-* Cardiology sheet*Date 30/11/2011 A) - history taking:I personal history:, 50 years , male , married , farmer , lives at banisuwayfe , patient was

s heavy smoker . II Diagnosis:- Ischemic heart disease. III- Complaint (c/o) \ chest pain during activity radiates to left scapula, axilla and left arm & burning pain in stomach. IV History of Present Illness (HPI):The condition started 9 years ago by gradual onset and regressive course of chest pain and dyspnea. - The patient was experienced dyspnea 9 years ago When very sever effort , by the time of progressive course patient complaint from moderate dyspnea relived by rest and sublingual nitrates , 3 years ago dyspnea developed to be at rest that lead to major defect in ADL that lead patient to do precautious trasnsluminal coronary angioplasty , The patient remained symptom-free for 2 years after first precautious transluminal coronary angioplasty operation then he developed exertional dyspnea again on ordinary effort. - Now patient have moderate dyspnea in form of heaviness o chest during activity as walking, climbing of first floor, patient have no orthopnea or PND. But have chest pain during sleeping. - retrosternal chest pain radiates to left shoulder , scapula and epigastric angel in form of heaviness on chest , this symptoms precipitated by heavy meal and cold weather for 5-15 minute. It is Relived by rest and sublingual nitrates. It is associated with sweating and some times headache. N.B) patient cannot differentiate between anginal pain & dyspnea, by more questions, patient have dyspnea in form of heaviness on chest without tachypnea, but with activity tachypnea appear. V Past history:-

There is past history of controlled DM that discovered after ischemia, investigated by blood glucose test, now it is treated by insulin. No HTN or other disease. Past history of previous 3 PTCA operations.

VI Family history:No consanguinity. No common diseases in the family.

No similar condition in the family. B) - Examination:-

General exam:Vital signs were in stable state during examination.

Local exam: Inspection:I-general appearance:-

Normal face color and normal expression. No eye lid puffiness.

Neither accessory muscles hypertrophy nor abnormal pulsation in the neck. No any signs of endocrine disorder. Normal body weight. Preferred position long setting.

II- peripheral signs:-

1- Hands \ no presence of clubbing fingers but there is peripheral cyanosis in

distal fingers.

2- In the face there is no corneal arcus, malar flush, jaundice, subconjuctival

hemorrhages nor ear lobe creases.

3- No presence of Central cyanosis, exanthemata, pallor.

III- jacular vein examination:Ask patient to turn his face to left side then detect 2 heads of SCM muscle after that look at JV By examination there is no jacular vein pulsation. Palpation:-

Point of maximum impact \ lies in left 5th space MCL under apex. There are normal localized motion & generalized motion.

Pulsations the same as above (no pulsation in the neck except carotid artery which is normal). There are No thrills. Auscultation:-

- 1st sound & 2nd sound are very clear. - Diastolic murmur, localized over the apex, with no other abnormal heart sound. C) - Investigation:-

Investigation was done to patient is cardiac catheterization that show:-

A) Left main coronary artery\ show distal 40-50% stenosis and then bifurcates to LAD & CX arteries.

B) LAD\ is diffusely diseased at its proximal and mid segment the rest of LAD is free, it gives retrograde to collaterals to the RCA.

C) CX artery\ this shows 70-80% stenosis at mid segment of 2nd proximal branch.

D) RCA\ it is dominant vessel, the proximal show a shadow of previous deployed occluded stent, the RCA receives retrograde collateral from the lt system. - Conclusion: - multivessel disease. - Recommendations: - multivessel CABG.

-*post operative problem list:I-respiratory problems:-

Shallow rapid breathing due to Decreased vital capacity. Abnormal breathing pattern from accessory muscles. Accumulated secretions due to previous smoking. Patient is Prone to infection due to delayed mucocilliary activity.

II-cardio vascular problems:-

Deep venous thrombosis (swelling redness pain). Circulatory in sufficiency = stagnation of blood. Edema of lower limb may be due to remove saphenous vein.

III-musculoskeletal system:-

Decreased joint movement especially in old age. May be joint stiffness especially in left shoulder. Muscle weakness may occur. Spasm and shortening of neck muscles. Chest pain due to incision. Decreased chest motion due to alteration in spinocostal angels. Bed sores may occur. Delayed wound healing.

IV-other problems:-

Sleeping problems. Decreased apatite. Mood depression. Constipation. This other problems go with time.

-* Objectives of phase1:-

Avoid post operative complication. Teach and encourage relaxation. To train postural awareness strengthening trunk and leg muscles. Assessing homodynamic response. Managing the psychological issue of cardiac patient. Educate the patient and his family.

-* phase 1 cardiac rehabilitation (patient in hospital) (7- 14/21) days: Patient stays in ICU 1-2 days for extra monitor if there is any complication patient stay more long period.

Mainly role of physiotherapy (respiratory, circulatory) exercise and positioning & passive movement. May apply extra O2 to patient through face mask.

apply deep breathing exercise in form of diaphragmatic breathing exercise patient is long sitting while therapist standing beside and his hand over epigastria angel , ask patient to take deep breath from nose and push my hand up then expire air from mouth , supine position not preferred , 3-5 times , do many man repetitions not in short periods , patient may hold towel on the incision.

ask patient to do active circulatory exercises if not able to do apply it passive , do it in pattern 5 slow times , then 5 fast , then 5 slow times of distal toes , ankle , fingers , hand.

Positioning of patient to avoid bed sores, turning to side lying RT & LT, no turning on prone position. Ask pat to do self feeding, minimal self care. Ask patient to get sitting from supine. Monitor the wound sutures; take care if there is infection.

Apply passive movement of all joints, the LT shoulder may move it from 1st day in available range MAXIMUM 15 DEGREE OR wait 1st week and then move it in more range.

If there is spasm or shortening of neck muscles apply massage, heat application of SCM, UPPER TRAPEZIUS.

then patient go to in patient ward (from 3rd 10th day )

Patient wear supporting belt on chest, monitor good hygiene to prevent pus on sutures. 3-4th day: preparation to postural drainage by humidification ,vibration , then apply postural drainage from long sitting , side lying ,sitting & leaning forward , monitor vital signs during application . Continuous all previous exercise but in more repetitions, stress more on breathing exercise as increase number of repetitions.

Teach patient how to cough to get rid of sputum.

more exercise may be added as SLR 3 repetitions , sitting in chair , more self care , isometric activity may started , may start walking in the ward. 5-6th day: the same previous exercise and more repetitions and add trunk mobility, increase distance of walking to be 50-100 M if patient Notable take rest. Apply localized breathing exercise in form of middle costal that is useful after surgery, patient in long sitting position and therapist standing beside, 2 hands on upper 6 intercostals space, ask patient to take deep breath and push hands lateral.

7-9th days the same , increase walking to 200 M , descending 2 steps of stair , more self care reach to patient shower himself. 10th day if the pat dont apply one of the previous exercise should apply it in this day and next 2 days , in addition to that increase intensity of climbing stairs , may start to ascending stairs , increase walking distance to be about 12 min.

The last day of phase one patient must do exercise tolerance test, patient is asked to walk 12 min in corridor, monitor number of pauses. -grade 1\ test cannot be completed. - Grade 2\complete test with more than 3 pauses. - grade III\complete test with pause. - grade IV\complete test without pause. - Grade V\ complete test with 5 KGS extra weight. -NOTES:-

Check recovery after 3 min by measure vital signs. N.B in 1st phase apply many sessions in day 5 session each one 10 min.

More stress on breathing, PD exercise due to effect of anesthesia, patient is previously heavy smoker. In this phase these exercises is obligatory to be done not immediately and can be modified according to patient state, but not cancel any one. At end of this phase should teach patient how o use incentive respirometer that will used at home as a graduation of respiratory exercise. To avoid edema in lower limb, patient should wear elastic stoking for 46 weeks after surgery, keep leg elevated. In this phase Doctor should ongoing care to monitor patient (blood tests, ECG, other investigations).

*-Post discharge phase:- (patient at home 2-3 weeks ) =1.5 phase:-

Ask pat to do exercise which is learned at 1st phase as breathing, walking. Give instructions to patient as :-

Life style changes (quitting smoking diet change being physical active, Decrease stress as much as he can). Control DM. Diet: (reduction of weight of obese patient ,avoid animal fat, avoid heavy meals) No lifting heavy objects or perform heavy exertion. No driving at 1st month. Return to work after full cardiac rehabilitation. In This phase must do 3 sessions per week, each on 1H.

At final Apply cardio pulmonary exercise test to know the parameters (target heart rate, maximal O2 consumption) that will be used in phase 2. *- phase 2 (monitoring phase) 3- 6/9 months:- It is called actual cardiac rehab phase. - THERAPIST DOES CARDIAC PULMONARY EXERCISE TEST.

Patient under high monitor in centers that have electronic treadmills, stepper of cardiac rehab, monitor to each patient, telemetry ECG. - THE ACTIVITIES AEE FROM SLOW TO MORE ACCORDING TO METS. - Patient comes to center 3 times per week, each session 2-45 min. - The exercise is stopped according to patient state, therapist skill in ECG.

*-phase 3 (maintenance phase) long-term maintenance:-

This phase in all his life. In that phase give limits to patient. Give him individual exercise programming. Give instructions as same of post discharge phase. Gradual fallow up should be preserved.

*- General guidelines for individual exercise programming:Start exercise when feeling physical active, not direct after eating, drink fluids during exercise is very important, Wear proper cloth and shoes. Be alert for symptoms if occur ask medical consultations. Shortness of breath during exercise, the rate and depth should not be uncomfortable. Discomfort in bones and joints either during or after exercise there may be slight muscle soreness but if back or joint pain develops discontinue exercise after medical evaluation. Watch for faintness or nausea after exercise if occur ask doctor. Chronic fatigue during day or evening of exercise should no persist if occur decrease intensity of exercise.

Stretching and flexibility exercise

1-Stretch for side of neck:Sit or stand with arms hanging loosely at sides. Turn head to one side then the other. Hold for 5seconds each other. Repeat 1-3 times.

2-stretxhes sides of neck:Sit or stand with arms hanging loosely at sides. Tilt head sideways first one side then other Hold for 5seconds each other. Repeat 1-3 times.

3-Stretches back of neck:Sit or stand with arms hanging loosely at sides. Gently tilt head forward to stretch back of neck. Hold for 5 seconds. Repeat 1-3 times.

4-stretches of shoulder and back of upper arm:- stand or sit and place right hand on left shoulder. -With left hand pull right elbow across chest toward left shoulder and hold 10-15 seconds. -repeat on other side.

5-stretch shoulder, middle back, arms, hands, fingers, wrists:- interlace fingers and turn palm out. - extends arms in front at shoulder height. - hold 10-20seconds relax and repeat.

6-stretch triceps, top of shoulder, waist:- Keep knees slightly flexed. - stand or sit with arm over head. - Hold elbow with hand of opposite arm. - Pull elbow behind head gently as you slowly lean to side until mild stretch is felt. - Hold 10-20 sec. - repeat on other side.

7-stretch middle back:- stand with hands on hips. - Gently twist torso at waist until stretch is felt. - Hold 10-15 sec. - repeat on other side. - keep knee slightly flexed.

8- Stretch ankles:- stand and hold onto sometimes for balance. - Lift right foot and rotate foot and ankle 8-10 times. - repeat on other side.

9- Stretch calf:-

- Stand and little way from wall and lean on it with forearms, head rest on hands. - Place right foot in front of you, leg bent, left leg straight behind you. - Slowly move hip forward until you feel stretch in calf of left leg. - Keep left heel flat and toes pointed straight ahead. - Hold easy stretch 10- 20 sec. - do not bounce. - repeat on other side. - Do not breathe.

10-stretch front of thigh:- stand a little away from wall and place left hand on wall for support. - Standing straight, grasp top of left foot with right hand. - Pull heals toward buttock. - Hold 10-20 sec. -repeat on other side.

11-relax hamstring, stretch calves, and ankles:- Shoulder- width apart. - Keep heals flat, toes pointed straight ahead. - assume bent knee position. - Hold 30 sec stand with feet.

12-stretch inner thigh:- Stand with feet pointed straight ahead a little more than shoulder- width apart. - bend right knee slightly and move left hip downward to ward right knee. -repeat on other side. - If necessary hold onto something for balance. 13-stretch side of hip, hamstring:- sit on floor with right leg straight out in front. - bend left leg, cross left foot over, place out side right knee. - pull left knee across body toward opposite shoulder.

- Hold 10-20 sec. - Breath easily.

14-stretch lower back, side of hip and neck:- sit on floor with left leg straight-out in front. - bend right leg, cross right foot over, place out side left knee. - bend left elbow and rest it outside right knee. - Place right hand behind hips on floor. - Turn head over right shoulder, rotate upper body right. - Hold 10-15 sec. - repeat on other side. - Breath in slowly.

15-stretch back of leg, lower back:- sit on floor, legs straight out at sides. - bend left leg in at knee. - Slowly bend forward from hips toward foot of straight leg until you feel slight stretch. - do not dip head forward at start of stretch. - Hold this development stretch 10-20sec. - repeat on other side. - Foot of straight leg upright, ankles and toes relaxed. - use a towel if you can not easily reach your feet.

16-stretch shoulders, arms, hands, feet and ankles:- lie on floor, extend arms over head, keep legs straight. - reach arms and legs in opposite directions. - stretch 5sec, relax.