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Cardio Case Discussion


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Cardio Case Discussion

  1. 1. Case Discussion Presented to: Subin sir On 9th March,2014 By : Kumar Vibhanshu MPT- I year
  2. 2. • Name: Mohammad Sardar • Age: 64 years • Sex: Male • Address: Mominpura, Mysore Road. • Marital Status: Married • Religion: Islam • Occupation: Autodriver Demographic data:
  3. 3. • Source Of History: Patient & His Wife. • Date of Admission : 6/03/14, 9:10 p.m. • Date of Assessment: 9/03/14
  4. 4. Chief complaints: • Patient complained of fever and chills from last 4 days. • Patient also complained of cough with sputum. From last 4 days. • Patient was also feeling difficulty in breathing from last 20 days. • Pateint also complained of left lower lateral side chest tightness.
  5. 5. HISTORY OF PRESENT ILLNESS Patient was apparently alright 2 weeks back and after which he developed fever with chills. Patient also had cough with expectoration and complained of difficulty in breathing mainly in morning, patient was brought to ESI Rajajinagar Hospital for treatment on 30/2/2014 from where he reffered to Udbhav Hospital for the treatment, on that very day. Patient was in ICU at Udbhav Hospital for 6 days where he he treated and reffered back to ESI Rajajinagar, for further treatment on 06/03/14.
  6. 6. Description of symptoms: Breathlessness Onset : 12 days back gradual Setting: gradual increasing initially while walking Severity: Patient not able to continue his activity. Not even able to speak. Frequency: 5-6 times a day Duration: 15-20 minutes.
  7. 7. Course: worse Associated symptoms: cough, chest pain. Aggravating factor: daily activities, walking. Relieving factor: rest Nail bed and lips do not turn blue at the episode of breathlessness Patient is K/C/O of Tuberculosis VAS : 6 ATS scale: Grade 3 Type of dyspnea : restrictive dyspnea
  8. 8. Cough Onset : 2 weeks gradual Productive Setting: initially occasionally later during almost all activity Severity: not affecting daily activities duration: continuous althrough the day. Course: worse in morning gets better as day passes by. Associated symptom: breathlessness and chest pain on left lower side of lung.
  9. 9. Aggrevating factor: smoking Relieving factor: rest and medication. Pattern: Cough first in morning
  10. 10. Sputum: Mucopurulent Color : yellow Consistency: thick Quantity : ½ cup/day Time of the day: continuous mainly in morning Odor: not foul smelling Hemoptysis: Not present.
  11. 11. Chest pain: Location: left lower lateral side of the chest. Onset: sudden Pattern: intermittent Provoked symptoms: coughing VAS: not able to score Time frame : acute Fever: Gradual, intermittent, high grade with chills.
  12. 12. Past medical history: not a known case of DM/HTN. K/C/O TB and Bronchial Asthma Past surgical history: not significant Personal history: smoking bidi everyday since 54yrs 4 packet/day non alcoholic has not smoked since 20 days Social history: total members – 15 earning – 3 socioeconomic status: poor
  13. 13. Family history: no history of TB or any respiratory illness Occupational history: worked as autodriver for 40 yrs and continuously exposed to pollution and was regular smoking at time of driving.
  14. 14. Differential Diagnosis Supporting Features Unsupporting Features Lobar Pneumonia -rigors,pyrexia -loss of appetite -cough, non foul -th. Expansion to one side -`chest tightness` Pleurisy -chest pain -fever -cough -secondary to TB -Productive cough Pleural Effusion -breathlessness -pain -secondary to TB -Cyanosis -Mediastinal shift -Reduced vocal
  15. 15. Lung Abscess -fever -cough -dyspnea -haemoptysis -halitosis -foul smelling sputum -bad taste in mouth
  16. 16. OBJECTIVE ASSESSMENT General appearance: cardio respiratory distress Awake, alert, attentive Built: ectomorphic Vitals: PR: 72/min volume rhythm normal RR: 43/min BP: Not able to monitor
  17. 17. Inspection Head: facial expression: showing cardio respiratory distress Eyes PERRLA : normal No ptosis, no central cyanosis No pursed lip breathing
  18. 18. Neck: Position of trachea: central Use of accessory muscles: SCM Trails sign and olivers sign: negative
  19. 19. Thorax: Posture: kyphotic with rounded shoulder Symmetrical chest Apex beat: not visible Pallor: absent Clubbing : absent Cyanosis: absent edema: absent No intercostal indrawing
  20. 20. Palpation: Tracheal position: central No tenderness over chest or accessory muscles. Chest symmetry: symmetrical chest movements.
  21. 21. Tactile Vocal Fremitus: Increased in lower lobe of left lung, upper lobe of left lung and lobes of right lung were less. Percussion Dull sounds on lower lobe of left lung, and resonant in other lobes of lung. Auscultation • Quantity: normal • Quality of sound: bronchial sounds on left lung • Added sound: crackles in lower lobe of left lung
  22. 22. • Measurement of chest expansion: – Upper Zone : 2.5cm – Middle Zone: 2.5cm – Lower Zone : 2 cm Conclusion: Reduced expansion of the lungs AP: Transverse diameter: 5:3
  23. 23. Investigation: Hematology: HB: 8mg/dl WBC: 6100/mm3 Sputum: Gram –ve bacteria Heavy growth of E.coli due to oral fungal infection.
  24. 24. X-ray •Trachea centralise •Cardio thoracic ratio is almost 1:2 which is normal •Homogenous opacity can be seen in lower lobe of left lung •Suggestive of left lobar pneumonia
  25. 25. Provisional Diagnosis: Left lobar Pneumina.
  26. 26. Problem list according to ICF Primary impairment • Cough with expectoration. •Breathlessness affecting daily activities like walking. •Chest pain on left side of the chest. Secondary impairment •Increased work of breathing •Reduced chest expansion
  27. 27. Activity limitation Daily activities like walking, dressing, stair climbing and descending, hygiene maintenance Participation restriction Unable to work
  28. 28. Contextual factors Personal factors Positive: Cooperative and motivated Good family support No significant surgical and family history Negative: Aged person Environmental factors Negative : Hygiene maintenance at home.
  29. 29. Management: To improve chest expansion. To increase the ease of brething. To return to his normal life.
  30. 30. • Positioning: – Right side lying. • To improve lung expansion: – Segmental Breathing exercise – Incentive spirometry • Huffing and coughing with splinting – Self assisted – Therapist Assisted Treatment plan:
  31. 31. Positions to relieve breathlessness
  32. 32. • Home advice – Performing breathing exercise regularly. – Use of medication regularly. – Lying on right side. – Avoid smoking.
  33. 33. Evidence based practice •Pontifex E,et al. The effect of huffing and directed coughing on energy expenditure in young symptomatic patients, Aust j Physiother ; 2002;48(3):209-213 •Feldman J., Traver GA, Taussig LM. Maximal expiratory flow after postural drainage,europe pubmed central;1979
  34. 34. •Patricia A. Downie. Cash textbook of Chest, heart and vascular disorders for physiotherapists. 4th edition. Jaypee Brothers publication •Robert L. Wilkin, Susan Jones Krider, Richard L. Sheldon. Clinical assessment in respiratory care.4th edition •Stuart Porter, Tidy’s Physiotherapy. 14th edition. Elsevier publication.
  35. 35. THANK YOU