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post MI cardiac rehabilitation.

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CLINICAL CASE
PRESENTATION
Presented by Suparna Bandyopadhyay
1st year MPT(Neurology)
CASE DETAILS
The patient is a 53-year-old male. He is an accountant but is presently retired.
He lives with his wife at 4th floor of their flat. He is about 5 feet 9 inches (176
cm) tall and weighs 191 pounds (87 kg); his body mass index is 28. The patient
was admitted to the emergency room after 2 hours of severe chest pain, which
began when he was working under his car. He has no history of heart disease.
He was dyspneic and anxious. On auscultation, crackles were audible over his
posterior bases. His chest x-ray was clear. An S3 heart sound was audible on
auscultation. Ventricular tachycardia was treated with lidocaine. His blood
pressure was 144/95 mm Hg. Nitroglycerine was instituted intravenously.
Oxygen was administered at 2.5 L/min by nasal prongs. After 60 minutes, his
arterial blood gases (ABGs) were pH 7.42, oxygen pressure (PaO2) 70 mm Hg,
carbon dioxide pressure (PaCo2) 38 mm Hg, bicarbonate (HC03) 26 mEqlL,
and arterial oxygen saturation (Sao2) 93%. Thrombolytic therapy was
initiated (intravenous tissue plasminogen activator and oral aspirin). Diagnose
the condition and prescribe treatment accordingly.
DEMOGRAPHIC DATA
Name: Mr. X
Age: 53
Sex: Male
Occupation: Ex-Serviceman
Address: XYZ
Date and place of assessment: 10th July
2023 at ABC hospital
CHIEF COMPLAIN
The patient may have come with the
following complains
• Difficulty in breathing
• Persistent Chest heaviness
• Palpitations
• Limitation in performing ADLs
CASE HISTORY
Mr. X, a 53
years old
male patient
had severe
chest pain
when he was
working
under his car
at 9 am
He reported
to the
hospital
emergency
room at 11
am
There he
received
oxygen
therapy,
Thrombolytic
therapy and
intravenous
Nitroglycerine
Now the
patient
is
hemody
namicall
y stable
Pain assessment
Onset Sudden
Type The pain may be Crushing or squeezing, burning or
aching, and chest heaviness
Duration of
symptoms
2 hours
Location and
source of pain
Center of the chest
Radiation of
the pain
Pain may radiate to the Left shoulder, neck and jawline
left arm
Aggravating
factor
Exertion may aggravate the pain
Relieving
factor
Nitroglycerine (IV)
ASSOCIATED PROBLEMS: Anxiety Breathlessness
Ad

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mi.pptx

  • 1. CLINICAL CASE PRESENTATION Presented by Suparna Bandyopadhyay 1st year MPT(Neurology)
  • 2. CASE DETAILS The patient is a 53-year-old male. He is an accountant but is presently retired. He lives with his wife at 4th floor of their flat. He is about 5 feet 9 inches (176 cm) tall and weighs 191 pounds (87 kg); his body mass index is 28. The patient was admitted to the emergency room after 2 hours of severe chest pain, which began when he was working under his car. He has no history of heart disease. He was dyspneic and anxious. On auscultation, crackles were audible over his posterior bases. His chest x-ray was clear. An S3 heart sound was audible on auscultation. Ventricular tachycardia was treated with lidocaine. His blood pressure was 144/95 mm Hg. Nitroglycerine was instituted intravenously. Oxygen was administered at 2.5 L/min by nasal prongs. After 60 minutes, his arterial blood gases (ABGs) were pH 7.42, oxygen pressure (PaO2) 70 mm Hg, carbon dioxide pressure (PaCo2) 38 mm Hg, bicarbonate (HC03) 26 mEqlL, and arterial oxygen saturation (Sao2) 93%. Thrombolytic therapy was initiated (intravenous tissue plasminogen activator and oral aspirin). Diagnose the condition and prescribe treatment accordingly.
  • 3. DEMOGRAPHIC DATA Name: Mr. X Age: 53 Sex: Male Occupation: Ex-Serviceman Address: XYZ Date and place of assessment: 10th July 2023 at ABC hospital
  • 4. CHIEF COMPLAIN The patient may have come with the following complains • Difficulty in breathing • Persistent Chest heaviness • Palpitations • Limitation in performing ADLs
  • 5. CASE HISTORY Mr. X, a 53 years old male patient had severe chest pain when he was working under his car at 9 am He reported to the hospital emergency room at 11 am There he received oxygen therapy, Thrombolytic therapy and intravenous Nitroglycerine Now the patient is hemody namicall y stable
  • 6. Pain assessment Onset Sudden Type The pain may be Crushing or squeezing, burning or aching, and chest heaviness Duration of symptoms 2 hours Location and source of pain Center of the chest Radiation of the pain Pain may radiate to the Left shoulder, neck and jawline left arm Aggravating factor Exertion may aggravate the pain Relieving factor Nitroglycerine (IV) ASSOCIATED PROBLEMS: Anxiety Breathlessness
  • 7. Associated problem Profuse sweating , fatigue, dizziness Nausea , vomiting History of constipation The subject may also have the following associated problems
  • 8. Past medical history The patient is having a history of Hypertension He may also have a history of Vascular disease He may also have a history of Diabetes, Dyslipidemia He had no history of underlying heart disease
  • 9. Drug history • History of drug allergy was reported M F Mr. X No family history is available for this case.
  • 10. Socioeconomic history According to the Kuppuswamy scale, he belongs to upper middle Class family Environmental history He lives with his wife at 4th floor of their flat.
  • 11. Personal history Patient is married Took mixed Indian diet Lifestyle is sadentary There may be history of smoking and alcohol consumption
  • 12. Subjective assessment Breathlessness Duration since 1st recognitions: 2 hours Severity of breathlessness
  • 13. Continue… • Pattern of breathlessness: Seasonal/Daily/Variation • Orthopnea (May be present ) • Paroxysmal nocturnal dyspnea (May be present ) Cough: • Productive/Dry/ early morning cough/Persistent/ after eating or drinking • Duration since 1st recognition • Pattern of cough: seasonal/variation/daily
  • 14. Continue… Sputum • Quality: Mucoid / Mucopurulent / Purulent • Colour: Yellow/ Dark Green/Brown/ Red/ pink • Hemoptysis: May be present • Pattern: seasonal/variation/daily
  • 15. Pain • Duration since 1st recognition • Type of pain: sharp/ central/ localized/ poorly localized/ retro sternal pain/stabbing pain/dull pain/ worse on inspiration/ Sudden onset/ pain on palpation/ worse on lying flat/band like sensation radiates to arm, neck, and jaw
  • 16. Functional assessment • Ambulation • Bathing and toilet • Dressing • Eating • Communication
  • 17. Objective assessment • Gcs score- May be reduced On observation: General observation: Patient is gasping Abdominal distension is not present Cyanosis may not be seen The patient is on supplemental oxygen provided by using nasal prongs
  • 18. Continue….. The patient may have the following Speech pattern: Long fluent paragraphs without discernible pauses for breath Quick sentence Just a few words Too breathless to speak Vital signs: Temperature: Afebrile Pulse rate: tachycardia Respiratory rate: tachypnea Blood pressure: 144/95 SPO2: 93%
  • 19. Continue…. Height: 5 feet 9 inch Weight: 191 pounds BMI: 28kg/m Pallor: may be present Peripheral cyanosis: may not be seen Capillary refill time: may be normal Tremor of hand: may be seen Breathing pattern: rapid shallow breathing
  • 20. On Auscultation: • Crackles heard during inspiration over the posterior base of the lung • S3 heart sound is audible ABG analysis pH 7.42 Oxygen pressure (PaO2) 70 mm Hg Carbon dioxide pressure (PaCo2) 38 mm Hg Bicarbonate (HC03) 26 mEqlL Arterial oxygen saturation (Sao2) 93% Pao2 slightly decreased
  • 21. chest x-ray was clear Chest x-ray ECG ECG either may be STEMI OR NONSTEMI
  • 22. Pathological Q Wave Hematological investigation Cardiac biomarker : Trop t and CPK-MB: Raised
  • 23. Differential diagnosis Prinzmetal Angina Gastroesophageal reflux disease Acute gastritis Aortic dissection
  • 28. • ROM, • stair climbing (one flight), • Deep breathing exercise Phase 1 • ROM, • Treadmill Walking • Arm ergometer, breathing exercise Phase 2 • Walking, ergometry, jogging, swimming, weight training, endurance sports, breathing exercise Phase 3 • Walking, running, ergometry, jogging, swimming, weight training, endurance sports, breathing exercise Phase 4 Arm ergometer
  • 29. Yudi et. al in 2020 conducted a rct with A total of 206 patients with ACS across six tertiary Australian hospitals were included in this randomized controlled trial. Participants were randomized to usual care (UC; including referral to traditional cardiac rehabilitation), with or without an adjunctive smartphone-based cardiac rehabilitation program (S-CRP) upon hospital discharge. The primary endpoint was change in exercise capacity, measured by the change in 6-minute walk test distance at 8 weeks when compared to baseline, between groups. Secondary endpoints included uptake and adherence to cardiac rehabilitation, changes in cardiac risk factors, psychological well- being and quality of life status. In patients with ACS, a S-CRP, as an adjunct to UC improved exercise capacity at 8 weeks in addition to participation and adherence to cardiac rehabilitation. 1 Recent advancement
  • 30. Chao je he et. al in 2022 conducted a study with 524 subjects who is having myocardial infarction in the absence of obstructive coronary artery disease (MINOCA). A total of 524 participants with MINOCA were recruited in this prospective cohort study from August 2014 to October 2016 and followed for three years. Subjects were randomly into an exercise-based cardiac rehabilitation group (CR+) and a control group (CR−). The CR+ group followed a home-based exercise-training program three times a week during the three years of moderate continuous training (MCT; 65%–75% of peak heart rate) on a bicycle or treadmill. A long-term exercise-based CR program was associated with superior physical health and a significant reduction in all-cause mortality and MACE in patients with MINOCA.
  • 31. Reference 1.Yudi MB, Clark DJ, Tsang D, Jelinek M, Kalten K, Joshi SB, Phan K, Ramchand J, Nasis A, Amerena J, Koshy AN. SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: a randomized controlled trial. Coronary artery disease. 2020 Jun 19;32(5):432-40. 2. He CJ, Zhu CY, Zhu YJ, Zou ZX, Wang SJ, Zhai CL, Hu HL. Effect of exercise-based cardiac rehabilitation on clinical outcomes in patients with myocardial infarction in the absence of obstructive coronary artery disease (MINOCA). International Journal of Cardiology. 2020 Sep 15;315:9-14.