Cardiopulmonary Case Study

N A T H A N D U G A N C O L U M B I A U N I V E R S I T Y

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Patient Case Presentation: Inpatient Cardiopulmonary PT

Patient Introduction

�  87 y/o female �  Admitted on 6/4/14 �  Pre-op diagnoses:

¡  AORTIC STENOSIS AND REGURGITATION ¡  MITRAL AND TRICUSPID REGURGITATION ¡  CORONARY ARTERY DISEASE ¡  ATRIAL FIBRILLATION

History of Present Illness

�  c/o SOB (lasting seconds to minutes) at rest and with exertion, beginning early 2013 ¡  Symptoms increased in frequency over past year ¡  Limited to 1 flight of stairs and a couple of blocks of ambulation

�  Associated diaphoresis, edema, palpitations �  Orthopnea and occasional PND �  Developed Afib in 2013 �  Abnormal TEE on 8/23/13

¡  LVEF 65%-75% ¡  AVA: 1.1 cm2 ¡  Mitral/Aortic insufficiency ¡  Bi-atrial enlargement ¡  Mild pulmonary HTN (42mmHg)

Past Medical History

�  Aortic Stenosis (with AVA=1.1cm2) �  Aortic Insufficiency �  Mitral Regurgitation �  Atrial Fibrillation (on coumadin) s/p DC cardioversion

x2 �  Pulmonary Hypertension (42 mmHg) �  CAD �  Hypertension �  Hyperlipidemia �  IBS �  Glaucoma �  Cataracts

Medications List

Medication Class Relevant Side Effects Piperacillin Tazobactam & Vancomycin

Antibiotic Hypotension, anemia, hypoglycemia, hypokalemia

Amiodarone Antiarrhythmic Hypotension, arrhythmias Amlodipine & Diltiazem Calcium channel blocker -

Antihypertensive Arrhythmias, bradycardia, tachycardia, postural hypotension

Metoprolol Tartate B1 selective receptor blocker – decreases contractility/HR/O2 demand

Arrhythmias, dyspnea

Ipratropium Bromide Bronchodilator Hypotension, arrhythmias, dyspnea, worsening of narrow angle glaucoma

Heparin & Warfarin Anticoagulant Increased risk of bleeding, hyperkalemia, hyponatremia

Simvastatin Cholesterol lowering agent Angina, cognitive impairment Docusate Sodium & Senna Stool softeners/laxatives None Esomeprazole Proton pump inhibitor – antacid Hypertension, arrhythmias,

hyponatremia

Brimonidine Tartate A2 receptor agonist – reduces intraocular pressure

Hypertension, syncope

Social and Functional History

�  Married and lives with 91 yo husband in private home with stairs ¡  Sons and other family live nearby and are available to help as

needed �  Retired �  Independent in all ADL and IADL prior to admission �  Did not use AD for mobility prior to admission

¡  Enjoyed walking prior to illness

Hospital Course

�  6/4/14: Surgery performed �  6/5/14: Extubated �  6/6/14: Re-intubated, suspected cardiac tamponade, chest re-

opened bedside (1L fluid drained), transferred to OR �  6/8/14: Chest closed �  6/10/14: PT initial evaluation in CTICU

¡  Seen for 16 sessions between 6/10-6/25 �  6/12/14: Extubated �  6/13/14: Transfer to 5GN, CTSDU �  6/16/14: First time I saw patient �  6/17/14: Chest tubes removed �  6/22/14: Converted to NSR �  6/23/14: NG feeding tube removed �  6/25/14: Discharge to acute rehab

Surgical Procedures Performed

¡  MAZE, tAVR, tMVR, TV Repair, CABG x3 ÷ LIMA->OM ÷ RIMA->LAD ÷ SVG from aorta->PDA

CABG Visualization

MAZE Visualization

Physical Therapy Initial Evaluation: POD #6

�  Very limited ¡  Intubated, +CT x3 to low wall suction, +SGC, +RIJ with

multiple drips, +R radial A-line ¡  Pt lethargic but able to follow simple directions, unable to

respond to questions �  Interventions performed:

¡  Patient education: Benefits of exercise, PT intervention, use of call bell, sternal precautions

¡  PROM x10 BUE & BLE �  Assessment:

¡  Pt has an excellent support network and is a good candidate for cardiac rehab with good prognosis

Physical Therapy Goals-IE

�  Short Term Goals (3 sessions): ¡  Rolling Mod A ¡  Scooting Mod A ¡  Sup<->Sit Mod A x2 ¡  Sit->Stand Mod A x2 ¡  Bed<->Chair Mod A x2

�  Long Term Goals (by d/c) ¡  Bed Mobility Independent ¡  Transfers Independent ¡  Household Ambulation Independent

Physical Therapy Plan

�  Continue goal-oriented physical therapy, 5-7x/week ¡  Patient and family education ¡  Gait training ¡  Therapeutic activities ¡  Therapeutic exercise ¡  Cardiac rehabilitation

Treatment Sessions 2-3: POD #7-8

�  Slow start to rehab �  Session 2:

¡  PROM x10 BUE & BLE ¡  Rolling ¡  STGs remain

�  Session 3: ¡  Extubated, SGC remains ¡  Rolling @ max A, sup<->sit @ mod A x2 & HOB elevated ¡  Able to sit EOB for ~5 minutes ¡  STGs remain

Treatment Session 4: POD #9

�  Slow start continues ¡  Better evaluation as patient able to converse ¡  SGC removed ¡  5LO2 via NC

�  Interventions: ¡  Rolling @ max A, sup<->sit @ mod A x2 & HOB elevated

÷ No improvement over previous session ¡  Able to sit EOB for ~5 minutes

÷ No improvement over previous session

�  Previous STGs remain


�  Standing! ¡  3LO2 via NC

�  Interventions: ¡  Rolling @ max A, sup<->sit @ mod A & HOB elevated,

sit->stand @mod A (performed 2 times) ¡  Standing x2 trials

�  STGs revised: ¡  Sup<->Sit Min A ¡  Sit->Stand Min A


�  Ambulation! �  Interventions:

¡  Rolling @ max A, sup<->sit @ mod A & HOB elevated, sit<->stand @ mod A (performed 4 times)

¡  Ambulation: 2 steps @ min A ¡  Standing x4 trials

�  Previous STGs remain


�  First time I worked with patient ¡  Eager to participate and then very reluctant to perform any activities

�  Interventions: ¡  Sup->Sit @ min A & HOB elevated, sit->stand @ min A, bed->chair @ min A ¡  Standing ~4 minutes

�  STGs revised: ¡  Rolling CS ¡  Scooting Min A ¡  Sup<->Sit CG, Sit->Stand CG, Bed<->Chair CG ¡  Ambulation: 20’ RW/CG ¡  IS to 500cc

�  LTGs revised (2-4 weeks): ¡  Bed mobility, transfers, household ambulation: independent ¡  Community ambulation, stair climbing CS ¡  IS >/= 1000cc


�  Back to ambulation ¡  Pt on room air, SpO2 >/=96% throughout

�  Interventions: ¡  Seated scooting @ I, sup->sit @ CG & HOB elevated,

sit->stand CG/min A (from low chair) ¡  Ambulation: 5’ RW/CG ¡  Standing ~2 minutes ¡  Incentive spirometry 500cc

�  Assessment: Pt had goal to make it to sink to wash her hands, unable to accomplish. Concerned with being independent, states “don’t touch me” during activities


�  Minor regression ¡  Chest tube and foley removed

�  Interventions: ¡  Sup->Sit @ min A x2 & HOB elevated, sit->stand @ min A ¡  BLE AROM

÷ Ankle pumps x20 ÷ Long arc quads x20 ÷ Seated hip flexion x20

�  Assessment: Pt stood for ~5s before sitting and refusing to participate further, education given. Low motivation 2/2 c/o lack of sleep.


�  Session 10: ¡  Interventions:

÷  Sup->Sit CS HOB elevated, sit->stand min A x2 ÷ Ambulation: 25’ x 2 RW/CG

¡  Assessment: Pt self-motivated to make it to bathroom �  Session 11:

¡  Interventions: ÷  Sit->Stand @ CG/min A, toilet transfer @ min A x2 ÷ Ambulation: 30’ x 2, 50’ x 1 RW/CG

¡  Assessment: Bathroom motivation still paramount �  Session 12 (w/e):

¡  Interventions: ÷  Sit->Stand @ min A/mod A ÷ Ambulation: 50’ x 2 RW/CG->min A


�  Session 13 (w/e) ¡  Sit->Stand @ min A, bed->chair @ min A ¡  Ambulation: 50’ x 4 RW/CG

�  Session 14 ¡  Sit->Stand @ min A

÷ Continues to require many cues for technique ¡  Ambulation: 50’ x 2, 100’ x 1

�  Session 15 ¡  Sit->Stand CS ¡  Ambulation: 100’ x 2 RW/CS

�  Session 16 ¡  Sup->Sit @ I & HOB elevated, sit->stand @ CS

÷ Able to perform transfers correctly with vague cues ¡  Ambulation: 70’ x 1, 100’ x 1 RW/CS

Graphic Representation of Sessions

2 0 5 0

50

110 100

200 200 200

170

15-Jun 16-Jun 17-Jun 18-Jun 19-Jun 20-Jun 21-Jun 22-Jun 23-Jun 24-Jun 25-Jun

Ambulation Distance (Feet) vs Time

Why Rehab?

�  Patient’s attitude of wanting to be independent although she is not

�  Significant weakness, especially in LEs �  Patient was completely independent prior to

admission �  Patient did not use an assistive device prior to

admission �  Lives with 91 yo spouse and has stairs in her home

Questions?

References

�  "Atrial Fibrillation Surgery - Maze Procedure." The Society of Thoracic Surgeons. 10 July 2014. http://www.sts.org/patient-information/arrhythmia-surgery/atrial-fibrillation-surgery

�  "Cardiac Tamponade: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine. 08 July 2014. http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm

�  Meinke, Laura. "Pulmonary Hypertension for Internists.” American College of Physicians. 10 July 2014. http://www.acponline.org/about_acp/chapters/az/mtg10_meinkepul.pdf

�  "Aortic Valve Area in Aortic Stenosis." UpToDate. 19 May 2014. Web. 10 July 2014. http://www.uptodate.com/contents/aortic-valve-area-in-aortic-stenosis

Cardiopulmonary Case Study

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