Clinical Placement V

Case Presentation
PTCP 2416
Prepared By:
Tang Chia Wang
BPHF 16041346
Subjective
Name Mr. Y

Age 58 years old

Sex Male

Date of Admission 5/7/2017

Date of Assessment 8/7/2017

Diagnosis Double vessel disease (DVD)

Doctor’s Management Surgical mx – CABG POST OP Day 1

(referred to physiotherapy)

Patient Complain Patient complains of slight chest and Lt shoulder pain (3/10)
Patient complains of tiredness
 Body Chart
Superficial, dull aching

Superficial, pulling pain

Pain Assessment
Area of Pain Anterior & medial aspect of chest and Lt shoulder pain

VAS 5/10 on chest and Lt shoulder even in slight movement

3/10 on chest and Lt shoulder at rest
3/10 when resting

Nature of Pain Superficial, pulling pain( chest)

Superficial, dull aching ( shoulder)

Type of Pain Constant

24hrs behavior NIL

Irritability Low

Agg Factor Coughing cause more chest pain

Stop moving shoulder for long cause shoulder pain

Ease Factor Take rest and stop coughing won’t cause chest pain
Moving shoulder can stop shoulder pain
Current History He had suffered from chest heaviness and sweating since 1
month ago. Sunway Hospital referred him to IJN after doctor
diagnosed him with CAD. Then he admitted into IJN on 5/7/19
and underwent surgical mx on 7/7/19. He was transferred into
ICU immediately and referred to physio for further
management

Past History Pt had hisotry of admission into Sunway Hospital because of

CAD. Doctor was giving him angiogram & left the stent about
2 years ago.

Past Medical History Diabetes, HPT & Cholestrol since 2 yrs ago

Family History His mother has diabetes

Personal History Ex smoker (quits since 2 years ago)

Occupation: constrcution
Medication Paracetamol Q1D
Pantoprazole OD
Lasix OD
Spironolactone OD
Cefazolin TDS
Tramal TDS
Investigation CXR findings (7/7/19): Lower zone lung collapse and mild
pleural effusion

ABG (8/7/19)
pH: 7.434
PCO2: 37.5
PO2: 154.3
HCO3:24.6
BE: 0.4
Interpretation: normal

ECG (25/6/19)
Left ventricle is dilated in size, EF is at 25%
Right ventricle & atrium are normal in size
Left atrium is dilated in size
OBJECTIVE
Vital Signs • RR :24/min
interrater reliability of vital • PR : 65 b.p.m
sign measurements • B/P: 125/54 mm/Hg
(K value 0.6-0.8) substantial • SP0₂ :99% (nasal prong)
agreement
(Edmonds, Z. V., 2002, p. 233-
237).

General Observation •Patient is half lying on bed alone with neck side
bending to Rt side.
Local Observation •Plaster on chest and bandage on both lower legs

•Tri lumen on Rt neck, brannula on Rt hand

•Chest drain

•ECG
Breathing Pattern: Shallow

Breathing Level : Apical

Cough : effective and non productive

Sputum : no
O₂ treatment : nasal prong 5L/min

Palpation Grade 1 Tenderness on incison scar

Muscle Spasm over the Lt shoulder
Auscultation
Kappa values for abnormal and
adventitious lung sounds achieved
moderate agreement in the upper
zones,
substantial agreement in the
middle zones,
moderate agreement to almost
perfect agreement in the lower
zones.
(Berry, M. P., 2016, p. 1374-1384).

Interpretation:
1. reduced air entry in bilateral lower zone
2. Mild crepitation in bilateral lower zone
(secretion)
Chest Measurement Interpretation: poor chest expansion for all levels.
(Thumb
Displacement) Level 1(cm) 2 (cm) 3 (cm) Avg
(cm)
Apical 1 1 1 1.0
Middle 0.5 0.5 0.5 0.5
Lower 0.5 0.5 0.5 0.5

Chest Symmetry Interpretation: chest expansion is symmetrical

Specificity and
positive predictive
value of 100%, Level Result
sensitivity was only Apical Symmetry
4.3%. good diagnostic Middle Symmetry
or confirmatory test.
(SHELLENBERGER, Lower Symmetry
R.A., 2017, p. 943-950).
Spirometer Pre op: 1750ml
Positive correlation Post op: 750ml
between DVC measured with
ventilometer and incentive Interpretation: reduced in lung capacity and
spirometer. function.
Using incentive spirometer as
DVC evaluation method was
of easy execution and
understanding by the
patient.
(Pinheiro , A.C., 2011, p. 1-5)

ROM Left and Right UL & LL are AFROM

 Analysis
Shoulder pain d/t poor posture
awareness
Apical breathing pattern d/t chest
pain and overuse of accessory
muscle
Reduced in chest expansion d/t
reduced in thoracic mobility
Reduced air entry d/t poor
diaphragm inflation and reduced in
chest expansion
Secretion in lower zone d/t poor
coughing effort and chest pain
Sudden onset of shoulder pain in them may have
been due to the cumulative effect of anxiety
and the tension and stretching imposed
during surgery. (Mousavi, S., 2017, p. 10-14)
Constant chest pain, overuse and tension in
the accessory respiratory muscles,
dysfunctional postures, and anxiety can be the
contributing factor of breathing pattern disorder.
(CliftonSmith, T., 2011).
Loss of thoracic cage compliance may
impede normal movement of the chest wall
(CliftonSmith, T., 2011).
Outward expansion of the thorax by the
respiratory muscles with descent of the
diaphragm creates negative intrathoracic
pressure. This causes passive air entry into the
lungs during inspiration. (Eckstein, M., 2013).
Not being able to remove respiratory secretions
due to his/her poor cough effort. (Sancho, J.,
2007, p. 1266- 1271)
Analysis Short term goals:
•Reduce the chest and shoulder pain to 2/10 VAS within 3/7
•Correct the posture within 3/7
•Correct breathing pattern within 3/7
•Improve chest expansion within 3/7
•Improve air entry within 3/7
•Improve coughing effort to remove secretion within 3/7
Long term goals:
• Regain back to his working within 2/12
•Prevent secondary complication such as DVT & edema

Plan of  Force expiratory technique

treatment Breathing exercise
Free active movement exercise
Bed mobility exercise
Patient education on posture
Home exercise
Intervention
Diaphragmatic breathing exercise
The patient in sitting position with hands rest on the
stomach, he is asked to breath in through the nose,
hold for 3 seconds and then breathe out through the
nose. It is done for 10 repetitions.

Improving in inflation of the alveoli, reversing

postoperative hypoxemia, improvement of ventilation
and oxygenation, decreasing the work of breathing,
and increasing the degree of excursion of the
diaphragm(Alaparthi, G. K., 2016)
Intervention
Incentive Spirometer
The patient in half lying position. As the spirometer is
holding at the face level, ask pt blow out the air before
suck it deep and slow for 5 reps

Volumetric incentive spirometer is better in case of

cardiac and thoracic surgeries provides the appropriate
feedback for a slow sustained inspiration and
volume. This is effective to promote lung expansion
rather than fast inspirations(Alaparthi, G. K., 2016)
Intervention
Coughing technique is done by the patient in half
lying position with holding a pillow. Patient is asked to
breath in and then forcefully expel out the sputum
from tracheostomy tube by coughing for 3 times.

The use of a sternal supporting vest in the

postoperative period can reduce pain during cough,
because it provides compression thus protecting the
sternum and reduce strain on the incision site.
(Brocki, B.C., 2010, p. 77-84)
Intervention
Active free movements
Physical activity and limbs exercises reduce sternal pain and may
be imperative for healing and remodelling of bone, which
responds to loading. (Katijjahbe, M. A., 2018, p. 97-106).

Ankle pumping exercises utilize a calf muscle pump function to

pump blood to the heart by muscle contraction. Ankle pumping
exercises are often used for the relief of edema and the
prevention of deep vein thrombosis. (Toya, K., 2016, p. 685-
688).

Patient is in half lying, pt will do full shoulder flexion, 90 abd,

elbow flexion, hip & knee flexion and ankle pump. 10 reps
Intervention
Patien Education & HEP

•Posture is corrected by asking patient to adjust the

head upright by himself, looking forward and not
sloughing the shoulder.

•Patient is encouraged to do breathing exercises and

AROM exercises as stated about for 20 repetitions in
every hours and maintain upright posture when sitting.
Evaluation Patient able to understand and obey all the
commands during the exercise session

Pain Ax: Remain the same.

Vital signs
BP: 126/65
HR: 65
RR: 22
SpO2: 100

Spirometer: 1000ml

Review •Reassess auscultation, chest expansion, spirometer,

bed mobility, vital signs
References
Alaparthi, G. K., Augustine, A. J., Anand, R., & Mahale, A. (2016). Comparison
of Diaphragmatic Breathing Exercise, Volume and Flow Incentive Spirometry,
on Diaphragm Excursion and Pulmonary Function in Patients Undergoing
Laparoscopic Surgery: A Randomized Controlled Trial. [Online] Minimally
Invasive Surgery, 2016, p. 1–12. Available at:
https://sci-hub.tw/http://dx.doi.org/10.1155/2016/1967532 (Accessed: 28/9/19).
Brocki, B. C., Thorup, C. B., & Andreasen, J. J. (2010). Precautions Related to
Midline Sternotomy in Cardiac Surgery: A Review of Mechanical Stress Factors
Leading to Sternal Complications. [Online] European Journal of
Cardiovascular Nursing, 9 (2), p. 77–84. Available at:
https://www.researchgate.net/publication/40850176_Precautions_Related_to_
Midline_Sternotomy_in_Cardiac_Surgery_A_Review_of_Mechanical_Stress_F
actors_Leading_to_Sternal_Complications
(Accessed: 28/8/19).
Toya, K. (2016). Ankle positions and exercise intervals effect on the blood flow
velocity in the common femoral vein during ankle pumping exercises. [Online]
J. Phys. Ther. Sci, 28, p. 685–688. Available at:https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC4793034/pdf/jpts-28-685.pdf(Accessed: 28/8/19).
References
Doyle, M. P., Indraratna, P., Tardo, D. T., Peeceeyen, S.
C., & Peoples, G. E. (2018). Safety and efficacy of aerobic
exercise commenced early after cardiac surgery: A
systematic review and meta-analysis. [Online] European
Journal of Preventive Cardiology. Available at:
https://sci-hub.tw/10.1177/2047487318798924 (Accessed:
28/9/19).
Nazari, N. (2012). Effect of Cardiac Rehabilitation on
Strength and Balance in Patients after Coronary Artery
Bypass Graft. [Online] Zahedan J Res Med Sci, 16 (1), p.
74-78. (Accessed: 28/9/19).
References
Mousavi, S. (2017). The Prevalence and Characteristics of Shoulder
Pain in Female Patients with Coronary Artery Bypass Graft (CABG).
[Online] JRSR, 4 (1), p. 10-14. Available at:
https://pdfs.semanticscholar.org/55f8/b07ff5bf643c7fe049a7bdcdea
da4c3ff770.pdf
(Accessed: 28/8/19).
CliftonSmith, T., & Rowley, J. (2011). Breathing pattern disorders and
physiotherapy: inspiration for our profession. [Online] Physical
Therapy Reviews, 16 (1), p. 75–86. Available at:
https://sci-hub.tw/10.1179/1743288X10Y.0000000025 (Accessed:
28/8/19).
Eckstein, M. (2013). Thoracic Trauma. [Online] Available at:
https://pdfs.semanticscholar.org/ec17/3d05bbe8b893449f9ad31e4e1
af4fb956556.pdf
(Accessed: 28/8/19).
References
SHELLENBERGER, R.A. (2017). Diagnostic value of the physical examination
in patients with dyspnea. [Online] Cleveland Clinic Journal of Medicine, 84
(12), p. 943-950. Available at:
https://www.mdedge.com/ccjm/article/152915/pulmonology/diagnostic-value-
physical-examination-patients-dyspnea
(Accessed: 27/8/19).
Berry, M. P., Martí, J.-D., & Ntoumenopoulos, G. (2016). Inter-Rater Agreement
of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth
Patterns Between Clinicians. [Online] Respiratory Care, 61 (10), p. 1374–1383.
Available at:
http://rc.rcjournal.com/content/respcare/early/2016/07/26/respcare.04214.full
.pdf
(Accessed: 27/8/19).
Edmonds, Z. V., Mower, W. R., Lovato, L. M., & Lomeli, R. (2002). The
reliability of vital sign measurements. [Online] Annals of Emergency
Medicine, 39(3), 233–237. Available at:
https://sci-hub.tw/10.1067/mem.2002.122017 (Accessed: 27/8/19).
Refereces
Katijjahbe, M. A., Granger, C. L., Denehy, L., Royse, A., Royse, C., Bates, R., El-Ansary,
D. (2018). Standard restrictive sternal precautions and modified sternal precautions
had similar effects in people after cardiac surgery via median sternotomy (“SMART”
Trial): a randomised trial. [Online] Journal of Physiotherapy, 64 (2), p. 97–106.
Available at: https://sci-hub.tw/https://doi.org/10.1016/j.jphys.2018.02.013 (Accessed:
28/8/19).
Pinheiro , A.C. (2011). Estimation of lung vital capacity before and after coronary
artery bypass grafting surgery: a comparison of incentive spirometer and
ventilometry. [Online] Journal of Cardiothoracic Surgery, 6 (70), p. 1-5. Available at:
https://cardiothoracicsurgery.biomedcentral.com/track/pdf/10.1186/1749-8090-6-70
(Accessed: 28/8/19).
Sancho, J., Servera, E., Díaz, J., & Marín, J. (2007). Predictors of Ineffective Cough
during a Chest Infection in Patients with Stable Amyotrophic Lateral Sclerosis.
American Journal of Respiratory and Critical Care Medicine, 175(12), 1266–1271.
Available at: https://www.atsjournals.org/doi/pdf/10.1164/rccm.200612-1841OC
(Accessed: 28/8/19).