Coronary Artery Diseases Case Study

8/2/2019 Coronary Artery Diseases Case Study

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CASE STUDYCABG

BY:

NUR SYAKILA MASNOM

07DPY0013 (COHORT1)


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Personal details.

Name: Mr. M

MRN: 22xxx

Age: 61 years old

Sex: male

Race: IndianJob: retired from bank staff

Date of admission: 17/6/09

Date of referral: 20/6/09 for pre-op CABG

Date of operation: 22/6/09

Date of assessment: 24/6/09 (post-op day 2)

Dr diagnosis : Coronary artery disease (CAD)

Dr management : post-op CABG (3 graft)


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Subjective Assessment

Present history

Pt admitted to DSH on 17/6/09 for

elective CABG

On 22/6/09 pt transferred to CICU forclose observation post-op CABG


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Pt c/o:

Pt complaint of pain at the operation

site, back aching, mild dizziness, andsleepy.


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Past medical history

Pt had done right AKA in 92 d/t MV A

Pt had DM since 4 years ago

Medication Actrophid 50mg

IV dopamine 200mg

IV levophed


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Social history

Pt was a smoker since 40 years agoand take roughly 5 sticks for a day

time but has been stopped since 5month ago

Pt lived with his wife accompanied with

his children


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Investigation Angiography on 16/6/09

Result:1) Left mainstem 50% stenosis

2) Left anterio descending (LAD)

3) Left circumflex 60% stenosis4) Right coronary artery (RCA)

proximal 60% stenosis, middle 95%stenosis

X-ray on 17/6/09

Result: normal (NAD) Echo on 18/6/09

Result: good LV function, EF 70%, chambers sizenormal and no pericardial effusion


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Vital sign

Bp: 102/56 mmhg

HR: 92 bpm

RR: 23 bpm

Temp: 36c

Spo2: 100%


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ABG on 24/6/09

pH: 741.7 ( 7.35-7.45)

PCO2: 35.8 mmol/l (35-45)

PO2: 167 mmol/l (95-100)

HCO3: 23 mmol/l (22-26)

BE: -1~ interpretation: metabolic normal


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Lab result

Hemoglobin: 10.2

Platelet:

White blood cell:


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Objective assessment

General observation

A medium size Indian man was slumped onbed

Pt conscious and obey to command Pt look tired and sleepy

Pt on nasal prong 3 l/min

Pt on IV drip at the left hand Pt CVL on right neck

Pt on CBD drainage


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Local observation

Pt was covered by gauze at theincision site (chest and left leg)

Swelling noted at the operation site ofleft leg and ankle

Pt had right AKA


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On palpation

Chest expansion: symmetrical

Upper lobe: fair

Lateral costal: fair

Diaphragm: poor

Auscultation

Crackle sound at the left and rightlower lobes


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Chest measurementResting Inspiration Expiration

1 2 3 1 2 3 1 2 3

Axillary 93 93 93 94.5 94 94.5 94 93.5 93

Xiphoid

process

86.5 86 86 87 87.5 87 86.5 86 86

10th rib 86.5 86.5 86.5 87.5 87.5 87 87 87 87


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Coughing

- unproductive cough

Sputum-slightly thick and greenish + blood with minimalamount

Test result

-spirometry: 1000ml (3x) Muscle power

- grade 3/5 : able to do by against gravity


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Problem listing

Pain at the operation site

Back aching

Reduce chest expansion and secretionretention

Unable to produce an effective cough

Muscle weakness at both upper andlower limb


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PT Impression

Pain at anterior chest wall area d/t operationwound

Back aching d/t prolonged lying and poorblood ciculation

Reduce chest expansion d/t poor breathingeffort and pain

Secretion retention over left and right basald/t effect of GA and poor breathing pattern


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Analysis

Short term goal Produce effective and productive cough by using pillow to

support at operation site at the chest

Increase chest expansion

Increase muscle strength

Improve to normal breathing pattern

Long term goal

To prevent other chest complication To regain normal ADL


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Treatment plan

Component of ACBT x2 set

DBE 3X

Spirometer with coughing 3x

Active exercise 3x

Sit

up at the edge of bed withsupport - 3x


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Home instruction

Keep doing spirometer to increase chest expansion

Do the active exercise that has been teach bytherapist

Support the chest wound with pillow when coughing Elevate the leg same level with heart when sitting or

lying

Dont lift up the heavy things

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Coronary Artery Diseases Case Study