This patient is a 53-year-old male who presented to the emergency room with 2 hours of severe chest pain that began while working under his car. On examination, he had crackles in his lungs, an S3 heart sound, and elevated blood pressure. Tests showed mildly reduced oxygen levels and mildly elevated carbon dioxide levels. He received oxygen, nitroglycerin, and thrombolytic therapy. He was diagnosed with a myocardial infarction. A rehabilitation protocol was prescribed including range of motion, stair climbing, exercise, and breathing exercises to improve cardiorespiratory fitness, activities of daily living, and quality of life.

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

24. Diagnosis
Myocardial infarction

26. Rehabilitation Goal
Improve Cardiorespiratory
fitness
Improve ADL and QOL

27. Rehabilitation protocol

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.

32. Thank you
Suparnamoom9.6@gmail.com