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CASE STUDY CABG

BY: NUR SYAKILA MASNOM 07DPY0013 (COHORT1)

Personal details.
Name: Mr. M MRN: 22xxx Age: 61 years old Sex: male Race: Indian Job: retired from bank staff Date of admission: 17/6/09 Date of referral: 20/6/09 for pre-op CABG Date of operation: 22/6/09 Date of assessment: 24/6/09 (post-op day 2) Dr diagnosis ∆: Coronary artery disease (CAD) Dr management : post-op CABG (3 graft)

Subjective Assessment Present history  Pt admitted to DSH on 17/6/09 for elective CABG  On 22/6/09 pt transferred to CICU for close observation post-op CABG .

back aching.Pt c/o:  Pt complaint of pain at the operation site. mild dizziness. and sleepy. .

Past medical history   Pt had done right AKA in 92’ d/t MV A Pt had DM since 4 years ago Medication    Actrophid 50mg IV dopamine 200mg IV levophed .

Social history   Pt was a smoker since 40 years ago and take roughly 5 sticks for a day time but has been stopped since 5 month ago Pt lived with his wife accompanied with his children .

Investigation    Angiography on 16/6/09 Result:1) Left mainstem – 50% stenosis 2) Left anterio descending (LAD) 3) Left circumflex – 60% stenosis 4) Right coronary artery (RCA) – proximal 60% stenosis. middle 95%stenosis X-ray on 17/6/09 Result: normal (NAD) Echo on 18/6/09 Result: good LV function. chambers size normal and no pericardial effusion . EF 70%.

Vital sign      Bp: 102/56 mmhg HR: 92 bpm RR: 23 bpm Temp: 36°c Spo2: 100% .

45)  PCO2: 35.8 mmol/l (35-45)  PO2: 167 mmol/l (95-100)  HCO3: 23 mmol/l (22-26)  BE: -1 ~ interpretation: metabolic normal  .ABG on 24/6/09 pH: 741.35-7.7 ( 7.

Lab result    Hemoglobin: 10.2 Platelet: White blood cell: .

Objective assessment General observation  A medium size Indian man was slumped on bed  Pt conscious and obey to command  Pt look tired and sleepy  Pt on nasal prong 3 l/min  Pt on IV drip at the left hand  Pt CVL on right neck  Pt on CBD drainage .

Local observation    Pt was covered by gauze at the incision site (chest and left leg) Swelling noted at the operation site of left leg and ankle Pt had right AKA .

On palpation     Chest expansion: symmetrical Upper lobe: fair Lateral costal: fair Diaphragm: poor Auscultation  Crackle sound at the left and right lower lobes .

5 3 93 86 2 94 87.5 3 94.5 87.5 86.5 86.5 87 87 87 87 .5 87 Expiration 1 94 86.5 87.5 86.5 86 3 93 86 Axillary Xiphoid process 10th rib 93 86.Chest measurement Resting 1 2 93 86 Inspiration 1 94.5 87 2 93.

    Coughing .grade 3/5 : able to do by against gravity .unproductive cough Sputum -slightly thick and greenish + blood with minimal amount Test result -spirometry: 1000ml (3x) Muscle power .

Problem listing      Pain at the operation site Back aching Reduce chest expansion and secretion retention Unable to produce an effective cough Muscle weakness at both upper and lower limb .

PT Impression     Pain at anterior chest wall area d/t operation wound Back aching d/t prolonged lying and poor blood ciculation Reduce chest expansion d/t poor breathing effort and pain Secretion retention over left and right basal d/t effect of GA and poor breathing pattern .

Analysis Short term goal     Produce effective and productive cough by using pillow to support at operation site at the chest Increase chest expansion Increase muscle strength Improve to normal breathing pattern Long term goal   To prevent other chest complication To regain normal ADL .

Treatment plan      Component of ACBT x2 set DBE – 3X Spirometer with coughing – 3x Active exercise – 3x Sit – up at the edge of bed with support .3x .

Home instruction      Keep doing spirometer to increase chest expansion Do the active exercise that has been teach by therapist Support the chest wound with pillow when coughing Elevate the leg same level with heart when sitting or lying Don’t lift up the heavy things .