR : 50 bpm

Bruce’s Protocol Test was performed with Modified

(18/09/2023) Bruce protocol, stopped at minute

09:57 due to fatigue, Borg Scale 17

(maximal stress test, achieved 90%

of maximal predicted heart rate)

Data for Exercise prescription:

Data result: maximal heart rate 155

bpm, baseline HR: 50 bpm, HR

reserve: 105 bpm

Ischemic heart rate : 112 bpm

75% Ischemic heart rate : 84 bpm

85% Ischemic heart rate : 95 bpm

Ischemic heart rate – 10 : 102 bpm

Result :

1. Adequacy Exercise test is

16
 adequate to measure ischemic

response test and fitness

classification

2. Symptoms during test None

3.Haemodynamic response

Appropriate

4.Arrhythmia : VES frequent

with quadrigeminy episode

5. Ischemic : Suggestive Ischemic

response test

6. Fitness Classification Very Poor

Fitness Classification, 7.97 METS

FC I

7. Clinical Recommendation :

Optimize medication

8. Exercise Recommendation :

Walking 3.25 km in 30 minutes

with target of HR 84 - 102 bpm

Sensations Fatigue

associated with Borg Scale 17

cardiovascular Chest pain (-)

and respiratory Palpitation (-)

functions

17
 6. FUNCTIONS OF THE DIGESTIVE, METABOLIC AND

ENDOCRINE SYSTEMS

6.1 Functions related to the digestive system

Function Items Results Interpretation

Ingestion function Good Normal

Swallowing Good Normal

Defecation Elimination of Spontaneous Normal

functions feces

7. NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED

FUNCTIONS

7.1 Functions of the joints and bones

Function Items Results Interpretation

Mobility of joint ROM UE and LE Full ROM Normal

functions

Stability of joint Laxity ligament No laxity Normal

functions

Mobility of bone Movement of Normal range and Normal

functions scapula, pelvis, movement

carpal and tarsal

bones

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 7.2 Muscle functions

Function Items Results Interpretation

Muscle power MMT UE and LE MMT 5/5, except

functions

Upper extremity

Wrist extension :

5/4

Finger flexion :

5/4

Finger extension :

5/4

Lower extremity

Hip Extension :

5/4

Muscle tone Tone of isolated Normal muscular Normal

functions muscles and tone

muscle groups

Muscle fitness Hand grip 10 kg / 7 kg Poor muscular

functions strength fitness

19
 7.3 Movement functions

Function Items Results Interpretation

Motor reflex Physiological BPR : 2+/3+ Normal /

function reflexes KPR : 2+/3+ Increased

ATR : 2+/3+

Pathological (-)

Reflex

Involuntary Berg Balance Sitting to standing : 4 Independent

movement Scale (BBS) Standing unsupported : 4

reaction Sitting unsupported : 4

functions Standing to sitting : 4

Transfers : 4

Standing with eyes

closed : 4

Standing with feet

together : 4

Reaching forward with

outstretched

arm : 4

Retrieving object from

floor : 4

Turning to look

behind : 4

20
 Turning 360 degrees

:4

Placing alternate

foot on stool : 4

Standing with one

foot in front : 4

Standing on one

foot : 1

Total 53/56

Control of Control of Flexion-extension of Normal

voluntary simple elbow, forearm, wrist,

movement voluntary hip, knee, ankle

function movement

Coordination of Finger to nose Normal/Fair

voluntary Heel to shin Normal/Normal

movement Diadochokinesia Normal

Sensations Sensation of No stiffness Normal

related to muscle stiffness

muscles and Sensation of No spasm Normal

movement muscle spasm

functions

21
 7.4 Gait Pattern Function

Heel strike Flat foot Midstance Heel off Toe off Initial Mid Swing Terminal
swing Swing

HIP Normal Flexi 30o Flexi 20o 0o Extensi 10o 0o 0o Flexi 35o Flexi 20-
30o

Flexi 300 Flexi 20o Flexi 3o Extension 00 00 Flexi 25o Flexi 20o
10o

KNEE Normal Flexi 5-10o Flexi 15o 0o Flexi 10o Flexi 30o Flexi 30o Flexi 50o Flexi 10-
20o

Flexi 120 Flexi 20o Flexi 5o Flexi 200 Flexi 40o Flexi 30o Flexi 50o Flexi 18o

ANKLE Normal 0o Plantarflexi Dorsiflexi Dorsiflexi Plantarflexi Dorsiflexio 0o 0o

5-10o 5o 10o 15o n 0o

Plantarflexi Plantarflexi Dorsiflexi 50 Dorsiflexion Plantarflexio Plantarflex Plantarflexi Dorsiflexio

5o 5o 10o . 150 ion 5o on 5o n 00

Gait analysis : Stance phase time left leg < right leg

22
 8. GENITOURINARY FUNCTION

Function Items Results Interpretation

Urination function Urination Spontaneous, Normal

Functions of complete without

voiding the any maneuvere

urinary bladder

Frequency of Urinate frequently Normal

urination 5- 6x/day

Urinary - Stress Continence

continence incontinence (-)

-Urgency with or

without

incontinence (-)

-Mixed

incontinence (-)

- Reflex

Voiding(+)

Sensations Sensations arising -Full sensation: Normal

associated with from voiding and Able to feel

urinary functions related urinary

23
 functions; -Micturition

sensations of sensation: Able to

incomplete feel

voiding of urine,
-Strong desire of
feeling of fullness
micturition: Able
of bladder
to feel

-Urgency

sensation (+)

-Complete

micturition

sensation: Able to

feel

Sexual function Patient fear to do Not able

sexual intercourse

Sensations Normal
associated with
genital and
reproductive
functions

9. FUNCTIONS OF THE SKIN AND RELATED STRUCTURES

9.1 Functions of the skin

Function Items Result Interpretation

24
Protective pressure injury (-)

functions of the

skin

V. BODY STRUCTURE

Organ system Area Location Type of

Pathology

Structure of Brain Cerebellum Infarct

nervous system

Structure of Heart Left atrium Dilated

cardiovascular Temuan intra Mitral annulus Dilated

system operasi : Tricuspid annulus Dilated

- Jantung ukuran

besar,

kontraktilitas

cukup

- Ditemukan LA

myxoma

dengan

pangkal di

IAS, dengan

ukuran 8x6x4

cm konsistensi

25
 kenyal dan

rapuh seperti

jelly

- Katup mitral :

dilatasi annulus

- Katup tricuspid

: dilatasi

anulus

VI. ACTIVITY AND PARTICIPATION

1. LEARNING AND APPLYING KNOWLEDGE

Activity Area Functional Result Interpretation

Purposeful Able to receive No limitation

sensory information, but

experiences slight impair to

retain new

information

Basic learning Able to do basic No limitation

learning, but

slight impair to

retain new

information

26
Applying Focusing Able to repeat No limitation

knowledge attention number sequence

Reading Could read & No limitation

understand

Writing Able to write No limitation

words &

sentences

Calculating Could do simple No limitation

calculation

Solving problem Able No limitation

Making decision Able No limitation

2. GENERAL TASK AND DEMAND

Activity Area Functional Result Interpretation

Undertaking a Simple task Able Adequate

single task Complex task Able

Carrying out daily Managing daily Able Adequate

routine routine

Completing daily Able Adequate

routine

3. COMMUNICATION

Item Result

27
Conversation Able

Using communication devices and Able

techniques

4. MOBILITY

4.1 Changing and Maintaining Body Position

Activity Area Item Result

Changing basic body Lying down Able

position Sitting Able

Standing Able

Bending Able

Squatting Able

Kneeling Able

Maintaining a body Maintaining a lying Able

position position

Maintaining a sitting Able

position

Maintaining a squatting Able

position

Maintaining knelling Able

position

Maintaining a standing Able

position

28
Transferring oneself While sitting Able

While lying Able

4.2 Carrying, Moving, and Handling Objects

Activity Area Item Result

Lifting and carrying Lifting Able

objects Carrying in the hands Able

Carrying in the arms Able

Putting down objects Able

Moving objects with Pushing Able

lower Kicking Able

Fine hand use Picking up Good / Fair

Grasping Able

Using one or both hands Able

to seize and hold

something

Manipulating Good / Fair

Releasing Able

Hand and arm use Pulling Able

Pushing Able

Reaching Able

29
 4.3 Walking and Moving

Activity Area Item Result

Walking Short distance Able

Long distance Able

On different surface Able

Around obstacle Able

Moving around Climbing Able

Running Able

Jumping Able

Moving around in Within the house Able

different locations Outside the house and Able

other buildings

5. SELF CARE

Activity Area Item Result

ADL Barthel Index 100/100

6. MAJOR LIFE AREA

Participation Item Result

Education Higher education Diploma

30
Work and employment Acquiring, keeping and Retire

terminating a job

Remunerative self Able

employment

7. COMMUNITY, SOCIAL AND CIVIC LIFE

Activity Area Item Result

Recreation and Hobby : Sport Not able

leisure Socializing Able

Religion and spirituality Praying and fasting Able

VII. ENVIRONTMENTAL FACTOR

1. SUPPORT AND RELATIONSHIP

Immediate family - His wife is the main Moderate facilitator

caregiver

- All family accept and

support the patient

- His wife is a housewife

2. SERVICES, SYSTEMS, AND POLICIES

Health service - The hospital far from Moderate barrier

his house

31
 - Using public

transportation

Health system Using BPJS Moderate facilitator

Health policies Using BPJS Moderate facilitator

VIII. SUPPORTING MEDICAL EXAMINATION

1. Head MSCT Scan

Kesimpulan :

- Infark di daerah cortical subcortical cerebellum kiri

- CT Scan kepala saat ini tidak menunjukkan adanya perdarahan

2. Echocardiography pre Evakuasi LA Myxoma (23 Juni 2023)

32
 Conclusion :

- Dilated LA

- LVEF : 60%

- Normal LV diastolic function with normokinetic at rest

- Normal anatomy and function of all valves, intermediate probability of

PH

- Normal RV systolic function

- Suggestive LA myxoma with functional obstruction at LV inflow

3. Spirometri (18 July 2023)

Prediksi Tanpda Bronkodilator

Angka %

FVC 3.81 2.95 77

FEV1/FVC 99.3

FEV1 3.00 2.93 98

PFM 6.05 450 74

Tes Faal Paru : Restriktif ringan

4. Kateterisasi Jantung pre Evakuasi LA myxoma (7 August 2023)

Kesimpulan : Non-Signifikan CAD

33
 Saran : Tindakan sesuai TS bedah Toraks dan Kardiovaskular

5. Echocardiography post Evakuasi LA myxoma (25 August 2023)

Conclusion :

- LVEF : 57%

- Normal all chambers dimension

- Normal LV diastolic function with normokinetic at rest

- Normal LV diastolic function

- Normal anatomy and function of all valves, low probability of PH

- Normal RV systolic function

6. Electrocardiography (25 August 2023)

Interpretasi : sinus ritme, tidak terdapat iskemia maupun aritmia

7. 6 Minutes Walking Test (25 August 2023)

- Distance : 173 m

- VO2 Max : 9,17

- METS : 2,62

34
 8. Bioelectrical Impedance Analysis ( 25 September 2023)

• Body Weight : 60.9 kg

• BMI : 21,3 kg/m2

• Whole body skeletal : 31.3 %

• Whole body subcutaneous : 15,0%

• Body age : 40 years

• Visceral fat : 6.5%

• Fat : 22,1%

• Metabolic basal : 1453 Kcal

9. Laboratory Finding (27 September 2023)

Result Unit Reference

Hemoglobin 13.2 g/dl 14-17.4

Hematocrit 41.3 % 41.5-50.4

Leukosit 9.66 103/uL 4.4-11.3

Eritrosit 4.87 Juta/uL 4.5-5.9

Trombosit 300 Ribu/uL 150-450

Kolestrol total 82 mg/dL <200

HDL 33 mg/dL >60

LDL 67 mg/dL <100

Trigliserida 95 mg/dL <150

HbA1c 5.0 % 4.5-6.2

35
Glukosa Puasa 79 mg/dL 70-100

SGOT 14 U/L 15-37

SGPT 15 U/L 0-55

Ureum 16.5 mg/dL 19-44

Kreatinin 0.81 mg/dL 0.72-1.25

Asam urat 4.7 mg/dL 3.5-7.2

IX. CASE RESUME

Male 48 years old, an educated person, was diagnose with post evacuation LA

myxoma with stroke infarct subacute phase. The risk factor is smoking and

unhealthy lifestyle. Patient had stroke on 20th June 2023 there were infarct at

cerebellum. After some examination, the doctor discovered there is LA

myxoma. The evacuation for LA myxoma was done at 21st August 2023. The

patient referred to cardiac rehabilitation on 25th September 2023.From

anamnesis and physical examination done on 25th September 2023 :

- He complaint easily fatigue when doing activities such as walking about

300 metre

- He got problem doing his job as the hardware technician because he got

difficulties at picking screw with his left hand

- General condition and vital sign are normal

- He had stop smoking since June 2023

- There is weakness on his left arm and left thigh with MMT 4

36
 - Decrease sensory function at left upper extremity and lower extremity

- There is disturbance in hand function where he was not good at

prehension, precision and power of his left hand

- There is increasing at physiological reflex for the left upper and lower

extremities

- Patient hand poor muscular weakness with hand grip strength is 10 kg /7

kg

- From cardiopulmonary test using modified bruce’s protocol, he got very

poor fitness classification with 7.97 METs and there is ischemic heart rate

at 112 bpm

X. DIAGNOSIS

1. MEDICAL DIAGNOSIS

Clinical Diagnosis Post evacuation LA myxoma

Post Strokes infract sub acute phase

Location Diagnosis Cardiovascular system

- Left atrium

- Mitral Annulus

- Tricuspid Annulus

Cerebrovascular system

• Brain

- Cerebellum

Etiological Diagnosis Cerebrovascular infarct

37
 2. REHABILITATION DIAGNOSIS

• Cardiorespiratory fitness disturbance that cause the patient feel easily

fatigue to do his activities

• Muscular fitness problem that cause patient cannot do his physical activities

optimally

• Vocational disturbance that caused by coordination disturbance

• Gait disturbance that cause the patient exert more energy to walk

• Sexual problem due to fear of sexual activity

XI. FUNCTIONAL PROGNOSIS

Quo ad vitam : ad bonam

Quo ad sanationam : ad bonam

Quo ad functionam :

• Back to vocational with improvement in left hand coordination

XII. REHABILITATION GOALS

1. Short term (6 weeks)

• Increasing cardiorespiratory fitness with target METs 9

• Physical activity increased

• Improvement hand coordination to support his vocation as a hardware

technician

12. Long term (6 to 12 weeks)

38
 • Further increasing cardiorespiratory fitness

• Increase in muscular fitness

• Maintaining healthy behaviour to prevent development of cardiovascular

risk factor

XIII. REHABILITATION PROGRAM

1. Cardiorespiratory fitness disturbance

Recent Target Program

Condition

- Patient hope he - Increasing 13. Aerobic

can doing his cardiorespiratory exercise

daily activity fitness with (hospital

without feeling target 9 METs based)

easily fatigue after phase 2 • Frequency : 2 times/week

- He want to go cardiac • Intensity : THR : 40-50% HRR

back to get a job rehabilitation + HR rest, maximal at 102

- Increasing beat/minute

physical activity • Time : 30 minutes

• Type : Aerobic exercise with

treadmill

• Progressivity : Increasing time

5 minutes every weeks and

intensity every 2 weeks

39
 14. Aerobic

exercise

(Home

Program)

• Frequency : 3 days a week

• Intensity : Borg Scale 9-10 or

HR below 100

• Time : 30 minutes

• Type : Aerobic exercise with

ground walking

Flexibility Exercise

• Frequency : 2 times/day

• Intensity : Stretch until slightly

discomfort

• Time : Hold for 10-30 second

static stretching, 3 repetition

• Type : Static flexibility

2. Muscular fitness disturbance

40
Recent Condition Target Program

- Low hand grip strength - Increasing 1. Resistance exercise

- Poor muscular fitness muscular fitness • Frequency : 2

classification after phase 2 with times/week

- Weakness at left hand fair classification • Intensity : Right : 50%

and thigh - 1 RM left side of of 1 RM Left : 70% 1

lower extremity RM

70% • Times ; 2 sets, 15

repetitions

• Type : bilateral

endurance and

strengthening

exercise of lower

extremity muscle

groups

2. Home program (resistance

exercise)

• Frequency : 2x/day; 5

days/week

• Intensity : 2 kg

dumbbell for each

hand, using

resistance band for

41
 lower extremity

• Times : 2 sets, 15

repetitions

• Type : isotonic for

upper and lower

extremity

3. Vocational disturbance

Recent Target Program

Condition

- Poor left hand - Improving left hand - Exercise the left hand for

coordination coordination so patient can coordination

grasp small screw with - Functional task exercise :

ease Upper and lower dressing,

- Increased ability to do wearing footwear, bathing,

bimanual activity and using computer with left

hand at home

4. Gait disturbance

Recent Condition Target Program

42
- Weakness on left - Able to walk longer 2. Home program (resistance

thigh distance in community exercise)

- Poor - Stance phase time left = • Frequency : 2x/day; 5

cardiorespiratory right days/week

fitness - Increased muscle strength • Intensity :, using

- Stance phase on left thigh resistance band for

time left leg < lower extremity

right leg • Times : 2 sets, 15

repetitions

• Type : isotonic for

lower extremity

3. Gait training (Hospital

based)

4. Education to walk

overground, stepping curb

and walk in community

5. Sexual Problem

Recent Condition Target Program

Patient did not had any Patient can do sexual Education about sexual

sexual intercourse since intercourse immediately activity that it is safe for

him to do that activity

43
June 2023 because of

fear to do sexual activity

XIV. FOLLOW UP

Follow up. Thursday, 2nd November 2023

S: The patient has done 9 sessions of hospital-based aerobic exercise. The

complaints of feeling tired easily is improved. Now he can walk about 1

kilometre without feeling tired.

He began to walk on the ground at his house for about 30 minutes 2-3

timer per week there was no complain.

From previous exercise there is no complain while he was exercising at

hospital. No chest pain nor exercise intolerance symptoms.

Poor coordination of left hand are still present.

He had sexual intercourse with his wife 1-2 times a week and there is no

complain.

O: Compos Mentis

Blood Pressure : 109/64 mmHg

Heart Rate : 60 beat/minute

Respiratory Rate : 20 times/minute

SpO2 : 99%

Muscle Performance : Quadriceps muscle 1RM 18,6 kg / 14 kg

44
A: Cardiorespiratory fitness, muscle endurance, vocational, gait disturbance

ec post vacuation LA myxoma, Stroke infarct sub acute phase

P: - Exercise program continues

- Education about physical activity at home, and adherence to exercise

Follow up. Wednesday, 15th November 2023

S: The patient has done 12 sessions of hospital-based aerobic exercise. No

exercise intolerance are reported. Complaint about easily tired has been

more improved. There are still complaint about left hand control when he

must picking small screw.

O: Compos Mentis

Blood Pressure : 109/65 mmHg

Heart Rate : 60 beat/minute

Respiratory Rate : 20 times/minute

SpO2 : 99%

6 Minute Walking Test :

- Distance : 354 m

- VO2 Max : 14,7

- METS : 4,2

Bioelectrical Impedance Analysis

- BB : 59

- BMI : 20.7

45
 - Whole body skeletal : 29.4%

- Whole body subcutaneous : 14,5%

- Body age : 41

- Visceral fat :6,3%

- Fat 21%

- Kal 1410

Hand Grip Strength : 14kg / 9 kg

Final test ( modified bruce’ protocol) 20/11/23

Data result : Maximal heart rate 170 bpm, baseline HR: 72 bpm, HR reserve :

98 bpm

- Adequacy : exercise test is adequate to measure ischemic response

test abd fitness classification

- Symptoms during test : None

- Haemodynamic response : Appropriate

- Arrhythmia : VES Frequent

- Ischemic : negative ischemic response

- Prognostic : -

- Fitness classification : Good fitness classification, 11,85 METs FC 1

- Clinical recommendation : Optimalize medication

- Exercise recommendation : Walking 4 km in 30 minutes with target

of HR 111-151 bpm

46
A: Cardiorespiratory fitness (Improve), muscle endurance (Improved),

vocational, gait disturbance ec post evacuation LA myxoma, Stroke

infarct sub acute phase

P: - Continue cardiac rehabilitation phase 3

- Education about physical activity at home, and adherence to exercise

XV. CASE DISCUSSION

Male, 48 years old come with a medical diagnosis of Post evacuation

LA myxoma, asymptomatic bradycardia because of SND with history

of strokes infract at sub acute phase. This patients was referred for

cardiac rehabilitation program phase 2 for the secondary prevention

program of cardiovascular disease through a hospital-based program

combined with home based cardiac rehabilitation program.

The evacuation of myxoma must be done immediately to prevent the

recurrence of cerebrovascular myxoma related events which typically

presenting as ischemic embolic and rarely as haemorrhagic events.1 There is

no evidence exists regarding to the optimal time to perform cardiac myxoma

surgery. Some study support that emergency cardiac myxoma evacuation must

be done after cerebrovascular manifestation and cardiac myxoma diagnosis.1

Functional limitation is common after the surgery, it is mediated by the chest

pain, respiratory complication, and anxiety due to resumption to daily activity.2

The functional limitation then can causes the patient to fall to a sedentary

lifestyle that must be avoided. The problem found in this patient is low

47
cardiorespiratory fitness, mobilization disturbance and poor musculoskeletal

fitness and strength which cause limitation in his work and daily activity.

Cardiac rehabilitation aims to help people with heart disease recover

their physical function, reduce their symptoms, and improve their overall

quality of life.3 It is important to this patient to help him return to his normal

activities of daily living and to return to his vocational activities by increasing

his functional capacity through cardiac rehabilitation. Patient who participate

in formal exercise (Hospital based program) programmes achieves their

optimum functional state more rapidly than who do not.3 A person’s functional

capacity is their ability to carry out routine activities. It is frequently assessed

by aerobic fitness, which is a measure of how well the body can use oxygen

during exercise.

The patient was diagnosed with stroke infarct sub-acute phase. Stroke is

classically characterized as a neurological deficit attributed to an acute focal

injury of the central nervous system (CNS) by a vascular cause, including

cerebral infarction, intracerebral haemorrhage (ICH), and subarachnoid

haemorrhage (SAH), and is a major cause of disability and death worldwide.

According to the symptoms and the diagnoses of this patient, the neurological

symptoms can be caused by the cardiac myxoma. There is study that said

neurological symptoms have been documented in about 26%-45% of person

with cardiac myxoma with cerebral embolic infarct being the most commonly

events.4 One major consequences for stroke patient is chronic sedentary

lifestyle that can be caused by impairments, activity limitation and participation

48
restrictions. Stroke survivors often have to use more energy to move around,

which can make them less active. Walking takes twice as much oxygen for

stroke survivors as it does for healthy people. Stroke survivors also often

experience fatigue, which can make them even less active. A sedentary lifestyle

can make stroke survivors fatigue worse5. There is strong evidence that aerobic

exercise after stroke can improve cardiovascular fitness, walking ability, and

upper-lower extremity muscle strength.6

Intervention on cardiorespiratory fitness in post evacuation LA

myxoma and stroke sub-acute phase in this patient are carried out by providing

aerobic exercise program and flexibility exercise regularly. Regular aerobic

exercise is an essential part of cardiac rehabilitation for patients who have had

heart surgery. Modern exercise-based cardiac rehabilitation programs use

aerobic exercises like walking and cycling to improve patients’ aerobic fitness

and ability to perform everyday activities. These programs can help to relieve

symptoms, slow the progression of heart disease, and reduce hospital

admissions and deaths.7 Aerobic exercise has effects on cardiorespiratory

system. It can increasing maximum aerobic capacity, increasing maximum

cardiac output, decreasing resting heart rate, and increasing stroke volume at

rest.8 Aerobic exercise can also increase the number of capillaries, reduce lipid

levels and increase fat-burning enzymes.9

Although exercise can be risky for people with stroke, the benefits

of exercise are greater than the risks. The potential health hazard of exercise

49
for stroke survivors are likely musculoskeletal injury, and sudden cardiac

death.5 Fall may occur with exercise training in stroke survivors, it occurred in

13% to 25% of intervention-group participants with stroke.5 Because the

patient had an LA myxoma evacuation and post stroke at sub acute phase,

aerobic exercise is done using treadmill. Treadmill offers at least 3 distinct

advantage for post stroke patient. First, it requires participants to perform a task

that people need to do in everyday life; walking. This should make it easier to

apply the skills they learn in the program to their daily lives. Second, the use

of handrails makes it possible for patients who would not be able to exercise

otherwise to walk on a treadmill. Finally, for patient who have trouble walking

at faster speed due to remaining gait and balance problem, the intensity of the

exercise can be increased by making the treadmill incline steeper.5

This patient was given aerobic exercise program that consist of

hospital-based an home-based exercise. Hospital-based exercise was

performed at intensity of 40%-50% with HRR method beginning at 30 minutes

per session with gradually increasing 5 minutes every week. Each exercise

showing positive result in vital sign and there was no exercise intolerance or

cardiac event.

The rationale for exercise in this patient is based on his modified

bruce’s test protocol results. There is ischemic heart rate at 112 bpm which

means that the target heart rate cannot be exceed 102 bpm. According to the

American College of Sports Medicine (ACSM), the recommended aerobic

50
exercise intensity for patients with cardiovascular disease is 40%-60% of their

heart rate reserve (HRR), and for patients with cerebrovascular accident

(CVA), it is 40%-70% of their HRR.9 However, we cannot give this patient

that intensity because he have ischemic heart rate. Previous research has shown

that aerobic exercise is feasible, safe, and significantly beneficial in improving

functional capacity in patients undergoneheart surgery.7

The goal for functional improvement in this patient to Increase from

7.97 METs to 9 METs by the end of phase 2 cardiac rehabilitation for 6 weeks.

Then, the patient are expected to continue to increasing physical activity,

improving his ability to perform everyday tasks, keep up their healthy habits,

and move on to the third phase of cardiac rehabilitation. This cardiac

rehabilitation is also expected to modified the behavioral of this patient to a

positive side. AACVPR recommendation 18-24 session of cardiac

rehabilitation phase 2 for moderate-risk patient.10

Muscular fitness is one of the problem we found in this patient. There

are various types of resistance training equipment, such as free weights, weight

machines, and resistance bands, can be effectively used to enhance muscular

strength and fitness. A higher level of muscular strength is linked to a lot of

health benefits, such as a better cardiometabolic risk factor profile, a lower risk

of death from all causes, fewer CVD events, a lower risk of developing

functional limitations, and nonfatal diseases.11 Strength training also has been

found to be beneficial in stroke survivors. A 12-week resistance training

program, done twice a week with gradually increasing intensity, was shown to

51
improve muscle strength, walking ability, and balance in people who have had

a stroke.5

In subacute phase with ataxia, the major goal of a rehabilitation is to

increase the quality of life in patient post stroke. Miayai et al. showed that with

intensive rehabilitation which 2 hours per day for 4 week that focused on

improving postural balance, gait and ADL could improve ataxia and gait speed

on patient with cerebellar ataxia. The goal for this patient is to do bimanual

activity by regain the precision of his left hand, so we hope that he can back to

his vocational. We also encourage patient to have activities that have purpose

such as typing on keyboard at home. This intention is to keep patient’s mind

active and increasing patient activities.

For the gait disturbance in this patient, we give resistance exercise

and education for gait optimalization. Walking speed was observed to be

improved in stroke patients following a 6-week isotonic muscle training

program targeting the knee flexors and extensors. However, leg muscle

stiffness did not increase12. Numerous studies that have shown a substantial

association between walking speed and the paretic side lower limb muscle

strength have reinforced the importance of muscular strength.12 Other than that,

we encourage the patient to do overground walking in his house and

environment. The patient was ask to stepping up a curb, walking around people

or crowd or walking on uneven surface and also we ask for the caregiver to

accompany him when he do the exercise.

52
XVI. CASE ANALYSIS

53
 Daftar Pustaka

1. Stefanou M-I, Rath D, Stadler V, Richter H, Hennersdorf F, Lausberg HF,

et al. Cardiac myxoma and cerebrovascular events: a retrospective cohort study.

Frontiers in neurology. 2018;9:823.

2. Ennis S, Lobley G, Worrall S, Powell R, Kimani PK, Khan AJ, et al. Early

initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study

protocol for a randomised controlled trial and economic evaluation. BMJ open.

2018;8(3):e019748.

3. Pell J. Cardiac rehabilitation: a review of its effectiveness. Coronary Health

Care. 1997;1(1):8-17.

4. Lee VH, Connolly HM, Brown RD. Central nervous system manifestations

of cardiac myxoma. Archives of Neurology. 2007;64(8):1115-20.

5. Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson CM, et

al. Physical activity and exercise recommendations for stroke survivors: a statement

for healthcare professionals from the American Heart Association/American Stroke

Association. Stroke. 2014;45(8):2532-53.

6. Pang MY, Eng JJ, Dawson AS, Gylfadóttir S. The use of aerobic exercise

training in improving aerobic capacity in individuals with stroke: a meta-analysis.

Clinical rehabilitation. 2006;20(2):97-111.

7. Doyle MP, Indraratna P, Tardo DT, Peeceeyen SC, Peoples GE. Safety and

efficacy of aerobic exercise commenced early after cardiac surgery: a systematic

54
review and meta-analysis. European Journal of Preventive Cardiology.

2019;26(1):36-45.

8. Hussein N. 27 - Acute Medical Conditions. In: Cifu DX, Lew HL, editors.

Braddom's Rehabilitation Care: A Clinical Handbook: Elsevier; 2018. p. 183-9.e8.

9. Bayles MP. ACSM's exercise testing and prescription: Lippincott Williams

& Wilkins; 2023.

10. Cardiovascular AAo, Rehabilitation P. Guidelines for Cardia Rehabilitation

and Secondary Prevention Programs-5th Edition (with Web Resource): Human

Kinetics; 2013.

11. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee I-

M, et al. Quantity and quality of exercise for developing and maintaining

cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy

adults: guidance for prescribing exercise. 2011.

12. Eng JJ, Tang PF. Gait training strategies to optimize walking ability in

people with stroke: a synthesis of the evidence. Expert Rev Neurother.

2007;7(10):1417-36.

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 Lampiran

1. MoCA-Ina

56
2. Barthel Index

57
3. Berg Balance Test

58
59
60
4. Final Test (Bruce’s test protocol)

61