CLINICAL PRESENTATION

Guided by: Dr. Brinda Joshi

Prepared by: Amrut Sosa1
DEMOGRAPHIC DETAILS

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 Name :Kalubhai bavliya
 Age :57 years
 Gender :Male
 Weight :69 Kg
 Height :172 cm
 B.M.I. :23.32 kg/m2
 Occupation :Farmer
 Marital Status :Married
 Address :Surendranagar
 Date of admission :08/11/2021
 DOA :13/11/2021

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[According to WHO classification]
BMI classification
Under weight: <18.5
Normal : 18.5 to 24.9
Over weight : 25 to 29.9
Obesity type 1 : 30 to 34.9
Obesity type 2 : 35 to 39.9
Extreme obesity : >40

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 Chief Complain
 Patient complaints of pain in chest and right leg
after surgery (11th Nov 2021).
 Having breathlessness while changing position.
 Also complaints of cough with sputum.

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History Of Present illness
 Patient having breathlessness since 1 year and chest
pain since 1.5 month. He consulted the Doctor in Muli
and ECG taken which shows inferior wall MI so,
Doctor referred him to the higher center.
 Patient admitted to CJ hospital for four days and get
diagnosed with hypertension and inferior wall MI.
patient discharged after getting primary treatment.
 On 1st Nov. 2021 patient consulted Dr. Surendra
Singh Chauhan (Consultant Cardiovascular and
thoracic surgeon) C.U. shah medical college and
hospital and referred to Dr. Jayesh Meniya
(Interventional Cardiologist) for further investigation . 6
 After a investigations Doctor suggested Early
CABG+ Medical Management.
 On 08/11/2021 patient admitted for the CABG and
after 2 Days CABG procedure done by Dr. Jayesh
Meniya.
 Patient is under observation in cardiac ICU after
surgery.

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Medical History
 Type 2 Diabetes Mellitus since 5 years.
 Hypertension since 1 month.
Surgical history
 Median sternotomy (Incision)
 Graft: Right Great Saphenous vein
 CABG (10 Nov. 2021)
Past Medical history
 Angina before1.5 month

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DRUG HISTORY
 Metformin
 Glimipiride
 Metoprolol
 Zifi CV
 Ecosprin
 Plavix
 Allstat
 Nexpro
 Glimison
 Nikoran
 Bploc
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Family History
Not present.

Socioeconomic History
Lower middle class (according to kuppuswamy
scale)

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PERSONAL HISTORY

 History of smoking from last 17 years .

10 cigarette /day
8.5 Pack-year
From last 3 months patient was smoking 1-2
cigarettes per day
 Diet: vegetarian
 Sleep: altered

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SUBJECTIVE ASSESSMENT

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Pain assessment
 Site of Pain – retro sternal pain and medial aspects
of right lower limb
 Onset of Pain – Sudden
 Type of pain –dull aching in retrosternal area and
medial aspects of right lower limb.
 Intensity of Pain (NPRS)– 4
 Aggravating factors –any activity
 Relieving factor -medication

0 4 10

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DYSPNEA

 Dyspnea : present
 Duration : 1 year
 NYHA grade 2
 Aggravating factor: any activity
 Reliving factor: medication and rest

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COUGH
 Cough: present
 Severity: Acute
 Grade: M2
 Productive in nature
 Time: any time
 Aggravating factor: changing position
 Reliving factor: Medication

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MILLER’S GRADING :

M1 : Normal saliva
M2 : Mucoid
P1 : Mucopurulent ( 1/3rd pus , 2/3rd mucoid )
P2 : Mucopurulent ( 1/3rd mucoid , 2/3rd pus )
H: Hemoptysis
F: Frothy

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 SPUTUM

 Sputum: Present
 Color : white sticky
 Quantity : 1-2 table spoon per day

Reference =Jennifer A. Pryor and Barbara A. Webber

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 Chest pain: Present (suture pain)
Grade 2

(Ref: Susan B. O'Sullivan) 20

 Hemoptysis: not present
 Other symptoms:
Fever: not present
Fatigue and weakness: present
Headache: not present

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OBJECTIVE ASSESSMENT

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ON OBSERVATION
 Body built : Mesomorphic
 Cynosis : not present
 Clubbing : Present
Schamroth sign : Absent
Grade 2
 Peripheral edema: Present
 External appliance: urine catheter, ECG leads and central
IV lines
 Incision: median Sternotomy
 Scar site: Sternum and medial aspect of right lower limb
 Chest deformity : not present
 Use of accessory muscles : not present
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 Clubbing grades
Grade 1: softening of nail bed
Grade 2: obliteration of nail bed angle
Grade 3: parrot beak or drum stick appearance
Grade 4: Hypertrophic osteoarthropathy (HOA)

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 Median sternotomy:
Length: 18 cm

Scar at harvesting site:

Length: 32 cm

SCAR 25
BREATHING PATTERN:
 Rate :22 breath/ min
 Depth : Rapid shallow breathings
 Type : Abdomino-thoracic

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POSTURE

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 ANTERIOR VIEW :

• Both ear lobs are at

same level
• Both shoulder are at
same level
• Both elbow and wrist
are at same level.
• Both ASIS are at same
level.
• Both knee and ankle
are at same level.

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 LATERAL VIEW :

• Ear lobe and

acromion process are
not at same level
( forward head )
• No any abnormality is
seen in spinal
curvature.

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 POSTERIOR VIEW :

• Both ear lobes are at

same level.
• Both shoulder are at
same level
• Both elbow and wrist
are at same level.
• Both PSIS are at
same level
• Both knee and ankle
are at same level.

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 ON PALPATION

Oedema : Present
pitting edema
Grade 1
Position of trachea : centrally placed
Chest symmetry : B/L symmetrical
Tactile Vocal fremitus : increased
Chest expansion :

At axillary level : 1 cm
At nipple level : 2 cm
At xiphisternum level : 3 cm

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SIZE OF CHEST :

AP diameter : 30cm

Transverse diameter : 35cm

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ON PERCUSSION

Diagnostic percussion : Hypo-resonance in

intercostal space of upper and lower lobe of
right lung.

ON AUSCULTATION

Breath sound : inspiratory Crackles present in

upper & lower lobe of the right lung.

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ON EXAMINATION
VITAL SIGN :

Blood pressure :138/77 mmHg

Heart rate : 98/min
Respiratory rate : 22 breaths/min
Spo2 : 98%
Temperature : 37⁰ C

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Range of motion
ROM of UL and LL is normal.

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6- min walk test
 Patient was not able to complete the test.
 As breathlessness started after walking 72m.
 Distance walked – 96.8m
Vitals Pre test Post test vital Post test Post test
vitals (0 min) vitals (2 min) vitals (4 min)

HR (bpm) 102 113 105 101

RR (cpm) 22 36 28 20

BP (mmHg) 138/70 155/73 140/72 138/71

SPO2 (%) 98 96 98 99

RPE 0 5 3 2
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PAR-Q

INTERPRETATION: He is a moderate risk patient and is

advised for supervised exercise regime.
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 Interpretation: according to Framingham
risk score to predict 10 year absolute risk
of CHD event in this patient is 25%.

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INTERPRETATION:
PHYSICAL SCORE: 28.79
MENTAL SCORE: 32.81

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INVESTIGATION

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X-ray

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ECHO DOPPLER REPORT

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Conclusion

 LVEF: 35%
 Hypokinesia: mid and basal inferior, infero-septal and
infero-posterior wall hypokinesia
 Normal LV size and moderate LV dysfunction with
RWMA
 Reduced LV compliance

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ECG:

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ICF(international classification of
functioning, disability and health)
 At the level of body structure –structure of lung
and heart, bones and muscle
 At the level of body function –respiration-airways
and cardiac function-hypokinesia.
 Activity limitation – walking, stair climbing,
bathing, toileting sit to stand supine to side lying
and prone.
 Participation restriction – social activity .

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DIAGNOSIS

CABG post IWMI

(Inferior wall myocardial infarction)

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PROBLEM LIST

 Breathlessness
 Cough
 Sputum
 Fatigue
 Weakness

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PHYSIOTHERAPY
MANAGEMENT

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 GOALS
• Education to the patient and family members
in the recognition, prevention and treatment of
cardiovascular disease.
• To gain the confidence of the patient.
• To prevent harmful secondary circulatory and
respiratory complications.
• Modifications of risk factors as far as possible.

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•To improve cardiovascular fitness.
•To improve chest expansion.
•To reduce work of heart.
•To maintain and improve the patient functional
capacity.
•To improve patients quality of life.
•To make patient maximum independent.

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Precautions after CABG

•Post revascularization ETT results are important.

•Low intensity aerobic training.
•Few repetitions throughout the day.
•Rest period importance.
•Avoid lifting, pushing, pulling objects for 4-6 weeks..

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• Avoid sternal discomforts.
• Avoid isometrics contraction after
surgery because of valsalva maneuvar.
• Intially go for two extremity exercise
then go for four extrimity.
• Lower limb exercise is more visible
than upper limb

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Cardiac rehabilitation

Phases of recovery
Phase 1: inpatient rehabilitation (1 week)
Phase 2: immediate post-discharge (2-6 weeks)
Phase 3: supervised outpatient phase (6-12 weeks)
Phase 4: long term maintenance phase more than
4-6 months. (unsupervised)

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Phase 1 (1-7 days):
 Day 1 → Level 1
( 1 - 1.5 MET)
• Total bed rest.
• Educate patient about disease.
• Arm supported for meal and other
ADLs.
• Breathing exercises
• Houghing and Coughing (supported
splinted coughing ) 56
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 SPIROMETRY

Incentive spirometry (sustained maximal inspiration)

A deep breath can be facilitated by an incentive
spirometry.
Procedure: patient should be in relaxed position.
Ask the patient to keep the mouthpiece into his
mouth then first exhales upto 5 sec approximately.
(To empty the lungs) then ask the patient to take
deep breath and hold it atleast for 3 to 5 sec and
exhale. Make sure that patient should not use
accessory muscles of respiration.
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 Day - 2 → Level - 2
(1.5 - 2 MET)

• Breathing exercises.
• Sitting position for 15 min 2 to 4 times per day.
• Leg exercises.
• Limited room ambulation.
• Few steps with assistance of physiotherapist.
• Educate patient about exercise being
performed.
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 Day - 3 → Level - 3

(2 – 2.5 MET)

• Breathing exercise.
• Foot exercise.
• Standing leg exercise.
• Self bathroom activity.
• Ambulation 4 to 5 min 1 time per day.

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 Day - 4 → Level - 4

(2.5 – 3 MET)

• Breathing exercise.
• Foot exercise
• Trunk exercise in standing.
• Ambulation 5 to 7 mins 4 times per day.

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 Day - 4 → Level - 5

(3 – 4 MET)

• Continue previous exercises.

• Progressive hall ambulation 10 mins 4
times per day.

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 Day - 5 → Level - 6

• Stair climbing one step at a time.

• Trunk exercise in standing.

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 Termination Criteria

• Systolic BP > 200 mm hg

• Diastolic BP > 100 mm hg
• If patient taken ß – blocker then HR should not
increases above 12 than resting HR.
• If patient have not taken ß – blocker then HR
should not increases above 20 than resting HR.

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• Moderate to severe angina.
• Fatigue
• Dyspnea
• Leg pain
• Hypertensive response
• Increase CNS symptoms (ataxia, dizziness)

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Phase – 2 to 4 :-
Home exercise program :
 Before giving the home exercise program
give the following command to patient.
• Train the patient to monitor himself.
• Written form of activity guidelines.
• 20 to 30 mins of walking daily which should
be gradually increase.
• No afternoon sleep.
• Proper diet, low cholesterol.
• If any discomfort during exercise, report to
doctor.
• Visit the consultant at regular intervals. 72
 Goals for Outpatient Cardiac Rehabilitation

• Develop and assist the patient to implement a

safe and effective formal exercise and lifestyle
physical activity program.

• Provide appropriate supervision and

monitoring to detect deterioration in clinical
status and provide ongoing surveillance data to
the patient’s healthcare providers to enhance
medical management.
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• Return the patient to vocational and recreational
activities or modify these activities contingent on
the patient’s clinical status.

• Provide patient and family education to maximize

secondary prevention through aggressive
lifestyle management and judicious use of
cardioprotective medications

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Exercise prescription :
 It depended on FITT principles
F = Frequency (5 days per week)
I = Intensity (40-60% of HR max)
T = Time (1 hour)
First 10 min warm up
40 -50 min exercises
last 10 min cool down
T = Type
Interval training
continue training
circuit training
circuit interval training
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Progression Of Exercise :
• Increase duration
• Increase intensity
• Increase frequency

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Guidelines for strength training

• Avoid holding breath.

• Be sure to warm up and cool down during
exercise to prevent injury and domes.
• Balance your exercise between muscle groups
like biceps and triceps , quadriceps and
hamstring , chest and upper back.
• Always include exercise that strengthen trunk.
• Avoid gripping the weight handles tightly to
prevent excessive blood pressure responds to
lifting.

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• Typically weight lifting is done after aerobic exercise.
• Begin with exercise for a major group of muscle such
as chest and back.
• Go for a smaller muscles such as biceps and triceps.
• Do not go for strength training everyday because
muscle requires at least one day to recover.
• DOMs may occur so, progress slowly and allow
muscle for the recovery time.

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DYSPNEA RELIEVING POSITION

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Sitting Position To Relieve Dyspnea

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TO IMPROVE THORACIC MOBILITY:

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 SECRETION REMOVAL
TECHNIQUES
PERCUSSION FOLLOWED BY EXPIRATORY THRUST
In progression
ACBT(Active cycling breathing technique)
 3 phases of ACBT:
1. Breathing control.
2. Thoracic expansion exercise.
3. Forced expiratory technique.

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Sequence of ACBT techniques

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 TO IMPROVE POSTURE :

• Isometric neck exercises

• Chin tuck exercises

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NUTRITIONAL ADVICE

Choose minimally processed, whole food

Eat whole grain
Eat a variety of fruits
Eat variety of vegetables
Eat low fat source of protein
Reduce intake of saturated fat
Do moderate physical activities

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Precautions and Ergonomic Advice

• No smoking, tobacco, alcohol intake

• Avoid allergens.
• Avoid going to polluted areas.
• Wear mask whenever possible.
• Maintain the hygiene.
• Regular exercise.

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 REFERENCES
 ACSM 8th edition
 American Heart Association Guidelines
 Susan B. O’ Sullivan Physical rehabilitation
 Egan’s fundamental of respiratory care
 Joanne Watchie : Cardiovascular and pulmonary physical therapy
 Tidys physiotherapy
 Therapeutic exercise foundation and techniques: Carolyn Kisner
and lynn Allen Colby
 AACVPR (the american association of cardiovascular and
pulmonary rehabilitation)

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